TFDA January/February 2024

today’s ORAL LESIONS ISSUE

A PUBLICATION OF THE FLORIDA DENTAL ASSOCIATION

Oral Lesions and Specific Diagnoses

FDA Governance Update

Q&A on Oral Pathology

A Clinical Reference Guide to the Treatment of Common Oral Lesions

Vol. 36, NO. 1 JANUARY/ FEBRUARY 2024

03 Tallahassee, FL 323 Ste. 201 545 John Knox Road, : 850.681.7737 Fax 7 759 77.

0.8 850.681.2996 80 ervices.com es.com www.fdas insurance@fdaservic

contents JANUARY/FEBRUARY 2024 floridadental.org

ORAL LESION ISSUE 12 Florida Board of Dentistry Meets in Gainesville 14 FDA Governance Update

32

28 Questions and Answers About Oral Pathology 32 Oral Lesions and Specific Diagnoses 38 A Clinical Reference Guide to the Treatment of Common Oral Lesions

55 FDC2024 Speaker – Managing Inventory for Fun and Profit 58 FDC2024 Speaker – Maximize Your Potential – Practical Ergonomic Tools and Wellness Strategies for Dental Professionals

60 Exhibit Marketplace 64 Engaging Floridians to See Their FDA Dentist Media Recap 66 A Cookbook Approach to Dental Issues

IN EVERY ISSUE 2

Staff Roster

5

President’s Message

7

Did You Know?

9

Legislative

71

10 Preventive Action 17 Dental Benefits Spotlight 18 New Dentist

Check out Today’s FDA online

20 news@fda 23 In Memoriam 71 Diagnostic Discussion 76 Career Center 79 Advertising Index 80 Off the Cusp

Today’s FDA | 1

545 John Knox Road, Ste. 200 Tallahassee, FL 32303 800.877.9922 or 850.681.3629

To contact an FDA board member, use the first letter of their first name, then their last name, followed by @bot.floridadental.org. For example, to email Dr. Hugh Wunderlich, his email would be hwunderlich@bot.floridadental.org.

EDITOR Dr. Hugh Wunderlich, CDE Palm Harbor

To call a specific staff member below, dial 850.350. followed by their extension.

BOARD OF TRUSTEES PRESIDENT Dr. Beatriz Terry Miami

PRESIDENT-ELECT Dr. Jeffrey Ottley Milton

FIRST VICE PRESIDENT Dr. John Paul Lakeland

SECOND VICE PRESIDENT Dr. Dan Gesek Jacksonville

IMMEDIATE PAST PRESIDENT Dr. Gerald Bird Cocoa

SPEAKER OF THE HOUSE Dr. Don lIkka Leesburg

TREASURER Dr. Rodrigo Romano Miami

EXECUTIVE DIRECTOR Drew Eason, CAE Tallahassee

TRUSTEES Dr. Tom Brown Orange Park

Dr. Christopher Bulnes Tampa

Dr. John Coroba Lake Mary

Dr. Bethany Douglas Jacksonville

Dr. Karen Glerum Boynton Beach

Dr. Fred Grassin Spring Hill

Dr. Reese Harrison Lynn Haven

Dr. Bertram Hughes Gainesville

Dr. Eddie Martin Pensacola

Dr. Richard Mufson Miami

Dr. John Pasqual Delray Beach

2 | January/February 2024

EXECUTIVE OFFICE Drew Eason • chief executive officer/executive director

deason@floridadental.org

Ext. 7109

Greg Gruber • chief operating officer/chief financial officer

ggruber@floridadental.org

Ext. 7111

Casey Stoutamire • chief legal officer

cstoutamire@floridadental.org

Ext. 7202

Lianne Bell • leadership affairs manager

lbell@floridadental.org

Ext. 7114

Lywanda Tucker • peer review coordinator

ltucker@floridadental.org

Ext. 7143

Breana Giblin • director of accounting

bgiblin@floridadental.org

Ext. 7137

Leona Boutwell • finance services coordinator

lboutwell@floridadental.org

Ext. 7138

Mitzi Rye • fiscal services coordinator

mrye@floridadental.org

Ext. 7139

Kaitlinn Sendar • fiscal services coordinator

ksendar@floridadental.org

Ext. 7165

ACCOUNTING

COMMUNICATIONS AND PUBLICATIONS Renee Thompson • director of communications and marketing

rthompson@floridadental.org

Ext. 7118

Jill Runyan • director of publications

jrunyan@floridadental.org

Ext. 7113

AJ Gillis • graphic design coordinator

agillis@floridadental.org

Ext. 7112

Kelsey Simmons • communications and media coordinator

ksimmons@floridadental.org

Ext. 7115

R. Jai Gillum • director of foundation affairs

rjaigillum@floridadental.org

Ext. 7117

Kristin Badeau • foundation coordinator

kbadeau@floridadental.org

Ext. 7161

Madelyn Espinal • foundation assistant

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Ext. 7122

FDA FOUNDATION

FLORIDA DENTAL CONVENTION AND CONTINUING EDUCATION Crissy Tallman • director of conventions and continuing education

ctallman@floridadental.org

Ext. 7105

Alyssa Bynum • FDC meeting assistant

abynum@floridadental.org

Ext. 7162

Brooke Martin • FDC marketing specialist

bmartin@floridadental.org

Ext. 7103

Lisa O’Donnell • FDC program coordinator

lodonnell@floridadental.org

Ext. 7120

Deirdre Rhodes • FDC exhibits coordinator

drhodes@floridadental.org

Ext. 7108

Joe Anne Hart • chief legislative officer

jahart@floridadental.org

Ext. 7205

Alexandra Abboud • governmental affairs liaison

aabboud@floridadental.org

Ext. 7204

Jamie Graves • legislative assistant

jgraves@floridadental.org

Ext. 7203

Larry Darnell • director of strategic initiatives and technology

ldarnell@floridadental.org

Ext. 7102

Charles Vilardebo • computer support technician

cvilardebo@floridadental.org

Ext. 7153

Kerry Gómez-Ríos • director of member relations

krios@floridadental.org

Ext. 7121

Megan Bakan • membership coordinator

mbakan@floridadental.org

Ext. 7136

Bettie Swilley • membership coordinator

bswilley@floridadental.org

Ext. 7110

Austin White • member access coordinator

awhite@floridadental.org

Ext. 7100

GOVERNMENTAL AFFAIRS

INFORMATION SYSTEMS

MEMBER RELATIONS

FDA SERVICES | 545 John Knox Road, Ste. 201 • Tallahassee, FL 32303 • 800.877.7597 or 850.681.2996 Scott Ruthstrom • chief operating officer

scott.ruthstrom@fdaservices.com

Ext. 7146

Carrie Millar • director of insurance operations

carrie.millar@fdaservices.com

Ext. 7155

Carol Gaskins • commercial accounts manager

carol.gaskins@fdaservices.com

Ext. 7159

Marcia Dutton • membership services assistant

marcia.dutton@fdaservices.com

Ext. 7148

Porschie Biggins • Central FL membership commercial account advisor

porschie.biggins@fdaservices.com

Ext. 7149

Maria Brooks • South FL membership commercial account advisor

maria.brooks@fdaservices.com

Ext. 7144

Davis Perkins • Atlantic Coast membership commercial account advisor

davis.perkins@fdaservices.com

Ext. 7145

Danielle Basista • commercial account advisor

dbasista@fdaservices.com

Ext. 7156

Kelly Dee • commercial account advisor

kelly.dee@fdaservices.com

Ext. 7157

Jamie Idol • commercial account advisor

jamie.idol@fdaservices.com

Ext. 7142

Maddie Lawrence • commercial account advisor

maddie.lawrence@fdaservices.com

Ext. 7154

Tessa Pope • commercial account advisor

tessa.pope@fdaservices.com

Ext. 7158

Liz Rich • commercial account advisor

liz.rich@fdaservices.com

Ext. 7171

Karina Scoliere • commercial account advisor

karina.scoliere@fdaservices.com

Ext. 7151

Group & Individual Health • Medicare Supplement • Life Insurance • Disability Income • Long-term Care • Annuities Professional Liability • Office Package • Workers’ Compensation • Auto • Boat

YOUR RISK EXPERTS Dan Zottoli, SBCS, DIF, LTCP director of sales • Atlantic Coast 561.791.7744 • cell: 561.601.5363 dan.zottoli@fdaservices.com

Joseph Perretti, SBCS director of sales • South Florida cell: 305.721.9196 joe.perretti@fdaservices.com

Rick D’Angelo, CIC director of sales • West Coast 813.475.6948 • cell: 813.267.2572 rick.dangelo@fdaservices.com

Mike Trout director of sales • North Florida cell: 904.254.8927 mike.trout@fdaservices.com

Dennis Head, CIC director of sales • Central Florida 877.843.0921 • cell: 407.927.5472 dennis.head@fdaservices.com

Today’s FDA | 3

THE DEADLINE TO RENEW YOUR DENTAL LICENSE IS FEBRUARY 28, 2024

28 HOURS OF GENERAL COURSE CREDIT Only 3 hours of the 28 hours of general credit can be practice management course credit

2 HOURS OF PRESCRIBING CONTROLLED SUBSTANCE CREDITS All dentists, regardless of DEA licensing, must complete this course requirement. This 2-hour course is included in the 28 hours of general course credit needed to renew.

2 HOURS OF MEDICAL ERRORS CREDITS

YOU MUST HAVE 30 HOURS OF CE CREDIT TO RENEW YOUR DENTAL LICENSE.

This course is required for all dentists and must be completed each license renewal.

2 HOURS OF DOMESTIC VIOLENCE CREDITS This course is due every third biennium. Check your CE Broker account to confirm the last time you took this course.

2 HOURS OF HIV/AIDS CREDITS This course is only required during your first license renewal cycle.

UPDATED CPR CERTIFICATE You must have a current CPR certification to renew. This course must be live or a “blended course” with the hands-on components in-person and test online. The CPR certification course hours do not count toward the 30 hours required to renew.

LOOKING FOR ADDITIONAL CE CREDIT?

READY TO REVIEW?

The FDA offers free online CE opportunities! You can earn up to 6 hours of CE credit at the convenience of your home or office.

Visit cebroker.com to view the CE credits you currently have or report any remaining credits you need to renew.

Visit floridadental.org/online-CE to learn more about these courses exclusively available for free for FDA member dentists.

Then, visit floridahealthsource.gov to begin the license renewal process.

QUESTIONS? Contact Belle McCreless at bmccreless@floridadental.org or 800.877.9922

president’s message

Here’s to a Successful New Year!

By FDA President Beatriz E. Terry, DDS, MS

Happy New Year 2024! I look forward to a great year at the Florida Dental Association (FDA) and wish you all many blessings.

This issue of Today’s FDA covers oral lesions and the significance they play in our dental professions. The discovery of an oral lesion may often lead to the discovery of a systemic disease.

Dentists may be the first to diagnose a serious medical condition and ultimately save a patient’s life. Fortunately, our dental education teaches us how to provide this service to our patients. This is a perfect example of how we serve as physicians of the mouth.

One of my favorite subjects in dental school was oral pathology. In fact, I enjoyed and excelled at it so much that I got paid to tutor fellow students who were struggling with the course. The money was a welcome plus, too. I think my interest in the subject was on the abnormal, the ugly, the unusual and the intrigue in figuring out what a particular lesion might be.

Skin lesions and oral lesions in the mouth are often interrelated and may be associated with autoimmune disorders and more serious ailments. This interrelationship between medicine and dentistry was very interesting and perhaps one reason I specialized in periodontics.

In addition, soft tissue and hard tissue enlargements fascinated me, and finding their etiology and diagnosis through biopsy was a welcome challenge. I hope you find this topic equally interesting; if not, this issue can provide extra continuous education to your dental practice.

Here’s to a year of professional growth, collective success and continued dedication to the well-being of those we serve!

FDA President Dr. Terry can be reached at bterry@bot.floridadental.org.

MY GOALS OR RESOLUTIONS FOR ALL FDA MEMBERS ARE: 1 May you fill staff shortages with amazing team members.

2 May you get insurance reimburse-

ments in a fair and timely manner.

3 May your overhead go down by 10%!

Today’s FDA | 5

6 | January/February 2024

did you know?

The ADA Has a Guide For Working with Locum Tenens Dentists A locum is a person who temporarily fulfills the duties of another. For example, a locum tenens dentist is a dentist who works in the place of the regular dentist when that dentist is absent, or when a practice is short staffed.

By FDA Chief Legal Officer Casey Stoutamire

Did you know that the American Dental Association’s (ADA) new “Locum Tenens and Dentistry” guide discusses how dental benefit plans should be notified, what information is needed for the plans, and information on billing plans and additional insurance considerations when locum tenens dentists are employed? In addition, thanks to Florida Dental Association (FDA) members

Drs. Sean Tomalty and Jessica Stilley, the ADA claim form now includes a box for dentists to check if the treating dentist is a locum tenens dentist. This will help with the filing of insurance claims. Go to bit.ly/4aidVK2 to access the guide.

FDA Chief Legal Officer Casey Stoutamire can be reached at cstoutamire@floridadental.org.

Today’s FDA | 7

ARE YOU A MEMBER OF

FDAPAC CENTURY CLUB? A portion of your dues is transferred to the Florida Dental Association Political Action Committee (FDAPAC). FDAPAC provides campaign contributions to dental-friendly candidates.

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FDAPAC Century Club members provide additional financial support of $150 or more for state campaigns. FDAPAC dues and contributions are not deductible for federal income tax purposes.

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NEED HELP WITH PATIENT COMPLAINTS? The Peer Review program is designed to help Florida Dental Association member dentists.

Avoid costly legal fees, malpractice suits and Board of Dentistry complaints by using this free service exclusively for members.

Learn more online at FloridaDental.org/PeerReview or by contacting FDA Peer Review Coordinator Lywanda Tucker at 850.350.7143 or ltucker@floridadental.org

8 | January/February 2024

legislative

Florida’s Dental Student Loan Repayment Program

By FDA Chief Legislative Officer Joe Anne Hart

The Florida Dental Association (FDA) successfully passed legislation in 2019 to codify the Dental Student Loan Repayment Program into law. Unfortunately, during the 2019 legislative session, the legislature did not approve the funding needed to implement the program. The good news is during the 2023 legislative session, the legislature finally approved $1.8 million in recurring state funds to support the program. From here, the process is turned over to the Department of Health (DOH), the state agency in charge of developing rules to create the criteria for participation and regulation of the Dental Student Loan Repayment Program. When rules are developed, there is a notice process that allows the public to view the proposed rules before they are finalized. This allows the public to review the proposed structure of how a law will be applied and ask questions that may need clarification.

As a reminder, the Dental Student Loan Repayment Program was created to incentivize dentists to work in rural and underserved areas around the state. To qualify, the dentist must participate as a Medicaid provider and work full-time in a public health setting such as a county health department or community health center. In return, dentists will be eligible to receive $50,000 a year for a maximum of five years. At this time, it is anticipated that the DOH will have rules adopted in time to start the application process in February.

In the meantime, the 2024 legislative session is underway, and legislation has been filed to make revisions to the Dental Student Loan Repayment Program. The proposed revisions would change the mechanism of how funds are distributed. Instead of $50,000 per year, the leg-

islation states that dentists would be eligible to receive 20% of their principal loan amount at the time when applied, but the amount cannot exceed $50,000 per year.

