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Special SportS DentiStry edition

inside‌ Re-evaluate and Replenish Dental Diversity The Phantom Dentist Get in the Game by Having Sports Dentistry in Your Practice The Expanding Role of Vital Pulp Therapy

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from the editor’s desk

Re-evaluate and Replenish The New Year is a time of re-evaluation and replenishment of one’s goals and aspirations for the next year. Have you had a satisfying year, or have you had a personally trying year? What went well and what events could have been handled in a more efficient manner? Are you clear on your personal and practice mission, or are you unclear as to what the future holds for you? Are you utilizing

others to help guide you in your decision making, or are you the lone wolf type who has the answers and wants to be in total control? Are there many things out of your control, or do you have a thumb on the pulse of your life? Have you set your plans for the next year, and have you reviewed your longer term goals maybe five or 10 years out or more? What is your current position in the continuum of life? Are you just starting out, in the middle productive years or nearing the twilight years of life?

improve my life situation, that now upon entering my twilight years in dentistry (no, I am not retiring yet, Mom), I look back with fondness at the many friends I have made in the organization. The effect these individuals have had on my life is incalculable. The friends I have made were from all around the state of Pennsylvania, from large cities, small towns and rural areas. They are men and women, young and old. I have been able to mentor new dentists and to be mentored by experienced dentists as well.

These are all questions I routinely ask myself and those I mentor. They are questions not just for the new year but throughout life. I must admit that I have had the good fortune to be active with the PAGD for the last 30 years and a member for over 35 continuous years. It was not as evident in my early years of membership, but my active participation in the PAGD and the national organization has given me so many opportunities to grow and

My New Year’s resolution is to recommend as many dentists join and get active in the Pennsylvania Academy of General Dentistry, and to share my enthusiasm for this collection of fine dentists. What is your resolution?

David A. Tecosky, DMD, MAGD Editor, PAGD Keystone Explorer

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Pennsylvania Academy of General Dentistry Board of Directors president (2018) andrew Stewart, dMd, MaGd, aBGd Fredericksburg, PA astewart109@comcast.net president-elect (2018) ann Hunsincker, dMd, MaGd Hellertown, PA immediate past president (2018) Frederick lally, ddS, MaGd Tunkhannock, PA fredlally772@msn.com Secretary (2020) Hema nair, dMd, MaGd West Chester, PA drnairdmd@gmail.com treasurer (2019) Richard Knowlton, dMd, MaGd Elizabethtown, PA 717.367.1560 rdknowlton@aol.com region 3 regional Director (2019) Kurt laemmer, dMd, MaGd Bradford, PA kurtlaemmerdmd@atlanticbb.net region 3 trustee (2019) eric Shelly, ddS, MaGd West Chester, PA ericshelly@verizon.net editor (2018) david tecosky, dMd, MaGd Philadelphia, PA teco1dmd@gmail.com

BoArD of DireCtorS lorena cockley, ddS, FaGd (2020) East Berlin, PA lcockleydds@eastberlinsmiles.com leigh Jacopetti, dMd (2019) Pittston, PA ljacopetti@aol.com Ray Johnson, dMd (2020) Russell, PA rayjj13@gmail.com thomas Kratzenberg, dMd (2018) White Oak, PA tom@ultimate-smile.com lance Miller, dMd (2020) Lancaster, PA lsmiller11@gmail.com John nase, ddS, FaGd, Ficd (2018) Harleysville, PA drjohn@nasedentalgroup.com

The OďŹƒcial Publication of the Pennsylvania Academy of General Dentistry editor David A. Tecosky, DMD, MAGD Assistant editor Christy Young Graphic Designer Gennifer Richie Contributors Maria Garubba, DMD Rick Knowlton, DMD, MAGD Steve Neidlinger, CAE Andrew T. Stewart, DMD, MAGD, ABGD David A. Tecosky, DMD, MAGD Cuong Tran, DMD, MAGD Martin Trope, DMD

david Sullivan, dMd, MaGd (2018) Pittsburgh, PA dave.sullivan@va.gov peAK track 1 Chair Brad Strober, dMd, MaGd Edison, NJ 732.549.5660 bstrober9@aol.com peAK track 2 Chairs John Gustafson, dMd, MaGd joey625@comcast.net Richard Knowlton, dMd, MaGd 717.367.1560 rdknowlton@aol.com

Keystone Explorer is owned and published quarterly by the Pennsylvania Academy of General Dentistry. The purpose of the journal is to print timely and appropriate material to stimulate, educate, inform, and recognize the general dentists of Pennsylvania in their pursuit of professional excellence. Views expressed in this publication are those of the authors and do not necessarily reflect the opinion of the Academy. Deadlines for material to be printed are the PAGD Board meetings in October, January and April, and the AGD annual meeting in June. Keystone Explorer reserves the right to edit or reject any article submitted for publication. Subscription is included in the annual dues of PAGD members. Domestic subscriptions are available to nonmembers at $26 per year. Patrons are invited to support this publication. Advertising and subscription queries go to the Executive Director, Steve Neidlinger, 4076 Market Street, Suite 209, Camp Hill, PA 17011. www.pagd.org Š 2018 PAGD. All rights reserved.

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president’s message

Dental Diversity By Andrew T. Stewart, DMD, MAGD, ABGD It occurred to me that general dentistry is a mix of science and art. Ah… the eclectic nature of general dentistry—isn’t it great? I’ve always liked to tinker. I have always enjoyed taking nonfunctional things apart to see what was wrong with them, and trying to figure out how they were supposed to work. The best part, which inevitably follows, is engineering a way to fix them. Before I throw out something, I am always scavenging parts from it. My wife frequently asks me, “Why are you saving that part? You’ll never use that.” My shop in the basement could be the envy of Fred Sanford. I often get to use these parts, being sure my wife knows how the repair was made possible. I had knobs from a dead clothes washer in my shop for years. Now, I’m pretty sure my wife has the only Crock-Pot® in the county with a spin cycle. She’s so proud.

