CDA Journal - January 2021: Silver Diamine Fluoride by California Dental Association

Journa C A L I F O R N I A

D E N TA L

Silver Diamine Fluoride Treating Deep Caries in 277 Adult Teeth With Silver Fluoride

A S S O C I AT I O N

January 2021 Caries Risk Assessment Streptococcus mutans: An In Vitro Study Clinical Trial of Three Endodontic Retrograde Filling Materials

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d e pa r t m e n t s

5 The Associate Editor/The Stories Inside 7 Letter to the Editor 9

Impressions

45 RM Matters/Unmasked Patients: Conflicts, Accommodations and Common Sense

48 Regulatory Compliance/Employee Exposure and Medical Record-Keeping

51 Ethics/Inviting Volunteer Help Into the Dental Office 52 Tech Trends

9 f e at u r e s

13 Treating Deep Caries in 277 Adult Teeth With Silver Fluoride This case report explores its potential for managing peripulpal decay in older adults and for preserving vital pulps. Michael Griffith, DDS, MS, MA

19 Use of Caries Risk Assessment by Oral Health Professionals This study examined oral health professionals’ knowledge, attitudes, practices and barriers toward CRA tools. Min Jeong Kim, MSDH, RDH; Lori Rainchuso, DHSc, MS, RDH; Jared Vineyard, PhD; and Lori Giblin-Scanlon, DHS, MS, RDH

27 Comparative Study of Antibacterial Activity of Five Luting Cements on Strains of Streptococcus mutans: An In Vitro Study The purpose of the study was to evaluate and compare the antibacterial activity of five luting cements on Streptococcus mutans. Sushil Kar, MDS; Arvind Tripathi, MDS; and Melwin Jhonson, MDS

35 A Prospective Comparative Randomized Clinical Trial of Three Endodontic Retrograde Filling Materials This clinical investigation aimed to compare three calcium silicate materials for retrograde filling of apexes in a randomized double-blind manner based on the rate of remineralization. Stephen Cohen, DDS, MA; Alicia Caro, DDS, MS; Gustavo Mahn, DDS; Veerasathpurush Allareddy, BDS, MBA, MHA, MMSc, PhD; and Veeratrishul Allareddy, BDS, MS

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Journa C A L I F O R N I A

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

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D E N TA L

Management Peter A. DuBois Executive Director Carrie E. Gordon Chief Strategy Officer Kristine Allington Chief Marketing Officer Alicia Malaby Communications Director

Editorial

Ariane R. Terlet, DDS President-Elect presidentelect@cda.org

Kerry K. Carney, DDS, CDE Editor-in-Chief Kerry.Carney@cda.org

John L. Blake, DDS Vice President vicepresident@cda.org

Ruchi K. Sahota, DDS, CDE Associate Editor

Carliza Marcos, DDS Secretary secretary@cda.org Steven J. Kend, DDS Treasurer treasurer@cda.org Debra S. Finney, MS, DDS Speaker of the House speaker@cda.org Richard J. Nagy, DDS Immediate Past President pastpresident@cda.org

Brian K. Shue, DDS, CDE Associate Editor Gayle Mathe, RDH Senior Editor

Volume 49 Number 1 January 2021

A S S O C I AT I O N

Jack F. Conley, DDS Editor Emeritus

Permission and Reprints

Journal of the California Dental Association Editorial Board

Robert E. Horseman, DDS Humorist Emeritus

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Charles N. Bertolami, DDS, DMedSc, Herman Robert Fox dean, NYU College of Dentistry, New York

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February/Business of Dentistry

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Letters to the Editor www.editorialmanager. com/jcaldentassoc

Subscriptions Annual subscriptions are available to association members at a rate of $36.

Andrea LaMattina, CDE Publications Manager Kristi Parker Johnson Senior Communications Specialist Blake Ellington Tech Trends Editor

The Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. The California Dental Association holds the copyright for all articles and artwork published herein.

Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental Medicine, Pomona, Calif. Mina Habibian, DMD, MSc, PhD, associate professor of clinical dentistry, Herman Ostrow School of Dentistry of USC, Los Angeles Robert Handysides, DDS, dean and associate professor, department of endodontics, Loma Linda University School of Dentistry, Loma Linda, Calif. Bradley Henson, DDS, PhD , associate dean for research and biomedical sciences and associate professor, Western University of Health Sciences College of Dental Medicine, Pomona, Calif. Paul Krebsbach, DDS, PhD, dean and professor, section of periodontics, University of California, Los Angeles, School of Dentistry Jayanth Kumar, DDS, MPH, state dental director, Sacramento, Calif. Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral health education, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Nader A. Nadershahi, DDS, MBA, EdD, dean, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Francisco Ramos-Gomez, DDS, MS, MPH, professor, section of pediatric dentistry and director, UCLA Center for Children’s Oral Health, University of California, Los Angeles, School of Dentistry Michael Reddy, DMD, DMSc, dean, University of California, San Francisco, School of Dentistry

The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal of the California Dental Association. The association does not assume liability for the content of advertisements, nor do advertisements constitute endorsement or approval of advertised products or services.

Avishai Sadan, DMD, dean, Herman Ostrow School of Dentistry of USC, Los Angeles

Brian J. Swann, DDS, MPH, chief, oral health services, Cambridge Health Alliance; assistant professor, oral health policy and epidemiology, Harvard School of Dental Medicine, Boston

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Harold Slavkin, DDS, dean and professor emeritus, division of biomedical sciences, Center for Craniofacial Molecular Biology, Herman Ostrow School of Dentistry of USC, Los Angeles

Richard W. Valachovic, DMD, MPH, president emeritus, American Dental Education Association, Washington, D.C.

Assoc. Editor

C D A J O U R N A L , V O L 4 9 , Nº 1

The Stories Inside Ruchi K. Sahota, DDS, CDE

undays are now spent on playdates with our “quarantine buddy.” My 5-year-old daughter and her friend run around the backyard “hiking” in the bushes. They investigate various imaginary mysteries by looking through a few holes in the fences. They create stories. They perform short plays. They shoot imaginary movies. And of course, Uno, Guess Who and Candyland tournaments ensue. Meanwhile, the “quarantine buddy” parents chat. Once the week’s full of funny stories run out, the I-friends (iPhones and iPads) enter the space. Games are played. Social media is scrolled. Content is consumed. Books are read. Even the very journal you are reading right now is studied. The most recent Journal of the California Dental Association and archives of past issues from many years’ past are housed on cda.org/journal. I, indeed, enjoyed perusing the paper copy when it came in the mail. The purposeful and poignant covers were always a delight to scrutinize. The images were always a personification of the content inside, thus enjoyable to dissect. Unfortunately, there was hardly enough time in the office to engross myself in the Journal when it first hit the desk. But that has changed, as the Journal format has changed. Playdate Sundays are now the perfect opportunity to engage with the content. But instead of bringing a stack of journals to the backyard, only one thing comes along — an iPad. The cda.org/journal website showcases issues as searchable PDFs. Issues are now accessed online where a tab titled “stories inside” serves as a visually appealing table of contents. All articles are easily scrollable and read on mobile devices as well.

When an article is shared and sent to a friend, colleague or partner, an opportunity for discussion develops.

Not only can the articles be read easily, they are also hyperlinked. The content is shareable on email, Facebook, Twitter and LinkedIn. Articles can be shared not just with colleagues in our local area, but globally. William Glasser, an author, psychiatrist and proponent of the humanistic tradition, said, “We learn … 10% of what we read, 20% of what we hear, 30% of what we see, 50% of what we both hear and see, 70% of what we experience personally and 95% of what we teach to someone else.” When an article is shared and sent to a friend, colleague or partner, an opportunity for discussion develops. Sometimes, it elicits a simple Facebook like. If the article is tweeted, it may be retweeted to reach even more people. Other times, sharing elicits the colleague to send another article back. But more often than not, it starts a chain of events of collaboration, engagement and sometimes even friendly contention. Reading on a screen was once not commonplace. The touch and feel of turning the pages of an incredible book is completely irreplaceable. A book beside the bed makes the room cozy and inviting. And of course, wandering the aisles of a bookstore or library has always been a stress-releaser. Reading a good book is one of my favorite pastimes. And, reading on a tablet once felt like blasphemy. However, as my baby grew up and tasks piled up, life began to move

along more quickly. The pre-baby life that included reading three books a month and attending a few different book clubs dwindled. Life changed. Convenience became more and more of a priority. Convenience is defined as something “fitting in well to a person’s needs and activities,” “involving little trouble or effort” and “situated so as to allow easy access to.” The need for convenience slowly abolished my judgements and hesitancy to change. As Nick Jonas said, “Life happens. Adapt. Embrace change and make the most of everything that comes your way.” While the Jonas Brothers are incredible musicians, they are not the most common benchmark for wisdom. However, this particular sentiment resonates. So, as life began to move along quickly, downloading the Kindle versions of new books became more commonplace. The library allowed downloads of electronic copies of favorite magazines. A paid subscription provided access to various dental journals. Convenience was at my fingertips. Accessing the online version of the Journal and reading it is now a treat. Living during a pandemic has led to more adaptation. My local dental society has offered access to free online continuing education for some time as a membership benefit. The pandemic has made usage of this benefit surge. In-person C.E. seemed like the only JANUARY 2 0 2 1

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ASSOCIATE EDITOR C D A J O U R N A L , V O L 4 9 , Nº 1

real option before. But the joy of being able to conveniently complete C.E. from the comfort of home — and in pajamas — is wonderful but has also become an unexpected commonplace. But again, it took many years, a few life changes and a pandemic to make myself be open to such a change. Twenty years ago, some classmates in dental school had a Tevo, one of the first digital video recorders, in their apartment. The shiny Tevo sat innocently in their living room, and while they studied on Sunday nights for the Monday morning exams, it quietly recorded away. A few floors down, many of my friends and I stuffed ourselves into another friend’s living room and sacrificed the same Sunday night study time to watch each week’s anticipated new “Sex and the City” episode. Back then, we scoffed at the Tevo. How could one not watch “Sex and the City” episodes live? Recording a show and watching at one’s leisure would result in a subpar experience. Watching primetime TV live was exhilarating. For example, I know which sofa I sat on while

watching the “Seinfeld” series finale. Don’t you? It had to be watched live. Grabbing snacks and refilling beverages during the commercial breaks provided opportunities for short respites. While it may sound like an exaggeration, the euphoria we all experienced first from the waiting for the episodes all week and then to watching it live and watching it together, was distinct. The discomfort of a dozen gals crammed together in a very small living room did not matter. We loved it and savored every minute together. There was nothing like it. Admittedly, the Tevo did not receive the respect it deserved. It was hard to admit that there may be a better way. Fast-forward 20 years and my DVR houses all of the television consumed in our home. Something that was so aversive before is the only way television can be consumed — once the 5-year-old sleeps. The 100-plus hours I recorded or banked during pregnancy helped us get through hours of late-night breastfeeding. The multiple episodes of Food Network’s “Kids Baking Championship” are available

at our beck and call to help provide some solace when TV time is allowed. “If nothing ever changes, there’d be no butterflies” —Unknown. Resistance to change can be innate. Routine is uncomplicated. Even something as simple as reading our Journal online can be a unique change that can soon result in a new unexpected commonplace. I challenge you to visit cda.org/journal. Share an article with a friend on Facebook. Discover the stories inside. n Ruchi K. Sahota, DDS, CDE, practices family dentistry in Fremont, Calif., and serves on the CDA Board of Trustees. She is also a certified dental editor, a consumer advisor for the American Dental Association, past president of the Southern Alameda County Dental Society and a fellow of the American College of Dentists, International College of Dentists and the Pierre Fauchard Academy.

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Letter

Antigen Testing

In an effort to understand enough about the SARS-CoV-2 pandemic so I could return to work in a reasonably safe way, I began to look for information about the virus. What is it, what does it do, how does it spread and, most importantly, how do I not get it? In a video interview, Michael Mina, MD, PhD, associate professor at the Harvard Chan School of Public Health, explains why we should be utilizing public health tools to mitigate the effect of the pandemic. He recommends frequent, rapid-antigen testing to identify those individuals who are infected with the SARS-CoV-2 virus as a means of preventing spread of the infection. This struck me as a great screening tool for dental offices as well as other venues where people are at risk on a daily basis. RT-PCR testing is the gold standard for identifying the presence of the coronavirus. It has both high sensitivity and specificity. However, the high cost and the time required for a result is limiting its use as a public health screening strategy. By the time an individual receives a positive test result, they may have unwittingly spread the virus to others. Antigen testing uses a saliva sample and inexpensive paper strips and gives a result within minutes. If enough of the virus is present, the test strip changes color. A person would then self-isolate pending confirmation with a PCR test. Paper-strip tests could cost in the neighborhood of $1 to $5 per test, and production could scale up to make them available to most of the U.S. population for daily testing. Antigen tests are very specific for the coronavirus although not as sensitive as PCR tests, which actually works to an advantage. A positive test correlates more closely with the window of

C D A J O U R N A L , V O L 4 9 , Nº 1

transmissibility of the infection, whereas a PCR test will continue to give a positive result long after the infection has declined to a level that does not create a potential threat of transmission. This would be ideal for point-of-care testing in dental offices. Another advantage of the antigen test strategy is that frequent, repeated testing by the public would slow the spread of the infection dramatically. This is where employers, schools, restaurants, etc., could utilize screening to begin a return to normal life. The major hurdle to integration of antigen testing in our offices and the general public is at the federal level. We need government advocacy to direct the FDA to approve paper-strip tests and to direct Congress to authorize production and distribution to all Americans. I recommend that everyone do what they can to spread the word. A great start is the rapidtests.org website. It will provide you with more background, links for videos, articles, academic papers, news releases, FAQs — basically, all things related to the rapid antigen tests. It also has the tools for you to submit a text or email to your federal representatives and governor showing your support for antigen testing. Wouldn’t you take that test every morning? Wouldn’t you have every member of your office team take that test every day? Wouldn’t you want to screen every asymptomatic patient before beginning treatment? I would. R i c h a r d G r a h a m , DDS

Rohnert Park, Calif.

Thank you, Dr. Graham

We appreciate your letter and interest in COVID-19 testing. Although there are several rapid COVID-19 tests that have been approved by the FDA under the Emergency Use Approval process,

there are no rapid tests that have yet been approved for use on asymptomatic patients. Consistent with California Department of Public Health dental guidance, dentists are already screening for potentially positive patients by asking a series of questions before appointments and conducting temperature checks on the day of the patient’s appointment. Consequently, any testing done in a dental setting would most commonly occur on asymptomatic individuals. The type of affordable and accessible rapid testing you advocate for has value and may become widespread and easily available at some point. However, regardless of how testing technology advances, in order for California dentists to perform any type of rapid COVID-19 test, they must first obtain the requisite licensure from Laboratory Field Services (LFS), a program within the California Department of Public Health. Currently, dentists are not eligible to obtain LFS licensure. CDA is actively working with the governor’s office, the legislature and the California Department of Public Health to allow dentists to immediately obtain LFS laboratory licensing. Additionally, CDA is working with the appropriate entities to advocate for JANUARY 2 0 2 1

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reimbursement for rapid COVID-19 tests by medical and dental benefit plans, including Medi-Cal. CDA is also advocating at state and federal levels to receive priority access to government-distributed COVID-19 tests for staff and patients if stockpiles of tests for asymptomatic individuals become available in the future. Find COVID-19 practice resources and information specific to testing, including a newly developed California COVID-19 testing toolkit, at cda.org/ Home/Practice/Back-to-Practice. n

The Journal welcomes letters

Make the call that makes things better. CDA’s Well-Being Program For dental professionals who suffer from alcohol or chemical dependency, the challenges of this past year may have profound impacts on health, personal relationships and practicing safely. Volunteer members and recovering dentists offer confidential peer-to-peer support, assistance finding facilities for evaluation or treatment and guidance for family members. Visit cda.org/well-being to learn more.

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Impressions

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The Periodontitis Link to Heart Disease

Evidence has shown that patients with periodontal disease may be much more likely to have negative outcomes with COVID -19, and this study could provide some clues as to why.

The link between periodontal disease and other inflammatory conditions such as heart disease and diabetes has long been established, but the mechanism behind that association has been a mystery. But recently, a team of scientists and clinicians led by the University of Toronto’s Faculty of Dentistry, found that mechanism is related to the body’s own hyperactive immune response. The team’s study was published in October 2020 in the Journal of Dental Research. “There are statistically significant correlations between periodontitis and systemic diseases ranging from diabetes to cardiovascular diseases,” said Howard Tenenbaum, DDS, PhD, professor at the University of Toronto’s Faculty of Dentistry, chief dentist at Sinai Health Systems in Toronto and one of the study authors. To find what links those conditions, the researchers focused on the behaviors of cells primarily activated by periodontitis — neutrophils, which are cells of the innate immune system. Through in vivo models, the researchers found that the immune system releases an abundance of these neutrophils to tackle the bacterial infections responsible for periodontitis. Activated to fight an oral infection, a systemic effect was noted: Once periodontal inflammation was present, an overabundance of neutrophils circulated, “primed” for attack. The hypervigilant immune system then responds with an excess of force to any secondary infection. That’s when the body becomes susceptible to damage from secondary inflammatory conditions. With the immune system already primed by the neutrophils for attack, a secondary event causes those immune cells to destroy affected tissues and organs. “The [neutrophils] are much more likely to release cytokines much more quickly, leading to negative outcomes,” the authors said. Produced initially in in vivo models, the findings were confirmed through a controlled clinical experiment. The study’s findings underscore the importance of oral health as a vital indicator of potential complications for other inflammatory conditions as well as disease model outcomes. “We believe this is the mechanism by which oral hygiene can impact vulnerability to unrelated secondary health challenges,” said lead author Noah Fine, a postdoctoral fellow at the University of Toronto’s Faculty of Dentistry. “Neutrophil (immune) priming throughout the body can connect these seemingly distinct conditions.” The study also may have important ramifications for an inflammatory disease at the top of everyone’s mind these days: COVID-19. Evidence has shown that patients with periodontal disease may be much more likely to have negative outcomes with COVID-19, and this study could provide some clues as to why. “Neutrophils are the cells that are at prime risk of causing cytokine storms. That’s the exact cell we show is primed with people with periodontal disease,” the authors said. Read more of this study in the Journal of Dental Research (2020); doi.org/10.1177/0022034520963710. n JANUARY 2 0 2 1

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Study Could Provide Breakthrough for Regenerative Dentistry Most Dentists Have Experienced Aggressive Patients Roughly half of U.S. dentists experienced verbal or reputational aggression by patients in the past year, and nearly 1 in 4 endured physical aggression, according to a new study led by researchers at the NYU College of Dentistry and published in October 2020 in the Journal of the American Dental Association. The study is the first to document aggression toward dentists in the United States. The research team surveyed 98 dentists practicing in the New York City metropolitan area; the dentists had been working an average of 17 years. Participants completed a confidential online survey assessing whether they had experienced any of 21 specific types of aggressive behaviors from their patients, including types of physical (e.g., being pushed or kicked), verbal (e.g., being insulted or sworn at) and reputational (e.g., threats of lawsuits or posting nasty comments on social media) aggression. A substantial proportion of dentists reported experiencing aggression from patients in the past year, including physical (22.2%), verbal (55%) and reputational (44.4%) aggression. An even larger proportion of dentists surveyed were subjected to physical (45.5%), verbal (74%) and reputational (68.7%) aggression at some point during their career. These rates of patient aggression toward dentists are high and comparable with those reported in other health care settings. 10 JANUARY

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New knowledge on the cellular makeup and growth of teeth can expedite developments in regenerative dentistry as well as the treatment of tooth sensitivity. The study, which was conducted by researchers at Karolinska Institutet, was published in the journal Nature Communications. Using a single-cell RNA sequencing method and genetic tracing, researchers at Karolinska Institutet, the Medical University of Vienna in Austria and Harvard University have identified and characterized all cell populations in mouse teeth and in the young growing and adult human teeth. “From stem cells to the completely differentiated adult cells, we were able to decipher the differentiation pathways of odontoblasts, which give rise to dentine — the hard tissue closest to the pulp — and ameloblasts, which give rise to the enamel,” said study authors Igor Adameyko, PhD, and Kaj Fried, PhD. “We also discovered new cell types and cell layers in teeth that can have a part to play in tooth sensitivity.” Some of the finds can also explain certain complicated aspects of the immune system in teeth, and others shed new light on the formation of tooth enamel, the hardest tissue in the human body. “We hope and believe that our work can form the basis of new approaches to tomorrow’s dentistry,” the authors said. “Specifically, it can expedite the fast expanding field of regenerative dentistry, a biological therapy for replacing damaged or lost tissue.” The results have been made publicly accessible in the form of searchable interactive user-friendly atlases of mouse and human teeth. The researchers believe that they should prove a useful resource not only for dental biologists but also for researchers interested in development and regenerative biology in general. Learn more about this study in Nature Communications (2020); doi. org/10.1038/s41467-020-18512-7.

Rates of aggression did not differ by dentists’ sex, race, ethnicity, specialty, age, years practicing or average number of patients treated per day. The rates of physical and reputational aggression toward dentists were similar to those from a parallel study by NYU researchers of aggression toward dental students published earlier in 2020 in the

Journal of Dental Education. However, practicing dentists experienced less verbal aggression from patients than dental students (55% versus 86%), suggesting that additional experience may reduce the risk of verbal aggression. Learn more about this study in the Journal of the American Dental Association (2020); doi.org/10.1016/j.adaj.2020.06.041.

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Tiny Jaw Reveals Origin of Complex Teeth A team of scientists led from Uppsala University in Greenland have described the earliest known example of dentary bone with two rows of cusps on molars and double-rooted teeth. The new findings offer insight into mammal tooth evolution, particularly the development of double-rooted teeth. The results were published in the scientific journal PNAS.

