Dental Abstracts 70_3_Final_Combined

DENTAL ABSTRACTS

Editor-in-Chief

Douglas B. Berkey, DMD, MPH, MS

Senior Publisher

Annie Zhao

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Abstract Writer

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DENTALABSTRACTS

ASELECTIONOFWORLDDENTALLITERATURE

EditorialBoard

Editor-in-Chief

DouglasB.Berkey,DMD,MPH,MS ProfessorEmeritus, SchoolofDentalMedicine, UniversityofColorado, Aurora,Colorado

AssociateEditor

DanielM.Castagna,DDS AssociateProfessor,DepartmentofPreventiveandRestorativeDentistry, UniversityofthePacific,ArthurA.DugoniSchoolofDentistry, SanFrancisco,California

P.MarkBartold,DDSc,PhD,FRACDS(Perio) ProfessorEmeritus SchoolofDentistry, UniversityofAdelaide Adelaide,Australia

RobBerg,DDS,MPH,MS,MA ProfessorandChair, DepartmentofAppliedDentistry, UniversityofColoradoSchoolof DentalMedicine, Aurora,Colorado

TylerH.Berkey,DMD GeneralDentist Aurora,Colorado

FionaM.Collins,BDS,MBA,MA ConsultantandEditor, GeneralDentist Longmont,Colorado

AnthonyJ.DiAngelis,DMD,MPH ChiefofDentistry, HennepinCountyMedicalCenter, Professor,UniversityofMinnesota, SchoolofDentistry, Minneapolis,Minnesota

RaulI.Garcia,DMD,MMedSc ProfessorandChairman, DepartmentofHealthPolicyandHealthServicesResearch, BostonUniversitySchoolofDentalMedicine, Boston,Massachusetts

MichaelSchafhauser,DDS GeneralDentist, St.Paul,Minnesota

JoeVerco,DClinDent PaediatricDentist NorthAdelaide,Australia

DENTALABSTRACTS

MAY/JUNE2025

VOL.70 No.3

Commentary

MeaningfulConnections166

BuildingConnections

MentoringandDEI167

InclusivityinMentoringRelationships

InclusioninDentistry

TheFrontOffice

Accommodation172

MakingReasonableAccommodations

CareConvergence173 InstitutingCollaborationsBetweenDentalandMedical CareProviders

CommunicationPolicies175 KeepingCommunicationSystemsCurrent Deepfakes176

TheDangerofFakesSpreadingMisinformation DentalTechnology177

InvestinginTechnology

HiringFramework179 RecruitingAssistantsandHygienists

Leadership180

ReachingLevelIVLeadership

Marketing181

ConvertingCallerstoNewPatients

PatientsReferringFriendsandFamily

PersonalityTypology184 Dentists’ PersonalityTraitsandDecision-Making Behaviors

SearchEngineOptimization185 EnhancingOnlineVisibilityforYourPractice

TheBigPicture

CurrentTrendsinDentistry187 WhatDentistsareDoingtoRemainSuccessful DentalCaries189

EarlyChildhoodCariesWorldwidePrevalence ApproachestoReduceEarlyChildhoodCaries

FutureofDentistry192 CurrentTrendsandAdvancesinDentistry GenerationalTransitions195 ChangingProfilesandPracticeModalities

PediatricDentistry

ChatGPT197 PediatricEducationMaterialPreparedByChatGPT DentalTrauma198 EpidemiologyandManagementofPediatricDental Trauma

EarlyChildhoodFluoride200 DispensingFluorideToothpasteToYoungChildren MyofunctionalTherapy201 NeurologicalRe-EducationThroughMyofunctional Therapy

Hands-On Cannabis204 DamagetoOralStructuresCausedByFrequent CannabisUse

E-CigarettesandOralCancer205 PatientGuidanceRegardingE-cigarettes

Endodontics207 IntraoperativeandPostoperativeTipsforRestoring EndodonticallyTreatedTeeth

FacialEsthetics210 ExpandingOralHealthCaretoFacialAesthetics ConcernsWhenDentalProfessionalsAddAesthetic Treatment

Training,Regulation,Safety,andEthics

IntraoralScanners213 ExpansionofIntraoralScannerUses

LipCancer217

IdentifyingLipCancer

OncologyandOralHealthCare218 ConcernsForDentalTeamsCaringForPatientsWith Cancer

DENTALABSTRACTS

Oral/SystemicConsiderations221

Non-HealingExtractionSocketProtocol

Peri-Implantitis223 NonsurgicalTreatmentforPeri-implantitis

Inquiry

AlveolarRidgePreservation226 ReducingAlveolarBoneRemodelingAfterExtraction

AntibioticsandExtractions/Implants227 ProphylaxisWithAntibioticsBeforeExtractionsin High-RiskPatients

AntibioticsUsedtoAvoidEarlyImplantFailure

CognitionandChewing229

MasticatoryFunctionandCognitiveStatusinOlder Adults

ToothLoss,CognitiveImpairment,andDementia

HalitosisandGIDisorders231 IdentifyingHalitosisRelatedtoGIDisorders

Oral/SystemicConnections233 LinksBetweenFlossingandCardiovascularDiseaseRisk

PediatricDentistryandSDF/ART234 ComparingSDFandARTasTreatmentForEarly ChildhoodCaries

ProbioticsandPeriodontitis235 CombiningProbioticswithPlaqueRemoval

SelectiveCariesRemoval237 Longer-termEvaluationofSelectiveCariesRemoval andCalciumHydroxide

Extracts

239 LivingLongerandBetter DistractedVersusMindfulEating

DentalWorld

FromtheExecutiveDirectore1 FromtheInternationalPresidente2 FromtheInternationalPresident-electe3 FromtheInternationalVicePresidente4 SectionNewse5

Notes TofacilitatetheuseofDentalAbstractsas areferencetool,allillustrationsandtablesincluded inthispublicationarenowidentifiedastheyappear intheoriginalarticle.Thischangeismeanttohelp thereaderrecognizethatanyillustrationortable appearinginDentalAbstractsmaybeonlyoneof manyintheoriginalarticle.Forthisreason, figure andtablenumberswilloftenappeartobeoutof sequencewithinDentalAbstracts.

StandardAbbreviations

Thefollowingtermsareabbreviated:acquiredimmunodeficiencysyndrome(AIDS),humanimmunodeficiency virus(HIV),andtemporomandibularjoint(TMJ).

COMMENTARY MEANINGFULCONNECTIONS

BuildingConnections

BACKGROUND

Althoughtodaywehaveunprecedentedconnectivity,social disconnectionisrampant.Face-to-facecommunicationisuncommon,whichaffectsthequalityofourpersonalrelationships. SomeofthiscanbeblamedontheCOVID-19pandemic,when wewereoftenseparatedfromlovedones,ourcommunities, andoursupportsystems,leadingtolonelinessandisolation.Today’spoliticallypolarizedenvironmenthasonlyexacerbatedthe problem.TheUSSurgeonGeneraldeclaredanationwide epidemicoflonelinessandisolationin2023thatwasevidenced byreportsofexperiencinglonelinessfromabouthalfofthepopulation.Humansarehardwiredtoconnect,withsocialsupports andhumanconnectionsaffectingphysicalhealthandwell-being througheffectssuchassupportforourbodymassindex,decreasesindepressivesymptoms,fewersymptomsofposttraumaticstressdisorder,andbettermentalhealth.Socialdisconnectionshavenegativeeffectsonmortalityandincreasethe riskforcardiovasculardisease,dementia,stroke,depression, andanxiety.Fosteringmeaningfulconnectionscanbeachieved throughsimpleandsometimesobviousactivities,includingmindfulcommunication,gratitude,andcuriosityratherthanjudgment.

MINDFULCOMMUNICATION

Digitalsignalsandnotificationscanmakeithardtofocusorfree ourselvesuptopracticeempathyindentistryandindailyinteractions.Mindfulnessistheabilitytobeinmoment-by-moment nonjudgmentalawarenessofourthoughts,feelings,bodysensations, andenvironment.Thisawarenessleadsustobetterunderstandthe perspectivesandemotionsofothersaswellashowwecanbest respondtotheirneeds.Insteadofplanningwhatwewillsaynext, weshouldlistencarefullytoothersandnoticetheirappearance, emotions,andbodylanguage.Allowingyourheartandmindto opentosocialinteractionsaswellasyourownemotionsandbody responsescanleadtoamorethoughtfulresponseandengagement.

EXPRESSINGGRATITUDE

Whenweexpressandreceivegratitude,relationshipswithone anothercanbebirthed,maintained,andstrengthened.Gratitude

strengthensromanticrelationshipsandfriendshipsandinspires coworkerstobemorehelpful.Notonlytheexpressionofthanks butalsoourengagementinreflectiononthoseforwhomweare gratefulcanhavepowerfulin fluencesonoursenseofconnection. Ourthankfulnesscanshowothersthevaluetheyoffertoour lives.Buildingacultureofgratitudeamongthedentalteamand practicecreatesahealthyenvironmentthatisfullofpositive emotionsandlesshostility.

CURIOSITYRATHERTHANJUDGMENT

Judgingotherpeopletendstopushthemaway,butasking questionshelpsusbetterunderstandandvaluetheirmotivations,perspectives,andbackground.Sincereinterestin learningaboutothersratherthanfocusingonourselvesbuilds connections.Remainingcuriousopensusuptodeeperand moremeaningfulrelationshipsthatweotherwisecouldmiss outon.

ClinicalSignificance

Humanconnectionisanessentialfoundationthat shouldbethecenterpieceofourdentalpracticesas wellasourpersonallives.Notmakingconnections withothersleadstocompromisedhealthandwellbeing.Thestepstobuildingconnectioncanbesmall butoffertheopportunitytolivelongerpersonallives, tohavelongerandmoresatisfyingcareers,andto createthrivingcommunities.

YamamotoKK:Cultivatingmeaningfulconnectionsindentistry andbeyond. JCalifDentAssoc 53:2450327,2025

Reprintsavailablefrom KKYamamoto,CollegeofDentalMedicine,CaliforniaNorthstateUniv,USA;e-mail: Karisa.Yamamoto@cnsu.edu

MENTORINGANDDEI

InclusivityinMentoringRelationships

BACKGROUND

Inmentoring,amoreexperiencedindividual(thementor) guidesalessexperiencedindividual(thementee)andteaches, sponsors,advises,andservesasarolemodelfortheusually youngermenteetowardthedesiredgrowthinmutuallyde fi ned goals.Bothpartiesbene fi tfromthisrelationship,andanyorganizationinwhichthementoringtakesplacealsobene fi ts,with betterrecruitment,moreassuredretention,andacohesive workforce.Goodmentoringexperiencescanbeidentifi ed throughseveralcharacteristics(Box1).Anoverviewofthe variousmentoringmodelswasgiven,alongwithanexplanation ofculturalinclusivityinmento ringunderrepresentedgroupsin healthprofessionsandsuggestionsregardinghowmentoring canenhanceeffortstoachievediversity,equity,andinclusion (DEI)indentistry.

MENTORINGMODELS

CoachingandSponsoring

Severalfactorscontributetothechoiceofmentoringmodel that fi tsasituation( Box2 ).Theseincludethementee ’sneeds, thementor’savailability,capacity,andskillset,andthetypeof mentoringthat fi tsthesituationandtypeofhelpneeded.Among theapproachesarecoachingandsponsorship. Coaching isa componentthatusesmentorswhoarewell-informed,strongly skilledininterpersonalrelations,abletoperformactivelistening well,andcapableofcreatingajudgment-freeenvironment. Sponsorship ,whichinvolvesadvocatingforthementeeand increasinghisorhervisibility,isariskierapproach,withthe sponsoringmentorriskinghisorherreputationshouldthe menteebeunsuccessful.

InformalandFormalMentoring

An informalmentoring approachcandeveloporganicallyor throughself-selectionbymentorormenteeandcanbeintegratedintovariousmentoringmodels.Theinformalapproach hasnoformalstructureortraining,nopresetgoals,andallowsfor fl exibilityandadaptationovertheevolutionofthe relationship.Amorerelaxedand fl uiddynamicdevelopsbetweenmentorandmentee.Incontrast, formalmentoring is highlystructured,withsettrainingroutinesandspeci fi cgoals. Mentorandmenteemustcommittofollowtheguidelinesand expectationsandadheretotheframeworkoftheformal model.Itcanalsobeintegratedintodifferentmentoring situations.

TraditionalMentoringandPairing

Traditional1-on-1mentoring,whichisalsocalled dyadic or vertical mentoring,involvesahighlyexperiencedprofessionalguidinga lessexperiencedmenteeandfocusesonpersonalsupportand long-termprofessionalrelationships.Surgicaltraininginthe20th centuryfollowedthismodel. Peermentoring pairsstudentswith studentsoryoungprofessionalswithyoungprofessionalstoprovidemutualsupportandcollaborativelearning.Itcanalsoincludea seniorlevelfacultymentor.Onthe flipside, reversementoring pairs youngermentorswitholdermenteestoshareknowledge,often thatrelatedtoculturaldifferencesortechnology.

Group-focused,E-mentoring,andFunctionalMentoring

Asinglementormayworkwithmultiplementeesorasingle menteemayworkwithseveralmentorsin group or multiple/ constellation/team-basedmentoring. Thegoalistoencourage diverseperspectivesandcollectiveproblem-solvingactivities. In e-mentoring,digitalplatformsconnectmentorsandmentees acrossgeographicboundariestomakementoringmoreaccessibleand flexible. Functionalmentoring isproject-focusedand pairsmentorandmenteeforspeci ficskilldevelopmentor projectcompletion.

MosaicMentoring

Inadditiontoallofthesemodels, mosaicmentoring createsa networkofmentorsfromdiversebackgroundsandexpertise tosupportdifferentaspectsofthementee’sdevelopment.This approachcanbeusedtoacknowledgedifferencesandbridge gapsthatcouldotherwisecreatebarriers,oftenforperson groupswhoareunderrepresentedinhealthcare.Inthisway, theseindividualscanbesupportedintheirquesttoreachprofessionalgoals.Mosaicmentoringusesaculturallyresponsive approachtohelpsupportthementeeinmeetingneedsandgoals.

CULTURALINCLUSIVITYINMENTORSHIP

Viewingmentoringthroughthesocialconstructframeworkrevealstheimportanceofcommunityinmentoring.Socialinteractionsandinterpersonalexchangesarein fl uencedbythe perceptionsofbothmenteeandmentor,leadingtoculturally informedrelationships.Socialcapitalisrelatedtotheconnectionsamongindividualswholiveandworkinacommunity andcontributetotheeffectiveo perationofthatenvironment. Socialcapitalmodelsshowhowrelationshipsandnetworks contributetothesuccessanddevelopmentofindividualsand groups.Inclusivementoringvaluesandappreciatestheculture

Reciprocity: Ensureequalengagementfromboththementor andthementee,fosteringabalancedandinteractive relationship.

Learning: Focusonacquiringknowledgethroughactive participationandengagementinthelearningprocess.

Relationship: Establishandmaintaintrustasthefoundationof thementoringrelationship,ensuringbothpartiesfeelsecure andvalued.

Partnership: Adoptacurrentparadigmthatencouragesactive involvementandcontributionfrombothpartnersinthe mentoringrelationship,promotingmutualgrowth.

Collaboration: Engageinthesharingofknowledge,learning together,andbuildingconsensustoenhancethementoring experience.

Mutuallydefinedgoals: Clearlyarticulateandagreeon learninggoalstoensureasatisfactoryandpurposeful mentoringoutcome.

Development: Focusondevelopingskills,knowledge, abilities,andthinking,guidingthementeefromtheircurrent statetotheirdesiredfuturestate

(CourtesyofChatmonBN,CampbellKM,MoutonCP,etal:Inclusivityin mentorship:Shiftingparadigmsofinclusionindentaleducation. DentClin NAm 69:131-144,2025.)

andbackgroundofmentorsandmenteesandaddressesthe needforadiverseworkforceinhealthcaretoachievebetterpatientoutcomes,moreful fi llingmentorandmenteelives,anda meansfordealingwithbias,stereotypicthreats,andlackofculturalcompetence.

Barrierstoinclusivementorshipcanincludelowmentorexpectations,goalmisalignment,andlimitedmotivationsformentorship.Ifmenteesexperiencesituationsthatblocktheirsuccess andleadershipdevelopment,thehealthcareinstitutioncanalso suffer.Thecreationofinclusivementoringexperiencesrequires definingoutcomes,aligningexpectations,supportingmenteeaspirations,andtrainingmentorstodevelopskillsincrossculturalcommunication.Mentorsmustbewillingtoundergo appropriatetraining,accessresourcesonhowtoworkwithindividualsfromdifferentbackgrounds,andseekinformationon howtorecognizethenegativeimpactofbiasonthementoring relationship.Whenthediversebackgroundsandperspectives ofmenteesareunderstood,thementoringrelationshipis enhancedandthementeethrives.Menteestendtodesireto mirrorthecommunitytheyserve,whichundergirdssocialjustice andtheneedforequitablerepresentationandinclusivity.

USINGMENTORINGTOACHIEVEDEIIN DENTALEDUCATION

Box2. MentoringModels

Mosaicmentoring: Integratesmultiplementoringrelationshipsto addressthediverseneedsofmentees.Thisapproach leveragesdifferentmentors’ uniquestrengthstoprovide comprehensivesupport,fosteringpersonal,professional,and academicgrowth.

Dyadic-traditionalone-to-one: Atraditionalmentoring relationshipwhereonementorsupportsonementee.This modelfocusesonbuildingastrong,personalconnection, allowingfortailoredguidanceandsupportbasedonthe mentee’sspecificneedsandgoals.

Group/team-basedmentoring: Involvesmultiplementorsand menteesinteractingtogether.Thiscollaborativeapproach encouragespeerlearningandsupport,enhancesnetworking opportunities,andfostersasenseofcommunityandshared learningamongparticipants.

Functional/skill-basedmentoring: Focusesondeveloping specificskillsorcompetencies.Mentorswithexpertisein particularareasprovidetargetedguidanceandtrainingtohelp menteesenhancetheirabilitiesandachievetheircareeror academicobjectives.

Peermentoring: Involvesindividualsatsimilarstagesintheir careersoreducationsupportingeachother.Thismodelfosters mutuallearningandunderstanding,offeringrelatableadvice andexperiencesthatcanbeparticularlyvaluablefornavigating sharedchallenges.

E-mentoring: Utilizesdigitalcommunicationtoolstoconnect mentorsandmentees.Thismodelprovides flexibilityand accessibility,allowingforremotementoringrelationshipsthat cantranscendgeographicboundariesandoffercontinuous supportthroughvirtualinteractions.

(CourtesyofChatmonBN,CampbellKM,MoutonCP,etal:Inclusivityin mentorship:Shiftingparadigmsofinclusionindentaleducation. DentClin NAm 69:131-144,2025.)

thestudents.However,thecurrentdentalschoolfacultyandthe communityofpracticingdentiststendtobelessdiversethanthe studentsenteringdentalschoolorthedentalworkforce.Mentoringisneededtoadvancetheinclusivitythatcanprovide neededdiversityinpractitionersandteachers.However,the goalsoftheindividualcanbeatoddswiththegoalsoftheacademicinstitution,whichcanlimitprogressinthisarea.

Theapprenticeshipmodelhasbeentheprimarymeansforpreparingthenextgenerationofdentaleducatorsandoralhealth carepractitioners.Technologyandexperientiallearningopportunitiesarenowprovidedtotrainstudents,withfacultydevelopmentopportunitiesusedtotransitionandretainthosewhoteach

Theacademicinstitutionshouldcreateanurturing,inclusive environmenttofostermentoringopportunitiesandrelationships thatpreparestudentsfortheirroleasdentalprofessionals.Mentoringhelpsthemprepareandnavigatechallengesandbarriers theymayface.Tocreateasuccessfulandeffectivementoringopportunityrequirestrustandsafety,diverseperspectives,cultural competenceandawareness,mutualrespect,learning,and growth,retentionandsuccess,andopportunitiestoexpand thementoringnetwork.Increatingauthenticandmeaningful mentoringrelationships,biascanbemanagedandproductivity andsuccesscanbesupported.Bothmentorandmenteeshould understandthegoalsoftherelationshipandthetraining.The mentorlifecycle modelcanachievethesegoalsthroughits Box1. CharacteristicsofGoodMentoring

matchingprocess,contracting,useofmentormodelsordiagnostictools,appraisal,andpeerandgroupsupervision.

Themosaicmodelcanbeespeciallyimportantwhenaddressing cross-culturalcommunicationandmentoringdyadsorgroups thatoftendon’tmatchtheculturalidentityofthementee.This modelfocusesonthevalueofthediverseperspectivesandexperiencesthementoringrelationshipoffersandsupportsanenvironmentwherementorsandmenteescanlearnfromone another.Addingthemosaicmodelensuresthatmentoringis bothinclusiveandadaptabletothementees’ variouscultural backgrounds,whichaddstotheeffectivenessandsatisfactionof thementoringencounter.

Dentalmentorsshouldunderstandissuesrelatedtosocialand ethnic/culturalidentitydevelopmentwhentheyareworking withmentees.Identityhasmultiplelayersandisshapedbysociety, politicalpowers,environmentalencounters,personalexperiences,andotherfactors.Cultureshouldbeunderstoodinthe contextofeachindividualandtrainingincorporatedthataddresses thetenetsofself-identity,community,andindividualneeds.

InclusioninDentistry

BACKGROUND

Inclusionorinclusivityhasbeenvariouslydefined,buttheconcept’simportanceisclearwhenitiscoupledwithdiversityandequity(DEI)(Box1).ThediversityoftheUSpopulationhasbeen changingandincreasingsignificantly,sothatby2034,thenumber ofadultsoverage65yearswillbegreaterthanthenumberofchildrenunderage18yearsandnon-Hispanicwhitepersonswillno longerbethemajoritygroup.Ifhealthcareprovidersoptimally mirrorthepopulationdemographics,significantchangesinthis workforcewillbeneeded(Figure1).Decadesofinequityand injusticehaveoccurred,sothathistoricallyunderservedand marginalizedgroupsaremoresusceptibletosignificanthealth problemsandhighermortality.Morerecently,strongevidencebasedtieshavebeenestablishedbetweenmedicineanddentistry, withgoodoralhealthneededtoensureoverallhealth.Todevelop aworkforcethatmirrorsthepopulation,dentistrywillneedto managechallengesassociatedwithmovingforwardandinstitute approachesthatwillcreateinclusiveenvironments.

CHALLENGESFACINGDENTISTRY

FromExclusiontoInclusion

Dentistryhasoftenbeenexcludedfrommedicalhealthcare becausethosewhotreatedteethweren’tconsideredqualified

ClinicalSignificance

Effectivementoringprogramsfordiversegroupsofindividualsmustaddressthesocialandethnic/cultural identitydevelopmentofeachperson.Mentorsmust beawareofthemanylayersofidentityandhowthey areshaped.Inclusivementoringindentaleducation isanimportantmeanstoachievethegoalofDEIand tocreateadiverse,supportive,andsuccessfulprofessionalenvironmentfordentalpractitioners.

ChatmonBN,CampbellKM,MoutonCP,etal:Inclusivityin mentorship:Shiftingparadigmsofinclusionindentaleducation. DentClinNAm 69:131-144,2025

Reprintsavailablefrom BNChatmon,1900GravierSt,Off5B14, NewOrleans,LA70112,USA;e-mail: bnwoko@lsuhsc.edu

tobeseenashealthcareproviders.Broaderhealthcarediscussionsanddecisionshaveomitteddentalinput,seeingdentistryas apracticethatisbetterseenasatradeandispracticedindependentlyratherthancollaborativelylikemedicine.Teethhavebeen viewedasdisposableandinevitablytobelost,whichlowered theirvalue.Inaddition,theconceptoforalhealthcarewasn’t embracedinthewaythatmedicalspecialtieswere.Asaresult, dentistrywaschallengedandhashadtoaddressthedynamics ofthedentalteam,themedicalsystem,andoralhealthdisparities, amongotherin fluences.

Amoreholisticandinclusivecaremodelisneeded,onethat viewsallthebodysystemsandthemouthasimportantcomponentsofhealthcare,puttingallcareprovidersonanequal footing.Humanmicrobiomeresearchhasindicatedtheneedto includetheoralcavityaspartofthebodyinachievinghealth carefortheentireorganism.

IntegratingtheDentalWorkforce

Dentalprofessionalswhopracticeoralsurgeryoftenhaveboth dentalandmedicaldoctoraldegrees,allowingthemtobe includedmorereadilyinobtaininghospitalprivileges,accessto surgicaltime,andrespectinboththedentalandmedicalworkforcesandinthegeneralcommunity.Incontrast,dentalhygiene

Box1. ExamplesofDefinitionsforInclusionintheContextofDiversity,Equity,andInclusion

AmericanDentalAssociation

Inclusion:Enablesustostrivetohaveallpeoplerepresentedandincludedandmakeeveryonefeelasenseofbelonging,notonlyfortheir abilities,butalsofortheiruniquequalitiesandperspectives.

AmericanDentalEducationAssociation

Inclusion:Thepracticeofleveragingdiversitytoensureindividualscanfullyparticipateandperformattheirbest.Inclusionisshared responsibilityofeveryonewithinthecommunity.Aninclusiveenvironmentvaluesdifferencesratherthansuppressingthem;promotesrespect, success,andasenseofbelonging;andfosterswell-beingthroughpolicies,programs,practices,learning,anddialogue.

FDIWorldDentalFederation

NationalHealthPolicy:ThenewdefinitionoforalhealthadoptedbytheFDIWorldDentalFederationGeneralAssemblyin2016haslaidthe frameworktoallowtheprofessiontoreflectonwhatoralhealthencompassesanditsimplicationfornationaloralhealthpolicies.Further,this definition,whichwasapprovedbyconsensusbyFDIconstituents,favorstheinclusionoforalhealthinallhealth-relatedpolicies...

OurValues

Cultureofinclusiveness:Wedeliberatelyandmeaningfullyengageandseekrepresentationfromthediverserangeoforalhealthprofessionals andthecommunitiesandindividualstheyserve.Thisisparamounttoachievingourmission.

InternationalAssociationforDentalResearch

SCIENCEPOLICY: Diversity,Equity,Inclusion,Accessibility,andBelongingStatement: Inclusionistherecognition,appreciation,anduseofthe talentsandskillsofallbackgroundsbycreatingawelcomingenvironmentthroughtheproactiveidentificationandremovalofthebarriersthat impedethesuccessofall.

NationalAcademiesofSciences,Engineering,andMedicine

EndingUnequalTreatment:StrategiestoAchieveEquitableHealthcareandOptimalHealthforAll.

Inclusion:Effortsusedtoembracedifferences;alsousedtodescribehowmucheachpersonfeelswelcomed,respected,supported,andvalued inagivencontext.

[WhiteHouse]ExecutiveOrder(14035)onDiversity,Equity,Inclusion,andAccessibilityintheFederalWorkforce

Theterm “inclusion” meanstherecognition,appreciation,anduseofthetalentsandskillsofemployeesofallbackgrounds.

(CourtesyofHalpernLR,KasteLM,SoutherlandJH:The “I” indiversity,equity,andinclusion:Thechallengeofinclusivityindentistry. DentClinNAm 69:1-15,2025.)

isoftenperformedbywomen,whohavehistoricallyfacedgender barriersaswellasadverseattitudestowardanypromotions, progress,andrespectfromotherhealthpractitioners.Increasing

preventionandaccessaregoalsrecognizedasimportantto healthcare,withdentalhygienistsactuallyservingaspreventive actionspecialists.Yetjust24dentalschoolsofferdentalhygiene

Figure1. Comparisonofselecteddemographicpercentagescirca2020bytotalpopulation,dentistworkforce, firstyeardentalstudents,dentalschool facultymembers,anddentalschooldeans.(CourtesyofHalpernLR,KasteLM,SoutherlandJH:The “I” indiversity,equity,andinclusion:Thechallengeof inclusivityindentistry. DentClinNAm 69:1-15,2025.)

programsandjust7%oftheseprogramscollaboratewithprogramsfordentalpractitionertraining.Aco-educationalgapexists thathasnotyetbeenresolvedevenwhentheprogramingdeliberatelypromotescollaborativepractices,includinginterprofessionaleducation(IPE).

Actionstohelpintegrateratherthanseparatethemedicaland dentalprofessionshavebeentaken,butuntildentistryisanintegralandacceptedcontributortotheprocess,noviablesolutions willbedevelopedtoaddresstheoralhealthcrisis.Dentistryhas beenexcludedfromUShealthcarecoverageviainsurance,with differentresponsescreatedinbothinsurancecoverageand managedcaresituations.Dentistryisn’tconsideredafullpartner inthe2003InstituteofMedicine(IOM)reportonUnequalTreatment.AlthoughMedicaidcoversoralhealth,eachstateisallowed tosetlimitstotheextentandtypeofcoverage.Medicarehasprovidedminimalcoveragefordentalstructuresorprocedures,and thedoublestandardbetweenmedicineanddentistryisseeninaccesstooralhealthcare,stilloftenviewingthemouthasoutside theconceptofhealth.

Seeingoralhealthincludedandintegratedintoprimarycareis widelydesired.TheAssociationofStateandTerritorialDental Directors(ASTDD)participatesinpolicydevelopmentandhas emphasizedtheimportanceofintegratingoralhealthintoprimarycareintheirpolicystatement.TheASTDDrolecaninfluencetheallocationofresourcestothevariousstatechief healthof ficers.

CREATINGINCLUSIVEENVIRONMENTS

InclusivityinResearchandProgramFunding

TheNationalInstitutesofHealth(NIH)hasdevelopedcrossinstitutecollaborations,someofwhichintersectwithdentistry. Inaddition,federalagencieshavesupportedtrainingforhealth careproviderstodevelopaprimarycareworkforcethatcan addresstheexpansionoftheUSpopulation.The firstphasesof theseprogramsincludedmedicineanddentistry.

HealthProfessionsEducationandInclusivity

AssociationalActivity

TheAmericanDentalEducationAssociation(ADEA)StrategicDirectionsWorkgroupfor2019-2022emphasizedthe importanceofdevelopingandsupportinginclusiveenvironmentsamongfaculty,students,staff,andadministrators.Inaddition,theInterprofessionalEducationCollaborative(IPEC)

providedthemeansforinvolvingdentistryinIPEandcollaborativepractice.However,recentreportsdonotincludedentistry intheoutcomesassessmentofIPE.Dentistrymustengageboth externallyandinternallytoexplorehowtoexpandeffortsto promoteinclusivityindentalpractice.

IntersectionalityandInclusion

Intersectionalityreferstotheefforttoprovideusefulandactionableinformationthatdealswithinequalitiesandincorporatesinclusionintheworld.Theeffortsaresimilartomediationbut focusonidentifyingandnamingthecomponentstobeaddressed. Anapplicationwasseeninthelackofequalityacrossallracial/ ethnicgroupsregardingtheincreasedrepresentationofwomen indentistryintheUSandUK.Asthebreadthanddepthofintersectionalityhaveintensi fied,somespeci ficfactorswereidenti fied thatmayaddtoinequalitiesanddisparities.Theseincludesocial determinantsofhealthandpersonalfactors,suchasproficiency inEnglish,health/dentalinsurancecoverage,religiouspractices, andgenderidentity.

ClinicalSignificance

Asdentistryevolves,inclusionisavitalaspectbothin dentaleducationandinexpandingtheworkforce. However,dentistrymustbepartofthediscussions anddecision-makingprocessesinvolvedinoverall healthcare.Oralhealthmustbeincludedingeneral healthinitiativesbasedontheevidence-supportedbidirectionalityoforalandoverallhealth.Dentaleducationandpracticemustdevelopinclusive,welcoming, andengagingenvironments.Theoralhealthcare teammembersshouldreceiveproperrespectand collaborativeopportunitieswithotherhealthcareprovidersastheyaddresshealthdisparitiesandinequalities.

HalpernLR,KasteLM,SoutherlandJH:The “I” indiversity,equity,andinclusion:Thechallengeofinclusivityindentistry. Dent ClinNAm 69:1-15,2025

Reprintsavailablefrom LRHalpern,DeptofDentalMedicine/ WMC/NewYorkMedicalCollege,MaceyPavilion,100Woods Rd,Valhalla,NY10583,USA;e-mail: halpernl@nychhc.org

THEFRONTOFFICE ACCOMMODATION

MakingReasonableAccommodations

BACKGROUND

TheAmericanswithDisabilitiesAct(ADA)allowsforreasonable accommodationstobemadesothatemployeeswithdisabilities cancontinuetoperformtheessentialfunctionsoftheirjobs.The processofseekingandobtainingsuchanaccommodationmaybe inquestioninsomesituations.Acasewaspresentedinwhichthe claimforaccommodationwasdenied.

CASEREPORT

OiryawaspromotedtotrainingcoordinatorattheMando AmericanCorporationbuthadseveralmedicalconditions thatimpactedtheworkingsituation.Theemployeehandbook statedthatemployeesseekingareasonableaccommodation foradisabilityhadtonotifythehumanresources(HR)department,butMandohadtherighttorequestmedicaldocumentation.Employeeswhowantedtoreportdiscriminationor retaliationalsohadtocontactHR.AlthoughMandoallowedemployeestotakeanapduringlunch,sleepingonthejobwasone ofthebehaviorsthatcouldresultinimmediatetermination. Oiryastatedthathissupervisorswereawareofhismedicalissuesandhadaccommodatedhimwhenhehaddif fi cultysleeping atnightandsleptatwork.Inaddition,theyknewthathesometimestookover-the-countermedi cationsthatresultedinmakinghimsleepy.

ThreecoworkersreportedOiryawasasleepathisdeskwhile notonanybreak,andthesupervisorissuedaLastChance Agreementratherthanaterminationnotice.Theprocess withthisagreementrequiredhimtorereadthehandbookand signaformstatinghehadreaditandwasawareofitscontent regardingthecompany ’smisconductpolicy.Hewasrequired tomeetallofthehandbook’sterms,beunderthetermsfor 2years,and,shouldhenotadheretotheterms,faceimmediate termination.Oiryaexplainedtheaccommodationsthathad beenextendedtohimandrefusedtosigntheagreement.He askedthathiscurrentsupervisor granthimaninteractiveprocess,includinganopportunitytorespondinwritingtothe agreement,advancenoticeinaformalwrittencomplaintstating thebreachesofpolicythatwerebeingalleged,afullevidentiary hearing,awrittendecision,andanopportunitytoappeal.His opinionwasthattherewasaninherentaccommodationinthe formofas-neededbreaksintheADApolicy.TheHR

departmentdecidedtoputeverythinginOirya ’ s fi leandnot pursuetermination.

Amonthlater,Oiryasufferedfoodpoisoningatacompanypizza partybutrecoveredafterpharmacologicaltreatment.Ten monthslater2coworkersapproachedhisnewsupervisorwith picturestakenthatshowedOiryaasleepathisdesknotduring lunch.TheHRdirectoragreedtotheterminationofOirya.He suedMando,sayinghehadn’tbeengivenareasonableaccommodationandwasbeingdiscriminatedagainstforrequestinganaccommodation.Severalmonthslater,Oiryaaddedacomplaint thathewasbeingwrongfullyterminatedandacomplaintthat hewasavictimofdisparatetreatmentbecauseanother employeeofMandohadbeengivenanaccommodationafterbeingfoundsleepingonthejob.Ajudicialmagistratedeniedboth claimsasbeinguntimely filed,andtheappellatecourtupheld thatdecision.

APPLICATIONOFADAPOLICYREQUIREMENTS

Theappealscourtshowedthattheplaintiffhadtoshowthat thedisabilityclaimedmustbecoveredundertheADA,that heorshewasquali fi ed,andthatheorshewascausedtosufferunwanteddiscriminationbecauseofthedisability.The courtalsoexpandedonthecharacteristicsofareasonableaccommodation,notingitwouldbeamodi fi cationoradjustmentthatallowstheemployeetoperformessentialjob functionsandcanincludevariousmodi fi cationsofthework scheduleoremploymentpoli cies.Onceclaimingadisability, theemployeehastheburdenofidentifyingthetypeofaccommodationheorshebelievesisreasonableandthataddressestheissuesheorsheisfacing.Theemployer’sduty toprovidetheaccommodationisn’ttriggeredunlessthe employeespeci fi callydemandsit.Theemployermustthen engageinaninformal,goodfaith,interactiveprocessthat statestheemployee’slimitationsandtheappropriatenessof theaccommodation.

Oiryarequestedafull,formalinvestigationofthecomplaint,an opportunitytodefendhimself,therighttomeaningfuldueprocess,andanappealifdesired.ThecourtfoundthatOiryadidn’t speci ficallydemandanaccommodationanddidnotshow MandodeniedhimareasonableaccommodationorthatMando

hadadutytoinitiateaninteractiveprocesswithhim.Thecourt statedthatheshowedhewasengagedinstatutorilyprotected conductandhadexperiencedanadverseemploymentaction, butcouldnotshowthatanycausalconnectionbetween theseelementswaspresent.Theretaliatorybehaviorwasn’t acceptedbecauseofthe10-monthdelay,sotheclaimofretaliationfailed.

ANALYSIS

Employeeswhohaveadisabilityofsometypeandrequesta reasonableaccommodationtocontinuemeetingthedemands oftheirjobcanbefoundinmanysituations.Some personsmaystatethattheindividualshouldsimplyseek anotherjob,andsome findthatsuchaccommodation shouldn’tbeconsideredabigdealandemployeesareentitled tosuchmeasures.

CARECONVERGENCE

ClinicalSignificance

TheADAisthelaw,andareasonableaccommodation requestthatmeetstherequirementsshouldbeinstituted.Withtheshortagesintheworkforcethatexistin thedentalcommunity,it’sclearlydifficultto findand keepgoodemployees.Negotiationscarriedoutin goodfaithshouldbeundertakentoidentifyreasonable accommodationsthatworkforbothemployeesand employers.

JerroldL:Onbeingaccommodating. AmJOrthodDentofacial Orthop 166:616-618,2024

Reprintsnotavailable

InstitutingCollaborationsBetweenDentalandMedical CareProviders

BACKGROUND

Technologicaladvances,afocusonpersonalizingcare,andthe knowledgethatoralandsystemichealthconditionsareconnectedhasledtotheconceptofcareconvergence.Care convergencereferstotheintegrationofmedicalanddental care,withabetterunderstandingthatnotjustoralhealth butoverallhealthprofilesareimportanttopatientmanagement.Amultidisciplinaryapproachwithcollaborationandinformationsharingamongprovidersofbothoralhealthand systemichealthprovidesaholisticenvironmentforcare.The advantagesofcareconvergenceand5strategiesforcombining carewerediscussed.

ADVANTAGESOFCARECONVERGENCE

Convergentcaremodelscanimprovepatientoutcomesbyaddressingsystemicconditionsthatcanin fluenceoralhealth.This collaborationcreatesacompetitiveedgeforthedentalpractice, whichcanoffervariousservicesandnewrevenuestreamsthat alignwithoutcome-basedcare.

Thesuccessfulintegrationoforalandsystemichealthcareusually restsonspeci ficstrategiesthatarethefocusofpractice.Rather thandoingmore,dentalpracticescandothingsdifferently,so thattheycanadaptexistingwork flowmodelsandavoidovertaxingtheteam.

STRATEGIESFORCOLLABORATION

UsingDiagnosticTools

Systemichealthassessmentscanbedoneaspartofthepatient’ s routineoralhealthcarevisits.Variousdiagnostictoolscanfacilitatetheincorporationoftheoverallhealthassessments, includingthefollowing:

Duringroutinecleanings,dentistscanusefullyintegrated work flowstoadministerscreeningquestionnairesfordetectingconditionssuchassleepapnea.Thesework flowsmayconnecttoanetworkofsleepspecialistsandprovide administrativesupportforthepracticetoprovideadiagnosis, treatment,andpaymentacrossthemedicalanddentalplans. Duringchairsidetime,thedentistcanobtainbloodsamples thatcanbeanalyzedformarkerstoidentifyinflammationor glucosecontrolproblems,forexample.Routinecheckups gainvaluewithoutinvestingsignificantfundsonnew equipment.

Salivarydiagnostictestsforperiodontalpathogensorinflammatorybiomarkerscanalsobeaddedchairside.Thispractice providesthedentalcareproviderwithactionableinsightinto thepatient’sdiseasestatusandhelpincraftingtreatment plans,providingfollow-upcare,andcollaboratingwithmedical careprovidersifasystemicproblemexists.Eventually,pointof-carediagnostictoolsmayoffertheabilitytoreliablydiagnosecommonoropharyngealcancers.Affordablepoint-of-

carediagnostictoolsmaysomedayusegenomicandprotein markeranalysisthatprovidesnoninvasive,real-timesolutions.