As a boy, I unwittingly honed my hand-eye coordination via building model airplanes. My mother becoming crazy trying to get me to come to dinner when I was in the middle of painting teeth on a P-40 is an ironic memory. Now, I get to play all day long. What I love best about general dentistry is that my day is filled with several completely different procedures. For that reason, and that reason alone, I would never want to specialize. I abhor the thought of doing the same type of procedure all day, every day, for the next many years. How mundane! Two avocations— engineering and working on small objects—no doubt drove me to general dentistry.

“You’ve achieved success in your field when you don’t know whether what you’re doing is work or play.” — Wa R R e n B e at t y

Balsa has been replaced with resin, and banana oil with monomer, but on some level, I’m still in the basement—not coming to dinner.

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executive director’s message

Sweet Home Chicago By Steve Neidlinger, CAE This past November, an intrepid group of PAGD members set west into the setting sun, searching to represent their profession and their home state of Pennsylvania. We headed to the far-off land of Chicago, to attend AGD’s yearly governance meeting. But unlike our rugged ancestors who struck out on an unforgiving landscape via wagon train to find their fortune, we flew coach. The agenda was thankfully light. There were not many proposed resolutions to cause consternation. But that does not mean that there was a shortage of highlights to remember: • PAGD congratulates its treasurer, dr. Rick Knowlton, dMd, MaGd, for receiving a presidential citation from AGD President Dr. Maria Smith. The citation was offered in recognition of Dr. Knowlton’s outstanding contributions and dedicated service to the public and the profession of dentistry. Hats off to Dr. Knowlton for the well-earned honor!

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• PAGD friend and neighbor dr. Manuel cordero, ddS, cpH, MaGd, from the distant land of New Jersey, was installed as president of AGD. In his acceptance speech, Dr. Cordero displayed his passion for dentistry, and how his participation in AGD has allowed him to excel in his profession through education. Dr. Cordero is a graduate of Temple Dental School. • PAGD received two honorable mentions for the aGd Universal awards, which recognize constituent society achievements. PAGD’s awards were the 2017 advocacy award and the 2017 William H. Howard ace award for its publications. No consolation prizes for 2018 though: We’re bringing that trophy home in our carry-on! • Nearly all of the resolutions considered by the House of Delegates were fairly benign: Flossing is good, sugar is bad. The one resolution that received the majority of debate was in regard to student dues. There was a proposal in the budget to increase student dues in AGD from $17 to $27. After much debate and hand-wringing, the increase was pegged at $20.

PAGD thanks all the delegates who took time away from their practices and attended the governance meeting: dr. andrew Stewart PAGD President dr. ann HunsickerMorrissey PAGD President-Elect dr. Hema nair PAGD Secretary dr. Rick Knowlton PAGD Treasurer dr. Kurt laemmer AGD Regional Director dr. eric Shelly AGD Trustee dr. leigh Jacopetti dr. Ray Johnson dr. tom Kratzenberg dr. dave Sullivan


sports dentistry

The Phantom Dentist By Cuong Tran, DMD, MAGD

professional ice hockey: A sport that brings to mind fights and missing teeth. So naturally a dentist involved with ice hockey would be a match made in heaven‌

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those were my first thoughts as i looked for a way to get involved with a professional ice hockey team. My involvement with the American Hockey League’s (AHL) Lehigh Valley Phantoms, a Philadelphia Flyers affiliate, started several years ago when the owners of the team decided to build an arena in downtown Allentown and bring the team from the New York Adirondacks to Allentown, Pennsylvania. My connection with the team was through the athletic trainer. The athletic trainer is the gateway to the program; he is in charge of the health and well-being of all the players, and answers to the coaches and owners. The trainer asked for my direct involvement with the team and that I be available at the games to handle onsite dental emergencies, as their goal is to safely have the players return to play. Additionally, I take care of the team’s overall dental needs through my office, including making mouthguards.

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My role as the team dentist is voluntary at the ice rink. I offer my services at the games and in my office to provide the best possible care for the athletes in exchange for a chance to be affiliated with a professional hockey team and for my own professional development. The injuries I have addressed encompass the spectrum from major traumas, like when the frozen puck hits a player’s face, to minor injuries from contact with sticks, elbows and skates. In most cases, I work along with the team physician or ER doctor to anesthetize and triage the best we can to stabilize the teeth for the player to return to the ice. Usually these players come to my office the following day for x-rays and more definitive treatment as necessary. Players with more serious injuries are rushed to the ER to be treated. Since working with the Phantoms, I have seen cases where teeth are fully avulsed, and where the teeth were

completely fractured to the gingiva and I have also seen maxillary sinus fractures and mandibular jaw fractures (see above and right). The players, through their employer, the Philadelphia Flyers, have dental insurance coverage for routine and preventive care and a very good workers’ compensation plan to cover any injuries as a result of playing. We submit claims as appropriate for the players. Unfortunately, most injuries are in the major category given the speed and intensity of professional play. In some cases, the players were not wearing their mouthguards and, in other situations, even the mouthguards did not protect them 100 percent. Some treatments require more time and follow-up, such as asymptomatic occlusal trauma, or later treatment with implants to replace missing teeth. To improve my overall care and emergency treatment, I have become a member of the Academy for Sports Dentistry and attended their annual symposium to learn more about all


c a l l

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CLINICAL ARTICLES

respect and appreciation for the athletic ability and skill of each player.