For the study, scientists investigated the jaw anatomy and tooth structure of a recently described new mammaliaform species named Kalaallitkigun jenkinsi. It was discovered on the eastern coast of Greenland and was a very small, shrewlike animal, probably covered with fur. It would have been the size of a large mouse and lived during the Late Triassic, around 215 million years ago.

Changing Stem Cell Response May Reverse Periodontal Disease In new research published in the journal Frontiers in Immunology, Forsyth Institute scientists have discovered that a specific type of molecule may stimulate stem cells to regenerate, reversing the inflammation caused by periodontal disease. This finding could lead to the development of new therapeutics to treat a variety of systemic diseases that are characterized by inflammation in the body. For the study, the research team removed stem cells from previously extracted third molars and placed the stem cells onto petri dishes. The researchers then created a simulated inflammatory periodontal disease environment in the petri dishes. Next, they added two specific types of synthetic molecules called Maresin-1 and Resolvin-E1, both specialized proresolving lipid mediators from omega-3 fatty acids. The scientists found that Mar1 and RvE1 stimulated the stem cells to regenerate even under the inflammatory conditions. Both Maresin-1 and Resolvin-1 reprogrammed the cellular phenotype of the human stem cells, showing that even in response to inflammation, it is possible to boost capacity of the stem cells so they can become regenerative, according to the study. This finding is important because it allows scientists to identify the specific protein pathways involved in inflammation. Those same protein pathways are consistent across many systemic diseases, including periodontal disease, diabetes, heart disease, dementia and obesity. “Now that we understand how these molecules stimulate the differentiation of stem cells in different tissues and reverse inflammation at a critical point in time, the mechanism we identified could one day be used for building complex organs,” the study authors said. “There is exciting potential for reprogramming stem cells to focus on building tissues.” Read more of this study in Frontiers of Immunology (2020); doi.org/10.3389/fimmu.2020.585530. Representative figures for each condition showing ARS calcified deposits.

Mammaliaform species Kalaallitkigun jenkinsi. (Credit: Marta Szubert)

Kalaallitkigun jenkinsi exhibits the earliest known dentary with two rows of cusps on molars and double-rooted teeth. The anatomical features place Kalaallitkigun jenkinsi as an intermediate between the mammals and the insectivorous morganucodontans, another type of mammaliaform. The researchers believe that the structural changes in the teeth are related to changed feeding habits. In this case study, the animals were switching to a more omnivorous/herbivorous diet and the tooth crown was expanding laterally. Broader teeth with “basins” on the top surface are better for grinding food. This development also forced changes in the structure of the base of the tooth. The biomechanical analysis that was carried out within the study found that multirooted teeth are better able to withstand mechanical stresses, including those of upper and lower tooth contact during biting, compared to single-rooted teeth. Human teeth, for instance, have this characteristic. The results suggest that the development of molar-like teeth with complex crowns may have developed together with biomechanically optimized dual roots. “Our discovery of the oldest mammalian ancestor with doublerooted molars shows how important the role of teeth was in the origin of mammals,” said Tomasz Sulej, PhD, a researcher at the Polish Academy of Sciences and the study’s lead author. Read more of this study in PNAS (2020); doi:10.1073/pnas.2012437117. JANUARY 2 0 2 1

silver diamine fluoride C D A J O U R N A L , V O L 4 9 , Nº 1

Treating Deep Caries in 277 Adult Teeth With Silver Fluoride Michael Griffith, DDS, MS, MA

abstract Background: Silver diamine fluoride has been widely studied as an agent for managing dental decay. This case report explores its potential for managing peripulpal decay in older adults and for preserving vital pulps. Case description: This is a case report on the use SDF with incomplete caries removal in adult asymptomatic deep caries in 277 teeth. All were indirect pulp caps that were immediately filled with resin or amalgam-bonded fillings in a one-step approach. Over 95% did not require root canal treatment after follow-up (average 16 months, up to six years) and there was no significant postoperative sensitivity. Practical implications: SDF has the potential to offer a fast, cost-effective approach for older patients with deep decay and offers guidance for treatment planning for cases of xerostomia and rampant decay. Key words: silver diamine fluoride; SDF; indirect pulp cap; partial caries removal; elder decay

AUTHOR Michael Griffith, DDS, MS, MA, was an assistant professor at the University of California, San Francisco, School of Dentistry. He is a fellow of the International Congress of Oral Implantology. Ethics Statement: The data were abstracted from patient charts by the dentist of record and then deidentified before analysis. This retrospective records review was exempt from IRB review.

his case series focuses on 277 teeth in a group of patients who received silver fluoride (SF) treatment as a part of their overall patient care. This clinical series was taken retrospectively from the patient records. Many patients had deep root lesions. Caries depth was often 0.2–1.5 mm from the pulp, in the inner one-third of dentin, classified as International Caries Detection and Assessment System (ICDAS) 5 and 6. Many elderly patients (60–90 years of age) benefitted from this inexpensive, one-visit treatment with minimal postoperative discomfort.

Treatment was designed as a one-step procedure. Initial partial caries removal to firm dentin was followed by the application of SF as an indirect pulp cap agent in order to avoid root canal therapy (RCT). The reasoning for this approach is as follows. The treatment of deep carious lesions continues to be reevaluated in the pursuit of protecting pulpal vitality. Several studies have focused on avoiding direct exposure of pulpal tissues and the attendant risk of root canals. Approaches have compared direct complete excavation to stepwise excavation (with complete excavation JANUARY 2 0 2 1

silver diamine fluoride C D A J O U R N A L , V O L 4 9 , Nº 1

on the second phase) to partial caries removal with no second reentry.1–5 Complete excavation to “sound dentin” has led to a higher rate of pulp exposures compared to two-step procedures or partial caries removal, yet caries removal to “sound dentin” has been the preferred approach for general dentists in the U.S.1,2 The profession is moving away from complete initial excavation. The process of partial caries removal — leaving caries “entombed” — shows promise because the technique’s pulpal survival rate is higher (83%) than in the one-step (42%) or two-step approaches (60%).2,6–8 Metastudies have commented on advantages of incomplete or “partial” caries removal.9 Caries seems to be arrested in well-sealed restorations and with many instances of long-term success.2,8 Silver diamine fluoride (SDF) has been widely studied as an agent for managing dental decay. Meta-studies have reviewed hundreds of articles in detail that have delineated the efficacy of SDF for managing caries in children as well as in adults (principally for cervical caries in adults).3,5,8–15 For several decades now, SDF has been shown to be an effective agent for the prevention and treatment of caries in China, Australia and Japan.9 This was well after G.V. Black first performed a study on the use of silver nitrate for controlling decay in 1891.5 SDF is now being used in the University of California, San Francisco, School of Dentistry. Moreover, SDF has provided protection from cervical caries in adults in both a primarily preventive manner as well as in a secondary therapeutic manner in controlling decay already in progress.10 In 2017, a workgroup formed by the American Academy of Pediatric Dentistry developed guidance and an evidencebased recommendation regarding the application of 38% SF to arrest cavitated 14 JANUARY

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caries lesions in primary teeth.7 In a recent study, SDF proved effective in halting the progression of clinical caries in children and in adult root surfaces.15

Materials and Methods

There was one dental operator in all cases (MG) who had practiced for over 40 years in one location. The review of patient records dated back to May 2012 and concluded June 2018. Patients were from a population of primarily older adults (average age 64, median age 66, age range 26–90). The median indicates that this

SDF has provided protection in both a primarily preventive manner as well as in a secondary therapeutic manner in controlling decay already in progress. population includes a larger proportion of elderly patients older than 60. The treatment approach used either (SDF or silver nitrate and sodium fluoride (AgNO3 + NaFl, SNSF). SDF was not available when this treatment began in 2012, so SNSF was used initially. Because SDF and SNSF have antibacterial properties from the silver ion, both formulations were used. For this clinical series, the term silver fluoride (SF) will be used to indicate either SDF or SNSF. Decay in this adult population typically developed on root surfaces, with deep interproximal lesions often beginning near the cementoenamel junction, under broken restorations and under crowns and could involve any tooth surface. Patients were selected for inclusion if their teeth had deep caries within the

inner one-third of dentin next to pulp, no significant percussion symptoms, no periapical pathology in digital images and no fistula formation. Some teeth preoperatively had mild symptomology to cold, sugar and discomfort or aching, but teeth with percussive pain were excluded. Teeth were placed into four categories: ■ Category I: Teeth had more superficial lesions and SF was not used. ■ Category II: Teeth had moderate caries and were judged to benefit from SF use, being more than 1.5 mm from the pulp chamber radiographically. Category II teeth were not included in the evaluation of efficacy. ■ Category III: Teeth had deep caries, estimated to be 0.75 mm –1.5 mm from live pulpal tissue. Many of these were in secondary dentin, as many pulps had retreated from the caries process over time. The depth estimation for categorization was a combination of X-ray appearance, caries excavation depth, secondary dentin appearance and visual pulpal outline in the floor of the tooth. ■ Category IV: Teeth had very deep caries, less than 0.75 mm to the pulpal area in X-rays. Clinically, excavation was carried forward to very near pulpal exposure, and despite the effort to avoid exposures, 14 teeth had frank pulp exposure and were treated by pulp cap procedures.

Filling Technique

High-speed excavation of caries with steel burrs was followed by slow speed removal of affected dentin using steel round burr and spoons and utilizing caries disclosing agents (Caries Check, Nippon Shika Yakuhin Co., Shimonoseki, Japan). Clinically, excavation was carried forward to very near pulpal exposure, removing

C D A J O U R N A L , V O L 4 9 , Nº 1

as much carious dentin as possible in that process. It was lightly air dried. SF was placed with a medium-sized applicator brush (typical of many different bonding systems), left to sit for 10–20 seconds, then exposed to a standard dental curing light for 10 seconds, resulting in dark staining in areas of residual decay, which was then thoroughly excavated, away from the pulpal area. The SF was reapplied to the entire excavation site for 10–20 seconds and light cured again for 10 seconds. Dark staining away from the pulp was excavated further and SF was reapplied briefly over the pulpal area and washed and dried. Filling with dentin bonding agents was placed immediately. SF was used in two formulations: Advantage Arrest by Elevate Oral Care LLC, West Palm Beach, Fla., and AgNO3 (38%) and 5% sodium fluoride formulated by Koshland Pharm in San Francisco. The AgNO3 preparation was used for an estimated one-third of the teeth (approximately 90 of the 277 teeth.) Advantage Arrest was used for the remaining two-thirds of the teeth. Four filling materials were used: amalgam, RMGI (Fuji II LC, GC America Inc., Alsip, Ill.), glass ionomer (Fuji IX GP, GC America Inc.) and conventional resins (Filtek, 3M, St. Paul, Minn.; Herculite, Kerr Corp., Brea, Calif.; and Core Paste build up, DenMat, Lompoc, Calif.) using a dentin bonding agent (Clearfil selfetch bond (SEB), Kuraray, New York). There was no acid etch employed, just the dentin primer of the Clearfil system and air drying was minimal. The bonding technique was when dentin bonding agent was used for resin and amalgam fillings. Bonding with Clearfil SEB involved applying primer for 20 seconds, air-

drying for five seconds and bonding resin with air thinning followed by 20-second curing light. Flowable resin was placed under various resins. Amalgams were placed using Clearfil SE BD, which included a dual curing component. Fuji fillings were placed after a dentin conditioner.

Direct Pulp Caps (DPC)

Pulpal exposures were managed by two approaches: application of hypochlorite or Superoxol (Sultan Healthcare, York, Penn.), mineral

Most teeth had “success” as defined as having no symptoms, no periapical lesions, negative to percussion and tested vital with cold or electrical challenge. trioxide aggregate (MTA), dried, and then placement of a glass ionomer base (Vitrebond, 3M) over the MTA. Smaller pulp exposures were treated with hypochlorite, dried and immediately bonded with Clearfil SEB and flowable resin.

Results: Comparing Category III, IV Outcomes

The population of this study was from a general practice of 1,100 patients with 277 teeth in 159 individuals treated for category III and IV caries using SF. Sixty-four teeth with shallow Class II lesions were excluded from this study. The average age was 63 and the sex ratio was 85 males, 74 females. Class III and IV teeth (277) were treated in 159 patients for an average of 1.74 teeth

per patient (excluding direct pulp patients); 4.7% (13 teeth) required endodontia. In Class III depth caries (153/277 teeth, 55.2%), one resulted in endodontia with none in the pulp caps. In Class IV depth caries (124/277 teeth (44.7%), 12 devolved to endodontia and 14 others required pulp caps of which three needed endodontic treatment eventually. Of the 14 direct pulp caps, three later needed endodontic treatment. Most teeth had “success” with 95% (264/277) as defined as teeth having no symptoms, no periapical lesions, were negative to percussion and tested vital with cold or electrical challenge. Almost none of the teeth had pain following treatment. No patients complained of discomfort on recall except for the 13 that ultimately degenerated and required endodontia. FIGURE 1 demonstrates Class IV restorations on teeth Nos. 12–14 and Category III restorations on Nos. 18 and 20. Tooth No. 21 was a deep core on a root canal tooth with SF used to control deep caries. FIGURE 2 indicates Class IV caries on teeth Nos. 12–14 with no periapical lesions. Of the 13 teeth that eventually needed endodontia, eight were under resin fillings and five under amalgams. Three of the resin fillings were on core build-ups for crown placement. None were under glass ionomer material fillings. As shown in TA BLE 2 , the age of the patients was similar to the entire group and the sex ratio was eight males and five females. Treatment was rendered from June 2012 through June 2018.

Discussion

As depicted in TA BLE 1 , a total of 277 teeth in 159 patients with very deep dentin decay had a pulpal survival rate of 95% (264 vital/277 total teeth) and were followed for an average of 2.5 years. TA BLE 1 demonstrates that the teeth that degenerated to needing JANUARY 2 0 2 1

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TABLE 1

Teeth Treated by Category of Caries Depth With Treatment Outcome (RCT or No)

endodontic treatment (4.7%) were distributed throughout the age ranges of the entire group, although there was a mild shift to an older age group. This degree of success establishes a proofof-purpose for a successful single-entry technique using SF for managing deep caries. This approach appears to be superior to the current one-step approach to hard dentin, better than other two-step approaches1,2,8 and an improvement over partial caries removal reported elsewhere.8 While this study was not a randomized clinical trial and has a risk of bias, it has the strength of one consistent operator using the same clinical judgment regarding degree of caries removal, application of SF and evaluating proximity to pulp tissue. Pulpal viability long-term will presumably decline; one patient needed endodontic care after five years, and this pattern is consistent with other studies showing breakdown of pulpal vitality several years after treatment.1,2,5 The pulp tolerated SF in close proximity based on the lack of postoperative sensitivity and the degree of success in avoiding pulpitis and pulpal necrosis. This agrees with Peng et al. who concluded that SDF had a “mild, selflimiting localized effect on the pulp.”12 SDF was approved as a desensitizing agent in 2014 by the U.S. Food and Drug Administration and may explain the minimal sensitivity experienced by patients. Thorough excavation of caries away from the pulp was accomplished by completely removing the SF-stained dentin and leaving darkened silver impregnated dentin immediately on the area proximal to the pulp. This mechanical caries eradication was achieved in conjunction with lower sensitivity. In Class IV caries, there were two or sometimes three applications of SF, with light exposure on each repetition, to provide maximal antibacterial effect while 16 JANUARY

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Class of caries

Depth from pulp*

Number of teeth

Average follow-up time

Number requiring endodontia

Average interval time to endodontia

Over 1.5 mm

16 months

—

III

0.75–1.5 mm

153

16.5 months

2 months

< 0.75 mm

124

16 months

12.1 months

Direct pulp cap

14 (2–53 months)

4 months

*Proximity to pulp estimated from X-rays, clinical excavation into secondary dentin, quality of dentin (visual tactile criteria). TABLE 2

Teeth Requiring Endodontia Total number of teeth in report

Teeth requiring RCT

277

Average age

63 years

68.2 years

Median age

67 years

66.5

Interval to RCT

—

12.3 months (2–60 months)

Sex ratio of patients with teeth requiring endodontia Sex ratio of entire group

6 males 7 females 85 males 74 females

minimizing pulpal sensitivity with the fluoride ion. In the opinion of the author, this multiple application represents a crucial aspect of this type of treatment. The light-exposed SF appeared to be a more sensitive caries-disclosing agent than conventional caries indicators Results presented on the Class II lesions with shallower caries were presented to demonstrate that the use of SF in moderate depths resulted in no pulpal morbidity within the time frames of this series. Recurrent caries was not observed in these fillings. The type of final filling did not affect pulpal survival. Failures requiring endodontia were associated with both resin filling (eight) and amalgam filling (five) materials. What was the same in all these cases was the resin-bonded interface with the dentin. The role of amalgam expansion has not been evaluated. The age range was 26–90. Older patients, many in their 70s and 80s, did as well as younger patients in contrast to other studies.10

In Duffin’s overview article, he concluded that “the adults and senior citizens are getting the same magnitude of benefit as the children,” which is also borne out by this current clinical series.3 Tooth staining was not a problem. The darkened remaining SDF was left immediately over the pulp. The more peripheral staining had been removed during tooth preparation, so aesthetic issues were not a clinical problem. Light curing of the SF activated staining of carious dentin so it could be effectively removed during preparation. In addition to the vast literature about clinical efficacy for caries arrest and prevention, SDF has a number of actions that make it an ideal anti-caries agent.4,5,13 SDF is bactericidal to Streptococcus mutans, Actinomyces and a great range of organisms, killing bacteria by several mechanisms (disrupting protein synthesis, DNA replication and disrupting the cell membrane).13 It prevents collagen degradation by mineral metallic proteins (MMPs) and enhances remineralization of

C D A J O U R N A L , V O L 4 9 , Nº 1

FIGURE 1. Class III and IV restorations and endodontia. FIGURE 2 . Three cervical Class IV restorations.

collagen in the dentin matrix. It promotes remineralization of dentin and protects dentin matrix from degradation in caries attack. SDF has shown the capacity to increase surface hardness in root caries.5,10,11 Silver deposited in bacteria that have died as a result can potentially later become an agent to kill other bacteria by releasing silver ions, the “zombie-like” effect of Horst.5 This attribute, to act as a reservoir for prolonged antimicrobial activity under sealed restoration, is further rationale for using SDF under deep fillings. The process of decay is different in enamel and dentin in that the former is more of an acid dissolution process of highly mineralized enamel while dentin decay includes also a process of breakdown of the organic matrix. SDF combats caries in both dentin and enamel. In 2016 in a meta-study, Hoefler et al. concluded that partial caries removal was more likely to preserve pulp vitality.8 Paradoxically, in a comparative analysis of three different groups of practitioners in the U.S., it was established that most dentists still practiced complete carious tissue removal to hard dentin.16 Importantly, in contrast to that approach and after analyzing much data, these authors also concluded that “preserving pulp health should be prioritized in the management of deep carious lesions,” and that entails avoiding mechanical exposure of the pulp. SDF seems to offer a cost-effective, conservative technique that can obviate the need for more extensive procedures

in older patients having problems with deep decay. It can be a major resource for vulnerable populations of elders by reducing the number of crowns and root canal procedures. Other clinical applications where SDF can be useful include high-risk caries patients (rampant decay); patients presenting with behavioral challenges; dentinal hypersensitivity; xerostomia of all kinds; Alzheimer’s disease and similar vulnerable populations with poor access to care; dental phobia; cognitive disabilities; the very young or very aged; and indigent populations where delivery of care is limited or nonexistent. This clinical series suggests an alternative treatment for treating very deep decay in adults.

Conclusions

Silver fluoride demonstrated the capacity to protect the pulp in this series of 277 teeth with very deep decay, with only 13 teeth requiring endodontia. It was successful in managing peripulpal caries with minimal recourse to endodontia and with asymptomatic clinical outcomes. This clinical series indicates the need for a randomized clinical trial with longer follow-up to clearly evaluate efficacy and predictability. n AC KN OW L E DGM E N T S Appreciation is extended to Dr. Nathan Kaufman and Dr. Jeremy Horst of the UCSF School of Dentistry for their consultation on preparing this report. The author thanks his office staff for their contributions to this effort.