The legislation also adds dental hygienists to receive assistance through the Dental Student Loan Repayment Program. Eligible dental hygienists would be eligible to receive 20% of their principal loan amount at the time when applied but cannot exceed $7,500 per year. In addition to the public health setting, the legislation adds private practice as an eligible place of employment to qualify for loan assistance, as long as the practice treats Medicaid recipients and other low-income patients and is located in a dental health professional shortage area or a medically underserved area. Another new program component requires 25 hours of volunteer dental services per year. The earlier version of the Dental Student Loan Repayment Program would require dentists to apply to the program annually. The new version of the Dental Student Loan Repayment Program makes the program a five-year program once accepted, and dentists and dental hygienists would continue in the program for five years unless they lose their eligibility. The objective is to have continuity of care in the program for those receiving services in these areas. The new legislation removes the limit of 10 applicants per year and adds additional funding to the program totaling approximately $13.2 million.

At the time of this article, the legislature is in session, and this legislation is still being considered. Also, the components of the original Dental Student Loan Repayment Program are being finalized by the DOH for implementation. Ultimately, it is safe to say that the legislature values this program and has made increasing access to dental care a priority for the state.

FDA Chief Legislative Officer Joe Anne Hart can be reached at jahart@floridadental.org.

Today’s FDA | 9

Protecting Your Dental Practice: Tips to Avoid Malpractice Lawsuits

By FDA Services Chief Operating Officer Scott Ruthstrom

Running a dental office comes with its own set of challenges, and one concern that looms large is the potential for a malpractice lawsuit. Legal issues jeopardize your reputation and can lead to significant financial consequences.

To safeguard your dental practice and provide the best possible care for your patients, it’s crucial to implement preventive measures. Here are some tips to help your dental office avoid becoming a victim of a malpractice lawsuit.

Prioritize Open and Transparent Communication Effective communication is key to avoiding misunderstandings and disputes. Ensure your team talks openly with patients, explaining treatment plans, potential risks and expected outcomes. Encourage patients to 10 | January/February 2024

ask questions and address any concerns they may have.

Document all communications in the patient’s record to provide a comprehensive treatment process overview.

Obtain Informed Consent Obtaining informed consent is a fundamental aspect of dental care. Clearly explain the proposed treatment, associated risks and alternative options to the patient.

Use understandable language, and make sure the patient acknowledges their understanding by signing a consent form. Regularly update consent forms to reflect any changes in treatment plans or procedures.

preventive action Preventing malpractice lawsuits requires a proactive approach and a commitment to providing the best possible care for your patients.

Maintain Thorough and Accurate Records Accurate record-keeping is crucial in the dental profession. Document patient histories, treatment plans and outcomes meticulously. In the event of a malpractice claim, detailed records can serve as evidence of the care provided and the patient’s response to treatment. Regularly review and update patient records to ensure they are current and comprehensive.

Stay Informed and Educated Keep your dental team up-to-date with the latest advancements, guidelines and best practices in dentistry.

Attend continuing education courses, seminars and workshops to enhance your skills and knowledge. Staying informed about industry updates improves patient care and demonstrates your commitment to providing high-quality services.

Implement Stringent Infection Control Protocols Infection control is a critical aspect of dental practice, and lapses in this area can lead to serious consequences, both for the patient and the dental office. Follow strict infection control protocols, adhere to guidelines from relevant health organizations and regularly review and update your office’s infection control policies.

Invest in Quality Assurance Programs Establishing a quality assurance program within your dental practice can help identify and address potential issues before they escalate. Regularly review patient outcomes, monitor infection control practices and conduct internal audits to ensure compliance with industry stan-

dards. Implementing a robust quality assurance program demonstrates your commitment to patient safety and satisfaction.

Foster a Culture of Teamwork and Communication A collaborative and supportive team environment is essential for delivering excellent patient care. Foster open communication among team members, encouraging them to discuss cases, share insights and address concerns. A strong team is better equipped to prevent errors and respond effectively to challenges.

Preventing malpractice lawsuits requires a proactive approach and a commitment to providing the best possible care for your patients. By prioritizing open communication, obtaining informed consent, maintaining thorough records, staying informed, implementing infection control measures, investing in quality assurance and fostering a collaborative team culture, your dental office can reduce the risk of legal complications and ensure a safer, more positive experience for both patients and practitioners. Regularly review and update your practice policies to align with industry standards and legal requirements, demonstrating your dedication to continuous improvement and patient well-being. To learn more about how to keep your practice safe and reduce your malpractice risk from experts at The Doctors Company, call 800.421.2368 or go to bit.ly/3Nxl8ME. FDAS Chief Operating Officer Scott Ruthstrom can be reached at scott.ruthstrom@fdaservices.com.

Contact FDAS For Your Insurance Needs! fdaservices.com | insurance@fdaservices.com | 800.877.7597 Today’s FDA | 11

board of dentistry

Florida Board of Dentistry Meets in Gainesville FDA Chief Legal Officer Casey Stoutamire

Consumer member Ben Mirza was absent.

As a reminder, at its August meeting, the BOD revised the rule language on record keeping to the proposed rule (below), which is now in effect.

64B5-17.002 Written Dental Records; Minimum Content; Retention.

A dentist shall maintain patient dental records in a legible manner and with sufficient detail to clearly demonstrate why the course of treatment was undertaken.

The next BOD meeting is scheduled for Friday, Feb. 16, at 7:30 a.m. ET in Ft. Myers.

The Florida Dental Association (FDA) was represented by Board of Dentistry (BOD) Liaison Dr. Steve Hochfelder and Chief Legal Officer Casey Stoutamire. Drs. Jerry Bird, Andy Brown, Jim Haddix and Bert Hughes were also in attendance, as were dental students

12 | January/February 2024

from the University of Florida and dental hygiene students from Santa Fe Community College.

BOD members present included: Dr. Claudio Miro, chair; Dr. Nick White, vice-chair; Drs. Christine Bojaxhi, Brad Cherry, Tom McCawley, Jose Mellado and TJ Tejera; hygiene members, Ms. Karyn Hill and Ms. Angela Johnson; and consumer member, Mr. Fabio Andrade.

(1) Dental Record: The dental record shall contain sufficient information to record each patient/ dentist in person or teledentistry encounter, identify the patient, support the diagnosis, identify and justify the treatment and document the course and results of treatment accurately, by including, at a minimum, patient histories; X-rays (if taken); examination results; test results; records of drugs prescribed, dispensed, or administered; reports of consultation or referrals; identification of all treatments and procedures preformed and when they were performed, and copies of records or reports or other documentation obtained from health care practitioners at the request of the dentist and relied upon by the dentist in determining the appropriate treatment of the patient.

It is much better to be a spectator than a participant in BOD disciplinary cases.

The BOD heard two petitions for variances or waivers. These petitions ask the board to waive a BOD rule in a particular instance; the board can only waive a rule, not a statute. The first petition was from a company that runs prison health care. It was requesting a waiver from the rule requiring all dental practice owners to be dentists. The board denied this waiver as it felt strongly that only dentists should own a dental practice, no matter the setting. The second petition was from a licensed dentist in New Jersey requesting he be allowed to work as a forensic odontologist without a Florida license. The board approved this waiver as he will be practicing under the supervision of the medical examiner and will not be seeing “live” patients.

The BOD heard presentations from the Council on State Governments, the American Dental Association, and the American Association of Dental Boards on their respective licensure compacts. Licensure will be

a hot topic in the legislature during the upcoming legislative session.

While the enactment of a compact can only be done by the legislature, the board was interested in the topic as licensure falls under the purview of the board. Please watch for the FDA’s Capitol Report during the upcoming legislative session for upto-date information on licensure and compacts.

Ms. Hill presented the Council on Dental Hygiene report and the BOD approved three proposed rule revisions. The first revision was putting language in the rule on remediable tasks to dental hygienists that mirrored what is already in statute. The second revision lowered the reactivation of a hygiene license fee by five dollars. The third revision reinstated rule language to require a dental hygiene applicant who graduated from a nonaccredited dental college who failed the hygiene exam on the first attempt to complete a twenty-hour remedial hygiene course offered by

a CODA-approved education institution. The rule language was reinstated because a program now meets this requirement.

The FDA thanks Dr. Miro for his leadership as Chair this past year.

We congratulate Dr. Mellado and Dr. White on their election as chair and vice-chair and look forward to working with them during the upcoming year.

There were seven disciplinary cases and one petition for modification of a final order, and one voluntary relinquishment that included, among other things, the death of a special needs patient after anesthesia in a dental office, failing to provide notice in the newspaper when relocating a dental practice and poor record keeping.

FDA Chief Legal Officer Casey Stoutamire can be reached at cstoutamire@floridadental.org.

Today’s FDA | 13

governance

FDA Governance Update FDA Chief Legal Officer Casey Stoutamire

We made it! As you may recall, for the past several years, the Florida Dental Association (FDA) has been updating its governance structure to ensure it is well-positioned for the future. The Board of Trustees (BOT) and House of Delegates (HOD) have updated the bylaws and manuals recommended by the Council on Ethics, Bylaws and Judicial Affairs. Now, it is time to put those changes into action! Please view the governance timeline on the following page.

On Jan. 22, the FDA introduced a new leadership hub on our website, “Leadership Central.” This is a one-stop shop where members and leaders can go to find information about the governance of the FDA. Here you can find the bylaws and manuals and information about the BOT, HOD, 17th District Delegation, councils, committees, etc.

Under Leadership Central you will find information on the FDA’s leadership program, Leaders Emerging Among Dentistry (LEAD), and details about how to get involved in councils and committees at the FDA level.

This is also where we will house information on how to run for all open FDA leadership positions. Yes, you read that right; the FDA will now hold elections for Secretary, President-Elect (automatically moves to President), six At-Large Trustees, Treasurer, Editor, and Speaker of the House. These positions will be elected by the FDA’s HOD and elections will begin at the June 2024 HOD meeting held during the Florida Dental Convention in Orlando.

The transition from the previous governance structure to the current one is not immediate. To ensure fairness, all those currently in leadership, when the governance structure was changed, will be allowed to finish out their term. It’s important to note that some terms are longer than others. Thus, the first elections being held this summer will be for the six at-large trustee positions, 14 | January/February 2024

Leadership - Central The FDA introduced a new leadership hub on our website, “Leadership Central.” This is a one-stop shop where members and leaders can go to find information about the governance of the FDA. editor, and speaker of the house. While the race for each of the six at-large trustee positions is wide open, there are currently incumbents for the editor and speaker of the house. Dr. Hugh Wunderlich is finishing up his first term as editor, a position with two-year terms and no term limits. Dr. Don Ilkka is finishing his second two-year term as Speaker of the House; however, this position has a limit of three terms.

The next question I’m sure you’re asking is, “What is the timeline for all of this?” All of that information can be found on the following page. The applications for all the open positions can be found on Leadership Central under the Search Committe. Here, you will also find job descriptions with the time commitments for each position. Also, watch your email because part of this process will include a virtual town hall where all FDA members will be invited to attend to hear remarks from the candidates and ask them questions.

The FDA is excited about the changes on the horizon and encourages all of you to get involved at either your local level or by running for one of the open positions.

If you have any questions, please reach out to me at cstoutamire@floridadental.org or 850.350.7202.

JANUARY 22 2024

Applications will be live on the FDA’s website

MARCH 15 2024

Last day to submit first round of applications

APRIL 15 2024

Initial slate announced to House of Delegates and FDA membership

MAY 16 2024

Last day to submit second round of applications

JUNE 7 2024

Final slate announced

JUNE 22 2024

Vote by House of Delegates; winners announced

The following seats on the Florida Dental Association’s Board of Trustees will be open and voted on during the June 2024 House of Delegates meeting: Speaker of the House, Editor, and At-Large Trustee (6 trustee positions). The timeline applies to all open positions.

Live Your “Why” and let’s do good together

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Apply A potential patient applies for the program through an application Screen A DLN/DDS coordinator reviews and screens the applicant Match Coordinator matches qualified patient with a volunteer dentist Treat Volunteer dentist sees patient in their own office

WHYIDENTAL.ORG Dental Lifeline Network is a national nonprofit and strategic partner of the American Dental Association. More than 12,700 volunteer dentists and 3,200 laboratories participate in DLN’s Donated Dental Services programs nationwide.

dental benefits spotlight

Centers for Medicare & Medicaid Services Recently Created Medicare Guidelines

By Bertram J. Hughes, DMD

There is a lot of confusion about Medicare in dentistry. The word “Medicare” is not trademarked. Thus, third-party carriers such as Humana, United Health Care, etc., can use the name as long as they disclose that their plan is not a government plan. This has been confusing due to Medicare Advantage plans. You may have “opted out” of Medicare through a preferred provider organization (PPO) plan you currently take within your office. However, some plans have ignored this “opt-out” request, thus leading to confusion for the public concerning your office, requiring staff time to handle calls from Medicare Advantage recipients and creating an

administrative burden for you and your team. Your office may want to send a certified letter to the insurance plan concerning your participation decision. As an appropriate precaution, you may want to consult your attorney before engaging with the insurance carrier.

Medicare has recently created guidelines for limited dental coverage. This reimbursement mainly deals with patients having organ transplants, cardiac valve replacement, valvuloplasty procedures, chemotherapy and other limited cancer treatments.

Dr. Bert Hughes is the FDA’s representative on the ADA Council on Dental Benefits program and can be reached at berthughes@me.com.

You may visit CMS.gov for a complete listing of guidelines and rules concerning coverage of dental procedures through Medicare.

Today’s FDA | 17

new dentist

Dental Success for the New Clinician The Learning Years

By ArNelle Wright, DMD, MS

The early days of your career will be dedicated to managing more than you’ve ever known about dentistry.

18 | January/February 2024

Becoming a dentist is one thing, but growing into a confident dental provider is another. Your evolution as such can also seem oversimplified and under-emphasized. Once you graduate from dental school, it's game on. Fast forward to "that day" in your mind's eye. You're in practice and seeing more patients than you ever have, all while navigating a new landscape, a new position and arguably a new season of growth. Aside from implementing all of the clinical training you've been taught over the past four years, you're now at the team's helm, and the patients are looking to you for simple answers to sometimes complex cases.

In the first year or so, you can expect not to always know what to do. The flip side is that you may have clinical answers to some cases but may not fully understand why. Allow me to be the first to assure you: this is common, and this is okay. I learned the following statement through a podcast during my first year as a licensed dentist: "You have your learning years and your earning years." - Dr. Bruce Baird. Your learning years are the early days in the field, where you connect the dots clinically with what you've recently learned in dental school. It's the years when you have multiple factors of the profession pulling at you at all times and from every angle. Clinical judgment, your clinical speed, insurance narratives and leading a team of people potentially older than you and in dentistry longer than you've been alive could

be a part of your story. These are all examples of something you may experience as you perform comprehensive dentistry.

What I want you to do early on, though, is to define some things about how you'll navigate the start of a rewarding career: 1. Keeping standards of care in mind: ask yourself what success looks like to you daily. Include your mentors and employers in this rhetorical line of questioning. By entering the profession with your measuring stick, you are setting yourself up for success early on and stewarding your health and well-being from the beginning.

Success for me starts with being comprehensive in my approach to clinical dentistry and equipping my patients with enough information to aid their informed decision-making. Once my patients say yes to treatment, I then strive for success by doing/completing the treatment I've diagnosed.