aspects of sports dentistry. Special thanks to Dr. Rick Knowlton for his exceptional knowledge in sports dentistry and for being my mentor through the process. I plan to present to the sports medicine residents at Lehigh Valley Health Network (LVHN) to expose them to sports dentistry, as they get very little information on treatment of dental traumas through their formal education. I am part of a team of physicians from LVHN and Coordinated Health (MD, orthopedics and ER doctors) and athletic trainers, and we all work together to keep the team healthy. Medical staff aside, I have gotten to know the players and the sport, and have gained a much higher level of

Most of the Phantoms are very young, as the AHL is a developmental league, and most still have all their teeth! Many have had their share of dental issues, but they keep a very positive attitude and are very appreciative of their fans. What most people don’t realize is that these players are professional hockey players and, on any given day, they may be called up to play with their NHL affiliate; thus, they are always playing their best in anticipation of that moment. Currently, there are seven players on the Philadelphia Flyers roster who played with the Lehigh Valley Phantoms last year. The excitement the Phantoms exude and their passion for hockey are contagious, and it makes me proud to be a part of such a great program.

Keystone Explorer is seeking clinical articles for publication in our quarterly newsletter. Such articles help our readers stay abreast of best practices and new developments in various areas of general dentistry. By publishing clinical articles, the Keystone Explorer serves both an informational and educational role for our members. We welcome the submission of your articles for possible publication in an upcoming issue of the Keystone Explorer. Please submit your articles to our editor, Dr. David Tecosky, via email at teco1dmd@gmail.com.

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sports dentistry

Get in the Game by Having Sports Dentistry in Your Practice By Rick Knowlton, DMD, MAGD As our own children and the athletes in our practice get involved in organized sports yearround, it is important for us as dentists to take a more active role in encouraging these players in all age groups to wear the proper protective equipment to prevent orofacial injuries. We must all take a proactive role in attempting to prevent orofacial injuries on the playground and in organized sporting events. Whether it be baseball, softball, soccer, football, hockey, wrestling, volleyball, rollerblading, skateboarding or mountain biking, these all pose significant risks.

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Sports dentistry is a part of our practices that few of us take advantage of. We all have the capability of fabricating quality protection for kids in our practice, neighbors, local teams, and our own children and their teammates. It has been estimated by the National Youth Sports Foundation that over 5 million teeth are lost annually in sports-related accidents, with over 300,000 orofacial injuries occurring yearly1. According to the American Dental Association and the National Athletic Trainers’ Association’s newsletter, NATA News, athletes who do not wear mouth protection face a seven times greater chance of suering an orofacial injury than those who use such protection2.

Mouthguards in Sports programs Unfortunately, 90 to 95 percent of people who wear mouthguards go to the sporting goods stores to purchase them, while only a little over 5 percent have them made by a dentist. Since rules were established in regard to the use of headgear and mouthguards in football in the 1960s, facial and dental injuries sustained on the field have dropped over 48 percent to 0.07 percent3. Though it has not been specifically proven in the medical and dental literature that a mouthguard will eliminate concussions, recent research presented at the fifth International Conference on Concussion in Sport held in Berlin in October 2016


suggested they might prevent such outcomes. A paper presented at the conference stated: “The evidence for mouthguard use in preventing SRC is mixed, but metaanalysis suggests a non-significant trend towards a protective effect in collision sports, and rigorous case–control designs are required to further evaluate this finding.”15 Baseball and softball are the most popular organized sports, with an estimated involvement of 25 percent of U.S. children. Protective headgear was used regularly during organized games by about 35 percent of these children. Unfortunately, mouthguards were used by only 7 percent of these athletes4. Of the 5 million children enrolled in soccer leagues yearly in this country, only about 7 percent wear mouthguard protection, while close to one-third of all injuries on the soccer field involve the head and face5. In basketball, more than 34 percent of the injuries involved the head, face or teeth6. It is understandable to see that dental injuries are the most common injuries sustained in sports. Of the dental injuries that occur, 80 percent of these involve the anterior maxillary incisors7.

Benefits of Mouthguards The use of mouthguards has been found to reduce the severity and prevent the occurrence of injuries such as coronal and radicular fractures, corpus fractures of the mandible, and fractures of the alveolar processes, condyles and gonial angles. They have been found to prevent displacement and avulsion of teeth, along with soft

tissue lacerations to the gingiva and oral mucosa. In addition, they can help to prevent some of the concussions that occur each year in athletics. According to the CDC, an estimated 300,000 sports-related traumatic brain injuries (TBIs) of mild to moderate severity, most of which are classified as concussions, occur in the United States each year8. It has been estimated that brain injuries from sports make up approximately 20 percent of all brain injuries that occur each year in this country9. At the present time only boxing, amateur lacrosse, football and ice hockey require the use of mouthguards10. It has been strongly urged by the Academy of Pediatric Dentistry for the mandatory use of mouthguards for baseball, softball and basketball at the youth and high school levels11.

the functions of Mouthguards The benefits of wearing a mouthguard are numerous. A properly made and worn mouth protector can help to hold the soft tissue of the lips away from the teeth thus helping to prevent lacerations and bruising. They help to cushion the teeth from direct blows and distribute forces that could fracture or displace the anterior teeth. They also help to prevent teeth in the opposing arches from violent contact, which might chip or fracture them. A properly fitting mouthguard will provide support for the mandible, absorbing forces that could fracture the angle of the mandible or the condyles. It can also minimize a potential concussion by preventing the upward and backward displacement of the condyles against the skull.