EnhancedCollaboration

Newwaystocollaboratecanbeusedtointegratethepracticesof medicalanddentalcare.Oneinnovativeapproachistoestablish partnershipswithlocalphysicians,endocrinologists,andcardiologists,whichcanfacilitatecross-referrals.Notonlycanthe dentalofficerefertothemedicalcareproviders,butmedical careproviderscanrefertodentalpractices.Forexample,patientswithhighC-reactiveprotein(CRP)levelscanbereferred toacardiologistforevaluation,andtheseproviderscanreferpatientstothedentistforperiodontalcare.Oftentelehealthplatformsareusedtoconsultwithspecialists,withthesevirtual collaborationsprovingbothcost-effectiveandtime-efficient whileensuringcoordinatedcarewithoutaphysicalreferral.

Cross-referralstodentalspecialistscanalsoprovidecareconvergencethatenhancesoutcomeswithfewchangesintheexisting work flows.Periodontalevaluationscanbecoordinatedbefore andduringorthodontictreatment,sothatperiodontalissues canbemanagedearly.Prosthodontistsalreadycollaboratewith periodontistsfororalrehabilitation.

StreamlinedProcessesandInformationSharing

Digitaltoolstodaycanallowforstreamlinedcommunication andfreeclinicalteamsfromrepetitiveadministrativetasks. Thiscanbeseeninaugmentedteams,electronichealthrecord (EHR)integration,andpatientmanagementsystems.Arti ficial intelligence(AI)enablesconvergentcarebyassistingclinical teamstoanalyzeandvisualizediagnosesandautomateprocesses,includingbilling,inventorymanagement,andcoordinationofcare.EHRsystemscanbeintegratedthroughpublicly availableapplicationprograminginterfaces,sothatdentists cansharecriticalhealthdatawithprimarycareproviders. Evenwithoutcompleteintegration,digitalsolutionscanfacilitatetheexchangeofreportsandreferrals,whichreduces administrativebarriers.Eventuallytheseintegrativeprocesses maybecomebundledasastandardoffering.

Patientmanagementsoftwarethatincludesspacefortracking nondentalhealthmetricsallowsforsharingwithpatients, payers,andmedicalprofessionals.Thiscanbepartofacomprehensivecareplanthattracksclinicaloutcomesandthetotal costofcare.

IntegrationofPreventiveCareintoRoutineAppointments

Thefocusofroutinecareappointmentscanbeexpandedto includepreventivemeasuresthataddressoverallhealth.Carious lesionsmaybetreatedthrough fl uoridevarnishapplicationsfor thoseathighrisk.Incipientlesionscanbeaddressedwith

innovativenoninvasivetreatmentsthatallowfortargetedremineralizationof “watchareas” beforemoreinvasiveprocedures arerequired.Thismaintainsthehealthofnaturaltoothstructuresandfreesupchairtimeformorecomplexprocedures.

Patienteducationismorereadilyundertakeninadentalappointmentthaninmedicalappointments.Patientscanlearnhoworal healthaffectsconditionssuchasheartdisease,diabetes,andpregnancycomplications.Thisachievesenhancedpatientawareness andencouragespatientstobemoreengagedinoralcareroutines.Inaddition,treatmentplanacceptancecanbehigher, improvingoutcomes.Thepatient’sneedsandcontextforthe visitareimportantcomponentsofthisintegration.Thedentist andteamshoulddeterminewhatisappropriateastheybuildtheir relationshipwiththepatient.

Value-basedCareDrivesLong-termSuccess

Value-basedcarepaymentmodelsanddentalbene fitdesignsthat encouragepreventionandcross-disciplinarytreatmentplansare requiredforthebestoutcomesofcareconvergence.Untilthese paymentmodelsareadopted,convergentcaremodelscan enhancethevaluetothepatientanddentalpracticeevenin fee-for-servicesituations.Private-paypracticesleadthewayin educatingandempoweringpatientstocarefortheirhealthand choosetreatmentandbene fitplansthatenablecareconvergence.Whileawaitingthebroaderadoption,dentalpractices canprovidecomplementaryservicessuchasbundledcarepackagesandoutcometracking.

CONCLUSIONS

Ratherthanrequiringdentalpracticeteamstodomore,care convergencemeansdoingthingsdifferently.Withthetechnologiescurrentlyavailableandinviewofthosecominginthenear future,dentalpracticescantakestepstointegratemedicalpursuitsintotheirexistingpatientwork flows.

ClinicalSignificance

Thecareconvergenceapproachwillenhancepatient outcomes,buildstrongerrelationshipsamonghealth careproviders,andpositiondentalpracticesinthe broaderhealthcareecosystem.Careconvergence shouldbeconsideredasastrongtoolforpractice growthandbetteroverallhealthforpatients.

FilipovaM:Careconvergence:5provenstrategiestoelevate dentalcareandpatientoutcomes. DentEcon 115:14-16,2025

Reprintsnotavailable

COMMUNICATIONPOLICIES

KeepingCommunicationSystemsCurrent

BACKGROUND

Updatestothevariousformsofcommunicationusedinadental practiceshouldbedoneregularlytomaintainaproperdialogue withpatients.Officepolicymanuals,healthhistoryforms,and theuseofelectronicanddigitalcommunicationformsshould bereviewedtoensurethatpatients’ preferencesarebeing used,theinformationiscurrent,andtheelectronicordigital communicationssystemsareappropriatelyprotectedfromunauthorizedaccess.

PATIENTCOMMUNICATIONPREFERENCES

Patientcommunicationchoicescancontributetoanincreaseinpatientnumbers,greaterlevelsofpatientsatisfactionandretention, andexpandingservicesandtreatmentacceptance.Theofficepolicy manualshouldspecifytheobjectivesofthepracticesothatthe dentalteamknowsthetargetedgoalsandhowtoachievethem.

Theuseofcontactmanagementsoftwarehasmadephonecalls topatientsregardingappointments,billing,andinsuranceissues theleastlikelymeansofcommunicationtobeselectedbypatients.Whenpatientsaregiventhechoice,mostwillselectemailortextsastheirpreferredmodeofcommunication.It’ s importantthatthepolicymanualsetsforththepractice’ s preferredproceduresforthiscontactandthatthepolicies ofHealthInsurancePortabilityandAccountability(HIPAA) arerespected.

Withthepreferenceforanelectroniccommunication,dental practitionershavelessphysicalorpersonalcommunication withpatientsbeforetheycomefortheirappointment.Thiscan beaddressedbytakingstepstobuildinstantrapportandcommongroundwithpatients.Thispatient-practitionerrelationship canresultinafullscheduleofpatients, filledhygienespots,a growthinpatientnumbers,andsuccessinmeetingproduction goalsandcollections.

Stepstotakeinbuildinggoodrelationshipswithpatientsinclude establishingcommonground;creatingrapportandtrustfrom the fi rstcontactmadewiththepatient;andprovidingclearexplanationsforpatients,whichmeanstakingcaretoavoidjargon, tonotspeaktoofast,andtonotmakestatementsabouttheprocedurethatareincompleteandcausefear.It’simportantto listenandmakeeyecontactwhenthepatientspeaks.Thedental teamshouldmaintaintransparencyintheircommunicationsso patientsarecompletelyadvisedandcanmakeanevidence-based decisiononcare.It ’sbesttotakethetimetoassesswhatthepatientknowsandthentailorfurthereducationtothatlevelof understanding.

HEALTHHISTORYFORMS

Settingupthedentalrecordsandestablishingsuccessfulinsurancebillingrelyonacompleted,detailedhealthanddentalhistory form.Somepatientsmaynotseetherelevanceoftheirmedical healthhistorytohavingtheirteethcleaned,sothedentalteam shouldexplainhowimportantthisinformationis.

Onlineformsforthehistoryallowpatientstocompletethe informationbeforetheirappointment.Thisavoidshavingthe patientfeelrushedandpermitsthemtohaveresourcessuch asthenamesoftheirprescribeddrugsanddosagesathand. Oftenpatientsrequirereadingglassestocompletephysical forms,whichcanbeawkwardinthedentalchairsetting.As aresult,theformscanbeincompleteorinaccurate,especially inrespecttothemedicationsbeingtaken.Thiscanaffect dentalcare.

Updatestopasthealthhistoryformscanbedonebeforepatientscomefortheirappointmenteitherthroughaform accessiblethroughthepracticewebsiteorthroughcontact software.Anyformforthehistoryshouldprovidesufficient roomforpatientstolistalltheirmedications,dosages,and reasonfortakingthemedication.Patientscanbeembarrassed tolistsomemedications,sothedentalteamshouldreviewthe historyforanyconditionsthatwouldbetreatedpharmacologically.Patientsshouldalsobedirectedtolistvitaminsand over-the-counterproductsandwhytheytakethem.The dentalteammayneedtoaddressthequestionofwhythe medicationisbeingtakenatappointmenttimeandupdate therecordthen.Somepatientstakemedicationssporadically andthisshouldalsobenoted.

ELECTRONICANDDIGITALSYSTEMS

Artificialintelligence(AI),electronichealthrecords(EHRs), practicemanagementsystems,digitalwork flows,and3-dimensional(3D)printingmaybeusedbythedentalpracticeinpatient andpracticecommunicationmethods.TheAmericanDentalAssociation(ADA)offersguidancefortheuseofsocialmediain particular,asfollows:

Thestandardrulesregardingdiscrimination,privacy,and employmentpoliciesapplytotheuseofonlinecommunications(socialmedia).

Becausefreespeechandopendiscoursearecurrently favored,it’sillegalundertheNationalLaborRelationsAct tohavepoliciesthatprohibitemployeesfromdiscussingthe termsandconditionsofemploymentwithotheremployees.

Thepractice’sgeneralpoliciesoremploymentpoliciescannot

discouragelegallypermissiblediscussionsaboutworkingconditions,hours,orwages.

Socialmedialawisevolving,sothepracticemustmonitordevelopmentsandmakeappropriateupdates.

Neithercopyrightednortrademarkedcontentcanbeposted withoutthepermissionofthecontentowneroracitation,as appropriate.

Thepractice’ scon fidentialorproprietaryinformationcannot bedisclosed.

Anappropriatewrittenconsent,authorization,waiver,or releasesignedbythepatientorguardianmustbeobtained topostinformationaboutpatients,employees,orotherindividuals.Thisincludestestimonials,photographs,radiographs, oreventhenameoftheindividual.

Allpostingsshouldbemonitoredforcompliancebyadesignatedteammember.Ifthepracticehasapolicytomonitorsocialmediaandfailstodosoordoesnotactoninformation foundduringthemonitoring,thepracticecouldbeheldlegally liable.Inappropriate,derogatory,ordisparagingpostings shouldberemovedatthediscretionofthepractice,butit’ s besttoerronthesideofcaution.

Evenifamonitorisdesignatedtomanagesocialmedia,the dentist/ownershouldhave finalapprovalonpostings.

DEEPFAKES

Employeesshouldn’tspeakonbehalfofthepracticeunless theyhavethedentist/owner ’sauthorization.

ClinicalSignificance

Communicationmethodsarechanging,andtherules forusingthenewerapproachesarealsoevolving.The dentalpracticeshouldensurethattheircommunication methodsareusedresponsiblyandinaccordancewith boththeneedsofthepatientsandtherulesofthe ADA,amongotherauthorities.Withtheadvances madeindigitalandelectroniccommunicationmethods, thedentalpracticecanreachmorepeoplewithgreater optionsincollectinghealthhistories,schedulingvisits, anddevelopinganetworkthatpatients findeasytouse.

VargasE:Howyoucanreassessdentalpracticecommunication policiesfor2025. DrBiscuspid.com, Dec10,2024

Reprintsnotavailable

TheDangerofFakesSpreadingMisinformation

BACKGROUND

Theterm deepfakes combinesdeeplearningandfakeasalabelof technologythatusesartificialintelligence(AI)algorithmsto createrealisticvideoandaudiorecordings.Oftentheserecordingsdepictthelikenessesandvoicesofhigh-pro fileindividuals suchasTomHankswithouttheirconsent.Thisprocessis donequiteeasilywiththeadvancesinAI,accesstolargedata sets,andincreasedcomputationalpower.Althoughthesetechnologiescouldpotentiallybeusefulforpositivepurposesineducationorentertainment,theycanalsobeusedmaliciously. Creatingmisleadingcontentwherethehigh-profileindividualendorsesormakesclaimsfortheefficacyofunprovenmedicalor dentalproductsiswellwithintherealmofpossibility.Celebrities tendtohaveasigni ficantimpactonconsumerbehaviorandindividualscanbeobliviousregardingtheneedforevidence-based recommendations.Thedeceptivepracticeofusingdeepfakes tospreadmisinformation,possibledangerousabusesrelatedto dentistry,andregulatorymeasuresneededtoaddressthesituationweredescribed.

DEEPFAKESANDINFLUENCERS

Anyonewithahigh-endgaminglaptopandbasicskillscan generateadeepfakevideo.OpenAI’srevelationofSofa,a

video-generationAI,hasfurthercomplicatedthedifferentiation ofmisinformationandauthenticatingcontent.Althoughthey canbecomparabletoin fluencer-drivenadvertisinginthemisinformationthatisoffered,deepfakesdeceptivelyusewell-known figurestoendorseandrecommenduntestedproducts.Unapprovedmedicalordentalproductsmayactuallybeableto harmpatients.Thevideosunderminethepublic’strustinscience andmedicine.Incontrast,influencersusuallypromoteproducts transparentlyandaremotivatedbysponsorshipagreements.To behonest,somein fluencersmaypostvideosonsocialmediawith productsorsecretsthat “doctorsdon’twantyoutoknow about.”

DENTISTRYDANGERS

Ifadeepfakeshowsawell-knowndoctorendorsinganewanduntesteddrugasamiraclecureforcurrentlyincurabledisorders, patientsarelikelytobeswayedtobelievetheproductoffersa realcure.Usuallynoevidenceofef ficacyorsafetythroughclinical trialsisoffered.Whentheagentdoesn’twork,thepublicconfusionandmistrustwouldincreasethedif ficultyimplementing properhealthmeasures.Iforthodonticdevicesaretoutedas abletoalignteethinaridiculouslyshorttime,ortherapiesfor rootcanalsorcavitiesarepromisedtobepainfreeandnoninvasiveforseriousdentalconditions,patientsmaybepersuadedto

trythesemeasuresandsuffersigni ficantharm.Thetechnology couldsigni ficantlyboostholisticorhomoeopathicdentistryand theanti-fluoridemovement,possiblyalteringpublicperspectives regardingdentalcare.

Productsthatareactuallyuselessorevendangeroushavebeen advertisedonsocialmedia.However,ifadentist’slikenessand voiceareimpersonatedwithouthisorherconsentandisused topromotetheseproducts,patientsmaybemisled,thedoctor’ s reputationcouldbeharmed,andthetrustofhisorherpatients couldbelost.Evensendingatakedownrequesttothesocialmediaplatformmaybeafutilepursuit.Boththeconsumerandthe personwhoseimagewasusedwithoutpermissionareatriskfor greatharm.Thedeepfakescreateaveneerofcredibilitythatleads unsuspectingconsumerstotrustinnon-trustworthyproducts. Forgoingproventreatmentstousethesealternativeapproaches canhavedirecthealthrisksforthepatient.

NEEDEDREGULATIONS

Patientsafetyandprofessionalintegrityareatthemercyofthese deepfakes.Immediateandfar-reachingdiscussionsareneededto setethicalguidelinesandregulatoryframeworksthatwillcurb thepowerofthefalseimages.Amongthemeasuresthatshould beinstitutedisamandatetoclearlylabeldeepfakecontenton socialmediaplatforms,similartowhatisaddedtoadvertisements andsponsoredcontent.Viewerscouldthendistinguishbetween whatisauthenticandwhathasbeenmanipulated.Inaddition, algorithmsneedtobeintegratedtodetectand flagillicit

DENTALTECHNOLOGY

InvestinginTechnology

BACKGROUND

TheGuidingLeadersorganizationoffersaleadershipanddevelopmentprogramforwomendentiststhatisfollowedupbyan alumnigroupchat.Thischatisaplacetoaskquestions,compare industrytrendsindifferentareasofthecountry,andoffer encouragementthroughoutone’scareer.Technologyisrelevant todentalpracticestoday,buttherearemanydetailsthatneedto beinvestigatedtodeterminewhattechnologyismostappropriateforaparticulardentalpractice.Dentistscanaskforpracticaladvicefromfellowpractitioners,ensuringthatthey recognizethebene fitsoftechnology,canidentifythetechnology thattheywouldusedaily,andlearnwhatinformationisneeded whenmakingapurchase.

BENEFITSOFTECHNOLOGY

Manypracticeshaven’tmadethemovetotechnology,andnew dentistsshouldbeawareofthevalueofseekingoutthose

deepfakes.Lawstoprotectpeoples’ imagerightsareessential. Onlinecontenthasrapidlyexpandedtohaveextensivereach, magnifyingthepotentialimpactofdeepfakes.Theregulationof theproblemwillrequireacomprehensivestrategythatuses technology,legalaction,andpubliceducationalongwith legislationatboththefederalandstatelevelstocombatmedical anddentalmisinformationspreadthroughdeepfakes.

ClinicalSignificance

Thepublictrustinhealthcarewasseverelyeroded duringtheCOVID-19pandemic.Havingdeepfakes launchedtospreadmisinformationaboutscientific topicscouldfurtherunderminehowpeopleviewand usescienti ficinformationandmedicalordentalrecommendations.It’snecessarytopreservewhatpublic trustremainsbysafeguardingagainstdeepfaketechnology. PatilS,LicariFW:Deepfakesinhealthcare:Decodingdigital deceptions. JAmDentAssoc 155:997-999,2024

Reprintsavailablefrom SPatil,RosemanUnivofHealthSciences, 10920SRiverFrontPkwy,SouthJordan,UT84095,USA; e-mail: spatil@roseman.edu

opportunitiesthatareforward-focusedandinnovative.Atthis pointinhistory,newdentistsshouldsurroundthemselveswith peopleopentochangeandthosewhoembracetechnologyas animportantpartofdentistry.Technologywillrequirealearning curvebeforeitcanbeproperlyused,buthavingatechnologyforwardviewpointoffersmanybenefits.Workflowsarestreamlined,acceptanceratesrise,patientperceptionisenhanced,referralsareincreased,andthereturnoninvestmentisworthit. Anotherbenefitisthefactthatthelatestproductsaredesigned foreaseofuse.

DAILYUSEDTECHNOLOGY

It ’simportanttoinvestintechnologythatwillbeusedandnot bedazzledbythehype.Amongthosetechnologiesusedevery dayareintraoralscanners,conebeamcomputedtomography (CBCT)units,in-offi cemills,andpracticemanagement software.

IntraoralScanners

Intraoralscannershavechangedhowdentistspractice,allowing imagesoftheteethinrealtimethatarebothaccurateandcompletepicturesoftheoralcavity.Theinformationisshownina readilyunderstoodformat,sointraoralscannersareessential.

CBCTUnits

Digitalx-rayshavebeenwidelyadoptedformorethan30yearsand areessentialtomoderndentistry.Thedigitalunitsofferedreduced radiation,improvedimagequality,andreducedwaste,sothebenefitsfaroutweighedthecostofthesescanners.CBCTunitsnow producemoredetailed3-dimensional(3D)viewsofbonesand softtissueandproduceaccuratedimensionsofthejaw,canidentify periodontallyinvolvedareas,andcanassessthenasalcavity.It’ s essentialtoallotsufficientspacefortheseunits.

In-officeMills

Patientslovetheideaofsame-daydentistryandnotwearingtemporariesforlongperiodsoftimeandhavingtotakeoffextratime fromwork.Dentistsarehappytheycantakecontrolof finaloutcomesandreducelaboratoryfees.Somemillsaresupportedby artificialintelligence(AI) powereddesignproposalsandcan drawfromanextensivearrayofdatabases.Thedesignsare highqualityand fitthepatient’suniqueneeds. Themillingsystemshouldoffermanufacturer-directsupportand continuingeducationalongwiththedevice.Afterbecoming comfortablewiththe firstmill,asecondorthirdmillmaybea goodpurchasesothatmultipledentistscanusetheunitswithout waitingforasingleunittofreeup.Thisalsosimpli fiesscheduling.

PracticeManagementSoftware

Forms,notes,appointmentschedules,reminders,follow-ups it allhastobeorganizedandeasytoaccess.Theuseofpractice managementsoftwarehasrevolutionizedtheprocess.Factors toconsiderwhenpurchasingpracticemanagementsoftware includethecomfortlevelandcapabilitiesoftheofficestaff;the officepriorities(speed,personalization,simplicity,etc);and howmuchthesoftwarecostsversusthefeaturesitoffers.

MAKINGAWISEPURCHASE

Technologyisexpensivebutifit’stherighttechnologyitwillpay foritself.Decidingontherighttechnologyrequiresthatseveral questionsbeaskedandanswered,asfollows:

Willitsavetimeand/ormoney? DoIneedit?

Canitbereasonablyimplemented? Whatarethe financingoptions?

Thetime/moneysavingsisthe firstquestiontoanswer.Ifthesoftwarewon ’tsaveeither,itisn’tagoodpurchase.Theanalysisto determinesavingsinvolvescalculatingthehourlyrateand comparingthetimesavingsthetechnologycanachieve.Ifthe dentistcanseemorepatientsorspendmoretimewithpatients, it’sprobablyagoodchoice.Ifitpaysforitselfinreducedlaboratoryfeesorincreasedcaseacceptancerates,it’salsolikely worthwhile,aslongasthetimetorecoupcostsisreasonable.

Thepractice’sneedsshoulddictatewhetherthetechnologyisa goodpurchase.Determiningwheremostofthetimeandmoney arespentwillallowthedentisttoplanhowtooptimizethepracticewithtechnology.

Ifthetechnologyistoocomplicated,thedentalteammay fi ndit hardtoimplementit.Apurchaseshouldn’tremaininthebox. Thedentalteamshouldbepartofthediscussionaboutwhat technologytoimplement,withthegoaltohavebuy-infrom everyonewhowillusethetechnology.

Financingoptionsshouldconsidertheannualpercentagerate (APR)andthemonthlypayments.Purchasingneartheendof theyearmayallowfortaxwrite-offs.A financialexpertcanguide thedentistindeterminingthewisdomoflargepurchases.It’ s alwayswisetoalsodoresearchsuchaslisteningtopodcasts, readingjournals,orspeakingwithtrustedfellowdentists.

ClinicalSignificance

Technologycanrevolutionizethepracticeofdentistry, butitmustbeneeded,used,andpurchasedwisely. Dentistsshouldenlisttheirdentalteamandevena financialexperttoensurethatthesequalificationsfor agoodpurchasearepresent.Maintaininganopen mindtowardtechnologywillbeakeycomponentin creatingadentalpracticethatwillbeseenastechnologicallysophisticatedandsmart.

BahI,MathewsL:Dentaltechnologypurchases:Strategiesand considerations. DentEcon 114:41-43,2024

Reprintsnotavailable

HIRINGFRAMEWORK

RecruitingAssistantsandHygienists

BACKGROUND

Theframeworkforhiringandstaffingfordentalofficesrequires anapproachthatisintentionaltoensurethatthebestcandidates areinterestedandcanbereached.TheAmericanDentalAssociation(ADA)HealthPolicyInstitutereportsthatdentalpractice capacityhasfallenby10%asaresultofopenassistantandhygiene positions,and9ourof10dentistsfeelit’sextremelyorverychallengingtosuccessfullyrecruitforthesepositions.Inaddition,a thirdoftheindividualsintheserolesplantoretireinthenext 5years.Fillingthesevoidswithtoptalentrequirescraftingan appropriateofferandchoosingchannels,screeningcandidates, andprovidingrecruitingpacketsandexperiences.Thelevelof recruitmentdependsonthesizeofthedentalpractice.

CRAFTINGTHEOFFERANDCHOOSING CHANNELS

FeaturesoftheOffer

Theofferofemploymentshouldbeclearlyconveyedthroughthe messagebeingsentout,notingtheclinicalsituation,whatis offeredrelationally,andwhatthe financialaspectsare.Because thesecomponentsde finetheoffer,theremustbeclearanswers providedintherecruitmentad.Languageshouldbesimpleand direct,focusingontheelementsthatthepracticemostvalues andwhatcanserveassellingpointstothemarket.

Ifthegoalistohiresomeonewhowillfollowthepractice ’ sprocessandsystemwhentheyjointheorganization,thecorevalues ofthepracticeshouldbeemphasizedasthe firstthingpotential candidateswillsee.Thenatureoftheorganization,suchasdynamic,generous,orhumble,shouldalsobeinaprominentplace. Theimportanceofthe fitinthedentalorganizationshouldbe clearlyconveyed,sothatpotentialcandidatescanseethe first year ’spathintheposition.

Eachdentalpracticehasastoryandtellingthestoryofthedental teamcanalsobeadrawtocandidates.Thedentalpracticeshould trytomakethemselvesrelevanttothetopcandidates,withanavatar ofwhatisdesiredinanassistantorhygienistonthatdentalteam.

SelectingChannelsandMediums

Variouschannelsandmediumsareavailable,andthechoice shouldbefocusedonwherethequalitycandidatesaremostlikely tobelookingforaposition.Digitalchannelsincludewebsites, paidads,landingpages,andsocialmediagroups,butalsojob boardssuchasIndeed,Monster,LinkedIn, DentalPost.net,IHire Dental.com,DentalJobs,net, DentalWorkers.com, DentReps.com,Hireclick,com,andDirect Dental.com.TheHandshake

appallowsanadtobedistributedtoallthedentalschoolswith whichitisaf filiated.

On-siteengagementscanbeheldatdentalschools,hygiene schools,andcontinuingeducation(CE)events.Referralscan comefromthedentalteamorpatients.Recruiterscanalsobe hiredtoseekoutprimecandidates.

Themedium’sefficacyshouldbetrackedthroughcandidateand leadtrackingsystemsandmeetingcadence.Responsestoads shouldbemeasured,withtheinitialresultsassessedandadjusted asneeded.

Adsshouldcarrynodatesifthepracticeiscontinuallyrecruiting candidates.Theyshouldberefreshedasneededandextraeffort madeifaspeci fictimetargetdevelops.Boththeadandtheavatar canbealteredtotargetspeci ficgroups.

Personsgraduatinginthenext6monthsmaybecontactedwhile theyareinschool,askingintheadiftheyaretryingtodetermine whattheirfuturewillbe.Communicatingwiththemaheadof timecanidentifydesiressuchason-sitetraining,whichmaybe accommodatedbyhiringthemasanassistantiftheareaallows fornoncertifiedindividualsinthisrole.

Incentivizingpatients,teammembers,theirfamilies,theirfriends, andpeersmayalsoleadtocontactswithgoodcandidates.It

s importanttoconnect,buildrelationships,andprovidevalue whenusingthesechannels.

SCREENINGCANDIDATES

Candidatescanbescreenedbythepractice ’shumanresources(HR)andoperationste am.Thisincludesareviewof theirapplicationsandpossiblyinitialZoomorphoneinterviews.Thedoctor,owner,orhiringleadershouldparticipate intheseinterviews.Inadditi on,topcandidatescanbeprovidedwithagift.

THERECRUITINGPACKETANDEXPERIENCES

Therecruitingpacketcanbedigitalorphysical.Thegoalisto packagetheareawherethedentalpracticeislocatedinaway thathighlightstheof ficeandtheopportunitiesthatareinthatsituation.Consideringtheprocessasarealestatetaskwillhelpto identifyconveniencesforthecandidatesandtheirfamiliesand notegoodschoolsinthearea.Somepracticeswagorpamphlets onthepracticemayalsobeincluded.Adigitalpacketcaninclude allthepracticeinformation.

Thehiringmanagershouldmeetweeklywiththedentisttoreviewprogress.Itmaybepossibletoidentifytrendswhereleads comefrom,reviewfeedbackfromthemarketingtools,andidentifychangestothemessagingormediumneededtoimprove responses.

LEVELSOFRECRUITING

Withtheseelementsallinmind,thedentalpracticeshouldscale theirrecruitingeffortstothesizeofthedentalpractice,as follows:

Abaselinelevelissufficientforasingle-facilitypractice.Itincludesateammemberavatar,practicewebsite,jobdescription,offer,andGooglereviews.

Thebeginnerlevelisappropriatewhenthereare2to3practicefacilitiesandconsistsofaclearhiringprocess,proactive recruitingefforts,referralgathering,useofapracticerecruitingpacket,andanequityshare.

Attheintermediatelevel,whichwouldworkfor4to10 practices,acareerspageshouldbeincludedonthepractice website,andthereshouldbeanarearecruitingpacket,a long-termrecruitingstrategy,andbrandexperience considered.

Whenmorethan10practicesareinvolved,theadvancedlevelapproachisdesirable.Thisincludesadedicatedrecruitingwebsiteandrecruitingteam,on-siteengagement,and applicanttrackingsoftware(ATS)andcustomerrelationship management(CRM)softwarethatcanmeasurethereturn oninvestment(ROI)forallrecruitingefforts.

LEADERSHIP

ReachingLevelIVLeadership

BACKGROUND

Leadershipskillsaredevelopedthroughprogressivestages,but becomingaworld-classleadercanbeinthecardsformany dentists.Dentistsarewell-trainedindentistrybutdental schooldoesn’tteachthemaboutleadingandtheyhaveno practicalrealityinwhichtoapplyleadershipskills.Leadership trainingrequiresleadingotherpeople,whetheritisthedental teamorpatients.Inbothofthesegroups,thepeoplehave theirowndesiresandbehaviorsandtheleadermustlearn toworkwithinthestylethat fi tseachsituation.Adaptation totheneedsofeachsituationisconstant.Mostrecently,dentistsaredealingwithstaffingshortagesandthedesiresof dentalteammemberstobebettercompensated.Meeting thesechallengesrequiresalevelofmanagementthathasn’t beenrequiredpreviously.The4levelsofleadershipmostdentistsgothroughandtheircharacteristicswereexplained,with afocusonLevelIVleadership.

Ifarecruiterishired,thedentist/hiringmanagershouldclosely monitorthesituation.Outsourcingcanbeagreathelp,butthe messagebeingdeliveredshouldbethepractice’ smessage.

Whenit’stimetomakeanoffer,thedentistshouldtakethe candidatetothebestplacesinthearea,sothatheorshecan seeallthethingstheareaoffers.Theteammembersshouldbe includedsotheycaninteractwiththecandidateandsothatthe candidatecanclearlyseethecultureoftheof fice.Beforethey aretakenouttodinner,thedentistshould findoutwhattheirfavoritedrinkandfoodaresothattheirexperienceispersonalized. Thebestcandidateshouldbegivenmanygoodreasonstojointhe dentalpractice.

ClinicalSignificance

Alloftheseeffortshopefullywillleadtotheopportunity tomakeanoffertoatleastonehighlyqualifiedand appropriatecandidate.Theformaloffershouldbe clear,open,andhonest.Anyquestionsthatarise shouldbeansweredsothecandidatecanhavetheinformationtomakeaninformeddecision.

Theultimatehiringandstaffingframeworkforassociatesandhygienists. DEOMagazine, Nov-Dec2024,pp24-26.

Reprintsnotavailable

LEVELSOFLEADERSHIP

The first3levelsofleadershiparecommonexperiencesamong dentists,butfewreachLevelIVcompetency.

LevelI:TheNewLeader

Newleadersmayhavestrongclinicalskillsbuttheylackexperienceinmanagingadentalpracticeorleadingadentalteam.Often thestyleofrunningthepracticecouldbetermed “winging” it, whichrequiresthatthedentistrisetoeachchallengeandwork to figureoutwhatmustbedone.Typicallydentistsremainat thislevelfor1to3years.

LevelII:TheCompetentLeader

Competentleadershipisdevelopedafterworkingandlearning throughexperienceforseveralyears.Thedentistisbuilding thepracticeandestablishingafoundationforsuccess.The

practicegraduallyneedsmorestaffforspeci ficpositions.The dentistspendsmostofthetimecaringforpatients.Thelevelof stress,chaos,andfatiguerisesasthedentisttriestojuggleimmediatedemands,catchup,adaptproceduresandsystems,andcorrectmistakessothatthepracticefunctionsmoreeffectively. DentistsusuallystayatLevelIIforjustafewyears.

LevelIII:TheOverworkedLeader

Leadersbecomeoverwhelmedafterabout4or5yearsofpracticeandmaycontinueinthisstageuntilretirement.Thisisn’ta goodplace,andthedentistexperiencessignificantstressand frustrationwiththebusinesssideofpractice.Notonlydoes thedentistworktoohard,butheorshetendstoearnsignificantlylessthanhisorheractualpotential.LevelIIIleadersare responsibleforchairsideworkbutalsospendconsiderable timeoutsideofpatientscheduledhourshandlingadministrative andmanagementissuesforthepractice.Growthhasresulted inadegreeofbusyness,chaos,stress,andfatiguethatcanbedifficulttomanageeveryday.Burnoutcanoccuratthisstage.

LevelIVLeader

LevelIViswheredentistshopetobeandinvolvesmuchless stress.Inaddition,thedentistislessinvolvedinadministrative areasandfocusesmoreonproductiveclinicalcareandreferral management.Typicallythedentistattendsthemorningmeeting thatisshortandrunbystaffmembers,thenfollowsupwitha schedulerunbythedentalassistants.Everyoneissowelltrained andhighlyskilledthatthedentist findsworkmorerelaxingand comfortable,withdelegationandtrainingservingasthekeysto attainingLevelIVleadership.

HOWLEVELIVLEADERSHIPWORKS

TheLevelIVleaderdoesn’tneedtospendtimesettinguptheday, managingtheteam,orhelpingotherpeopledotheirjobs.Heor shedoesn’tspendthetimeansweringquestions.Instead,team membersknowwhattodo,whentodoit,howtodoit,and whattheresultsshouldbe.Thisknowledgeresultsfromthe training,time,andeffortthedentistputinduringearlierstages. Alloftheteammembersnowthinklikeownersandaretrusted toperformtheirtaskswell.

MARKETING ConvertingCallerstoNewPatients

BACKGROUND

Thefrontdeskpersonnelmayseetheirtasksaslimitedto handlinginsurance,collectingpayments,managingpatientrecords,greetingpatients,orderingsupplies,andhandlingthe schedule,butsalesisanothertasktheycanexcelat.Salesshould

Trustingdentalassistantstobeinchargeofschedulingresultsin thedentist’sgreaterrelaxationandcomfortinlettingthemanticipatewhatcomesnextandinguidingthedentisttotheproper roomandpatient.Dentistscanfocusondoingwhattheydo anddelegateothertaskstothedentalteam.Oftentheteam hasanopeningandclosingchecklistforeachdayandtheycompletetheirresponsibilitieswithoutsupervision.

TheLevelIVleaderhasbecomeanexpertatdelegation,andthe teamhastheskillsettoacceptthedelegation.Aslongastheteam memberislegallyallowedtodoatask,heorsheistrainedinit. Havinganownershipmindsetleadsteammemberstoquickly mastertheirtasksandfreethedentisttofocusondoingdentistry andhelpingpatients.

Dentistsatthislevelroutinelyreliedonthehelpofexpertadvisorsinpreviouslevelstoimplementupdatedsystemsandtrain theteamtobeabletousethosesystems.Theseadvisorsmay alsohelpthedentistwith financialplansandpreparationfor retirement.

ClinicalSignificance

LevelIVleaderstendtoexperienceexcitingandfulfillingdentalcareers.Theyhaveeliminatedthechaos, stress,fatigue,andburnoutfromtheirlivesbytraining andthentrustingtheirdentalteamtodotheirjobswell. Theirleadershipskillsareaccompaniedbyprofessionalandpersonalsatisfaction,andtheyattribute theirsuccesstoawell-trainedandhighlymotivated professionalteam.

LevinRP:Thedentistasaworld-classleader. DentEcon 115:8-10, 2025

Reprintsnotavailable

beviewedashelpingsomeonewhohasaproblemmakean informeddecisionabouthowtosolveit.Goodsalespersons listentotheproblemandidentifywhethertheyaretherightpersontohelp.Dentalofficesonlyconvertabout35%oftheirnewpatientopportunitieswhocontacttheof fice,whichmeansthat mostofthetime,salesaren’tbeingmade.Thereasonsforfailing

toconvertcallerstonewpatientswereexplained,andsomesales skillsthatwillhelpthedentalpracticegrowwereprovided.

WHYMORECALLERSDON’TBECOME PATIENTS

Generally2keyreasonsexplainwhycallerstothedentalof fice don’tchoosetobecomenewpatients.The firstishavingcalls gounanswered.Peoplewhocalltheof ficehaveaproblemand arelookingforananswer.Ifthefrontdeskpersonistoobusy toanswerorhasgonetolunch,thecallerwillmoveontothe nextpossiblesolutiontotheproblem.Itisn’tnecessarytohire morepeople.Answersinsteadcanbeassimpleashavingthepersonnearesttothephonegrabitandtakedowntheinformation sothefrontdeskpersoncancontactthepersonlater.Inaddition, anarti ficialintelligence(AI)chatbotcananswerquestionsonthe practicewebsiteorGoogleadlandingpage.Onlinescheduling canbeencouragedbybeginningthepracticevoicemailwitha statementthatthenewpatientcangotothewebsitetoschedule avisit.Thegoalistopickupthemarketingleadswheretheyare andbeforetheyturnsomewhereelse.

Thesecondreasoninvolvestheassumptionsthatcanbemade whenpeoplecallin.Ifthecallerbeginsaskingaboutwhetherthe officeacceptshisorherinsurance,thefrontdeskperson shouldn’tjumptotheconclusionthatallthecallercaresabout isinsurance.Thecallerlikelyisconcernedaboutwhetherheor shecanaffordcare,whichisareasonableconcern.Frontdesk personnelcanalsoassumethatthecallerisjustpriceshopping whenheorsheasksaboutaprocedure.Patientswanttounderstandwhythepracticeisworthmoreandcanbeledtobecome apatientifthefrontdeskpersonexplainstheexperienceofthe dentistandwhyheorshecandotheproceduremorequickly orbetterthansomeonewhoischeapandmaytakelonger.

SALESSKILLS

Learningtochangeacallerintoanewpatientdoesn’thappen overnightbutrequirespractice,role-playing,self-evaluation, andhelp.Severalskillscanbedevelopedthatwillhelpthefront deskpersonneltoimprovetheirabilitytosellthepractice.

ActiveListening

Perhapsthemostimportantskillistoactivelylistenandunderstandpatients’ needsandconcerns.Whenthestaffmember reallylistens,heorshecanaskclarifyingquestionsandbeempatheticwiththecaller,whothenfeelsvaluedandunderstood.This beginstheprocessofbuildingtrust,whichcanleadtoaprogressionfrominquiryintoappointments.

EmpathyandCompassion

Dentalvisitsarestressfulformanypersons,sothefront deskpersonnelshouldbesensitivetotheanxietyand

concernsofcallers.Empathywillacknowledgethecaller ’ s feelingsandcanleadtothecompassionofofferingreassurance.Thisapproachcansigni fi cantlyimprovethecaller ’ s senseofcomfortandbuildtrustthattheclinicalstaffwill beequallycaring.

ProductKnowledge

Thefrontdeskpersonnelmustunderstandthedentalservices thattheofficeprovides.Theymustbeabletoanswerthecallers’ questionsaboutproceduresandproductsandwhattheadvantagesareforeach,andtheyneedtoprovideneededreassurance. Theanswersofferedshouldbeclearanddeliveredcon fidently. Bene fits,costs,andthevalueofthepracticeovercompetitors shouldalsobepartoftheconversation.

OvercomingObjections

Callersoftenvoiceobjectionsorconcernsaboutcosts,time,or treatments,amongotherworries.Thefrontofficestaffmustbe abletoexplaintheadvantagestheof ficeprovideswithconfidence andmaintainempathyforthecaller.

Problem-solving

Thecallershavelegitimateproblemsandtheydeservesolutions. Thefrontdeskpersonnelmustbeabletoarticulatehowtheofficecansolvetheproblembetterthananyotheroptionsandgive thecallerasolutionthatwillcalmanyfears.