RE F E RE N C E S 1. Hoefler B, Nagaoka H, Hiller CA. Long-term survival and vitality outcomes of permanent teeth following deep caries treatment with stepwise and partial-caries-removal: A systematic review. J Dent 2016 Nov;54:25–32. doi: 10.1016/j.jdent.2016.09.009. Epub 2016 Sep 21. 2. Bjørndal L, Fransson H, Bruun G, et al. Randomized clinical trials on deep carious lesions: Five-year follow-up. J Dent Res 2017 Jul;96(7):747–753. doi: 10.1177/0022034517702620. Epub 2017 Apr 14. 3. Duffin S. Back to the Future: The Medical Management of Caries. J Calif Dent Assoc 2012 Nov;40(11):852–8. 4. Bjorndal L, Reit C, Bruun G, et al. Treatment of deep caries lesions in adults: Randomized clinical trials comparing stepwise vs. direct complete excavation, and direct pulp capping vs. partial pulpotomy. Eur J Oral Sci 2010 Jun;118(3):290–7. doi: 10.1111/j.1600-0722.2010.00731.x. 5. Horst JA, Ellenikiotis H, Milgram P. UCSF protocol for caries arrest using silver diamine fluoride: Rationale, indications and consent. J Calif Dent Assoc 2016 Jan;44(1):16–28. 6. Maltz M, Alves LS, Jardim JJ, et al. Incomplete caries removal in deep lesions: A 10-year prospective study. 2011 Am J Dent Aug; 24(4):211–214. 7. Koopaeei MM, Inglehart MR, McDonald N, Fontana M. General dentists’, pediatric dentists’ and endodontists’ diagnostic assessment and treatment strategies for deep carious lesions. J Am Dent Assoc 2017 Feb;148(2):64–74. doi: 10.1016/ j.adaj.2016.11.001. 8. Schwendicke F, Dörfer CE, Paris S. Incomplete caries removal: A systematic review and meta-analysis. J Dent Res 2013 Apr;92(4):306–14. doi: 10.1177/0022034513477425. Epub 2013 Feb 8. 9. Slayton RL. Caries arrest with SDF and glass ionomers. Greater New York Dental Meeting, 2017. 10. Shuping Zhao I, Gao SS, Hirasishi N, et al. Mechanism of silver diamine fluoride on arresting caries: A literature review. Int Dent J 2018 Apr;68(2):67–76. doi: 10.1111/idj.12320. Epub 2017 May 21. 11. Peng JJ-Y, Botelho MG, Matinlinna JP. Silver compounds used in dentistry for caries management: A review. J Dent 2012 Jul;40(7):531–41. doi: 10.1016/j.jdent.2012.03.009. Epub 2012 Apr 3. 12. Zhao IS, Mei ML, Li QL, et al. Arresting simulated dentine caries with adjunctive application of silver nitrate solution and sodium fluoride varnish: An in vitro study. Int Dent J 2017 Aug;67(4):206–214. doi: 10.1111/idj.12291. Epub 2017. 13. Owais AI, Lu G, Keratithamkul K, et al. Silver diamine fluoride chemical mechanisms of action as a caries-arresting and preventing agent. J Calif Dent Assoc 2018 Feb;46(2):113–120. 14. Maggio JJ. How low should you go? Treatment of the deep caries lesion. Greater New York Dental Meeting, 2017. 15. Fung MHT, Duangthip D, Wong MCM, Lo ECM, Chu CH. Randomized clinical trial of 12% and 38% silver diamine fluoride treatment. J Dent Res 2018 Feb;97(2):171–178. doi: 10.1177/0022034517728496. Epub 2017 Aug 28. 16. Schwendicke F, Stangvaltaite L, Holmgren C, et al. Dentists’ attitudes and behavior regarding deep carious lesion management: A multinational study. Clin Oral Investig 2017 Jan;21(1):191–198. doi: 10.1007/s00784-016-1776-5. Epub 2016 Mar 12. T HE AU T HOR , Michael Griffith, DDS, MS, MA, can be reached at michaelgriffithdds@gmail.com. JANUARY 2 0 2 1

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caries risk assessment C D A J O U R N A L , V O L 4 9 , Nº 1

Use of Caries Risk Assessment by Oral Health Professionals Min Jeong Kim, MSDH, RDH; Lori Rainchuso, DHSc, MS, RDH; Jared Vineyard, PhD; and Lori Giblin-Scanlon, DHS, MS, RDH

abstract Background: Caries risk assessment (CRA) is an evidence-based approach to patient-centered caries management. This study examined oral health professionals’ knowledge, attitudes, practices and barriers toward CRA tools. Method: This study used a quantitative, descriptive, cross-sectional design employing a nonprobability sampling strategy for recruitment. Participation was limited to oral health professionals practicing in the U.S. The survey instrument was validated and prepared as a web-based questionnaire and was launched online on multiple oral health professional platforms. Results: The study had an 88.5% response rate, with a total of 162 participants. Despite positive attitudes and high confidence in using CRA, 43.2% reported rarely or never using CRA. Time was reported as a significant barrier to use (52%) followed by knowledge of how to implement the tool (44.8%). Conclusion: Although the majority are not using a CRA tool, oral health professionals show a positive attitude toward implementing CRA tools and would consider using a CRA tool in the near future. Practical implications: Highlighting a need to offer more CRA application-based training to increase awareness and assessment capabilities and encourage active involvement in caries prevention and disease management within the standard of care. Key words: Caries risk assessment; CRA; evidence-based caries management; dental caries prevention

AUTHORS Min Jeong Kim, MSDH, RDH, is a dental hygiene instructor at Foothill College in Los Altos Hills, Calif. Conflict of Interest Disclosure: None reported.

Lori Rainchuso, DHSc, MS, RDH, is a professor in the School of Healthcare Business at MCPHS University in Worcester, Mass. Conflict of Interest Disclosure: None reported.

Jared Vineyard, PhD, is a postdoctoral fellow and adjunct faculty teaching associate in the Forsyth School of Dental Hygiene at MCPHS University in Worcester, Mass. Conflict of Interest Disclosure: None reported.

Lori Giblin-Scanlon, DHS, MS, RDH, is an associate professor and an associate dean for clinical programs in the Forsyth School of Dental Hygiene at MCPHS University in Worcester, Mass. Conflict of Interest Disclosure: None reported.

ental caries is one of the most widespread diseases in the United States that is caused by host, agent and environmental factors.1,2 According to the 2019 Oral Health Surveillance Report from the Centers for Disease Control and Prevention (CDC), approximately 26% of adults aged 20 to 64 years, 12.7% of adolescents aged 12 to 15 years, 20.4% of teenagers aged 16 to 19 years, 16.4% of children aged 6 to 8 years and 10.4% of children aged 2 to 5 years in the U.S. have untreated dental caries.2 The overall prevalence of dental caries has since JANUARY 2 0 2 1

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decreased compared with the previous report data, but dental caries still remains one of the most common chronic diseases in the U.S. among adults and children.1,2 Recent studies have shown early detection and prevention have a relevant effect on decreasing the development of dental caries.3,4 Oral health professionals are in a key position to support and implement an effective caries prevention strategy for individual patients. Research indicates that dental caries are preventable by modifying the disease cause and associated risk factors.5,6 This approach can be easily accomplished by caries risk assessment (CRA), which is a patient-centered caries management tool used to determine the probability of caries incidence during a certain period of time as well as changes in size or activity of any lesions already present in the mouth.5 CRA is ideally designed to assist a clinician’s decision-making process for treatment and additional diagnostic procedures.7 The most common CRA tools are available from the American Academy of Pediatric Dentistry (AAPD), the American Dental Association (ADA), the California Dental Association (CDA) and a computer-based CRA, the Cariogram.8–11 These tools are specific to certain age groups and provide a format to assess dental caries risks for an individualized, comprehensive dental care plan for each patient.4,12 Since 2014, procedure codes known as Current Dental Terminology (CDT) codes for CRA have been available and used to achieve uniformity, consistency and specificity in accurately documenting dental treatment.13 The caries management by risk assessment (CAMBRA) system is a methodology that assesses the presence of specific risk factors to identify the cause of caries.10–12 The CAMBRA tool lists 24 factors including disease indicators, risk 20 JANUARY

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factors and protective factors that oral health professionals can use to evaluate patients’ level of caries risk.12 Based on the results of positive factors, oral health professionals can easily categorize patients into low, moderate, high or extreme risk.9 Research suggests the use of CAMBRA can assist oral health professionals in making informed recommendations for individual patient’s caries prevention as well as management of existing issues.9–11 Previous studies have examined different types of CRA systems, including the CAMBRA system, and found

Despite the knowledge of dental caries prevention and treatment, dental caries remains a significant problem for both children and adults in the U.S.

them to have acceptable accuracy, particularly with children who present with having caries experience at the time of the baseline examination.3,4,12 The implementation strategies of CRA fit various professional dental settings and are easily accomplished by identifying moderate and high caries risk factors.4 The results and specific findings from CRA are essential for appropriate patient care, effective caries prevention and restorative caries management as well as for determination of recall intervals.10–12 Despite the knowledge of dental caries prevention and treatment, dental caries remains a significant problem for both children and adults in the U.S.3 CRA can assist oral health professionals in helping patients avoid severe stages of dental caries as well as prevent

future dental caries.4,12 It is important to identify and understand caries risk factors if early caries prevention and management are to occur.3,4,12 The purpose of performing CRA is to prevent oral disease by identifying and minimizing risk factors and optimizing preventive factors. CRA is considered an essential component of the clinician’s decision-making process and can be performed by oral health professionals. For optimal results, CRA should be accompanied by appropriate intervention, prevention, treatment and patient education.12 Multiple studies have been conducted to assess the effectiveness of CRA, and several of these studies have investigated knowledge, attitudes and behaviors regarding the use of CRA, particularly by dentists or dental hygienists.12,14,15 However, few studies have examined oral health care professionals’ perceptions and attitudes regarding the use of a CRA tool, experience with using a CRA tool or the application of CRA information when developing an individualized treatment care plan.14,15 Additionally, further research is needed regarding the use of CRA tools as a process of care in various dental settings that involve all members of the oral health profession and help to measure the effectiveness of their involvements.14–17 Lastly, gaps of knowledge exist regarding assessment of oral health professionals’ skills, perceptions and perceived barriers toward application of a CRA tool in practice. The aim of this study was to examine oral health professionals’ knowledge, attitudes, clinical experience and perceived barriers for caries risk assessment as a means of caries prevention and disease management in professional dental settings. For the purposes of this study, oral health professionals were defined as dentists, dental hygienists, dental

C D A J O U R N A L , V O L 4 9 , Nº 1

therapists, advanced dental therapists and dental assistants. Additionally, professional dental settings were defined as private dental practices, including pediatric and other specialty dental practices as well as dental clinics including mobile, community health/ dental and public health/dental clinics.

Methods

This study used a quantitative, descriptive, cross-sectional design. A nonprobability convenience sampling method was employed for participant recruitment. Inclusion criteria for study participation was limited to oral health professionals: dentists, dental hygienists, dental therapists and dental assistants who were currently practicing in their respective specialty in a professional dental setting within the U.S. Additionally, participants needed to have access to the internet to complete the web-based survey. Individuals who were not currently practicing or no longer practicing in the U.S. were excluded. The research setting included multiple oral health professional social media platforms such as Facebook, LinkedIn and other community dental/dental hygiene/dental therapists/dental assistants’ websites. Social media groups were selected based on the number of members and posts. Selection criteria included greater than 1,000 members, and the number of activities needed to be more than 100 in the last 30 days. Additionally, specific websites for posting were selected via keywords including dental, oral health, dental hygiene, dentists, dental assistant, dental therapist and dental professionals.

Survey Instrument

The survey instrument was developed using new questions and questions used with permission from two previously published research studies conducted

by Francisco et al. (2013) and Urban et al. (2015).5,7 Questions employed from these two surveys were modified due to the previous studies having different criteria for study inclusion. The questionnaire was divided into three sections with a total of 31 questions. The first section included questions to assess the knowledge and familiarity of CRAs. The second section focused on attitudes and comfortability in implementing CRAs and the use of CRA factors for caries management recommendations in a professional dental

The survey was developed using new questions and questions used with permission from two previously published research studies.

professionals with extensive knowledge and long-term experience with CRA tools, including two academic dental hygienists, a dentist and a dental assistant. Questions were modified and eliminated based on panel responses and results of I-CVI. The overall S-CVI score for this survey was 1, which was an adequate representation of content validity. Additionally, prior to launching, the survey was face-validity tested for timeliness and understanding with a participant who met the study’s inclusion criteria. Revisions were made in consideration of their recommendations and suggestions; however, the results were not included in the final research study. The survey instrument was prepared as a web-based questionnaire via SurveyMonkey. This study was approved by the University IRB committee and received “exempt” status, protocol number IRB041918R. To ensure the participants’ anonymity, implied consent was used with no identifiable information being collected from the study participants. An initial email request was sent to authorizing personnel in charge of the selected study sites to request permission to post the survey link. The web-based questionnaire remained open for four weeks.

setting. The last section was demographic questions relating to the respondent’s gender, age, ethnicity, professional position, practice settings, year of graduation, working hours and an average number of patients seen per week. A 5-point Likert-type scale option, ranging from “strongly agree” to “strongly disagree,” Data Analysis For the descriptive portion of including “neither agree nor disagree” this study, the sample demographic and “do not know” options, was used to information and response to survey rate the knowledge and familiarity of CRAs. A 4-point Likert-type scale option, questions were summarized and reported with measures of variance ranging from “strongly agree” to “strongly (e.g., standard deviation). Next, all disagree” and “unsure” options, was used variables were analyzed for statistical to rate the attitude and comfortability assumptions including normalcy and toward implementing CRAs. colinearity. Variables were assessed To ensure the effectiveness of the for transformation to address issues survey instrument, the questionnaire of non-normal distributions. The was tested for content validity by data were analyzed for missing data, an expert panel of four oral health JANUARY 2 0 2 1

caries risk assessment C D A J O U R N A L , V O L 4 9 , Nº 1

TABLE 1

Sample Demographics (n =162) Gender Age

Profession

Practice setting

Ethnicity

Count

95% CL lower 95% CL upper

Male

3.1%

1.2%

6.6%

Female

157

96.9%

93.4%

98.8%

18–29

15.4%

10.5%

21.6%

30–49

48.1%

40.5%

55.8%

50–64

31.5%

24.7%

38.9%

65+

4.9%

2.4%

9.1%

Other (please specify)

2.5%

0.8%

5.8%

Dentist

6.8%

3.7%

11.4%

Dental hygienist/RDHAP/ADHP

130

80.2%

73.6%

85.8%

Dental therapist/ Advanced dental assistant

9.3%

5.5%

14.4%

General dental practice

122

75.3%

68.3%

81.5%

Pediatric dental practice

10.5%

6.5%

15.9%

Other specialty practice

11.1%

7.0%

16.6%

Mobile dental clinic

1.9%

0.5%

4.9%

Community health center/ dental clinic

9.9%

6.0%

15.2%

Public health center/dental clinic

9.9%

6.0%

15.2%

White or Caucasian

135

83.3%

77.0%

88.5%

Black or African American

2.5%

0.8%

5.8%

Hispanic or Latino

3.1%

1.2%

6.6%

Asian or Asian American

13.0%

8.5%

18.8%

American Indian or Alaska Native 0

0.0%

—

Native Hawaiian or other Pacific Islander

0.0%

—

Note: % = count/n, lower and upper 95% CL = 95% confidence level of the proportion. Proportion is calculated as the count divided by 162 unless otherwise indicated. A portion of participants endorsed multiple practice settings, thus the percentage may be greater than 100%.

and any participant with less than 80% of responses completed was removed from parts of and the whole analysis. Online surveys often yield low response rates, which could lead to bias in statistical estimations. As a result, the completion rate (number of completed surveys/number of attempts) was calculated and reported for the survey and the response rate was omitted because it was not appropriate for a nonprobability sampling method. To explore the relationship between variables, Spearman’s rank-order correlations were used. The acceptable alpha level for this study was set at .05 22 JANUARY

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for hypothesis testing, and all measures of effect size (e.g., 95% confidence interval) were determined and reported.

Results

A total of 183 oral health professionals opened the survey link, and 162 were valid for analysis, resulting in a completion rate of 88.5%. A total of 80.2% (n = 130) of respondents were dental hygienists, 9.3% (n = 15) were dental therapists or advanced dental therapists, 6.8% (n = 11) were dentists and 1.2% (n = 2) were dental assistants. The majority of the respondents were female (96.9%), white or Caucasian

(83.3%), and the most frequent age group was 30 to 49. Most of the respondents reported that they were employed in general dental practices (75.3%), and the mean working hours was 28.39 hours per week. The number of patients seen per week ranged from one to 50, and the mean was 32.12. The majority of the respondents graduated from prospective schools or programs within the past 18.06 years ( TA BLE 1) . Knowledge was first examined by determining the number of correct responses out of five items about dental caries and health. From the sample, 124 oral health professionals (76.5%, 95% CI: 69.3–82.8) answered five knowledge questions correctly. The highest number of incorrect responses was associated with the two items “dental caries is a transmissible disease” (41, 25.3%, 95% CI: 18.8–32.7) and “a white spot lesion is a clinical sign of early caries” (43, 26.5%, 95% CI: 19.9–34.0). A majority agreed CRA tools predict future caries (123, 76.4%, 95% CI: 68.6–82.3), improve caries prevention and disease management (136, 84%, 95% CI: 77.4–89.2) and untreated dental caries can lead to life-threatening health complications (149, 92.5%, 95% CI: 86.7–95.7). A total of 55 participants (34.2%, 95% CI: 26.7–41.8) stated they or their supervisor were unfamiliar with CRA (n = 29) or were unsure (n = 26) ( TA BLE 2 ) . The total number of correct responses by profession type are displayed in TA BLE 3 . This study evaluated attitudes and beliefs with two questions regarding the importance of CRA and two additional questions about participants’ belief that a CRA tool is effective at reducing caries. Participants overwhelmingly agreed that oral health professionals are in a key position to implement CRA tools (159, 98.1%, 95% CI: 94.7–99.6) and thought caries prevention was equally important

C D A J O U R N A L , V O L 4 9 , Nº 1

TABLE 2

Response to Knowledge Questions (n = 162) Frequency (%) Strongly agree count (%)

Agree count (%)

Neither agree nor disagree count (%)

Disagree count (%)

Strongly disagree count (%)

Don’t know count (%)

Assessment of caries risk for a patient can predict whether or not that patient will develop caries in the future.

33 (20.6)

90 (56.3)

26 (16.3)

11 (6.9)

0 (0.0)

Caries risk assessment improves caries prevention and management in a clinical dental practice.

47 (29.7)

89 (56.3)

14 (18.9)

6 (3.8)

2 (1.3)

0 (0.0)

Untreated dental caries disease can lead to life-threatening health complications

83 (51.9)

66 (41.3)

5 (3.1)

1 (0.6)

0 (0.0)

Correctly identified count (%)

Not endorsed count (%)

Dental caries is a transmissible disease.

121 (74.7)

41 (25.3)

Dental caries is a multifactorial disease.

162 (100.0)

0 (0.0)

A white spot lesion is a clinical sign of early caries.

119 (73.5)

43 (26.5)

Decreased saliva flow increases risk for dental caries.

159 (100.0)

0 (0.0)

Chlorhexidine is known to kill all caries pathogenic organisms.

133 (82.1)

29 (17.9)

Evidence-based research indicates that the use of caries risk assessment results in a reduction of new caries over time.

131 (80.9)

31 (19.1)

Note: Not all participants answered all questions. Count = number of item endorsement for category; % = count/number of participants who answered the item.

TABLE 3

Number of Knowledge Items Correctly Answered by Profession (n = 162) 1 Count

2 %

Count

3 %

Count

4 %

Count

5 %

Count

Dentist

0.0%

18.2%

0.0%

27.3%

54.5%

Dental hygienist

0.0%

9.2%

15.4%

40.0%

35.4%

Dental therapist

0.0%

13.3%

60.0%

26.7%

Note: Numbers 6 and 7 are omitted from the table because no participant correctly answered more than five items. % = number of participants/number of participants for that profession type. TABLE 4

Response to Attitude and Confidence Questions and Percentage Correct by Profession (n = 162) Frequency (%)

I am confident in my ability to choose an appropriate caries risk assessment for a patient.

Strongly agree

Agree

Unsure

Disagree

Strongly agree

60 (37.0%)

75 (46.3%)

14 (8.6%)

9 (5.6%)

4 (2.5%)

I am confident in my ability to conduct a caries risk assessment with a patient.

70 (43.8%)

66 (40.7%)

13 (8.0%)

10 (6.2%)

3 (1.9%)

I am confident in my ability to explain caries risk assessment results with a patient.

71 (43.8%)

9 (5.6%)

3 (1.9%)

I am confident in my ability to recommend prescription fluoride dentifrices or other out-of-pocket expenses.

86 (53.1%)

69 (42.6%)

5 (3.1%)

2 (1.2%)

0 (0.0%)

Note: Proportion is calculated as the count divided by 162 unless otherwise indicated. JANUARY 2 0 2 1

caries risk assessment C D A J O U R N A L , V O L 4 9 , Nº 1

TABLE 5

Responses to Practice Questions Frequency (%) Always

Usually

Sometimes

Rarely

Never

Our office uses a caries risk assessment tool for a patient (n=153).

38 (24.8%)

22 (14.4%)

27 (17.6%)

22 (14.4%)

44 (28.8%)

Our office assesses caries risk by using a professionally recognized caries risk assessment tool from the AAPD, ADA and/or CDA (n=148).

35 (23.6%)

25 (16.9%)

10 (6.8%)

11 (7.4%)

67 (45.3%)

Our office uses Current Dental Terminology (CDT) codes for caries risk assessment on every claim form and/or documentation (n = 122).

16 (13.1%)

18 (14.8%)

8 (6.6%)

16 (13.1%)

64 (52.5%)

Note: Percentage equals proportion of endorsed to all who responded. Proportion is calculated as the count divided by 162 unless otherwise indicated. The denominator value varied for each question based on participants responding “unsure,” thus those responses were not included and values are reported separately for each question.

(70, 43.2%, 95% CI: 35.5–51.2) or more important (91, 56.2%, 95% CI: 48.2–63.9) than restoration of dental caries. Agreement with feeling convinced the assessment is effective at reducing the risk of caries was endorsed by 141 (87.6%, 95% CI: 80.9-91.8) of participants, but 43 (26.5%, 95% CI: 19.9–34.0) stated they were unsure when also asked about their employer or supervisor. This study also examined participants’ confidence with various aspects of CRA tools. TA BLE 4 shows the frequencies of participants’ responses to confidence questions. For all three questions, participants felt confident and comfortable with caries assessment implementation with agreement ranging from 83.9% (95% CI: 76.7–88.7) for choosing the appropriate tool to 88.8% (95% CI: 81.6–92.3) for explaining caries risk assessment.