types of Mouthguards The term mouthguard can involve a number of different types with varying degrees of protection, cost and comfort. The store-bought Stock mouthguard may not provide a good fit and comfort to the wearer because it is not intended to conform to the individual’s mouth. It allows for tooth movements in the mouth, and therefore a number of orthodontists encourage them because of this freedom of movement. Another store-bought mouth protector is the Boil-andBite mouthguard. This is the most common one sold and is shaped by heating the material in boiling water, placing it in cold water and then forming it in the mouth. A dentist or dental laboratory makes custom mouthguards. The custom Vacuum Formed mouthguard is fabricated by heating the material, placing it over a stone model of the patient’s mouth, and suctioning it down by vacuum to conform to the shape of the mouth and teeth. The Type IV is presently considered state-of-the-art. The custom pressure laminated mouthguard is made in layers. The laminate sheets are heated and placed over the stone model as in the vacuum formed. The difference is that these layers are pressed onto the model or previously laminated mouthguard under high pressure.

Advantages of Custom Mouthguards The Pressure Laminated and the Vacuum Formed mouthguards have several advantages over storebought ones. They remain in place far better during activity. This allows for

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much more effective communication. Interference with breathing is minimized. They show less wear in chewing and biting. By being more comfortable to wear, they are worn more regularly by the participants.

for your office. Or you can purchase the equipment yourself and start to fabricate your own from DENTSPLY/RainTree (800-883-8733), Glidewell, or Great Lakes Orthodontics (716-871-1161).

Of the four general types available (Stock, Boil-and-Bite, Vacuum Formed, and Pressure Laminated), the Custom Pressure Laminated is considered to be superior because:

Sports Mouthguards Are not Created equal

1. Commercial mouthguards (Stock and Boil-and-Bite) lost most of their thickness in the occlusal chewing surfaces by 70 to 99 percent when manufacturer’s instructions were followed. 2. Dental custom-made Vacuum Formed mouthguards decreased in thickness more than 25 percent while some surfaces decreased by more than 50 percent11. 3. Vacuum Formed, though significantly superior to storebought mouthguards, only retain their shape at best for about three to four weeks after delivery. 4. The Pressure Laminated will allow the lamination of layers. This can be done using hard or soft layers of laminates. This allows a dentist to custom make the thickness or rigidity of the mouthguard to fit the particular sporting event and needed protection. These machines have 10 times the pressure of vacuum systems. Since pressure is even it allows for a uniform thickness of the mouthguard. A few dental laboratories, particularly Glidewell (800-854-7256) and SportsGuard Laboratories (330-673-6932), can fabricate these types of mouthguards, and both have excellent marketing materials

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Pressure Laminated mouthguards are substantially superior to all other types. They are the only type that can be counted on to offer the best protection for our children’s teeth during all sports activities12. It has been found that the store-bought Boil-and-Bite mouthguards provide a false sense of protection due to the dramatic decrease in thickness when an athlete bites it into place during its softened state. Unless dramatic improvements are made, dentists should not promote the Boil-and-Bite guards to their sporting patients13.

It is up to all of us to encourage our patients in sports to wear good mouth protection. So be on the winning side … not only will you and your practice benefit but most of all your patients will! references 1. American Dental Association, Council on Dental Materials, Mouth Protectors and Sports Team Dentists, JADA 1984 109.84-7 2. NATA News, National Athletic Trainers Association, October 1995. 3. Flanders, Bhat, The Incidence of Orofacial Injuries in Sports, JADA Vol. 126, April 1995: p. 491-6. 4. American Dental Association, JADA April 1996. 5. National Institute of Dental Research, January 1996. 6. American Dental Association, JADA April 1995. 7. Dental Injury Fact Sheet, National Youth Sports Foundation for The Prevention of Athletic Injury Inc., Needham Massachusetts, 1992. 8. Centers for Disease Control, Sports-Related Recurrent Brain Injuries, March 14, 1997. 9. Sosin, Sniezek, and Thurman Brain Injuries, 1996. 10. Andreason, Saunders, 1981. 11. Academy of Sports Dentistry, December 1991. 12. Park, Shaull, Overton, Donly, Improving Mouthguards, J. Prosthet Dent 1994, 72(4): 373-380. 13. Padilla, 15th Annual Symposium of Sports Dentistry, May 1996. 14. Park, First International Symposium on Dental Materials, August 1993. 15. 5th International Conference on Concussion in Sport held in Berlin, October 2016 http://bjsm.bmj.com/ content/early/2017/04/26/bjsports-2017-097699

Welcome New Members! eileen Barfuss

DDS

Sara Barna

Pittsburgh

PA

Venetia

PA

Allen Geng

DMD

Darby

PA

Aynaz imanian

DDS

Reading

PA

Jessica Liao

DMD

Pittsburgh

PA

Alexandra park

DMD

Kennett Square

PA

Garima purohit

DDS

York

PA

Jason Sampat

DMD

Royersford

PA

richard Wilcko

Pittsburgh

PA

William young

Allison Park

PA


PAGD news

New Dentists: We Want to See Your Smiles By Maria Garubba, DMD I am fortunate. I found myself at a PEAK track event before I even had a job as a dentist. My potential boss had suggested it as a way for us to spend time together and assess if I would be a good fit as an associate to her practice. In a way, PEAK was my first glimpse at real-world dentistry. I’ve attended two PEAK events each year since completing my residency, and intend on prioritizing PEAK dates moving forward. With each conference, there are more and more new dentists attending, but the population of participants is still greatly skewed toward the more established dentist. The PAGD and PEAK organizations are primarily directed by those who have had long-standing careers and have a completely different focus than those of us who are just starting to navigate the profession. With this revelation, a new dentist committee has been formed, made up of new and established dentists, along with PAGD staff. This committee met in the fall of last year and recognized that PAGD can offer more to support new dentists. However, we may not be doing

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enough to get you involved in what’s already available. Currently, PEAK tracks are the best way for new dentists to really “get their hands dirty” with intangible benefits, yet so many of you don’t even have it on your radar. You may have some uncertainties holding you back from jumping into a PEAK track. As a representative for the new dentist committee, I’d like to settle your concerns, bust some perceptions, and convince you that this is something you need to be doing so that you will continue to experience your career with the fresh eyes of a new dentist, even when you’ve been practicing for over 20 years, as I see in so many of the PEAK veterans.