Closing

Inclosingacall,thefrontdeskpersonnelshouldtakecharge andtellthecallerwhatthebestcourseofactionis.This canbestated,as “Let’sdothis...” andwilloftenhelpcallers infollowingthroughwiththesuggestion.Decisionfatiguecan bepresent,soit’sbesttonotaskbuttellthecallerabouthow theof ficecanprovideasolutiontotheproblem.Sometimes otherscenarioswilloccur,sothefrontofficepersonnel shouldsearchtheliteratureontypesofsalesclosesto fit varioussituations.

Practice

Thedentalpracticeshouldcounselfrontdeskpersonneltobepatientinlearningthesesalesskills.Itcanbehelpfultoengagein role-playingscenarios,hireacallconversionspecialist,oreven usecall-recordingtechnologysoactualcallscanbereviewed andevaluated.

CONCLUSIONS

Salescanbeconsideredanawfulthingbysomepeople.Inthe dentalsituation,thecallersarelookingforasolutiontotheir problem,andtheyareseekingitfromthedentaloffice.Those callsshouldbemanagedwithapositiveandcaringexperience thatcanleadtothecallerbecominganewpatient.

ClinicalSignificance

Salesarerequiredtogrowadentalpractice.Theycan beobtainedethicallywhencallerscontacttheoffice withquestionsorwithproblemsthatneedresolution. Ifthesecallsarehandledwell,thereputationofthe dentalofficewillbethatthisisaplacewherecaring peoplecan findanswersandhelp.Learningskillsto ensurethatencountersbyphonearemanagedwell shouldbeavaluedexerciseincaringaboutpeople whomayneeddentaltreatment.

WinansX:Thefrontdeskadvantage:Salesskillseverydentalofficeneeds. DentEcon 114:29-30,2024

Reprintsnotavailable

PatientsReferringFriendsandFamily

BACKGROUND

Referralsfromexistingpatientscanbetheultimatecompliment tothepractice.Havingsatis fiedpatientstellothersabouttheir greatdentistisfreeadvertising.However,manypatientsdon’t understandthevaluethesereferralshaveforadentalpractice, ortheymaybeafraidiftheytellothers,theschedulewill fillup andmakeithardtogetanappointment.Toensurethatpatients knowtheycanhelptomakethedentalofficemoreprosperous bytellingothers,somesimpleremindersandincentivescanbe offered.

REMINDERS

Thedentistcan,atthecorrecttime,simplyaskapatienttoprovideareferral.Whenthepatientcomplimentsthedentistonthe careheorshereceived,it’seasytoexpressgratitudeforthekind words,thensuggestthatthepracticewouldbehonoredifthepatientcouldpassthosewordstohisorherfriendsandfamily members.Thestaffcanalsoengagepatientsdirectly.Thepractice canincludeincentivestostaffmemberstoaskforthesereferrals, includingabonusorotherperkswhenthereferralleadstoanew patient.

Patientswhocomplimentthedentistorstaffcouldbegivengift certi fi catesasathankyou.Certi fi catescancarrythe existingpatient ’ snameandbedesignedtobegiventothe prospectivepatient.Customizablegiftcerti fi catetemplates areavailableonlineforMicrosoftWordandotherprograms. Theoffercouldbeafreetoothbrush,adiscountforcare, orafreeexaminationand/orcleaning,allofwhichcanbe enoughtoinducethepatient ’ sfriendsorfamilytocometo thedentist.

Theof fi cecanalsopostsignsthatletpatientsknowhowmuch referralsareappreciated.Businesscardholderscanhave “ Thankyouforreferringothers ” inscribedonthemand beplacedinaconspicuousplacetosubtlysuggestreferring others.Check-inandcheck-outdesksareperfectforthese reminders.

Bulkmailore-mailcampaignstargetedtocurrentpatientscan includereferraloffersorgiftcertificates.Themailmergefeature ofMicrosoftPublishercanbeusedtocustomizethegiftcertificatesforeachpatient.Theycanbeincludedwithaletterright beforetheholidayseasonandthelettercanmentionwhata wonderfulgiftthecerti ficatescanbe.

INCENTIVES

Thenamesofeveryonewhoprovidesareferralcanbeaddedtoa basketanddrawnforaprize.Personalizedgiftcertificatesthat wereprovidedtothepatientsandreturnedbytheirfriendsor familycanbeputintothedrawing.Thenicertheprizeis,the morelikelypatientswillbeincentivizedtoprovidereferrals. Amongthepossibilitiesfortheprizearea flat-screentelevision, whichcostsmuchlessthanthereturnfromthenewpatients. Otherincentivesincluderestaurantgiftcards,donationstopatients’ favoritecharitiesintheirname,credittowarddentaltreatments,orfreebleaching.Thesemaybegivenoutthroughthe drawingorsimplytoeveryonewhoprovidesareferral.The dentalpracticeshouldcheckwithstateandlocallawstosee whatispermittedlegally.

Whenapatientrefersanewpatient,thepracticecansendagiftof thanksthatcanspurfuturereferrals.Inaddition,thegiftshould havethepractice ’snameonitsootherpeoplecanbecomefuture

referrals.Thegiftshouldbeofsufficientqualitythatthecurrent patientwilluseit.Forexample,coolersorfoldablechairsare goodforparentswhosechildrenplaysports.Whenotherparentsseethename,theymayaskwhatthepatientthinksofthe dentist.Womenwithprofessionalcareerscouldbesent flowers totheoffice,sothatcoworkerscanseethevaseandbecome futuredentalpatients.

ClinicalSignificance

Gettingpatientstoreferothersisanexcellentwayto growapracticewithminimalinvestment.Thosewho cometothepracticeonthewordofafriendorrelative aremorelikelytoaccepttreatment,moreeasilyretained,andmoreapttoprovidefurtherreferrals.

GangwischRP:Askandyeshallreceive. InsideDent 20:8,10,2024

Reprintsnotavailable

PERSONALITYTYPOLOGY

Dentists’PersonalityTraitsandDecision-Making Behaviors

BACKGROUND

Toolsarewidelyavailablethathelpfutureemployersandstudentslearnmoreaboutthemselvesandthepeoplearound them.TheMyers-BriggsTypeIndicator(MBTI)providesan outcomeof4lettersthatindicateone’spersonalitytraits,speci fi callywhetherapersonisintrovertedorextroverted,if theyvaluedstructure,andwhethertheymakedecisionsbased onintuitionandfeelingsorfactsandlogic.Generationsofdental studentshavetakenthetestsot heybetterunderstandtheir personalitytraitsandcandevelopamindsetonwhichtobuild asuccessfulteamintheirpractice,academicsettings,business dealings,andpersonallifeaftergraduation.Thetrendsinpersonalitytraitsanddecision-makingbehaviorsamongdentists werestudiedatvariouspointsintimesince1964,noting possibleexternalfactorsthatin fl uencedchangesinthese trends.

PERSONALITYTRAITDIFFERENCESOVERTIME

A20-yearstudy(1964-1984)doneatCreightonUniversity SchoolofDentistryfoundthatmostdentistswereintroverted, valuedstructure,andbasedtheirdecisionsonfactsratherthan intuitionandfeelings.Babyboomerssharedthesepersonality traits,whichin fl uencedtheirpracticemanagement,practice culture,andpersonnelstructurewithmultigenerational employees.

Afollow-upin2018foundthatthemostcommonpersonality traitshiftedtoextrovertandfa ct-baseddecision-makingwas valued.Newtraitswerenotedinintroverteddentistswho

beganintegratingdecision-makingprocessesbasedonthepatient’spointofviewcoupledwithexternalfactors,facts,and logic.Otherfactorssuchassocialdeterminantsofhealth weregivenvalue,causingdentiststobecomemoreempathetic andunderstandingofthepatient’ sneeds.Thesechangeswere likelyin fl uencedbythetrendamongpatientstochooseactive lifestylesandprioritizetheirhealth.Thisledtosearchingforreviewsofdentistsandtheirpractices,whichincreasedthevalue ofpatients ’ comfortsothattheypreferredadentalhome focusedonoverallwellnessandoutcomesratherthanprice. Value-basedoralhealthcarewaschosenasawaytoimprove dentalpatientoutcomes.

In2024,thedentalpersonalitytypeschangedagain,withdentistsrevertingtotheintrovertedpersonalityandbasingdecisionsonfactsandlogic.Techn ologyhasmadeinformation readilyavailableandmayhavecontributedtothefocuson data-drivendecisionmaking.Inaddition,thepandemiccaused ashiftineducationfromin-persontoonlineplatforms,with somehybridcoursescontinuingtobeavailable,whichsupports introversion.

KEYPERSONALITYTRAITOBSERVATIONS

Whentheyareconcernedaboutothers,dentalstudentstryto considereveryone’sopinionsandensureeveryonehasavoice.In contrast,dentalstudentswhobasetheirdecisionsonfactsandlogic don’tusuallyconsiderothersintheirchoices.Theextrovertstudents thriveinlargegroups,buttheintrovertstendtobreakdownlarge groupsintomoremanageableone-on-oneconversations.

TheAmericanDentalEducationAssociationfoundthatthemost commontraitsofdentistswereasfollows(althoughtheseweren’t allthetraits):

Comfortablewithclosepersonalinteractions

Easytotalkto

Trustworthy

Goodcommunicator

Leader

Caringandconcerned

Passionateaboutprovidingcaretothoseinneed

ClinicalSignificance

Researchhasshownthatdentistsarebecomingmore fact-andlogic-basedintrovertsratherthanpersonandpatient-centeredextroverts.Patientswantto havedentistsremaincenteredontheirneedsanddesires,abletolistentotheirconcerns,andacting accordingly.Overall,itwouldbebestiftherecould beabalancebetweenthe2extremes.Dentistsneed tovaluethedifferencesofothersandestablishapracticepersonawithpatientsinwhichtheyandtheirpatientscanlearnfromoneanother.

WatanabeMK:Unboxingpersonalitytypologyindentistry. JCalif DentAssoc 52:2406979,2024

Reprintsnotavailable

SEARCHENGINEOPTIMIZATION

EnhancingOnlineVisibilityforYourPractice

BACKGROUND

Knowingaboutlocalsearchengineoptimization(SEO)isvitalfor maximizingyourdentalpractice’svisibilityinlocalonline searches.LocalSEOissimilartotraditionalSEO,withthesame goalofgivingthepracticegreatervisibilityinGooglesearches. However,theydifferinwhereusersseethepractice,howresults aremeasured,andhowthoseresultsareachieved.Adviceto guideyouinachievingthebestlocalSEOpossibleisoffered, withrecommendationsforactionsthatwillyieldthebestresults.

LOCALANDTRADITIONALSEOCOMPARISON

PlacementandMeasurements

LocalSEOcampaignsfocusonyourGoogleBusinessProfile (GBP)andGoogleMapsPack.TheresultthroughalocalSEO istheplacementofthepracticeintheGoogleMapsPackas wellasphonecallsandwebsitevisitsfromtheGBP.Tracking shouldfocusonthenumberofnewpatientsyousee,butpreviousmetricscanhelpinevaluatingtrends.

TraditionalSEOcampaignsfocusonrankingsforspeci fickey wordsandorganicvisitstothepracticewebsite.Theonlyways visitorscangettothewebsitearedirectthroughtheaddress, referredthroughalinkonanotherwebsite,paidthroughapaid adcampaign,andorganic,whichisfromaGooglesearchincluding theGBP.

TraditionalSEOonlyfocusesonorganictraf fic.Numberofnew patientsremainsthemostimportantinformation.Atraditional SEOsearchrelatedtolocalbusinessesislimitedtopaidGoogle ads,GoogleMapsPack,andtraditionalorganicsearches.

Overlap

AnoptimizedlocalSEOapproachmightyieldbettertraditional SEOresults.Localcampaignsusuallyhave2parts:aGoogleMy BusinessOptimizationCampaignandaCitationCampaign. YourGBPisthefoundationofalocalSEOcampaignandisthe cruxofyourlocalpresence.TheGBPisfreeandcanbeobtained byvisiting business.google.com toclaimyourprofileandverify yourpractice.Fillingitoutcompletelyisessentialbecauseit’ sunknownwhatGBPfactorswilldrawinclicksfromsearchers. BecauseGoogleoftenupdatesthedatayoucanaddtothe GBP,it’simportanttomonitoringyourprofile.Tocheckthe strengthofyourprofile,youcanlogintotheGoogleaccount andGoogleyourbusiness’ name.TheProfileStrengthindicator shouldbegreenandsay “Looksgood.”

OPTIMIZATIONOFLOCALSEARCHRESULTS

Googlerandomlyshiftsthemapspackpositionaroundaspartof theiralgorithm.It’sbesttofollowGoogle’srecommendations andoptimizeyourprofiletothebestofyourability,generatereviews,andrunacitationcampaign.

ThemostimportantrankingfactorforlocalSEOsearchesis proximity.Becausedentiststreatpatientsfrommultiplelocal areas,thiscanbefrustratingbecauseGooglelimitswhatiscalled local.Apracticecanberankedinmultiplelocalities,butit’ sunlikelythatyouwillrankinasecondareawherecompetitionof anysortispresent.

WhenoptimizingyourGBP,thenumber1rankingfactorisPrimaryCategory,followedbyon-pagesignals,whichincludeshavingyourname,address,phonenumber,andhoursonyour website.Reviewsarenextandshouldbe filledwithcurrent,positiveselections.

Theterm link isusedtodescribeonewebsiteconnectingto another,andhigh-authoritysitescansharetheirauthority.In localSEOcampaigns,linksusuallymeancitations,whichisalisting foryourbusinessonanaggregatorordirectory-typewebsite. Googlewantslocalbusinessestohavecitationsbecausethey believethemoreaccurateandconsistentcitationsabusiness has,thebettertheproofthatthebusinessislocal.Inacitation campaign,yousubmityourpractice’sinformationtomultiple listingsitessoyouwillhaveapresenceonthosesites.Some havemoreauthoritythanothers,sothegoalistolistyourpracticeonthetopsites.Aggregatorsareservicesthatsubmityour informationtoagroupofcitationproviders,suchastheYellow PagesandtheGPSlisting.Inthiscampaign,it’simportanttocorrectoldorincorrectlistingssotheinformationisasconsistentas possibleforGoogle.

Youshouldknowthatthereisnowaytoquantitativelystatethat your20citationswillplaceyouinabetterpositionthansomeone else’s19orthatyourtop10authoritycitationswillorwillnot placeyouaboveacompetitor’s100low-authoritycitations.No standardhasbeensetregardingthecorrectnumberofcitations tohaveorhowhavingmoreorfewercitationswillaffectlocal listings.

Althoughacitationcampaigncanberunmanually,withsubmissionsofinformationto50ormorewebsites,manycompanies providecitationsubmissionservices.Althoughtheycostmoney tomakethesubmissions,itmaybeworthwhiletohavethemtake onthistask.

Citationsshouldbeconsistentacrossthewebbutthisisn’t somethingtostressover.Ifmostareconsistent,afewerrantlistings

won ’tbeadealbreaker.It’simportanttoensuretheaccuracyofthe topsites,suchasGBP,Facebook,andAppleBusinessConnect.

Oncecitationshavebeensubmitted,theyusuallycan’tbe removedbutonlyupdatedunlessthebusinesscloses.Thismeans youdon’thavetokeeppayingforaservicetokeepthatcitation open,althoughyoumightwanttosoyoucankeepitcurrent.If youworkwithacompanyforcitationsubmissions,don’tbe trickedintopayingiftheythreatentoundothecitationworkif youleaveorstoppaying.

LOCALSEOBESTPRACTICES

Thefollowingareimportanttorememberasyoudealwithlocal SEO:

YoumustowntheGBP,evenifagenciesmanageitfor you.

Onyourcontactpage,providewrittendirectionsusinglocal landmarkstoreinforcethefactthatyouarelocal. RegisteryourpracticewithAppleBusinessConnectbecause AppleMapsmaybeusedinsteadofGoogleMaps. Formetrics,focusonreportsofthenumberofcallsfrom yourGBPandhowmanyvisitorscometothewebsite fromGBP.

It’sOKtomanageyourGBPandcitationspersonallyorto handthetasktoanagencyforhelp.

ClinicalSignificance

LocalSEOwillhelpyourdentalpracticeappearinlocal searchresults.AnoptimizedGBPisbest,andthecitationcampaignwillhelptoensureyourpractice’s name,address,andphonenumberareconsistent acrosstheweb.

WankDA:Highvisibility. Dentaltown 26:44-48,2025

Reprintsnotavailable

THEBIGPICTURE CURRENTTRENDSINDENTISTRY

WhatDentistsareDoingtoRemainSuccessful

BACKGROUND

Eachyear InsideDentistry surveysreaderstoidentifythetrends thataretakingplaceindentistry.In2024,theareasofmostinterestwerepracticemanagement,clinicalcare,andpurchasingand adoptingtechnology.Manypracticesadoptednewapproachesto managetherisingoverheadcosts,economicpressures,andshiftingpatientexpectations.Thecurrentstateoftheprofessionand howcliniciansarehandlingthechallengesinthese3areaswhile prioritizingexcellentpatientcareweredetailed.

PRACTICEMANAGEMENT

Income

Thenumberofrespondentswhosepracticeswereinthetop3 incomebracketsdeclined,butthepercentagewhousedpractice managementconsultantsremainedunchanged.Reimbursements aren ’tincreasing,soevenwithincreasedproduction,profitsare lower.Practicesthatworkwithmanagementconsultantstended tomaintainsteadynetincomes,showingthathavingtheright consultantcanidentifycriticalpointsandhelpcraftpersonalized approachestoshoreupincome.

Tobalanceprofitabilitywithkeepingcarecompetitivelypriced andaccessible,manypracticeshavedecidedtoincreasepatient volume.Somepracticeshavechosentodeliverhigh-quality caretopatientswhovalueit.Thesedentistshavedecidedto workatbeingabetterclinicianwhocandelivercomprehensive caretoremainprofitableratherthanseeingmorepatients. Theybelieveprovidingthislevelofcarecanbemorefulfilling thanscalingforvolume.Whilebothapproacheswork,thechoice isuptotheclinician.

PatientFactors

Patientswantoptionsbecausetheyareoftenburdenedwithtight budgetsandlittleextramoneyforcomplexdentalcare.Asa result,making financingavailabletopatientsisanimportant component,with flexiblepaymentoptionsallowingpatientsto moveforwardwithneededtreatment.Signi ficantlymoredental officesareacceptingprivatedentalinsurance,offeroraccept alternativeplans,andconnectpatientswithhealthcare financing. Inaddition,somepracticeschangetheirwork flowstomakethe treatmentmoreaffordable.Digitaltechnology,forexample,can lowereconomicbarriers.

Marketing

Establishedpatientsgivethebestnewpatientreferrals.Although dentalpracticesstillusee-mail,printads,anddirectmail,more arenowusingwebsites,socialmedia,andonlineadstoboost thenumberofnewpatients.Awebsiteisoftencheckedby referredpatients.It’simportanttotrackthereturnoninvestmentforthevariousmarketingoptionstoensureeachisworthwhile.Mostrespondentsdon’tseetheusefulnessofchatbotsin makingtheirwebsitesuccessful.

DentalSupportOrganizations(DSOs)

JoiningaDSOcanprovidemanybene fi tstopractitionerswho carelessaboutthebusinessaspectsofdentalcareandwho wanttofocusonpatientcare,arelookingtoselltheirpractices, wanttocollaborate,orareseekingabetterwork-lifebalance, amongotherinterests.Moredentistsareopentojoininga DSO,butthenumberofdentistswhoarenotatallopenor onlysomewhatopentothispathhasincreased.Thisindicates acoolingofinterestinDSOsandpossiblyanegativesentiment.

JoiningaDSOmaybeavoidedifthedentisthas,overtheyears, establishedthepatients,schedule,team,andprofessionalfulfillmentheorshedesires.Somedentistsrecognizethatittakes timetodeveloptheknowledge,skills,andbusinesssensetoprovideexcellentcare,createefficiencyatthechair,andmaximize profitability.Thesedentistswouldratherstayinasituationwhere allthosehavecometopassthanswitchtoaDSO.TheAmerican DentalAssociationfoundthatdentistsinDSOsaremoreoptimisticaboutcurrenteconomicconditionsthanthosenotinDSOs.

CLINICALCARE

Overall,manyclinicaltrendsindentistryremainedstableor changedonlyslightly.Thisincludedthenumberofdirectrestorativeorcrownandbridgecasesdonemonthly,thenumberof endodonticproceduresdone,mostorthodontistsbelievingclear alignertherapyshouldbemanagedinperson,orcliniciansperformingsedationdentistry.Whiteningchairsideisnowbeing offeredbymorethanhalfofthesurveyrespondents,ajump fromthe8%reportedpreviously.

ImplantTreatment

Withrespecttoimplant-support edrestorations,thepercentageofdentistswhoplacedscrew-retainedrestorationsjumped

by10%andthoseplacingcement-retainedrestorations decreasedby15%from2019to2022,butthesenumbers havestabilized(TypeofImplantRestorationsPerformed Figure).Sixty-ninepercentofthedentistsplacescrewretainedrestorationsand49%placecement-retainedones. Theexplanationforchoosingcementretentionwasthatscrew retentionisnotyetthestandardforeverythingandpractitionersaren ’tfamiliarwiththemoderncomponentsandscanningprotocols.Thecementretentionwasusedformany yearstoavoidmisalignedscrewchannelsandcompleximpressionprocedures.Itwilltaketimetobecomecomfortablewith advancedscanningandangledabutmentsandhexdrivers,which haveovercometheproblemswithscrewretention.

SleepDentistry

Sleepdentistryisbecomingmorespecializedbecauseofreduced reimbursements,higherlaboratorycosts,andtheincreased complexityinmedicalbillingandinsurancerequirements,allof whichmaketheprocessless financiallyviableandaccessiblefor generaldentists.Inaddition,commercialinterestshaveinserted themselvesintodentalsleepeducationandcausedconfusion overinconsistenciesbetweenprotocolsandworkflows.Even somelargedentalpracticescan’tovercomethesedrawbacks.

ComplexTreatmentPlans

Overthepastyear,patientacceptanceofcomplextreatment planshasdropped,withjust54%ofthedentistssurveyedindicatingmostproposalsareaccepted.Only11%ofthedentists hadacceptanceratesexceeding80%and22%reportedacceptancerateslessthan25%.Thesetreatmentplanshavealways beenamajorcontributortothedentalpractice ’ssuccess,but arenowsufferingfrominflatedoverhead,patienthesitancy, highinterestrates,andDSOin fluences.Manycliniciansareperformingmoretransitionalbondingproceduresratherthan higher-costandmorede finitivetreatments.

OtherClinicalTrends

Withrespecttoin-houseprocedures,aslightdecreasewasseen inmillingrestorationsandanincreasewasnotedin3Dprinting permanentrestorations.Inaddition,asmallincreasewasreportedinthepercentageofdentistswhocommunicatedinpersonorbyphonewiththelaboratoryonthemajorityoftheir complexcases.A12%increaseoccurredinthepercentageofrespondentswhopreferredtoavoidusingteledentistry.Many practicesappeartoberethinkingthevalueofremoteappointmentsnowthatthepandemicisover.

PURCHASINGANDADOPTINGTECHNOLOGY

PurchasingPractices

Inthepastyear,themajorityofdentistscontinuedtoworkwith 1to3distributorsordealers,withaboutafourthparticipating

ingrouppurchasingorbuyinggroups.Purchasingdecisions weremadebasedonclinicalresearchaccordingto80%ofthe respondents.Mostreliedontherecommendationsofkey opinionleadersandstudyclubresourcesratherthanother sources.Theonlineservicesmostoftenusedforpurchases werethewebsitesofmanufacturersanddealers,but5%more dentiststhaninthepasthaveturnedtoAmazon.Thissiteoffers morealternativeinstruments.Specializedimplantabutments andscrewsareusuallysourcedfromimplantcomponentwebsites.Althoughmostdentistsstillchoosetraditionaldentalsupplychannelsfortheirmaterials,themoderngrouppurchasing modelisgainingacceptance.

ImplementingNewTechnology

Surveyrespondentswhoreportedspending15%to30%of theirpracticebudgetsonnewtechnologydecreasedtheir spending.However,theprevious48%whospent10%or lessincreasedto58%.Theeconomylikelyledtothe decreasedspending,butpractitionerssaidtheystillmake well-consideredtechnologyinvestmentsbecausetheycanincreaseproductivity.Investmentsinnewtechnologyshould providea fi nancialreturn,enhanceworksatisfactionforclinicians,anddeliverbetterpatientexperiences(DentalTechnologyUsedFigure).Mostdentistscontinuedtouseair-driven handpieces,electrichandpieces,andcone-beamcomputedtomography(CBCT)machinesatthesamepercentagesasreportedinprevioussurveys.Increasedusewasnotedfor digitalradiographysensorsand3Dprinters,butadecrease wasnotedforlasers.Digitalimpressionsystemsareusedin signi fi cantlymorepractices,re fl ectingtheimprovedef fi ciency andconsistenthigh-qualityres ultsthatarenowobtained.In addition,thepricepointhascomedown,makingthisinvestmentmoreaffordable.

AI

Althoughthe2023surveyreportedamorecriticalattitudetowardtheuseofdentaltechnologiespoweredbyAI,thepercentageofdentistswhoreportedintegratingsomeAImodulesinto theirwork fl owsdoubledin2024.Thepercentageofdentists whoindicatedtheyweremonitoringthedevelopmentsinAI andconsideringitfellfrom26%to19%,butthepercentages whoweren’ tconsideringAIproductsbutmaybeopento themandthosewhorejectedAIaltogetherremainedthe sameaspreviously.Thesetrends appeartoindicatethatthose whohadalreadymadeuptheirmindsremainedunchanged, butmanywhowereconsideringAIadoptedit.Teamsseemto stillbedecidinghowAI fi tsintheirwork fl ows(UseofArti fi cial IntelligenceFigure).Asigni fi cantamountoftrustisneeded beforeAIiswidelyaccepted.Futuredevelopmentsintechnologymaybringmorecontroltoproceduresandleadtogreater con fi denceregardingoutcomes.

ClinicalSignificance

Dentistsfacedanumberofchallengesin2024, includinghighlevelsofinflation,increasedoverhead, staffingshortages,lowinsurancerates,andincreased competitionfromDSOs.Manystillfoundwaysto remainprofitable,suchasofferingmore flexiblepaymentoptions,increasingpatientvolume,including bettermarketingonwebsitesandotherchannels,expandingtreatmentoptions,andaddingnewtechnologies.Eachpracticemustdeterminewhatisbestfor theirspecificsituation.Usingavailableresourcesto investinwell-consideredoptionsandthenworking tomaximizetheirimpactwillyieldthesuccessthe practiceseeks.

FialkoffS:Overcomingchallengestoprofi tability. InsideDent 20:16-18,20,22,24,2024

Reprintsnotavailable

DENTALCARIES

EarlyChildhoodCariesWorldwidePrevalence

BACKGROUND

Earlychildhoodcaries(ECC)manifestsas1ormoredecayed, missing,or fi lledtoothsurfacescausedbycariesintheprimarytoothofachildunderage6years.ECCispreventable, butremainsaglobalhealthproblemandcausesnegativeeffectsonthechild ’ squalityoflife,development,andgrowth patterns.ECCisfoundinasmanyashalfofthetoddlers acrosstheworld.Theprevalenceisbelievedtobesigni fi cantly in fl uencedbythefamily’ssocioeconomicstatus.Asystematic reviewandmeta-analysiswasdonetoinvestigateECCprevalenceandexperienceovera10-yearperiodandreportthe distributioninvariouscountri esandinrelationtosocioeconomicfactors.

METHODS

ThedataweregatheredfromthePubMed,Embase,Scopus,and OpenGreyliteraturedatabases,alongwithahandsearchforspecificcountries.Thedatacollectedincludednumber,age,and genderofthepatients,cariesprevalenceexpressedasapercentage,andcariesexperience(decayed, filled,treated[dft]teeth). Meta-analysesweredoneforoverallECCprevalenceandexperiencebycountryofpublicationandsocioeconomicindicators,specificallygrossnationalincome(GNI)andinequalityindex(Gini index).

RESULTS

Onehundredpublicationswereincluded,with67reportingECC prevalence.PrevalencewashighestinthePhilippines(98.0%)and lowestinJapan(20.6%)andGreece(19.3%).InNorthAmerica, theUnitedStateshadthehighestprevalenceat53.0%;inSouth America,Argentinahadthehighestat85.8%;inEurope,thehighestprevalencewasinAlbaniaat84.1%;andinAfrica,Angolahad thehighestrateat57.9%(Figure2).

TheglobalestimatedprevalenceofECCwas49%.Thepooled cariesprevalencewas34%inCentral/SouthAmerica,36%inEurope,42%inAfrica,52%inAsia-Oceania,57%inNorthAmerica, and72%intheMiddleEast.

ThehighestdftwasfoundinthePhilippinesandthelowestwasin Japan.InNorthAmerica,thehighestdftwasnotedintheUnited States;inSouthAmerica,itwasfoundinColombia;inEurope,it wasinBosnia-Herzegovina;andinAfrica,itwasinMorocco.

AstatisticallysignificantconnectionwasnotedforECCprevalenceandgeographicalareas.ThehighestECCprevalencewas foundinAsia,whichhasalowGNIandahighunemployment rate.WhentheGiniindexwasconsidered,ECCprevalence rangedfrom39%forareaswithlowinequalityto62%forareas withnoinequality.LifeexpectancyandECCprevalenceranged

Figure2. WorldwideECCprevalencemap.Prevalencewascolorcodedasfollowing: A, <29%-lowprevalence(darkgreen); B, 29.1%-39%-mediumlow prevalence(lightgreen); C, 40%-49.9%-mediumprevalence(yellow); D, 50%-60%-mediumhighprevalence(orange);50%-80%-highprevalence (lightred); E, >80%-veryhighprevalence(darkred).(CourtesyofMaklennanA,Borg-BartoloR,WierichsRJ,etal:Asystematicreviewandmeta-analysis onearly-childhood-cariesglobaldata. BMCOralHealth 24:835,2024.)

from28%incountrieswiththehighestlifeexpectancy,whichwas morethan80years,to62%incountrieswithalifeexpectancy between71and75years.

Highmeandftwassignificantlyassociatedwithgeographical areas,withthehighestvaluesnotedinAsia.Thiswaslinkedto alowGNI,butnottounemploymentrate.

Countrieswiththehighestlifeexpectancyhadthelowestpooled meandftof1.34teeth.Thehighestdftwas5.18teethandoccurred incountrieswithalifeexpectancyof71to75years.Whenthe Giniindexwasconsidered,thelowestmeandftwas1.62teeth andoccurredincountrieswithlowinequality,withthehighest meandftof3.95teethfoundincountrieswithnoinequalities.

CONCLUSIONS

TheECCprevalenceratesvarywidelyacrossthegeographic areasintheworldbutremainhigh.Aclearlinkhasbeenfound betweenoralhealthhabitsandsocioeconomicdisparitiesincommunities.Amorein-depthlookintotheculturalandsocioeconomicdifferencesthatmayleadtoECCisneeded.

ClinicalSignificance

Thecurrentprogramsformonitoringandaddressing theissueofECCappeartobeinsufficientbecause ratesofECCremainhigh.Theindividualneedsincommunitiesandsocioeconomicrealitiestheinhabitants faceshouldbeconsideredinanyfutureprograms thataredeveloped.Researchisneededtodevelop personalizedandsociety-basedapproachesthat mayachievebetterpreventiveresultsinreducing ECCprevalenceandexperienceacrosstheworld.

MaklennanA,Borg-BartoloR,WierichsRJ,etal:Asystematicreviewandmeta-analysisonearly-childhood-cariesglobaldata. BMCOralHealth 24:835,2024

Reprintsavailablefrom AMaklennan,DeptofRestorative,PreventiveandPediatricDentistry,SchoolofDentalMedicine,Univof Bern,Freiburgstrasse7,Bern3010,Switzerland;e-mail: anastasia.maklennan@students.unibe.ch

ApproachestoReduceEarlyChildhoodCaries

BACKGROUND

Despiteprogramstopreventdentalcaries,theprevalenceofthis problemhascontinuedtorise,especiallyinyoungchildren.Oral diseases,includingearlychildhoodcaries(ECC),affectalmost3.5 billionpeopleworldwide,withuntreatedcariesthemostcommonhealthcondition.Newapproachesarebeingtakento addresscaries,buttheproblemofunequaldistributionofpreventivemeasuresremainstobeaddressed.Variousapproaches, includingmicrobialpathways,perinatalapproaches,genomics, socialdeterminants,teledentistry,epidemiologyandtherapeutics,andevidence-basedcare,wereexplored,notingthecurrent andpotentialstatusofeach.

NOVELAPPROACHESTOMANAGINGECC

MicrobialPathways

Nitrogen-containingcompounds,whichwouldincludeurea,arginine,andnitrate,aremetabolizedbyoralbacteria.Asaresult,the intraoralpHrises,biofilmsarehealthier,andpathogenicbacteria andcariesareinhibited.Thereductionofnitratealsoisakey componentoftheenterosalivarypathwayfornitricoxideproduction,linkingtheoralmicrobiomewithsystemichealth.Patientscouldhaveahealthieroralenvironmentandbetter cardiometabolichealthwithhighersystemicnitricoxidelevels.

PerinatalApproaches

Theperinatalstage,whichincludesthepregnancyandpostpartum stages,offersanimportantopportunitytointerrupttheburdenof ECC.Mothersappeartohaveanin fluenceontheirchild’soral Candidaalbicans acquisitionintheearlyinfancyperiod.Thisincludestheinteractionsbetween Calbicans and Streptococcusmutans andtheirimpactonthechild’soralmicrobiome.Screening infantsandmothersfororalfungalcarriageandprovidingearly antifungalinterventionscanaccompanycurrentlyperformed ECCpreventionprotocols.MobileapplicationssuchastheA1 Cariesappcanpotentiallyprovidearti ficialintelligence(AI) poweredcariesdetection,aninteractivecariesriskassessment, evidence-basedcariesmanagement,andpersonalizededucation.

Genomics

ToolsdevelopedbytheHumanGenomeProjecthavebeen appliedtothe firstgenome-widechildhoodcariesstudies.AsignificantassociationhasbeenshownbetweenECCandbittertastereceptorgenes.Inaddition,havingacariogenicbacterialcommunity atage2yearspredictscarieswilldevelopbyage5years.Twoyear-oldsinanoncariogenicbacterialcommunitywhohaveacariogenicgeneticbackgroundhaveariskofcariesonsetbyage5years similartothatofchildrenlivinginacariogenicbacterialcommunity.Furtherexplorationsareneededtobetterunderstandindividualandpopulation-specificriskfactorsforECC.

SOCIALDETERMINANTS

Cultural,economic,social,andpsychologicalfactorsin fl uence diseaseandcanhaveasigni fi cantimpactonhowweviewthe rootcausesofhealthandhealthpromotion.Socialdeterminants canexacerbatetheriskforECC,butchallengesremainin applyingthisknowledgetoassessmentandinterventiontools. Thecurrentmodelsshowthatfamily-levelpsychologicaland psychosocialfactorscanpredictECConset.Thevariablesare likelytooperatethroughbehavioralpatterns,oralhygienepathways,andhealthcareaccess.Attentionshouldbepaidtothesocialdeterminantswhencrafting preventionandintervention approaches.

Teledentistry

Teledentistryofferstheabilitytoscreenvulnerableinfantsand toddlersandachieveone-on-oneinteractionswithyoungchildren,theirparents,andgeneraldentists,whichhasbeenespeciallyusefulfortriageandreferralstopediatricdentists.Having betteroralhealthoutcomesandestablishingadentalhome,especiallyinpoororunderservedruralorurbancommunities,are additionaladvantagesrelatedtoteledentistry.

EpidemiologyandTherapeutics

Prospectivecohortstudiesandrandomizedcontrolledtrials (RCTs)haveprovidedclearevidenceofthecausationofcaries andtheef ficacyofinterventions.It’sbeencon firmedthat, comparedtoplacebo,38%silverdiamine fluoride(SDF)provides betterresultsinarrestingdentalcariesinUSchildrenwithsevere ECC.Theeffi cacyof10%povidoneiodineinreducingrelapsein childrenwho’vebeentreatedinthehospitalforsevereECCis underreview.Suchhigh-qualityclinicaltrialshelpinevaluating theef ficacyofinnovativetreatments.Consideringcariesa chronicdiseaseandtargetingevidence-basedstrategiestothose mostatriskmayhelptoreducedisparitiesincariestreatment.

Evidence-basedCare

Therearedistincttrajectorypatternsforcariesduringchildhood, sotheapproachtocariesriskandmanagementshouldconsider thelifecourseofthepatient.Thedevelopmentofrisk-based toolsformedicalsettingsandaccompanyingeconomicmodels canhelpinevaluatingthecost-effectivenessofrisk-based caries-preventiveapproachesthatbeginatage1year.

CONCLUSIONS

SomeprogresshasbeenmadeinreducingECCprevalencein children.Thisincludesabetterunderstandingofthemicrobial andgenomicinfluences,theroleofsocialdeterminants,and howteledentistryandinterprofessionalapproachescanimprove thereachoforalhealthcareproviders.Itremainstoaddressthe systemicinequitiesinoralhealthamongthemostvulnerable

childrenlivinginurbanandruralcommunitiesthathavelimited ornoaccesstooralhealthcare.

ClinicalSignificance

Multifacetedandmultimodalapproachesinperinatal andpostnatalcareaswellasadrivetoward evidence-basedcaremodelsareneededtomoveforwardwiththepreventionofECC.Theapproachesthat arealreadyunderwayholdpromise,butweneedto seethatnochildisleftbehindinthebattletoreduce earlydentalcariesworldwide.

FUTUREOFDENTISTRY

Kopycka-KedzierawskiDT,FontanaM,MarazitaML,etal:Dental caries:Thewayforward. JDRClinTranslationalRes 10:4-6,2025

Reprintsavailablefrom DTKopycka-Kedzierawski,Deptof Dentistry,UnivofRochester,625ElmwoodAve, Rochester,NY14620,USA:e-mail: Dorota_kopyckaKedzierawski@urmc.rochester.edu

CurrentTrendsandAdvancesinDentistry

BACKGROUND

Dentistryconsistsofmanyspecialtiesthat,together,provide comprehensiveoralhealthcare.However,afterthepandemic anditseffectonaccessibility,thenumbersofpracticingdentists hasdeclined.Inaddition,socialandculturalinfluenceshave changedthedynamicsofdentalcare,patientbehaviors,andattitudestowarddentistry.Asadvanceshavebeenmadeinseveral dentalspecialties,oftendrivenbytechnologicalinnovationor research findings,newapproacheshavebeendevelopedand oralhealthcarehasshiftedtofocusmorepurposefullyonpreventionandcomprehensivepatientcare.Thetrendsbeingseen andadvancesinvariousspecialtieswerereviewed,withthe goalofpredictingwhatthefutureofdentistryintheUnited Kingdom(andelsewhere)maylooklike.

CURRENTTRENDS

ThebudgetallocatedtoNationalHealthServices(NHS)dentistry includescutsthatmakeitunabletomeetthedemandfororal care.Ifthiscontinues,thestandardoforalhealthmaydeteriorate nationwide,leadingsomepatientstochoosetoseeprivatedental practitionersandotherstochoosenodentalcareunlessitisan emergencysituation.Oftenfamiliesareforcedtoremainonwaitinglistsforlongperiodsoftime.Ifsuchbacklogsandinsufficient resourcescontinue,dentistswilllikelychoosetoleavetheirNHS contractsandprospectivedentistswon’twanttoestablishthem.

Asurgeofdemandforpatientsmaydevelop,butthefundstopay fordentistrymaybelacking.Dentalstaffmemberswhoareoverworkedwilldevelophigherstresslevelsthatcouldaffecttheir performanceandpatientsatisfactionlevels.Eventuallypatients willstopcomingandchildhoodcarieswillbecomemore

common,allfromalackofprophylacticcare,education,and timelyinterventions(Figure1).

Privateaestheticdentaltreatmentisextremelyexpensive,makingitunattractiveformanyindividuals.Somewillseektohave theseproceduresdoneabroad,withTurkeycurrentlyseenas aprominentdestinationfordentaltourism.

Socialmediacanalsoinfluenceperceptionsaboutdentistry,oral aesthetics,andoralhealthawareness.Platformsencouragethe spreadofinformationandanecdotesaboutdentalpractices. Thishasthepotentialtoproducemisconceptions.