2. Keep in mind that we're all juggling the multitude of things happening in our lives throughout the day, but you get to decide the ball that doesn't get dropped. With wellness in mind, all of us are so committed to outcomes that we may sacrifice family time and/ or personal time for our patients' urgent needs. Yes, our patients are important; without them, we have no business(es). However, without you, dear doctor, the oral-systemic connection is at greater risk, and more patients potentially go without treatment.

If you haven't figured it out already, during the early days of your new life as a dentist, it's critical that you take as much care of yourself as you care for the team, the practice, and your patients of record. To help with this idea, here are four areas of focus you should remember as new dentists: 1. Develop Clinical Approach.

Also known as clinical judgment, it is critical that you remain curious about dentistry, and I've committed to this in a number of ways.

For starters, I still place a high premium on self-assessment. This is before, during, and after treatment has been rendered. Not only do I constantly make mental notes about my performance, but I also seek new information to guide my decision-making while challenging my implementation.

2. Leverage the learning years.

Although I've mentioned this earlier, there's another point for you to consider about the learning years — more often than not, our colleagues take pride in coming alongside us at various stages of our careers. What's necessary, though, is that you seek mentorship, and once found, you should share your challenges. Only then can your senior colleague help you avoid further pitfalls. What will be even more beneficial is that you build your network and learn different aspects of dentistry so that you can later apply the method that best aligns with your clinical philosophy.

3. Carve out time for your well-being.

Healing the healers has surfaced as a topic of discussion, and it's

only growing in prevalence. By applying our clinical knowledge with our clinical skills, dentists can change lives in some of the most meaningful ways. We are also constantly up against meeting and surpassing the expectations of our patients, which has been to our detriment at times. One of the most valuable advances I've made in my professional and personal life is creating room for my well-being, even in the simplest ways. I believe that when I'm my best, I bring that energy to the workplace and at home.

4. Enjoy the financial increase.

I'll bet this one caught you by surprise because very few share openly on the monetary side of health care. However, you need to reward yourself on at least a small scale for the work you've put in thus far. What you want to avoid doing, though, is overindulging.

Student loans are back in repayment, rates have skyrocketed in the home lending department, and with the ensuing economic recession, the best thing we can all do is plan for the oscillation of the future.

The early days of your career will be dedicated to managing more than you've ever known about dentistry.

During those days, I want to remind you to give each patient the best care you have in your wheelhouse and lead your team with confidence, but when the dust settles, insert time for you to recharge intentionally.

Dr. ArNelle Wright is the FDA’s 17th District Alternate Delegate to the ADA and can be reached at arnellewrightdmd@gmail.com.

news@FDA Renew Your Dental License by February 28 RE M IND ER

Renew Your Dental License

by February 28, 2024.

Reminder: All Florida-licensed dentists must renew their dental license by midnight on Feb. 28. Visit CEBroker.com to review your current continuing education (CE) credits or self-report other courses you may have completed.

When you are ready to renew your dental license, visit flhealthsource.org.

Do you still need CE hours to renew your license? The Florida Dental Association (FDA) offers free online courses exclusively for FDA members at floridadental.org/online-ce.

Recently Retired or Retiring Soon?

If you are no longer practicing or have plans to retire before March 31, please contact our membership team at membership@floridadental.org or 850.681.3629 to complete your retired affidavit through a quick and easy DocuSign form. Most retired members pay little or no dues to maintain their membership and keep access to all their benefits and services.

Register to Volunteer for the 2024 FLA-MOM Today!

Please visit FLAMOM. org and register to volunteer at the state’s largest charitable dental clinic. The Florida Mission of Mercy (FLAMOM) provides dental care to any patient at no cost, with the goal of serving the underserved and uninsured in Florida. The 2024 FLAMOM clinic will be held in Lakeland and will treat residents of Polk County and the surrounding communities.

With a goal of treating 2,000 patients, FLA-MOM needs volunteer dentists, dental hygienists, dental assistants, dental lab techs, physicians, nurses, EMTs and community volunteers. Volunteer with FLA-MOM and enjoy the best two days of dentistry! Go to FLAMOM.org for more information about the ninth FLA-MOM.

20 | January/February 2024

Make Plans to Attend the 2024 Florida Dental Convention Start your year by planning to attend the 2024 Florida Dental Convention (FDC) on June 20-22 at the Gaylord Palms in Orlando. FDC2024 features more than 130 course options, including AI in dentistry, bone augmentation, dental implants, 3D printing, dental photography, full arch restoration and so much more! Featured speakers include Dr. Mark Kleive, Dr. Sarah Jockin, Dr. Sully Sullivan, Ms. Laci Phillips-Newland, Dr. Kevin Suzuki, Ms. Debra Engelhardt-Nash, Dr. Mario Romero and more. FDC is your gateway to explore the frontiers of dentistry, shaping a future that suits your vision. Go to bit.ly/47BH8NM to view all course and speaker details.

FDA Members Get FREE FDC2024 Registration!

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Make plans to attend June 20-22 at the Gaylord Palms Resort & Convention Center. Registration opens March 1 at floridadentalconvention.com.

Elevate Your Practice With the FDA’s \Webinar Series, Rooted in Dentistry!

Stay ahead of the curve in dentistry with webinars designed for you. Boost your expertise with the FDA’s webinar series, “Rooted in Dentistry!” Elevate your practice and earn up to five hours of continuing education credit from the comfort of your home or office. Our online webinars are designed to fit your schedule, ensuring you stay ahead of the curve in the ever-evolving field of dentistry.

As an FDA member, you’ll receive exclusive access to live courses and on-demand recordings for each paid webinar. Don’t miss out on this opportunity to enhance your skills and knowledge. Access all six webinars for $149 or register for individual webinars for only $29. Learn more and register today at floridadental.org/ webinars.

American Dental Association Reaffirms Policy Opposing Direct-to-Consumer Dentistry The American Dental Association (ADA) sent out a press release at the end of the year regarding direct-to-consumer dentistry, which stated the following. In light of recent news reports concerning a direct-to-consumer manufacturer and marketer of teeth aligners, the ADA reaffirms its policy which strongly opposes offers of direct-to-consumer dentistry because of the potential for irreversible harm to individuals, who are treated as “customers” rather than as patients.

Go to bit.ly/3vErXpG to read the press release in its entirety.

Corporate Transparency Act Requires Most Dental Practices to Report Information About Their Ownership The Corporate Transparency Act, enacted

by Congress in 2021, intends to combat the use of businesses as money-laundering operations. Effective Jan. 1, the law now requires certain businesses to report beneficial ownership information to the U.S. Department of the Treasury’s Financial Crimes Enforcement Unit. All existing dental practices and companies that meet the requirements have one year to file before facing penalties.

The ADA created a FAQ document to help dentists with questions. Visit fincen.gov/boi to file a report, view informational videos and webinars, find answers to frequently asked questions, connect to the contact center and learn more about how to report.

Seen on Social Recently, FDA officers participated in a media training with Moore managing directors Liz Underwood and Shannon Smith, a former spokesperson for the governor’s office and reporter. All were engaged and stood ready to interact with members of the media and the public to explain the importance of oral health.

Who will be seen on social next?

Today’s FDA | 21

news@FDA Learn more by visiting our virtual Member Center at floridadental.org

Welcome New FDA Members The following dentists recently joined the FDA. Their memberships allow them to develop a strong network of fellow professionals who understand the day-to-day triumphs and tribulations of practicing dentistry.

Atlantic Coast District Dental Association Dr. Ahron Ben-Jacob, Boynton Beach Dr. Reynaldo Gomez Valenzuela, Port St. Lucie Dr. Cole Herzik, Vero Beach Dr. Samantha Keck, Jupiter Dr. Julia Kohler, Fort Lauderdale Dr. Tracy Liang, Miami Lakes Dr. Anabel Marchante, Pompano Beach Dr. Darren Morgan, Fort Lauderdale Dr. Houssein Moussa Robleh, Palm Beach Gardens Dr. Tika Shah, Fort Lauderdale Dr. Dean Yaron, Fort Lauderdale

Central Florida District Dental Association Dr. Andrea Agudelo, Weston Dr. Leslie Andujar, Lake Mary Dr. Rolando Catral, Orlando Dr. Marie Colon Melendez, North Miami Dr. Kerolos Elsayed, Clermont Dr. Christine Gonzalez-Cacho, Kissimmee Dr. Austin Grovenstein, Gainesville 22 | January/February 2024

Dr. Ryan Jaffe, Longwood

Dr. Liliane Barbosa, Hialeah

Dr. Daniel Monroy Giamundo, Orlando

Dr. Leuman Barreras Pestana, Hialeah

Dr. Alexia Patel, Ocala

Dr. Roxana Colangelo, Hialeah

Dr. Heidar Shahin, Gainesville

Dr. Arsalan Danesh, Fort Lauderdale

Dr. Nataly Yoncee, Sanford

Dr. Denise Dorra, Aventura

Northeast District Dental Association

Dr. Merve Duran, Aventura Dr. Erika Falcon, Hialeah

Dr. Justin Blazejewski, Fernandina Beach

Dr. Claire Freijo Barrios, Hialeah

Dr. Brittany Byrne, Jacksonville

Dr. Edward Gelfand, Toronto, ON

Dr. Jackson Caggiano, St. Augustine

Dr. Liana Kahn, Hollywood

Dr. Renata Dias De Oliveira, St. Johns

Dr. Sarah Laks, North Miami Beach

Dr. Adriana Padron, Jacksonville

Dr. Carolynn Landman, Aventura

Dr. Fernando Padron, Jacksonville

Dr. Milap Lavani, Davie

Dr. Bethany Wolpin, Jacksonville

Dr. Jossie Perera, Miami

Northwest District Dental Association

Dr. Roberto Ramirez de la Cruz, Miami Dr. Miguel Ignacio Solorzano, Miami

Dr. Grayson Bell, Pensacola

Dr. Angela Sun, North Bay Village

Dr. Shaina Day, Gulf Breeze

Dr. James Villena, Miami

Dr. Franklin Hoy, Bradenton

West Coast Dental Association

Dr. Elizabeth Siok, Fort Walton Beach

Dr. Yainet Blanco, Sarasota

Dr. Epiphany Washington, Monticello

Dr. Yalice Cardona, Polk City

South Florida District Dental Association

Dr. Ugne Cepele, Sarasota

Dr. Jose Alberto, Miami

Dr. Susan Davidson, Riverview

Dr. Mary Dahdal, Land O Lakes

In Memoriam

Dr. Jared Folke, Naples

in memoriam

Dr. Mallory Gowey, Clearwater TheFDA FDA honorsthe thememory memoryand and The FDA honors the memory and passing of the following members: The honors passing ofthe thefollowing following members: Dr. Ingmar Andrea Hernandez, Fort Myers passing of members:

GETFREE FREECOURSE COURSETUITION TUITION GET PeterPrincipe Bayer Richard EdwardsATDonald Hansen Clare McCreary Nelson Castellano RobertEttleman Ettleman Gilbert Gilbert Dr. Bakr Jandali, Port Richey FDC2023!

Nelson Castellano Robert Principe AT FDC2023!

Longwood Fort Walton Beach Clearwater Gulf Breeze Largo Tampa Tampa Longwood Tampa Tampa Dr. Joseph Lotfi, Tampa Died:2/12/2023 2/12/2023 Died:1/23/2023 1/23/2023 Died: Died: Age: 83 Age: 69 Dr. Larisa Macedo, Estero Age: 83 Age: 69

Died: 1/12/2023 Died: 12/16/23 Died: 1/12/2023 Age: 80 Age: Age:84 80

Dr.Michael Neil MacInnes, BrandonWendell Hall Chanatry Michael Chanatry Wendell Hall Jacksonville Tampa Dr. Christine Marino, Palm Harbor Jacksonville Tampa Died: 2/12/2023 Died: 2/12/2023 Died: 2/12/2023 Died: 2/12/2023 Dr. Hetienne Mota Macedo, Naples Age: 88 Age:72 72 Age: 88 Age: Dr. Ian Pagel, Winter Haven CharlesInfante Infante SilasDaniel Daniel Charles Silas Dr. Liz Ruano Abad, Tampa Plantation Seminole Plantation Seminole Died:2/15/2023 2/15/2023 Died:1/10/2023 1/10/2023 Died: Dr. Died: Michael Ryan, Sarasota Age: 92 Age: 74 Age: 92 Age: 74 Dr. Martine Saad, Tampa

EdwardStokes Stokes Edward Died: 1/11/2023 Died: 1/11/2023 Age:76 76 Age:

Dr. Maria Celina Sanchez, Wesley Chapel Dr. Amanda Tran, Riverview

Volunteer to be an FDC

Volunteer to11/19/23 be an FDC Died 11/15/23 Died: 11/28/23 Died: Speaker Host.

Speaker Age: 91 Age: 70Host.

Age: 107 Volunteers provide an invaluable service to the Florida Dental Volunteers provide an invaluable service to the Florida Dental Convention. Speaker Hosts will be responsible for introducing Convention. Speaker Hosts will be responsible for introducing the speaker, making announcements in front of the course, the speaker, making announcements in front of the course, passing out and collecting surveys, and contacting convention passing out and collecting surveys, and contacting convention staff if AV assistance is needed. staff if AV assistance is needed.

Volunteering has its perks!

Volunteering has its perks!

• All Speaker Hosts receive a $20 lunch voucher for Exhibit Hall • All Speaker Hosts receive a $20 lunch voucher for Exhibit Hall concessions. concessions.

• Lecture Speaker Hosts receive free course tuition for the hosted • Lecture Speaker Hosts receive free course tuition for the hosted course. course.

Volunteer today at education.floridadentalconvention.com Volunteer today at education.floridadentalconvention.com

QUESTIONS? QUESTIONS?

Dr. Anthony Vasconez, New Port Richey

Contact Mackenzie Johnson at Contact Mackenzie Johnson at mjohnson@floridadental.org or 850.350.7162. mjohnson@floridadental.org or 850.350.7162.

Dr. Michael Williams, Lakeland

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Today’s FDA | 23

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Today’s FDA | 27

Questions and Answers About Oral Pathology

By Today’s FDA Diagnostic Discussion author Dr. Neel Bhattacharyya

What initiated your interest in Oral Pathology?

I always wanted to help my patients in different ways than a typical dentist can, and I found that through oral pathology, I can help not only my fellow dentists but also patients directly in a unique way. Oral and maxillofacial pathology is the specialty of dentistry and pathology which deals with the nature, identification and management of diseases affecting the oral and maxillofacial regions. It combines research, diagnosis and management of patients with oral diseases.

Should the biopsy technique vary by suspected lesion?

The two main methods of biopsy are incisional and excisional biopsy. Many lesions that are easily accessible, small and benign-appearing can be removed in their entirety, which is called an excisional biopsy. Such lesions may include small fibroma, mucocele, papilloma, 28 | January/February 2024

pyogenic granuloma, etc. Other lesions that generate suspicion of malignancy or premalignancy, are large or widespread or require a diagnosis before further treatment or removal is needed can be biopsied by taking a sample of the lesion, called an incisional biopsy. Such lesions may include leukoplakia, squamous cell carcinoma, lichen planus, etc. Other methods, such as cytologic smear, may be used to scrape against the oral tissue and take surface cells or organisms to confirm the presence of yeast or rule out premalignancy. There are other methods of obtaining a biopsy as well.