Practice Behaviors and Barriers

Despite positive attitudes and high confidence with CRA tools, many participants said their office infrequently or never used CRA tools (TABLE 5). Only 37.3% of participants stated their office usually or always used a CRA tool, with all 37.3% indicating that the tool they used was considered a professionally recognized CRA tool. From the sample, 37 participants indicated their office did not currently use a CRA tool 24 JANUARY

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and declined to answer the barriers questions, which left 125 responses. Time was the highest rated barrier with 65 participants (52%, 95% CI: 42.1–60.2) agreeing or strongly agreeing there was not enough time during an appointment to perform an assessment, followed by knowledge of how to implement the tool (44.8%, 95% CI: 35.9–54.0) and then patients’ perception and acceptance (40.8%, 95% CI: 32.1–49.9). Support for implementing CRA tools in the future was endorsed by 74 of the 134 participants (55.2%, 95% CI: 46.4–63.8) with 36.6% (95% CI: 28.4–45.3) indicating they were unsure. To assess the relationship between barriers, practices, intention to implement caries risk assessment and demographics, this study conducted Spearman rank-order correlations. TA BLE 6 is the correlation matrix for each variable of interest. Intention to implement was correlated with several variables, but was most strongly related to endorsing the item “Caries risk assessment improves caries prevention and management in a clinical setting” (rho(83) = .45, P < .001) and least associated with having enough time during the appointment to conduct the caries risk assessment (rho(68) = .02, P = .32). Intention to implement caries risk assessment was not significantly associated with barriers (Ps > .05).

A pattern emerged in which the confidence questions were significantly correlated with concern about patients ‘perception and acceptance (rho = –.25 to –.35, Ps < .05) and being interested, but not knowing how to implement the tool (rho = –.48 to –.54, Ps < .05). However, this was not correlated with having enough time (P > .05) ( TA BLE 6 ) . Oral health professionals who endorsed higher confidence were more likely to disagree with each of the barriers. Participants who were interested in implementing the tool but unaware of how to do so were less likely to work in an office that used caries risk assessments (rho(103) = –.26, P < .05) or professionally recognized CRA tools (rho(101) = –.27, P < .05). Participants who agreed they did not have time to conduct a CRA tool during the appointment were also less likely to work at an office where a CRA tool was being used (rho(115) = –.20, P < .05). For demographic variables, only the average number of hours worked per week was correlated with other variables. Participants who worked more hours per week agreed they worked in offices using caries risk assessments (rho(150) = –.30, P < .001) and professionally recognized CRA tools (rho(145) = –.29, P < .05).

Discussion

This study examined oral health professionals’ knowledge, attitudes and practices toward using a CRA tool in professional dental settings. Few studies have been conducted to assess knowledge, attitudes and practices regarding a particular CRA tool or use of CRA tools by the particular position of oral health professionals such as dentists or dental hygienists.5,7 This descriptive, cross-sectional study highlighted that oral health

C D A J O U R N A L , V O L 4 9 , Nº 1

TABLE 6

Correlation Matrix of Practices, Barriers and Intention to Implement CRA (n = 162) 1

Our office uses a caries risk assessment tool for a patient.

—

Our office assesses caries risk by using a professionally recognized caries risk assessment tool from the American Academy of Pediatric Dentistry (AAPD), American Dental Association (ADA) and/or California Dental Association (CDA).

.82**

—

Our office uses Current Dental Terminology (CDT) codes for caries risk assessment on every claim form and/or documentations.

.54**

.65**

—

There is not enough time during an appointment to perform a caries risk assessment on each patient.

–.20*

–.13

.04

I am interested in caries risk assessment, but do not know how to implement the tool.

–.26**

–.27** –.14

.08

—

I am concerned about my patients’ perception and acceptance of caries risk assessment.

.15

.12

.18

.06

.18

—

I or my employer/supervisor support the use of and will consider using the caries risk assessment in the near future.

.51**

.39**

.34**

.03

.13

.16

—

* Correlation is significant at the .05 level; ** correlation is significant at the .001 level. All correlations in the table are Spearmen’s rank order two-tailed tests.

professionals’ knowledge, attitudes and practices regarding CRA tools varied depending on working environments, experiences and perception of oral health beliefs. The majority of respondents understood the concepts of CRA systems and were very familiar with CRA tools. Also, most of them showed positive attitudes toward CRA tools and were confident to implement a CRA tool with their patients. They believed CRA tools were relevant to their patient care and that CRA improves caries prevention and management. Oral health professionals highly ranked a commitment to evidence-based care and were aware that CRA tools helped to improve patients’ motivation for oral health care as well. About 24.8% of respondents reported they were always using some type of CRA tool, with 23.6% of respondents reporting that they were always using a professionally

recognized CRA tool during patient care. Despite the reported use of a risk assessment tool, the majority of participants reported that they did not use CDT codes for CRA on every patient claim form and/or documentation. This finding indicates that there may be a potential need to offer more professional education regarding care plan inclusion and appropriate coding for CRAs. Appropriate tracking of preventive services could provide an awareness among private and public dental insurers and potentially lead to future policy change regarding reimbursement of risk assessment procedures for oral health-related disease. A similar study assessing knowledge, attitudes and practices of CRA by dental hygienists found only 29% of respondents agreed or strongly agreed that time was a barrier to including caries risk assessment in patient care,15 whereas this study found 52% of participants agreed

or strongly agreed that time was a major barrier to CRA implementation. The authors postulate this notable increase could be due to this study’s inclusion of a variety of dental professionals with many practicing in alternative settings, which may entail more time constraints. Although time, not knowing how to implement the tool and patients’ perception and acceptance were identified barriers, the majority of respondents also reported that either they or their supervisor supported CRA use or would consider using a CRA tool in the near future. This finding highlights that use or future use of a CRA tool is potentially favorable despite the barriers noted. A previous study conducted by Francisco et al. examined dental hygienists’ current knowledge levels, attitudes and practice behaviors regarding CRA and caries management. The study showed that dental hygienists had high knowledge of CRA with the exception of white spot lesions as a risk factor (42%).14 In contrast, this study found 79% of dental hygienist respondents correctly recognized a white spot lesion as a clinical sign of early caries development. Although this study assessed multiple professionals within oral health, the majority of respondents identified as dental hygienists 80.2% (n = 130). Reasons for increased knowledge on white spot lesions between these two similar studies are unclear. Additionally, the Francisco et al. study showed only 23% of dental hygienists actually used CRA in a private practice setting,14 while this study found a similar, yet small increase in respondents reporting they were always using a professionally recognized CRA tool during patient care (24.8%). Lastly, both studies revealed the majority of respondents were comfortable with JANUARY 2 0 2 1

caries risk assessment C D A J O U R N A L , V O L 4 9 , Nº 1

performing CRA, and these findings reflected that they have positive attitudes toward the CRA tools. Oral health professionals need to recognize the process of evidence-based caries prevention and management and provide a comprehensive assessment to identify an individual’s caries risk factors and protective factors. Based on the study results, time was the highestrated barrier with a higher number of participants agreeing or strongly agreeing there was not enough time during an appointment to perform a CRA tool. However, participants who agreed they did not have time to conduct a CRA tool during the appointment were also less likely to work in an office where a CRA tool was implemented. Participants who worked more hours per week agreed they worked in offices using professionally recognized CRA tools. As the results show, time by itself may not be the major barrier in conducting a CRA tool. This study had several limitations and recommends further exploration to assess the progress of implementing CRA tools by oral health professionals. Although study participants included all identified members of the oral health profession, a higher number of dental hygienists (80.2%) participated in this study. Potential reasons for the response abundance from one profession may be the research topic being of greater interest to this professional group. Additionally, more dental hygiene professional websites and social media venues were known or available to the investigators than other professions, thus the survey link had increased views from those sites.

Conclusion

This study revealed that although oral health professionals had a high level of CRA knowledge and showed a

26 JANUARY

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positive attitude toward implementing CRA tools in a professional dental setting, the majority are not using a CRA tool. Although intention to implement CRA tools in the future was not significantly correlated with any of the barriers, intention was positively correlated with the beliefs that CRA tools were relevant to patient care and that these tools can improve caries prevention and management. While results indicated an increased awareness of CRA tools, implementation skills are needed among oral health professionals. This highlights a need to offer more CRA applicationbased training not only to increase CRA awareness and assessment capabilities, but also to encourage active involvement in caries prevention and disease management within the standard of care. Dental care establishments must improve their ability to manage patient care appointments, allotting time for completion of a thorough and comprehensive CRA and appropriate documentation. Future studies are needed for an indepth exploration of perceived barriers and strategies for implementation of a CRA tool. Additionally, as time was the greatest obstacle to implementing a CRA tool, the authors suggest the development of a CRA short form to address this barrier and potentially improve CRA implementation among dental professionals. n AC KN OW LE DGM E N T S The authors thank Dorothy J. Rowe, RDH, MS, PhD, and Ruth A. Urban, RDH, MS, at the University of California, San Francisco, School of Dentistry and Elena M. Francisco, RDH, RDHAP, MSDH, for granting survey permission/modification. RE FE RE N CE S 1. Centers for Disease Control and Prevention. Oral and dental health. www.cdc.gov/nchs/fastats/dental.htm. Updated 2017. Accessed July 16, 2019. 2. Centers for Disease Control and Prevention; 2019. Oral Health Surveillance Report: Trends in dental caries and sealants, tooth retention and edentulism, United States. www.cdc.gov/oralhealth/pdfs_and_other_files/Oral-HealthSurveillance-Report-2019-h.pdf. Accessed Oct. 28, 2019. 3. Marrs JA, Trumbley S, Malik G. Early childhood caries:

Determining the risk factors and assessing the prevention strategies for nursing intervention. Pediatr Nurs 2011 Jan–Feb;37(1): 9–15; quiz 16. 4. Basavaraj P, Khuller N, Khuller RI, et al. Caries risk assessment and control. J Oral Health Comm Dent 2011;5(2):58–63. doi: 10.5005/johcd-5-2-58. 5. Hurlbutt M, Young DA. A best practices approach to caries management. J Evid Based Dent Pract 2014 Jun; 14 Suppl:77–86. doi: 10.1016/j.jebdp.2014.03.006. Epub 2014 Mar 28. 6. Zero D, Fontana M, Lennon AM. Clinical applications and outcomes of using indicators of risk in caries management. J Dent Educ 2001 Oct;65(10):1126–32. 7. Tellez M, Gomez J, Pretty I, et al. Evidence on existing caries risk assessment systems: Are they predictive of future caries? Community Dent Oral Epidemiol 2013 Feb;41(1):67–78. doi: 10.1111/cdoe.12003. 8. American Academy of Pediatric Dentistry. Caries-risk assessment and management for infants, children and adolescents. 2014. www.aapd.org/media/Policies_Guidelines/ BP_CariesRiskAssessment.pdf. Accessed July 31, 2019. 9. American Dental Association. Caries risk assessment and management. 2017. www.ada.org/en/member-center/oral-healthtopics/caries-risk-assessment-and-management. Accessed July 16, 2019. 10. Featherstone JD, Crystal YO, Chaffe BW, et al. An updated CAMBRA caries risk assessment tool for ages 0 to 5 years. J Calif Dent Assoc 2019 Jan;47(1):37–47. 11. Featherstone JD, Alston P, Chaffee BW, et al. Caries management by risk assessment (CAMBRA): An update for use in clinical practice for patients aged 6 through adult. J Calif Dent Assoc 2019 Jan;47(1):25–34. 12. Fontana M, Zero D. Assessing patients’ caries risk. J Am Dent Assoc 2006 Sep;137(9):1231–9. doi: 10.14219/jada. archive.2006.0380. 13. American Dental Association. CDT 2018: Dental Procedure Codes. Chicago: American Dental Association; 2018. 14. Francisco EM, Johnson TL, Freuden, Louis G. Dental hygienists’ knowledge, attitudes and practice behaviors regarding caries risk assessment and management. J Dent Hyg 2013 Dec;87(6): 353–361. 15. Urban RA, Rowe DJ. Knowledge, attitudes and practices of dental hygienists regarding caries management by risk assessment. J Dent Hyg 2015 Feb;89(1):55–62. 16. Domejean-Orliaguet S, Gansky SA, Featherstone JD. Caries risk assessment in an educational environment. J Dent Educ 2006 Dec; 70(12):1346–1354. 17. Halasa-Rappel YA, Ng MW, Gaumer G, et al. How useful are current caries risk assessment tools in informing the oral health care decision-making process? J Am Dent Assoc 2019 Feb;150(2):91– 102.e2. doi: 10.1016/j.adaj.2018.11.011. T HE CORRE S P ON DIN G AU T HOR , Lori Rainchuso, DHSc, MS, RDH, can be reached at Lori.Rainchuso@mcphs.edu.

luting cements C D A J O U R N A L , V O L 4 9 , Nº 1

Comparative Study of Antibacterial Activity of Five Luting Cements on Strains of Streptococcus mutans: An In Vitro Study Sushil Kumar Kar, MDS; Arvind Tripathi, MDS; and Melwin Jhonson, MDS

abstract The purpose of the study was to evaluate and compare the antibacterial activity of five luting cements on Streptococcus mutans. Agar diffusion test (ADT) and direct contact test (DCT) were carried out to measure the antibacterial activity. In the DCT, the bacterial growth was highest in polycarboxylate cement, but zinc phosphate cement produced the maximum zone of inhibition in the ADT while no zone of inhibition was found in polycarboxylate cement. Purpose: To evaluate and compare the antibacterial activity of five luting cements (zinc phosphate, zinc polycarboxylate, glass ionomer, resin-modified glass ionomer and resin cements) on the strains of Streptococcus mutans using the direct contact test and agar diffusion test. Material and methods: For the agar diffusion test, three readings of the inhibition halo were recorded at 24 hours, 48 hours and 72 hours, respectively, and were repeated seven times for each material. In the direct contact test, the kinetics of the bacterial outgrowth were recorded at 650 nm in a temperature-controlled spectrophotometer for 24 hours, 48 hours, 72 hours and one week, respectively. The antibacterial activity of the tested specimens was analyzed using mixed ANOVA and Bonferroni post hoc tests (P < 0.05). Results: In the DCT, the bacterial growth was highest in polycarboxylate cement with mean (95% CI) growth of 0.58 mm and least in resin modified glass ionomer cement with mean (95% CI) growth of 0.26 mm. Although zinc phosphate cement showed the maximum zone of inhibition with mean value of 23.69 mm, zinc polycarboxylate cement did not produce any inhibition halo in the ADT.

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luting cements C D A J O U R N A L , V O L 4 9 , Nº 1

Conclusion: Resin-modified glass ionomer cement possessed the best antibacterial efficacy when the DCT was employed while zinc phosphate cement produced the best antibacterial property in the ADT. No zone of inhibition was found in polycarboxylate cement. Key words: Quantitatively; qualitatively; incubation; inhibition; bacterial growth

AUTHORS Sushil Kumar Kar, MDS, is a professor in the department of prosthodontics at the Saraswati Dental College and Hospital in Lucknow, India. Conflict of Interest Disclosure: None reported. Arvind Tripathi, MDS, is a professor and the head of the department of prosthodontics at the Saraswati Dental College and Hospital in Lucknow, India. Conflict of Interest Disclosure: None reported.

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Melwin Jhonson, MDS, is a resident in the department of prosthodontics at the Saraswati Dental College and Hospital in Lucknow, India. Conflict of Interest Disclosure: None reported.

he oral cavity harbors a great diversity of microbial species that have a strong tendency to colonize dental surfaces.1,6 Streptococcus mutans is found to be the main etiological agent for dental caries that adheres to the acquired pellicle. Preventing initial adhesion is practically impossible, hence it is necessary to develop other methods to prevent caries.2 Because microleakage can’t be controlled, the antibacterial properties of dental cements assume clinical relevance.3,7 Zinc phosphate, zinc polycarboxylate, glass ionomer, resin-modified glass ionomer and resin cement are widely used as luting cements in dental practice. In addition to their better cohesive and adhesive properties, cements possessing antibacterial properties may reduce bacteria-induced fixed partial denture complications.4 The agar diffusion test is a standard assay in most of the studies irrespective of its known limitations. Problems associated with the agar diffusion test include its qualitative nature, inability to distinguish between bacteriostatic and bactericidal effects, difficulties in comparing a large number of samples and controlling variables like density of bacterial inocula, growth medium, agar viscosity, storage conditions of agar plates, size and number of specimens, incubation time and temperature. Weiss et al. introduced the direct contact

test, which quantitatively measures the interaction between the microorganism and the tested materials regardless of their solubility and the diffusiveness of their components.5 Very few studies have been conducted quantitatively using the direct contact test. Therefore, the purpose of this study was to evaluate and compare the antibacterial efficacy of five luting cements against Streptococcus mutans using the direct contact test and agar diffusion test.

Material and Methods

This in vitro study was conducted to evaluate and compare the antibacterial efficacy of five luting cements against Streptococcus mutans in collaboration with the department of microbiology and immunology. Ethical clearance was obtained from the institutional research and development committee (IRDC). The luting cements selected were zinc phosphate cement (DeTrey Zinc, Dentsply Sirona, York, Pa.), glass ionomer cement (Ketac Universal glass ionomer, 3M ESPE, St. Paul, Minn.), resin-modified glass ionomer cement (Nexus RMGI, Kerr, Brea, Calif.), zinc polycarboxylate cement (Durelon cement, 3M ESPE) and resin cement (RelyX ARC, 3M ESPE). Agar diffusion and direct contact methods were used to qualitatively and quantitatively assess and compare the antibacterial property of each cement against strains of Streptococcus

C D A J O U R N A L , V O L 4 9 , Nº 1

TABLE 1

Comparison of Bacterial Growth Rate Between Study Groups at Different Time Intervals Using Mixed ANOVA Group

Fresh material

24 hours

Mean

48 hours Mean

1 week Mean

DeTrey Zinc

0.06

0.01

0.25

0.03

0.29

0.02

1.46

0.11

Ketac Universal glass ionomer

0.14

0.01

0.23

0.02

0.26

0.02

1.35

0.31

Nexus RMGI

0.09

0.01

0.10

0.01

0.15

0.03

0.70

0.10

Durelon cement

0.21

0.02

0.29

0.01

0.31

0.01

1.48

0.06

RelyX ARC

0.15

0.01

0.24

0.02

0.26

0.02

1.51

0.03

Within-subjects effects

Between-subjects effects F

p-value

Time

1661.38

< 0.001*

Intercept

3184.86

< 0.001*

Time * group

23.79

< 0.001*

Group

44.15

< 0.001*

* P < 0.05 statistically significant

mutans. The bacteria were grown aerobically from frozen stock cultures in brain-heart infusion broth (BHI, HiMedia Laboratories, West Chester, Pa.) containing 8 µg/mL of bacitracin for 48 hours at 37 C before use.

Direct Contact Test

To overcome the limitations of the agar diffusion test, Weiss et al. introduced the direct contact test. The direct contact test is based on turbidimetric determination of bacterial growth in 96-well, flat-bottomed microtiter plates that quantitatively measures the effect of direct and close contact between the test microorganism and the tested materials. Six wells of the microtiter plates were evenly coated with the mixed cements by a small, flat-ended dental spatula while the plate was held vertically. The material was allowed to set. Subsequently, 10 µL bacterial suspension was placed directly on the tested material using a micropipette (Nunclon, Thermo Fisher Scientific, Waltham, Mass.) while the plate remained vertical. Evaporation of the suspension’s liquid caused direct contact between the bacteria and the tested materials. Brain-heart infusion broth along with 25 µg/mL bacitracin (220 µL) were added to each of the wells and

gently mixed for two minutes using a micropipette. The kinetics of the outgrowth in each well was recorded at 650 nm through a temperaturecontrolled spectrophotometer (iMark microplate reader, Bio-Rad, Hercules, Calif.) set at 37 C. A similar procedure was performed for each of the tested materials that were subsequently aged for 24 hours, 48 hours, 72 hours and one week, respectively. Aging was performed with phosphate-buffered saline (PBS) containing 25 µg/mL bacitracin.

Agar Diffusion Test

The agar diffusion test is a qualitative test for testing the antibacterial properties using Mueller Hinton agar plates. Each plate was inoculated with 200 µL of freshly grown streptococci mutan that were evenly spread with a Dragalsky glass stick in a zigzag fashion. After inoculation, five wells were punched (5 mm in diameter), three on one plate and two on the other. The specimens were mixed following the manufacturer’s instruction and were placed immediately into the punched hole. After incubating (incubator, Swastik Scientific Co., Mumbai, India) at 37 C for 24 hours, the plates were inspected for the presence of an

inhibition zone. Two perpendicular measurements of the inhibition halo were made with a digital Vernier caliper (Hawk) ( FIGURE 1) . If any zone of inhibition was predictable beneath the disk, this was considered a qualitative observation showing the antibacterial activity on the contact surface. The diffuse zone of inhibition was the zone of inhibition that was more than the 5 mm diameter of the disk. A total of three readings of the inhibition halo were recorded at 24 hours, 48 hours and 72 hours, respectively ( FIGURE 2 ) . The agar diffusion test was repeated seven times for each material.

Statistical Tools Employed

The statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 15.0 statistical analysis software. The values were represented in number (%) and mean ± SD. The antibacterial activity of the tested specimens was analyzed using mixed ANOVA and Bonferroni post hoc tests (P < 0.05).

Results Direct Contact Test

After the fresh inoculation, the bacterial growth rate for polycarboxylate was found to be maximum with a value of 0.21 mm JANUARY 2 0 2 1

luting cements C D A J O U R N A L , V O L 4 9 , Nº 1

TABLE 2

Comparison of Bacterial Growth Rate Estimated marginal means (between time intervals ignoring effect of the study groups) Time

(0.02). The values were gradually increased for all the cements until the end of the first week. The bacterial growth was significantly increased in the study groups over the different time intervals, F (1.02, 25.46) = 1661.38, p < 0.001 and the interaction between time and the study group also had a great influence on the bacterial growth, F (4.07, 25.46) = 23.79, p < 0.001 ( TA BLE 1) . Based on the estimated marginal means, the mean (95% CI) bacterial growth in fresh material was 0.13 mm (0.12–0.14), which gradually increased to 1.30 mm (1.24–1.36) at the end of the first week. A statistically significant increase in bacterial growth was observed between each time interval (p < 0.001). An increase in the incubation period significantly increased the bacterial growth irrespective of the study group under consideration. The bacterial growth was highest in the polycarboxylate cement with mean (95% CI) growth of 0.58 mm (0.54–0.62) and least in the resinmodified glass ionomer cement with mean (95% CI) growth of 0.26 mm (0.22–0.30) ( FIGURE 3 ) . On pairwise comparison, resin-modified glass ionomer cement had a significantly lower bacterial growth as compared to other study groups (p < 0.05), but no significant difference in the bacterial growth was observed between other study groups (p > 0.05) ( TA BLE 2 ) .