ADVANCESINSPECIALTYDENTISTRY PediatricDentistry

Withtheunavailabilityofappointments,childhoodcariesrates mayincrease,whichhasanextensiveimpactonthehealthof youngpatients.Theimpactofsocialmediainfluencersadvocating fororalhealthandaddressingtheavailabilityofdentalvisitsfor youngpatientsmaybeabletomitigatethisproblem.

Prosthodontics

Technologicaladvancesandtheintegrationofartificialintelligence (AI)arebeingviewedwithhopeconcerningtheabilitytorevolutionizeimplantdesigns,materials,andtreatmentapproaches. Dentalprostheticscouldbecomemoredurableandeffective,offeringmoresustainableandpossiblyaffordableoptions.

OperativeDentistryandEndodontics

Researchintonew fillingmaterialsisfocusedonmaterialswhose propertiescloselymimicnaturaltoothstructures.Thiourethane-

Figure1. Impactassessment:ConsequencesofNHSdentistrybudgetcutsintheUK.(CourtesyofEshoT:Isthefutureofdentistryasbrightaswehope? Apersonalexplorationintodentistry’snationalandglobalprospects. BrDentJ 237:761-764,2024.)

based fillingmaterialsmayprovidelongevityanddurabilityfor enamelanddentinrestorations.Inaddition,bioactiveglass fillings mayincreaselongevityalongwithpreventiveef ficacy.These fillingsreleaseessentialmineralionsanddissolveoncontact withbodily fluids,formingapatitecrystalsontheirsurface.This permitsbondingonamicroscopiclevelwithapatitecrystalson thetoothsurface.Thesematerialsofferanextendedlifespan withlessneedforfrequentreplacementsandmaycreatedurable restorations.

It’sexpectedthatendodontistswillsoonfocusonregenerative approacheswherebypulptissuecanberevitalizedthroughtissue engineeringandstemcelltherapy.Theresultswouldbeamore biologicallysoundandlongerlasting.

Nickel-titanium fileshavebeenarecentdevelopmentforendodontistsandgeneraldentists,butcontinuoustestingisexpectedto resultinmore flexible,durable,andfracture-resistant files.These new fileswillenhanceefficiencyandleadtobetterclinicaloutcomes.

Orthodontics

Clearalignersarethepreferredwaytoaddressaestheticconcerns,offeringadiscreteappearance,customizabilityandaquick turnoverthatdecreasestheprevalenceofcariesrelatedtoprolonged fixedbracesuse.Theabilitytoremovethealignersmeans thepatientcancleanallteethandachievebetteroralhygiene, evenwhenusedforpatientswithrestrictedhandmovements. Fixedbracestendtomakeyoungerindividualsfeelselfconsciousandcanleadtoonlinebullying.Theproblemiseven worseifthepatientmustwearextraoralappliancessuchasorthodonticchincupsandheadgear.

Adrawbackisthatself-ligatingbraceslackthecolorcustomizationoptionsthattraditionalbracesoffer,whichmaybeadisadvantageintheeyesofyoungerpatients.Practitionerswillhave tonavigatetheevolvingpatientpreferencesandsocialin fluences toachievetreatmentacceptanceandbetteroutcomes.

PeriodontalTreatmentandSystemicHealth

Increasingly,evidenceisbuildingthatsupportsalinkbetween periodontalhealthandsystemicwellness.Plaqueaccountsfor 20%oftheriskfordevelopingperiodontitis.Theremaining 80%prevalenceofnon-plaque-inducedperiodontitistendsto occuratyoungerages.Someofthenewerdrugsmayinadvertentlycompromiseperiodontalhealth,soacomprehensivepatientassessmentandpreventivemeasuresareessentialin caringforpatients.

Focalinfection,whichimpliesthatsystemicinfectionscanbe eithertriggeredorexacerbatedbyoralhealth,underscoresthe needtohelppatientsmaintaingoodoverallhealthsoadequate prophylacticdentalself-careisn’thindered.Lifestylefactorscan affectperiodontalhealthaswell.Patientsneedtobeeducated abouttheimportanceofeatingahealthydietandavoidinga sedentarylifestyle.

TechnologicalInnovations

Lasertechnologyhasbeenintegratedintoperiodontalandsurgicalprocedures.Itoffersreducedpain,minimalbleeding,and fasterrecovery,soitsuseispopularwithpatientsand practitioners.

Digitaldentistryincludescomputer-aideddesign/computer-aided manufacturingthatprovidesmoreprecisetreatmentplanning andcustomization,betterclinicaloutcomes,andhigherlevels ofpatientsatisfaction.The3-dimensional(3D)printingoftooth structuresandothersystemictissueshasyettobeintroduced, butisexpectedinthefuture.

AIandpredictivemodelshavebeenusedtopredicttheprobabilityofpermanenttoothloss,alongwithotherbehavioralandlifestyleelements.Ageandregulardentalvisitsareprimary indicatorsrelatedtotoothloss,butsocioeconomicfactorsalso

influencetheoutcomes.AIisevolvingintopotentialusesindaily dentalcaresituationstocustomizetreatments.

Virtualandaugmentedreality(VR/AR)mayenhancepatient engagementandtreatmentplanning.Patientswhocanseethe treatmentoutcomesmaybemorelikelytoapprovetreatments andthosewithdentalanxietymaybelessanxious.VR/ARcan helpdentalprofessionalsvisualizeandmanipulate3Drepresentationsofthepatient’sanatomicalstructures,helpingthemto achievemoreaccurateandef ficientdeliveryoftreatment.

Radiation-freeimagingtechniquescouldnotonlybesaferforpatientsbutalsofordentalprofessionals.Thesetechniquesoffera moreclinician-friendlyapproachtomedicalanddentalradiography.

Teledentistryexpandsaccesstodentalcare,allowingthedentist tousedigitaltechnologiestoprovidedentalcare,consultations, education,andtreatmentatadistance.Patientsdon’thaveto bephysicallypresentinthedentaloffice.Advancesinteledentistrybeyondwhatwasachievedduringthepandemicallowdental professionalstoconsult,monitorprogress,anddeliverpreventiveeducationtopatientsregardlessofwheretheyarelocated.

CONCLUSIONS

Opportunitiesareopeninginmanydentalspecialties.Inaddition, technologicaladvancescanprovidetreatmentsmoreeffectively, makethemmoreaccessible,andkeepthemaffordable.With theseadvancesandahalttothelossofdentalpractitioners plusadequatefunding,therecouldbeanationalimprovement inthehealthcareofallpatients.

ClinicalSignificance

Newdentalmaterials,processes,technology,andprioritiescanhelpdentistrymoveforwardintreatingpatients.Thestaffingshortagesthatplaguehealthcare currentlycanbesomewhatrelievedbysomeofthese approaches,andpatientsmaybemoresatisfiedwith thetreatmentsandresultsthattheyobtainfroma dentalvisit.Dentalpractitionersmaybelesslikelyto leavetheprofessionandmorelikelytoexplorethe transformationsthatmaybepossible.

EshoT:Isthefutureofdentistryasbrightaswehope?Apersonal explorationintodentistry’snationalandglobalprospects. BrDent J 237:761-764,2024

Reprintsavailablefrom TEsho,MedicalUnivofPlovdiv,Facultyof DentalMedicine,HrisoBotev,3Plovdiv,4000,Bulgaria;e-mail: temidentist@gmail.com

GENERATIONALTRANSITIONS

ChangingProfilesandPracticeModalities

BACKGROUND

Theoralhealthprofessionissignificantlychanginginanumberof waysandinresponsetovariousfactors.Oneofthewaysthese changesmanifestsisagenerationaltransitionthatwilllikelyaffect dentistryasacareerchoice,dentaleducation,andcollaborations betweenmedicalanddentalpractices.

FACTSOFGENERATIONALCHANGES

ChartingtheagedistributionfortheUSdentistworkforcein 2001,2017,and2023,alongwithprojectionsinto2028,shows thechangesthathavealreadytakenplaceandthosethatwe mayseeinanother5years( Figure ).In2001,mostdentists wereintheir40s,withfewintheirearly30sortheirlate 60s.In2017,2largegroupsofdentistswereseen,with1group intheir30sandtheotherintheir60s.Thisrepresentsthebaby boomerdentistsnearingretirementastheyageintotheir60s, coupledwiththeexpansionofdentalschoolenrollmentbased onmoredentalschoolsbeingestablishedandhigherenrollmentsatexistingdentalschools.In2023,fewerdentistsintheir 60swereactiveandanincreaseofdentistsintheir30swas obvious.Notonlydidthegrowthofdentalschoolenrollment contribute,butthebabyboomerscontinuedtoretirefrom practice.

Theprojecteddentistworkforcein2028willshowmanyfewer babyboomerdentists.Inaddition,dentalschoolgraduations willcontinuetoincrease,sothattheaverageageofthedentists willbeyoungerthanitistoday.

SIGNIFICANCEOFTHESECHANGES

Althoughitmayseemmerelyachangeintheageofdentiststhat hasoccurred,inactuality,therearechangesintheprofilesof thesedentistsandintheirpracticemodalityaccompanyingthe shiftinage.

Profiles

Practicingdentistsage65yearsorolderare15%womenand81% White.Incontrast,the2023graduatesofdentalschoolwere55% womenand48%White.Inaddition,57%oftheincomingdental studentsin2023werewomen.Variousdentalworkforceoutcomesarerelatedtothesechanges.It’slesslikelythatfemale dentistswillowntheirpractice,andfemaledentistsaremore likelytotreatMedicaidbene ficiaries.Raceandethnicityalso contributetothesetrends,withdentistswhoareintheminority morelikelytotreatMedicaidbeneficiaries.Femaleandminoritizeddentiststendtomakeless,withnorelationshiptotheyears ofexperienceofthesepractitioners.

Figure. Agedistributionofthedentistworkforce. Source: Datafor2001,2017,and2023arefromtheAmericanDentalAssociationHealthPolicyInstitute analysisofADAmaster fileonOctober2,2024. Source: Projected2028dataarederivedfromtheAmericanDentalAssociationHealthPolicyInstitute dentistworkforceprojectionmodel.(CourtesyofVujicicM,FlynnB,MunsonB:Weareinthemidstofamajorgenerationaltransitionindentistry. JAm DentAssoc 156:85-86,2025.)

Dentist age, y

Age distribution of the dentist workforce

PracticeModality

Youngerdentistsaremuchlesslikelytoowntheirpracticethan youngerdentists20yearsago.Theyarealsomorelikelyto choosedentalgrouppracticeandtobeaf filiatedwithdentalsupportorganizations(DSOs)thanolderdentists.Grouppractice andDSOaffiliationaren’tnecessarilyconsideredapathtoeventualpracticeownership.Thelevelofdentaleducationaldebt showslittlecorrelationwithchoiceofpracticemodality.

Overa5-yearperiod,mostnewdentiststendtoremainwhere theywereinpracticesizeandaffiliationwithaDSO.Solodental practiceisn’talwaystheirnextstep,withjust10%to14%ofnew dentistschoosingsolopracticeandmoreshiftingfromalarge grouppracticetoasmallerone.Thiswillhaveimplicationsfor variousstakeholdersinthefuture.

CONCLUSIONS

Thepracticeprofilesandmodalitiesofdentistsinupcomingyears differfromwhatwastrueforthepast20years.Asthegenerationaltransitioncomestoanend,it’sstillnotclearwhetherthese changesareapositivemoveoranegativeone.

ClinicalSignificance

Thechangesthathavebeentrackeddon’tnecessarily fallintothecategoryofproblematicorprogressivefor patients,providers,andotherkeystakeholders.Being awareofwhathashappenedandwhatwelikelywill seeinthenearfuturemaybringinsightsintotheimplicationsofthesenewpatternsandhelpinpreparingfor anewreality.

VujicicM,FlynnB,MunsonB:Weareinthemidstofamajor generationaltransitionindentistry. JAmDentAssoc 156:85-86, 2025

Reprintsavailablefrom BFlynn,HealthPolicyInst,American DentalAssoc,211EChicagoAve,Chicago,IL60611,USA; e-mail: flynnb@ada.org

PEDIATRICDENTISTRY

CHATGPT

PediatricEducationMaterialPreparedByChatGPT

BACKGROUND

Artificialintelligence(AI) supportedtoolssuchasChatGPT offertheabilitytomimichumanlanguageprocessingabilities andgeneratehuman-liketext.Indentistry,ChatBPTcanbe usedindigitaldatarecording,imaginganalysis,diagnosisand treatmentplanning,dentaltelemedicine,anddentalandpatient education.Itoffersconvenienceinconveyinginformationand canprovideinstantfeedback.Inpediatricdentistry,parentsare encouragedtobringtheirchildrenfortheir firstdentalvisit beforeage1year.Someofthetopicsthatarediscussedatthese earlyvisitsareearlychildhoodcaries(ECC), fluorideuse,and traumaticdentalinjuries.Becauseparentsmayaccessthe internettodealwiththeseissues,offeringthemaccurateand relevantinformationatthesevisitsisessential.Withoutguidance, ChatGPTcanmakelogicalerrorsorcreateinformationthathas nofactualbasis.Astudywasundertakentotestthequality, readability,andoriginalityofpediatricpatient/parentinformation andacademiccontentprovidedthroughChatGPT.

METHODS

ChatGPT-3.5wasusedtocollectinformationfromanAImodel. Sixtyquestionsthatpediatricpatients/parentsmightaskwere developedintheareasofdentaltrauma, fluoride,andtooth eruption/oralhealth.Bothquestionsforthepatient/parentand thoseconsideredacademicconcernswereincluded.Ten experiencedpedodontiststrainedtousethemodi fiedGlobal QualityScale(GQS)evaluatedthequalityandsimilarityofthe answers,whereastheFleschReadingEaseandFlesh-Kincaid GradeLeveltestswereusedtoassessthereadabilityandgrade levelofthepatient/parentandacademicquestions.

RESULTS

ScoresforQuality,Readability,GradeLevel,andSimilarity

TheaverageGQSscoreforthepediatricpatient/parent questionswas4.3,whereasthatfortheacademicquestions was3.7.Thedifferencebetweenthe2wasstatisticallysignificant. Readingeaseanalysisfoundanaveragescoreof41.5forthe

pediatricpatient/parentquestionsand34fortheacademic questions.Thisdifferencewasstatisticallysignificantandindicatedthatthematerialwasunderstandableatacollegestudent level.TheFlesch-KincaidGradeLevelaveragescoreforpediatric patient/parentquestionswas12.7,whereastheaveragescorefor academicquestionswas13.7.Thedifferencewasn’tstatistically significantandindicatedunderstandabilityatcollegestudentlevel. Averagesimilarityrateforthepediatricpatient/parentquestions was8.4%,butthatfortheacademicquestionswas5.7%.The differencewasn’tstatisticallysignificant.

Subject-relatedScores

Nostatisticallysigni ficantdifferencewasnotedfortheaverage qualityscoresforthepediatricpatient/parentquestions regardingdentaltrauma, fluoride,andtootheruption/oral health.Fortheacademicquestions,thehighestaveragescores werenotedinquestionsabout fluorideandtootheruption/ oralhealth.Theseweresigni ficantlyhigherthantheaverage scoresfordentaltrauma.Forreadability,thehighestscore wasnotedfortootheruption/oralhealthandthelowestfor fluorideonthequestionsforpediatricpatient/parents,with thedifferencestatisticallysignificant.Thevaluesforreadability oftheacademicquestionsandpatient/parentquestionsdid notdiffersignificantly.

Comparisonofsimilarityrateshowedthehighestrateforthe pediatricpatient/parentquestionsregarding fluorideandfor thetooth-eruption/oralhealthamongtheacademicquestions. Thedifferencesbetweenthequestionsforthe2groupsweren’t statisticallysigni ficant.

CONCLUSIONS

TheanswersprovidedbyChatGPTwerereasonablyaccurate andusefulforthepediatricpatient/parentquestions,butless acceptableforacademicquestions.Amongtheacademic questions,thelowestscorewasnotedfordentaltraumaand theanswerswereinadequateforaddressingtechnicalandcase questionswithup-to-dateandclearinformation.

ClinicalSignificance

BeforeadoptingChatGPT-creatededucationalmaterialsinapediatricdentalpractice,thedentistshould reviewtheaccuracyofthematerial,especiallywithregardtoacademictopics.Inaddition,materialswritten atacollegestudentlevelmaybetoodifficultforpediatricpatient/parentgroupstofullyunderstand.Theinformationneedstobeatanefficientandreadily understoodleveltoprovideguidanceformostparents ofpediatricpatients.

DENTALTRAUMA

NahirCB:CanChatGPTbeguideinpediatricdentistry? BMC OralHealth 25:9,2025

Reprintsavailablefrom CBNahir,DeptofPediatricDentistry,FacultyofDentistry,TokatGaziosmanpasËaUniv,Tokat,Turkiye;email: canannbayraktarr@gmail.com

EpidemiologyandManagementofPediatricDental Trauma

BACKGROUND

Possiblyrelatedtotheactivelifestylesandsportsinwhichthey engage,traumaticdentalinjuries(TDIs)arecommoninchildren. Theseinjuriesmayaffectthehardtissuesofthetooth,involvethe pulp,orinjuresupportingstructuressuchasbone,ligaments,and gingiva.Immediateinterventionisoftenrequiredtoincreasethe chancesofsuccessfultreatmentandavoidlong-termcomplications.Inaddition,bothchildandparentsmustbereassuredto preventthedevelopmentofdentalanxietyordistress.The prevalenceofTDIsinpediatricpatientsvarieswidelybasedon geographiclocation,socioeconomicstatus,anddemographic factors.Treatmentusingconservativeprinciplescanhelpto preservethevitalityoftheinjuredtoothandavoidunnecessary extractions.Asystematicreviewwasdonetoupdatecurrent knowledgeoftheprevalence,types,management,complications, andpreventionofdentaltrauma(Figure1).

METHODS

AsearchoftheScopus,WebofScience,andPubMeddatabasesfor studiesovertheperiodfrom2010to2024yielded12studiesthat wereeligibleforqualitativeanalysis.Theanalysiswasfocusedon epidemiology,diagnosisandtreatment,innovativetreatments,clinicaldecisionsupporttools,andtheimpactonthechild’squalityoflife.

RESULTS

Epidemiology

Studiesfocusingontheprevalenceofdentalinjuries,common causes,andimportanceoftimelyinterventionandeducation identi fiedaprevalenceofabout1.25%,withboysage7to12years beingaffectedmoreoftenthangirls.Causesinvolvedfalls,object

strikes,andbikeaccidents.Studiesindicatedvariouscommon injuries,includingEllistypeIVfracture,usuallyinvolvingthe maxillarycentralincisorsandaccompanyingsofttissueinjuries; subluxationandavulsioninprimaryteeth;andcrownfractures inpermanentteeth.Amongtheteethmostoftenaffectedwere maxillaryincisorsinbothdentitions.Therewasahigher incidenceofTDIsinpermanentthaninprimarydentitions, withtheyoungerchildrenmoreoftensufferingsofttissue injuries.Preventivedentalcareandeducationprogramsare neededtomanageandpreventchildhooddentalinjuries.

Studiesofspecialneedschildrenfoundthat23.1%ofthesepatients sufferedTDIsthatwereoftenrelatedtofallsandstrikingobjects. HigherTDIprevalencewasassociatedwithobesityandinadequatelipcoverageinsomeanalyses.Mostinjuriesoccurredat school,andonlyafourthoftheaffectedchildrenweretakenfor dentalcare.

DiagnosisandManagement

Tomitigatelong-termdentalanomalies,childrenshouldbe broughtforearlyandaccuratediagnosis.Amongtheinjuries associatedwithlong-termconsequencesarecrownandroot dilacerationinpermanentincisorsthatdevelopaftertheprimary incisorswereinjured,whichcouldleadtointrusiveluxationsand avulsions.Thesecanproduceenamelhypoplaxiaanderuption disruptionsinpermanentteeth.Inaddition,earlytraumain primaryteethwasfoundtoleadtoenamelhypoplasiaandother complicationsinpermanentteeth.Asaresult,parentsanddental careprovidersshouldstresstheneedforpromptdiagnosisand treatment,withregularfollow-upsandprompttreatmentto preventorminimizelong-termcomplications.

Figure1. Conceptmapofdentaltraumainchildren.(CourtesyofLaforgiaA,InchingoloAM,InchingoloF,etal:Paediatricdentaltrauma:Insightsfrom epidemiologicalstudiesandmanagementrecommendations. BMCOralHealth 25:6,2025.)

InnovativeTreatments

Variouspulpotomymaterialsareusedtomanagetraumatized immaturepermanentteeth.TheInnovativeBioCeramixwas comparedwithtraditionalcalciumhydroxide(CH)andachieved ahigherpulpsurvivalrate,althoughthedifferencedidn’treachstatisticalsigni ficance.TheBioCeramixproductalsoofferedeasier handlingpropertiesthanCH.Ifanewermaterialoffersbettersealingpropertiesandgreatereaseofuse,itmayprovetobeofvalue.

Deciduousautologoustoothstemcells(hDPSCs)that regeneratedentalpulpininjuredteethhasbeenimplantedinto rootcanals,followedbysealingwithmineraltrioxideaggregate (MTA).ThehDPSCssignificantlyimprovedvascularandneural formationandincreasedrootlengthandwidth.hDPSCsmay beusefulforsalvagingyoungteethandenhancingrootdevelopment.Thisproduct fitswellwiththefocusontissueregeneration andthecreationofaconductivemicroenvironmentforhealing.

ClinicalDecisionSupportTools

Clinicaldecisionsupporttools(CDSTs)mayimprovedental traumamanagement.Whenstudiedfortheireffectonthe managementofprimarydentitionTDIs,significantimprovements werenotedindiagnosticandmanagementskills,especiallyamong dentalstudents.IntegratingCDSTsintoeducationprograms shouldbeconsidered.

ImpactonChild’sQualityofLife

Whenspecialneedschildrenwerestudied,thegroupswithcerebralpalsyandobesityhadhigherratesofdentaltrauma.Inaddition,amongpreschoolchildren,TDIsandcavitatedlesions negativelyaffectedoralhealth relatedqualityoflife(OHRQoL).

Whensocioeconomicfactorswereconsidered,lowerincome andmother’seducationallevelwerelinkedtocariesprevalence. ParentalperceptionofpoororalhealthcorrelatedwithanegativeOHRQoL.

CONCLUSIONS

Inpediatricdentistry,dentaltraumaindeciduousteethisboth prevalentandsigni ficant.Inaddition,theseinjurieshavelongtermconsequences.Commoncausesofthistraumaarefalls, sportsinjuries,andaccidentswithobjectsorbicycles.Earlydiagnosisandinterventionareneededtopreservethevitalityof injuredteethandpreventcomplications.ManagementofTDIs shouldbeimmediatetoimproveoutcomes.Conservativeapproachesareadvisable,alongwithfrequentfollow-upvisitsand monitoringforlong-termcomplications.

ClinicalSignificance

Dentalstudentsshouldbetrainedinearlyintervention strategiesandconservativeapproacheswhenmanagingpediatricdentalpatientstopreventlatecomplications.Policymakersshouldfocusonpreventive measuresandeducationalprogramstohelpinavoidingdentalinjuriestochildren.Followingrecommendationsbasedonevidencewillenhancethequalityof careandensurebetterlong-termoutcomesforchildrenwhosufferdentaltrauma.

LaforgiaA,InchingoloAM,InchingoloF,etal:Paediatricdental trauma:Insightsfromepidemiologicalstudiesandmanagement recommendations. BMCOralHealth 25:6,2025

Reprintsavailablefrom FInchingolo,DeptofInterdisciplinary MedicineUnivofBari “AldoMoro,” Bari70124,Italy;e-mail: francesco.inchingolo@uniba.it

EARLYCHILDHOODFLUORIDE

DispensingFluorideToothpasteToYoungChildren

BACKGROUND

Arecommendedmethodforavoidingearlychildhoodcaries (ECC)isbrushingyoungchildren’steethwitha fluoridecontainingtoothpaste.Specialinstructionsandwarningsare includedfortheuseof fl uoridetoothpastesforchildren.These statementsdealwiththedegreeof fluorideincludedinthetoothpaste(0.1%to0.15% fluoride)andtheamountoftoothpasteto use(apea-sizedamount; Table1).Parentsshouldbeawareof theseinstructionsandwarningsandshouldalsosupervisethe brushingoftheiryoungchild’steeth.Theyshouldalsoknow aboutothersourcesof fluoride,includingtablets, fluoridated salt,someinfantformulasthatarebasedonsoy,andartificially ornaturally fluoridatedwaterinthecommunity.Dentistsoften apply fluoridatedvarnishestwiceayearaswell,andthesecontain 5%sodium fluoride.Studiesindicatethatahighpercentageofchildrenage18to30monthsswallowallthetoothpaste,putting themselvesatriskfordevelopingdental fluorosis.However, about40%of3-to6-year-oldchildrenreceivemorethanthe recommendedpea-sizedamountoftoothpaste,withmostparentsusingmoretoothpastethanrecommended.Thereal-life doseof fluoridetoothpasteusedbyparentswhosechildren wereuptoage24monthswasinvestigated.

METHODS

Parentsat5daycarecentersinGermanywereaskedtoplacea doseof2different fluoridetoothpastesthattheywouldnormally givetheirchildontoothbrushes.Theamountoftoothpasteon eachwasweighed.Anexampleoftherecommendedrice-sized dosewasperformed5timesbyexperienceddentistsusinga naturalgrainofriceasanexample.Thiswasusedasthestandard againstwhichtheparents’ samplesweretested(Figure1). Parentswerealsoaskedtoreportthetotalfrequencyoftooth brushingperday,whattheyknewabouttheconditionsofuse andwarningson fluoridetoothpastes,andwhethertheyused fluoridetabletsaswellasa fluoridetoothpaste.

RESULTS

The61parentsdosedameanof0.263goftoothpasteAand 0.281goftoothpasteB.ThetoothpasteAdosewas5.9times higherthanrecommendedandthetoothpasteBdosewas7.2 timeshigher.Thesedifferenceswerestatisticallysigni ficant.

Parentsreportedtheybrushedtheirchild’steeth2or3times aday.Whenaskedabouttheconditionsofuseandwarnings on fl uoridetoothpaste,about39%wereunawareofthese conditions,eventhoughtheyappearedonthepackageof fl uoridetoothpaste.Withrespecttotheuseof fl uoridetablets,about15%usedthemandabout85%didn’t(Table2 ).

Table1. Recommendationsofthe EuropeanAcademyof PaediatricDentistry onthedoseof fluoridetoothpastefor children,takenfrom[6].(Reproducedwithpermissionfrom ToumbaKJ,TwetmanS,SpliethC,etal:Guidelinesontheuseof fluorideforcariespreventioninchildren:AnupdatedEAPDpolicy document. EurArchPaediatrDent 20:507-516,2019.)

Age

Fromthe firsttooth upto24months Grainofrice1000 2–6yearsPea1000 >6yearsUptofulllength ofbrush 1450

(CourtesyofSudradjatH,MeyerF,FandrichP,etal:Dosesof fluoride toothpasteforchildrenupto24months. BDJOpen 10:7,2025.)

Figure1. Referencedoses.Photographofthereferencedoses(i.e.,agrain ofrice sizedamountoftoothpaste)asrecommendedfortoothpastesfor childrenagedupto24monthswith1000ppm fluoride[6,7]ortoothpaste A(left)andtoothpasteB(right)onchildren’stoothbrushes.Anaturalgrain ofricewasusedasmodel.Bothamountsweredosedbyanexperienced dentist(seeTable4forweightresults).(CourtesyofSudradjatH,MeyerF, FandrichP,etal:Dosesof fluoridetoothpasteforchildrenupto 24months. BDJOpen 10:7,2025.)

Table2. Sourcesof fluorideinfoodandbeverages(examples)

SourceFluorideconcentrationReference

Soybeanbeverages8.5–15.5mg/L[51]

Blacktea1.6–6.1mg/L[52]

Rice0.53–3.61mg/kg[16]

Bananas0.86–1.98mg/kg[16]

Coffee0.845–1.465mg/L[53]

Cow’smilk0.016–0.18mg/L[54]

(CourtesyofSudradjatH,MeyerF,FandrichP,etal:Dosesof fluoride toothpasteforchildrenupto24months. BDJOpen 10:7,2025.)

CONCLUSIONS

Thecorrectamountoftoothpastewasnotdispensedbythe parents.Theamounttheydispensedwas5.9to7.2timeshigher thantherecommendeddose.

ClinicalSignificance

Toreduceanoverabundanceof fluoridebeinggiven whenparentsbrushedtheirchild’steeth, fluoridefreetoothpastemaybeused.However,thesereplacementsshouldcontainananti-cariesagenttoprevent ECC.Thisapproachshouldpreventdental fluorosis andothersideeffectsof fluoride.

SudradjatH,MeyerF,FandrichP,etal:Dosesof fluoridetoothpasteforchildrenupto24months. BDJOpen 10:7,2025

Reprintsavailablefrom JEnax,DrKurtWolffGmbH&Co.KG, ResearchDept.Johanneswerkstr34-36,33611Bielefeld, Germany;e-mail: joachim.enax@drwolffgroup.com

MYOFUNCTIONALTHERAPY

NeurologicalRe-EducationThroughMyofunctional Therapy

BACKGROUND

Myofunctionaltherapy(MT)isusefulformanagingorofacial myofunctionaldisorders,whichcaninvolvethemusclesand thefunctionsofthefaceandmouth.Thedevelopingordeveloped craniofacialstructuresandtheirfunctionareshapedbyneurologicalre-educationthroughMT.Musclefunctionisoptimized,and structuralalignmentiscorrectedtopromotehealthygrowthand development.Thetargetedmuscleexercisesimprovetone, proprioception,andmobility,allowingforthecorrectionof habits,interceptivetreatmentofsleep-disorderedbreathing (SDB),andthepromotionoforofacialdevelopment.Thevarious rolesofMTinpediatricdentistrywereexplainedandrecommendationsweremaderegardingtheinterdisciplinaryapproachthat supportsMT.

ROLEOFMTFORPEDIATRICPATIENTS

Varioussituationscandevelopinchildrenthatmaybene fitfrom MT Figure1.TheseincludeSDBandairwaydevelopment,nonnutritivesuckinghabits(NNSH),andfacialgrowthand development.

SDBandAirwayDevelopment

AmongthetypesofSDBareobstructivesleepapnea,hypoxemia, upperairwayresistance,hypoventilation,andcentralsleepapnea. ThesymptomsassociatedwithSDBincludesnoring,bruxing, open-mouthbreathing,andapnea,whichcancausepoorsleep, daytimesleepiness,andbehavioraldisorders.Severalstudies

identifytheeffectofbreathingpatternsonfacialmuscles,function,andef ficacywithrelationtoupperairwayresistanceandfrequencyofcollapse.Snoringandadenotonsillaryhypertrophy showlinks,asdodentoskeletalanomaliessuchasanunderdevelopedmaxillaryarchandintricateocclusionpatterns.SDBdevelopmentisinfluencedbytongueposition,facialdevelopment,and oralhabits.

MTcanimproveSDBwithinabout6monthsbystrengtheningthe orofacialmuscles,promotingnasalbreathing,andimprovingthe tongue’srestingposition.ItcanalsoreduceSDBseverityby maintainingairwaypatencyduringsleep.Bothpediatricandadult populationscanhavelowerapnea-hypopneaindices(AHIs)with MT,andtheseimprovesnoring,oxygensaturation,and sleepiness.AdjunctivetherapywithMTcanhelptreatSDBwhile promotinghealthiersleephabits.

NNSH

ProlongedNNSHcancausedentalmalocclusion,alteredtongue positioning,andorofacialdysfunction,allofwhichcanpredispose childrentoSDBanddisorderedcraniofacialgrowthanddevelopment.Theseabnormalitiescanleadtoahigherriskforupper airwaycollapseduringsleep.Someevidenceindicatesupto 68%ofchildrenhaveNNSHand38%haveanterioropenbite. Anterioropenbitemaybelinkedtogeneticfactorsandis associatedwithnonnutritivehabits,tonguethrust,andopenmouthbreathing.Theseproblematicconditionscancausespeech andfeedingdif ficulties,aswellasTMJdisorders.

Figure1. Processdiagramofassessmentforneedofmyofunctionalinpediatricdentistry.(CourtesyofLeungCK,VanNoyM:Theroleofmyofunctional therapyinpediatricdentistry. JCalifDentAssoc 52:2400418,2024.)

MTcancorrectthesehabitsthroughneuromuscularreeducationandexercisesoftheorofacialmuscles.Tongueposture andnasalbreathingarealteredtoactivatetheparasympathetic responseandeliminatetheneedforNNSH.Oncethechildno longerexhibitsNNHS,therecanbeimprovementsinanterior openbit,craniofacialstructure,andcontinueddevelopment.

FacialGrowthandDevelopment

Althoughfacialdevelopmentbeginsinuterowhenthepalateis formedaroundthetongue,whichnearly fillstheoronasalcavity, itcontinuesafterbirth,withthetongueapplyingpressuretothe palateandshapingit.Thetongue’shighpositiononthepalateis

optimalatbirth,buteventuallynaturalpalatalexpansionoccurs andanidealfacialgrowthpatterndevelops.Notonlydoesthe tongueshapethepalate,butit’scriticalforproperbonegrowth. Somein fluencesthatcanleadtoaloweredpositionofthe tonguearemouthbreathing,muscleweakness,geneticpredispositionfortonguespace,anddetrimentalhabits.Thelowered tonguecanleadtoahighand/ornarrowpalate.

Duringcraniofacialdevelopment,theorofacialmusclesare crucial,withdysfunctioncausedbytongueposition,SDB,or NNSHleadingtoabnormalgrowthpatterns.MTpromotes normalmusclefunction,leadingtomoreappropriatecraniofacial

Figure2. Evaluationandidentificationofmyofunctionalissuesalgorithm.(CourtesyofLeungCK,VanNoyM:Theroleofmyofunctionaltherapyin pediatricdentistry. JCalifDentAssoc 52:2400418,2024.)

growthanddevelopment.EarlyinterventionwithMTcanhelp preventormitigatedevelopmentalissueswithbetterlong-term outcomesforchildren.

PEDIATRICDENTISTANDMYOFUNCTIONAL THERAPISTCOLLABORATION

Collaborationsbetweenpediatricdentistsandmyofunctional therapistsareessentialincraftingearlyinterventionsand comprehensivetreatmentplansforchildrenwithorofacial muscledysfunctionandimproperoralhabits.Pediatricdentists ororthodontists,speech-languagepathologists,andotherdental professionalsshouldseekoutprofessionalscertifiedbyorganizationssuchastheInternationalAssociationofOrofacialMyology ortheAcademyofOrofacialMyofunctionalTherapy.Professional conferences,interdisciplinarystudygroups,andprofessionaldirectoriesoffereffectivewaystocontactqualifiedmyofunctional therapists(Figure2).

ClinicalSignificance

MThelpsinaddressingSDBandNNSHandmanaging theireffectsongrowthanddevelopmentinyoung children.Thefunctionsoftheorofacialmusclesare targetedbythedentalprofessionalandmyofunctional therapisttoimproveairwaypatency,promotehealth craniofacialgrowth,andhelpinreducingoreliminating detrimentalhabits.

LeungCK,VanNoyM:Theroleofmyofunctionaltherapyinpediatricdentistry. JCalifDentAssoc 52:2400418,2024

Reprintsavailablefrom CKLeung;e-mail: drc@seastar pediatricdentistry.com

HANDSON CANNABIS

DamagetoOralStructuresCausedByFrequent CannabisUse

BACKGROUND

Cannabisuseincreased60%between2002and2019inthe UnitedStates.Withtheexpansionoflegislation,increased prevalence,andchangingattitudestowardcannabis,it’slikely thatdentalprofessionalswillencounterpatientswhouse cannabis.Cannabisisassociatedwithvariouseffectsonthehumanbody.Itoffersreliefofpain,relaxation,releasefromanxietyanddepression,andantiemeticproperties,withcentral nervoussystemcannabinoidreceptorsandendocannabinoids underreviewforrolesaspossibletherapeuticagents.However,thehardandsofttissuesoftheoralcavitysufferdetrimental effectsfromcannabisuse.Amongtheproblemsareahigher incidenceofcariesinregularcannabisusers,xerostomialasting 16hours,increasedconsumptionofsweetandcariogenicfood anddrink,andperiodontaldisease.Inaddition,theprevalence ofolderadultswhousecannabishasincreaseddramatically, raisingconcernovercariesandtoothloss.Frequentrecreationalcannabis(FRC)useinadultswasevaluatedforitsinfluenceonuntreatedcoronalcaries,untreatedrootsurface caries,andseveretoothloss.

METHODS

DatawerederivedfromtheNationalHealthandNutritionExaminationSurvey(NHANES)continuouscycles2015-2016and 2017-2018.Atotalof5656individualsage18through59years (averageage39years)whosecannabisusedatawereavailable wereincluded.Individualswhousedmarijuanaorhashishat leasteverymonthformorethanayearwereclassi fiedas FRCusers,withthosewhodidn’tfulfi llthiscriterionconsiderednon-FRCusers.Thedentaloutcomesevaluatedwereuntreatedcoronalcaries(atleast1toothinvolved),untreated rootcaries(atleast1toothinvolved),andseveretoothloss (fewerthan9remainingpermanentteeth).Otherfactors consideredwereage,sex,raceorethnicity,nativity,educa-

tionalattainment,familyincometopovertyratio,andalcohol consumption.

RESULTS

Theoverallprevalenceofuntreatedcoronalcarieswas22%,with thatofuntreatedrootsurfacecariesat11%.About5%ofthe samplehadseveretoothboss.Approximately29%oftheparticipantsreportedFRCuse.TheprevalenceofFRCusewashighest amongthenon-HispanicBlackparticipantsatabout37%,and menweremorelikelytoparticipateinFRCusethanwomen (about35%versus24%).

MoreFRCusershaduntreatedcoronalcaries(about28%) comparedtonon-FRCusers(about20%).Theproportionof FRCuserswithuntreatedrootsurfacecarieswasalmosttwice thatofnon-FRCusers,withratesofabout16%versus9%.Severe toothlosswasnotedinabout7%ofFRCusersandabout4%of non-FRCusers.

FRCusersweremorelikelytohaveuntreatedcoronalcaries,untreatedrootsurfacedentalcaries,andseveretoothlossthannonFRCusers.Theseassociationsremainedsignificantaftercontrolling forcovariatesandpotentiallyconfoundingfactors.ForFRCusers, theprobabilityofhavinguntreatedcoronalcarieswas17%higher thanfornon-FRCusers.Inaddition,theFRCusershadoddsofhavinguntreatedrootsurfacecariesandseveretoothlossthatwere 55%and41%,respectively,higherthanthosefornon-FRCusersaftercontrollingforthepotentiallyconfoundingfactors.

CONCLUSIONS

AdultswhoengageinFRCusearemorelikelytodevelopuntreatedcoronalcaries,untreatedrootsurfacecaries,andsevere toothlossthanthosewhodon’tusecannabisinthisway.

ClinicalSignificance

Dentistsshouldreviewtheirintakequestionnaireswith thegoalofspecificallyaskingaboutcannabisuse. Withthisinformation,dentalcareproviderscanidentifyandaddresstheeffectsofFRCuseandtalktopatientsabouttheproblemsassociatedwithfrequent cannabisuse.Oftenpatientsdon’trealizethedamage thatFRCusecaninflictontheirteethandoralsofttissues.Inaddition,additionallongitudinalresearchis neededtoevaluatetheeffectsofFRCuseonthenaturaldentitionoftheUSpopulationnowthatcannabis useisacceptableandevenlegalinmanyareas.

ClonanE,ShahP,CloidtM,etal:Frequentrecreationalcannabis useanditsassociationwithcariesandseveretoothloss. JAm DentAssoc 156:9-16,2025

Reprintsavailablefrom EClonan,114SquireHall,UnivatBuffaloS Campus,Buffalo,NY14214,USA;e-mail: elclonan@buffalo.edu

E-CIGARETTESANDORALCANCER PatientGuidanceRegardingE-cigarettes

BACKGROUND

IntheUnitedKingdom,afreevapingstarterkitwasgivento1 millionsmokerstoencouragethemtogiveuptobaccoproducts, withtheambitiousgoalofmakingEnglandsmoke-freeby2030. Theterm electronicnicotinedeliverysystems (ENDS)refersto e-cigarettes,electronicvaporizers,andvapingpens.Theuseof e-cigarettes(“vaping”)hasincreasedexponentiallyfromtheir firstintroduction,makingitlikelythatthedentalteamwillneed toanswerquestionsfrompatientsaboutthesafetyandeffects ontheoralcavityofusingthesedevices.Althoughthese devicesaretoutedasasaferalternativetocigarettesmoking, thedentalteamshouldbepreparedtooutlinetherisksofvaping onoralhealth,anylinkstooralcancer,andotherinformationfor patients.