Do any lesions surprise you in their frequency?

Yes, malignancies always surprise me, especially when least expected, such as in younger individuals or unusual locations. Some other well-known conditions, such as plasma cell gingivitis, have increased in frequency in the last few years. Foreign material-related lesions are also surprising when not expected by the clinician.

Which lesions go under biopsied?

Any time a lesion mimics something innocuous, it gets overlooked, such as gingival carcinomas that mimic rou-

The main concepts in performing a biopsy, rendering a diagnosis and prognosis of lesions have remained steady over the years. The reasons for doing a biopsy also remains unchanged.

tine gingivitis or periodontitis and may only get biopsied late in the disease stage. Pigmented oral lesions may be small, mimic conditions such as amalgam tattoos and get overlooked. Drug-related lesions, especially ulcers, often do not get biopsied due to their transient nature.

Which lesions are the most challenging to diagnose?

In my experience, challenging to diagnose lesions can be divided into clinically challenging and microscopically challenging. Clinically, lesions that mimic routine inflammation are often difficult to diagnose since inflammation in the oral cavity is very common. There are many examples of lesions that are microscopically challenging.

Often, this problem is compounded when a biopsy specimen is altered due to squeezing, crushing or freezing or if the sample size is inadequate, incomplete or shallow, all of which make diagnosis very difficult.

Do you see cyto-salivary staining procedures as valuable?

I am not familiar with the term cyto-salivary which I am interpreting to mean fine needle aspiration of a lesion and is typically restricted to salivary tumors of the major salivary glands like the parotid. We do not get any such samples at our laboratory. However, we do many cytologic smears – good for identifying certain conditions, such as candidal infection – using a simple periodic acid Schiff (PAS) staining procedure, which we perform routinely in our laboratory. We occasionally perform PAS staining for ruling out premalignant changes when a cytosmear from a suspicious lesion is performed by a clinician. However, this technique is prone to errors due to a lack of specificity and sensitivity.

How have instrumentation and staining procedures changed over the years?

We are in an incredible age of artificial intelligence (AI), digitization, and next-generation sequencing. Though our

laboratory does not digitize slides and images routinely, many labs nationwide are going 100% digital. Soon, digital diagnosis with AI-enhanced image analysis will become the way of the future for pathology. Many institutions worldwide, including our department, are participating in research, creating databases and methods of increasing the accuracy of digitally enhanced diagnosis of lesions. Many laboratory procedures have exploded in the last two decades, and new techniques, stains and discoveries are being made daily, making it almost impossible to keep up. The laboratory instruments and automation are extremely advanced and require years of additional training.

What would you like to tell your referring doctors to improve their biopsy technique?

My only advice to referring clinicians is to keep in mind: 1) a deep, narrow specimen is always better than a shallow, broad specimen; 2) for ulcerated lesions, a specimen containing both a portion of the ulcer and a portion of the surrounding “normal” is ideal; 3) crushing, squeezing or letting a specimen dry on the operating surface or placing it in saline/water should be avoided; 4) a specimen from a flat lesion should be submitted on a small piece of cardboard to avoid curling of the tissue; 5) remember to submit a clinical photograph or radiograph (where indicated) – “a picture is worth a thousand words.”

t Today’s FDA | 29

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Q&A How frequently do you have to collaborate on a submitted specimen?

We collaborate with the clinician frequently and believe that a quick telephone call, email or communication in any other form is essential in arriving at an accurate diagnosis and saves a lot of backpedaling and corrections later. It helps improve the care of their patients, which is our ultimate goal. Accurate diagnosis takes a perfect blend of clinical and microscopic input. We often have to contact referring clinicians for additional medical history, previous and current radiographs, clinical photographs and other data. In other words, we collaborate on a continuous basis.

Does your diagnosis go into a de-identified national database?

Only the malignancies are reported to the State of Florida Cancer Registry and only diagnosis and diagnosis/loca-

tion of lesion codes are reported. We do not participate in any national database currently.

How soon after the biopsy does it degrade and not be useful?

Ideally, the biopsy should be placed in formalin (10% formaldehyde solution). A specimen left to dry out on a table or napkin surface for more than 30 minutes may create artifacts and may even render the specimen unreadable. Also, it is important to place the specimen in formalin and not in normal sterile saline or distilled water for more than a few minutes for the same reason.

University of Florida College of Dentistry professor, Dr. Indraneel Bhattacharyya provides insight and feedback on common, important, new and challenging oral diseases. He can be reached at IBHATTACHARYYA@dental.ufl.edu.

Read, Learn and Earn!

Visit floridadental.org/online-ce for this FREE, MEMBERS-ONLY BENEFIT. You will be given the opportunity to review the “Diagnostic Discussion” and its accompanying photos. Answer five multiple choice questions to earn one hour of CE.

Contact FDC Program Coordinator Belle McCreless at bmccreless@floridadental.org or 850.350.7106.

Today’s FDA | 31

oral lesions

Fig. 1

Fig. 2

Fig. 3

Oral Lesions and Specific Diagnoses

By Njood Hawari*, DDS, Neel Bhattacharyya, DDS and Nadim M. Islam, DDS

Dentists, in their day-to-day practice, come across oral lesions that may have overlapping clinical presentation, particularly when it comes to oral bumps and lumps. Overlapping clinical presentations can make specific diagnoses difficult.

This article will briefly present common oral lesions and provide valuable insight for dentists.

Fibroma Irritation fibroma is a reactive fibroepDr. Bhattacharyya ithelial overgrowth in response to local irritants, typically on the buccal mucosa along the bite line (Fig. 1). The labial mucosa, tongue and gingiva are familiar sites. Clinically, it appears as a sessile, dome-shaped lesion with the color of the surroundDr. Islam ing mucosa. It may be ulcerated often upon repeated trauma, such as a sharp tooth edge. It is more prevalent in females between the ages of 40 and 60. Treatment involves excision and identification of the underlying factor.

32 | January/February 2024

Papilloma Papilloma is a low-risk Human Papillomavirus (HPV)-induced oral wart.

It is characterized as a common asymptomatic, exophytic, finger-like growth of the oral mucosa. It accounts Dr. Hawari for 3% of adults and 8% of pediatric oral biopsies. Even though it can be observed anywhere in the mouth (Fig. 2), it mainly grows on the soft palate, with a white or pink color. Papilloma is indistinguishable from other HPV-induced oral lesions. Surgical excision, including the base of the lesion, is advised to prevent recurrence.

Peripheral ossifying fibroma Peripheral ossifying fibroma (POF) is a typical “bump on the gum” lesion with unclear pathogenesis, but it is thought to originate either from the periodontal ligament

or gingival connective tissue. POF appears as a pedunculated or sessile-raised bump with an ulcerated surface on the tooth-bearing gingiva (Fig. 3). Approximately twothirds of the cases occur in young adult females. It may exhibit a high recurrence rate. Local surgical excisions down to the periosteum, followed by scaling of neighboring teeth to remove any potential irritants, may prove curative.

Peripheral giant cell granuloma Peripheral giant cell granuloma (PGCG) may also be limited to the gingival tissues, similar to the POF. (Fig. 4). It has a high incidence in the fifth and sixth decades of life.

PGCGs are mostly deep red or blue nodular masses that can also cause “cupping” alveolar bone resorption, which is radiologically evident. PGCG is usually treated by local surgical excision down to the underlying periosteum/ bone.

Fig. 4 Clinical image displaying a peripheral giant cell granuloma (PGCG) on the interdental papilla between teeth #10 and #11 (blue arrow).

Pyogenic granuloma Pyogenic granuloma (PG) is an exuberant, vascular lesion manifesting as lobulated painless growth, most commonly on the gingiva. PG has a definite female predilection, with the rapid growth and tendency to bleed is a concern for both the patient and the clinician (Fig. 5). Any gingival irritation or poor oral hygiene conditions can be contributing factors. Pregnancy is a common period for its development in response to hormonal changes. The treatment of choice is a conservative surgical excision, followed by histological examination to exclude other more serious pathologic entities.

Mucocele Mucocele is a distinct category of oral lesions where local trauma to mucosal areas with minor salivary glands leads to the spread of mucin into soft tissues, resulting in granulation tissue formation. Clinically, these lesions present as fluctuant, bluish, swollen nodules with a preference for the lower lip primarily due to increased susceptibility to biting (Fig. 6). It is common in children, who are more vulnerable to trauma. While mucoceles are self-healing, surgical excision with nearby minor salivary glands and feeder duct is essential to prevent a recurrence. Microscopic examination is prudent to rule out other malignancies that may present similarly.

t

Fig. 5 Clinical image presenting a bleeding pyogenic granuloma resembling a gingival swelling on the facial gingiva (pointed out by the blue arrow).

Fig. 6 Clinical image featuring a mucocele on a young patient’s lower labial mucosa/ lower lip (blue arrow).

Today’s FDA | 33

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34 | January/February 2024

oral lesions

Papilloma is indistinguishable from other HPV-induced oral lesions. Surgical excision, including the base of the lesion, is advised to prevent recurrence.

Geographic tongue Geographic tongue is not uncommon, with a prevalence of 2% to 3% in the general population without age or gender correlation. It is also known as benign migratory glossitis and lingual erythema migrans. It primarily affects the tongue but can migrate to other oral mucosal sites (Fig. 7). It presents multiple, well-democratic erythematous areas with white circinate borders. The condition recurs and self-limits, with an unknown etiology. No treatment is required, but patient reassurance is essential. In certain instances, it may induce a burning sensation. In severe cases, topical corticosteroids may be beneficial.

Fig. 7 Clinical image of ‘erythema migrans” (ectopic geographic tongue) on the lower labial mucosa/lower lip (blue arrow).

Lipoma A rare benign neoplasm of fat within the oral cavity, which makes up only 1% to 5% of benign tumors of the oral mucosa. Typically, lipomas appear yellowish, painless, soft and smooth-surfaced (Fig. 8). Lipomas are uncommon in children; they are more prevalent in individuals around the age of forty and if present, the buccal mucosa and vestibule are the usual location. The primary management of intraoral lipomas involves complete excision.

Fig. 8

*Resident, Oral & Maxillofacial Pathology

Clinical image showing a lipoma as a yellowish mass on the labial mucosa of the upper lip (highlighted by the blue arrow).

Photo captions: Fig. 1: Clinical image showing a fibroma on the buccal mucosa (blue arrow).

Fig. 2: Clinical image presenting a papilloma on the right side of the lateral tongue (blue arrow).

Fig. 3: Clinical image showcasing an ulcerated peripheral ossifying fibroma (POF) between teeth #4 and #5 (denoted by the blue arrow).

References 1. Brierley, Daniel J et al. “Lumps and Bumps of the Gingiva: A Pathological Miscellany.” Head and neck pathology vol. 13,1 (2019): 103-113. doi:10.1007/s12105-019-01000-w.

2. Zahid, Esha et al. “Overview of common oral lesions.” Malaysian family physician : the official journal of the Academy of Family Physicians of Malaysia vol. 17,3 9-21. 1 Aug. 2022, doi:10.51866/rv.37.

3. Ashika, B K et al. “Intraoral Lipoma: A Case Report.” Journal of pharmacy & bioallied sciences vol. 15, Suppl 2 (2023): S1338-S1340. doi:10.4103/ jpbs.jpbs_143_23.

Today’s FDA | 35

36 | January/February 2024

Today’s FDA | 37

oral lesions

A Clinical Reference Guide to the Treatment of Common Oral Lesions

By Janet Zalucha, DDS; Felipe Nör, DDS, MS, PhD; and David Tindle, DDS, MS

Janet Zalucha

Felipe Nör

This special Today’s FDA Journal article is created as a quick reference for practitioners to assist their patients who present with some of the most common oral pathology manifestations. When encountering these conditions, please consider coordinating care and collaborating with practitioners who have had additional, specialized training in the respective fields. Treatment recommendations for each condition described are included. Note that many of these are considered off-label use of the listed agents. Full prescribing information is beyond the scope of this quick reference guide, so practitioners should thoroughly familiarize themselves with each agent chosen for use.

David Tindle

38 | January/February 2024

Alert Many of the listed medications are considered off-label use. Practitioners should familiarize themselves with prescribing information for each agent chosen and consult with the patient’s PCP when necessary.

Table 1 – Abbreviation Key BMS: burning mouth syndrome ODT: oral disintegrating tablet Tx: treatment QD: once a day (“quaque die”) BID: two times daily (“bis in die”) TID: three times daily (“ter in die”) QID: four times daily PO: by mouth (“per as”) PCP: primary care physician

VDO: vertical dimension of occlusion

Recommended treatment:

OTC: over the counter

1. Clonazepam (1 mg) In the a.m., take ½ to 1 tablet and dissolve in mouth before swallowing. Repeat at bedtime.

U/mL: units per milliliter HH1/HSV1: human herpesvirus 1/ herpes simplex virus 1 HH2/HSV2: human herpesvirus 2/ herpes simplex virus 2 HHV3/VZV: human herpesvirus 3/ varicella zoster virus IgG: immunoglobulin G C3: one of 60 blood plasma complement proteins DSG1/DSG3: group of desmoglein autoantibodies RT: radiation therapy TMJ: temporomandibular joint IMRT: intensity modulated radiation therapy Gy/cGy units of radiation: 1 Gy (gray)= 100 rad = 100 cGy (centi-gray)

Burning Mouth Syndrome1-5 (BMS)

• BMS (glossodynia) is a type of chronic pain disorder

that is typically associated with the anterior two thirds of the tongue. Other intraoral sites may also be involved, such as the hard palate (anterior), and labial mucosa. Importantly, no visible lesions are noted in association with this condition.i-ix

• Most symptoms seem to have a sudden onset, and

may be accompanied by xerostomia, dysgeusia (altered taste), and thirst. Dysgeusia may alter the patient’s capability to taste bitter, sour, and/or sweet.

The pain may decrease during eating; it also tends to be low after awakening, with a continuous progression throughout the day with worsening at bedtime.

• Demographic incidence favors females>males, es-

pecially for peri- and post-menopausal women, ≥40 years old.

• The diagnosis is one of exclusion. Therefore, other

etiologies need to be ruled out (i.e., xerostomia, candidiasis, medications (systemic or topical), nutritional deficiencies (vitamin B12, iron, folate), diabetic neuropathy, autoimmune conditions (Sjogren’s and lichen planus, food allergies, etc.).

2. Clonazepam (0.25 – 0.5 mg oral disintegrating tabs – ODT) Dissolve 1 tab in the a.m. and p.m. and 2 tabs at bedtime.

3. Amitriptyline or nortriptyline (10-25 mg tablets), take 1 tablet at bedtime.

4. Capsaicin (0.025%) cream, disp: 1 tube, apply small amount to affected areas TID/QID. Special Considerations: For Tx #1 and #2: Medication may cause drowsiness; do not drive/operate machinery until considered stable. For #1 Use with caution in elderly due to fall risk.

For #1-3: Consider working with specialist and PCP due to medication nuances and restricted drug schedule.

For #4: Expect increase of discomfort for the first 2-3 weeks (the repeated activation of the nerve fibers may create desensitization of those pain receptors).

Candidiasis1-3,6-12 Oral candidiasis is considered an opportunistic infection primarily by Candida albicans due to a shift in the normal oral microflora induced by medications (antibiotics, corticosteroids, etc.), altered immune status, xerostomia/ hyposalivation, etc. This condition may present clinically in multiple forms.iii,vi,x-xvii Some are listed below.