Agar Diffusion Test

For the agar diffusion tests, zinc phosphate cement showed the maximum zone of inhibition with a value of 23.66 mm (1.12) at 24 hours, and there was a steady incline in the readings until the end of 72 hours. Surprisingly, in the polycarboxylate cement group, no zone of inhibition was observed during the study period. 30 JANUARY

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Mean

Std. error

95% confidence interval Lower bound

Upper bound

Fresh material

0.13

0.003

0.12

0.14

24 hours

0.22

0.003

0.22

0.23

48 hours

0.25

0.004

0.25

0.26

1 week

1.30

0.03

1.24

1.36

Estimated marginal means (between the study groups ignoring the time factor) Group

Mean

Std. error

95% confidence interval Lower bound

Upper bound

DeTrey Zinc

0.51

0.02

0.48

0.55

Ketac Universal glass ionomer

0.49

0.02

0.46

0.53

Nexus RMGI

0.26

0.02

0.22

0.30

Durelon cement

0.58

0.02

0.54

0.62

RelyX ARC

0.54

0.02

0.50

0.58

The zone of inhibition was significantly increased in the study groups over the different time intervals, F (1.05, 31.54) = 13.38, p < 0.001, but no significant effect of interaction between time and the study group was observed on the zone of inhibition, F (4.21, 31.54) = 1.96, p = 0.12 ( TA BLE 3 ). Based on the estimated marginal means, the mean (95% CI) zone of inhibition was highest in the zinc phosphate cement with a mean value of 23.69 mm (23.15– 24.23) and least in polycarboxylate cement with mean (95% CI) growth of 0 mm ((–)0.54–0.54). On pairwise comparison, the difference in the zone of inhibition was found to be statistically significant (p < 0.05) between all the study groups except between the glass ionomer cement and the resin cement where the difference was nonsignificant (p = 0.27). The mean (95% CI) zone of inhibition showed a steady incline from 14.29 mm (14.03–14.55) at 24 hours to 14.47 mm (14.23–14.70) at the end of 72 hours ( FIGURE 4 ) . A statistically significant increase in zone of inhibition was observed between each time interval (p < 0.05). An increase in the incubation

period significantly increased the zone of inhibition irrespective of the study group under consideration ( TA BLE 4 ) .

Discussion

Tooth preparation for crown and bridge exposes the dentinal tubules. These tubules provide a pathway for the ingress of microorganisms that may infect the pulp and periradicular tissues. The major strain responsible for carious lesion is Streptococcus mutans. Boeckh et al. studied the antibacterial effects of dental biomaterials against Streptococcus mutans and the important role played by this microorganism in carious etiology.6 Microleakage is the clinically undetectable passage of bacteria, fluids, molecules or ions between a tooth and the restorative or filling materials, which can lead to secondary caries followed by abutment failure and gradually failure of the prosthesis itself.7 Banerjee et al. discussed the rationale behind carious dentine excavation and concluded that it is advisable to use cements that provide a long-term seal and antibacterial activity against cariogenic strains.8 In the present

C D A J O U R N A L , V O L 4 9 , Nº 1

TABLE 3

Comparison of Inhibition Zone Between Study Groups at Different Time Intervals Using Mixed ANOVA Group

24 hours

48 hours

Mean

DeTrey Zinc

23.66

1.12

23.68

0.99

23.73

0.97

Ketac Universal glass ionomer

15.67

0.76

15.87

0.71

15.96

0.73

Nexus RMGI

17.24

0.86

17.45

0.88

17.60

0.84

Durelon cement

0.00

RelyX ARC

14.88

0.42

14.99

0.40

15.04

0.40

p-value

Time

13.38

0.001*

Intercept

14829.65

< 0.001*

Time * group

1.96

0.12 (NS)

Group

1093.82

< 0.001*

Tests within-subjects effects

72 hours

Tests between-subjects effects

* P < 0.05 statistically significant

TABLE 4

difficult to obtain in routine lab setup. Turbidimetric analysis is performed using a microplate spectrophotometer Estimated marginal means between time intervals ignoring effect of the study groups on freshly mixed cements and Group Mean Std. error 95% confidence interval subsequently aged for 24 hours, 48 Lower bound Upper bound hours and one week, respectively. The DeTrey Zinc 23.69 0.26 23.15 24.23 cements with the least optical density, Ketac Universal 15.83 0.26 15.30 16.37 i.e., the least bacterial turbidity, are glass ionomer considered to be the cements with Nexus RMGI 17.43 0.26 16.89 17.97 the best antibacterial property. Durelon cement 0.00 0.26 –0.54 0.54 In the agar diffusion test, the zinc phosphate cement produced the RelyX ARC 14.97 0.26 14.43 15.51 maximum zone of inhibition with a value Estimated marginal means between the study group ignoring the time factor of 23.66 mm (1.12) at 24 hours that Time Mean Std. error 95% confidence interval gradually increased to 23.73 mm (0.97) Lower bound Upper bound at the end of 72 hours. Surprisingly, 24 hours 14.29 0.13 14.03 14.55 no zone of inhibition was observed for zinc polycarboxylate cement during the 48 hours 14.40 0.12 14.16 14.64 study period. In the direct contact test, 72 hours 14.47 0.12 14.23 14.70 the antibacterial effect of the cements lasted for a relatively short period, and upon aging the samples for one week, all study, we analyzed and compared the low cost, realistic nature and rapid except resin-modified glass ionomer lost antibacterial property of five luting characterization of antibacterial effects, their antibacterial property. The mean cements against the Streptococcus but it does not provide any information mutans. Cements used in this study about the viability of the microorganisms bacterial growth for zinc phosphate, glass were polycarboxylate cement, resinand the antibacterial activity of insoluble ionomer, resin-modified glass ionomer, polycarboxylate and resin cement was modified glass ionomer cement, zinc materials. On the other hand, the direct 0.06 mm (0.01), 0.14 mm (0.01), 0.09 phosphate cement, glass ionomer contact test is a quantitative test that mm (0.01), 0.21 mm (0.02) and 0.15 cement and resin cement, respectively. reduced the growth of bacteria that mm (0.01), respectively, in fresh material The agar diffusion test and direct are directly in contact with the tested contact test were performed to test the specimens irrespective of their diffusibility. that subsequently increased to 1.46 mm (0.11), 1.35 mm (0.31), 0.70 mm (0.10), antibacterial activity of the specimens. However, the direct contact test requires The agar diffusion test is a qualitative the use of a microplate spectrophotometer 1.48 mm (0.06) and 1.51 mm (0.03), respectively, at the end of one week. test with potential advantages of its to measure the optical density, which is Comparison of Inhibition Zone

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luting cements C D A J O U R N A L , V O L 4 9 , Nº 1

FIGURE 1. Perpendicular measurements of the inhibition halo were recorded with a digital Vernier caliper. Wells 1, 2 and 3 depicted a distinct zone of inhibitions and well 4 showed a diffuse zone of inhibition.

It was observed that zinc phosphate cement produced the largest inhibition halos and highest antibacterial property in the agar diffusion test. For the direct contact test, the anticariogenic property of the zinc phosphate cement was best when it was freshly mixed. This finding was in accordance with the results of a study conducted by Dastjerdie et al. who described zinc phosphate to have superior antibacterial property when it was freshly mixed.9 The antibacterial property of the zinc phosphate cement was due to its low pH as described by Haraishi et al. in their study.10 Thus, cements with low pH should be cautiously used. The antibacterial effects of the zinc phosphate cement could also be attributed to inhibition of acidic and alkali products produced by oral streptococci by zinc ions.11,12 In the present study, the anticarious activity of resin-modified glass ionomer and glass ionomer cement showed consistent results in both the agar diffusion test and the direct contact test, which can be attributed to the combined effect of fluoride release and low pH. This finding was consistent with the results of a study done by Vermeersch et al.13 The rate of release of fluoride in a specific material does not depend upon its concentration, rather it is influenced by sample size, the amount, composition, temperature, pH of the contact solution and sample load.14,15 Palenik studied the inhibition of microbial adherence 32 JANUARY

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FIGURE S 2 . Three readings were recorded at 24 hours (2A), 48 hours (2B) and 72 hours (2C), respectively. Wells 3, 4 and 5 contain zinc phosphate, glass ionomer and resin-modified glass ionomer cements, respectively.

FIGURE 3 . Line diagram depicting bacterial growth in direct contact test.

FIGURE 4 . Graph showing cements with inhibition zone measurements.

C D A J O U R N A L , V O L 4 9 , Nº 1

and growth by various glass ionomer cements and found that fluorides inhibited the growth of oral bacteria and their adhesion.16 Jeevarathan et al. studied the effect of fluoride varnish on Streptococcus mutans counts in plaque and concluded that fluoride level influences the bacterial composition and alters the plaque ecosystem.17 However, Yap et al. reported there was no antibacterial property despite the presence of fluoride in the agar around the set materials.18 Thus, an extensive research on the antibacterial property of fluoride-releasing cements is necessary. An interesting finding in this study was that although the zinc polycarboxylate cement did not show any zone of inhibition in the agar diffusion test, it proved some antibacterial property in the direct contact test, which might be due to the lack of diffusible component that can enter aqueous media and exert potential antibacterial effect. Filiz Keyf et al. studied the water sorption and solubility of different luting and restorative dental cements and concluded that all the tested materials demonstrated different degrees of sorption and solubility.19 Furthermore, despite the low initial pH of the zinc polycarboxylate cements after mixing, their pH after preparation is slightly higher in comparison to zinc phosphate cements that are nondestructive for Streptococcus mutans. However, polycarboxylate cement does release some fluoride, which may account for its antibacterial property as seen in the direct contact test.20 In the present study, the resin cement also had good anticariogenic activity that could be attributed to its low initial pH and fluoride release. The finding was inconsistent with the study conducted by Gerth et al., who studied the chemical and bonding reaction of RelyX Unicem and Bifix composites and found RelyX Unicem to have fluoride-releasing property and a low initial pH of 2.1–2.3.21 The low pH of the luting cements always resulted

in a strong irritation to the dental pulp after its application, which promotes research into luting materials that not only have antibacterial properties but should be non-irritating to the pulp as well.22–24 Because the direct contact test and agar diffusion test were the tests carried out outside the oral cavity, the results should be interpreted with caution. The present study was carried out for a short duration and the result obtained might not be conclusive; long-term investigations are needed to explore the anticariogenic efficiency of these luting cements. Furthermore, the observed antibacterial effects in this study were specific to Streptococcus mutans, so whether the antibacterial properties of cements are effective against other bacteria requires further investigation.25–28

Conclusion

Within the limitations of this in vitro study the following conclusions were drawn: ■ Zinc phosphate cement produced the largest inhibition zones and the best antibacterial property against Streptococcus mutans, as observed in the agar diffusion test. This can be attributed to its low initial pH on mixing. ■ Resin-modified glass ionomer cement had the best antibacterial efficacy against Streptococcus mutans when the direct contact test was employed. ■ Zinc polycarboxylate cement did not produce any inhibition halo in the agar diffusion test but displayed some antibacterial property in the direct contact test. ■ The fluoride release in luting cements seems to play an important role in the inhibition of Streptococcus mutans. However, further clinical trials are required for explaining antibacterial effects due to fluoride release. n

AC KN OW L E DG M E N T S The authors acknowledge the technical support provided by all the faculty members and postgraduate students of the department. The authors also acknowledge the management of the institution for their valuable support and the department of microbiology for access to conduct the study. RE F E RE N C E S 1. Fernandes JMFA, Menezes VA, Albuquerque AJR, et al. Improving antibacterial activity of dental restorative materials. In: Virdi M, ed. Emerging Trends in Oral Health Sciences and Dentistry. London: Intech Publications; 2015:65–82. 2. Klai S, Altenburger M, Spitzmüller B, et al. Antimicrobial effects of dental luting glass ionomer cements on Streptococcus mutans. Sci World J 2014:1–7. doi: doi.org/10.1155/2014/807086. 3. Daugela P, Oziunas R, Zekonis G. Antibacterial potential of contemporary dental luting cements. Stomatologija 2008;10(1):16–21. 4. Slutzky H, Weiss EI, Lewinstein I, et al. Surface antibacterial properties of resin and resin-modified cements. Quintessence Int 2007 Jan;38(1):55–61. 5. Matalon S, Slutsky H, Weiss EI. Antibacterial properties of four orthodontic cements. Am J Orthod Dentofacial Orthop 2005 Jan;127(1):56–63. 6. Boeckh C, Schumacher E, Podbielski A, et al. Antibacterial activity of restorative dental biomaterials: An in vitro study. Caries Res 2000;36(2):101–7. doi: 10.1159/000057867. 7. Luczaj-Cepowicz E, Marczuk-Kolada G, Zalewska A, Pawińska M, Leszczyńska K. Antibacterial activity of selected glass ionomer cements. Postepy Hig Med Dosw (Online) 2014 Jan 22;68:23–8. doi: 10.5604/17322693.1086069. 8. Banerjee A, Watson TF, Kidd EA. Dentine caries: Take it or leave it. Dent Update Jul–Aug 2000;27(6):272–6. doi: 10.12968/denu.2000.27.6.272. 9. Vahid Dastjerdie E, Oskoui M, Sayanjali E, Tabatabaei FS. In vitro comparison of the antimicrobial properties of glass ionomer cements with zinc phosphate cements. Iran J Pharm Res 2012 Winter;11(1):77–82. 10. Haraishi N, Kitasako Y, Nikaido T, et al. Acidity of conventional luting cements and their diffusion through bovine dentine. Int Endod J 2003 Sep;36(9):622–628. doi: 10.1046/j.1365-2591.2003.00700.x. 11. Boyd D, Li H, Tanner D, et al. The antibacterial effects of zinc ion migration from zinc-based glass polyalkeonate cements. J Mater Sci Mater Med 2006 Jun;17(6):489–94. doi: 10.1007/s10856-006-8930-6. 12. Phan T, Buckner T, Sheng J, et al. Physiologic actions of zinc related to inhibition of acid and alkali production by oral streptococci in suspensions and biofilms. Oral Microbial Immunol 2004 Feb;19(1):31–8. doi: 10.1046/j.09020055.2003.00109.x. 13. Vermeersch G, Leloup G, Delmee M, et al. Antibacterial activity of glass-ionomer cements, compomers and resin composites: Relationship between acidity and material setting phase. J Oral Rehabil 2005;32(5):368–74. doi: 10.1111/j.1365-2842.2004.01300.x. 14. Markzuk-Kolada G, et al. Fluoride release and antibacterial activity of selected dental materials. Postepy Hig Med Dosw (Online) 2006 Aug 9;60:416–20. 15. Hattab FN, el-Mowafy OM, et al. An in vivo study on release of fluoride from glass ionomer cement. Quintessence JANUARY 2 0 2 1

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Int 1991 Mar;22(3):221–4. 16. Palneik CJ, Behnen MJ. Inhibition of microbial adherence and growth by various glass ionomer: An in vitro study. Dent Mater 1992 Jan;8(1):16–20. doi: 10.1016/0109-5641(92)90047-g. 17. Jeevaranthan J, Deepti A. Effect of fluoride varnish on Streptococcus mutans counts in plaque of cariesfree children using Dentocult SM strip mutans test: A randomised controlled triple blind study. J Indian Soc Pedod Prevent Dent 2007 Oct–Dec;25(4):157–63. doi: 10.4103/0970-4388.37010. 18. Yap AU, Khor E, Fee SH. Fluoride release and antibacterial properties of new-generation tooth-colored restoratives. Oper Dent 1999 Sep–Oct;24(5):297–305. 19. Keyf F, Tuna SH, Sen M, et al. Water sorption and solubility of different luting and restorative cements. Turk J Med Sci 2006;36(1):47–55. 20. Hristov I, Dimitrova S, Markova K, et al. A comparative study of solubility, pH and temperature changes taking place in several types of cements used in modern dentistry. J of IMAB: annual proceeding (scientific

papers), book 2:2006. Caries Res 1991;23:14. 21.Gerth HU, Dammaschke T, Zuchner H, et al. Chemical and bonding reaction of RelyX Unicem and Bifix composites — A comparative study. Dent Mater 2006 Oct;22(10): 934–941. doi: 10.1016/j.dental.2005.10.004. Epub 2005 Dec 20. 22. Costa CA, Nascimento AB, Teixeira HM. Response of human pulp following acid conditioning and application of a bonding agent in deep cavities. Dent Mater 2002 Nov;18(7):543–51. doi: 10.1016/s01095641(01)00089-6. 23. Smith DC, Ruse ND. Acidity of glass-ionomer cements during setting and its relation to pulp sensitivity. J Am Dent Assoc 1986 May;112(5):654–7. doi: 10.14219/jada. archive.1986.0069. 24. Sonoda H, Inokoshi S, Otsuki M, et al. Pulp tissue reaction to four dental cements. Oper Dent 2001; 26:201–7. 25. Weiss EI, Shalhav M, Fuss Z. Assessment of antibacterial activity of endodontic sealers by direct contact test. Endod Dent Traumatol 1996 Aug;12(4):179–184. doi:

10.1111/j.1600-9657.1996.tb00511.x. 26. Matalon S, Slutzky H, Mazor Y, et al. Surface antibacterial property of fissure sealants. Pediatr Dent 2003 Jan–Feb;25(1):43–48. 27. Matalon S, Slutzky H, Weiss EI. Surface antibacterial properties of packable resin composites: Part I. Quintessence Int 2004 Mar;35(3):189–193. 28. Slutzky H, Matalon S, Weiss EI. Antibacterial surface properties of polymerized single-bottle bonding agents: Part II. Quintessence Int 2004 Apr;35(4):275–279. T HE CORRE S P ON DIN G AU T HOR , Sushil Kumar Kar, MDS, can be reached at drsushil_kar@yahoo.co.in.

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retrosealants C D A J O U R N A L , V O L 4 9 , Nº 1

A Prospective Comparative Randomized Clinical Trial of Three Endodontic Retrograde Filling Materials Stephen Cohen, DDS, MA; Alicia Caro, DDS, MS; Gustavo Mahn, DDS; Veerasathpurush Allareddy, BDS, MBA, MHA, MMSc, PhD; and Veeratrishul Allareddy, BDS, MS

abstract Background: A clinical trial was designed to evaluate bone regeneration in patients who received one of three retrosealants after apicoectomies in teeth with periapical lesions of endodontic origin to determine which is the best. Methods: Three retrosealants (EndoSequence, ProRoot MTA, Biodentine) were used following microsurgical apicoectomies in a prospective comparative randomized clinical trial in 74 patients who were selected from the endodontics department at the Universidad de Valparaiso, Chile. Clinical and CBCT evaluations were performed up to six months following the procedure. Results: There were no significant statistical differences in the bone regeneration among the three groups. The distribution of outcome was examined by the Kolmogorov-Smirnov test for normality. The Kruskal-Wallis test was used to examine differences among the three groups and pairwise comparisons were conducted by using Mann-Whitney tests. Conclusions: There were no significant differences in the healing of the periapical bone lesion between the three materials used in this investigation. Other studies with a larger number of cases and a longer follow-up time are recommended. Practical implications: Based on the results of this study, the clinician can choose any of the three retrofilling cements to seal the canals after an apicectomy. Key words: Cone beam computed tomography; microsurgery; periapical lesion; remineralization; retrograde filling material; ProRoot MTA; EndoSequence; Biodentine

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retrosealants C D A J O U R N A L , V O L 4 9 , Nº 1

AUTHORS Stephen Cohen, DDS, MA, is an adjunct professor of endodontics at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco. Conflict of Interest Disclosure: Dr. Cohen is a consultant for the Septodont Corporation. Alicia Caro, DDS, MS, is the chair and program director of the department of endodontics at the University of Valparaíso in Valparaíso, Chile. Conflict of Interest Disclosure: None reported. Gustavo Mahn, DDS, is an operative dentistry /biomaterials master’s resident in the division of comprehensive oral health at the University of North Carolina at Chapel Hill. Conflict of Interest Disclosure: None reported.

Veerasathpurush Allareddy, BDS, MBA, MHA, MMSc, PhD, is a professor and the head of the department of orthodontics and the Brodie Craniofacial Endowed Chair at the University of Illinois at Chicago College of Dentistry. Conflict of Interest Disclosure: None reported. Veeratrishul Allareddy, BDS, MS, is a clinical professor of oral and maxillofacial radiology and the director of oral and maxillofacial radiology, oral pathology, radiology and medicine at the University of Iowa College of Dentistry and Clinics. He is a diplomate of the American Board of Oral and Maxillofacial Radiology. Conflict of Interest Disclosure: None reported.

ineral trioxide aggregate (MTA) was first introduced by Mahmoud Torabinejad in 19931 for retrosealing roots following periapical curettage as a biocompatible replacement for the less effective materials that had been used throughout most of the 20th century, such as amalgam, IRM, Super EBA, etc.1 Within the last 10 years, biocompatible calcium silicate materials (Biodentine and EndoSequence) have been introduced as replacements for MTA. The purpose of this prospective comparative randomized clinical trial was to determine which material was most effective in patients with periapical lesions of endodontic origin who underwent apical microsurgery and received one of three retrograde filling materials: EndoSequence (Brasseler, Savannah, Ga.), ProRoot MTA (Dentsply Sirona, Tulsa, Okla.) or Biodentine (Septodont, Saint-Maur-desFossés, France).