What if you’re not focusing on attaining fellowship or Mastership? That’s okay! Nobody is going to kick you out of a PEAK meeting because you haven’t proven that you’ve earned these credentials. You should still come to see some of the highest quality CE available in Pennsylvania. Aside from the quality of the CE, it is often a great deal. For example, an Invisalign® certification course was offered last spring. Typically a course that costs around $2,000 on its own was grouped with additional PEAK courses for half the cost.

What if you don’t want to make a presentation? Then don’t! But you should come and watch everyone else make their own before you count yourself out forever. Presentation day at PEAK can be the most valuable portion of the entire weekend. It is a relaxed and communal environment for you to show some of your best (or worst) work. You will not be ripped apart for your techniques and you will not be quizzed on the chemical makeup of the materials you are using. It is an opportunity for the dentists in attendance to “check in” on each other, just like if you had a “weight loss buddy.” Making presentations keeps you accountable for continuing to grow your clinical and practical skills based on what you learned from the last meeting. It provides an opportunity to share successes, struggles, tips and experiences. It gives perspective and confidence that you can succeed in performing more advanced dentistry, and solace to see that not everyone has success all of the time. We shouldn’t hide our failures from each other when we have the opportunity to problem solve together.

What if i can’t take off of work for that many days? The new dentist committee acknowledges that being the new dentist often means you aren’t the


Continuing Education boss and you are assigned to work Fridays and Saturdays. If you are the boss, you’ve got a lot on your plate to push aside for four days of conferencing. My personal experience has been that the gain from these four days are worth any financial strain or emotional headaches you will incur from taking the time away from your job. If you are still hesitant, we encourage you to attend as much of the event as you can, particularly including the social events in the evenings. This is where you will find endless resources in the other participants, mentorship and advisors in the more established attendees that will help you to shape your future path. You will form friendships and support in the other new dentists, the people who will be your colleagues for the remainder of your career. You may get some financial advice that will help you achieve your goal of retiring by age 45. You may be convinced to sign up for that fashionable subscription service you’ve been wondering about. You may get a perfect suggestion for your next vacation where you’ll make fabulous memories with your family. If you are still shy to attend a PEAK conference, keep your eyes open for new opportunities for new dentists. The new dentist committee has recently initiated an effort to schedule an additional event catered to your availability and interests. PAGD staff has been collecting information regarding what’s most convenient for you and what kind of education you want available as a new dentist. As the future of the profession, we would love to form a more meaningful relationship, and create the opportunity to work together for many years to come.

paGd SUpeRcoURSe ••• tHRee locationS! pittSBurGh

hArriSBurG

phiLADeLphiA

February 16, 2018 8:30 a.m. to 4:30 p.m. Doubletree by Pittsburgh 910 Sheraton Drive Mars, PA 16046

February 23, 2018 8:30 a.m. to 4:30 p.m. Dixon University Center 2986 N. Second St. Harrisburg, PA 17110

April 13, 2018 8:30 a.m. to 4:30 p.m. Sheraton Bucks County Hotel 400 Oxford Valley Road Langhorne, PA 19047

this three-part supercourse, presented in conjunction with dentsply Sirona, will feature three regulatory-required educational courses:

Current infection prevention protocols and recommendations – Are you in Compliance? Theresa Johnson, RDH, MBA, Dentsply Sirona Infection prevention is essential for the health and safety of both patients and dental health professionals. Preventing the transmission of microorganisms and disease requires breaking the chain of infection. This entails performing a series of repeatable and sequential steps for effective infection prevention. The CDC recommendations on infection control for the dental setting include standard precautions that should be followed on a daily basis, and include procedures to be performed at the beginning of the day, before and after treating each patient, and at the end of the day. The objective of this course is to provide the dental health care professional with an overview of current infection prevention protocols that are required to break the chain of infection and prevent disease transmission.

A radiology portfolio: today’s Solutions for Successful imaging Theresa Johnson, RDH, MBA, Dentsply Sirona Advances in technology have made a significant impact on the field of dental radiography. For dental practices to make a smooth transition to new technology, an understanding of the basic principles of intraoral radiography and the modifications to these principles required by new technology is beneficial. This course provides the dental professional with techniques to utilize with their current technology, analog or digital, to produce quality, diagnostic images on the first exposure.

recognizing and reporting Child Abuse: training for Mandated reporters Steve Neidlinger, CAE, PAGD The goal of this course, developed by the Pennsylvania Family Support Alliance, is to gain an understanding of your role as mandated reporters in meeting your legal obligations in the area of child protection as per the Child Protective Services Law (CPSL). Attendees will be able to describe and apply current information on the CPSL, recognize elements and indicators of child abuse and neglect, and demonstrate reporting procedures.