SOURCEOFINFORMATION

Althoughtheevidenceregardingvapinganditseffectsonoral healthisscant,thePubMeddatabasewassearchedtoidentify studiesofe-cigarettes,ENDS,vaping,oralcancer,andoralhealth. Themostrecentstudieswereselected.

RESULTS

ENDSproductsweredevelopedtoofferasaferalternativeto conventionalcigarettesmokingandarepopularnotonlywith smokersbutalsowithpreviouslynonsmokingadolescents,who enjoytheadded flavorings.ENDScompriseabattery-powered heatingelementtoaerosolizetheliquidforinhalation.Theliquid containsvariousingredientsthatoftenincludenicotine, flavoring agents,andpropyleneglycoland/orglycerin.Somearenicotine free,butthosecontainingnicotinevaryintheiramounts.Other

componentsincludetobaccoalkaloids,formaldehyde,glycerol, andheavymetals.Toxiccontentalsovaries.Asaresultofthese variations,thedeleteriousoralhealtheffectsdifferwiththeproductsinvolved.Thesecond-handtoxicexposuresviatheaerosol andexhaledvapehavenotyetbeenshowntoposeameaningful biologicalrisk.

AppealofENDS

TheprimaryappealofENDSistheirstatusasasaferalternative tocigarettesmoking.However,childrenexperimentwithvaping becausetheylikethe flavorsandbecausetheyseepeersusing them.Overhalfofneversmokershavereporteduseto “giveit atry” comparedtojustabout25%ofthosewhohaveever smoked.

OralEffectsofENDSExposures

TheeffectsofexposuretoENDSonoralhealthincludedysbiosis andchangestotheoralmicrobiomethatfosteranincreaseinthe numbersofopportunisticpathogens.ENDSmayhaveanadverse effectonhead,neck,andoralcells,producingaberrantmorphology, cytotoxicity,reducedviability,delayed fibroblastmigration,and genotoxicity.However,thedegreeofadverseeffectsissignificantly lessthanthatseenwithconventionalcigarettesmoking.

ENDSandCancer

ENDSareasaferalternativetoconventionalcigarettesbasedon theirlowercontentoftoxicandcarcinogeniccompounds.However,it’sdif ficulttoestablishreliabletoxicityprofilesofthese productsbecausetheyvaryindesign,manufacturingmethods, andingredients.Althoughe-cigarettescontainsubstantiallylower amountsandfewercarcinogensthantobaccoproducts,thebasic

mechanismsofDNAdamagemaystillapply.Theriskofdevelopingheadandnecksquamouscellcarcinomaislowerwith ENDSthanwithcigarettesmoke.

Heavymetalcontentismuchlowerthaninconventionalcigarettes butchronicexposuresthroughsmokingtoheavymetalsincreases theriskofheadandneckcancer.FormaldehydeisaGroup1 humancarcinogenwithariskforcausingnasopharyngealcancer.

OncogeniceffectsrelatedtoENDScaninduceDNAdamage, oxidativestress,DNAdouble-strandedbreaks,apoptosis,necrosis,andgenotoxicityinvarioustypesoforalcells.TheENDSliquidscaninducechangesthatcontributetotumorigenesisin normalepithelialcellsandpromoteaggressivephenotypesin pre-existingmalignantcells.However,long-termprospective andlarge-scalecasecontrolstudiesareneededtoprovide furtherinformationregardinganycausalrelationship.

ENDSandNicotine

ENDSproductsaremoreeffectivethannicotinereplacement therapy(NRT)inhelpingconventionalsmokersquitsmoking. However,theeffectsofthelong-termuseofnicotineremain tobeidenti fied.Noadverseeventshavebeenlinkedtoeither NRTorENDS,butNRTusersaremorelikelytoexperience nauseaandENDSusersaremorelikelytoreportmouthor throatirritation.

OtherEffects

Anumberofothereffectshavebeensuggested,asfollows:

ENDSmayincreasechemotherapyresistance.

E-cigaretteshaveadecreasedexpressionofimmune-related genesthatmaysupporttheassociationbetweenENDSuse andoralhumanpapillomavirusinfection.

ENDSmayhaveanindirecteffectrelatedtothelikelihoodof futuretobaccosmokingamongadolescentusers.

Poor-qualityevidencesuggestsotheroralsymptoms,suchasxerostomia,burningsensation,irritation,pain,oralulceration,nicotine stomatitis,hairytongue,andangularcheilitis,mayoccurwith ENDS.Inaddition,accidentshavebeenreportedthatcausedburns fromexplosionsandmalfunctionsthatinjuretheoralcavity.

GUIDANCEFORDENTALPRACTITIONERS

Obtainingthepatient’ssmokingstatusshouldbethe firststepin deliveringanysmokingcessationcounseling.Smokingstatus questionsshouldbeincludedintheintakequestionnaireor confirmedverbally.Asimpletoolforthedocumentationof smokingstatushelpsclinicianscapturemeaningfulandcomplete

Table2. ASystematicTooltoCapturePatients’ ENDSStatus. (DatafromJoseT,HysJT,WarnerDO:Improveddocumentation ofelectroniccigaretteuseinanelectronichealthrecord. IntJ EnvironResPublicHealth 17:5908,2020.)

E-cigaretteuseCurrent – daily

Current – somedays

Former Passiveexposure

Never

DevicetypeRechargeablee-cigarette

Refillablee-cigarette

Disposablee-cigarette E-cigar E-pipe

Other

Numberofrefills/disposableunitsperday?

Cessationcounsellingprovided?

(CourtesyofCameronA,YipHM,GargM:Currentthinkingabouttheeffectsofe-cigarettesonoralcancerrisk. BDJTeam 11:470-473,2024.)

datarelatedtoENDSuse(Table2).Itprovidesforthestrati ficationofindividualoralhealthriskfactorsandofferstailoredcessationadvice.

Cliniciansshoulddocumentthepatient’sENDSuseaspartofthe healthrecordandofaholisticassessmentoforalcavitycancer risks.TheyshouldcounselpatientsthattheevidenceforENDS safetyislackingandthefullriskpro fileisn’tyetavailable.ENDS productsaresaferthanconventionalsmoking,butnonsmokers shouldn’tbeginusingthem.

ClinicalSignificance

ThevariousENDSproductscarrydifferingpotentialfor deleteriousoralhealtheffects.Forpatientswho choosetouseENDSproducts,dentalpractitioners canofferguidancebasedonthecurrentevidence. Thisindicatestheseproductsarelessharmfulthan conventionalsmokingbutcan’tbeconsideredsafe andrisk-free.Extensiveresearchisneededtobe abletoaccuratelyevaluatetheeffectsofENDSuse ontheoralcavity.

CameronA,YipHM,GargM:Currentthinkingabouttheeffects ofe-cigarettesonoralcancerrisk. BDJTeam 11:470-473,2024

Reprintsnotavailable

ENDODONTICS

IntraoperativeandPostoperativeTipsforRestoring EndodonticallyTreatedTeeth

BACKGROUND

Oncetheendodonticclinicianachievesapicalpatencyandpreservesperi-cervicaldentin,variousintraoperativefactors relatedtoobturationand flare-upsofpainandswellingmust bemanaged.Inaddition,postoperativeconsiderationsthat arerelatedtotheoverallsuccessandlongevityofendodontic treatmentsmustbeaddressed.Tipsfordealingwithintraoperativeandpostoperativeissuesaswellasocclusionweresuggested,andtheprognosisrelatedtothesefactorswas determined.

INTRAOPERATIVEFACTORS(TABLE1) Obturation

Amongthefactorstobeconsideredintraoperativelyarethe lengthoftherootcanal fillingandthedensityandtaperofthe rootcanalobturation.

RootCanalFillingLength

Fewstudieshaveevaluatedtheeffectofleavingachemomechanicallydebridedrootcanalunfilled,butthoseavailableshowabout 40%to60%offailuresarerelatedtoinadequateobturationofthe rootcanalsystem.Thiscaninvolveover filling,underfilling,or poorquality filling.Currentthinkingisthatthequalityofthecoronalrestorationismoreimportantforperiapicalhealththanroot filling.Root fillingshouldstillbedonetomanageinfectionremainingaftercleaningandshapingandwillhelppreventmicroleakage ifthecoronalsealiscompromised.Thepatient’sspeci ficneeds shouldguidetheclinician’sdecisionratherthanusingthesame approachforallcases.Root fillingstowithin2mmoftheapex havesuccessratesof81%.

Theclinicianshoulduseelectronicapexlocatorstodetermine thepreciseworkinglength,avoidingover fillingorunderfilling ofthecanalsandensuringtheroot fillingisatthedesiredlength. Double-checkingtheworkinglengthisbestaccomplishedusinga cone-fitradiographwiththemastergutta-perchapointinplaceif noradiographwastakenearlier.The fillingmaterialshouldbein the0-to2-mmrangefromtheapex.Useofawarmvertical compactionorcontinuouswavecondensationcanaidoptimal fillevenincomplexcanalstructures.

DensityofObturation

Achievingagood3-dimensional fillcanavoidresidualinfectionafterchemomechanicaldebridement.Satisfactoryobturationshave significantlybettersuccessrates.Aradiographicallydenseroot fillingmayhelptodelaymicrobialseepageshouldacoronalsealfail.

Theuseofmagni ficationandillumination,lateralcondensationor warmverticalcompactiontocreateuniformandvoid-freeobturation,andcon firmationwithradiographswillensurequality obturationandimprovedprognosis.Sealerscanbeusedto fill anyvacantspacebetweenthedentalwallandthecore fillingmaterialandestablishagoodseal.Withtheuseoftraditionalsealers, it’swisetoensurethecore fillingmaterial fillsmostofthecanal space,thuspreventingsealer-relatedproblems.Thenewercalciumsilicate basedsealerssimplifytheprocessandreduceobturationtime.

TaperofObturation

Preparingandcreatingataperintherootcanalsfacilitatesirrigationandeffectivechemomechanicaldebridementandreduces theriskofextrudingirrigantsandobturatingmaterials.Overtaperingcanweakenrootsbycompromisingpericervicaldentin, whereasunder-shapingcancompromisetheprognosis.

InterappointmentPainandSwelling

Interappointment flare-upsofpainandswellinghaveapoorer treatmentoutcomeinmanycases,representingexacerbations ofperiapicalinflammationorinfection.Causesincludeinadequate asepsisordisinfection,improperirrigation,ormaterialextrusion. Amongtheeffectsofthese flare-upsareimpairedmouthopening, damagetotheprovisionalrestoration,andcompromisedprognosis.Ifmicroorganismsremainwithinperiapicaltissuesafter treatmentandprovokeaninflammatoryresponse,tissueirritation andperiapicalinflammationcanbeexacerbated.

Avoidingthiscomplicationinvolvesusingrubberdamisolation foranasepticoperating field;adoptingaconservativeandgentle approachduringcanalinstrumentation;usingintermittentirrigationtechniqueswithaside-ventedneedleto flushdebris anddisinfecttherootcanalsystem;andprovidingpatients withcleardirectionsregardinghowtoaddressdiscomfort, swelling,andothercomplications.Theclinicianshouldprescribeappropriateanalgesicsandrecommendmeasuressuch ascoldpacksoranti-inflammatorymedicationstoalleviate postoperativesymptoms.

POSTOPERATIVEFACTORS(TABLE2)

Amongthepostoperativefactorstobeaddressedwhenseekinga goodprognosisarethecoronalsealandpost-endodonticrestorationsandthetimingofcuspalcoverage.Inaddition,theocclusionplaysasignificantroleintheprognosisofendodontically treatedteeth.

Table1. PrognosisBasedonVariousIntra-operativeFactors

StageCategoryFactorParameterstoconsiderPrognosis

Intra-operativeApicalpatencyPreviously untreated/Primary RCT

Peri-cervicaldentine (PCD)

NegotiableGood

Inabilitytoachievetechnical patency(debris/complex anatomy)

RetreatmentAbletoremoveasignificant amountoftheexistingroot filling material

Accesscavity preparation andremaining coronalwalls

ObturationLengthofrootcanal obturation

Densityofrootcanal obturation

Taperofrootcanal obturation

Intra-appointmentpain andswelling

Questionable(Forevery 1mmshortfromtheapical terminus – prognosis changesfromquestionable topoor)

Questionable

Inabilitytoremove fillingmaterialNon-SalvageablePoor

AdequatepreservationofPCD withUCACorCACforms

CACpreparationsneedingsome removaloftoothstructure, adequatecoronalresidualwalls

TACneedinggreaterremovalof toothstructure,adequate coronalresidualwalls

TACneedinggreaterremovalof toothstructure,compromised coronalresidualwalls

Root fillingextending0 -<1mmshortofradiographic apex

Root fillingsending attheradiographicapex (or1–2mmshort)

Root fillingswithbiomimetic sealersendingbeyondthe radiographicapex(overfilling)

Root fillingswithtraditionalsealers endingbeyondtheradiographic apex(overfilling)

Root fillingending>2mmshortof radiographicapex(underfilling)

Novoidpresentintherootcanal obturation

GoodGood

Fair

Questionable

CompromisedPoor

GoodGood

Fair

FairGood

Questionable

CompromisedPoor

GoodGood

Void(s)limitedtocoronalthirdFair

Withvoid(s)withinthe mid/apicalthird CompromisedPoor

Consistentlytaperedfromcoronal parttoapex

GoodGood

InadequatetaperFair

Inconsistentorirregulartaper (overorundershaped)

Asymptomaticbetween appointments(no flareups)

CompromisedPoor

GoodGood

Symptomaticbetween appointments( flareups) Fair

(CourtesyofEachempatiP,HarrisA,LambournG,etal:Toptipsfortreatmentplanning:Tooth-by-toothprognosis – Part3:Endodonticprognosis. BrDentJ 237:686-690,2024.)

CoronalSealandPost-endodonticRestorations

Teethwhoserootcanalshavebeenthoroughlydisinfectedcan developcoronalleakage,leadingtoendodonticfailure.Bacterial penetrationcannotbeguaranteedforanextendedduration; insteadtherestorationisdesignedtoprovidethelong-term integrityofthecoronalseal.Oncetheaccesscavityisrestored, theteethareoftengivenfull-coveragecrownsforoptimal

structuralsupportandprotection.Therestorationsprotect againstmicroleakage,defendagainstfracturefromocclusal forces,andprovidecontactsandcontoursthatsupportahealthy attachmentaroundthetreatedtooth.

Theneedforcuspalcoverageisdeterminedforeachindividualtooth. Factorstoconsiderincludetheremainingtoothstructure,any

StageCategoryParameterstoconsiderPrognosis

Post-operativeCoronalseal&post endodonticrestoration

Adequatecoronalrestoration:Awellbonded coronallysealingrestorationwhichappearsintact radiographically

Inadequatecoronalrestoration:Finalrestoration appearssub-optimalradiographicallywithopen marginsorpositivemargins

Inadequatecoronalrestoration:recurrentcaries, partialtemporary fillingsorno filling.

TimingofcuspalcoverageRestoredwithdirectorindirectdefinitiverestoration withnoorminimaldelay

Good

Questionable

CompromisedPoor

GoodGood

Restoredwithdirectorindirectdefinitiverestoration withdelayoflessthanfourmonths Fair

Restoredwithdirectorindirectdefinitiverestoration withdelayofgreaterthanfourmonths

Teethreceivingnodefinitivecuspalcoverage restoration

OcclusionCanineguidancewithnolateralexcursivecontacts onthetooth

Questionable

CompromisedPoor

GoodGood

Groupfunctionwithsmoothlateralexcursive contactsdistributedonallteeth Fair

Anyocclusalschemewitheccentriccontacts/ heavylateralloadingonthetooth

CompromisedPoor

(CourtesyofEachempatiP,HarrisA,LambournG,etal:Toptipsfortreatmentplanning:Tooth-by-toothprognosis – Part3:Endodonticprognosis. Br DentJ 237:686-690,2024.)

cracks,andtheopposingdentition.Mostposteriorteethwithatleast 1missingproximalwallwillneed cuspalcoveragerestorations.

Biomimeticdentistryisfocusedonpreservingtoothstructure andreplicatingnaturalbiomechanicswithminimallyinvasive preparationsandselectivecariesremoval.Modernadhesives andstress-reducedcavitypreparationminimizetheconfiguration factorandreducestressindentalcompositerestorations.The dentistshouldbecomefamiliarwiththebiomimeticdentistry principlesandchooseminimallyinvasivetechniquesandselective cariesremovaltoenhancelong-termsuccess.

Theapproachtorestoringendodonticallytreatedteethwill dependonfactorssuchasremainingwallvolumeandaccess cavitypreparation.Thetreatmentplanshouldbecustomized toeachpatient’sneedsandcircumstances.Anteriorteeth bene fitfromdirectcompositerestorationsifthemarginal ridgesareintact.Heavilyrestoredteethmayneedadirect compositeoranindirectrestoration.Posteriorteethcanbe restoredusingdirectcompositeifthemarginalridgesare intact.Heavilyrestoredteethinposteriorareasmaybe managedbestwithdirectcompositewithreinforcedultrahighmolecularweightpolyethylene fiber,withthepossible useofanindirectrestorationorcrownplacement.Ifaposteriortoothwascrownedpreviouslyandnowhaslostmarginal ridges,thebestchoicemaybeareinforcedcorewithaconventionalpost,areinforcedultra-highmolecularweightpolyethylene fiberpost,oranendocrown.

TimingofCuspalCoverage

Teethwithrestorationsmademorethan4monthsaftertheendodontictherapyarenearly3timesmorelikelytobeextracted thanthoserestoredwithinthat4-monthperiod.Anotherspike infailureoccurs18monthsaftertreatment,suggestingthere maybeacriticalperiodforfracturedevelopment.

Ahighersurvivalisnotedforteethrestoredwithindirectrestorationswithin6monthsofendodontictherapycomparedtothat forthoserestoredwithdirect fillings.It’spossiblethatteethwith amorefavorableprognosisarerestoredwiththeindirectrestorations.Root- filledteethwithoutcrownshaveasatisfactorysurvivalrateforupto3years,butdeterioratethereafter.The outcomesafter5yearsforteethrestoredwithdirectandindirect restorationshavebeencomparable,butafter10years,those withindirectrestorationshavebetteroutcomes.

Dentalpractitionersshouldevaluatetheneedforcuspal coveragerestorationsduringfollow-upappointments,especially whentherestorationwasdelayed.Thiscanavoidcomplications andensurethebestoutcome.Patientsshouldbeeducatedabout theimportanceofatimelyrestorationafterrootcanaltreatment. Complyingwithrecommendedtreatmenttimelineswillimprove outcomesandlong-termsurvivalofthetooth.

Occlusion

Theprognosisofendodonticallytreatedteethappearstobe significantlyconnectedtotheocclusion,althoughevidence

forthisislacking.Properocclusionensuresevendistribution offorcesacrossthedentalarch,whichreducestheriskfor excessivestressonindividualteeth,whichwouldincludethose managedendodontically.Occlusalforcescanalterthe longevityofarestorationplacedonatoothwitharootcanal. Stabilityanddurabilityofrestorationscoupledwithalower riskoffailureaccompanyproperlydistributedocclusalforces.

Whenit’sdesirabletoavoidlateralforcesoncompromisedposteriorteeth,canineguidanceispreferredbecauseitdirects forcesawayfromtheseteeth.Groupfunctionisbestwhenthe goalistodistributeforcesacrossmultipleteeth.

ClinicalSignificance

Preoperative,intra-operative,andpostoperativefactorsinfluencetheprognosisofendodonticallytreated teeth.Toensurethebestoutcome,theclinicianshould conductpatient-speci ficassessmentsandtailorthe treatmentplantothatspecificpatient.Usingadvanced diagnostictoolsandfollowingevidence-basedpracticeswillenhancetheprognosisfortheserestorations andensurebetterlevelsofpatientsatisfaction. Communicationwithpatientsabouttheprognosisis essentialinfosteringinformeddecision-makingand obtainingtheoptimaloralhealthoutcomes.

EachempatiP,HarrisA,LambournG,etal:Toptipsfortreatmentplanning:Tooth-by-toothprognosis – Part3:Endodontic prognosis. BrDentJ 237:686-690,2024

Reprintsnotavailable

FACIALAESTHETICS

ExpandingOralHealthCaretoFacialAesthetics

BACKGROUND

Aesthetictreatmentsofthefaceaffectnotjustthepatient’sphysicalappearance,butalsohisorherpsychologicalandsocialwellbeing.Thesetreatmentsincludedermal fillersandbotulinum toxin(BoNT-A)injections,whichareespeciallypowerfulboth aestheticallyandtherapeutically.Oralhealthproviders(OHPs) aretrainedasexpertsinheadandneckanatomy,musthave manualdexteritytoperformtheiroralhealthcarewell,andprioritizepatienthealthandsafety,makingreferraltospecialistsas needed.Thistrainingandtheseskillspositionthemtoaddsafe, expertlydeliveredfacialaesthetictreatments.Ontheoralhealth side,theycanmanageconditionssuchasbruxism,TMJdisorders, trigeminalneuralgia,sialorrhea,orofacialpain,andfacialasymmetrycausedbyfacialparalysis.Theyworkinaregulatedclinical environment,candealwithpatientanxiety,andhavetheknowledgetomanagemedicalemergenciesthatmightarise.Areview waspresentedtoidentifythetrainingandexpertiserequiredto deliverfacialaesthetictreatments,theethicalresponsibilityassociatedwiththesetreatments,andtheprioritizationofpatient safety.

REQUIREDTRAININGANDEXPERTISE

Specializedtrainingandexpertisearerequiredinseveralareas tobequalifiedtopracticefacialaesthetics.OHPsmustbe

trainedincomprehensiveanatomicalknowledgeoftherelevantanatomyaswellaspossiblevariations.Theymustdevelop anabilitytoaccuratelyevaluatefacialfeaturesandpatientspeci ficalternatives.Clearunderstandingoffacialproportions, symmetry,andharmonyisneeded,alongwithknowledgeof aestheticunitsandhowtheyinteracttocreatenaturaloutcomes.TheOHPmustdevelopandapplyanaestheticsensibilitytorespectethnic,cultural,anduniquedifferencesforeach patient.

TreatmentplanningdependsontheOHP’sskillinvarioustreatmentmodalitiesandhisorherunderstandingofhowtheycanbe safelyusedincomplementaryroles.Relevantpharmacologyand physiologyshouldberecognizedandaccommodated.TheOHP mustalsobeawareofpossiblecomplicationsandalertthepatient beforebeginningtreatment.Pathwaystorecognizeproblems earlyandavoidormanageanyadverseeventsshouldbe established.

Patientsshouldbescreenedforpsychologicalin fluencesontheir requestforfacialaestheticprocedures.Thisincludestherecognitionofmentalhealthissuessuchasbodydysmorphicdisorder. Areferralpathwayforhelpinmanagingtheseissuesshouldbeestablished.OHPsshouldmanagepatientexpectations,notinginfluencesfromsocialmediaorothersources.

Thespecializedtrainingspeci fictofacialaesthetictreatments includesafocusontechniques,modalities,andtechnologies thatwouldbeemployed.Thisknowledgeshouldbekeptcurrenttomaximizetheprobabilityofobtainingoptimalpatient outcomes.

ETHICALRESPONSIBILITY

OHPsmusteducatethepatientabouttheaesthetictreatments, withevidence-basedinformationregardingtherisksandrealistic outcomesthatrefutesandreplacesanysocialmedia baseddisinformation.Theymustalsomaintaincurrencyregardingthesafest andmosteffectiveapproaches.Patientwell-beingmustbeprioritizedovercommercialissues,soOHPsshouldbepreparedto refusetreatmentiftheyaretopracticeethically.

Referraltootherspecialistsshouldbeconsideredwhenthe requiredtreatmentexceedstheOHP’sskills,sothatthepatient receivesholistic,ethicalcare.Thepatient’soverallhealthand long-termwell-beingshouldbeprioritized.

PATIENTSAFETY

Intheabsenceofspecificregulationsorframeworksfor requiredtraining,theOHPshouldselectappropriateeducationalandskillstrainingfocusedonensuringpatientsafety. Althoughsomecomplicationscanbemild,theOHPshouldalwaysrecognizeseriousproblemsthatrequireimmediateresponses.ThisalsorequirestheOHPtostaycurrentwith

thebestevidence-basedinformationregardingtherisksof aestheticproceduressoheorshecantreatthepatientsafely. Inaddition,theOHPshouldconductthoroughconsultations withthepatienttoensurethathisorherhealthstatusand aestheticgoalsareappropriateforthedesiredtreatment. Basedontheseconsultations,theOHPshouldbeableto recognizewhenapatientisn’tanidealcandidate.

ClinicalSignificance

OHPshaveanopportunitytoexpandtheirclinical practicebymovingintofacialaesthetics.Theyare alreadytrainedinmanyoftheessentialareasand skilledinmanualdexterity.Withadvancedtraining, theyshouldbeabletomanagepatients’ psychosocial factorsandcommittoethicalpracticeinfacialaesthetics.Thiscareshouldbebalancedwiththepatient’slong-termhealthtoachieveexcellenceinthe outcomes.

SamizadehS:Theroleoforalhealthcareprofessionalsinfacial aesthetics:Acriticalexaminationoftraining,safety,ethicsand psychosocialimpact. BrDentJ 237:787-788,2024

Reprintsnotavailable

ConcernsWhenDentalProfessionalsAddAesthetic Treatment

BACKGROUND

Addingfacialaesthetictreatmentstotheproceduresdonebya generaldentalpractitionercannotonlyprovidevarietybut alsodiversifypatientcareandaddanadditionalrevenuestream. Concernshavearisenbecauseofthelackofregulationoffacial aesthetictreatmentinpartoroverall.Dentalpractitionersand theirstaffwhoprovidethesetreatmentsshouldadheretoprinciplesinvolvingsafety,regulations,andethics.

SAFETY

Patientscanlegallyreceiveaesthetictreatmentfrompersonswho lackanymedicaltrainingorexperience.Dentalpractitionerswho choosetoperformtheseproceduresshouldensuretheyaredone safelyandresponsibly.Coursesareavailabletomembersofthe dentalteam,includingdentists,dentaltherapists,anddentalhygienists,andtheinstructioncanvaryinlengthoftimespent,cost,and content.Qualifyingtoperformtheproceduresdoesn’tguarantee competency.Dentalpractitionerswhowanttoperformaesthetic

proceduresshouldcarefullyevaluatetheirowncompetencyand seektrainingintheseproceduresasnecessary.

REGULATIONS

Facialaesthetictreatmentisn’tclassi fiedasdentaltreatment,but ifadentistprovidesit,theUKGeneralDentalCouncil(GDC)expectstheprovidertofollowtheirprofessionalstandards,which includesobtainingvalidinformedconsent.Ifthepatientisunawareoftherisksassociatedwithfacialaesthetictreatments, nothavingreceivedeffectiveexplanationsfromthedentalpractitioner,heorshecan’tprovidevalidconsent.Practitioners mustalsobeequippedandknowledgeableaboutthemanagement ofpotentialcomplicationsandmedicalemergencies.

RulesRegardingBotulinumToxin

Dentistsaretheonlydentalteammemberswhocanprescribe andadministerbotulinumtoxin,buttheGDCallowshygienists andtherapiststoadministeritiftheyhavebeentrainedandare

competentandindemnifiedtodoso.Whendentistsprescribe botulinumtoxin,theprescriptionshouldonlybegivenafterperformingafullassessmentofthepatientinpersonandnotvirtually.Fillertreatmentsareconsideredamedicaldeviceanddon’t fallundertheserestrictions.

TheGDCdoesn’tcommentonwhetheradentalnursecanoffer treatmentswithbotulinumtoxin.ThissuggeststhatGDCregisterednursesshouldnotdothis.

Dentistswhoofferbotulinumtoxintreatmentsshouldknowthe AdvertisingStandardAgency’s(ASA’s)rulesbeforetheypromotethisaction.Brandnamesmustnotbeadvertised,norcan thetreatmentbereferredtousingeuphemismssuchas ‘antiwrinkleinjections. ’ Thepostingofbefore-and-afterphotosonsocialmedia,beingtaggedinpatients’ photos,andpromotingthe medication’sbene fitsarealsoforbidden.

ETHICS

Dentalpractitionersshouldfollowtheguidancetodono harm,putthepatient’sinterests first(beforepersonalgain), andworkwithintheirknowledge,skills,professionaltraining, andabilities.Inaddition,theASA findsitunacceptableto

exploitpatients’ insecuritiesortoperpetuateharmfulgender stereotypes.

ClinicalSignificance

It’sinevitablethatregulationswillincreaseandlegal challengesfrompatientswillbecomemorecommon. Thesechallengesmayincludequestioningthetreatmentprovidedbydentalteammemberswhoaren’t trainedtoevaluatepatients’ mentalhealthstatus, whichisanimportantcomponentofaesthetictreatmentmanagement.Asaresult,dentalpractitioners shouldchoosepatientswithcare,remaincurrent withtherulesandregulationsthatareappliedto aesthetictreatment,workwithintheirlevelofcompetence,andmakesuretheyareproperlyindemni fied.

ThakrarB:Facialaesthetics – friendorfoe? BrDentJ 237:789-790, 2024

Reprintsnotavailable

Training,Regulation,Safety,andEthics

BACKGROUND

Dentistsarewelltrainedinfacialanatomy,whichcanbean importantfoundationforperformingfacialaestheticprocedures preciselyandsafely.Alookatthenonsurgicalfacialaesthetic (NSFA)procedures(suchasinjectionsor fillers)andwhatis involvedwhentheseproceduresaredonebydentalpractitioners notedpossibleuses,regulations,andsafetyandethicalconcerns.

MEDICAL-DENTALUSESOFNSFAMETHODS

Althoughperhapsconsideredjustamedicaltechnique,NSFA methods,especiallythoseusingbotulinumtoxin(BoNTA)injections,havemanyusesfororofacialconditions.Theseinclude bruxism,TMJdisorders,chronicmigraine,andsialorrhea.BoNTA’seffectonmoodhasthepotentialtohelppatientswith depression.

Dermal fillersusedtoaugmentlipsandcheekscanalsobeapplied therapeuticallytomanagefacialasymmetryortrauma,provide contoursforstructureswheresurgeryiscontraindicated,and evenaccomplishwholefacevolumeregenerationafterfatatrophy,whichwastheinitialuseofsemi-resolvable fillersinHIVpatients.Othertreatmentsincludeplatelet-richplasmatherapy, whichisusefulmedicallyforwoundhealingandtissueregeneration,butalsohasaroleindentalimplantology.

REGULATIONS

Concernsoverpatientsafetyhaveledtosignificantchangesinthe regulationofNSFApractice.Withadesireforprofessional accountability,regulatorsarenowregisteredwiththeprofessionalstandardsauthority.TheJointCouncilforCosmeticPractitioners(JCCP)hasestablishedguidelinesandlimitationsthat ensureaestheticproceduresaredonebyappropriatelytrained andqualifi edpractitioners.Theseregulationsaredesignedto addresstherisksthatpatientsfacewhenpoorlytrainedandunregulatedpersonsperformtheseproceduresandmarketaestheticsonsocialmedia.

Avoluntaryregisterhasbeendevelopedtoserveasabenchmark forsafe,ethicalpractice.Formalqualificationsandtrainingare spelledout,withanemphasisoncontinuingpersonaldevelopmentandclinicalcompetency.Theregulationshavehighlighted theneedforstructured,rigoroustrainingprogramsineducationalsettingsthatfollowthestandardssetbytheJCCP.

Prescribingaestheticinjections,whichhasbeendonebydental careprofessionals(DCP),referringtodentalhygienistsandtherapists,maybefurtherrestricted.Itmaynotbepossibletoindependentlyaccessoradministerprescription-onlymedications. DCPscouldonlyofferaestheticserviceswhenclosely

collaboratingwithaprescriber,whichwouldbeadentist,doctor, ornursewithprescribingrights.Aformalconsultationbetween patientandprescriberisrequiredbeforeprescription-onlymedicinesareadministered.BecauseDCPscontinuetobeinterested inNSFA,trainingprogramsintheaestheticproceduresthat don’t’ requireaprescriptionareavailable.

SAFETYANDETHICALCONCERNS

Withthenationalinitiativetoestablishenforceablestandards, dentalpractitionersshouldbecarefultoevaluatepatients’ motivationsandhealthstatus,assesstheirunderstandingofpossiblecomplications,andcommunicaterealisticexpectations.Oftenthe socialmediapoststoutthetalentsofunregulatedand/orinadequatelytrainedproviders,shapingpatients’ expectationsthataren’t realistic.Dentalpractitionersshouldcountertheconsumer-driven desireforfacialaestheticswithprofessionalaccountabilityandan ethicalapproach,educatingpatientsonthelimitsoftheseproceduresandtheriskstheyface.Thepractitionermayevenrecommendthatthepatientnothavetheseinterventions.

INTRAORALSCANNERS

ClinicalSignificance

Takingonfacialaestheticsasanadditionalofferingin thedentalofficerequiresskillandanatomicalknowledgebutalsoafocusonprotectingthepatientagainst misinformationfromthemedia,unrealisticexpectations,andunqualifiedpractitioners.Byholdingtothe standardsofsafetyandethicalbehavior,dentists maintaintheintegrityandsafetyoffacialaesthetics treatments.

StagnellS:Trainingandclinicalbene fits. BrDentJ 237:791-792, 2024

Reprintsnotavailable

ExpansionofIntraoralScannerUses

BACKGROUND

Intraoralscanners(IOSs)canacquireintraoralopticalimpressions(IOIs)andrepresentdataasdetailedvirtualmodels.AdvancesinthehardwareandsoftwareofIOSshaveimproved efficiencyandaccuracyincomputer-aideddesignand computer-aidedmanufacturing(CAD-CAM),themostcommon useforthesetools.Whenimagingmethodsarecombinedwith IOSs,theyfacilitateoutcomesindiagnostics,treatmentplanning, andmonitoring(Figure1).Futuredevelopmentsmayleadto additionalapplicationsindentistryoverallaswellasoraland maxillofacialsurgeryspecialties.AdvancesinIOShardwareand software,diagnosticapplications,integrationintoclinicalsettings, andspecializedandemergingapplicationswerediscussed.

ADVANCESINIOS

IOSmanufacturersaretheprimarydriversintheinnovationsof IOSsusedinpatientcare.Theseincludedevelopmentsinhardwareaswellassoftware.

HardwareDevelopments

Keyadvancesincludefasterscanning,noneedforscanningpowder,andbettercolorimageacquisition,allofwhichcanenhance efficiency,patientcomfort,andtheuserexperience.Thecore designisessentiallythesame,butuniqueergonomicfeatures differentiatethevariousmodels.Newdevicesmaybewireless andbattery-poweredsotheyaremoremobileandconvenient,

butthiscanreduceoperationaltimeandmaycompromiseconnectivity.Hapticfeedbackcanofferguidanceduringimageacquisition.Heatersarenowintegratedtomitigatecondensation duringextendeduse.AlthoughIOSscanbestandalonedevices, chairsidefabricationwhentheyarepartofanintegratedCADCAMplatform.SomeIOSdevicesofferautocalibration,reducing theneedforfrequentmanualcalibration.Adryoperating fieldis requiredtoavoiderrors.IOSshavedif ficultycapturingsubgingivalpreparationmargins.

SoftwareDevelopments

Continuousimagecaptureisavailablethroughadvancedalgorithmsstitchingimagesseamlesslytooptimizescanning.IOSs cansimultaneouslycaptureandprocessthesurfacefeaturesand opticalinteractionsinaspecifiedareabyusingoversamplingand averagingmultiplemeasurementspoints.SomeIOSsaredesigned toscanandexportdata,whereasothersarecomprehensiveplatformsthatdelivermorethanintraoralopticalimpressions.Dental professionalscanaccessenhanceddiagnostics,patientcommunication,monitoring,andtreatmentplanning,andsoftwareapplicationscanbetailoredtothedesiredtasks.IOSscanminimizenoise andimageartifacts,omitunneededimagingdata,andexclude extraneouselementsfromtheimpressions.

TheformerclosedsystemsthatrestrictedCAD-CAMtoproprietarysolutionshaveevolvedintoopeninterfaceswhereimpressiondatacanbeexportedinatleast1standard fileformat,users

Figure1. Schematicdiagramwithanoverviewofthediverseapplicationsofcontemporaryintraoralscanners(IOSs).(CourtesyofEggmannF,BlatzMB: Recentadvancesinintraoralscanners. JDentRes 103:1349-1357,2024.)

havegreater flexibility,interoperabilityincreases,andcustomizationisenhanced.Datacanbestoredinseveral fileformats,with advantagesanddisadvantagesvaryingwiththeformat.

Thesoftwarecanperformin-depthanalysis,permittingprecise segmentationofeachindividualtoothfromtheimpression dataforuseindiagnosisandtreatmentplanningfororthodontics,orthognathicsurgery,andprosthodontics.Operatorscan performspaceanalysis,treatmentsimulation,movementprediction,andtoothshapeanalysis.Becausepatientconditions varysignificantly,boundarydetectionbetweenteethand gingivawilldiffer.Precisionisneededforreliablesegmentation outputs,soautomatictoothsegmentationcanbechallenging. Specializedtrainingisrequiredtouseafullyautomated, fault-awaresystembasedondeeplearning.Deepneuralnetworkswithunsupervisedpretrainingandsupervised finetuningcanachieveprecisetoothsegmentationinimpressions. Thisreducestherelianceonextensivelabeledtrainingdata andwillstreamlinetoothsegmentationprocessesandimprove diagnostictechnologies.

Manuallyplacedlandmarksondentalmodelsserveanessential purposefordiagnosticandoutcomeassessmentsinorthodontics.However,theprocessispronetoerrorsandistimeconsuming.Newsoftwarecombinesmachinelearningandlinear programmingtoautomaticallyrecognizeandlabeleachtoothand itslandmarks.Humanveri ficationisstillrequired,butidenti ficationismorepreciseandrapid.However,automateddigitalmodel analysescandifferfrommanualones,soprecisionmaystill requiremanualmethods.

Anotheradvanceisleadingtowardautomatedsystemsthatproducedentalchargesdirectlyfromimpressions.Thesoftwareis underpinnedbydeeplearning,makingitabletocategorizemolars accordingtothepresenceandtypeofrestorationpresent.

DIAGNOSTICAPPLICATIONS

IOSscanperformusefultasksincariesdetection,toothwear monitoring,oralhygieneassessment,softtissueevaluation,and toothshadedetermination.

CariesDetection

IOSsfordetectingcariesarebasedoneither fluorescencetechnologiesusinglightwithawavelengthof415nmornear-infrared imaging,whichuseslightwavelengthsbetween727and850nm. IOSscandetectproximal,occlusal,orbothcariouslesions.The diagnosticaccuracyachievedwith fluorescenceiscomparableto thatwithvisualexaminations,butfalse-positiveresultscanoccur ifbio filmispresentonocclusalsurfaces.Assessmentsofnearinfraredscanshavehigherdiagnosticaccuracywhendonebyexpertscomparedtonovices,showingthelearningcurveneededto optimizebene fits.Thediagnosticaccuracyofnear-infraredimagingIOSremainsequivocal.OptimizedIOSscanbevaluableadjunctsincariesdetectionandmayproducemorereliable assessments.RadiationexposureisreducedwithIOSscompared toothermethods.

ToothWearMonitoring

Imagesuperimpositionsoftwarebasedonbest-fitalignmentallowsquantitativeassessmentofsurfacechanges.However,the

Figure2. Intraoralopticalimpressionofamandibulararchwithprepared teethandanimplantholdingascanbody.(CourtesyofEggmannF,Blatz MB:Recentadvancesinintraoralscanners. JDentRes 103:1349-1357, 2024.)

lackofstableoralreferencepointsmakesthisapproachproneto inaccuracies.AlthoughIOSscan’tpreciselydetectminutelevels ofwear,theycandetectandtrackchangesthatsurpassspeci fied thresholds.