Candidiasis — Angular Cheilitis (Fig. 1)

• Infection (fungal but can

also be coincident with bacterial) located at the corners of the mouth involving skin and labial mucosa, typically bilateral.

• Characterized by cracking, Fig. 1

erythema, moisture, fissuring, and pain at corners of mouth. t Today’s FDA | 39

oral lesions

• Additional etiology may be vitamin B (riboflavin,

thiamine, folic acid) and/or iron deficiency as well as decrease in vertical dimension of occlusion (VDO).

Recommended treatment: 1. Clotrimazole cream 1% or 2% (OTC). Apply a thin film to corners of mouth TID/QID for 10-14 days and use for 4 additional days after lesions clear (disp: 15 g or 30 g tube). Combine with mupirocin 2% ointment if suspected bacterial co-infection.

2. Nystatin cream or ointment (100,000 U/ml) apply to corners of mouth TID/QID for 14 days (disp: 15 g tube).

2. Chlorhexidine digluconate (0.12%) same directions as nystatin suspension.

3. 3% sodium hypochlorite diluted in water (1:10) same as nystatin instructions, need to rinse thoroughly before seating in mouth.

4. Can use any of the angular cheilitis topical options to paint on the denture.

5. Can use the pseudomembranous options as well (see below).

Special considerations:

3. Iodoquinol/hydrocortisone cream (1%) Apply to corners of mouth TID/QID for 10 days (disp: 15 g tube).

All: Complete denture, partial denture, athletic mouthguard, etc., should not be left in the mouth overnight.

Special considerations:

For Tx #3: Only for complete dentures, not safe for metal clasps/metal substructures (i.e. partials) or soft liners.

• All: Stop using lipsticks and chapsticks, and replace

toothbrush/denture brush when starting treatment, as these can be source of reinfection.

Candidiasis — Pseudomembranous1-3,6-12 (Fig. 3)

Characterized by white • For Tx #1: Typically marketed for athlete’s foot or jock • plaques that often can be itch.

• For Tx #3: Most expensive option.

Candidiasis — Denture Stomatitis1-3,6-12 (Fig. 2)

• Considered a form of erythematous candidiasis associated with the prolonged use of removable prosthesis.

• Limited to areas contact-

ing the internal surface of removable prostheses.

Rarely symptomatic.

• May be symptomatic (mild burning sensation).

• Typically located on palate, buccal mucosa, and dorsal of the tongue.

Recommended treatment:

Fig. 2

Recommended treatment: Denture soaks: 1. Nystatin suspension (100,000 U/ml) soak denture overnight in container with liquid covering denture, change liquid every day for 10 days.

40 | January/February 2024

removed by wiping with dry gauze/scraping off exposing normal or erythem- Fig. 3 atous tissue below.

1. Fluconazole (100 mg capsules) 200 mg loading dose, 100 mg QD for 10-14 days.

2. Clotrimazole (troche 10 mg) dissolved PO 5x/day for 10-14 days (2 troches in succession a.m., 1 p.m., and 2 at bedtime). Do not eat or drink for 20-30 min after use.

3. Nystatin oral suspension (100,000 U/ml) use 15 ml, rinse 2-3min and expectorate QID for 10 days.

Special considerations:

Geographic Tongue1-3,10,15 (Fig. 5)

• For TX #1: Check for multiple drug interactions.

• Erythema migrans/benign • For TX #2: May have nausea, vomiting; contains sugar. migratory glossitis. condition; most • For TX #3: If swallowed, may have nausea, vomiting, • Common cases are asymptomatic.

iii,vi,xiv,xvi,xx

diarrhea. Often high sugar content to mask bitter taste.

Drug-Induced Gingival Overgrowth (DIGO) (Fig. 4)

1-3,13,14

• Prevalence for drug-re-

lated gingival overgrowth with Dilantin (phenytoin) for dentate patients is about 50% compared to Fig. 4 other medications (10% for calcium channel blockers and 30% for cyclosporine)iii,vi,xvi,xviii,xix

• May have hormonal etiology as it is most common for children and teenagers taking Dilantin.

• Amount of enlargement seems to be related to

patient’s susceptibility and oral hygiene. If excellent oral hygiene is present, the amount of overgrowth is significantly reduced or eliminated. Patients taking multiple medications associated with gingival enlargement will have an increase in prevalence, but not in severity.

Recommended treatment: 1. Good/excellent oral hygiene for plaque control.

2. Change medication (if possible).

• Characterized by multiple

Fig. 5

well-demarcated erythematous areas of loss of filiform papillae on the anterior two-thirds of the tongue surrounded by white-yellow scalloped borders. In rare cases, it may also be seen in other intraoral sites, such as buccal mucosa, labial mucosa, soft palate, and floor of the mouth.

• Patients may report a painful or burning sensation with certain foods (i.e. spicy foods).

• De-papillated areas may take a few days to weeks to heal and can occur in new locations.

Recommended treatment: 1. Topical steroid (betamethasone 0.05% cream or fluocinonide 0.05% gel/cream) dry area and apply to affected site(s) TID/QID, do not eat/drink for 20 min after use.

2. Dexamethasone rinse (0.5 mg/5 ml) (disp: 300 ml or more): swish with 5 ml for 2-3 min and expectorate TID/QID; no food/drink for 20 min after use.

3. Zinc supplement.

4. Topical anesthetic (viscous lidocaine 2%): swish with 5-15 ml and expectorate, TID/QID prn pain).

3. Professional plaque control with surgical intervention (gingivectomy).

Special considerations:

4. Chlorhexidine mouthwash (0.12%) BID for 2 min. Do not eat/drink/rinse or use fluoride mouthwash within 30 min of use (especially post-surgery).

Herpes Simplex Virus1-3,9,12,15-17

Special considerations: Discussion with medical team/PCP required to determine if changing medication is possible.

If asymptomatic, no treatment required.

The Human Herpesvirus family includes HH1/HSV1, HH2/ HSV2, HHV3/VZV (plus many others) which are discussed in this section. Following a primary symptomatic infection, the virus will remain dormant in a ganglion until reactivation, then cause symptomatic and/or asymptomatic infections (recurrent).iii,vi,xvi,xvii,xx-xxii t

Today’s FDA | 41

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Full prescribing information is beyond the scope of this quick reference guide, so practitioners should thoroughly familiarize themselves with each agent chosen for use.

Herpes Simplex Virus1-3,9,12,15-17 Acute Herpetic Gingivostomatitis (Fig. 6)

•

HSV1/2 (>90% cases with HSV1)

Special considerations: For children: Avoid viscous lidocaine and topical benzocaine due to association of lidocaine-induced seizures and methemoglobinemia, respectively.

• Infection usually oc-

curs before 30 years of age, most common in patients 6 months to 3 years old.

6. Viscous lidocaine (only adults).

Fig. 6

• Characterized by acute onset, fever, cervical lymph-

adenopathy, nausea, irritability, avoidance of eating due to ulcerative lesions.

For Tx #5: A dyclonine rinse is available only through a compounding pharmacy.

Herpes Simplex Virus 1-3,9,12,15-17 Recurrent Herpes Labialis/Intraoral (Fig. 7)

• HSV1/2, “cold sores,” “fever blisters.”

recurrent infection • Lesions initiate as vesicles that rapidly rupture, creat- • The typically occurs at site of ing ulcerations that frequently coalesce to form larger ulcerations. The lesions present most commonly on keratinized gingiva, non-keratinized alveolar mucosa, and may even extend past the mucosal wet line onto the vermilion border.

• Cases may take 5 days to 2 weeks to resolve.

Recommended treatment: 1. Hydration, analgesics/antipyretics during viral cycle.

Retroviral therapy at first prodrome to decrease severity: 2. Valacyclovir (1 g tabs) 2 tablets at onset of symptoms, then 2 tablets 12 hours after first dose.

Systemic for acute herpetic gingivostomatitis: 3. Acyclovir (200 mg tabs) 5x/day for 5-7 days (for adults, children 12+ years old or >88 lbs (40 kg).

4. For children (<12 years old), acyclovir (suspension) rinse and swallow 15 mg/kg 5x/day for 5 days.

Palliative Care: 5. Dyclonine hydrochloride lozenges (OTC).

Fig. 7

primary inoculation but may also occur at sites supplied by the affected ganglion.

• Lesions may present as vesicles on lip/perioral skin (labialis), or gingiva/hard palate (intraoral).

• Herpes labialis will present with crust covering the ruptured lesions and start to heal.

• Intraoral lesions will rupture and create small ulcerations that may coalesce into larger lesions.

• Prodromal signs (burning, erythema, warmth of site, itching/tingling) typically occurs 6-24 hours prior to the first appearance of vesicles.

• Lesions take about 7-10 days to resolve. for recurrence: • Triggers/stimulants Sunlight Stress Infection Trauma •

•

•

(including dental treatment)

•

t Today’s FDA | 43

oral lesions Recommended treatment: Anti-viral therapy at first prodrome to decrease severity: 1. Valacyclovir (1 g tabs) 2 tablets at onset of symptoms then 2 tablets 12 hours after first dose.

Systemic for labialis: 1. Valacyclovir (500 mg or 1 g tabs), take 1 g BID for 1 day.

Systemic for intraoral: 2. Acyclovir (200 mg tabs) Take 200-400 mg 5x/day for 5-7 days.

3. Valacyclovir (500 mg tabs) Take 500 mg – 1 g BID for 1 day.

Topical for labialis: 4. Penciclovir cream (1%) Apply at first prodrome every 2 hours while awake for 4 days.

5. Acyclovir cream (5%) Apply 5x/day for 4 days.

6. Docosanol (Abreva) OTC cream (10%) Apply 5x/day until healed.

Special considerations: Use sunscreen as preventative for herpes labialis.

Herpes Simplex Virus1-3,9,12,15-17 Herpes Zoster (Shingles) (Fig. 8)

• VZV (HHV3) Varicella Zos-

ter Virus (VZV) is causative agent.

• Primary infection

sensory nerve) is affected, but two or more may be involved. The most common location is the thoracic region. The lesions characteristically terminate at the midline.

• 3 phases of infection: prodrome, acute, chronic. The

prodrome is characterized by sharp, severe pain and tingling associated with the affected dermatome. ext, the acute phase presents with vesicles in the dermatome that will quickly rupture about 3-4 days, with crusting at around 7-10 days. They may take about 2-3 weeks to heal for healthy adults. In the chronic stage, pain may manifest and can persist for more than 90 days after rash development. This is known as post herpetic neuralgia (PHN). Commonly the areas with lesions may heal with scaring and hypo/hyperpigmentation.

• Encourage patients to get herpes zoster vaccine (will

not always prevent shingles but can significantly prevent PHN at a rate of 89% for those 70+ years old and 91% for 50 to 69 years old).

• If the lesions present on the dermatome associated with V1 (ophthalmic branch of trigeminal nerve), including the tip of nose, it is critical to refer to an ophthalmologist.

Recommended treatment: 1. Valacyclovir (500 or 1000 mg tabs) take 1000 mg TID for 7 days within 72 hours of vesicle formation.

2. Famciclovir (500 mg tab) Take 1 tab TID for 7 days within 72 hours of vesicle formation.

Fig. 8

(chickenpox) presents as vesicles on skin and in the mouth that can result in ulcers. Peri- and/or intraoral lesions may be the first sign of the primary infection.

• Reactivation of virus (shingles) tends to occur in older patients and immunocompromised patients, including those with medication- related immunosuppression.

44 | January/February 2024

• Typically, one dermatome (epithelium of affected

Special considerations: Shingles vaccine (Shingrex) to prevent shingles and PHN. If detect lesions associated with V1 (ophthalmic branch of trigeminal nerve), such as tip of the nose, it is critical to refer to an ophthalmologist.

Lichen Planus1-3,18-21 Erosive Lichen Planus and Reticular Lichen Planus (Figs. 9-10)

• Considered a chronic,

inflammatory, immune mediated condition involving mucosal surfaces and skin.iii,vi,xvi,xxiii-xxvi

• Most common in those

• Hyperkeratosis or parakeratosis.

• Hydropic degeneration of basal layer.

• Dense, band-like infiltrate of T-lymphocytes in lamina propria.

Fig. 9

≥40 years old, 3:2 ratio of females:males; rare in children.

•

• Main features for histopathology:

Fig. 10 In the dental setting, 1/3 of patients with oral lichen planus will have cutaneous involvement.

• Debated in medical community if lesions can prog-

ress to cancer (1%-2% possible rate of progression). If patient also has HPV, then potentially there may be an increased risk for squamous cell carcinoma.xxiii

• Different forms: reticular, patch, atrophic, erosive,

• Epithelial rete ridges as “saw tooth” pattern.

• Colloid (Civatte) bodies detected.

• Direct immunofluorescence studies: shaggy

(linear/fibrillar), non-specific deposits of fibrinogen in the basement membrane zone.

Erosive Lichen Planus recommended treatment: Topical corticosteroids Class 1 steroids: 1. Clobetasol propionate (0.05%) gel/ointment, disp: 15 g tube.

2. Betamethasone dipropionate (0.05%) gel, disp: 15 g tube.

Class 2 steroid: 3. Fluocinonide (0.05%) gel/ointment, disp: 15 g tube.

bullous:

Nonsteroidal topical agent:

• Erosive: painful, atrophic, erythematous,

4. Tacrolimus (0.1%) ointment.

ulcerated, usually with white lines (Wickham striae) bordering ulcerations and atrophic areas (Fig. 9).

• Reticular: often asymptomatic, bilateral, posterior buccal mucosa with white lines (Fig. 10).

 If erythematous background check for coexisting candidiasis.

Apply each of these based on location and ease for patient (avoid eating and drinking 20-30 min after use):

• Dry area, apply to site for TID/QID.

• Saturate moist

Fig. 11

gauze or moist makeup remover pad with gel and apply to affected for 20 min BID/TID.

 May occur on any mucosal surface including the dorsum of the tongue.

• Place thin strip of gel in medicament tray and wear for

• Gingival lesions:

Rinse:

• Keratotic: raised, white papules, plaque-like, linear or reticular lesions.

• Erosive or ulcerative (i.e., desquamative

gingivitis): localized or generalized, bleeding, exacerbated even by brushing.

• Vesicular or bullous: raised, fluid filled. Rare, short lived, rupture and leave ulcerations.

• Atrophic: erythema from epithelial tissue thinning.

20 min BID/TID. (Fig. 11)

5. Dexamethasone (0.5 mg/5 ml) Disp 300 ml or more, swish with 5 ml for 2-3 min. and expectorate TID/QID. Erosive Lichen Planus special considerations:

• Consider taking digital impressions for medication

tray fabrication (will avoid further desiccation and desquamation of tissues if using conventional impression taking methods). (Fig. 11)

t

Today’s FDA | 45

oral lesions • First re-evaluation at 2-3 weeks, then maintain at 3-6 month intervals.

Mucous Membrane Pemphigoid1-3,20,22 (Figs. 13, 14, 15)

tions.

• Characterized as a chronic,

• May develop candidiasis while using these medica• For Tx #4: very expensive/not recommended for first line treatment/may burn on application.

Reticular Lichen Planus recommended treatment: 1. If asymptomatic, continue to observe lesions.