Materials and Methods Brief Overview of the Study

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This prospective comparative randomized clinical trial was conducted to evaluate the extent of healing following the use of three retrograde filling materials in patients who underwent apical microsurgery for the treatment of periapical lesions of endodontic origin. The participants received one of three retrograde filling materials: EndoSequence, ProRoot MTA or Biodentine. Patients returned for clinical and cone beam computed tomography (CBCT) assessments for up to six months after the procedure. The patients were selected from the endodontics department at the University of Valparaíso, Chile. This endodontics department receives referrals from other

departments within the university, peripheral hospitals and health centers, private practices and the Chilean Navy Dental Center. The investigation was coordinated by Finis Terrae University in Santiago, Chile, which was responsible for approving the protocols and study design. The University of Valparaíso and the Chilean Navy in Valparaíso, Chile, were responsible for conducting the screenings and surgical procedures and the clinical and radiographic controls. The study was approved by the Institutional Review Board of Finis Terrae University, Resolution nr. 15/2017, Santiago, Chile. A total of 74 patients underwent surgery. Fifteen patients were eliminated after surgery due to vertical root fracture or fissures encountered during the surgical procedure or because of unavailability to perform the follow-up assessments. Of the resulting 59 eligible patients, 51 patients completed two months of follow-up, 45 patients completed four months of follow-up and 35 patients completed six months of follow-up. Details about the sequence of patient selection and dropout are specified in FIGURE 1 , following Consolidated Standards of Reporting Trials (CONSORT) guidelines.2 The 59 patients were allocated for intervention based on block randomization in three groups (E = EndoSequence, M = ProRoot MTA, B = Biodentine) using an unpredictable random sequence by means of a softwarebased algorithm (www.random.org). Patient inclusion criteria3 were adult patients, American Society of Anesthesiologists (ASA) classification I and II; any tooth with a single chronic periapical lesion requiring apical microsurgery; and informed consent signed prior to surgery. Patient exclusion criteria were a background of drug or alcohol abuse, adjacent periapical lesion and periodontal disease.

C D A J O U R N A L , V O L 4 9 , Nº 1

Enrollment Assessed for eligibility (n = 84)

Excluded (n =10) • Unavailable to perform surgery

Randomize and underwent surgery (n = 74)

Allocation

Group 1 EndoSequence (n = 25)

Group 2 ProRoot MTA (n = 25)

Group 3 Biodentine (n = 24)

• Received allocated intervention (n = 20)

• Received allocated intervention (n = 24)

• Received allocated intervention (n = 15)

• Did not receive allocated intervention (n = 5)

• Did not receive allocated intervention (n = 1)

• Did not receive allocated intervention (n = 9)

• Due to vertical fracture, fissures encountered during surgery or unavailability for follow-up appointments

Follow-Up 2 Months Lost to follow-up (n = 3) • Unavailable for follow-up appointments

Lost to follow-up (n = 8) • Unavailable for follow-up appointments

Lost to follow-up (n = 3) • Unavailable for follow-up appointments

Follow-Up 4 Months Lost to follow-up (n = 3) • Unavailable for follow-up appointments

Lost to follow-up (n = 1) • Unavailable for follow-up appointments

Lost to follow-up (n = 4) • Unavailable for follow-up appointments

Follow-Up 6 Months Lost to follow-up (n = 1) • Unavailable for follow-up appointments

Lost to follow-up (n = 1) • Unavailable for follow-up appointments

Final Assessment 6 Months

Analyzed (n =13)

FIGURE 1. Patient intervention flowchart.

Analyzed (n =14)

Analyzed (n =8)

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retrosealants C D A J O U R N A L , V O L 4 9 , Nº 1

TABLE 1

Surgical Protocol Applied to All Interventions 1. Premedication with amoxicillin 2 g and meloxicam 15 mg (or azithromycin 500 mg if patient is allergic to amoxicillin) one hour before the apicoectomy.8,9 2. Local anesthesia with lidocaine HCl 2% 1:100,000 epinephrine.

Laboratory tests prior to surgery included a complete blood count, partial thromboplastin time, prothrombin time, fasting plasma glucose level and bleeding time.

Patient Screening

At the first screening appointment, all patients received a thorough clinical examination and further explanation of the surgical procedure from the endodontist. If eligible, the patient was asked to be part of this prospective comparative study; if the patient agreed, written instructions with the rules and conditions were given. Subsequently, the patient signed the informed consent and was incorporated into the study. Participants then completed a preoperative CBCT exam in the radiology department at the Chilean Navy Dental Center.

Surgical Procedure

The surgical procedure was performed by a single trained endodontist assisted by endodontic residents and assistants. Each procedure was performed in a stateof-the-art surgical room under a clinical microscope using ultrasonic handpieces and specialized microsurgical instruments. Three biomaterials were used for this study: EndoSequence, ProRoot MTA and Biodentine.4–7 The material for each procedure was randomly selected by an assistant following the generated random sequence and mixed (if necessary) according to the manufacturer’s instructions and out of the sight of the surgeon; the material was then handed to the surgeon for placement in the Class 1 apical preparation. Although randomly selected, the identities of some retrograde filling materials were evident upon presentation and packaging. Therefore, at this point, the participants were blinded from 38 JANUARY

2021

3. Full-thickness flap in alveolar mucosa below the level of the tooth apex using a No. 15 scalpel blade.10,11 4. Minimal osteotomy (no greater than 5 mm) using a high-speed handpiece and new carbide burs at 45 degrees under continuous normal saline solution irrigation. 5. Initial curettage using micro curettes. 6. 3 mm apicoectomy with 0- to 10-degree angulation using carbide-tapered burs (Zekrya, Dentsply Sirona, Charlotte, N.C.). 7. Fragment and remnant examination using methylene blue staining for root outline. 8. Additional curettage if necessary and hemostatic control. 9. 3 mm retrograde preparation with ultrasonic points (ProUltra Surgical, Dentsply Sirona).12–17 10. Drying of the surgical site using sterile paper points. 11. Retrograde filling using the randomly selected retrograde filling material. 12. Flap reposition and suture stitches using 4.0 silk. 13. Local compression and immediate ice application. 14. Scheduled follow-up appointment for suture removal in seven days.17,18

material selection, but the surgeon was not blinded from the material, which was visibly different from others. The surgical protocol detail can be found in TA BLE 1 .

Data Acquisition and Follow-Up

After the microsurgery was completed, patient information was entered into a Microsoft Excel spreadsheet and sent to CBCT postoperative control at the radiology department of the Chilean Navy Dental Center. The date of each procedure and the patient data were sent to the study coordinator without revealing the material used; the identity of the material was kept blind until the results and statistical analysis were completed. To assure randomization of each patient without revealing names or personal data, a six-digit number was assigned to each patient using an online number generator (www.random.org). Therefore, both the radiologist and the biostatistician were blinded from the patient identity and the material used. The patients were called back after two,

four and six months for clinical and CBCT assessments. The DICOM archives were extracted every two weeks until final completion, and the data for the completed cases were sent via Dropbox to an oral radiologist at the University of Iowa in Iowa City, Iowa, for radiographic analysis and statistical comparison. Five CBCT scans were acquired on a 3D Accuitomo 170 machine (Morita, Tokyo). The scans were acquired at a field of view of 4.2 cm by 4.2 cm at 0.13 mm/slice resolution with the voltage at 80 kVp and a tube current of 5 mA. CBCT scans were acquired preoperatively, postoperatively and at two, four and six months. The CBCT scans were evaluated using Invivo6 software (Anatomage Inc., Santa Clara, Calif.); multiplanar reconstructions (MPR images) with crosssectional images of the site of interest were evaluated. Scans were repositioned to ensure similar image orientation prior to measurements and evaluations of the areas of interest to prevent errors

C D A J O U R N A L , V O L 4 9 , Nº 1

FIGURE 2 . CBCT scans; example of one procedure on tooth No. 6. Preoperative CBCT sagittal view showing the radiolucent area (2A). Postoperative CBCT sagittal view

showing the radiolucent area with a defect in the bone area where the surgery was performed (2B). Two-month postoperative CBCT sagittal view showing early evidence of remineralization (2C). Four-month postoperative CBCT sagittal view showing significantly more remineralization (2D). Six-month postoperative CBCT sagittal view showing continuing remineralization; the outline of the original radiolucent area has been preserved showing the extent of the healing (2E).

due to variability in patient orientation during the process of image acquisition. All images were evaluated by a boardcertified oral and maxillofacial radiologist with more than 15 years of experience. The size of the periapical radiolucent area associated with the treated tooth was measured in each of the five scans. In light of the relatively small sample size of the patient population and to prevent bias during the process of evaluation of measurements on the scans, the measurements of the radiolucent area were performed with at least a one-week interval between any two scans in the same patient. All evaluations were done twice to assess intraobserver reliability. The radiolucent area was measured to obtain the largest dimension of the lesion. Each dataset was scrolled through multiple times to accurately judge the largest possible dimension in any of the three directions (axial, coronal and sagittal views) and correlated with measurements on the cross-sectional views. The radiologist was fully blinded as to which material was used for treatment in all of the patients. Measurements were made on each scan; the extent of healing was evaluated subjectively on each of the postoperative scans and all data were tabulated. Subjective evaluation of healing was classified as follows (FIGURES 2A–2E for healing progress in an example case): ■ Radiolucent with no evidence of healing (e.g., see initial preoperative or postoperative scans in FIGURES 2A and 2B ).

Some degree of healing within the radiolucent area (e.g., see twomonth interval scan in FIGURE 2C ). ■ Moderate degree of healing within the radiolucent area. ■ Good healing with minimum evident radiolucent area (e.g., four-month and six-month scans for the same case shown in FIGURES 2D and 2E ). In the initial postoperative cases, performed immediately following the procedure, all readings were classified as radiolucent with no evidence of healing, as expected (i.e., they showed low density). Although subjective, the original outline of the lesion could be assessed in each of the postoperative scans even though the scans demonstrated evidence of progressive osseous healing at different time intervals. ■

Statistical Analysis

After all the measurements were performed for the completed cases, the data were tabulated for each of the patients and provided to the statistician for analysis. Statistical analysis included testing of the reliability of measurements as assessed by intraclass correlation coefficients. The distribution of outcome data was examined using Kolmogorov-Smirnov test for normality. If the outcomes data were not normally distributed with the small sample size, nonparametric tests were used to examine differences in outcomes among the three treatment

groups. The Kruskal-Wallis test was used to examine differences among the groups and pairwise comparisons were conducted by using Mann-Whitney tests.

Results

The intraobserver reliability was excellent. The assessment revealed high reliability for all the measurements (intraclass correlation coefficients are > 0.98 for all measurements on the preoperative, postoperative, twomonth, four-month and six-month measurements). There were no significant statistical differences in the healing progress among patient groups treated with the different retrograde filling materials. Regardless of the material used, the size of the radiolucent area increased on the immediate postoperative scan (which was expected due to the necessary curettage) and then decreased in size at the two-, four- and six-month intervals. Healing progression ranged from none to minimal (five patients) to complete remineralization (seven patients). The radiolucent areas were generally largest when associated with the canines. In five patients, there was a relatively large radiolucent area greater than 5 mm; this persisted even six months postoperatively, suggesting a longer healing (or possibly no healing) process or possibly cicatrization; however, this was not dependent on the type of material used for treatment. On the subjective evaluation, most of the cases (19 patients of the 35 who completed the full six months of follow-up) showed good progress toward complete remineralization JANUARY 2 0 2 1

retrosealants C D A J O U R N A L , V O L 4 9 , Nº 1

TABLE 2

CBCT Measurements Prior to Treatment and at Different Time Points Posttreatment Treatment group 1 Objective Measurement

Sample size

Mean

Median

Percentiles 25

P-values (Kruskal-Wallis test) 50

Preoperative

3.5

2.3

4.1

0.0

2.3

7.6

0.83

Postoperative

6.0

5.0

2.6

4.5

5.0

8.1

0.73

Preop to postop change

2.5

2.6

1.7

0.7

2.6

4.1

0.24

2 months

4.9

4.7

2.3

3.0

4.7

6.5

0.74

Preop to 2 months change

1.4

1.5

2.3

–0.6

1.5

3.5

0.79

4 Months

3.2

3.0

2.2

1.6

3.0

3.6

0.96

Preop to 4 months change

–0.3

0.3

3.3

–2.7

0.3

2.8

0.81

6 months

2.5

2.2

0.8

2.2

3.0

0.78

Preop to 6 months change

–1.0

–0.4

3.3

–3.0

–0.4

2.1

0.83

Sample size

Mean

Median

Percentiles

Treatment group 2 Objective Measurement

P-values (Kruskal-Wallis test) 50

Preoperative

3.3

2.9

2.1

2.0

2.9

4.8

0.83

Postoperative

5.3

4.9

1.6

3.9

4.9

6.7

0.73

Preop to postop change

2.0

1.7

1.1

1.3

1.7

3.2

0.24

2 months

4.2

3.5

1.5

3.1

3.5

5.4

0.74

Preop to 2 months change

0.9

1.7

0.3

0.9

1.9

0.79

4 Months

2.9

2.6

1.5

2.0

2.6

3.8

0.96

Preop to 4 months change

–0.4

–0.5

1.8

–1.4

–0.5

0.7

0.81

6 months

1.9

1.7

1.5

1.2

1.7

2.8

0.78

Preop to 6 months change

–1.4

–1.5

1.8

–2.4

–1.5

0.0

0.83

Objective Measurement

Sample size

Mean

Median

Percentiles

Preoperative

3.3

2.9

3.3

Treatment group 3 P-values (Kruskal-Wallis test)

0.2

2.9

5.8

0.83

Postoperative

6.2

5.4

2.9

4.0

5.4

9.4

0.73

Preop to postop change

2.9

3.3

0.9

2.2

3.3

3.8

0.24

2 months

4.6

3.9

2.9

2.8

3.9

6.7

0.74

Preop to 2 months change

1.4

1.1

0.8

1.1

2.0

0.79

4 Months

3.3

2.8

3.2

1.0

2.8

4.6

0.96

Preop to 4 months change

0.1

0.3

1.5

–1.2

0.3

0.8

0.81

6 months

2.2

1.5

2.6

0.0

1.5

3.9

0.78

Preop to 6 months change

–1.1

–0.6

1.4

–2.4

–0.6

–0.1

0.83

40 JANUARY

2021

C D A J O U R N A L , V O L 4 9 , Nº 1

TABLE 3

Comparative P -Values Between Treatment Groups P-values (Mann-Whitney)

Comparison between group 1 and group 2

Comparison between group 1 and group 3

Comparison between group 2 and group 3

Preoperative

0.511

0.798

0.918

Postoperative

0.481

0.942

0.539

Preop to postop change

0.319

0.828

0.064

2 months

0.423

0.664

1.000

Preop to 2 months change

0.610

0.885

0.495

4 months

0.752

0.913

0.973

Preop to 4 months change

0.627

0.971

0.539

6 months

0.451

0.715

0.945

Preop to 6 months change

0.512

0.800

0.891

( FIGURE 2E ) ,

whereas only two subjects showed no evidence of remineralization, suggesting possible fibrous healing (cicatrization). The subjective evaluation was not dependent on the material used and was not statistically significant. The objective measurement data for all time points as well as the Kruskal-Wallis P-values are shown in TA BLE 2 . Pairwise comparisons are detailed in TA BLE 3 .

Discussion

This clinical investigation aimed to compare three different calcium silicate materials for retrograde filling of apexes in a randomized double-blind manner based on the rate of remineralization at two, four and six months following periapical microsurgery using CBCT. Originally, we intended to have only nonsmokers included in this investigation; over time, we found this was unrealistic, so we allowed a few smokers to be included in our study. Radiographic findings and outcomes were evaluated only for completed cases. For consistency, we had the same surgeon perform all surgeries. The endodontic surgeon performing the surgery did not know which calcium silicate was selected by her assistants, but some of the materials used have distinctive packaging or presentation design that could have been identified by the surgeon before applying them. Nevertheless,

random selection of the material prior to placing it was assured. The delivery and application of the calcium silicate materials were approximately the same for all three materials. The main observable differences between the three materials were the setting time and ease of handling. For example, ProRoot MTA was noticeably slower in setting than the other two calcium silicate materials. This made the procedure more cumbersome, because after surgery, bleeding and fluid contamination could prevent the seal between the calcium silicate material and the root surface. Apparently, this event did not happen in this study because the radiographic findings were similar, but additional care must be taken if this material is used. Handling of the material was also noticed to be different. Biodentine is presented in a capsule with exact powder/liquid ratio and dispensed using a capsule gun, making the mix and the application of the material easier and more predictable. EndoSequence presented no major complications, but the material comes in a syringe that must be manually applied, eventually favoring the incorporation of air and bubbles into the mix. This study aimed to compare three materials with both the radiologist and the surgeon blinded from material selection, which had never been done before. Other studies have tested MTA

as retrograde filling material in vivo with good clinical results,19,20 but either they have not compared the outcomes of different materials at the same time prospectively or they were not double blinded. The results of this study might be attributed to the inherent characteristics of the biomaterials, which can seal the dentin interface to an apparently acceptable extent. These characteristics make them similar in performance considering the setting mechanism and the wet characteristics of the root canal.21,22 Furthermore, the compatibility of these materials with the endodontic and periodontal tissues seems to aid in the healing after the microsurgery, making the procedure successful.23

Conclusion

At the end of six months, there were no significant clinical differences between the three retrograde sealing materials used for this randomized doubleblind investigation. If circumstances permit, we recommend using this study design with a 12-month follow-up. n AC KN OW L E DG M E N T The authors thank the University Finis Terrae for coordinating this demanding clinical trial, the Chilean Navy for the use of the radiology facilities and providing patients and the University of Valparaíso for the clinical assessments, providing patients and the use of surgical facilities. RE F E RE N C E S 1. Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod 1993 Dec;19(12):591–5. doi: 10.1016/ S0099-2399(06)80271-2. 2. Moher D, Schulz KF, Altman DG. The CONSORT statement: Revised recommendations for improving the quality of reports of parallel-group randomized trials. Ann Intern Med 2001 Apr 17;134(8):657–62. doi: 10.7326/0003-4819-134-8200104170-00011. 3. Abramovitz I, Better H, Shacham A, Shlomi B, Metzger Z. Case selection for apical surgery: A retrospective evaluation of associated factors and rational. J Endod 2002 Jul;28(7): 527–30. doi: 10.1097/00004770-200207000-00010. 4. Velvart P, Peters CI, Peters OA. Soft tissue management: Suturing and wound closure. Endod Topics 2005;11(1): 179–95. doi.org/10.1111/j.1601-1546.2005.00165.x. 5. Caron G, Azérad J, Faure MO, Machtou P, Boucher Y. Use of a new retrograde filling material (Biodentine) for endodontic JANUARY 2 0 2 1

retrosealants C D A J O U R N A L , V O L 4 9 , Nº 1

surgery: Two case reports. Int J Oral Sci 2014 Dec;6(4): 250–3. doi: 10.1038/ijos.2014.25. Epub 2014 May 9. 6. De-Deus G, Canabarro A, Alves G, Linhares A, Senne MI, Granjeiro JM. Optimal cytocompatibility of a bioceramic nanoparticulate cement in primary human mesenchymal cells. J Endod 2009 Oct;35(10):1387–90. doi: 10.1016/j. joen.2009.06.022. Epub 2009 Aug 15. 7. Charland T, Hartwell GR, Hirschberg C, Patel R. An evaluation of setting time of mineral trioxide aggregate and EndoSequence root repair material in the presence of human blood and minimal essential media. J Endod 2013 Aug;39(8):1071–2. doi: 10.1016/j.joen.2013.04.041. Epub 2013 Jun 19. 8. Gutierrez JL, Bagan JV, Bascones A, Llamas R, Llena J, Morales A, et al. Consensus document on the use of antibiotic prophylaxis in surgery and dental procedures. Med Oral Patol Oral Cir Bucal 2006 1;11:E188–E205. 9. Reis LC, Roças IN, Siqueira JF Jr., De Uzeda M, Lacerda VS, Domingues RM, et al. Bacteremia after endodontic procedures in patients with heart disease: Culture and molecular analysis.