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clinical dentistry

The Expanding Role of Vital Pulp Therapy— From Trauma to the Carious Exposure By Martin Trope, DMD Until recently, the indications for vital pulp therapy were extremely narrow. Three basic requirements were thought essential: 1.) A healthy pulp before treatment, 2.) A good coronal seal after treatment, and 3.) The use of calcium hydroxide as the vital pulp medicament. Thus, only traumatic exposures treated within the first few hours of the accident ensured a healthy pulp allowing for a direct pulp cap. If symptoms of pulpitis or a carious exposure even without symptoms were present, root canal treatment in mature teeth was recommended. If the tooth was immature, a pulpotomy (not pulp cap) could be attempted in the hope that the inflammation had not spread to the root pulp. If we examine the studies that have led to the conclusions above, some re-evaluation of the philosophy is in order. In the 1970s, a series of studies led us to the conclusion that the inflamed pulp (symptoms or carious exposure) could not be treated successfully. The studies of Tronstad and Mjor1 in monkeys on inflamed pulps showed that, in general, direct pulp capping was unsuccessful. Interestingly, in retrospect, the groups with calcium hydroxide capping and amalgam coronal restorations were less effective than ZOE placed directly on the pulp. Barthel et al2 among many others generally using amalgam as the coronal seal above calcium hydroxide confirmed that the procedure was not predictably successful in humans. This has remained the conclusion that predominates even today. Calcium hydroxide was thought to be essential because of its predictable effect on the pulp. Since the calcium hydroxide has a PH of >12, the superficial layer of pulp was necrosed and any microbes in this area killed3.

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Under the necrotic layer, a hard tissue defensive layer was predictably produced protecting the pulp from further damage4. A landmark study in 1987 by Cox et al5 showed that the coronal seal was the critical factor for successful pulp capping and that, in fact, almost any material and not only calcium hydroxide was effective as a capping agent as long as the coronal seal above was adequate. They capped healthy pulps with different materials that were either used as usual (not sealed on the outside) or the same material placed on the pulp but with an external seal of zinc oxide eugenol. They found that all materials used as the entire seal resulted in inflammation of the pulp, whereas when a ZOE surface seal was present, all tested materials could be used as pulp capping agents with no inflammation of the pulp (Figure 1). If we take into account that most of the studies done in the 1970s that concluded vital pulp therapy was not predictable used amalgam as the coronal seal, which the Cox et al study showed leaked and resulted in further inflammation, and calcium hydroxide, which washes out on contact with moisture was the capping agent, it is not difficult to understand why the procedure was not predictably successful.

cox cF et al, 1987: amalgam

Surface Seal

no Surface Seal

Figure 1. The reaction of the pulp when capped with amalgam with a surface seal vs. without a surface seal.


When microbes due to leakage do not reach the pulp (surface seal), there is no inflammation; however, when they do reach the pulp (no surface seal) inflammation is present. The example seen above with amalgam was repeated with many other materials illustrating that it is the seal that is important and not the material that is placed on the pulp.

manipulate, and is hard to remove. Clinically, both gray and white MTA stain dentin, presumably due to the heavy metal content of the material or the inclusion of blood pigment while setting. Thus, its use is limited in the esthetic zone when performing vital pulp therapy (Figure 2).

However, if there was a material that, like calcium hydroxide, had a high pH when placed on the pulp, sealed the cavity like zinc oxide euginol but did not wash out if challenged by saliva, there would be the possibility that capping the inflamed pulp resulted in predictable success.

Bioceramic technology in endodontics Bioceramics are ceramic materials specifically designed for use in medicine and dentistry. They include alumina and zirconia, bioactive glass, coatings and composites, hydroxyapetite and resorbable calcium phosphates, and radiotherapy glasses6–8. Bioceramics are widely used for orthopedic applications (joint or tissue replacement), for coatings to improve the biocompatibility of metal implants, and can function as resorbable lattices that provide a framework that is eventually dissolved as the body rebuilds tissue9. There are numerous bioceramics currently in use in dentistry and medicine. Alumina and zirconia are bioinert ceramics used in prosthetics. Bioactive glass and glass ceramics are available for use in dentistry under various trade names. In addition, porous ceramics such as calcium-phosphate-based materials have been used for filling bone defects. Also some calcium silicates (MTA, Tulsa Dental) and Bioaggregate (DiaDent) have been used in dentistry as root repair materials and for apical root filling materials.

pre-op

Follow-up (20 months)

Mineral trioxide Aggregate (MtA)

Figure 2. 20-month follow up of tooth pulp capped with MTA. Note the grey

Few clinicians realize that original MTA is a classical bioceramic material with the addition of some heavy metals. MTA is one of the most extensively researched materials in the dental field10, 11. It has the properties of all bioceramics, i.e. high pH when unset, biocompatible and bioactive when set and provides an excellent seal over time. It has some disadvantages, however. The initial setting time is at least three hours. It requires mixing (resulting in considerable waste), is not easy to

discoloration.

Bogen in 200812 performed a clinical observational study with direct pulp capping on carious exposures in teeth diagnosed with reversible pulpitis. Patients ranged in age from 7 to 49 years with a follow-up of between one and seven years. Overall success (no symptoms and testing vital to sensitivity testing) was 97.96 percent, while the success after five years was 94 percent.