2. Determine when necessary to complete incisional biopsy.

Lichenoid Mucositis1-3,18-21 (Fig. 12)

• Although the clinical

manifestations will appear similar to lichen planus, lichenoid mucositis typiFig. 12 cally refers to a group of mucosal lesions from contact with dental materials, contact stomatitis, medications, or dental restorations, in addition to a long list of medications, flavoring agents (i.e., cinnamon, mint flavor), and dental materials including amalgam and gold alloys have demonstrated an association.

• The most common presentation is the erosive type, but the reticular type may also occur.

• If the source of reaction is successfully identified and

removed, the lesions should heal, but this may take several weeks or months and may result in hyperpigmentation.

Recommended treatment: 1. Aim to rule out potential medications/source of reaction.

2. Consider discussing care with PCP if medication changes are possible.

3. Topical agents (see Erosive Lichen Planus section).

Special considerations: Many of the associated medications causing lichenoid mucositis are for managing systemic conditions; changing medication may not be medically recommended.

46 | January/February 2024

vesiculobullous, autoimmune disorder. Often presents with scarring affecting mucous membranes Fig. 13 (oral, conjunctiva, nose, vagina, rectum, esophagus, urethra). Desquamative gingivitis is the clinical term for lesions affecting the attached gingiva and Fig. 14 is the most common oral manifestation.i,iii,vi,xvi,xxiii

• Positive Nikolsky sign

(bulla formed when applying firm lateral pressure on Fig. 15 unaffected mucosa/skin).

(Fig. 15.)

• Females>males, ≥ age 50, rare in children, 20% have skin lesions.

• Lesions usually rupture after 2-3 days. Healing time may take ≥3 weeks.

• Symblepharon: adhesion of the eyelid to eyeball may occur due to lesions on the conjunctiva (leading to scarring, corneal damage, and blindness).

• If patient presents to dentist first, 25% will have ocular lesion (25% of patients first manifesting oral lesions will also develop ocular lesions). It is critical to refer to an ophthalmologist.

• Histopathology:

• Epithelium separates from connective tissue + inflammatory cells = vesicular lesion.

• Inflammatory cells = mainly lymphocytes and

plasma cells, but also neutrophils and eosinophils.

• Direct immunofluorescence studies: linear

deposition of immunoreactants (primarily IgG and C3) on the basement membrane.

Recommended treatment: 1. Obtain biopsy for definitive diagnosis.

2. Topical agents (see Erosive Lichen Planus section).

3. Consider systemic medication (consult with specialist and/or PCP).

Dapsone (25 mg) starting with 25 mg and gradually increase to 75-100 mg/day.

Special considerations: If considering Dapsone, severe side effects, such as anemia/hemolytic anemia may occur, and both baseline and intra-treatment monitoring is necessary.

1-3,20,22,23

(Figs. 16-17)

• Most common type of

the pemphigus diseases.

Presents as small to large bullae which rupture and create extensive ulcerations.i,iii,vi,xvi,xxiii,xxvii

• 60% of cases present with

Fig. 16

and C3 deposition in intercellular spaces.

• Indirect immunofluorescence=if negative may be

an early stage. When positive it may indicate more severe disease.xvi

2. Topical agents (see Erosive Lichen Planus section).

3. Consider systemic medications (consult with specialist and/or PCP).

Prednisone 0.75-1 mg/kg for 7-10 days with taper over 2-3 weeks.

Mycophenolate mofetil (500 mg) take 500 mg-1500 mg BID. Azathioprine, take 1-2 mg/kg daily.

Refer to dermatologist and rheumatologist; dental role is primarily supportive with this condition.

For systemic options, need to closely monitor immunosuppression, renal, and liver function; GI upset is a common side effect.

Fig. 17

oral lesions as first clinical sign (oral lesions are typically “the first to show, and the last to go”).

• Locations: soft palate (80%), buccal mucosa (46%), ventral, dorsal tongue (20%), lower labial mucosa (10%). Positive Nikolsky sign.

• Presents as desquamative gingivitis when gingiva is affected.

• Histopathology:

• Cell-cell adhesions damaged by desmoglein autoantibodies (DSG) leads to suprabasilar clefting.

• Acantholysis (+)Tzanck cells within the cleft.

• “Tombstone appearance” of remaining basal cells.

• Increased DSG1  increased severity of cutaneous disease.

• Direct immunofluorescence studies= IgG/IgM

Special considerations:

• 10% mortality rate,

females>males, ≥ age 40, possible in newborns and children.

disease.

Recommended treatment: 1. Obtain incisional biopsy for definitive diagnosis.

Refer to ophthalmologist.

Pemphigus Vulgaris

• Increased DSG3  increased severity of oral

Radiation Therapy1,3,20,22,24-28 (Fig.18)

• Radiation therapy (RT) of

the head and neck, with or without chemotherapy, may increase the risk for acute and long-lasting Fig. 18 debilitating effects, such as trismus, xerostomia, taste alteration, mucositis, radiation caries, candidiasis, etc.i,v,vi,xvi,xxiii,xxviii-xxxii

• The risk for trismus increases when radiation involves the muscles of mastication and the temporomandibular joint (TMJ). When delivered at 60cGy or more of radiation, the prevalence for trismus is 25.4% with conventional radiation therapy compared to 5% for intensity modulated radiation therapy (IMRT).

t Today’s FDA | 47

48 | January/February 2024

oral lesions

• Mucositis presents as atrophic, erythematous, epithe-

lial sloughing with painful mucosa that may resemble oral ulcers and/or burns. Virtually all radiation therapy patients will experience mucositis, typically starting a week after RT is initiated. The severity for mucositis increases with metallic restorations present, if the dose of RT is ≥200cGy/week, and more so in patients with immunocompromised status (medications, blood values, chemotherapy, etc.).

• Salivary gland dysfunction may lead to xerostomia,

which will exacerbate mucositis. It will also increase the risk for radiation caries, and significantly affect the patient’s ability to eat, speak, function, and their overall quality of life. IMRT has the ability to avoid unnecessary radiation exposure to the major salivary glands. If ≤26Gy, it is possible for the major glands to recover after 12 months.xxxii

Recommended treatment: Topical anesthetics: 1. Viscous lidocaine.

2. Ice chips (melt in mouth, do not chew, swallow, prn for pain).

For systemic analgesics, avoid interactions with current medications.

Avoid under-treating. Opioids may be indicated for pain management if non-opioids alone are not sufficient.

Taste Disorders1,4,5,22,29

• Ageusia is classified as a lack of taste, dysgeusia is

considered a persistent abnormal taste or phantom taste, hypogeusia is a noted reduction in taste, and hypergeusia is an increased sense of taste.ii,iii,v,vi,xxxiii

• Causes for taste and smell disorders may be associ-

ated with infections (bacterial, viral, fungal), medications (multiple medications can affect taste), or trauma (i.e., dental/facial surgery). Taste alterations tend to be less tolerated by patients compared to olfactory alterations alone.

• COVID-19 had a significant impact on taste and smell disorders, with the prevalence of taste disturbances increasing to 71%-88.8% and olfactory disturbances rising to 68-85%.xxxiii

3. Zilactin (OTC).

• Although zinc deficiency is rare, multiple studies and

4. Salt/soda rinse (½ tsp. salt, ½ tsp. baking soda, add to glass of 8-16 oz water, put in refrigerator for 2 hours to chill, rinse and expectorate prn for pain).

Recommended treatment:

5. Magic Mouthwash (viscous lidocaine, Maalox, Kaopectate, diphenhydramine).

Salivary substitutes/stimulants (see Xerostomia section).

Antifungals (see Candidiasis section).

Systemic analgesics.

Special considerations: For Tx #1: Avoid in pediatric patients. Patient needs to be evaluated before, during, and after radiation therapy by a dentist.

For Tx #5: may have high sugar content.

reviews demonstrated patients who had COVID-19 and took a zinc supplement had significant benefit.

If discomfort is reported, topical options: 1. Viscous lidocaine.

2. Diphenhydramine (OTC Benadryl).

3. Dyclonine.

Zinc Supplement: 4. Zinc supplement with B vitamins (Z-BEC OTC) take 1 tab QD with food or after eating.

5. Zinc lozenges (OTC) dissolve in mouth QD/BID. Special considerations: For Tx #1: Avoid in pediatric patients. If associated medication is stopped, may take a few months for taste to return. t Today’s FDA | 49

oral lesions Traumatic Ulcers (Fig. 22)

Ulcers1,3,22

• Ulcers that have a history

Recurrent Aphthous Ulcers

•

Most recurrent ulcers are considered idiopathic but may be a local altered immune response. Multiple recurrences may be associated with Behcet’s, Crohn’s/ inflammatory bowel disease, diabetes, anemia, vitamin deficiency, and immunosuppression.

• Risk factors for developing aphthous ulcers: stress,

trauma, endocrine alteration, diet (acidic foods, gluten), allergies (sodium lauryl sulfate in toothpaste).

May also have a genetic predisposition (ask if parents also have history of ulcers).

• Ulcers will present as painful, episodic, or continuous, can be single or multiple, typically only on nonkeratinized mucosa, with clearly demarcated borders, a central, yellow fibrin membrane, and an erythematous halo surrounding the border.

Minor Aphthous Ulcer (Figs. 19 and 20)

• Size ≤0.5cm.

• Most common recurring aphthous ulcer.

• Typically, will heal after 2 weeks, and rarely leave a scar.

months to fully heal; can leave scars.

• Most common type in patients with HIV/AIDS. • Due to size and presen-

Fig. 19

Fig. 20

lip biting during chewing, aggressive toothbrushing habits, broken teeth and broken oral appliances, sutures, facial trauma, parafunctional habits (i.e. picking at gingiva, biting tongue/buccal mucosa, etc.). If the source of trauma can be removed, then lesion should heal in 2 weeks depending on size of ulcer. If lesion does not heal once the suspected source is removed, an incisional biopsy is indicated.

Burns (Fig. 23)

• There are 2 main types of

burns that can occur in the oral cavity: electrical and thermal burns.

Fig. 23

produce heat up to 3000°C and cause significant tissue destruction.

Electrical burns for the oral cavity usually are associated with a patient chewing through a live wire or the female end of an extension cord that is plugged into a socket.

• 90% of electrical burns in the oral cavity are found with patients who are ≤4 years old.

• Process of burn healing: Fig. 21

tation, may mimic granulomatous or malignant conditions. If present with ≥6 lesions, consider Behcet’s (ask if have any ocular or genital ulcers in past/ present).vi,xvi

50 | January/February 2024

• Trauma can be due to sharp or coarse food, tongue or

• Electrical burns can

Major Aphthous Ulcer (Fig. 21)

• Size >0.5 cm.

• May take 6 weeks to

or identifiable cause from trauma. These may present an enlarged tissue demonstrating past irrita- Fig. 22 tion/trauma (i.e. lesion on fibromas, nodules, exostoses, etc.).

• Immediate to 12 days: Edema.

• Around day 4: Tissue will slough with/without bleeding.

• Several weeks to months: lesion will heal and nerve paralysis, if present, should resolve at this point.

• May require surgical intervention with a specialist (plastics, oral surgeon) to avoid wound contracture of the mouth especially if the burn involves the commissures.

• Thermal burns are associated with foods of

elevated temperatures. This tends to be com mon with foods that are heated in the micro wave and may feel cool on the outside while the inner contents are much hotter.

• Most common locations: Palate, tongue, posterior buccal mucosa. The patient may also present with a burn in the upper digestive tract and/or upper airway. If the upper airway is not affected and the patient is without breathing difficulties, most burns will resolve in 2 weeks, depending on the size.

Recommended treatment: (Recurrent Aphthous Ulcers — Minor, Recurrent Aphthous Ulcers - Major, Traumatic Ulcers, Burns) Topical Anesthetics (see list for Radiation Therapy and Erosive Lichen Planus), also numerous OTC products for “canker sores.”

Triamcinolone acetonide in orabase dental paste (0.1%).

1. Topical steroids/Nonsteroids gels/creams, dexamethasone rinse.

2. Zilactin.

3. Dyclonine lozenges.

4. Viscous Lidocaine.

5. OTC Canker Relief (Canker Cover).

For more severe cases of aphthous ulcers, consider systemic options as well to decrease recurrence: 1. Pentoxifylline (200 mg) take 400-800 mg TID. 2. Colchicine (0.6 mg tablet) take QD/BID. 3. Thalidomide (50 mg) take 50-100 mg BID/TID then gradually decrease weekly to maintenance dose or discontinue.

Special considerations:

Xerostomia1-4,22,26 (Fig. 24)

• The sensation of de-

creased salivary flow can occur for multiple reasons, such as medications/ polypharmacy, cancer Fig. 24 therapies, infection, dehydration, pathosis (blockage-sialolith), systemic conditions (Sjogren’s, diabetes, etc.), and others as well as past surgeries.i,v,vi,xvi,xxx

Recommended treatment: Topical: 1. Rinse (e.g., Biotene, ACT DryMouth, Colgate Hydris DryMouth, etc.).

Mechanical: 2. Lozenges (e.g., ACT DryMouth lozenges, Xylimelts, SalivaSure, etc.).

3. Gum (Sugarfree/Xylitol gum e.g., Spry gum, Trident gum).

Systemic (muscarinic agonists): 4. Pilocarpine (Salagen) (5 mg tablets) Disp: 100 tablets, take 1 to 2 tablets TID, an extra tablet may be taken at bedtime. Max 6 tabs/day.

5. Cevimeline (Evoxac) (30 mg capsules) take 1 capsule QID. Special considerations: Need to increase fluoride exposure (consider Rx fluoride toothpaste, e.g., Prevident DryMouth toothpaste).

For Tx #4 and #5: Mild to moderate side effects include hot flashes, excessive salivation and sudoresis (excessive sweating); check for drug interactions.

Reprinted with Permission from the Michigan Dental Association.

For Tx #4: Avoid in pediatric patients.

References Available Upon Request

Keep patient hydrated.

Janet Zalucha, DDS, is a third-year periodontics resident at the University of Michigan. Felipe Nör, DDS, MS, PhD, is a clinical assistant professor at the University of Michigan School of Dentistry. David Tindle, DDS, MS, is a clinical associate professor and the academic discipline coordinator for oral medicine and oral pathology at the University of Michigan School of Dentistry.

For systemic medications, many side effects can occur, need to coordinate with specialist and/or PCP. Severe/major aphthous ulcers may require corticosteroid injections (shallow on the ulcer bed) to aid with healing.

Today’s FDA | 51

Award Winners 2024 Dental STUDENT AWARD

Ms. Gabriela Hunter RodriGuez

New Dental Leader Dr. KaYcee Wilcox

Public Service Awards Dr. Bao Tran Dao Dr. Christopher Starr Dr. Samira Meymand

Leadership Awards Dr. Greg Chace Dr. Sudhir Agarwal

SPECIAL RECOGNITION AWARD Dr. Katie Miller

HELPING MEMBERS SUCCEED TEAM IMPACT AWARD MS. LIANNE BELL

FDA President Award Dr. Beatriz Terry

Dentist of the Year Dr. Chris Bulnes

J. Leon Schwartz Lifetime Achievement Award Dr. Jolene Paramore

Congratulations to the 2024 FDA Award winners!