J Endod 2016 Aug;42(8):1181–5. doi: 10.1016/j. joen.2016.05.013. Epub 2016 Jun 29. 10. Gutmann JL, Harrison JW. Flap design and incisions. In: Surgical Endodontics. Boston: Blackwell Scientific; 1991: 162–75. 11. Von Arx T, Salvi G. Incision techniques and flap designs for apical surgery in the anterior maxilla. Eur J Esthet Dent Summer 2008;3(2):110–26. 12. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: A review. J Endod 2006 Jul;32(7):601–23. doi: 10.1016/j.joen.2005.12.010. Epub 2006 May 6. 13. Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome of endodontic surgery: A meta-analysis of the literature — part 1: Comparison of traditional root-end surgery and endodontic microsurgery. J Endod 2010 Nov;36(11):1757–65. doi: 10.1016/j.joen.2010.08.007. Epub 2010 Sep 17. 14. Peters CI, Peters OA, Barbakow F. An in vitro study comparing root-end cavities prepared by diamondcoated and stainless steel ultrasonic retrotips. Int Endod

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42 JANUARY

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J 2001 Mar;34(2):142–8. doi: 10.1046/j.13652591.2001.00367.x. 15. Von Arx T. Apical surgery: A review of current techniques and outcome. Saudi Dent J 2011 Jan;23(1):9–15. doi: 10.1016/j.sdentj.2010.10.004. Epub 2010 Nov 11. 16. Von Arx T, Walker WA 3rd. Microsurgical instruments for root-end cavity preparation following apicoectomy: A literature review. Endod Dent Traumatol 2000 Apr;16(2):47–62. doi: 10.1034/j.1600-9657.2000.016002047.x. 17. Lui JN, Khin MM, Krishnaswamy G, Chen NN. Prognostic factors relating to the outcome of endodontic microsurgery. J Endod 2014;40(8):1071–6. doi: 10.1016/j. joen.2014.04.005. Epub 2014 May 27. 18. Trope M, Bunes A, Debelian G. Root filling materials and techniques: Bioceramics a new hope? Endod Topics 2015;32(1):86–96. doi.org/10.1111/etp.12074. 19. Çalışkan M, Tekin U, Kaval M, Solmaz M. The outcome of apical microsurgery using MTA as the root-end filling material: 2-to 6-year follow-up study. Int Endod J 2016 Mar;49(3):245–54. doi: 10.1111/iej.12451. Epub 2015 Apr 10. 20. Saunders WP. A prospective clinical study of periradicular surgery using mineral trioxide aggregate as a root-end filling. J Endod 2008 Jun;34(6):660–5. doi: 10.1016/j. joen.2008.03.002. Epub 2008 Apr 25. 21. Biocanin V, Antonijevic D, Postic S, Ilic D, Vukovic Z, Milic M, Fan Y, Li Z, Brkovic B, Duric M. Marginal gaps between 2 calcium silicate and glass ionomer cements and apical root dentin. J Endod 2018 May;44(5):816–821. doi: 10.1016/j. joen.2017.09.022. Epub 2018 Jan 12. 22. Han I, Okiji T. Uptake of calcium and silicon released from calcium silicate-based endodontic materials into root canal dentin. Int Endod J 2011 Dec;44(12):1081–7. doi: 10.1111/j.1365-2591.2011.01924.x. Epub 2011 Jul 21. 23. Escobar-García DM, Aguirre-López E, Méndez-González V, Pozos-Guillén A. Cytotoxicity and initial biocompatibility of endodontic biomaterials (MTA and Biodentine) used as rootend filling materials. Biomed Res Int 2016; 2016:7926961. doi: 10.1155/2016/7926961. Epub 2016 Aug 9. T HE CORRE S P ON DIN G AU T HOR , Stephen Cohen, DDS, MA, can be reached at scohen@cohenendodontics.com.

Business loan options Patient screening Practice interruptions Local ordinances & regulations Leaves of absence Infection control Dental billing &time telehealth Paid & unpaid off Patient communication Employeevs. communication Mandates recommendations Termination & unemployment Rescheduling appointments License Sick leaverenewal policies& C.E. HIPAA considerations Informed consent forms

NEW & COMPLEX QUESTIONS? Today, the countless sources and rapid pace of news make it more challenging than ever to navigate the business side of dentistry. That’s why CDA’s Practice Support analysts have developed new tools to guide members through the COVID-19 crisis and toward practice recovery. Access 24/7 online resources and tap into specialized expertise on practice management, compliance, employment and dental benefits.

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IT’S A VERB.

RM Matters

C D A J O U R N A L , V O L 4 9 , Nº 1

Unmasked Patients: Conflicts, Accommodations and Common Sense TDIC Risk Management Staff

ven before COVID-19 inexorably changed social and clinical protocols, dental offices dealt with patients who claimed to “know better” than their providers when it came to health risks. From unvaccinated patients to incomplete health histories, failure to cooperate results in ethical and legal challenges for dentists. In today’s practice environment, these challenges also include navigating interactions with patients who simply refuse to wear face masks. Dentists and their team members are put in uncomfortable positions when this occurs. For a patient who truly has a medical or psychological concern, how can the practice make safe accommodations? For patients who refuse to wear a mask on a philosophical basis, how can the practice communicate effectively, reduce conflict and preserve staff safety? Regardless of patients’ needs or just “knowing better,” start with plain-speak communication about the practice’s expectations. Notify patients of increased safety protocols in advance of their appointments. Patients should understand what to expect: mandatory masks, temperature checks, hand sanitization, screening questions, guest limitations or reception room restrictions. Share safety protocols and COVID-19 policies through appointment reminder emails, text messages and phone calls as well as through the practice website and social media pages. Providing early notice allows patients to cancel or reschedule if they aren’t comfortable complying with the safety guidelines. Reinforce the policies again by displaying signage on the office’s front door and at the front desk to be specific, clear and conspicuous to patients upon their arrival.

Mask-Exemption Accommodations

The Centers for Disease Control and Prevention offers guidance on individuals who could be exempt from wearing a face covering. These exemptions are generally rare and include children under age 2 and people of any age with certain disabilities or sensory, cognitive or behavioral disorders. Unfortunately, fraudulent “face-mask exemption” cards are circulating in the public, but there is no legitimate boilerplate letter or blanket exception. If a patient requests an accommodation for a disability that

is not obvious, providers are permitted to request medical documentation that’s personalized to the individual patient’s condition. If the patient’s disability is apparent, additional information should only be requested if necessary. Reasonable accommodations for patients with legitimate conditions may include: ■ Offering a teledentistry appointment to determine a treatment plan and then scheduling an in-office appointment time that reduces risks while accommodating needs.

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RM MAT TERS C D A J O U R N A L , V O L 4 9 , Nº 1

■

Asking a patient to wait in the car or an area away from others until treatment time. Scheduling the patient as the last one seen at the end of the day. Allowing a patient to wear a loose face covering or face shield instead of a mask.

Responding to Mask Refusal

Even with early and direct communications about practice protocols, some patients will come to their appointments still refusing to comply. Being prepared for difficult conversations and using tactics to de-escalate tension are key to reducing potential liabilities. Start by training employees on how to handle uncooperative patients. A united front demonstrates to the dental team that they are supported and that their safety is valued. As part of regular conflict resolution training, develop a specific plan on how to respond to patients who refuse to follow safety policies. This may include: ■ Recognizing indicators of possible noncompliance before the appointment, such as hesitation during a reminder call or overly specific questions about mask enforcement. ■ Addressing the unmasked patient outside the practice door or in the doorway, if possible, to avoid allowing the patient to enter common areas as the conversation continues. ■ Offering the patient the option to wear a disposable mask provided by the practice, rescheduling the appointment when they are willing to comply or scheduling a telehealth consultation. ■ Assessing the situation for signs of escalation and feeling comfortable asking practice leadership to intervene. 46 JANUARY

2021

Documenting a clear chain of command and designating a specific team member, such as the office manager, to respond quickly in noncompliance situations and steer toward the best solution. ■ Establishing a tactical approach to dealing with patient aggression or potential violence (threats, verbal assault or physical assault), such as exiting to a safe area of the practice or calling security or an emergency number. ■ Updating workplace violence policies in the employee handbook to cover patient-violence scenarios and the procedure for reporting them. See additional guidance from the CDC on limiting workplace violence associated with COVID-19 prevention policies. Staff can encourage patients to comply with practice protocols, but they are not expected to enforce them — especially without proper support or when facing hostility or safety risks. If an employee believes they are not supported in responding to uncooperative patients, the employee might be prompted to leave the practice and possibly file a hostile work environment claim. By documenting violence policies and following through on those policies in support of employees’ mental and physical well-being, practice owners may mitigate liabilities and improve the team’s confidence in working in a challenging climate. In the event a patient refuses to follow practice protocols, the health and safety of the work environment is compromised for employees and other patients. Assuming there is no other protected classification in which the patient falls and the practice gives adequate notice and an opportunity to find other care, noncompliant patients ■

may be dismissed. Dentists must also remain available for emergency treatment (for a minimum of 30 days) until the patient finds care through another practitioner. To reduce the potential for patient-abandonment claims, contact your professional liability carrier for advice, especially if the patient is midtreatment. Consult your dental society and state occupational safety division for additional regulations or considerations specific to your region. Balancing obligations to the dental team and all patients can be a challenge, but expert guidance is available through the California Dental Association and The Dentists Insurance Company. If you are facing concerns about potential claims stemming from patient or employee situations, call TDIC’s Risk Management Advice Line and speak with an experienced analyst. n The Advice Line is a benefit available at no cost to CDA members as well as to policyholders protected by TDIC. Visit tdicinsurance.com/RMconsult or call 800.733.0633 to schedule a consultation.

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Regulatory Compliance

C D A J O U R N A L , V O L 4 9 , Nº 1

Employee Exposure and Medical Record-Keeping CDA Practice Support

OVID-19 is forcing dental practices to maintain a greater number of records pertaining to employee health. Employees undergo temperature checks every workday and employers must track employees’ potential exposures to the virus. If a dental practice tests employees for COVID-19, additional record-keeping is necessary. The maintenance, retention and access to these records are governed by a Cal/OSHA regulation, specifically Title 8 Section 3204, Access to Employee Exposure and Medical Records. The regulation defines employee exposure records, employee medical records, toxic substances and harmful physical agents covered by the regulation, dictates how long employers must retain these records and safety data sheet (SDS) information and establishes minimum requirements for allowing employees and others access to those records. Employers must keep records of employee exposure to toxic substances and harmful physical agents. Typical exposure records in a dental practice include results from chemical monitoring (such as for nitrous oxide) and dosimeters, reports of exposure to bloodborne pathogens and other viruses of concern and a safety data sheet (SDS) of materials identified as hazardous to human health. If an SDS is to be disposed because the material is no longer used by the dental practice, a chemical inventory must be created in order to record the identity of the toxic substance or harmful physical agent and where and when it was used.

Employee medical records include the following: ■

Medical and employment questionnaires or histories (including job description and occupational exposures).

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■

■ ■

■

The results of medical examinations (preemployment or episodic, for example) and laboratory tests taken for the purposes of establishing a baseline or detecting occupational illness and all biological monitoring not defined as an “employee exposure record.” Medical opinions, diagnoses, progress notes and recommendations (from, for example, a bloodborne pathogens exposure incident). First aid records. Descriptions of treatments and prescriptions. Employee medical complaints.

Employee medical records do not include:

Physical specimens. Records concerning health insurance claims if maintained separately from the employer’s medical program and its records and not accessible to the employer by employee name or other direct personal identifier. ■ Records created solely in preparation for litigation, which are protected from discovery. ■ Records concerning voluntary employee assistance programs (alcohol, drug abuse or personal counseling programs) if maintained separately from the employer’s medical program and its records. Toxic substances or harmful physical agents are defined in the regulation as any chemical substance, biological agent (bacteria, virus, fungus, etc.) or physical stress (noise, heat, cold, vibration, repetitive motion, ionizing and nonionizing radiation, etc.), which: ■ Is regulated by any state or federal law or rule as a health hazard. ■ Is listed in the latest printed edition of the National Institute ■ ■

■

for Occupational Safety and Health (NIOSH) Registry of Toxic Effects of Chemical Substances. Has yielded positive evidence of an acute or chronic health hazard in human, animal or other biological testing conducted by or known to the employer. Is the subject of an SDS kept by or known to the employer, which indicates that the material may pose a hazard to human health.

Record Retention

Employee medical records must be maintained and preserved for at least the duration of employment plus 30 years, except for certain types of records that do not have a specified retention period: ■ Health insurance claims maintained separately from an employer’s medical program and records. ■ First aid records of one-time treatment and subsequent observation of minor injuries that do not involve medical treatment, loss of consciousness or restriction of work. ■ Medical records of employees who worked for less than one year if the records are provided to an employee at the end of employment. Employee exposure records also must be preserved and maintained for at least 30 years. These records in a dental practice include: SDSs as needed to comply with provisions of the Hazard Communication regulation (Title 8 Section 5194) and, when substances are no longer used and the associated SDS are destroyed, records of the identity of the substance or agent, where it was used and when it was used. Biological and environmental monitoring results designated as exposure records.

C D A J O U R N A L , V O L 4 9 , Nº 1

Access to Records

An employee, their designated representative and the state Division of Occupational Safety and Health (DOSH) have the right to access medical and exposure records. The employer has 15 days to provide access and may not charge for the initial copy. An employee must provide written consent or authorization for release of the records except when DOSH is requesting the records.

Additional Employer Responsibilities

Each employee must be informed of the existence, location and availability of the medical and exposure records, the applicable regulation and their right to access the records. Employers are required to maintain a copy of this regulation and provide a copy to an employee upon request. When an employer sells or transfers the business, the medical and exposure records must be transferred to the new owner, who must maintain them. If an employer closes the business, affected employees must be provided with notice three months before closure so that they may access the records. If the employer closing their business has already notified employees and intends to destroy the medical and exposure records, the employer must notify the director of NIOSH at least three months prior to doing so. n Regulatory Compliance appears monthly and features resources about laws that impact dental practices. Visit cda.org/ practicesupport for more than 600 practice support resources, including practice management, employment practices, dental benefit plans and regulatory compliance.

JANUARY 2 0 2 1

Specialists in the Sale and Appraisal of Dental Practices

Serving California Dentists since 1966

How much is your practice worth??

2021 shall be a Phenomenal Year by Being Optimistic, Believing in Yourself and Taking Control of Your Destiny

NORTHERN CALIFORNIA (415) 899-8580 – (800) 422-2818 Raymond and Edna Irving Ray@PPSsellsDDS.com www.PPSsellsDDS.com

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SOUTHERN CALIFORNIA

(714) 832-0230 – (800) 695-2732 Thomas Fitterer and Dean George PPSincnet@aol.com www.PPSDental.com

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6186 SACRAMENTO Located in a well-established neighborhood; this office has been a community asset for 35-years. Virtually no competition. Revenues streams have topped $600,000 each year. Available Profits topped $280,000 in 2019. 5-days of Hygiene. Well laid out 4-op suite. 6185 CHICO – SACRAMENTO’S NORTH VALLEY Highly regarded as evidenced by 6-days of Hygiene. Revenues average $470,000 per year. 4-ops, attractive setting. Retain the 2-Hygienists and the patients shall continue. 6184 SAN FRANCISCO’S EAST BAY – LAMORINDA AREA Unique opportunity to practice in high income area. Revenues have averaged $390,000 a year on part-time basis. Highly regarded. 3-days of Hygiene. Excellent candidate to go out-of-network. 6183 REDWOOD CITY Collected $730,000 in 2019. 4-day Hygiene schedule. 5-ops, paperless, digital Pano. Ideal for nearby Dentist seeking larger facility, or perfect acquisition by nearby Dentist who vertically integrates the goodwill into their office. Seller shall become the Pied Piper by continuing in an association for up to a year for transition. 6182 NAPA VALLEY Collections last three years have averaged $1,000,000. 2019’s Available Profits totaled $374,000. Current annualized performance trending $1.1 Million. All specialty work referred. 4-Hygiene days. Paperless charting. Well-designed office. Great location. Great staff. Perfect platform to provide additional services and immediately improve the performance. 6181 CARMEL VALLEY’S “THE VILLAGE” - START-UP 48-year history providing dental care at this $1 +Million location. Equipped & furnished 4-ops. Only practice in Village. Next practice 10-minutes away. Landlord is daughter of original dentist who worked as Hygienist and later Manager. Closed April. Purchase equipment & furnishings; enter into Lease, open doors, patients return. Operate out-of-network. 6180 SAN FRANCISCO’S LOWER PACIFIC HEIGHTS Collected $796,500 in 2019 with Available Profits of $391,500 in 2019 with 9-weeks off. 2020 trending collections of $810,000 with Available Profits of $425,000. Fees shall continue! $258,000 spent in décor, delivery systems & technology. Average adjusted gross income per household in this zip code is $286,800. 6177 MONTEREY BAY AREA - SALINAS Exceptional opportunity to create a full-service practice. Under-performing practice collected $935,000 in 2019. Current annualization is $1+ Million in collections. 7-days of Hygiene. Has averaged 130-new patients/year the last 2-years. Housed in beautiful 6-op building. Free-standing condo included in package sale. Perfect platform to bring in specialists. 6176 SANTA CRUZ Delta PPO practice seeks Successor skilled in implants. Last 2-years averaged $1,180,000 in Collections and $735,000 in Available Profits. $480,000 invested in technology. 4-days of Hygiene. Full Price $650,000. Compare to similar nearby "For Sale" practice asking $1,350,000 with another brokerage. 6174 HUMBOLDT COUNTY’S UNIVERSITY COMMUNITY – ARCATA Best location, great foundation. Owner voted “Best Dentist” in 2020 Reader’s Poll. Owner works 3-day week by choice. 2019 collected $360,000. Receives new patient calls constantly, and which are turned away. Practice will be full-time by simply working 5-days if that is your intent. Full Price $25,000. 6172 WALNUT CREEK – OUT-OF-NETWORK 2019 collected $850,000 with Profits of $430,000. 4-days of Hygiene. Great Downtown location. Seller shall work-back to assist in transition. 6171 SANTA ROSA Great DNA in long-established practice. Strong patient foundation per 6+ day Hygiene Schedule. 2019 collected $990,000 with Available Profits of $338,000. Great Team. 2020 is doing extremely well. 6165 ROSEVILLE ORTHO – OUT-OF-NETWORK Stanford Ranch. $455,000 invested in build-out, furnishings, computers and equipment. 3-chair Bay. Digital Pan with Ceph. Averages 3 New Patients per month. Full Price $125,000.

Great Time to Think about Change. Not doing the Type of Dentistry You would like to do? Look to Tom Fitterer & PPS to plan your future.

SOL

D SOL D SOL

BEAUMONT/ BANNING 26,000 new homes planned. 2 retiring Dentists; buy one or both. 2,000 sq.ft. condo. Hygiene booked. Live in Palm Springs or Redlands. CULVER CITY Grossed $853,000 in 2019. Referred 55-Endo; 28-Perio; 60-OS & Implant cases last year. Loyal Patients. EAST LOS ANGELES Long established. 2 days grossing near $200,000 cash. Full Price $150,000. GP INNOVATOR Grossing $1.7 Million; Nets $1+ Million. Unusual opportunity. Very Conservative, Refers out a lot. HEMET Includes apt & dental building. Long established. Beautiful 5 ops. Open part-time. Will do $500,000. KOREAN DENTIST SOUGHT FOR 2 YEAR APPENTICESHIP Learn while working. Implants, OS. Airplane provided. Great pay while learning to produce $2 Million/year by Senior Korean Maestro. Call Tom Fitterer. KOREA TOWN Low overhead. No Denti-Cal. PPO & Cash. Grossing $250,000. Full Price $150,000. KOREA TOWN Grossing $700,000+. Great visibility. INLAND EMPIRE 7-ops. Grossing $1.5 Million. Includes real estate. LA HABRA Huge shopping Center. 6 ops. Seller will work back. LAGUNA NIGUEL Hi visibility shopping center. 3-ops Husband / Wife work part-time. Grossing $414,000. Needs more Doctor days. LAGUNA WOODS Did $1 Million in 2019, will do $1+ Million. Shopping plaza completed $6 Million remodel. New tenants will be patient magnets. $5,000/mth HMO. 4-ops, rent $3,831. Successor double shifts with present crew. Near Leisure World and affluent new growth. Implant DDS will net 500k working 3 days. LA MIRADA $5,000/month HMO check. Collects $569,000. 7 ops; 2,700 sq.ft.; rent $2,800. Entire 10,000 sq.ft. building “For Sale.” No vacancies. ORANGE COUNTY Merger candidate. Near Chapman and Tustin Streets. 4 ops. Merge or grow. PT owner grossing $400,000. ORANGE COUNTY Popular shopping center. 20-year practice. 9,000 charts. Full-time Owner will do $1.5 Million and Net $500,000. PALM DESERT Hi identity on Highway 111. 2 days grosses $300,000. Full Price $150,000. PALM SPRINGS Grossing $1.5 Million. Specialists gross $300,000. Pay Owner $150,000. Shall pay rent and practice loan. 8-ops. Full Price $875,000. PASADENA Busy shopping center near large medical center. Grossing near $1 Million. If your lease is up, merge. PASADENA Husband DDS / Wife Hygienist have small practice to merge. Lost lease. PICO RIVERA Paramount and Whittier. High visibility shopping center. 4-ops. Grossing $200,000. $4,000/month HMO check. REDLANDS Near City Hall. Rent $1,400. No patients but ready to go. 3-ops plumbed 2 equipped. Full Price $50,000. RIVERSIDE 215 FREEWAY High visibility real estate. Make Implant & Family Dental Center. Riverside or Colton Dentist should move here. 250,000 autos pass daily. TORRANCE HMO Check of $5,000/month. 70,000+ autos pass popular intersection per day. Entrance to Palos Verdes. 6-ops in hi visibility dental office. Gorgeous. Grossing $700,000+.

Ethics

C D A J O U R N A L , V O L 4 9 , Nº 1

Inviting Volunteer Help Into the Dental Office Paul Hsiao, DDS, MPH, JD

ager students of all backgrounds often approach dental offices to shadow the dentists or other dental auxiliaries, complete their extern hours or volunteer to give back to the community. For example, within the last year I have had dental residents ask if they can shadow me at my practice and dental assistant students ask if they could complete their extern hours in my office. The first thing in my mind should not be “free help” or for my staff to think about giving these helpers all the tasks they don’t want to do. These students should not be given only janitorial or mindless tasks. After a short period of time, they should be able to perform like a dental assistant with some experience. I also want this resident or student to have a positive experience because this is an introduction to what will hopefully be a long and successful career in dentistry. It is our duty and obligation to take part in improving our profession and the support staff we develop over time in our community. The CDA Code of Ethics refers to professionalism and selfgovernance as a “hallmark of a profession” and states that “dentistry will thrive as long as its members are committed to actively support and promote the profession and its service to the public.” By helping to shape new members of the profession by exposing them to ethical decision-making, consistent office policies and accountability, everyone benefits. This is also an opportunity to act in a professional and compassionate way toward someone who needs help. As a profession of high integrity, it is important to take the time to educate these individuals in many areas of practice if we choose to allow them to volunteer in our office. They are not second tier to our paid staff members. What we do not want to see are students leaving the dental office with limited dental knowledge and very little dental experience.