OralHygieneAssessment

Planimetricmethodstoquantifydentalplaquecoverageprovidea detailedlookattheindividual’soralhygienestatus.Periodontal andplaqueparametershavebeenevaluatedusingasmartphone athomeafternonsurgicaltreatment.Thepatientsreceivedautomatedmotivationalmessagesbasedonmachine learning supportedevaluationsofvisiblesupragingivalplaque andgingivalinflammation.Thisapproachmayallowpatientsto sendintraoralimagesviasmartphonesforpersonalizedoral healthcounseling.

SoftTissueEvaluation

Increasingly,IOSsareusedtoevaluategingivalrecessionand peri-implantsofttissuestabilityandtomonitorsofttissue changes.ClinicalandlaboratorystudiesshowIOSassessments aremoreaccuratethanconventionaltechniques,butprecision dependsontheoperator’sskill,thedeviceused,andthescan location.

ToothShadeDetermination

IOSswithcolorimagingcanbeusedtodeterminetoothshade, theaccuracyofshadematchinghasbeenquestioned.IOSswith colormatchingtoolscanonlyprovidequalitativecolordata becausetheycan’tmaintainuniformilluminationandcandeviate fromtheoptimalangleforcolorreadings,makingthemmoreofa supplementarytool.

Figure3. Digitaldesignofmonolithiccrownsformaxillarycentralincisors usinganintraoralscannerplatformthatincludescopy-and-mirrortoolsto optimizethedesignprocessandagridoverlaytoassistinprecisealignmentandproportionassessment.(CourtesyofEggmannF,BlatzMB: Recentadvancesinintraoralscanners. JDentRes 103:1349-1357,2024.)

CLINICALUSES

BenefitsandBarriers

AlthoughIOStechnologiesusedfordiagnosisaren’tyetbecome routinelyaccepted,theycancontributesignificantlybyeliminatingsomeofthediscomfortconventionalimpressiontaking causes.Thisraisespatientsatisfactionlevels.Thepredominate usesforIOSsisinfabricatingsingle-unitrestorations.Costis theprimarybarriertotheiruse,withbetterclinicalef ficiency themostcommonreasonforadoption.Largedentalinstitutions canhavedifficultyintegratingIOSsoftwarewithcurrentelectronichealthrecordsystems,ensuringdatasecurity,managing datastorage,andtrainingcliniciansandstaff.

IOSAccuracy

TruenessandprecisionarethemeasuresofreliabilityandaccuracyinIOSs. Trueness isthedegreeofclosenessofintraoralopticalimpressions(IOIs)totheoriginalobject. Precision refersto theconsistencyofrepeatedscans.AlthoughIOSaccuracyhas improved,thelatestIOSsaren’tknownforthehighestaccuracy, withparticulardif ficultyinedentulousareas.Onlypreliminary stageimpressionswithIOSareadvisablewhencompletedenture fabricationortissuemovementcaptureisdone.

Augmentedaccuracyisneededforapassive fitofimplantsupportedrestorations.WhileIOSsofferacceptableaccuracy forsingleormultipleimplants,theyhavelimitedefficacyfor full-archimpressions(Figure2).Horizontallypositionedscan gaugeshelpwithaccuracy.

Whenusedforcrowns,marginalaccuracyisacceptableandcomparablebetweenIOSandconventionalimpressions(Figure3). Theclinicaloutcomesofimpressionsfor fixedprostheses, whethertooth-supportedorimplant-supported,arealsocomparablebetweenthe2approaches,butsubstantialvariationsinaccuracyarefoundbetweendifferentIOStechnologiesand differentgenerationsofaspeci ficIOS.

EnhancedTreatmentPlanning

AccurateIOSsarecriticaltocomprehensivetreatment-planning platforms.Precise “digitaltwins” canbecreated,whichare3-dimentional(3D)modelsthatprovideaccurateanatomicaldetails andspecialrelationships.Proceduresthatusethemincludeorthodonticmini-implantplacement,endodonticaccesscavity preparation,insertionofdentalimplants,andtooth autotransplantation.

SPECIALIZEDANDEMERGINGAPPLICATIONS

Prosthodontics,orthodontics,oralandmaxillofacialsurgery,teledentistry,andforensicdentistryofferopportunitiesforIOSuse. In prosthodontics, maxillomandibularrelationshipsrequireaccuracy,yetpresentcomplexitiesinachievingthisgoal.Polyvinyl siloxanehasbeenusedforfull-archscanningandphysicalbite recording,butscanningthebuccalsurfacesofaquadrantwith teethinmaximumintercuspalpositionwasmoreaccuratein staticinterocclusalregistration.Digitalbiteregistrationischallengingformultispanimplantrestorations.Digitalscanscan contributetodynamicmandibularmovementanalysis,butminor inaccuraciesinmeshalignmentpersist,causingintercuspalrelationshipstodeviatesignificantly.

Photogrammetrycaptureshigh-resolutionphotographsfrom variousanglesofimplantsandusesscrew-retained fiducial markersforreference.Advancedsoftwareallowstheidentificationofcommonpointsacrossphotographs,soaccurate3D modelsofdentalimplantpositionscanbecreated.Anadditional impressionusingIOIorconventionalmethodscapturesadjacent structures,butsupportfortheaccuracyofphotogrammetryin implantscansremainslimited.

In orthodontics, orthodonticalignerdevelopmentusesIOIsand virtualtreatmentplanning,butdiscrepanciesbetweenthedigital andconventionalmethodshavebeennoted.Inaddition,orthodonticsoftenrequiresfull-archscanswithcrowdedteethandappliances,afurtherchallengefordigitalapproaches.IOSshavethe advantageofnotrequiringbracketsandarchwirestobe removed.Rootpositionmayalsobecapturedfromdetailed3D toothmodelscreatedfromIOSs.

In oralandmaxillofacialsurgery,IOSshavebeenusedforpatients ofallages,whetherawakeorundergeneralanesthesia,indiagnostics,treatmentplanning,andorthopedicappliancefabrication.

AirwaysafetyisimprovedduringimpressiontakingwithIOSs, whichcanalsofabricateappliancesforinfantsandspeechenhancingobturatorprosthesesinchildrenwithcleftlipandpalatedeformities.IOSsaremoreaccessibleandlessexpensivethan extraoralfacialscanners,somoreinnovativedigitalsolutionsand costreductionsmaybeachieved.Somedefectsare,however, beyondtheabilitiesofIOSs.

Teledentistry canbene fitfromdatasharingthroughIOSsand enableremoteassessments.Approximatetrue-colorIOIscan helptodetectdentalsituations,butperiodontalconditionresults remaininconsistent.Addingbetterimagequalityandintegrating theIOSwithadditionalpatientdatafromradiographs,for example,couldmaketheIOSsmoreefficientforscreeningpatientsandperformingtriage.

Forensicdentistry canbene fitfromthespeedofIOSimaging.The identi ficationprocessmaybere finedifpreexistingimagingdata arealsoavailable.

ClinicalSignificance

IOSsremainextremelyeffectiveforCAD-CAMintegrationtofabricateindirectrestorationsandorthodontics toaidintreatmentplanning.Theycanalsobeintegratedwithvariousimagingmodalities,afacilitythat helpswhenpersonalizingtreatment.Challenges remainwithrespecttoadoptionbylargedentalinstitutions,accuracywhenscanningedentulousareasand implantsincasesoffull-archedentulism,andthe needforbetterdiagnosticaccuracy.Futureusescould evolveintheareasofprosthodontics,orthodontics, oralandmaxillofacialsurgery,teledentistry,and forensicdentistry.

EggmannF,BlatzMB:Recentadvancesinintraoralscanners. J DentRes 103:1349-1357,2024

Reprintsavailablefrom FEggmann,DeptofPeriodontology,Endodontology,andCariology,UnivCtrforDentalMedicineBasel UZB,UnivofBasel,Mattenstrasse40,CH-4058,Basel, Switzerland;e-mail: florin.eggmann@unibas.ch

LIPCANCER

IdentifyingLipCancer

BACKGROUND

Manydentalpractitionerscheckpatientsformouthcancer,but lipcancercanbeoverlooked.Theincidenceoflipcancerisfairly low,butthedentalteamshouldbeabletorecognizehealthylip tissuesandwhatisnormalforeachpatientaswellaswhatis abnormal.Oftenpatientsdon’thavesymptomsorconcern overaesthetics,buthaveaproblemthatrequiresreferral.The componentsofevaluatingpatientsforlipcancer,includingrisk factors,examination,andcommonsignsandsymptoms,and thetreatmentoflesionswerepresented,plusacasestudyto illustrateanactualpatient’ssituation.

COMPONENTSOFLIPCANCEREVALUATION RiskFactors

Whentakingthepatient ’ smedicalhistory,potentialrisk factorsforlipcancershouldbediscussed.Theseinclude tobaccoandheavyalcoholuse,excessivesunexposure,actinic cheilitis,humanpapillomavirus(HPV),herpesvirusinfection (coldsores),andaweaken edimmunesystem.Thesun exposureleadstoabout90%oflowerlipcancers,withthe upperlipangleddownwardandprotectedbythenose.The exposureincludestheuseofarti fi ciallightfromsunbedsas wellasthesunitself.Menoverage40yearswithfairskin areatspecialrisk.

Mostlipcancersbeginassquamouscellcarcinoma(SCC)andare firstseeninthin, flatcellsinthemiddleandouterlayersofthe oralmucosaandskin.Lipcancersthataremelanomaaremore dangerousanddevelopinthelip’smelanocytes.Usuallythecancersarisefromthevermillionborder,spreadinglaterallytothe adjacentskinorbydeepextensionintotheunderlyingmuscles ofthemouth.Melanomasspreadquickly,sotheearlierthey aredetected,thebetter.Liplesionsareeasilydetectedandassessedvisually.Basalcellcarcinomaisamalignancycommon foundinupperlipareas.

Examination

Thedentalpractitionershouldbefamiliarwiththeanatomyand physiologyoftheupperandlowerlips,knowhowtoexamine them,andtakepropernotes.Severalorganizationsoffereducationalonlineresourcesthatcanguidepractitionersintofamiliaritywiththisregion.

Theexaminationshouldbeginwiththefacialskinaroundthelips, thevermillionandvermillionborder,andthecornersofthe mouth.Pullingbackthelipswiththe fingerstosteadythemucosa (gauzecanmakeitlessslippery)allowsthepractitionerto examinethenonkeratinized/wetmucosalsurfaceofthelipsand

thelabialsulcus/vestibule.Bothhandsshouldbeusedtofeel thelipsforswellingoramass.Thedentalpractitionershould thenrecordthelocation,size,shape,color,configuration,and consistencyofalllesionsandwhetherthereismucosalor gingivalbleedingorulcers.Thedentistshouldnoteanysores, lumps,blisters,patches,orulcersonthelipthatwon’theal; bleeding;painornumbness;andjawswelling.Thedentistshould alsoinstructpatientsinhowtoexaminetheirlipsandmouthat home.

Treatment

Referralisoftenneededtoaspecialistwhowillperformproper therapy.Whenlipcancerisfound,surgeryisthemostcommon treatment.Smalllipcancersmayberemovedinaminorprocedurethathasminimalimpactonthepatient’sappearance.Larger lipcancerscanrequiremoreextensivetreatment.Suchinterventionsshouldbecarefullyplannedtopreservethepatient’sability toeatandspeaknormallyaswellasofferarestorationthatprovidesasatisfactorypostoperativeappearance.Radiotherapyor chemotherapymayberequired,butthelong-termsurvivalrate forlipcancerishigh.Newerapproachesincludeimmunotherapy, withresearchintoDNArepairandidentifyingmarkerstohelp withearlydetection.

CASESTUDY1

Woman,75,wasafarmer’swifewhowasactiveinthecommunity andsawthedentistregularlyonayearlybasis.Atherregularvisit,a visiblelesionwasnotedonherlowerlip(Figure1).Extra-oralexaminationshowednofacialasymmetryorpalpablenodes.The lowerliphadevidenceofactinickeratosis,whichwasalight

Figure1. MrsJ,thepatientinCasestudy1.UsedwithpermissionfromDr RobertBate,BDS.(CourtesyofLoweA:Lookingoutforlipcancer. BDJ Team 11:464-469,2024.)

leukoplakiaofthevermillionandawhitishsheenovertheexternal lip.A10×10mmshallowulcerwasjustleftofthemidline.Itwas expressingkeratinasa flakyexophyticmassthatdetached,leaving agranularbasethatbledreadily.Themarginsofthelesionwere slightlyelevatedandhadacircumferentialwhitezone.

Thepatientexplainedthelesionwasahealingcoldsore,butithad beenpresentforseveralmonths,withsteadycrustingand occasionalbleeding.Lipbalmprovidedsoothingreliefsoshe couldfocusoncaringforherhusbandwhohadadvanced dementia.

Thedentalprofessionalreferredthepatienttothehospital, wherethelesionwasconfirmedtobeanearly-stage,superficial, well-differentiatedcarcinomaofthelip.

Analysis

The findingsthatledtothediagnosisoflipcancerwereanonhealinglesiononsun-exposedskin,evidenceofsolarkeratosis, andamistakenviewthatitwasacoldsore.Thelesiononthelower lipwasjusttoonesideofmidlineandproducedkeratin.The

marginsshowedinfiltrationandraisededges.Coldsoresusually resolvein2weeks,sothislesionwasn’tjustacoldsore.Thelesion wouldlikelydevelopmoreadvancedfeaturessuchasaraised,exophyticulceratedmass,distortionandindurationofthelip,andpain.

ClinicalSignificance

Lipcancershavenotyetbeenclearlyidentifiedas mouthorskincancer.Exposuretosunlightisacausativefactorinmostcases,soit’swisetoweara broad-spectrumSPBlipbalmregardlessofone’s age,gender,orskintype.Preventioniskey,soprotectingthelipsfromultravioletlightisessential.

LoweA:Lookingoutforlipcancer. BDJTeam 11:464-469,2024

Reprintsnotavailable

ONCOLOGYANDORALHEALTHCARE

ConcernsForDentalTeamsCaringForPatientsWith Cancer

BACKGROUND

Earlierdiagnosisandtailoredtreatmentplanscombinedwithan agingpopulationhaveledtomorecancersurvivorsindeveloped countries.Theadvancesincancertreatmentsarealsoassociated witheffectsonoralhealththatcanin fluenceoralhealthcaredelivery.Oralconditionsassociatedwithcanceranditstreatments, includingmucositis,infections,xerostomia,trismus,osteonecrosis,tastechanges,andulceration,canalterdentalcareoptions.In addition,cancerpatientsareathigherriskfordevelopingdental cariesandcanhavecompromisedoverallhealth.Theprimary caredentalteammayseethepatientbefore,during,oraftercancertreatment,andeachofthesestagespresentschallengesfor thedeliveryoforaltreatments(Table1).Thecurrentpractices andbeliefsaboutdeliveringprimarydentalcaretopatients whohaveorhavehadcancerwerediscussed.

METHODS

The4onlinefocusgroupsincluded15dentalprofessionals(DPs). Sessionsrangedfrom44to75minutes(average59minutes).Ten themeswereidenti fi edandconcernsdiscussed.

RESULTS

PatientswithVariousCancers

Themostcommoncancersamongthepatientstreatedwere breastandprostatecancer,butotherssawhematologicalcancers suchaslymphoma,leukemia,andmyeloma.Patientswithhead andneckcancer,stomach,bowel,lung,andskincancerswere alsoseen,aswellassomereceivingpalliativecare.

RoleoftheDentalTeam

DPsunderstoodthattheroleofallteammemberswastomanage andmaintaintheoralhealthofthepatients,whethertheywere pre-,mid-,orpost-cancertreatment.Dentistscitedthesuperior experienceofdentaltherapistswhoprovidedoralhygieneandinstructionstopatients.Becausethepatientswerebeingseenata veryemotionalperiodintheirlives,thedentalteamrecognized thattheyhadapastoralandsupportiveroleinadditiontoclinical care.OftenthepatientsandDPshadknowneachotherforalong timeandhadanestablishedrelationship.DPsalsorecognizedthe limitationstheyfacedwhendealingwithsomeoftheemotional andfunctionalissues,butwereclearthattheyhadaresponsibility tosignposttheirpatients.

Table1. StagesofCancerTreatmentandRelatedRolesofPrimaryDentalCareTeam

) Priortosurgical,systemicanticancertherapy

) orradiologicalintervention

) Duringsystemicanti-cancertherapyor radiologicalintervention

) Aftersurgical,systemicanti-cancertherapyor radiologicaltreatment

Providingpreventionandinformationabouttherisksofcancertreatmentonoralhealth. Eliminatinganyoralsourcesofinfectiontoavoidriskofsystemicspread(e.g.sepsis)

Eliminatinganyteethofparticularlypoorprognosisinanattempttoreducetheneedfor extractionsorminororalsurgeryinthefutureinsituationswherethepatientmaybeat riskof:

Medicationrelatedosteonecrosisofthejaw(MRONJ)

Osteoradionecrosis(ORN)

Addressingacuteproblemsincludingdentalpainandinfection.

Managementofdrymouthororalmucositis.

Managingoralmanifestationsofbacterial,fungalandviralinfectionsduetoincreased riskofinfection.

Considerationofincreasedbleedingandinfectionriskiftreatmentisbeingcarriedout. Ongoingprevention

Preventionofdentaldisease

Managingreducedmouthopening(trismusduetoeffectofradiotherapyonmuscles andothersofttissuescancauseproblemswithaccesstooralcavityforself-performed plaquecontrolandexecutingdentaltreatment)

Managementofdrymouthandassociatedoralsoreness.

ManagementofpatientsatriskofMRONJorORNwhoneeddentaltreatment. DiagnosisandreferralofpatientswithMRONJorORN.

Headandneckcancersurveillance-particularlyforpatientswhohavehadoralor oropharyngealcancer.

Considerationoflaryngectomiesortracheostomiesandanydietaryconsiderations. Maintenanceofprosthodonticrehabilitationsincludingimplantsupportedorretained prostheses.

(CourtesyofWemyssC,AbdulsalamA,BeatonL,etal:Experienceofprimarydentalcareteamsinmanagingtheoralhealthofoncologypatients. BMCOralHealth 24:1554,2024.)

Communication

MixedHealthCareMessages

DPsfeltmixedmessagesweregiventopatientsabouttheneed forcareduringcancertreatmentandtheimportanceoforal health.Someoncologyteamsadvisedpatientsnottoattend dentalappointmentsbeforeorduringtheirtreatments.Inaddition,oralhygieneadvicewasalsoinconsistent,withsomemedical teamstellingpatientstouseasofttoothbrush,whichisaninstructioncontestedbyDPs.

CommunicationBetweenDentalandMedicalTeams

Sometimescommunicationbetweenthedentalandmedical teamswaseffective,withoncologyanddentalteammembers supportiveofoneanother.Thistendedtovarybylocationand thedentalservicetheDPworkedin.Atothertimes,communicationdif ficultiesdeveloped,withtheoncologyteamadvisingpatientstohaveanoralhealthassessmentbeforecancertreatment, butnoformallinesofcommunicationexistingbetweenthe oncologyanddentalteams,socarewasn’twellintegrated.Sometimesthemedicalteamseemeddismissiveofanyconcernsover thepatient’soralhealth.Whenpatientsweren’tinformedabout theircareorwhenthemedicalteamdidn’tshareinformation, suchasthepatient’sprognosis,withthedentalteam,moreproblemsarose.

PatientExperience

DealingwiththeExperience

Thephysicalandmentalexperiencesofpatientsandtheirquality oflifewhenoncarepathwayswereofconcernforDPs.Treatmentscausemanyphysicalproblemsforpatients.Thesitespeci ficsideeffectsoftreatmentforpatientswithheadand neckcancerwereespeciallydebilitatingandcarriedsigni ficant risks.Patientsandtheirfamiliesoftenbecameemotionalattheir dentalvisitsoverthingsthathadhappenedintheirmedicalvisits, orhadconcernstheyweren’tencouragedtoshareinothersettings.DPsdealtwithpatientswhohadgeneralhealthcareanxiety alongwithdentalanxietyandthementalstrainofdealingwith cancer.Sometimestheanxietywascausedbytheimmensevolumeofinformationpatientsaregivenastheygothroughtheir cancerjourneyandhowtheyfeltoverwhelmedasaresult.

PatientEngagementwithHealthCare

Insomecases,patientswithcancerhadpoorpreexistingattitudes towardtheiroralhealth,andDPsquestionedwhetherpatients understoodtheimportanceoftheirdentalhealth.Manyfocus groupsnotedthatpatientshadtroubleunderstandingtheircancerdiagnosisandtreatment.Therewere,however,patients whoweretakingaproactiveapproachtotheirhealthcare, includingdentalcare.

TreatmentPlanning

Especiallyintheirpatients ’ pre-cancertreatmentstage,DPs facedchallengesintreatmentplanning.Thepre-cancertreatmentstagecanbechaoticandinvolveshorttimeperiods whenallnecessarydentaltreatmentmustbedonebefore cancertreatmentcanproceed.Poorpreexistingoralhealth wasachallengethatoftenrequiredcomplextreatment.Dependingonthecancertherapybeingprovided,theoralhealth treatmentcouldsometimesbeaggressive,makingitdiffi cult tomanagepatientexpectationsaftertheirrecentcancerdiagnosisandrequiringDPstoengageindif fi cultconversations withpatients.Thedentalteamfeltpressuredtomakedecisionsonteethwithaquestionableoruncertainprognosis. Oftenpatientshadheavilyrest oreddentitionsthatincluded severalcrownsorbridgeworkandhadbeeninplacefor yearswithoutcausingproblems.Whenthequalityofthe workhadthepotentialtocausefutureproblems,patients struggledtounderstandwhyallthisdentalworkhadtobe undone.DPsrecognizedthateachcasehadtobetakenon itsownmeritandthattreatmentplansshouldbecarefully craftedforeachindividualpatient.

DentalTeamApprehension

DPswereoftenapprehensiveaboutwhatcanbesafely managedinprimarycareorfearedthetreatmentofcertain oncologypatients.Fearwasoftenrelatedtotheriskofinfectionorbleedingduringproceduresandwasbasedonprevious experiencesortraining.Afactorthatstronglyin fluencedDP apprehensionwastheinnovationincancercareoverrecent decades.Someapprehensionabouttreatmentresultedfrom alackofknowledge.

WiderSystemFactorsandManagement

Secondarycarewastightlyrelatedtowhathappensinprimary care.Thepressuresandcapacityforcarewereofconcern,but itwasbelievedthatguidancecouldhelpbysupportingpatient managementinprimarycaresettings.DPsworkinginhospitals andsecondarycaresettingsusuallyhavemoreaccesstopatients’ medicalinformationandtooncologycolleaguesthroughthedigitalsystemsintheseinstitutions.

Continuityofcarewasanissue.DPssaidlackofaccesstoGDPs madethemunabletodischargesomepatientswhodidn’thavea GDPorwereunlikelytocontactaGDP.

Thewaydentistsworkingunderregulationsarepaidin fluenced whatcanandcannotbeprovided.Patientchargesareapplied invariouswaystooncologypatientsdependingontheregulationsinplace.

Table5. SummaryofSuggestionsforGuidanceand AccompanyingResources

Suggestionsfortopicstoincludeinguidance

Clearoralhealthmessagesandadvicefordentalandmedicalteams

Summaryofoncologytreatmentsanddrugsandassociatedsideeffects

Dosanddon’tsfordentalexaminationandtreatment

Treatmentplanningadvice

SuggestionsforAccompanyingResources

Patientinformation

Oncology ‘passport’ proformawhichwouldcontainthepatient’s diagnosis,treatmentandcontactdetailsforoncologyteamandusedto aidcommunication

Photographsofsideeffectstolookoutfor

ListofadviceDPsshouldprovidetoapatientpre-cancertreatment

Signpostingtofurthersupportforpatients(e.g.mentalhealthadvice)and furthersupportforDPs(whoandwhentocontactforadvice)

(CourtesyofWemyssC,AbdulsalamA,BeatonL,etal:Experienceof primarydentalcareteamsinmanagingtheoralhealthofoncologypatients. BMCOralHealth 24:1554,2024.)

Someparticipantsidenti fiedbarrierstosecondarycaredental serviceswhenfacedwithcomplexdentalproblemsfor oncologypatients.Referringpatientswiththesecomplex dentalproblemscausedpositiveandnegativeexperiencesfor thepatientandDPS.

Support

FocusgroupDPsprovidedexamplesofwheretheybelieved theywouldneedsupport.Theywereoftenunawareofall thespecialty-speci ficguidanceavailableorofnewlyaccepted orevenpreexistingguidelines.DPsdesiredinformationabout howtomanagecancerpatientsandhowtoaccomplishtransfersamongmedicalprovidersanddentalpractices.Guidance andresourceswerefelttobelacking(Table5),including thingsasbasicaslea fletsforpatientinformation.However, DPsoftenmentionedsupportivecolleaguesinbothdental andmedicalteamswhoprovidedinvaluableinformationand guidance.

CONCLUSIONS

Theprimarydentalcareofpatientswhohaveorhavehadcancer iscommon,sothedentalteamshouldbeawareofwhatcanbe safelyprovided,theconcernsthatthesepatientsmayhave,and howbesttoapproachtheircareandmanagethechallenges theypresent.Communicationbetweenandamongcareproviders,understandingthefactorsthatinfluencecaredelivery, andobtainingandprovidingsupportforthepatientsasthey faceacomplexsystemareamongtheconcernsthatdentalteams mustmanage.

ClinicalSignificance

Dentalteamsarefacedwithnumerouschallengesas theyseektoprovidecareforpatientswithcanceror whohavehadcancer.Thetopicsbroughtupinthediscussionscanbeusefulindirectingtheprovisionofadditionalresourcesandincraftingeffectivecommunication systemsbetweentheoncologyanddentalcareteams. Additionalresearchintothesetopicsshouldhelpinaddressingthechallengesthathavebeenidentifiedand addothersthatmaynothavebeendiscussed.Additional supportinseveralareasisneeded.

WemyssC,AbdulsalamA,BeatonL,etal:Experienceofprimary dentalcareteamsinmanagingtheoralhealthofoncology patients. BMCOralHealth 24:1554,2024

Reprintsavailablefrom LBeaton;e-mail: lbeaton002@dundee. ac.uk

ORAL/SYSTEMICCONSIDERATIONS

Non-HealingExtractionSocketProtocol

BACKGROUND

Mostdentalextractionshealwithoutcomplications,although somedeveloppain,swelling,bleeding,infection,andtrismus.A smallpercentageofpatientsexperiencedelayedhealing,usually relatedtoalveolarosteitisordrysocket,whichcausescontinuous,severe,deep-seated ‘bone’ paininoraroundthesocket beginning2to3daysafterextraction.Certainsystemicdiseases canalsocausedelayedhealing,includingalcohol-relatedliverdiseaseandnutritionaldeficiencies.Inrarecases,theextractionsite doesn’thealforweeksormonths,promptinganinvestigation intowhatisgoingonandreferralforspecialistcare.Areview oftheliteratureidenti fiedcaseswhereanon-healingextraction socketresultedfromaserioussystemicdiseaseormalignancy (oftenunknowntothepatient)orwascausedbysystemic therapy.

METHODS

AsearchwasdoneinthePubMed,Embase,Scopus,ProQuest, andGoogleScholardatabases.Fiftycasesofnon-healingextractionsocketswereidenti fied.

RESULTS

The50casesinvolved28womenand22men(agerange26to 81years,averageage55.2years)whohadatotalof71teethextracted.Forty-oneoftheextractedteethweremandibularposteriorteeth.Reasonsforextractionwereusuallynonspecific, includingtoothmobilityorlooseness,swelling,periodontitis, pain,andinfection.Onewomanhadparesthesiaoftheright lowerlipandchinleadinguptotheextraction;shewassubsequentlydiagnosedwithmetastaticbreastcancertothemandible.

Figure1. SCCpresentingasanon-healingextractionsitewithanulcerative, mixedredandwhitedestructivelesionanderythemaofthelefthardpalate. (ReproducedwithpermissionfromRichardsetal., ‘Slowtohealorslowto diagnosecancer?’ BDentJ 230:518-522,2021.18)(CourtesyofUkwasA, ElbegoA,AlbegoM,etal:Non-healingextractionsocket:Adiagnostic challengeforgeneraldentalpractitioners. BrDentJ 237:911-916,2024.)

Table2. PotentialLocalandSystemicCausesofDelayedandNon-healingExtractionSockets(ListIsNotExhaustive)

LocalcausesSystemiccauses

Delayedhealing

Non-healing

Alveolarosteitis(drysocket)

Localinfection(egperiodontitisorinfected granulationtissue)

Foreignbody(Alveogylremnants)

Alveolarbonesequestrum

Tobaccosmoking

Osteomyelitis

Radiationtothejaws

PrimarymalignancyegSCC

Neoplasmsofmaxillarysinusornasalcavity

Odontogenictumouregameloblastoma

Langerhanscellhistiocytosis(monostotic)

Oldage

Obesity

Diabetesmellitus(particularlyuncontrolled)

Smoking

Alcohol-relatedliverdisease

Corticosteroidtherapy

Chemotherapy

Malnutrition/nutritionaldeficiency

Severeanaemiaorblooddyscrasia

MRONJ

Metastaticcancer

Langerhanscellhistiocytosis(polystoticand disseminated)

Sarcoidosis

Hyperparathyroidism

(CourtesyofUkwasA,ElbegoA,AlbegoM,etal:Non-healingextractionsocket:Adiagnosticchallengeforgeneraldentalpractitioners. BrDentJ 237:911-916,2024.)

Sixty-eightpercentofthecasesinvolvedadiagnosisofmalignancy, with24primaryand9metastatic.Amongtheprimarymalignancies, themostcommonwassquamouscellcarcinoma(SCC),whichwas seenin60%oftheprimarycancercases(Figure1).Amongthemetastaticlesions,3originatedinthelung,2inthebreast,andtheothers fromtheliver,kidney,andcolon(1each).Onepatientwith metastaticangiosarcomahadnooriginidentified.Fiveofthepatients withmetastaticdiseasehadnopriorhistoryofmalignancy.The averagewaitfordiagnosisofpatientswithmetastaticnon-oralmalignancieswas3months,with1patientwaiting6months.

Medication-relatedosteonecrosisofthejaw(MRONJ),often relatedtozoledronicacidordenosumab,wasfoundin10 women.Sevenpatientswhoweretakingrelevantmedication thatwasassociatedwithMRONJhadmetastaticbreast cancer,and1eachoftheremaining3patientswithMRONJ hadmetastaticthyroidcancer,rheumatoidarthritis,andosteoporosis.OnecaseeachwasfoundtoinvolveLangerhans cellhistiocytosis,ameloblastoma,osteomyelitis,invertedmaxillarypapilloma,browntumorofhyperparathyroidism,and sarcoidosis.

Table3. Pre-operativeFeaturesThatMayBeSuggestiveofIncreasedRiskofLaterExtractionSocketNon-healing*

History

Clinicalexamination

Radiographicinvestigation

Historyofcancer

Historyofradiotherapytotheheadandneck

Historyofanti-resorptiveoranti-angiogenetictherapy

Historyofimmunosuppression

Suddenloosenessofteethwithouthistoryoftrauma,orrecentdentaltreatment

Suddenonsetofnumbnessoftheliporchinwithnohistoryofrecenttraumaorfracturetothe mandible

Suddenonsetofnumbnessortinglingsensationoverthecheekorupperlip

Extremelymobiletooth/teethwithnoapparentfractureorperiodontaldisease.Thisshouldbe assessedinthecontextoftherestofmouth

Excessivebleedingonprobingwhichcannotbestoppedwithlocalmeasures

Severe(oftenirregular)destructionofbonesothatthetoothorteethappearasbeing floatingin air(Fig.3)

Toothassociatedwithapunched-outormultilocularradiolucencynotconsistentwithacyst

Tooth/teethassociatedwithapoorlydefinedradiolucencyormixedradiopaque/radiolucent lesi

Key:

*Ifapatientpresentswithoneormoreofthesemanifestationsbeforeextraction,theyshouldbescheduledforaregularfollow-upfollowingextraction oratleastaweeklybasis,andshouldbereferredifnosignsofhealingaredetectedasdescribed(2weeksifmalignancyissuspected).

(CourtesyofUkwasA,ElbegoA,AlbegoM,etal:Non-healingextractionsocket:Adiagnosticchallengeforgeneraldentalpractitioners. BrDentJ 237:911-916,2024.)

RECOMMENDATIONS

Completesealingofthesocketafterextractionofatooth shouldoccurinabout4to6weeks.Ifnosignofhealing occursbythispoint,thedentistshouldevaluatethepatient forpossibledisordersassociatedwithreducedhealing potential(Table2).Adelayindiagnosingandmanagingthesediseasesincreasestheriskofsignificantmorbiditiesandmoreinvasivetreatment.

Thedentistshouldtakecompletedental,medicalandsocialhistories(Table3).Inaddition,carefulextra-oralevaluationshould bedoneoftheregionallymphnodesandmouthopening.The extractionsocketandsurroundingarearequirecarefulevaluationundersufficientlighttodetectsignificantsignsofamore seriousproblem.Thiscouldincludeasinustrackorabscess, foreignbody,sequestrum,oroantral fistula,erythematous swellingaroundthesocket,oranexophyticgrowthfromthe socket.Radiographscanbetakenbutanyseverebonedestructionshouldbeassessedinthecontextoftheentireoralcavity andnotbelimitedtoperiapicalviewsbutalsoconsider orthopantomograms.Thesocketcanbecurettedandthespecimensentforhistologicevaluation.Referraltospecialistcareis appropriateforpatientswhohavenoproperhealingafter 4weeksorwitha2-weekurgentreferralifmalignancyis

PERI-IMPLANTITIS

suspected.Thepatientshouldbegivenathoroughexplanation ofthereasonforthereferralandprovidedacopyofthe referralform.

ClinicalSignificance

Dentistsneedtoremainvigilantafteranextractionto ensurethathealingproceedsaccordingtoanormal pattern.Ifthesitedoesn’thealwithin4to6weeks andtherearenoindicationstoexplainthedelay,the patientshouldbecarefullyevaluatedandsenttoa specialistforadditionalinvestigationsandadefinitive diagnosis.

UkwasA,ElbegoA,AlbegoM,etal:Non-healingextraction socket:Adiagnosticchallengeforgeneraldentalpractitioners. BrDentJ 237:911-916,2024

Reprintsavailablefrom AUkwas,UCLEastmanDentalInst,Univ CollegeLondon,UK;e-mail: abdouldaim.ukwas.09@ucl.ac.uk

NonsurgicalTreatmentforPeri-implantitis

BACKGROUND

Implanttherapycanrestoremissingteethandaddfunctionaland aestheticrestorationstothedentition.However,about22%of patientswithimplantsdevelopperi-implantitisthatcancause thelossofosseointegration.Preventingperi-implantdiseasesis vitaltolong-termsuccess,butpatientswithcertainriskfactors canbemoresusceptibleandlesslikelytoavoidthesedisorders. Theriskfactorsincludeasusceptibilitytoperiodontitis,diabetes mellitus,andthepresenceofabacterialbio filmontheimplant surface.Overall,thecausesofperi-implantdiseasesresemble thoseforperiodontaldiseasesaroundnaturalteeth.Regular maintenanceofgoodoralhealthisanessentialingredientof avoidingperi-implantdiseases.ThetreatmentinterventionsrecommendedforinclusioninnonsurgicalstepstotreatperiimplantitiswerebasedontheEuropeanFederationofPeriodontology’s(EFP’s)S3-levelclinicalpracticeguidelines.

NONSURGICALTREATMENTCOMPONENTS

ControlofLocalRiskFactors

Inadditiontothesystemicriskfactors,severallocalfactors canin fl uencethedevelopmentofperi-implantitis.These includetheoralbacterial fl ora,thetypeofrestoration

applied,failuretoprovidecleansingability,andaesthetics.Accesstooralhygieneisaprimaryrequirementtolowerthe riskofperi-implantitis.Inaddition,implantplacementshould beplannednotjustforaestheticsbutalsotoavoidniches thatcan ’tbereachedduringoralhygiene.Patientsat increasedriskforperi-implantitisinnonaestheticareasshould receivetissue-levelimplants,withbone-levelimplants reservedforaestheticregions.

OralHygiene

Patientsneedregularmonitoringthatdocumentstheirplaque controlaswellasclinicalsignsofperi-implantitis,suppuration, increasedprobingdepth,andboneloss.Theseparametersshould berecordedonatleast4sitesaroundtheimplant,andanintraoralradiographshouldbeobtained.Patientswillrequirerepeated instructionsonhowtoachieveadequatecleaning.Toolsfor interproximalhygieneshouldbeadaptedtoincreasepatients’ efficacy.

ClinicalPathwaytoManagePeri-implantDiseases

Asystematicclinicalapproachisdesirable(Figure1).Supramucosal/mucosaltherapyandsubmucosaltreatmentcanbeperformedatthesameappointment.Supraconstructionis

Figure1. Therapeuticstepsfortreatmentofperi-implantmucositisandperi-implantitis.(CourtesyofMeyleJ,Fischer-WaselsL:Non-surgicaltreatmentof peri-implantitis. BrDentJ 237:780-785,2024.)

removedtofacilitateaccesstotheimplant’ssubmucosalareasif needed.Shallowpocketsmaynotrequirethisstep.

SupramarginalandSubmarginalInstrumentation

Allcalcifiedandnoncalcifieddepositsshouldbecompletely removedfromtheinfectedimplantsurface.Completecleaning isdif ficult,eveninvitro.Mechanicalcleaningusingsteelcurettes ortitaniumhandinstrumentsisn’trecommended.Plasticcurettes,metalcurettes,rotatingtitaniumbrushes,andanultrasonicscalingsystemwithacarbontipandpolishing fluiddonot

restorethebiocompatibilityofroughtitaniumsurfaces.Remnantsfromsoftcurettescanbehardtoremove.Evenso,curettes andultrasonicdevicesareusedforsubmarginalcleaningand debridement.Reducingdamagetotheimplantsurfaceisachieved byusingultrasonicdeviceswithplastictips(Figure5).Inaddition, theair-powderabrasivesystemwithsodiumbicarbonatepowder isunlikelytoharmthe fibroblast-titaniumsurfaceinteractionaftertreatingsmoothorroughsurfacesevenwhencontamination ispresent.Thebiofilmremnantscanberemovedusingtheperionozzlecombinedwitherythritolpowder.Thechitosan-based

Figure5. Ultrasonic/air-polishingdevice. B, Ultrasonichandpiecewithtipmadeofpolyetherketoneinordertoreducedamagetotheimplantsurface. C, Handpieceforair-abrasivetreatmentwithnozzleforsubmucosaldebridement. D, Clinicalsituationwithperionozzleinsertedatimplantsite.(Reproduced withpermissionfromMeyleJ,Fischer-WaselsL:Non-surgicaltreatmentofperi-implantitis. BrDentJ 237:780-785,2024.).

Box2. CriticalEndpointsofNon-surgicalTherapyofPeriimplantitis(AccordingtoHerreraetal.2023).

Residualprobingdepths %5mm

Bleedinguponprobingat %1site/implant

Nosuppuration

(CourtesyofMeyleJ,Fischer-WaselsL:Non-surgicaltreatmentof peri-implantitis. BrDentJ 237:780-785,2024.)

oscillatingbrushhaslimitedef ficacyagainstlocalin flammation. Usingbiofilmdilutingagentshasbeenassociatedwiththelowest residualbleedingonprobingofalltheapproaches.

AdjunctiveTherapies

Chlorhexidine(CHX)solution flushinghashadlimitedeffectand wasunabletoresolvelocalinflammationinmostlesions.Useofa gelatindepositofCHXreducedbleedingonprobing,butresidual bleedingscoresindicatedincompletehealingofthelesion.The adjunctiveuseofantimicrobialsisn’trecommended,noristhe useofadjunctiveprobiotics.Newtherapiescombinethebio film resolutionbyhypochloriteincombinationwithchloramine,followedbylocaladministrationofhyaluronicacid.Signi ficantreductionswereseeninpocketprobingdepthsandclinicalattachment gainsaroundnaturalteeth.Hyaluronicacidhassomebene ficial aspects.

Lasers

Laser-assistedtherapiesarelimitedintactilesensationandvisual control.Residualbleedingonprobingshowsthecleaningandbiofilmremovalareincomplete.Asaresult,theEFPS3guidelinesuggestsnotusinglaserseitheradjunctivelyorasmonotherapyinthe nonsurgicalsubmarginalperi-implantinstrumentation.