Keystone explorer | Winter 2018 15


Recently, new pure bioceramic materials have been introduced into the market. Bio-Dentine is considered a second generation bioceramic material with similar properties to MTA and thus can be used for all the applications set out above for MTA13. Its advantages over MTA are that it sets in a shorter time (approximately 10 to 12 minutes) and has a compressive strength similar to dentin. A major disadvantage is that it is triturated for 30 seconds in a preset quantity (capsule) making waste inevitable since in the vast majority of cases only a small amount is required.

endodontic pre-Mixed Bioceramics These products are available in North America as Endosequence® BC Sealer™ (BC sealer), Endosequence® Root Repair Material Paste™ (BCRRM Paste Syringable)

and Endosequence® Root Repair Material Putty™ (BCRRM Putty) (Brasseler, USA Dental LLC, Savannah, Georgia). Recently, these materials have also been made available outside North America as Totalfill® BC Sealer™, TotalFill® BCRRM-Paste™ and TotalFill BC RRM-Putty™ (Brasseler, USA Dental LLC, Savannah, Georgia). All three forms of bioceramic are similar in chemical composition (calcium silicates, zirconium oxide, tantalum oxide, calcium phosphate monobasic and fillers), have excellent mechanical and biological properties, and have good handling properties. They are hydrophilic, insoluble, radiopaque, aluminumfree, high pH, and require moisture to set and harden. The working time is more than 30 minutes, and the

setting time is four hours in normal conditions, depending on the amount of moisture available. In addition, Endosequence or TotalFill Fast Set Putty has recently been introduced into the market that has all the properties of the original putty but has a faster setting time— approximately 20 minutes (Figure 3). We now have the material ideal for vital pulp therapy: 1. High pH when unset. 2. Hard with superior seal when set allowing for placement of a coronal restoration under ideal conditions and also ensuring the seal even if the coronal restoration breaks down over time. 3. No discoloration allowing it to be used in all areas of the mouth.

Figure 3. The Endosequence root repair materials. All are premixed and differ only in their flowability due to the particle size of the silicate component. Root repair flowable, RR putty and Fast set root repair.

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Cases

a: pre-op

B: pulp exposure

c: Bc putty Base

d: post-op

e: 6-month Follow-up

F: 2-year Follow-up

Courtesy: Dr. Mohammed A. Alharbi

pulp Cap

Figure A shows the pre-operative radiograph of a deep carious lesion on #19 of a 20-year-old male patient. A diagnosis of reversible pulpitis was made based on the history and clinical exam. After anesthesia and caries removal an exposure was seen (B) that was covered with a RRM fast-setting BC putty (Endosequence™) (C). After the BC base had fully set, a bonded resin was placed and a post-operative radiograph taken (D). At the six-month follow-up visit, the tooth was asymptomatic and tested vital. Radiographically no signs of pathology were noted (E). At two years, the tooth remains asymptomatic, a reparative barrier has formed below the bioceramic capping material and the canal has not calcified, implying a good seal (F).

a: pre-op Radiograph

B: pulp exposure

c: cvek pulpotomy

d: Bc putty on pulp

e: immediate Follow-up

F: 18-month Follow-up

Courtesy: Dr. Mohammed A. Alharbi

Cvek partial pulpotomy/pulpotomy

The pre-operative radiograph of an apparent carious exposure on #19 of an 11-year-old male patient. A diagnosis of reversible pulpitis was made based on the history and clinical exam. After anesthesia and caries removal an exposure was seen (B). Due to difficulty in controlling bleeding at the exposure site, a full pulpotomy on the mesial canals and a Cvek partial pulpotomy on the distal aspect of the tooth were performed to remove the superficial inflamed layer of tissue (C). When the bleeding was controlled and the cavity washed with sodium hypochlorite, the pulp was covered with a RRM BC putty (Endosequence™) (D). After the BC base had set a bonded resin was placed and a post-operative radiograph taken (E). At the 18-month follow-up exam, the patient was asymptomatic. The radiograph shows that the apices have closed, the canals remain open and a hard tissue barrier has formed around the bioceramic material (F).

Keystone explorer | Winter 2018 17


full pulpotomy

a: pre-op

B: immediate post-op

c: 1-year Follow-up

d: 2-year Follow-up

In the following case, the tooth tested vital but with clinical signs of irreversible pulpitis. It was decided to treat with a full pulpotomy in order to improve the chances the remaining pulp would survive and stay healthy. The pre-operative radiograph (A) shows extensive caries in the tooth and a widened apical periodontal ligament. A full pulpotomy was performed using the BC putty and after it set a coronal restoration was placed, thereafter an immediate post-operative radiograph is seen (B). At the one-year follow-up visit, the tooth is asymptomatic and the radiograph (C) shows continued root development, a healthy apical periodontium. At two years the patient remains asymptomatic and the radiograph shows continued formation of the roots (D).

Courtesy: Dr. Guillaume Jouanny

Conclusion The new premixed bioceramic materials are able to duplicate the positive properties of calcium hydroxide on the pulp while not washing out when exposed to fluids due to leakage. In addition, the bioceramic material itself provides a bacteria tight base, with an excellent seal, onto which a permanent restoration can be placed under ideal conditions. Thus, conclusions made that pulp capping a cariously exposed (inflamed) pulp is not possible can now be challenged due to the superiority of the materials available today compared to those in the 70s.