It’s important to consider that free help is not really free. These individuals need to develop the experiences to succeed in the dental field. They trust that our intentions are to teach them dental skills so they can find a job in the dental field. We are doing them a disservice if they leave our offices clueless, not to mention diminishing our own reputation when they work for a colleague after the externship is over. Many of them will not last very long at their first real jobs if they have not had their skills developed; therefore, they have a false expectation of their dental job. It is important to consider our ethical obligation to these individuals, because

they come to us wanting to learn. We should only offer them a volunteer position if our dental team is willing to undertake their educational endeavors. Let us not exploit their needs, but offer them valuable training that will benefit them, their future practice and the profession. Ultimately, the entire dental profession improves because of the actions of each individual, so let’s make their experiences both educational and rewarding. n Paul Hsiao, DDS, MPH, JD, is a general dentist practicing in Fresno, Calif. He is a fellow of the American College of Dentists and the International College of Dentists. Dr. Hsiao served on the CDA Judicial Council.

JANUARY 2 0 2 1 LDM_CDA_Journal_1.3_Square_LindaBrown_05_23_17.indd 1

5/24/2017 9:21:40 PM

Tech Trends

C D A J O U R N A L , V O L 4 9 , Nº 1

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

Amazon Halo ($99, Amazon) The Amazon Halo is another entry into the crowded fitness tracker space. It boasts many incredible health tracking features in an affordable package, but Amazon’s measured approach appears to have created new, unexpected disadvantages. A point of emphasis first: The Amazon Halo is a wristband and does not have a screen. This undoubtedly improves its battery life and form factor, but it does not improve comfort, as there is still a watchsized metal object protruding from the top of the wristband. The lack of a screen requires a smartphone to interact with. The changeable band is cloth and takes a surprisingly long time to dry; for everyday use, a third-party band is recommended. Ultimately, the Halo is about “honing your health,” and this is where the device shines. It tracks all the metrics its competitors do — activity, sleep quality, pulse — while also monitoring the user’s tone of voice. When activated, tone tracking analyzes the user’s mood. The accuracy was suspect, but nonetheless interesting and prompted self-reflection. Worth noting is that fully enabled tone tracking drains the Halo’s batteries at an extraordinary speed and will require daily charging. Outside of tone tracking, the Amazon Halo’s features are replicated or represented in a superior fashion with competing products. For the first-time, fitness-tracker user, the Amazon Halo is a wonderful option with only a small upfront investment. For experienced users, it represents little more than a curiosity. — Alexander Lee, DMD

Keychron K1 Wireless Mechanical Keyboard (starts at $69, Keychron) Advancements in technology have led to the evolution of thinner, lighter and more powerful personal computing devices. An unintended consequence is the disappearance of beloved features that were taken for granted until their absences were felt, such as the mechanical keyboard. The thin profile of keyboards today is possible because of membrane keyboard technology, which is quiet, reliable and economical, but lacks the tactile and audio feedback of mechanical keys. A resurgence in popularity for mechanical keyboards, such as the Keychron K1, aims to return this beloved technology to touch typists. 52 JANUARY

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The Keychron K1 is a mechanical, low-profile keyboard compatible with Mac and Windows and can operate both wired or wirelessly via Bluetooth on up to three devices. The keyboard body is aluminum, providing solid weight to prevent slipping on a desktop surface. The front of the body has two switches: one to set between Mac/Windows modes and the other to set the keyboard to wired/ wireless/off operation. Wired mode and battery charging for wireless operation is done through its USB-C port and a USB-A to USB-C cable is included. The keyboard is available in 87-key TKL (10 keyless) or 104-key (full-sized) versions. Additionally, an array of mechanical key switch options (red, blue, brown) and white or RGB (red, green, blue) color backlight options are available, but not interchangeable; buyers must carefully decide their customizations based on user preference. Using the keyboard is a throwback experience that returns the satisfaction of typing on typewriters and early personal computers to modern devices. Depending on the mechanical switch options chosen, tactile resistance and/or the audible clicking accompanying the physical travel of pressing keys is delightful and distinctive. The keyboard accurately registers key presses, but some combinations that users are accustomed to will require open-source third-party software (links provided in the user manual) to remap keys in order to work as expected. A dedicated light effect key allows users to toggle the backlight between varying brightness levels and effects. Wireless operation on a single charge can last up to several days depending on backlight settings. In wireless mode, the keyboard is set by default to auto-sleep after sitting idle for 10 minutes to save battery. Users must turn this feature off for uninterrupted wireless operation or key presses may be missed during the short interval required for the keyboard to wake and reconnect. A keycap puller and Windows specific keycaps are included to switch keys between platforms used. Overall, the Keychron K1 provides the mechanical keyboard experience that touch typists have been missing with membrane keyboards. There are plenty of features and customization options to satisfy any nostalgic user without sacrificing productivity. — Hubert Chan, DDS

Making your transition a reality.

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Dr. Russell Okihara

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(916) 812-3255 (619) 694-7077 (925) 330-2207 (909) 239-2800 45 Years in Business 38 Years in Business 10 Years in Business 46 Years in Business

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(916) 812-0500 (949) 300-0312 (707) 391-7048 (949) 675-5578 (951) 314-5542 (408) 687-5001 (949) 675-5578 36 Years in Business 35 Years in Business 30 Years in Business 30 Years in Business 26 Years in Business 16 Years in Business 11 Years in Business

PRACTICE SALES • VALUATIONS/APPRAISALS • TRANSITION PLANNING • PARTNERSHIPS • MERGERS • ASSOCIATESHIPS NORTHERN CALIFORNIA ALAMEDA: 4 Ops in busy shopping center. 29 yrs Goodwill. 2019 GR $246K on 27 hrs/wk. Room to grow!#CA1268 ALAMEDA: 4 Ops, Practice housed in a beautiful Victorian home. 2019 GR$1.4M+. Real estate also available if desired. #CA1287 CITRUS HEIGHTS/FAIR OAKS: New Listing! Hi-traffic retail location, 4 Ops, Digital and paperless. Doctor looking for a fast sale. 2019 GR $295K. #CA1832 FAIRFIELD AREA: New Listing! 7 Ops, Dentrix, Digital, Digital CB/Pano, newer equipment. 9+ hyg days/wk and specialties referred. GR $1.7M. #CA1824 FOLSOM/EL DORADO HILLS: New Listing! 5 Ops, 4 Equip, 5 hyg days/wk w/ specialties referred. 2019 GR $530K. #CA1629 DAVIS/WOODLAND: New Listing! 37 yrs Goodwill w/ Condo. 2019 GR $770K. 6 Ops, 5 Equip, Digital Sensors and Pano in sought-after area. #CA1732 EAST BAY: 5 Ops, 4 equipped. Beautiful updated digital office with 23 yrs Goodwill, Digital, Pano, Lasers, and Nitrous Oxide-ready. Avg 30 NP/mo. Open 4 days, this is a CASH AND PPO office! 2019 GR $614K. #CA684 EAST BAY/CONTRA COSTA COUNTY: Central beautiful location with 4 Ops in 1,350 sf. 2019 GR $659K on only 4 doctor days/week. #CA644 GREATER EL DORADO HILLS: Multidoctor, 3,000 sf office, 8 Ops, 7 Equip, I/O Cam, Digital X-rays & Pano. 2019 GR $2.2M. Sellers will consider working back P/T. #CA578 GREATER SACRAMENTO: Price Reduced by $50K! PPO Practice with 4 Ops, digital sensors, imaging system, I/O Cam. Practice open 33 yrs. 2017 GR $652K; Office Condo available for purchase. #CA561 GREATER SACRAMENTO: Great area w/ 38 yrs Goodwill. 4 Ops in 1,100 sf. 2018 GR of $1M+ on 32 hrs/wk. #CA656 LAKE TAHOE AREA: New Listing! 4 Ops, 37+ yrs Goodwill. Rural lifestyle GP in growing resort community. 2019 GR $760K. #CA1715 LAKE TAHOE AREA: GP practice with 5 Ops w/ 6th Open, Operatory views of Lake Tahoe, only 34 Delta Premier patients, 2,100 sf. 2019 GR $579K on 22 avg. Dr. hrs/wk. #CA608 MILLBRAE: Role Reversal, 5 Ops. 2019 GR $1M+ on 4 days/wk. and 6 hyg days. Seller offering 6 mo. employment and work back 6 mo. after sale. Digital, Pano, Waterlase & Periolase. #CA1139 NORTHERN CA FOOTHILLS AREA: Fast growing practice in 2,500 sf w/ 6 equip. Ops, 1 add’l plumbed. 2019 GR on track to exceed $1.2M on 3 avg. Dr. days/wk. #CA632 NORTHERN CA PERIO: 4 Ops, Consult Rm, Upgraded Tech with Digital, LANAP, Paperless. 2019 GR $900K+. Draws from lg area with little competition. #CA1553 OAKLAND: 3 Ops, Room to expand, Digital X-rays, Paperless, 40+ yrs Goodwill. 2019 GR $675K with room to grow Specialties. Prime location, retiring doctor will help with a smooth transition. Seller-owned RE to purchase or lease. #CA1380 PLEASANTON FACILITY ONLY: New Listing! Drop-dead gorgeous office in most desirable area. 5 Ops with X-rays, upgraded cabinets. 1/3 of price to build out your own. #CA1972 REDDING AREA: Modern practice in 1,600 sf with 4 equipped Ops, 1 additional plumbed. 2019 GR $558K on 32 hrs/wk. #CA648

SACRAMENTO: 5 Ops, 4 Equip. 50+ yrs. Goodwill. Digital, CBCT, New computers, 2019 GR $434K (seller took 3 mo. off) #CA678 SAN FRANCISCO FACILITY ONLY: 3 Ops in the heart of the city! Leasehold and equipment only, low rent. Asking $125K. #CA677 SAN FRANCISCO: Low Rent! 30+ yrs Goodwill. Beautiful 4 Op office w/ strong hyg program. 2019 GR $740K+. #CA657 SAN JOSE: New Listing! Evergreen district, mixed-use building. 4 Ops, Digital, Film Pano. Seller will work back one day/wk. if wanted. 2019 GR $1.4M. #CA1817 SAN JOSE: Great cash flow in beautiful retail space with high traffic/visibility. Spacious 3,150 sf with 10 Ops, 6 Equip. 2019 GR $745K. #CA600 SAN JOSE: 6 Ops, Paperless, Digital, CAD/CAM, Digital Pano. Seller will stay on P/T, if desired. 2019 GR $1.3M+. #CA1140 SONOMA COUNTY: Lrg GP, 2019 GR $2.3M+. Stand-alone 3,000 sf prime Real Estate, 72 NP/mo. & 10 hyg days. 6 Ops, Pano, Dexis, Cameras, Laser, Dentrix. Both Business & RE for sale or Lease. Doctor Retiring. #CA544 SONOMA COUNTY: 2019 GR $948K with high profit. 3 Ops w/opportunity to expand. Paperless, Dentrix, Digital, I/O Cam. Selling both Practice and portion of dental building ownership. #CA594 VACAVILLE AREA: Centrally-located & hitraffic location with 25+ yrs Goodwill. 5 Ops in 1,700 sf. 2019 GR $556K on 32 hrs/wk. #CA645 VALLEJO: 4 Ops, 1,650 sf w/ below-market rent. 2019 GR $791K, 4 hyg days/wk, low OH. #CA469 VALLEJO/BENICIA/MARTINEZ: Downtown practice+RE with add’l tenants. 3 Ops with 4th available. Digital Pano, Laser. Most Specialties referred. #CA321

CENTRAL CALIFORNIA CENTRAL COAST: 5 Ops, digital, 25+ yrs Goodwill. Newly renovated, practice sees 30 NP/ mo. Strong hyg prog. 2019 GR $1.1M+. #CA1218 CENTRAL VALLEY PEDO PRACTICE: Shared space w/ Ortho, 7 Op, 3,800 sf. 2019 GR $610K as part-time practice. Great starter practice or satellite office. #CA660 FRESNO AREA: Price Reduced-under $150K! GP/Prosth Practice prime for a GP buyer. 4 Ops with Digital Sensors, Film Pano, attractive office building and space. 2019 GR $409K. #CA588 GREATER FRESNO: PRICE REDUCED $100K! 4 Ops, Digital, PPO/Denti-Cal, fast-growing area, 22 Yrs. Goodwill, Digital. Bldg available to purchase. 2019 GR $523K. #CA676 MODESTO AREA: Established neighborhood with 60+ yrs Goodwill. 5 Ops, 1,450 sf. 2018 GR $1.1M+ on 3 day/wk. Dental Condo also available for purchase or lease. #CA635 MONTEREY: 4 Ops, 1,600 sf, desirable area w/ free parking. 32 hrs/wk. 2019 GR $938K. #CA650 SANTA CRUZ: New Listing! 3 Ops, Digital, Pano, Reasonable rent. 40+ yrs. goodwillMinutes from beach. 2019 GR $592K. #CA4709 STOCKTON: 1/3-2/3 share of 3 GP partner practice. 2019 GR $508K on 32 hrs/wk. Digital, paperless. Most specialty referred. Add’l 1/3 ownership of separately listed practice in group also avail, allowing 2/3 ownership. #CA1389 STOCKTON: PRICE REDUCED/WILL CONSIDER CHART SALE! Unique opportunity to buy 1/3 share of a 3 GP, mostly PPO, partner practice. 2019 GR $462K on 32 hrs/wk. Digital. Add’l 1/3 ownership of separately listed practice in group also avail, allowing 2/3 ownership. #CA1624 STOCKTON AREA: Great opportunity to purchase practice/bldg, 3,000+ sf, 6 Ops, Good hyg recall. 2019 GR $1M+ on avg 37 hrs/wk. #CA616

Northern California Office

800.519.3458

Henry Schein Corporate Broker #01230466

SOUTHERN CALIFORNIA BAKERSFIELD: 6 Ops, 40 years goodwill, with a great reputation in the area. 6 days hyg./wk. and most specialty work referred. Digital pano, digital x-rays. 2019 GR $600K. RE also for sale. #CA1274 BAKERSFIELD: 7 Ops w/ high-end equipmentCEREC, Digital X-rays, Cone Beam, Implant motor. 7 hyg days/wk, room to grow. GR $1M+ with low overhead. Bldg for sale at $650K. #CA1120 BAKERSFIELD: Well-established, 5 Ops, 4 Equip. In-house dental lab, could be re-purposed. Main thoroughfare location w/ busy traffic flow. Wonderful reputation/internal referrals galore. Retiring doctor. Condo also for sale. 2019 GR $365K on 3 days/wk. 2019 GR $416K. #CA674 BAKERSFIELD PEDO: Rare opportunity to purchase a successful 30+ yr old Pedo practice with Ortho and Oral Surgery services. Over 4K active patients, avg. 40 NP/mo. $2.5M+ GR for past 3 yrs. #CA599 CORONA: New Listing! 4 Ops, Digital, excellent growth opportunity. Main street location in small strip center. 2019 GR $280K. #CA2002 COVINA: 4 Ops, 67 yrs in location, 22 w/ seller. Strong hyg prog, room to grow w/ Specialties. 2019 GR $804K. #CA692 EAST LOS ANGELES FACILITY ONLY: New Listing! 3 Ops, Great retail location in small neighborhood center, signage, on busy street. Seller moving. #CA1786 EL CENTRO: Great location with low rent. 4 Ops, 3 Equipped, Digital, 25 Yrs Goodwill. 2019 GR $850K. #CA680 HUNTINGTON BEACH: PRICE REDUCED FOR QUICK SALE! 5 Ops, desirable location, Digital, strong hyg prog. 2019 GR $604K. #CA685 HUNTINGTON BEACH: 4 Ops, located in a busy retail center with great visibility. Practice utilizes Digital X-rays and Easy Dental PMS. 2019 GR $466K. #CA673 LAGUNA BEACH: New Listing! 2 Ops, private practice, office bldg 2nd floor w/ elevator. Nice location, est. 1975 with low OH. 2019 GR $161K. #CA1499 LONG BEACH: RE ownership an option! Upper middle-class residential practice est. in 1950. Existing 4 Ops, 3 Equip, easy expansion next door to add another 3 Ops, 2 are equip. Digital. Most specialties referred. Strong post-COVID production. 2019 GR $696K. #CA671 LOS ANGELES: New Listing! Associate-run, 6 Ops, parking, and room to grow. 2020 receipts are $850K as of 9/1, will be $1M+ by year-end, Digital, modern. #CA1681 NORTH ORANGE COUNTY: 5 Ops, open since 1965. Dentrix, digital Pano. Retiring seller will assist w/ smooth transition. One-story prof. bldg. 2018 GR $231K. Room to grow. Most Specialty procedures referred out. #CA558 ORANGE COUNTY: 5 Ops, Beautiful office, Digital, Paperless, hi-traffic area with great signage and low-rent. 2019 GR $501K. #CA670 ORANGE COUNTY: 5 Ops, Digital, Retiring seller. Excellent reputation, affluent area, high quality care. Modern, welcoming office with strong hyg prog. Room to grow specialties. 2019 GR $642K. #CA1676 ORANGE COUNTY: New Listing! Beautiful office located at a major intersection in a strip center. 2019 GR $329K with low overhead and great take-home Net. 5 Ops, 3 equipped, seller works average 25 hrs./wk. Great potential, low asking price of $175K. A must-see! #CA1728 OXNARD: 4 Ops, Digital X-rays, Est. 35+ yrs ago. Seller owned it for 3 yrs and has a primary office in LA. 2019 GR $662K. #CA1164

www.henryscheinppt.com

PALM SPRINGS AREA MULTI-SPECIALTY: Priced to sell @ $775K! 5 Ops, lecture room, 28 yrs Goodwill. Hi-end, mostly cash patient base. Dentrix, Digital, CT Scan & Gemini Dual Wave Laser. History of $1.2M+/yr on 4 days/wk. #CA604 SAN GABRIEL VALLEY: 4 Ops, Digital X-rays, 65 yrs Goodwill. Most specialty work referred out, most PPO plans are accepted. Busy road with great visibility, open 4 days/wk. Nicely appointed; excellent opportunity. #CA596 SIMI VALLEY: 6 Ops, 5 Equip, Great location, low rent, 45 yrs goodwill. 2018 GR $297K w/ $89K Adj. Net. #CA637 SOUTH BAY LOS ANGELES PEDO: 3 Ops+ Recovery/Consult Room, Digital, well-run, RE also for sale. Potential upside with keeping Ortho inhouse. 2019 GR $668K #CA1653 SOUTH BAY LOS ANGELES: Ready to retire! 7 Ops, RE for sale. 50% Denti-Cal, some HMO/PPO. 2019 GR $568K. #CA1050 SOUTH ORANGE COUNTY PERIO: 4 Ops, 3 Equip, Coastal Community, Modern, Busy strip center location near hi-end residential. 2019 GR $845K. #CA643 SO CAL DESERT AREA: 4 Ops 27 yrs Goodwill. Strong hyg prog w/ hi-end patient base. 2019 GR $809K. #CA691

SAN DIEGO ENCINITAS: 4 Ops. Busy retail center. Remodeled 5 yrs. ago with new equipment. Dentrix, Digital, Pano, and Laser. 4 hyg days/wk. 2018 GR $813K. #CA574 LA JOLLA: UTC Area, Leasehold with patients. 7 Ops Digital in retail center with strong anchors. Priced to sell! #CA663 LA MESA: New Listing! 7 Ops, 4 Equip, Digital, Stand-alone office w/ freeway access. Room to grow with specialties. 2019 GR $696K. #CA1915 NATIONAL CITY: 6 Ops, 14 yrs Goodwill, strip mall with high visibility, Digital, loyal staff and patients. 2019 GR $754K. #CA1465 SAN DIEGO: 3 Ops, busy strip mall location, Digital, well-organized, office with stable patient base. 2019 GR $686K. #CA1905 SAN DIEGO: Rare opportunity in prime location. Solid practice with 17 yrs Goodwill. 5 hyg days/ wk. 6 Ops, 5 Equip, digital X-rays, Pano. Most specialty work referred out. 2019 GR $1.1M+. #CA1448 SAN DIEGO: 7 Ops, 5 Equipped, located in a large retail center. EagleSoft, PPO/Cash, 3 year average collections of $509K. #CA687

OUT OF CALIFORNIA HONOLULU, HAWAII: Highly desirable area, 40 yrs Goodwill, 3 Ops. Digital X-rays, DigiDoc, Planmeca E4D, Laser, Densys Operating System. Seller is retiring. #HI1112 HILLSBORO, OR: 5 Ops, Scan-X, Pano, Laser, and recent cosmetic upgrade. Great NP flow with 7 hyg days/wk. and 4 Doctor days. Near key employers, on a major thoroughfare. Room to expand. GR $1.1M+. #OR1355 SOUTHWEST PORTLAND, OR: 7 Ops, 6 Equip, Dentrix, Digital, Pano. Well-maintained leased space. 2019 GR $598K. #OR115 SOUTH OF PORTLAND, OR - ORTHO: New Listing! Growing community outside “Big City”. Well-estab near referring doctors. Updated, spacious, turnkey! 2019 GR $1.3M+ #OR1550 BURIEN AREA, WA: 3 Ops, Busy Area w/foot traffic. Very low overhead and good cash flow. Could relocate in Bldg to bigger suite. #WA102 TACOMA, WA: New Listing! 4 Ops in highly desirable area. MacPractice, Soft/hard Tissue Laser, E4D. Owner well-versed in same-day dentistry and will help transition using tech. #WA2436

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