AdjunctiveAntibiotics

The7-day-longsystemicadministrationofmetronidazolealong withultrasonicinstrumentationandCHXrinsingachievedsignificantlybetteroutcomesafter12monthsandwassuccessfulin 56%ofthepatientsinthetestgroupbutjust25%ofthecontrol group.Routineprescriptionofsystemicantibioticsadjunctively tononsurgicaltherapyisn’trecommended.

EndpointsofTreatment

Nonsurgicaltreatmentsshouldbeevaluated6to12weeksafter treatment.Duringhealing,patientsshouldbemonitoredregularlyandoralhygienereinforcedasneeded.Residualprobing depths,bleedingonprobing,andsuppurationshouldberecordedontheimplantleveltodocumentthecriticalparameters (Box2 ).

RESULTSOFNONSURGICALTREATMENT

Nearlyallnonsurgicalinterventionscannotachievecomplete resolutionofperi-implantitis.Thepercentageofbleedingsites canbereducedsignificantly,indicatingapossibleef ficacyofthe intervention,butclinically,thesetreatmentsaren’tconsidered efficient.Completeresolutionofdiseaseusingnonsurgicaltechniquesisunlikely.

ClinicalSignificance

Currently,thetreatmentofperi-implantitisisfoundedonsurgicalinterventionsthatallowcleansingofthedefectsand implantsites,possiblere-shapingifneeded,andreconstructionofthedefecttoremovenichesandreestablishconditions leadingtore-osseointegration.Nonsurgicaltreatmentisless invasive,moreconservative,andoftenmorecomfortable forpatients.Itcanreduceinflammationandthebacterial loadbeforesurgicalinterventionsareundertaken.Therefore, nonsurgicalperi-implanttreatmentcanrenderlocaltissuesto aconditionwhereasurgicalinterventionismorereadily achievedandwhenfailureriskisreduced.Combiningnonsurgicalapproachesmayimproveoutcomes,andsynergisticeffectsmayenhancetheoutcomes.

MeyleJ,Fischer-WaselsL:Non-surgicaltreatmentofperiimplantitis. BrDentJ 237:780-785,2024

Reprintsavailablefrom JMeyle;e-mail: Prof.Dr.J.Meyle@tonline.de

INQUIRY

ALVEOLARRIDGEPRESERVATION

ReducingAlveolarBoneRemodelingAfterExtraction

BACKGROUND

Aftertoothextraction,spontaneoushealingresultsin3dimensionalalveolarboneremodeling,withthewidth decreasingbyabout3.8mmandtheheightreduction rangingfrom1.24to1.7mm.Thesedataarebasedon studiesthatincludedextractionsatanterioraswellaspremolarareas.Furtherstudiesindicatethatextractionsat molarsiteshavegreaterreductionsthanthoseatnonmolar sites.Alveolarridgepreservation(ARP)includesvarious regenerativetreatmentmodalities,suchastheuseofbone substitute(socketgrafting),soft-tissuegrafts(socketseal), oracombinationofboth.AlthoughARPiswellrepresentedbyitsabilitytoachieveaestheticresultsat maxillaryanteriorareas,itspossiblebene fi tsinmolarareas arelargelyunknown.SomereviewsindicateARPcanreduce boneresorptionaftertoothextraction,maintainalveolar ridgevolume,andavoidadditionalboneaugmentationproceduresinimplanttherapy.AsystematicreviewandmetaanalysisevaluatedtheeffectofARPatmolarextractionsites comparedtothatwithspontaneoushealingonhardtissue changesandtheneedformoreaugmentationduringimplant placement.

METHODS

AsearchofthePubMed,Embase,WebofScience,Cochrane CentralRegisterofControlledTrails,andtheSystemforInformationonGreyLiteratureinEuropeidenti fi ed7studies thatwereapplicable.Thesein cluded4randomizedcontrolled trials(RCTs),2prospectivenonrandomizedclinicaltrials,and 1prospectivecasecontrolstudy.Theprimaryoutcomewas thechangeinalveolarridgewidthandheight,withsecondary outcomesofsinuspneumatizationandneedformore augmentationwhenimplantplacementisdone.Thestudies included237molarextractionsocketsin236patients (meanageabout49to59years,range21to70years). Thechangesindimensionwereevaluatedusingcone-beam computedtomography(CBCT).

RESULTS

ARPwasdonein126sitesandtheremainderself-healedwithout ARPintervention.Noneofthepatientshadactiveoruntreated periodontaldisease.Comparedtospontaneoushealing,ARP significantlyreducedthehorizontal,verticalmid-buccal,and verticalmid-lingualdimensions.Theridgewidthdifferences weren ’tstatisticallysignificantbetweenthe2groups.Using ARPreducedtheneedforadditionalaugmentationduring implantplacementcomparedtoself-healingafterextraction.

CONCLUSIONS

TheuseofARPlimitedhorizontalandverticalhardtissue changesatmolarextractionsitesduringsockethealing.More studiesareneededtoconfirmthese findings.

ClinicalSignificance

Longerfollow-uptimesandalargerpatientsampleare neededtocon firmthe findingsofthisreview.Itseems apparentthatARPcanreducesocketboneandridge changes,makingadditionalaugmentationprocedures inmolarregionsunnecessaryinmanycases.No consensushasbeenfoundregardingtheefficacyof thevariousproceduresorofthebiomaterialsused.

WeiY-P,HanZ-Y,HuW-J,etal:Alveolarridgepreservationat molarextractionsites:Asystematicreviewandmeta-analysis. J EvidBaseDentPract 2025:[102074]

Reprintsavailablefrom WHu,DeptofPeriodontology,Peking UnivSchoolandHospofStomatology,NatlCtrforStomatology, NatlClinicalResearchCtrforOralDiseases,NatlEngineering ResearchCtrofOralBiomaterialsandDigitalMedicalDevices, No.22,ZhongguancunSAve,HaidianDist,Beijing,100081,PR China;e-mail: huwenjie@pkuss.bjmu.edu.cn

ANTIBIOTICSANDEXTRACTIONS/IMPLANTS

ProphylaxisWithAntibioticsBeforeExtractionsin High-RiskPatients

BACKGROUND

Teetharemostoftenextractedbecauseofdentalcariesandperiodontaldisease,whichareinfectiousdiseasesthatcancause problemsforsupportingstructuresandleadtolocalandsystemic complications.Asaresult,systemicantibioticsareoftenprovided topreventpost-extractioncomplications.Thisuseofantibiotics isn’twellsupportedbyevidence,withseveralstudiesidentifying nobene fittousingantibioticstopreventcomplicationsoverthe useofnoantibioticsoraplacebo.VeteransAffairs(VA)dental patientstendtohaveahigheroralandsystemicdiseaseburden thanisfoundinthegeneralpopulation.Theyalsohaveahigher rateofcariesandmentalandphysicalcomorbidities,including depressionanddiabetesmellitus.Thispopulationwasstudied toevaluatetheeffectivenessofantibioticprophylaxistoprevent localandsystemiccomplicationsafteradentalextraction.

METHODS

Theretrospectivecohortstudycoveredaperiodof5yearsand included385,880dentalvisitsof269,003patientswhohadan extraction,duringwhich122,810patientsreceivedantibioticprophylaxis.Theprimaryoutcomewaspost-extractioncomplications occurringwithin7daysoftheextraction.Thesecondaryoutcome wassubsequentmedicalcarerequiredthatwasrelatedtoapostextractionoralcomplicationwithin7daysoftheextraction.The effectofantibioticprophylaxisoneachoutcomewasevaluated.

RESULTS

Mostpatients(about93%)wereage65to79years,withabout 48%betweenages65to79yearsandabout32%betweenages 45and64years.About61%hadjust1toothextracted,andabout 59%hadnonsurgicalextractionsperformedattheirinitialvisit. Dentalprovidersperformedabout92%oftheextractions, with8%donebyoralsurgeonsand0.2%byresidents.About 3%hadahistoryoforalinfection,1%implanthistory,and1% oralinfectionatbaseline.Dentalpractitionersweremorelikely togivepatientswhohadsurgicalextractionsantibioticprophylaxiscomparedtothosewhohadnonsurgicalextractions.The mostcommonantibioticsprescribedwereamoxicillinand clindamycin.

Apost-extractioncomplicationoccurredinlessthan1%ofthe patients,with1%ofthesecomplicationsinpatientswhohad antibioticprophylaxisand0.8%inpatientswhohadnoprophylaxis.Diabeteswasasigni fi canteffectmodi fi eroftherelationshipbetweenantibioticprophylaxisandpost-extraction complication.

Inthe7daysafterextraction,just0.09%ofthepatientsreceived medicalcarerelatedtoapost-extractionoralcomplication.Antibioticprophylaxiswasn’tsigni ficantlyassociatedwithpostextractionmedicalcare.

CONCLUSIONS

Theuseofantibioticprophylaxisdidnotreducepostoperative infectionortheoccurrenceofdrysocketcomparedtonot receivinganantibioticprescription.Thepostoperativecomplicationratewaslessthan1%,soantibioticprophylaxisisunlikely toprovideabene fi tthatisgreaterthantheriskofadverse eventsassociatedwiththeuseoftheantibiotic.

ClinicalSignificance

Dentalprovidersshouldreviewtheirprotocolforusing antibioticprophylaxisafteradentalextraction.Itisrecommendedthatonlypatientswithacurrentsystemic infectionthatwillrespondtotheantibiotictreatment shouldbeprescribedthesedrugs.

McGregorJC,WilsonGM,GibsonG,etal:Theeffectofantibioticpremedicationonpostoperativecomplicationsfollowing dentalextractions. JPublicHealthDent 84:343-350,2024

Reprintsavailablefrom KJSuda,CtrforHealthEquityResearchand Promotion,VAPittsburghHealthCareSystem,3609ForbesAve, 2nd Flr,Pittsburgh,PA15213,USA;e-mail: ksuda@pitt.edu

AntibioticsUsedtoAvoidEarlyImplantFailure

BACKGROUND

Dentalimplantsareafrequentchoicetoreplacemissingteeth, usuallyasaresultofdentalcaries,periodontaldisease,ortrauma. Thisprocedureisgenerallysuccessful,butcomplicationscan occurearlyorlate.Iftheimplantislostinthe firstmonthsafter insertion,usuallyasaresultofosseointegration,thecauseisusuallybacterialcontaminationduringimplantsurgery,althoughfactorssuchassurgicaltechnique,implantcharacteristics,the surgeon ’sexperience,orahistoryofperiodontitisandsmoking cancontribute.Theriskofinfectionhasbeenaddressedbyprescribingantibioticsforpatientshavingimplantsurgery.However, noplacebo-controlled,randomizedclinicaltrial(RCT)hasshown thereisastatisticallysigni ficantrelationshipbetweenantibiotic prophylaxisandreducedratesofearlyimplantfailure.Even showingsucharelationshipdoesn’tmeanthatroutineantibiotic prophylaxisisclinicallyrelevant.Asystematicreviewandmetaanalysisweredonetoevaluatetheef ficacyofpreoperativeantibioticstopreventearlydentalimplantfailureandtodetermine thecertaintyoftheevidence.

METHODS

AsearchwasdoneinthePubMed(Medline),WebofScience,and CochraneLibrarytoidentifyRCTscomparingantibioticprophylaxiswithnoantibioticsorplaceboinpatientswhowereconsideredhealthyandhadreceiveddentalimplants.Twelvestudies wereselected,with7includedinthemeta-analysis.Theprimary outcomewastheeffi cacyofpreoperativeantibioticstoprevent earlydentalimplantfailure;thesecondaryoutcomewastodeterminethecertaintyoftheevidence.Thelatterwasevaluatedusing theGradingofRecommendations,Assessment,Development andEvaluations(GRADE)approach,ratingtheRCTsashigh, moderate,low,orverylowincertainty.

RESULTS

The7studiesincluded929patientswhoreceivedantibioticsand 930whoreceivedplacebos.Twentypatientsintheantibioticgroup and31intheplacebogroupdevelopedearlyimplantfailures.In4 RCTs,theimplantfailureratewaslowerinthegroupsgivenantibioticprophylaxis,in2RCTs,theimplantfailureratewaslowerin thegroupreceivingplacebos,andin1RCT,therateofimplantfailurewasthesameinbothgroups.Overall,theimplantfailurerates wereverylowandlessthan6.5%inallgroups.

TwoRCTsmeasuredpatient-reportedoutcomemeasures (PROMs)forpainand/orqualityoflife.Noneofthe7RCTs

reportedanystatisticaldifferencesinthegroupsforearlyimplant failureorpostoperativeinfection.

Themeta-analysisofthe7studiesshowednosignificantdifferencesbetweengroups.Theantibioticgroupsandplacebogroups didnotdiffersignificantlyinanysub-groupmeta-analyses.

Amoderatedegreeofcertaintysupportedthehypothesisthat theeffectofantibioticprophylaxisinpreventingimplantfailure wassmall.

CONCLUSIONS

TwooftheRCTsconcludedthatroutineuseofprophylacticantibioticsmaybeadvisable,buttheother5foundantibioticprophylaxismaynotbeneeded.Thenumberneededtotreat (NNT)topreventearlyimplantfailurein1patientwas143, forwhichthecon fidenceinterval(CI)wenttoin finity.The routineuseofantibioticprophylaxiswouldlikelymeanthata verylargenumberofpatientswouldreceiveantibiotics unnecessarily.

ClinicalSignificance

Whenthenumberofpatientswithimplantfailureand thehighnumberofNNTpatientstopreventimplant failurein1patientareconsidered,itseemsthatthe routineuseofantibioticprophylaxisforimplantsurgeryisinappropriate.Usingantibioticscarriesarisk ofsideeffectsandanincreasedriskofantibioticresistance.Theprovisionofantibioticprophylaxisforallpatientswhohaveimplantsurgeryisn’tsupportedby significantevidence.Itmaybetimetodevelopnew clinicalguidelinesforantibioticprophylaxisinimplant surgery.

MomandP,Naimi-AkbarA,HultinM,etal:Isroutineantibiotic prophylaxiswarrantedindentalimplantsurgerytopreventearly implantfailure? – Asystematicreview. BMCOralHealth 24:842, 2024

Reprintsavailablefrom PMomand,DeptofOrofacialMedicine, FacultyofOdontology,MalmoUniv,MalmoSE-20506,Sweden; e-mail: Palwasha.momand@mau.se

COGNITIONANDCHEWING

MasticatoryFunctionandCognitiveStatusinOlderAdults

BACKGROUND

Withtheagingofthepopulation,dementiaandcognitiveimpairment areseenmoreoften,especiallyamongolderindividuals.Inaddition, cognitiveimpairmenthasbeenlinkedtopoorqualityoflifeinolder persons.Variousriskfactorshavebeenproposed,withsomebeing modifiableandothersnot.Amongthepossiblymodifiablefactors arereducedmasticatoryfunction,toothloss,andchronicinflammationcausedbychronicperiodontitis.Poorcentralnervoussystem (CNS)functionandreducedmasticatoryfunctionhavebeenstudied, withsomeinvestigationsusingnumberofteethasasurrogate markerformasticatoryfunctionandothersusingocclusalbiteforce, color-changingchewinggum,andotherdirectmarkersofchewing ability.Asystematicreviewwasdonetodetermineifthereareassociationsbetweenobjectivelyandsubjectivelymeasuredmasticatory functionandcognitivestatusamongolderadults.

METHODS

AsearchwasdoneinthePubMed,WebofScience,andCumulativeIndextoNursingandAlliedHealthLiterature(CINAHL) databases.Twenty-onestudiesmetthecriteriaandweredivided into11cross-sectionalstudiesthatobjectivelyevaluatedmasticatoryfunction,9cross-sectionalstudiesthatsubjectivelyevaluatedmasticatoryfunction,and1prospectivecohortstudy.The studiesusedvariousmeansforevaluatingcognitivestatus, includingtheMini-MentalStateExamination(MMSE),theHasegawaDementiaScale-Revised(HDS-R),theFrontalAssessment Battery,theJapaneseversionoftheMontrealCognitiveAssessment(MoCA-J),andtheClinicalDementiaRating(CDR)scale.

RESULTS

ObjectiveEvaluationStudies

Amongtheobjectiveevaluationstudies,allofthecross-sectional studiesfoundpositiveassociationsbetweenmasticatoryfunction andcognitivestatusintheunivariateanalysis.Adjustmentsforconfoundingfactorscausedtheassociationstodisappearin2studies,1 studyfoundtheMMSEscorewaslowerinthegroupwithlow chewingabilityandmoderatechewingabilitywasariskfactorfor cognitiveimpairment,and4studiesshowedapositiveassociation betweenmasticatoryfunctionandcognitivestatus.

SubjectiveEvaluationStudies

Ninecross-sectionalstudiesperformedsubjectiveevaluations ofmasticatoryfunctionandcognitivestatusincommunitydwellingadults,with8doneinolderadultsand1inmiddle-

agedorolderadults.Self-reportsofchewingabilitywereused in7studies.Allreportedapositiveassociationbetweenmasticatoryfunctionandcognitivestatusintheunivariateanalysis, butonly6showedthepositiveassociationpersistedafteradjustingforriskfactors.

ProspectiveStudy

Astudyof860community-dwellingolderadultsrecordedthe maximalocclusalforceatbaseline.Thismeasurewasassociated withcognitivestatusatfollow-upafter3years.Alowercognitive statusmeasureatbaselinewasassociatedwithfewerteethand lowerocclusalforce,butthelowerscoredidn’tpredictchanges inthenumberofteethortheocclusalforceafter3years.The authorsspeculatedthatnumberofteethandocclusalforceofindividualsuptoage70to80yearsmayberelatedtocognitive status.

CONCLUSIONS

Severalstudiesindicatedthatmasticatoryfunctionwaspositively relatedtocognitivestatus.Thereviewwasunabletoconclude whetherornottheassociationwascausal.

ClinicalSignificance

Thecurrentstudiesdon’tconclusivelyindicate whethermasticatoryfunctionaffectscognitivestatus. Variousmeasureswereusedtodeterminecognitive function,andthecut-offlevelsfortheMMSEwere inconsistentamongthestudies,makingithardto drawaccurateconclusions.Futurestudiesshould includelongitudinalinvestigationsaswellasinterventionstudiestodetermineifacausalrelationshipispresent.

MaekawaK,MotohashiY,IgarashiK,etal:Associationsbetween measuredmasticatoryfunctionandcognitivestatus:Asystematic review. Gerodontology 41:452-463,2024

Reprintsavailablefrom KMaekawa,DeptofRemovableProsthodonticsandOcclusion,OsakaDentalUniv,1-5-17Chuo-ku, Otemae,Osaka,Japan;e-mail: maekawa-k@cc.osaka-dent.ac.jp

ToothLoss,CognitiveImpairment,andDementia

BACKGROUND

Thelossorreductionofmasticatorysensorystimulationand toothloss associatednutritionaldeficitsmaycontributetoa linkbetweentoothlossandcognitiveperformance.Ithasbeen suggestedthatposteriorteethand/orocclusalpairsmaybe importantbasedonthefactthattheyareessentialformastication.Lossofposteriorteethorocclusalpairscompromises masticationandcontributestonutritionaldeficits,andchronic nutritionde ficitsmaycontributetotheriskfordementia.Inaddition,masticationstimulatesvariousdementia-relatedbrainareas, andtheunilateralandbilateraluseofposteriordentitionmay stimulatebrainareasdifferently.Metabolicsyndromeand obesity,alongwithotherdementia-relatedriskfactors,maybe linkedtothelossofposteriorteethorocclusalpairs.Chewing dysfunctionhasbeenassociatedwiththemorphologicalandfunctionaldeteriorationofhippocampalneuronsanddeficitsin learningandmemory.Theimpactofvariousdental health relatedstructuraland/orfunctionalmarkerswasinvestigated,notingtheeffectscreatedbyanteriorversusposterior toothloss,posteriorocclusalpairloss,andchewingabilityon cognitionaswellasthe11-yearcognitivedeclineriskandthe 15-yeardementiarisk.

METHODS

Thedataweretakenfromthepopulation-basedFinnishHealth 2000(H2000)andHealth2011(H2011)Surveys.Thesample fromH2000comprised8028personsage30yearsorolder wholivedinFinland.Most(6360persons)alsoparticipatedin somepartofthefollow-upH2011survey.Theparticipants wereclassifiedintodentateoredentulousandtotalnumberof posteriorocclusalpairs(POP)present.Usingtheconceptofa shorteneddentalarch(SDA),POPlosswasclassifiedas>7teeth, 4-7,and<4remaining.Cognitiveassessmentevaluatedverbal fluency,immediaterecall,anddelayedrecall.Verbal fl uency wastestedbyhavingparticipantsnameasmanyanimalsas possiblein60sec.Theimmediaterecalltestconsistedofhaving participantsmemorizeandrepeat10wordsin90sec,whereas delayedrecallrequiredparticipantstorecallwordsfromthe wordlist5minutesaftertheimmediaterecalltest.Thedata fromthesetestswereevaluatedforassociationswithposterior occlusalsupport(POS)loss,anteriorversusposteriortooth loss,chewingabilitywithbaselinecognitionand11-yearcognitive decline,and15-yearincidentdementiarisk.

RESULTS

Participantswith4-7or<4POPwereolder,hadlowerlevelsof educationandincome,wereathighercardiovasculardisease (CVD)riskandhigherdepressivesymptomrisk,hadlower

overalltoothcount,haddifficultychewing,andhadahigherincidenceofdementia.

CognitiveEvaluations

Anteriorandposteriortoothlosswasnotrelatedtothe11-year cognitivedecline.However,having<4POPwasassociatedwitha declineinverbal fluency.UnilateralinadequatePOSwasrelated toadeclineinimmediaterecall,whereasbilateralinadequate POSwaslinkedtoaverbal fluencydecline.Chewingchallenges wererelatedtoimmediaterecalldecline.Sensitivityanalysis foundnoassociationsforanteriororposteriortoothloss,but asigni ficantassociationforchewingdif ficultywasnotedwith immediaterecalldecline.Having<4POPshowedatrendforverbal fluencydeclineandwaslinkedtolowerdelayedrecalldecline risk.UnilateralinadequatePOSwasassociatedwithimmediate anddelayedrecalldecline,whereasbilateralinadequatePOS wasrelatedtooverallcognitivedeclineandtendedtoberelated toverbal fluencydecline.

These fi ndingswerealsofoundamongparticipantsage55years orolder.Althoughanteriortoothlosswasn ’trelated,posterior toothlosswaslinkedtoadeclineinoverallcognition,immediate recall,anddelayedrecall.Having4-7POPwaslinkedtoimmediaterecalldecline,whereas<4POPwasrelatedtodeclinesin verbal fl uencyandimmediaterecalldecline.UnilateralinadequatePOSwasrelatedtooverallcognitivedecline,whereas bilateralinadequatePOSwasrelatedtoverbal fl uencydecline. Chewingdif fi cultywasassociatedwithadeclineinimmediate recall.

IncidentDementiaRisk

Atotalof136participantsdevelopeddementia.Neitheranterior toothlossnorchewingdif ficultywereassociatedwithdementia, butparticipantshaving<15posteriorteethhadsigni ficanthigher dementiarisk.Having4-7or<4POPsigni ficantlyincreasedthe riskfordementia.Inaddition,bilateralinadequatePOSwas relatedtodementia.

CONCLUSIONS

Thelossofposteriordentitiontendedtoaffectcognitiveoutcomes.The15-yeardementiariskinindividualswithposterior toothlossandPOPlosswashigher.Associationsbetweenposteriortoothlossandcognitivedeclineweresigni ficantforparticipantsoverage55years.POPlosssigni ficantlycontributedto cognitivedeclinerisk.Unilateralandbilateraluseofposterior dentitionmaystimulatedifferentbrainareas,sothereareunclear outcomesregardingtheeffectsizeoftheselosses.Chewingabilitydidn’taffectdementiarisk,butdidcontributetocognitive decline.

ClinicalSignificance

Bothposteriortoothlossandocclusalpairlossappear tosigni ficantlyinfluencetheriskofdementia.Preservingnaturaldentition,especiallywhenposteriorteeth areinvolved,shouldbeapriority.Morewelldesignedstudiesareneededtoinvestigatethepotentialtooth-relatedmechanismsthatmightberelatedto cognitivedeclineandmaybealteredbydentalinterventions.

AsherS,SuominenAL,StephenR,etal:Associationoftooth location,occlusalsupportandchewingabilitywithcognitive declineandincidentdementia. JClinPeriodontol 52:24-39,2025

Reprintsavailablefrom SAsher,InstofDentistry,UnivofEastern Finland,Yliopistonranta1C,POBox1627,Kuopio,Finland; e-mail: samash@uef. fi

HALITOSISANDGIDISORDERS

IdentifyingHalitosisRelatedtoGIDisorders

BACKGROUND

Halitosisaffects5%to65%oftheworld’spopulation,soit’soften seenindentalpracticepatients.Itmanifestsasunpleasantodors thatemanateconsistentlyfromtheoralcavityandcansignificantlyaffectone’squalityoflife.Patientswithhalitosiscanexperienceinsecurity,lowself-esteem,embarrassment,andpersonal discomfort,especiallyinsocialinteractions.Patientswithgastrointestinal(GI)disordersmayalsocomplainofhalitosis,butthe scienti ficliteraturerevealsthatjustasmallproportionofcases diagnosedashalitosisarerelatedtotheGItract.Conditions suchasgastritis,gastroesophagealrefluxdisease,xerostomia, andintestinaldiseasesarerelatedtohalitosis.Areviewofthe relationshipbetweenhalitosisandGIdisorderswaspresented.

METHODS

AsearchwasdoneinthePubMedandWebofSciencedatabases toidentifystudiesofpatientswithGIdisorderswhohavehalitosis.Thepublicationsofferedinformationabouttheclassi fication,etiology,anddiagnosisofhalitosis;associationsbetween halitosisandGIdisorders;andguidancefordentalprofessionals whoaredealingwithapatientwhohashalitosis.

RESULTS

ClassificationandEtiology

Halitosiscanbegenuinehalitosis,whichcanbesubdividedinto physiologicalorpathologicaltypes;pseudohalitosis;orhalitophobia.Physiologicalhalitosisisatransientbadorderpresentinthe oralcavityuponwakingandiscausedbynocturnalhyposalivation.Itdisappearsaftereating,brushingtheteeth,ordrinkingwater.Incontrast,pathologicalhalitosiscanbeintraoralor extraoralandiscausedbyconditionsassociatedwiththeoral cavityorwithsystemicconditionsthatoriginatefromnon-oral

areas.Pseudohalitosisreferstoapatientclaimingtohavebad breaththatcan’tbedetectedbyhealthcareprofessionals.Halitophobiaistheexcessivefearofhavinghalitosiswhenitdoesn’t existandoftenoccursaftertreatmentofgenuinehalitosis.

Inmostpatients,halitosisoriginatesintheoralcavityandinvolves microorganisms.Anaccumulationofbacteriawhereorganic compoundputrefactionoccursisthesourceofthehalitosis. Themetabolismoftheoralmicrobiotacancreatevolatilesulfur compounds(VSCs).Halitosiscanalsoresultfromdeepcarious lesions,infectionsintheoralcavity,peri-implantdisease,pericoronitis,mucosalulceration,impactedfood,andacoatedtongue.

Extraoralhalitosisisseeninabout10%to15%ofcasesandcan resultfromrespiratorydisorders,GIdisorders,systemicdisorders,neoplasms,andsomemedications.Itcanpresentasignificantdiagnosticandtherapeuticchallengetohealthcare professionals.Afterexcludingthepossibleoralandotorhinolaryngologicalcausesfortheodor,thehealthcareprofessional shouldfocusonpossibleGIdisordersasthecauseofthehalitosis.

Diagnosis

Thediagnosticapproachesincludetheorganolepticmethod,the sulfidemonitordevice,andgaschromatography. Organoleptic diagnosisinvolvesthepatientbreathingdeeplythroughthe nose,thenexpellingtheairthroughthemouthwhiletheexaminersmellstheodor.Thisisasubjectivemethodandisn’tprecise quantitativelybutisagoodqualitativemethod.The sulfidemonitor device ismoreobjectiveandcancorrelatethequantityofVSCin thebreathsamplewithspeci ficdisorders,qualityoflife,andmalodorintensity.Theportablemonitorcannotdistinguishbetween thetypesofsul fidesordetectotherVSCclasses. Gaschromatography differentiatesandidentifiesVSCsanddistinguishesthem

Figure3. InfographicoftheprevalenceofhalitosisforGERD,gastritiswith H.pylori infection,andIBD.(CourtesyofVianaKSS,EleuterioFHPF,MacielVG, etal:Associationbetweenhalitosisandgastrointestinaldisorders:Areview. JCalifDentAssoc 52:2426249,2024.)

fromothercompounds.Theequipmentisexpensiveandrequiresaproperlytrainedoperator,soit’snotavailableinmost dailyclinicalpractices.

Thepatientcanself-reporthalitosisorpeoplearoundthepatient maybeabletoreportthesituation.Self-reportstendtobequite accurateandcorrespondtothepresenceofhalitosisfoundusing theorganolepticmethodwhenthehalitosisismildtomoderate andstrong.

GIDisordersCausingHalitosis

TheGIconditionsassociatedwithhalitosisarestomachinfection by Helicobacterpyloris,gastroesophagealrefluxdisease(GERD), anddisorderscausinggastriccontentretention.Thelastinclude inflammatoryboweldiseases(IBDs),whichcanaffectthecolon andsmallintestine,withulcerativecolitisandCrohn’sdisease includedasextraoraldisordersassociatedwithhalitosis (Figure3).ThemostcommonGIsymptomsinthesedisorders areabdominalpain,reflux,nausea,andesophagealandduodenal alterations.Medicationsusedtotreatthesedisorderscanalsobe associatedwithhalitosis.

Thehalitosistreatmentforthesepatientsisfocusedontheunderlyingdisorder.Thedentistshouldconductameticulousintraoralandoropharyngealexaminationandperforman organolepticevaluationtocon firmthebadbreath.Iftheseinvestigationsindicatethehalitosishasanextraoralorigin,thepatient shouldbereferredtothemedicalspecialistwhocanaddressthe underlyingdisorder.

GastritisandHpyloriInfection

Gastritisisanin fl ammationofthegastricmucosathatusually resultsfrominfectionscausedby Hpylori .Thesebacteria colonizetheGImucosaandcontributesigni fi cantlyto gastritis,gastricandduodenalulcers,andgastriccarcinoma.

Morethanhalfoftheworld’spopulationcarries Hpylori infection,withtheoralcavitypossiblyservingasanextragastricreservoirfor Hpylori .

Symptomscanbesignificantlyreducedoreradicatedifthemicroorganismiseliminated.However,chlorhexidinemouthrinseis ineffectivewhenusedfor Hpylori halitosis.

GERD

InGERD,retrograde fl uxofthestomach ’scontenttothe esophaguscausesunpleasantsymptomsandcomplications. Thesesymptomscanproduceadverseeffectsonthepatient’ s well-being,includingheartburn,regurgitation,esophagitis,Barrett ’sesophagus,andesophagealadenocarcinoma.Extraesophagealmanifestationscanalsobefound.Halitosisisa notablemanifestationandresultsfromvarioussources,such asthefollowing:

Theodorfromthetongue’sposteriordorsumareacomes mainlyfrompostnasaldrippingaccumulatinginthatregion. Theacidcontentfromthestomachcanreachthenasopharynxandcauseirritationofitswalls,producingreferred postnasaldrippingandtonguecoatingandresultingin halitosis.

Thefunctionoftheesophagealsphincterisalteredinpatients withGERD,sothatintestinalandstomachgasesreturntothe esophagusandproducebadbreath.

Directdamagecanresultwhenpepticacidentersthesupraesophagealmucosa.

IBDs

IBDautoimmunedisordersmaycauseextra-intestinalproblems,evenreachingtotheoralcavity.Asigni fi cantassociation hasbeenfoundbetweenhalitosisandsevereulcerativecolitis, withanincreaseinthenumberofbacteriathatreducesul fi de

compoundsinthebowelcreatinghigherconcentrationsof hydrogensul fi de.

SomemedicationsusedforIBDmayhavesideeffectsontheoral cavity.Thisincludesreducingsalivary flowrate,whichleadsto hyposalivationandxerostomia.

CONCLUSIONS

Halitosiscanbecausedbyanumberofsystemicaswellasoral disorders.Oralhealthcareprofessionalsmayseepatientswith halitosiswhohavebeenreferredtothembecausethepatient’ s medicalprofessionalisunfamiliarwiththepossibleetiologyof theproblem.Afterhavingidenti fiedwhethertheproblemis oralorextraoral,thedentistshouldaddresstheproblemwith eitheroralhealthcaremeasuresorareferraltothepropermedicalprofessional.

ClinicalSignificance

Additionalresearchintothecausesandprocesses thatcanproducehalitosisisneeded.Studiesshould beundertakentoidentifytheexactmechanismsby whichVSCsareproducedinextraoralsitesandthen cometobeexpelledthroughtheoralcavity.Halitosis isjustasymptom,withvarioustestsrequiredtodeterminetheextraoralororalcauseoftheproblem.A multidisciplinaryapproachmayleadtobettermanagementofhalitosis.

VianaKSS,EleuterioFHPF,MacielVG,etal:Associationbetween halitosisandgastrointestinaldisorders:Areview. JCalifDentAssoc 52:2426249,2024

Reprintsavailablefrom KSSViana,DeptofDentalClinics,Oral SurgeryandOralPathology,SchoolofDentistry,Universidade FederaldeMinasGerais(UFMG),BeloHorizonte,Brazil; e-mail: karolinasilvaviana@gmail.com

ORAL/SYSTEMICCONNECTIONS

LinksBetweenFlossingandCardiovascularDiseaseRisk

BACKGROUND

Evidenceindicatesthatperiodontaldisease(PD)andcardiovasculardisease(CVD)areindependentlylinked.PDresultswhen pathogenicbacterialplaqueaccumulatesaroundtheteethand gingiva,causinganin fl ammatoryresponsethatcanprogressively damagethestructuressupportingtheteeth.PeoplewithPD haveaconsistentlyincreasingriskfordevelopingCVD,which causesathirdofalldeaths.Themechanismsthatmaycontribute tothislinkandcauseatherogenesisandthromboticevents includebacteremia,chronicin fl ammation,andendothelial dysfunctioncausedbythePD.ThetreatmentofPDcanlower theriskforCVDeventsandimprovethepatient’satheroscleroticpro fi leandvascularfunction.Conversely,thefailureto maintainoralhygieneislikelyaCVD-linkedriskfactor.Daily oralhygieneself-care(OHS)isanessentialpartoftheprimary preventionofPD.Researchershaven’talwaysfoundsuf fi cient supportfortheadjunctiveoralhealthbene fi tsof fl ossing comparedtotoothbrushingalone.However,homeinterdental cleaningdonecorrectlycanreducetheburdenoforaldiseases andimprovePDparameters.Withthisbackground, fl ossing mayimprovePDparametersandcouldofferaddedsystemic bene fi ts.Anationwidedatabasewasevaluatedtodetermine theimpactofself-reported fl ossingbehavioronCVDprevalenceandmortalityrisk.

METHODS

ThedataweretakenfromtheNationalHealthandNutritionExaminationSurvey(NHANES)2009-2010,2011-2012,20132014,and2015-2016.Asampleof18,801individuals(meanage about53years)wasaskedtoprovide flossingbehaviordata. Theparticipantsweredividedintogroupsasfollows:not flossing (0days/week[d/wk]),occasional flossing(1-3d/wk),frequent flossing(4-6d/wk),anddaily flossing(7d/wk).Theprimary outcomewasprevalenceofmajorCVDeventsandwasbased onaskingparticipantsiftheyeverreceivedadiagnosisofcongestiveheartfailure,coronaryheartdisease,angina,heartattack,or strokefromahealthcareprofessional.Mortalitywasmeasured basedonNationalCenterforHealthStatisticsandtheNational DeathIndexdata.PlasmaC-reactiveprotein(CRP)levelswere alsomeasuredin3ofthe5NHANEScomponents.Covariates includedage,sex,race,ethnicity,educationlevel,smokingstatus, alcoholconsumption,energyintake,HealthyEatingIndex(HEI) score,andphysicalactivityusingthemetabolicequivalentsof task,bodymassindexandincome-to-povertyratio.

RESULTS

Theprevalenceofthe fl ossingcategorieswasabout31%not fl ossing,25%occasional fl ossing,about12%frequent fl ossing,

andabout32%daily fl ossing.Signi fi cantdifferenceswerefound forthecovariatesbasedon fl ossingbehavior.Thosewhodidn’t fl ossdailywereyounger,moreoftenfemale,hadhighereducationandincomelevels,andweremorelikelytoengageinleisure timephysicalactivityandlesslikelytosmokeordrinkalcohol. Daily fl ossershadlowerenergyintakeandbetterHEIscores thannon fl ossers.

FlossingandCVDEventPrevalence

Flossingbehaviorwasdirectlyassociatedwiththeprevalenceof self-reportedCVDeventsevenafteradjustingforcovariates. Eachadditionaldayof flossingsignificantlyloweredthelikelihood ofbeingassociatedwithaCVDevent.

FlossingandAll-causeandCVDMortality

Aninverserelationshipwasfoundbetween flossingbehaviorand all-causemortality.Theinverserelationshipremainedsignificant evenwhenadjustmentsweremadeforHEIscoreandenergy intake,metabolicsyndrome,andCRP.

Afteradjustingforageandsex,thedaily flossinggrouphada52% decreasedriskofexperiencingCVD-linkedmortalitycompared tothenonflossinggroup.Evenwithadjustmentsforvariouscovariates,theinverseassociationbetween flossingbehaviorand CVDmortalityremainedsignificant.

FlossingandCRP

FlossinglessfrequentlywasaccompaniedbyhigherconcentrationsofCRPinthe2009-2010and2015-2016NHANEScycles.

Thisrelationshipremainedsignificantevenafteradjustingfor covariates.

CONCLUSIONS

Whenindividualshavepoor flossingbehavior,theyputthemselvesatriskforahigherprevalenceofCVDevents,ahigher riskfordyingfromaCVDcause,andhavingelevatedCRPlevels.

ClinicalSignificance

Dentalprofessionalsshouldencouragepatientsto flossdailyandinformthepatientsofthebene fitsofdoingthis.Inaddition,cardiologistsshouldadvisepatientstoimprovepersonaloralhygienepractices alongwithofferingthemguidancewithrespecttotheir dietandexerciseregimen.

PhilipN,TamimiF,Al-SheebaniA,etal:Theeffectofselfreported flossingbehavioroncardiovasculardiseaseeventsand mortality. JAmDentAssoc 156:17-27,2025

Reprintsavailablefrom NPhilip,CollegeofDentalMedicine,Qatar Univ,Office160C,BldgH12,Doha,Qatar;e-mail: nphilip@qu.edu.qa

PEDIATRICDENTISTRYANDSDF/ART

ComparingSDFandARTasTreatmentForEarly ChildhoodCaries

BACKGROUND

Earlychildhoodcaries(ECC)affectschildrenunderage6years andisdefinedasthechildhavingatleast1decayeddeciduous tooththatwaslostduetocariesorrestored.InBrazil,ECCaffectsabout54%ofpreschoolers,usuallythosefromlowincomefamiliesand/orthosewholiveinruralareaswithout goodaccesstodentalcare.BothtreatmentandpreventivemeasuresareneededwithECC.Follow-upvisitsallowdentiststo determinewhichmeasuresaremosteffectivetoavoidprogressionofthecaries.Twomeasuresthathavebeensuccessfulare atraumaticrestorativetreatment(ART)andsilverdiamine fluoride(SDF).WithART,decayedtissuesareselectivelyremoved usinghandinstrumentsandthecavityisrestoredwithhighviscosityglassionomercement(GIC).ARTcanbeperformed inareaslackingelectricityandrunningwaterandcausesless

discomfortcomparedtoconventionalcariestreatment.Asa result,it’iswellreceivedbychildren.SRTisalow-cost,easily appliedtopicalcariostaticagentthatarrestscarieslesionsinchildren.It’snoninvasive,doesn’trequiretheremovalofdecayedtissueorsealingofthecavity,andisconsideredsafe.Theprimary adverseeffectswithSDFarethestainingoftheskinandthecaries lesion,butparentsareoftensatis fiedwiththeappearanceoftheir child’stoothafterSDFapplication.Theoutcomesachievedbythe 2methodswerecomparedinpreschoolersinBrazil.