They will be recognized at the annual FDA Awards Luncheon held in conjunction with the Florida Dental Convention on Friday, June 21 at the Gaylord Palms Resort & Convention Center. Tickets available to purchase beginning Spring 2024. sponsored by:

FDA

Career Center The American Dental Association, Florida Dental Association and your local dental association all work together to provide members with every level of service and support. This three-tier system forms a cohesive partnership to ensure the success of individual members and their practices, as well as the dental profession.

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SAVE THE DATE

fdc2024 speaker

Managing Inventory for Fun and Profit Six tips to reduce out-of-control supply costs

By Director of Clinical Education, Design Ergonomics Angie Bachman

Each unique opportunity to work with amazing dental teams starts with the “Number Story.”

The numbers tell us where we are and then give us the vehicle to measure the success of the plans in place.

Many years ago, I worked in a very successful practice with an amazing couple of doctors who could perform almost any procedure. The practice was booming — but it was chaos! That wasn’t fun.

As luck would have it, I was at a course and bumped into a dentist who was also a scientist and who made all the things that seemed to be so complicated very easy! Something like having the right supplies, dealing

with room turnaround delays and training new team members; it turns out there’s a science to all this. That started my journey and mission to make this easy for all of us! In June, at the Florida Dental Convention (FDC), we’ll dive into simple and surprisingly easy solutions for all the day-to-day roadblocks you run into when trying to make your practice better, faster and more profitable.

I would encourage everyone with clinical or clinical management responsibilities to attend this program. That includes you, too, doctors!

t

Today’s FDA | 55

fdc2024 speaker The lesson is if you make the systems that support your practice more efficient and more accessible, then doing the dentistry you love will also become more efficient and more manageable. And a whole lot more profitable!

While I’ll cover many efficiency topics in my presentation, let’s highlight one you can do today to make your practice more manageable and productive. It’s all about getting a firm grip on your supplies. And by supplies, I mean everything, from paper towels to cotton rolls, cassettes to implants, handpieces to bonding agents.

Let me fill you in on a couple of secrets: 1. Supply management is knowing what you have at all times.

2. Knowing what you have is only possible if you can see it.

First, get a handle on what you work with day-to-day.

It’s been a long time since you’ve Marie Condo’d your supplies. Get everything out of drawers, cabinets and closets. Sort what you use from what you don’t use. If the product still applies to how you practice today, keep it; if it doesn’t, get rid of it. Everything else is a waste! Donate it or throw it away. If it “sparks joy” but doesn’t apply to how you practice today, take it home. Add it to your “theway-I-used-to-do-dentistry” museum.

Once you’ve figured out what you need, the next step is to centralize your inventory using a visual system to make tracking supply levels simple and fast.

Drawers and cabinets are the biggest culprits when losing control of your supplies. What do we do with drawers and cabinets? We shove as much in them as possible, and once those items are out of sight, they are definitely out of mind. Doctor, could you immediately find what you need if you had to come in for an emergency on a Sunday morning? That alone is a great litmus test to determine if your resupply setup is adequate.

56 | January/February 2024

So, what does it take to create a “visual” system? It’s simple, inexpensive and something you can do at your practice tomorrow.

1. Get inexpensive tilt bins and clear containers - enough to have one space for every item.

2. Maintain a maximum of four-six weeks of resupply inventory.

3. Remove any doors where supplies are located.

4. Get everything out of boxes.

5. Label in sequence.

6. Use logic (don’t put suture materials next to etch).

It’s not rocket science, but it can take some hands-on effort.

Keeping small items in big boxes is not only a huge waste of space, it kills your efficiency when prepping for procedures!

Clear tilt bins and open shelving make it easy to find what you’re looking for, allowing you to check inventory levels at a glance.

So, how do you know if you have a supply issue in the first place? Try a little self-reflection. If you’re frustrated with your supply costs, if you run out of supplies, if it takes a team member more than an hour to place and order, and they have to do it more than once a month — you’ve got issues. Or rather, you’ve got an opportunity. You can get your inventory and supply management under control, and it will save you both money and time. Let me give you an example.

About a year ago, a Florida dentist asked me to help figure out what was holding him back from achieving the financial success he wanted. I visited his practice, and we examined the operation with an open mind ... and uncovered some remarkable data. We found that his supply costs were over 14% of his adjusted production (which is crazy high). This $3 million practice spent, on average, $35,000 a month on supplies. It’s nearly impossible to achieve a reasonable profit margin at that rate. We needed to stop the hemorrhaging.

Before I left, he said, “Angie, you just saved me six figures.” A year later, he proved the truth of that prediction when he reported that his 14% supply cost percentage had dropped to 5%. But what surprised him the most was how much more productive his team was.

For two days, I worked directly with his clinical leads and an office manager who was once a clinician. First, we did an honest review of the “system” he had in place, and I use the term loosely. There was stuff everywhere, very little of it with any sense of organization, and almost none of it visible upon a quick inspection.

That’s my goal for you. It should be your goal, too. I look forward to helping you achieve it at FDC 2024 in June!

We broke down every square inch of his storage, implementing the abovementioned steps and others I’ll touch on at FDC2024. We determined the materials his team needed to do their jobs, where they should be located, and created more innovative (read, “more visible”) ways to store them. In short, we took the supply chaos that many of you are familiar with and created a proper inventory management system that is efficient, easily replicated and simple to train new team members.

The lesson is if you make the systems that support your practice more efficient and more accessible, then doing the dentistry you love will also become more efficient and more manageable. (And a whole lot more profitable!)

Ms. Angie Bachman is a certified dental assistant and director of clinical education and training at Design Ergonomics. Ms. Bachman is a dental practice administrator and dental practice consultant and earned her LEAN Six Sigma Yellow Belt from Bristol Community College. Ms. Bachman can be reached at abachman@desergo.com. She will present the course “Make Inventory Easy: A Practical Lesson In Organizational Excellence (PM06)” on Friday, June 21 at 2 p.m. during the 2024 Florida Dental Convention. Learn more at floridadentalconvention.com.

FLORIDA DENTAL CHATTER This Facebook group is designed for dentists to interact with other members, receive the latest updates and information, and engage with FDA leaders and staff across the country.

This is the place to be in the know!

Join us at facebook.com/groups/floridadentalchatter.

Today’s FDA | 57

fdc2024 speaker

Maximize Your Potential: Practical Ergonomic Tools and Wellness Strategies for Dental Professionals

By Caitlin Parsons, RDH, CEAS, C-IAYT, RYT-500

Reports indicate that up to 97% of dental professionals experience pain in their careers. Due to the nature of our work within the dental industry, instances of work-related musculoskeletal disorders and injuries remain exceedingly prevalent.

In addition, elevated levels of stress and burnout manifest across all dental professionals. Numerous practitioners, including myself, have confronted dilemmas concerning the sustainability of their careers, seeking disability insurance, and even contemplated transitioning to alternative careers due to the considerable pain they experience regularly.

Many dental professionals struggle with what to do and how to take care of themselves to continue providing the 58 | January/February 2024

best care for their patients while enjoying a long-lasting career in dentistry. You might be wondering the same thing. The reality is that there is no universal formula or strategy to prevent pain for every dental practitioner.

However, many tools are at our disposal, which could substantially diminish the risk of injury if harnessed effectively.

My personal experience of pain began within the first year of becoming a dental hygienist. Like many clinicians, I initially overlooked the discomfort, hoping it would eventually subside — until it got so bad I had to confront it.

That’s when I stumbled into my first yoga class. After a few classes of hot yoga, I noticed some relief. However, I remember thinking, “There has to be some kind of yoga out there that is therapeutic and designed for what we do as dental professionals.” After my Google searches came up empty, I knew I had to find a way to make it happen; I didn’t want other dental professionals to face the same challenges. Within six months, I became a registered yoga teacher and completed advanced yoga training with a therapeutic focus. I knew my end goal, so I moved across the country, enrolled in a 1,000-hour yoga therapy training, and became a certified yoga therapist.

Although I found relief through generic yoga classes, it wasn’t until I truly understood yoga therapy and incorporated it into my daily life that I started to get to the root of my pain. I focused on releasing tension, building strength and improving my posture; slowly, my pain disappeared. After, I started to focus on my ergonomics. The first half of my 12 year clinical hygiene career was filled with pain, stress and burnout; I felt really good in the second half of my career. My energy levels, communication and numbers improved.

I started delivering even better care, built better relationships with my patients and team, and became a leader in my practice.

While some of us were taught ergonomics in school, we know that the dynamics shift once we step into the busy dental office. Whether we forget what we’ve learned, technology has evolved, or we’ve established bad habits over time, it’s essential to

While some of us were taught ergonomics in school, we know that the dynamics shift once we step into the busy dental office.

remain current with ergonomic practices. The process isn’t as straightforward as ensuring that you and your patient are in a good position; there’s much more to ergonomics in the dental office. All dental practitioners must continue to refine their ergonomics throughout their careers to reduce additional wear and tear on their bodies.

Beyond enhancing better ergonomics, there are many ways to incorporate healthier habits into your practice as a clinician to reduce aches and pain and, in turn, reduce the risk of burnout. We can utilize different yoga practices throughout our workday that can be done in the office — and even in the operatory.

Here are three different chairside stretches you can incorporate to help you thrive in dentistry.

Cat/Cow: This is one of the most common yoga poses. We can modify this movement to practice chairside.

Start seated with a long spine and open chest. Place your hands on your thighs and relax your shoulders away from the ears. As you inhale, arch your back and broaden across your collar bones. As you exhale, round your back and hug the belly button towards the spine. Repeat this slowly five-10 times.

Lateral Bend: Lateral bends are one of the five basic movements of our spine and play a significant role in supporting healthy posture. From a

seated position, inhale as you raise your right arm overhead, relaxing your shoulders from the ears. As you exhale, slowly lean towards the left, accessing a side-body stretch on the right. Ensure your spine is long. Take five-10 long breaths into the space between your ribs, then repeat on the other side.

Forward Fold at Desk: Forward folds are another important movement for the spine. Start standing with your feet, hips distance apart, facing a desk, chair or wall. Place hands evenly onto a flat surface and keep them there as you walk your feet back behind you until your spine is parallel to the floor. Bend your knees as needed. Relax your head and shoulders and take five-10 breaths into the sides of your body.

Ms. Cailtin Parsons is a registered dental hygienist. She is a certified yoga therapist and certified ergonomics assessment specialist. Ms. Parsons is the founder and ergonomics consultant for The Aligned Hygienist and The Aligned Practice and can be reached at caitlinnparsons@gmail.com.

Ms. Parsons will be presenting the course “Ergonomics and Therapeutic Yoga for Dental Professionals – A Deep Dive” on Thursday, June 20 at 8 a.m. (DD02) and Friday, June 21 at 9 a.m. You can learn about her course offerings at floridadentalconvention.com.

Today’s FDA | 59

2024 FLORIDA DENTAL CONVENTION • JUNE 20-22 • GAYLORD PALMS RESORT • ORLANDO

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Today’s FDA | 63

ENGAGING FLORIDIANS TO SEE THEIR FDA DENTIST In 2023, the Florida Dental Association (FDA) and the Moore agency engaged in proactive media and advertising campaigns to educate Floridians about the importance of routine dental visits, engage patients to find and see their FDA member dentist, and promote the work that FDA dentists are doing to improve oral health in Florida.

Our efforts highlighted the importance of routine dental care for maintaining good oral health and overall health and how FDA member dentists serve as trusted health care partners.

2023 PUBLIC & MEDIA RELATIONS SUCCESS HIGHLIGHTS Public relations, advocacy and media efforts reinforced the FDA as Florida’s advocate and expert on oral health; member dentists’ commitment to the health and well-being of their patients; and the importance of not delaying routine dental care.

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– FLORIDA’S DENTAL DESERTS LEAVE MILLIONS WITHOUT ACCESS TO ORAL CARE Tampa Bay Times, Florida Trend, Health News Florida, Florida Politics

South Florida event will offer 2,000 people free dental care

2023 DIGITAL ADVERTISING SUCCESS Digital ad campaigns reached targeted Floridians throughout the state, engaging them to find and see their FDA dentist using the FDA “Find-A-Dentist” member search directory.

In addition to paid search (Google Adwords) advertising reaching Floridians searching for dental services, we ran two creative ad campaigns displayed on Facebook, Instagram and YouTube.

FIND YOUR PERFECT FDA MATCH:

ORAL HEALTH IMPACTS OVERALL HEALTH:

This video campaign targeted young professionals and families to encourage them to not be nervous about going to the dentist and to find their perfect FDA member dentist match.

This video campaign ran in both English and Spanish to educate Florida families about the impact of oral health on overall health and key health conditions.

While this campaign reached targeted families across the state, it was created to engage Florida’s growing bilingual Hispanic audiences

CAMPAIGN HIGHLIGHTS

1.3+ MILLION

targeted impressions

251K+

completed video views

34K+ ad clicks 56K+ clicks to the FDA

member dentist search

AS AN FDA MEMBER, YOU CAN TAKE ADVANTAGE OF THESE EFFORTS BY: •

Completing your American Dental Association (ADA)/FDA member profile so your profile rises to the top of the search. To complete your profile visit ada.org/myada or contact fda@floridadental.org.

•

Displaying your FDA member logo on your website, social media platforms and marketing. Log into the member section of the FDA website and select “Download member logo.”

•

Sharing this content on your own social media channels. To access campaign content, connect with the FDA on Facebook, Instagram, Twitter and LinkedIn and check your FDA communications.

A Cookbook Approach to Dental Issues

By Richard L. Sherman, D.D.S., M.S

It is well known that the lack of dental literacy is one factor that contributes to many dental issues seen in children and adults. We should make it easier for our members to educate adults and parents of children about their dental health needs.

Wouldn’t it be advantageous to provide a “cookbook” approach to a preventive dental presentation that would encourage more dentists to participate in very needed dental health education?

Over the years, I have realized that there are many approaches to preventing dental caries. Audiovisual support always makes presentations more dynamic and easier to follow for the audience and the presenter. Most importantly, however, it must be simple and informative.

It should be systematic and organized. Try to only go out on tangents if questions lead in that direction.

The first part of the presentation should be simple and brief: “How do we get cavities?’’ The second part of the presentation addresses each step and how to alter it to prevent the formation of cavities.

66 | January/February 2024

Part I: How do we get cavities?

1. Teeth are constantly coated with a “gooey,” “gummy” sticky material called plaque.

2. Plaque is made up of many things, in cluding bacteria.

3. When you eat or drink anything containing sugar, the plaque’s bacteria produce acid.

4. When the acid sits against a healthy tooth, it starts

weakening the enamel (decalcification or demineralization) and, over time, it can cause a cavity.

Part II: How do we prevent cavities?

1. Clean teeth will not decay. Therefore, removing the

plaque (bacteria) from all five sides of your teeth is essential. a. Brushing: twice a day using a manual or electric toothbrush. Brushing will remove plaque from the smooth surfaces of your teeth (cheek/lip side and tongue side).

dental cookbook Brushing the tops of the teeth is important but compromised since some pits and fissures usually do not get clean.

Jack, etc.) cheese after eating a sugary food makes the dental plaque less acidic within two minutes of consumption.

b. Flossing once a day. Flossing cleans in between the teeth where they touch. If you do not floss daily, you leave about half of your teeth surfaces full of plaque.

f. Besides regular soda, diet soda can lead to tooth decay.

Diet sodas and other sugar-free drinks are usually highly acidic, which weakens the enamel on your teeth and makes them more susceptible to cavities and dental erosion.

c. Certain oral rinses can help if recommended in some instances, but brushing and flossing are more important.