references: 1. Tronstad L, Mjör IA. Capping of the inflamed pulp. Oral Surg Oral Med Oral Pathol. 1972;34(3):477-485. 2. Barthel CR, Rosenkranz B, Leuenberg A, Roulet JF. Pulp capping of carious exposures: treatment outcome after 5 and 10 years: a retrospective study. J Endod. 2000;26(9):525-528. 3. Schroder U, Granath LE. Early reaction of intact human teeth to calcium hydroxide following experimental pulpotomy and its significance to the development of hard tissue barrier. Odontol Revy 1971;22:379. 4. Cvek M. A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. J Endod 1978;4:232. 5. Cox CF, Keall CL, Keall HJ, et al. Biocompatibility of surface-sealed dental materials against exposed pulps. J Prosthet Dent 1987;57:1. 6. S.M. Best, A.E Porter, E.S Thian, J Huang. Bioceramics: Past, present and for the future. Journal of the European Ceramic Society 28 (2008) 1319-1327. 7. V.A. Dubok, BIOCERAMICS: YESTERDAY, TODAY, TOMORROW, Powder Metallurgy and Metal Ceramics, Vol 39, Nos 7-8, 2000. 8. L. Hench. Bioceramics, From Concept to Clinic, J. Am. Ceram. Soc., 74 (7) 1487-510 (1991). 9. (4)K. Hickman. Bioceramics, Internet (Overview) April 1999 (www.csa.com/discoveryguides/archives/bioceramics.php) 10. Parirokh M, Torabinejad M. Mineral Trioxide Aggregate: a comprehensive literature review Part II – Leakage and biocompatibility investigations. J Endod 2010 Feb; 36 (2): 190-202. 11. Parirokh M, Torabinejad M. Mineral Trioxide Aggregate: a comprehensive literature review Part I – Chemical, physical and antibacterial properties. J Endod 2010 Jan; 36(1): 16-17. 12. Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral trioxide aggregate: an observational study. J AM Dent Assoc. 2008 Mar;139 (3):305-15. 13. Malkondu O, Karapinar Kazandag M, Kazazoglu E. A review on biodentine, a contemporary dentine replacement and repair material. Biomed Res Int. 2014:160951. 14. Zhang S., Yang X., Fan M. Bioagreggate and iRoot BP Plus (RRM™ Putty) optimizes the proliferation and mineralization ability of human dental pulp cells. International Endodontic Journal. 2013. 15. Z. € Oncel Torun, D. Torun, K. Demirkaya, S. T. Yavuz, M. P. Elc, M. Sarper &F. Avcu; Effects of BC RRM Putty and white mineral trioxide aggregate on cell viability and the expression of genes associated with mineralization. IEJ 2014 October 16. S. Shi, Z. F. Bao, Y. Liu, D. D. Zhang, X. Chen L. M. Jiang & M. Zhong. Comparison of in vivo dental pulp responses to capping with iRoot BP Plus and mineral trioxide Aggregate. IEJ February 2015: product List: MTA – Dentsply; Biodentine – Septodont; Endosequence and TotalFill Root Repair Materials - Brasseler

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advocacy

State Board of Dentistry Report NOVEMBER 17, 2017 MEETING SUMMARY By Steve Neidlinger, CAE Roll was called, and a quorum was achieved. The minutes from the Sept. 15, 2017 meeting were approved with minor grammatical edits.

Commissioner’s report Bureau of Professional and Occupational Affairs (BPOA) Commissioner Ian Harlow reported that separate regulations, including general revisions, a licensure fee update and volunteer licensure provisions, were packaged together by the Governor’s Policy Office and are expected to be published in the Pennsylvania Bulletin soon. Additional regulations regarding child abuse continuing education will be published in December/January. The governor issued an executive order requiring all state occupational boards to engage in a comparison with surrounding states. BPOA will produce a report and submit it to the SBOD in June or July of 2018. Mr. Harlow was adamant that the intention of the comparison study was not to reduce the value of professional licensure, but to bring Pennsylvania’s licensure requirements in compatibility with other states to potentially increase the portability of licensure.

prosecution The first case was resubmitted after the SBOD considered the original penalty too lenient. It involved an oral surgeon with inadequate infection control protocols, and had drugs improperly stored and prepared by dental assistants outside of their scope of practice. The civil penalty was increased from $5,000 to $6,000, with a monitoring program increased from 18 months to 36.

The next case also involved improper infection control. The office was using an ozonator for infection control, which is not an approved device for that purpose. Spore testing had not been done properly since 2015. The licensee was assessed a $5,000 civil penalty and three years of monitoring. The next case was a reciprocal license from New Jersey, and involved inaccurate billing and record keeping. A $1,000 civil penalty and reprimand were assessed. The doctor’s Pennsylvania license in the next case expired in 1993, but had been cited by New Jersey for unauthorized use of botox. A $1,500 civil penalty was assessed in Pennsylvania. The next case was resubmitted after the penalty was considered too lenient. It involved the writing of nondental prescriptions for staff, including Vicodin. The doctor surrendered their DEA license, and the civil penalty was upped from $2,000 to $3,000. A cease-and-desist order was filed that will disallow the doctor from writing prescriptions for 36 months after the DEA license surrender expires. The next case involved infection control violations, including expired materials and untreated instruments. The licensee received a $4,000 penalty and 18-month probation, and is required to hire a dentist to handle infection control. The next case involved a licensee in Texas whose Pennsylvania license expired in 2009. They were assessed a $1,000 penalty for failed restorations and poor follow-up in Texas.

The next case was a resubmittal. It involved the misprescribing of Oxycodone and poor record keeping. The doctor was not prosecuted for misprescribing. They received 15 months of Accelerated Rehabilitative Disposition (ARD) program, and are eligible for expungement this month. Their license is suspended for one month, with a 35-month probation and $5,000 civil penalty, and they will permanently surrender their license. For the next case, the members of the probable cause screening committee recused themselves. A licensee refused mental and physical evaluation, and permanently surrendered their license instead.

Committee reports The licensure committee is recommending that the board consider a review of the Western Region Examining Board (WREB) licensure exam, which is moving to a compensatory scoring system, which would allow an applicant to fail a particular part of the exam but still pass overall. There was discussion among board members on how to address this. The committee will have the Commission on Dental Competency Assessments (CDCA) testify at the January meeting on the subject, and would like to hear from WREB before deciding on the continued acceptance of this exam.

elections Dr. Jack Erhard was re-elected to continue as chair, and Mariellen Brickley-Raab was re-elected to continue as secretary.

next Meeting The next SBOD meeting will be on Jan. 19, 2018.

Keystone explorer | Winter 2018 19


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