METHODS

The118preschoolers(age2to5years,meanage3.53years) wereevaluatedforgeneralhealthanddentalhistory,clinical andradiographicexaminationresults,andthedecayedormissing teethduetocariesor filledtoothindex(dmf-tindex).Theclinical

examinationnotedcariestissuetextureashardorsoft,andthe cariesactivitywasclassifiedasactiveorinactive.Parentsprovidedsocioeconomicandsociodemographicdata,dietaryinformation,informationaboutnonnutritivesuckinghabits,oral hygienebehaviors,and fluorideexposure.Recallexaminations weredoneafter6,12,18,and24months,notinghowmanyarrestedcarieslesionswereintheSDF(test)groupcomparedto theART(control)group.Secondaryconcernsincludedtime foreachtypeoftreatmenttobeperformed,possibleadverseeffects,parentalaestheticperception,childanxietybeforeandafter treatment,andbehaviorofthechildduringtreatment.

RESULTS

PrimaryOutcome

Ninety-eightchildrencompleted12monthsoffollow-upand46 completedupto24months.At6months,therateofarrestedcaries lesionswas84%intheSDFgroupand92.9%intheARTgroup.After 12months,thevalueswere91.5%fortheSDFgroupand90.2%for theARTgroup.Atthe18-monthfollow-up,theSDFgrouphada rateof72%andtheARTgrouphadarateof90.9%.At24months, theratewas72%fortheSDFgroupand95.2%fortheARTgroup.

Consideringtheteeththatwereratedasunsuccessfulbecauseactive carieswaspresent,5hadspontaneouspain(3intheSDFgroupand2 intheARTgroup)and2had fistulas(1ineachgroup).IntheART group,8childrenhadtherestorationcompletelyorpartiallyrebuilt after6months,7wereredoneafter12months,and1eachneeded repairatthe18-monthand24-monthfollow-upvisits.

SecondaryOutcomes

Treatmenttimeaveraged6.08minutesintheSDFgroup,witha medianof6.00minutesintheARTgroup.TheARTgrouphada significantlylongermeantreatmenttimethantheSDFgroup.

Twenty-sixadverseeventsoccurred,with12intheARTgroupand 14intheSDFgroup.TheARTgroupreportedpainorsensitivityin theteethmostoften,withtheSDFgroupreportingspotsorpigmentationoftheskinormouthinmost cases.Sevenofthepreschoolers

hadadverseeffectsineachgroupaccordingtotheparents.TheSDF groupcomplaintsincluded2regardingtheappearanceoftheteeth.

Anxietywasevaluatedbutdidnotdifferbetweenthe2groups. Patientbehaviorwasalsosimilarinthe2groups.Positive behaviorwasobservedin45childrenintheSDFgroupandin 40childrenintheARTgroup.

CONCLUSIONS

TheabilityoftheARTandSDFtreatmentstoarrestdentincaries inprimarymolars,theanxietyofthechildren,theadverseeffects, theaestheticperceptions,andthepatients’ behaviorduringtreatmentdidn’tdiffersigni ficantlybetweenthe2groups.SDFwas appliedmorequicklysothepatienthadminimalchairtime comparedtoARTtreatment.

ClinicalSignificance

SDFwasfasterandlessinvasivethanARTintreating carieslesions.Thismightmakeitabetterchoicefor youngerchildren.TheaestheticsofSDFapplications wasaconcernforsomeparents.ARTwasaseffective asSDF,althoughitrequiredmoretimetoperformthe proceduresandwasmoreinvasive.

RodriguesGF,VolluAL,VargasTR,etal:Efficacyof30%silver diamine fluoridecomparedtoatraumaticrestorativetreatment inarrestingdentincarieslesionsinpreschoolers:Arandomized clinicaltrial. ClinOralInvest 29:3,2025

Reprintsavailablefrom AFonseca-Gonçalves,DeptdeOdontopediatriaeOrtodontia,FaculdadedeOdontologia,UFRJ,R.Prof. RodolphoPauloRocco,325,21941-617RiodeJaneiro,RJ,Brazil; e-mail: afgoncalves16@yahoo.com

PROBIOTICSANDPERIODONTITIS

CombiningProbioticswithPlaqueRemoval

BACKGROUND

Periodontitisaffectsabouthalfoftheglobalpopulation,makingit theseventhmostprevalentdiseaseworldwide.Thisdiseaseprogressesthroughthepresenceofdysbioticbio film,sotheprimary treatmentgoalistoreduceharmfulmicroorganismsandrestore ahealthy floraaroundteeth,whichcreatesabiologicallycompatiblerootsurfaceforreattachment.Theuseofprofessional

mechanicalplaqueremoval(PMPR)canachievethat,buteffectivenessvarieswithfactorssuchasthepresenceofdeepprobing depthsandhard-to-reachareas.Toaddressthissituation,it’ s beenproposedthatprobioticsbecombinedwithotheradjuvants tosubgingivalinstrumentation.Antibioticsareoverusedandhave contributedtothedevelopmentofresistantbacteria.Understandingthemechanismofactionofprobioticsastheymodify

themicro floraofperiodontalpatientsisanessentialelementin craftingeffectivetreatments.Probioticscompetewithperiodontalpathogens,reducetheimmunogenicityofthemicro flora, modulateimmunologicalandin flammatorypathways,andreduce inflammation.Theresultisimmunologicalhomeostasisandthe preventionofplaqueformationbyloweringsalivarypHandinhibitingthegrowthofbacteria.Aliteraturereviewidentifiedarticlesdealingwithadultperiodontitispatientsingoodgeneral healthwhoweretreatedwithPMPRandvariousprobiotics versusPMPRalone.Thegoalwastodeterminetheeffectiveness ofthevariousapproachesintermsofprobingpocketdepth (PPD)reduction,clinicalattachmentlevel(CAL)gain,and bleedingonprobing(BOP)reduction.

METHODS

ThesearchwasdoneintheMEDLINE(viaPubMed),LILACS,CochraneCentralRegistryofControlledTrials(CENTRAL),GoogleScholar, ClinicalTrials.gov,andDANSEASYArchive databases.Thirty-threearticlescovering1290patientswere identi fied.Follow-upperiod(shortorlong)wasdonetostratify the findings,andsensitivityanalyseswereconductedbasedon probiotictherapyduration.Theprobioticsincluded Bifidobacterium,Bacillus,Lactobacillus,Streptococcus, and Saccharomyces alone orincombination.Theprimaryclinicalparametersassessed wereprobingpocketdepth(PPD),clinicalattachmentlevel (CAL),andbleedingonprobing(BOP).ThesecondaryparametersweremeanchangesinBOP,plaqueindex,andcolonyformingunits(CFUs).Networkmeta-analyseswerealsodone.

RESULTS

PPD

Inshort-termstudies,8probioticinterventionscombinedwith scalingandrootplaning(SRP)hadsignificantlygreaterreductions inPPDthanSRP+placebo(Splac).Themeandifference(MD) wasfrom0.18mmwithSRP+ BifidobacteriumlactisDN to 1.48mmwithSRP+ Lactobacillusreuteri. Inlong-termstudies, SRP+ LreuteriDA signi ficantlyreducedPPDwithanMDof 0.80comparedtoSplac.

CAL

Inshort-termstudies,16probioticinterventionscombinedwith SRPproducedsigni ficantlymoreCALgainthanSplac.TheMD wasfrom0.16mmwithSRP+ BlactisDN to1.05mmwith SRP+ Lacidophilus,Lrhamnosus,Blongum ,and Saccharomycesboulardii.Inlong-termstudies,2probioticinterventionscombined withSRPproducedsigni ficantlymoreCALgainthanSplac.The MDwasfrom0.32mmwithSRP+ Lreuterisingle to0.43mm withSRP+ Lreuteriincremental

BOP

Inshort-termstudies,4probioticcombinationswithSRPhada significantreductionofBOPcomparedtoSplac.TheMDwas

from13.26%withSRP+ LreuteriD to33%withSRP+ Lreuteri AA.Inlong-termstudies,4probioticcombinationswithSRP significantlyreducedBOPmorethanSplac.TheMDwasfrom 5.02%withSRP+ Streptococcusoralis,uberis, and rattus to 23.31%for Slreutincrem.

Heterogeneity

Studiesthatlastedamonthorlessdemonstratedheterogeneity oftheanalysisthatdecreasedfromconsiderabletonotimportant.Forthoselastingmorethan1month,theheterogeneityremainedgreaterthan70%.Noclinicallyrelevantchangeswere observed.Short-termstudiesofBOPretainedconsiderableheterogeneityatmorethan70%.Noclinicallyrelevantchangeswere noted.

Rankings

ThebestprobioticregimenforPPDandBOPreductionandCAL gainis Lactobacillusreuteri. Whenthisprobioticwasusedin conjunctionwithSRP,itwasthemosteffectivewhetherthestudy wasashort-termorlong-termevaluation.Combining Lactobacillus with Bifidobacterium and Sacharomyces mayhaveabetter impactonCALgaininstudiesthathaveafollow-upofatleast 3months.

CONCLUSIONS

Thedurationoftheprobiotictherapydirectlyaffectedthesuccess oftheintervention.AlthoughmostprobioticscombinedwithSRP couldimprovePPDandCALoverSplac,thecertaintylevelswere verylow.Inaddition,nearlyallthestudiesshowedthatgroups withsubgingivalinstrumentationreceivingprobiotictherapyhad moreCFUreductionsthanthoseintheplacebogroup.

ClinicalSignificance

Probioticscombinedwithprofessionalmechanical plaqueremovalmayhavearoleinimprovingtheclinicalparametersusedtoevaluatetheresultsofperiodontaltherapy.Integratingprobioticsinto periodontaltreatmentprotocolscouldcontributeto avoidingadverseeffectsandnotexacerbatingthe problemofantibiotic-resistantbacteria.

DuartedeMendonçaC,PereiradaMataADS,AzevedoLFR, etal:Probioticsinthenon-surgicaltreatmentofperiodontitis: Asystematicreviewandnetworkmeta-analysis. BMCOralHealth 24:1224,2024

Reprintsavailablefrom DNdaSilvaMarques;e-mail: duarte.marques@campus.ul.pt

SELECTIVECARIESREMOVAL

Longer-termEvaluationofSelectiveCariesRemovaland CalciumHydroxide

BACKGROUND

Techniqueshavebeendevelopedthatcanpreventunintended pulpexposure,makingthetotalremovalofdeepcarieslesions, alsocalledselectiveremovalto firmdentin(SRFD),aless preferredprocedure.Astep-wisecariesremovaltechnique (SW)wasintroducedthatincludesabreakbetweenthe2steps andaimstostimulatereactionsfromthepulp-dentincomplex. Becauseofshortcomingswiththistechnique,selectiveremoval ofsoftdentin(SRSD)wasdeveloped,whichinvolvesselectively removingthecarieswithinasinglesession.Thistechniquehas beenrecommendedforthetreatmentofdeepcarieslesionsextendingthree-fourthsofthewayintodentin.Fewstudieshave evaluatedthelong-termclinicaloutcomeofSRSDinpermanent

teeth.ThevitalityofteethtreatedwithSRSDorSRFDand whetherbaselinevariablesorcalciumhydroxide(CS)application affectsoutcomeswereevaluated.

METHODS

The165teethin134patients(age13to44years,77femaleand 57male)weredividedintoanSRSD(test)groupandaSRFD (control)group.TheSRSDgroupwasdividedintoasubgroup ofSRSDwithCS(45teeth)andSRSDwithoutCS(45teeth). Teeththathadpulpexposure(PE)duringcariesremovalwereassignedtothePEgroup(29teeth).Thevitalityoftheteethwas testedthroughclinicalandradiographicexaminationafter5

Figure4. Radiographyoftooth#25treatedwithSRSDwithCSat(A)baseline;(B)immediatelyaftertreatment;(C)at5-yearfollow-upwithdentinbridge formation,photographyofrestoration;(D)atbaseline;and(E)5-yearfollow-upwithacceptableFDIscores.(CourtesyofGozetici-C Ë ilB,C Ë etinT,BittarA, etal:Clinicaloutcomesofselectiveremovaltosoftdentinversus firmdentinfordeepcarieslesions:Arandomizedcontrolledtrialupto5years. ClinOral Invest 29:23,2025.)

years,whentherewere31teethintheSRSDwithCSgroup,34 teethintheSRSDwithoutCSgroup,33teethintheSRFDgroup, and22teethinthePEgroup.Restorationswereevaluatedfor integrityandqualityusingtheFDIWorldDentalFederation criteria.TheeffectofbaselinevariablesandCSapplicationon treatmentoutcomewasevaluated.

RESULTS

Inthe5-yearanalysis,thesuccessrateofSRSDwithCSwas100% andtherateforSRSDwithoutCSwasabout94%,bothofwhich weresignificantlyhigherthantheSRFDrateofalmost76%and thePErateofnearly82%.Amultivariateanalysisshowedhigher successratesforteethwithSRSDwithorwithoutCScompared toteethmanagedwithSRFD.

Thesuccessratesrelatedtobaselinevariablesweresignificantly higherforpremolarsthanmolars,forlesionsextending three-fourthsofradiographicdepthcomparedtothosemore thanthisfar,andforteethwithoutpreoperativesensitivity comparedtoteethwithmoderateorseverehypersensitivity. Similarresultswerenotedfortheimpactoftoothtypeon treatmentoutcome.Noneoftheotherbaselinevariableshada significanteffectonoutcomes.

Whensurvivedrestorationswereconsidered,dentinbridge formationwasmostlikelyinthePEandSRSDwithCSgroups (Figure4).Cavitytypeanddepthinfluenceddentinbridge

formation,withCSapplicationafterSRSDindeepercavities leadingtothisimprovedhealing.

CONCLUSIONS

ThesuccessrateofSRSDwasgreaterthanthatofSRFD.Toothtype affectedoverallsuccessandCSapplication,cavitytype,andradiographicdepthinfluencedtheformationofadentinbridge.

ClinicalSignificance

TheuseofSRSDwithorwithoutCSmayofferagood approachtomanagingdeepcarieslesions.CSoffers anantimicrobialeffectthatmightstimulatereactive andreparativedentinogenesis.

Gozetici-ÇilB,ÇetinT,BittarA,etal:Clinicaloutcomesofselectiveremovaltosoftdentinversus firmdentinfordeepcarieslesions:Arandomizedcontrolledtrialupto5years. ClinOralInvest 29:23,2025

Reprintsavailablefrom BGozetici-Çil,DeptofRestorative Dentistry,SchoolofDentistry,IstanbulMedipolUniv,Birlik Mah.BahçelerCad.No.5,Esenler,Istanbul34250,Turkey; e-mail: bgozetici@medipol.edu.tr

EXTRACTS LIVINGLONGERANDBETTER

Nofountainofyouthhasbeenfoundyet,butresearchshowsthatgeneticsarejustonepartofourlengthandqualityoflife.Instead, lifestylechoicesplayasubstantialroleinhowwecanlivelong,healthylives.Dietandexercise thingsthatwecancontrol havea significantinfluenceonourlongevity.AmandaBoyce,HealthScientistAdministratorattheNationalInstituteonAging,explained, “Thequestionwereallyshouldbeaskingandfocusingoniswhatishealthyagingandhealthspan,notlifespan.” Currentscienti fi c evidenceindicatesthebest,mostactionablerecommendationsforlivinglongerandaginggracefullyinvolvediet,weightloss, limitingsitting,increasingexercise,andnotsmoking.

DIET

TryaMediterraneanorJapanesedietbecauseresearchconsistentlyassociatesthemwithimprovedlongevityanddiseaseprevention.Bothemphasize fishasasourceofproteinaswellasrichinbrain-boostingandheart-healthyfats;wholevegetables,whether freshorfermented;andfewheavilyprocessedfoodsorsugars.KristinKirkpatrick,anutritionistattheClevelandClinic,advises, “Focusononecomponentatatimeandmakesureit’ssomethingthat fitswithinyourpersonal,religious,and/orculturalpreferences.Forexample,ifyouenjoylentils,usetheminsteadofwhitericeinveggiebowls.Butifyoudislike fish,thenfocusonother sourcesofprotein.”

WEIGHTLOSS

Obesityislinkedtocardiovasculardisease,diabetes,otherchronicillnesses,andashorterlifespan.Sheddingafewexcesspounds canhaveahighlybene ficialeffectonlongevityandoverallhealth.Learnabouttheidealbodyweightforyourage,sex,andheight.A lossofjust5%ofyourbodyweightcansigni ficantlyimpacteverythingfrombloodsugartobloodpressure.FrankB.Hu,Professor ofNutritionatHarvardT.H.ChanSchoolofPublicHealth,says, “Clinicaltrialshaveshownthatweightlossachievedthrough lifestylechanges,medicationssuchasGLP-1agonists,orweightlosssurgeriesisassociatedwithareducedriskofchronicdiseases, includingdiabetes,cardiovasculardisease(CVD),andcertaincancers,andprematuredeath.”

LIMITINGSITTING

Todayweallowmoresedentaryhabitsinourlives,butscienceisshowingthenegativeeffectsofsitting.Husays, “Sedentary behavior,suchasprolongedTVwatching,hasbeenassociatedwithanincreasedriskofchronicdiseases,includingdiabetes, cardiovasculardisease(CVD),andprematuredeath.Thisheightenedriskisprimarilyattributedtoincreasedobesityandthe displacementofphysicalactivity.” Evenifyouexerciseregularly,sedentarybehaviorcarriesserioushealthrisks.Increaseyour physicalactivitythroughouttheday,evenifit’sjustwalkingaroundyourhouseorof ficeandevenifyoualreadyexerciseregularly.

EXERCISE,EXERCISE,EXERCISE

Thebene fitsofregularexercisedon’tjustfocusonyourbodybutalsoonbrainhealthandcognition.Amongolderadults,cardiorespiratory fitnessisanexcellentindicatorofbrainhealth,includingmemory.Findwaystoincreasephysicalactivity,cutdownon sedentarytime,andenjoythehabitsoit’ssustainable.Adultsshouldgetaminimumof150minutesaweekofmoderate-intensity physicalactivity.Establishinghabitsthatsimultaneouslyreducesedentarybehaviorsandincreaseactivityisperfect.Boyceadds, “Youcanalsobuildphysicalactivityintoyoureverydaylife.Forinstance,getoffthetrainonestopearlyandwalkorbundle behaviorslikeonlywatchingTVwhileyou’reexercising.”

STOPSMOKING

Thesciencestillsaysifyoustopsmokingyouwilllivelonger.AstudyledbyHushowedthat “ never ” smokingisakeyfactorfor prolonginglifeexpectancy.Othersaremaintainingahealthyweight,engaginginregularphysicalactivity,eatingahealthydiet,and onlyconsumingalcoholinmoderation.Smokingcessationlowersyourriskofeverythingfromcancerandheartdiseaseto diabetesandchronicobstructivepulmonarydisease(COPD)andcanaddupto10yearstolifeexpectancy.

TOPRECOMMENDATIONS

Theexpertsgavethefollowingrecommendationsforlongevity:

Maintainahealthybodyweightthroughdietandexercise. Whateveryou’redoingforphysicalactivity,add30moreminutestoit. Moveyourbody.

Thinkholisticallyaboutthingsotherthaneating includingexerciseandsleep. Matchyourdietarypatterntoyour “why.” Ifyourwayisnotwantingtosufferdementialikeyourmother,payattentiontorelevantsupplements,adequateexercise,andanutrient-speci ficpatterncoupledwithstressmanagementandpropersleep. Don’tlookforaquick fixbutadopthealthylifestylehabitsifyouwantalongerlife.

[MammoserG:5Science-BackedWaystoLiveaLongerLife. Healthline.com, Jan2,2025]

DISTRACTEDVERSUSMINDFULEATING

Whenweareworking,playingwithoursmartphones,orgoingsomewhere,about70%to75%ofusarealsoeating.Being flexible withwhereweeatandhavingdistractionsatthesametimeaseatingcanseemlikemultitaskingandagoodthing.Studiesshowthe opposite:whenwe’redistractedwetendtoeatmore,weofteneatagainsooner,andasaresult,wegainweight.Distractionsalso preventusfromactuallytastingorenjoyingwhatwe’reeatingandwemissthesignalsinourbrainthattelluswe’vehadenough. Whenweeat,ourgutsreleasesatietyhormones,includingleptin,ghrelin,andGLP-1.Thesesignalourbrainsthatwe’regetting full,whichtakesabout20minutes.Distractionsaddcognitiveloadstoourbrainsthatcompetewithandreduceourabilitytosense howmuchwe’veeaten,howfullweare,andhowthefoodtasted.A2013studyledbyLottevanDillen,professorofsocial psychologyatLeidenUniversity,had42subjectssweetentheirownlemonadewithgrenadine.Someweredistractedbyan easycognitivetest,andothershadaharderone.Thosecalledontodothehardertaskadded50%moresugarysyruptotheir drinksbutdidn’treportthedrinkassweeterthanthosedoingtheeasiertask.

Adistractedbrainhaslessactivityintheinsula,wheretasteisprocessed,andtheprefrontalcortex,whichcarriesouthigher-level cognitiveprocesses.Theconnectivitybetweentheinsula,prefrontalcortex,andnucleusaccumbens,whererewardisprocessed, isdisrupted.Thesedistractionsblunttastessuchashigh-fat,bitter,sour,salty,andumamianddullourabilitytosmellfood.Allof thesesensesarepartoftheenjoymentoffood,soweenjoyitlessandtendtomakeupforourlackofenjoymentbyoverindulging, calledhedoniccompensation.

Eatingslowerandmoremindfullygivesusmoretimetosensesatietysignals,tastethefood,andreduceconsumption.Chewing morecanalsodecreasehowmuchfoodpeopleconsumeandhowhungrytheyreportfeeling.Eatingmindfullyincludesdecreasing distractions,planningmeals,andtryingsensoryeating.Manydistractionswouldberemovedifweputourmobiledevicesawayor switchedthemoff.Thiscanbeimpractical,unrealistic,andcertainlynotfun.KatyTapper,professorofpsychologyatCity UniversityofLondon,said, “Everyonehastoeat,anditissomethingthatbringsusalotofpleasureandisboundupinallsorts oftraditionsandoursociallives.” Shecautionsthatallthoseaspectsneedtobebalancedwithhealthyeating.Shefoundthat socializingwhileeatingisn’tassociatedwithahigherbodymassindexandspeculatedthatconversationtypicallyisn’tdonewhile we ’retalkingandpeopletendtoeatslowerinsocialsettings,makingthemmorelikelytosensethesignalsforfullness.

Mealplanningcaninvolvesettinghoursforeatinganddrinking.Duringthesetimes,thefocusshouldbeonthejoyfulnessofthe experience.Insensoryeating,younoticethetaste,smell,look,andfeelofthefood.Beingmoreawareofthesesensoryproperties canreducehowmuchyoueatandincreaseyourenjoyment.Easingintosensoryeatingmightbehelpedbypretendingtobeafood criticandimagininghowyouwoulddescribethefood.

Mindfuleatingincludespayingattentiontointernalfeelingsofhungerandfullness,noticingwhatpromptsyoutoeat,andtakinga nonjudgmentalviewoffood-relatedthoughts.Moreresearchisneededtoinvestigateallthatmakesupmindfuleatingandhow effectivethecomponentsareinachievinghealthyhabits.Evenifyouareeatingdistracted,youcanperiodicallybringyourattention backtothefoodyou’reeating.

[SimaR:DistractedEatingCanMakeUsGainWeight.MindfulEatingCanHelp. TheWashingtonPost, Jan9,2025]

From the Desk of the Executive Director

Greetings from the International Headquarters!

Spring has officially started here in and around the Washington, DC area, and this past week was the peak time for our cherry tree blossoms around the tidal basin. As many of you may know, this area is renowned for its many cherry trees which are a reminder of the renewal of spring and the spirit of international friendship since the trees were a gift from Japan.

The Pierre Fauchard Academy is off to a quick start this year. We have already conducted several induction meetings in the US, including in Arkansas, Hawaii, Illinois, Kansas, Louisiana, Massachusetts, Oklahoma, Pennsylvania, and Utah, as well as a joint induction meeting in Georgia for new Fellows from Alabama, Florida, and Georgia. Internationally, new induction programs were held in The Netherlands and Poland. We welcome all our new PFA Fellows!

By now, all PFA Fellows should have received an email from Elsevier (the publisher of Dental Abstracts and Dental World). This email, sent in mid-March, gave detailed instructions on how to log in to access your online subscription to Dental Abstracts / Dental World – a key part of your member benefit when you maintain your status as a current Fellow.

I am also happy to report that, thanks to the hard work of our Continuing Education Committee, we received acceptance as a Program Approval for Continuing Education (PACE) provider from the Academy of General Dentistry. Starting soon, all CE programs will adhere to the PACE requirements and CE credits will be available from PFA as an Approved PACE Program Provider.

The PFA Board of Trustees recently concluded its interim Board Meeting here in the Rockville, MD office. The Board spent a full day on strategic planning and a second day on the work of the PFA. The good news is that we are in excellent financial shape, and the addition of over seven hundred new Fellows in 2024 helped us reach our goal. The second big piece of news from the Board Meeting was a PFA Bylaw change agreed to by the PFA Board. This change entails the removal of the position of PFA Past President from the PFA Officers and Trustees, which will save our organization travel dollars. PFA Past Presidents had no official duties while serving as a member of the Officers and Trustees and going forward will officially become President of the PFA Leadership Foundation at the conclusion of their term as PFA International President.

The other item to report following our Board Meeting is the work of an ad hoc Committee that has been studying the current structure of PFA Regions and Sections and has also conducted an analysis of Section Dues. The Committee reported excellent progress to date, while much work remains. The only significant change to date is that PFA Trustees will now be able to re-organize Sections within their Region to maximize support.

I would also like to reemphasize that leaders listen to those around them, and that we look to you as leaders in dentistry for your guidance and support. As a leader it is, of course, always important to recognize that you may be in a position of leadership and to consider whether you are actually leading. Are you a leader of courage, or a leader of comfort? As John Maxwell once said, “He that thinketh he leadeth, and hath no one following, is only taking a walk.” PFA Fellows around the world are leading their communities to better oral health. As an organization, the PFA could ask for nothing better.

Please also remember to nominate your colleagues for Fellowship in our outstanding organization; the nomination form on the website is simple to complete.

Last but certainly not least, I look forward to seeing many of you at our Annual PFA Gala on October 25, 2025, in Washington, DC!

Sincerely,

—Mr robert Cattoi, Executive

Director

of the Pierre Fauchard Academy

Mr. Robert Cattoi

Subscription Information:

The Pierre Fauchard Academy publishes the Dental World as a service to its Fellows and it is distributed as part of the Dental Abstracts Journal.

Please send change of address information or subscription inquiries to the Central Office of the Pierre Fauchard Academy at:

Pierre Fauchard Academy 103 North Adams Street, Rockville, MD 20850.

E-mail: centraloffice@fauchard.org Phone: +1 (240) 658-8070

Submissions:

Please send to the Dental World Office for possible publication any editorials, or articles and photos about PFA Section activities, or Foundation grants and scholarship activities. Please contact the Dental World Editor for more information.

Dental World Office: Email: drfionacollins@gmail.com

Dental Abstracts Senior Publisher: Annie Zhao, Elsevier

Dental Abstracts Editor-In-Chief: Dr. Douglas B. Berkey

Dental Abstracts Journal Manager: Sangamithrai S, Elsevier

Dental World Editor: Dr. Fiona M. Collins

From the Desk of the international President

Greetings to all Fellows.

The future of the Pierre Fauchard Academy looks bright, and we are in the process of growing at a record-breaking pace. We all play a part in this expansion, including our Trustees and Section Chairs who work tirelessly throughout the world. Our Leadership Foundation is also expanding and as it grows and funding increases, the Foundation will be able to offer more philanthropic scholarships, volunteer assistance, and continuing education.

Since humbly assuming my role as our International President, I have been reminded of the esteem in which the PFA is held internationally. Our Sections

look to our Trustees and Section Chairs to guide them and encourage participation, while we must all adhere to our bylaws. At times this can be challenging due to both the global nature of PFA and geographical distances from our international headquarters.

To date, I have met with Sections in several locations and regions while serving as our International President. In November 2024, I was welcomed in India to participate in three PFA induction ceremonies. A graduation was also scheduled for Sri Lanka in April. The first induction ceremony took place in Bengaluru (Bangalore) India, an area that is part of our Asia-at-large section and that is staying active in the PFA.

PIERRE FAUCHARD ACADEMY www.fauchard.org

Dr. Cheryl Bradford Billingsley

New Fellows inducted in Bengaluru (Bangalore), India together with Dr. Cheryl Billingsley (International President), Dr. Nagesh, Dr. Prasad and other dignitaries from the Bengaluru Section.

New Fellows inducted in Delhi, India into the in the Asia-at-large Section, together with Dr. Cheryl Billingsley, Dr. Anmol Bagaria (Chair), Dr. Ashish Pandey (Co-chair) and other dignitaries.

Eighteen new Fellows were installed, and introduced themselves with a short bio – this proved to be a very meaningful way to enhance graduation. Thank you to Dr. Nagesh and Dr. Prasad who together planned this lovely and intimate event.

The second induction ceremony in the Asia-at-large Section was conducted in Delhi, India. While in Delhi, over one hundred dentists were installed as Fellows in a beautiful event that was sponsored by the company Cynodent. All details were meticulously arranged, and excellent continuing education courses were offered. This area is led by Dr. Anmol Bagaria (Chair) and Dr. Ashish Pandey (Co-chair), a dynamic duo that is inducting a large number of new Fellows in this area and beyond.

The third induction ceremony in India was held in Indore, India which is part of the oldest Section of the India Pierre Fauchard Academy. During this beautiful event more than one hundred new Fellows were inducted, and excellent continuing education courses were provided. A sincere thank you to Dr.

Maya Ramesh, Dr. Garg (Secretary), and Dr. Chugh (Vice Chair) for executing a well-orchestrated ceremony.

As Mother Theresa once stated, “I can do great things you cannot, you can do great things I cannot. Together we can do great things.”

From the Desk of the International President-elect

A Vision for the Future: The Next Chapter for PFA Fellows

Dear Esteemed Fellows, The Pierre Fauchard Academy has long stood as a beacon of leadership, ethics, and professional growth in the dental community. However, with the evolving landscape of dentistry and as we continue to uphold the legacy of excellence in dentistry, it is essential that we look ahead, adapt, innovate, and strengthen our mission.

Our collective responsibility as Fellows is not only to preserve the values

that define our organization; it is also our responsibility to actively contribute to its growth. One of our primary goals is to expand Fellowship engagement by strengthening the bonds between members through collaborative initiatives, leadership programs, and global networking opportunities. By fostering a stronger sense of community, we can ensure that the PFA remains a vital platform for professional connection and advancement.

Another key focus is mentorship and professional development. As leaders in the field, we have an opportunity to guide young and emerging dentists, providing them with the wisdom

Our cherished PFA will succeed and grow in the coming years, and we will all assist in this worthwhile endeavor.

Sincerely,

—Dr. Cheryl braDforD billingsley, International President of the Pierre Fauchard Academy

and support that will help them excel in their careers. Additionally, innovative education is critical in staying at the forefront of the profession. By expanding our mentorship programs and increasing access to continuing education and skill-building resources, we can help shape the next generation of dental professionals while upholding the high standards of practice that define our Academy.

Our commitment to community outreach and service remains at the heart of our mission. Many PFA Fellows are already engaged in humanitarian efforts, serving underserved populations and promoting oral health initiatives worldwide.

Dr. Ghabi Kaspo

New Fellows inducted in Indore, India, together with Dr. Cheryl Billingsley, Dr. Maya Ramesh, Dr. Garg (Secretary), and Dr. Chugh (Vice Chair) for this Section.

Moving forward, we aim to increase our collective impact, ensuring that our contributions continue to make a meaningful difference in the lives of those in need.

As part of our strategic vision, we are also working to strengthen our global presence. Through new partnerships with academic institutions, dental organizations, and healthcare leaders, we can extend our influence and create more opportunities for Fellows to contribute to the profession on an international level.

As a valued Fellow, your insights, experience, and dedication play a crucial role in shaping this vision. We encourage you to get involved in PFA leadership, mentor the next generation, and participate in discussions that drive innovation within the Academy. Whether through leadership roles, humanitarian projects, or professional development initiatives, your contributions will help propel PFA into a new era of excellence. This is an exciting time for our Academy, and we welcome your thoughts,

ideas, and feedback on how we can collectively elevate our mission and impact.

Thank you for your continued dedication and passion for our profession. Together, we can ensure that PFA not only preserves its proud legacy but also thrives for generations to come.

Best regards,

—Dr. ghabi Kaspo, International

President-elect of the Pierre Fauchard Academy

‘Plus ça change, plus c’est la même chose’

Since time immemorial, change has been a constant feature throughout the world. Most recently, it seems that the pace of change has increased greatly, and that it will continue to do so.

For many reasons, societies and their organizations have always faced challenges, such as economic issues, changing social structures, communication and priorities, and intergenerational change. As the saying goes, the more things change the more they stay the same. Our response as the Pierre Fauchard Academy is to understand

the changes that occur and to embrace these.

In the most recent years, we have fostered an increase in communication and collaboration between Sections, such as joint meetings and induction ceremonies, and this trend continues. We also encourage the sharing of Best Practices among our Sections on what works best in engaging our Fellows and adding value. Plus, we are continuing to increase personalized communication, in particular at the Section Chair and Section level. In addition, while virtual events began as a necessity during the COVID-19 pandemic, this is no longer the case –we are now holding virtual events in addition to in-person events to increase

opportunities for participation when it is not practical or feasible to meet in person. Examples include induction ceremonies, such as the recent induction for the ‘Section-at-large,’ and the hosting of webinars. Engaging Fellows in goal setting is also of importance, especially at the Section level where most of our engagement and activities are focused.

As the Pierre Fauchard Academy continues to strengthen, I look forward to working with our Fellows in the coming years.

Sincerely,

—Dr. luis felipe JiMenez squella, International Vice President of the Pierre Fauchard Academy

From the Desk of the International Vice President

Dr. Luis Felipe Jimenez Squella

The Western Australia Section hosted its annual lunch on November 24, 2024, at the Cottesloe Golf Club in Swanbourne, Western Australia. The highlight of the event was welcoming five new Fellows who have made significant contributions to the dental profession, above and beyond the call of duty. Drs. Nick Albatis, Sam Bennett, Lisa Bowdin, Graham Carmichael, and Mohammed El-Hakim were sworn in by Prof. Deborah Cockrell, Trustee for Region 8 (Australasia). We were also delighted to host Commodore (Ret.) Mike Deeks to speak on his years of experience as a submariner and naval officer, providing transferable lessons on leadership.

In keeping with the theme of our meeting, we launched our Fellow Leadership

Initiative. All Western Australia Section Fellows will be eligible for grants (up to $300) from PFA to attend a leadership or management course of their choice. Details to come.

The Hawaii Section of the Pierre Fauchard Academy held its Annual Dinner and CE Meeting at the Oahu Veterans Center in Honolulu on January 29th, 2025. We were delighted to welcome Dr. Dan Castagna, Past International President and currently Treasurer of the Pierre Fauchard Academy. Dr. Castagna administered the oath during the induction of three new Fellows – congratulations to Drs. Anthony Kim, Angela Chin

and Riichiro Sato, as well as Dr. Cecile Sebastian who was inducted at our Annual Gala Induction Ceremony in October 2024 in New Orleans. During our joint ACD/ICD/PFA meeting, the Ethics CE program was given by Dr. Karen Foster, ICD Regent for District 14.

Sincerely,

—Dr. nora harMsen, Section Chair for Hawaii

Western Australia

Prof. Deborah Cockrell (Trustee for Region 8) together with our new Fellows, Drs. Nick Albatis, Sam Bennett, Lisa Bowdin, Graham Carmichael, and Mohammed El-Hakim.

Dr. Gregory Gee (Section Chair for Western Australia) addressing our Fellows.

Section News

TheMassachusetts Section of the Pierre Fauchard Academy held its Annual Breakfast Meeting on January 31, 2025. Approximately 45 Fellows were in attendance, as well as Dr. Jay Skolnick, our new Trustee. During the meeting, Dr. Robert Lewando was awarded the Distinguished Dentist Award for his years of service, especially his work in

the access to care arena and in insurance company policy.

Dr. Richman announced that she would be stepping down as Chair of the Massachusetts Section, and that Dr. Cherie Bishop, a long-term Fellow, would be assuming the position of Section Chair for the 2025-26 year. Dr. Moriarty will continue in her position as Vice Chair.

Massachusetts

L to R: Dr. Pankaj Patel (former International President) together with Dr. Cecile Sebastian (new Fellow).

L to R: Dr. Anthony Kim (new Fellow), Dr. Dan Castagna (Treasurer of the Pierre Fauchard Academy), Dr. Angela Chin (new Fellow), Dr. Norma Harmsen (Chair of the Hawaii Section), and Dr. Riichiro Sato (new Fellow).

Dr. Andrea Richman (outgoing Section Chair for Massachusetts), Dr. Cherie Bishop (incoming Section Chair for Massachusetts), and Dr. Jay Skolnick (Trustee for Region 2, NE USA) together with our new Fellows inducted during the Massachusetts Section's Annual Breakfast Meeting.

The Oregon Section Annual meeting was held in conjunction with the International College of Dentists and the American Collee of Dentists meetings, as most of our members are involved with multiple honors societies. During the meeting, we inducted Dr. Julie Spaniel as a new PFA Fellow. Dr. Spaniel is an outstanding dentist and philanthropist, and she provided us with an update on her most recent projects running a school and opening a dental clinic in Kenya.

We also discussed future coordination of our annual event with the ICD and ACD, and recruiting efforts, and made a plan to work together on a new annual event which would include speakers, mission trip planning, and social time.

Sincerely,

—Dr. anthony raMos, Section Chair for Oregon

L to R: Dr. Anthony (Tony) Ramos (Section Chair for Oregon) together with Dr. Jule Spaniel (new PFA Fellow).

L to R: Dr. Andrea Richman (Section Chair) together with Dr. Robert Lewando, recipient of the Distinguished Dentist Award.

Dr. Jay Skolnick (Trustee for Region 2, NE USA) addressing participants at the Massachusetts Annual Breakfast Meeting.

L to R: Dr. Janis Moriarty (Vice Chair for the Massachusetts Section), Dr. Andrea Richman (outgoing Section Chair), Dr. Cherie Bishop (Incoming Section Chair), and Dr. Jay Skolnick (Trustee for Region 2, NE USA).

Mission

Our mission as Fellows in the Pierre Fauchard Academy is to recognize and develop outstanding leadership in our profession, internationally.

Central Office:

Robert Cattoi, Executive Director 103 North Adams Street, Rockville, MD 20850

E-mail: centraloffice@fauchard.org

Phone: +1 (240) 658-8070

Fax: +1 (240) 266-9188 www.fauchard.org

Cheryl Billingsley, President Virginia, USA

Pierre Fauchard Academy Officers

Ghabi Kaspo, President-elect, Michigan, USA

Pankaj Patel, Immediate Past President, Kenya

Luis Felipe Jimenez, Vice President, Chile

Robert Cattoi, Executive Director, Maryland, USA

Trustees

REGION 1—Europe

Paul O’Dwyer, Ireland

REGION 4—Midwest USA

Kim Gardner, Ohio, USA

REGION 7—Latin America

Federico Perez Diez, Mexico

REGION 10—Central USA

Lucynda Raben, Kansas

REGION 2—Northeast USA Jay Skolnick, New York

REGION 5—Western USA CR Anderegg, Washington, USA

Dan Castagna, Treasurer, California, USA

Pankaj Patel, Secretary, Kenya

Dan Castagna, Treasurer, California

REGION 8—Australasia Deb Cockrell, Australia

REGION 11—Africa Tom Ochola, Kenya

REGION 3—Southeast USA Paul Obrock, Tennessee

REGION 6—Canada Lisa Bentley, Ontario

REGION 9—Asia

Ricardo R. Gatbonton, The Philippines

EDITOR—Dental World Fiona M. Collins, Georgia

Ghabi Kaspo, President, Michigan, USA

Robert Cattoi, Ex officio, Maryland, USA

Leadership Foundation of the Pierre Fauchard Academy