2. It isn’t easy to eliminate sugar from your diet, so it is crucial to be a wise consumer.

a. After consuming sugar, the plaque produces about a 20-minute “acid attack” on your teeth. Therefore, the frequency of exposure to sugar is more important to control. Three regular meals a day are fine. However, the in-between snacks should be as sugar-free as possible and healthy. b. How long the sugar stays in your mouth and in contact with your teeth is also important. The retention of sugary foods on your teeth could cause the most problems. It would help to avoid sticky, gooey candy, dried fruit rollups and raisins, especially at snack time. c. Never let your child fall asleep on a bottle or breast.

A water bottle is the best bottle at night or nap time.

However, if that is not possible, you must wipe the teeth with a gauze or washcloth after they fall asleep to remove the milk. Milk contains sugar, and this sugar will “pool” around the teeth (especially the front top) and, over a period of time, can cause severe cavities even before the child reaches two years of age (early childhood cavities).

Saliva flow decreases when you fall asleep; therefore, the natural washing of the sugar milk from the mouth is eliminated. d. Chewing sugar-free chewing gum will help prevent cavities. Chewing gum stimulates salivary flow, which acts as a natural cleansing material. Xylitol, a common ingredient in sugar-free gum, has been found to help prevent tooth decay. e. Cheese can help prevent cavities. It has been shown that eating natural, non-processed (cheddar, Monterey

3. There are ways to make your teeth stronger and less susceptible to cavities.

a. Consuming the proper amount of fluoride (systemic: in water or supplements) during tooth development makes the teeth less prone to tooth decay. Topical fluoride (in water, toothpaste, rinses and applications in a dental office) after teeth erupt helps to strengthen and remineralize weakened tooth enamel. b. Dental sealants (plastic coatings) are the best way to prevent cavities in teeth pits and fissures (grooves).

Sealants seal out food debris, plaque and bacteria in the grooves of the back teeth where the toothbrush bristles cannot effectively clean.

This presentation is simple and usually flows very nicely.

Even so, be prepared for some questions. Usually, just repeating specific segments of the presentation answers most questions. One question that is asked many times is, “My friend never brushes, never flosses and eats junk all day but never gets a cavity, why?” The simple answer: genetically lucky. Many genetic factors affect the susceptibility of teeth to tooth decay. For example, the amount and consistency of saliva. What elements are in the saliva? The position of the teeth — are they crowded or spaced out? Do the teeth have deep grooves, or are they smooth? These items can explain why some are exempt from the standard rules for preventing decay.

Just remember, you are the expert in oral health and prevention. Always feel confident and know that you are increasing the dental literacy of your audience.

Dr. Richard L. Sherman can be reached at kidsmiledoc@gmail.com.

Today’s FDA | 67

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THANK YOU! to Dr. Indraneel Bhattacharyya and Dr. Nadim M. Islam for more than 20 years of contribution to Today’s FDA! Since 2003, Drs. Bhattacharyya and Islam have contributed more than 100 quizzes for “Diagnostic Discussion.”

Dr. Indraneel Bhattacharyya

Drs. Bhattacharyya and Islam can be reached at oralpath@dental.ufl.edu.

Dr. Nadim M. Islam

diagnostic discussion

Diagnostic Quiz

By Drs. Hisham Alshuaibi*, Neel Bhattacharyya and Nadim M. Islam.

A 32-year-old female was presented to Dr. Avi Schetritt, a practicing periodontist at North Broward Center for Laser Periodontics & Implant, Deerfield Beach. Upon examination, Dr. Schetritt noticed a firm but mobile soft tissue lesion on the facial gingiva adjacent to tooth #19 (Fig. 1). The patient mentioned that he noticed the lesion several months ago, and it had grown in size. On palpation, the lesion felt slightly firm with no bleeding tendency. The patient had good oral hygiene, and her medical history was unremarkable. Dr. Schetritt performed an excisional biopsy of the lesion. The excised tissue was subsequently submitted for microscopic evaluation to the UF College of Dentistry, Oral & Maxillofacial Pathology Biopsy Service.

Fig. 1. The clinical photograph shows tissue-colored nodular growth on the buccal gingiva of tooth #19 (Blue Arrow)

Question: Based on the findings, what is the most likely diagnosis?

A. Pyogenic Granuloma B. Gingival Cyst C. Oral Focal Mucinosis D. Parulis or Gum Boil E. Peripheral Ossifying Fibroma t

Today’s FDA | 71

diagnostic discussion A. Pyogenic Granuloma

C. Oral Focal Mucinosis

Incorrect. This is an excellent choice since pyogenic granuloma should always be included in the differential diagnosis for “bump on the gum” lesions. However, the histologic features were not supportive of the diagnosis.

Pyogenic granuloma is a common tumor-like growth of the oral cavity and is non-neoplastic in nature. Pyogenic granuloma is an exuberant tissue response to local irritation or trauma. A smooth or lobulated mass is usually pedunculated, and the surface is ulcerated and ranges from pink to red to purple, depending on the age of the lesion. Typically, it is painless and bleeds easily. They show a striking predilection for the gingiva. It is most common in children and young adults and exhibits a definite female predilection. They are frequently seen in pregnant women. Microscopically pyogenic granulomas show exuberant granulation tissue with innumerable blood vessels and an intense inflammatory infiltrate.

These are treated by surgical excision down to the periosteum, and adjacent teeth should be thoroughly scaled to remove any source of continuing irritation. In the case of our patient, the histopathologic features did not support Pyogenic granuloma.

Correct! Oral focal mucinosis (OFM) is a rare benign tumor-like lesion of unknown etiology, although thought to arise due to the overproduction of hyaluronic acid by local fibroblast. OFM occurs in adults, with higher prevalence in women, between the fourth and the fifth decades of life. These lesions are not associated with mucinosis-related systemic diseases. Clinically, it is most commonly found on the gingiva and presents as a painless, sessile, or pedunculated mass with elastic hardness and showing the same color as the surrounding mucosa.

OMF is treated by surgical excision and does not tend to recur. Microscopically, it shows lobular areas composed of loose myxomatous connective tissue intermixed with occasional capillaries, spindle, and stellate-shaped fibroblasts. (Fig. 2A, 2B). The lobular myxomatous tissue

B. Gingival Cyst

Fig. 2A. H&E section shows loose unencapsulated myxomatous tissue surrounded by dense collagen bundles. (Blue arrows) (x4 magnification).

Incorrect. Gingival cysts are usually cystic, as the name implies, and appear bluish and dome-shaped. Like the lateral periodontal cyst, they demonstrate a striking predilection for the mandibular canine-premolar area (2/3rds of the cases). The gingival cyst of the adult is an uncommon lesion and is considered the soft tissue counterpart of the lateral periodontal cyst. They are invariably located on the facial gingiva or alveolar mucosa and rarely on the marginal gingiva. They arise from the rest of the post-functional dental lamina. Clinically, they are typically painless, dome-like swellings and often appear bluish or bluish-gray. In some instances, the cyst may cause a superficial “cupping-out” of the alveolar bone, which is not detected on radiographs. They are often called “mucoceles” because of their similar appearance, but as stated before, this diagnosis is incorrect since salivary gland tissue is absent in the gingiva. In the case of our patient, the clinical and histopathologic features did not match the diagnosis of the gingival cyst.

72 | January/February 2024

Fig. 2B. H&E section shows loose myxoid connective tissue (Arrowhead) with scattered stellate and spindle-shaped fibroblasts (Blue arrows) (x20 magnification).

is non-encapsulated. Immunohistochemical examination showed diffuse connective tissue positivity to Alcian blue stain ph 2.5, indicating it contained hyaluronic acid (Fig. 3).

D. Parulis or Gum Boil Incorrect. A good choice, but parulis is usually associated with a symptomatic tooth or a dental inflammatory process. These lesions are associated with a draining sinus tract from a local acute inflammatory process, usually of either pulpal or periodontal origin. A parulis represents a mass of subacutely inflamed granulation tissue at the

these lesions with excision down to the periosteum is advisable since recurrence is more likely if the base of the lesion is allowed to remain.

References Available Upon Request

Fig. 3. The alcian blue stained section exhibits fibrillary and loose connective tissue positivity, confirming the presence of abundant hyaluronic acid production. (Blue arrow) (x4 magnification).

distal opening of an intraoral sinus tract. In addition, a draining abscess is usually mildly symptomatic, but here the patient was asymptomatic. A parulis appears angry, red, swollen and more like a pyogenic granuloma than a cyst. Long-standing parulis may become fibrosed and resemble organized pyogenic granulomas or fibroma.

In contrast, the gingival lesion in our patient’s case, the tooth is vital; moreover, the histological features were distinctive for OFM.

E. Peripheral ossifying fibroma Incorrect, but peripheral ossifying fibroma is an excellent guess. Peripheral ossifying fibroma is a common hyperplastic growth occurring exclusively on the gingiva. Like the other bumps on the gum, it is considered reactive rather than a true neoplasm and frequently caused by chronic irritation (i.e., calculus, ill-fitting crown, orthodontic appliances) and/or trauma. Half of all cases occur in the incisor-cuspid area of the maxillary arch. Children and young adults are commonly affected, with the peak incidence range between 10 and 19 years. These lesions tend to occur much more frequently in females. Clinically, peripheral ossifying fibroma appears as a red/pink sessile or pedunculated nodular mass that is firm or hard on palpation. Microscopically peripheral ossifying fibroma composed of inflamed fibrous connective tissue and/ or granulation tissue containing foci of calcified material such as cementum, osteoid and/or bone, in which this feature was not seen in the present case. The recurrence rate is estimated to be up to 20%. Therefore, treating

Dr. Bhattacharyya

Dr. Islam

Diagnostic Discussion is contributed

by University of Florida College of Dentistry professors, Drs. Indraneel Bhattacharyya and Nadim Islam who provide insight and feedback on common, important, new and challenging oral diseases.

The dental professors operate a large, multi-state biopsy service. The column’s case studies originate from the more than 16,000 specimens the service receives annually from all over the United States.

Clinicians are invited to submit cases from their practices.

Cases may be used in the “Diagnostic Discussion,” with credit given to the submitter.

Drs. Bhattacharyya and Islam and can be reached at oralpath@dental.ufl.edu.

Conflict of Interest Disclosure: None reported for Drs. Bhattacharyya and Islam.

The Florida Dental Association is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at ada.org/goto/cerp.

* Resident, Oral & Maxillofacial Pathology

Today’s FDA | 73

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Today’s FDA | 75

career center

FDA’s Career Center The FDA’s online Career Center allows you to conveniently browse, place, modify and pay for your ads online, 24 hours a day. Our intent is to provide our advertisers with increased flexibility and enhanced options to personalize and draw attention to your online classified ads!

Office for Lease, South Miami. Of-

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South Miami dental office with 1,000 sq ft.

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We are a patient focused office dedicated welcoming environment. Dentistry includes

Part Time Hygienist, Ormond Beach. Searching for a part time hygienist

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Interested applicants please send resume.

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76 | January/February 2024

most respected dental offices in Ormond Beach and perhaps Volusia County. For over 40 years (and 30+ years at the current location) we have continued to bring the highest level of dental care and technology. We care about our patients and treat them as family.

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Visit the FDA’s Career Center at careers.floridadental.org.

Post an ad on the FDA Career Center and it will be published in our journal, Today’s FDA, at no additional cost.

Today’s FDA is bimonthly, therefore, the basic text of all active ads will be extracted from the Career Center on roughly the 5th of every other month (e.g., Jan. 5 for the Jan/Feb issue, March 5 for the March/April issue. etc.).

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referred to as the “Venice of America,” is a gem nestled in Southeast Florida that offers an unrivaled quality of life. With its intricate and pic-turesque network of canals, this city is a haven for boating enthusiasts and water lovers. The arts and cultural scene is both vibrant and diverse, with venues such as the NSU Art Museum, which hosts international art exhibitions, and the Broward Center for the Performing Arts, which showcases top-tier performances spanning theater, ballet, and music. Families are drawn to the area because of its commendable school systems, some of which rank among the state’s best, ensuring a solid foundation for the city’s youth. For those with a penchant for the outdoors, Fort Lauderdale doesn’t disappoint. The city offers pristine beaches, scenic parks, and the captivating Hugh Taylor Birch State Park, perfect for kayaking, bird-watching, or simple nature walks. The culinary scene is equally enticing, boasting an array of restaurants that cater to global palates, from sumptuous seafood joints to high-end international eateries. Additionally, Fort Lauderdale frequently receives high liv-ability ratings, reflecting its safety, infrastructure, and the overall satisfaction of its residents. It’s not just a city, but a lifestyle, blending the best of urban living with the charm and ease of a coastal paradise.

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General Dentist, Naples. Job Summary. This position will provide comprehensive dental care to patients in a primary health care delivery system. The dentist assumes the responsibility of providing the best care possible for all of patients. Provide preventive and restorative treatments for

Seeking Qualified Dental Radiographer?

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replace teeth, using rotary and hand in-

and residents during their rotations at

struments, dental appliances, medications,

HCN’s dental facilities as agreed upon with

and/or surgical equipment. Evaluate the

the AEGD Director. Performs other related

current health and condition of the patient’s

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ing the diagnosis and treatment of diseases,

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injuries, and malformations of teeth, gums,

ability to interact with all departments and

and related oral structures. Consults with

t Today’s FDA | 77

career center all levels of staff effectively. May be required

derstanding of and ability to use Electronic

to perform the duties of other employees,

Dental Record. Experience with Denticon

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Bi-lingual in Spanish/ English and/or Creole/

Dental Hygienist in Spring Hill.

We are currently looking for an enthusiastic Dental Hygienist to join our dental team.

SoftDent and Dexis experience a plus but not required. Local Anesthetic license is required. Pay is hourly, plus bonus pay. Job Type: Part-time or Full-time. Salary: Up to $45.00 per hour. Lakeside Family Dental Care. Dr. Grothe & Dr. DiFrancesco. 8454 Northcliffe Blvd. Spring Hill, Florida 34606 Registered Dental Hygienist (Required).

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Today’s FDA | 79

off the cusp

A Common Case of LEGOitis Oh I Wish I Had a Picture

By Hugh Wunderlich, DDS, CDE, FDA Editor

At what age should a child receive his or her first dental exam? When I was in dental school, the recommendation was that a child should visit the dentist at age two. The American Academy of Pediatric Dentistry now recommends a first dental exam when the first tooth erupts. But if you live in Pasco County, like I do, a pediatric patient could be anyone who cannot yet collect social security. So, under 62 is the norm in my neighborhood.

Strangely, the dentition, or lack thereof, of a two-year-old and a 62-year-old is very similar. I used to think age two was too early for an exam. After all, any congenital issues would be spotted by their pediatrician, right? How about an exam at three months? Is that too young? Consider the story of my youngest patient and my earliest “extraction.”

Some years ago, the mother of a three-month-old came in for routine prophylaxis. After an uneventful cleaning and exam, she asked me if I wouldn’t mind examining her son. I looked around the operatory hoping to spot an eager, cooperative cherub of a child with hands pressed into midday prayer. Nope, she reached for a baby bucket and before I could stammer “My mother is calling,” I had young Stewart in my lap.

As I pondered my plight and approach to a restless and reluctant Stewie Griffin clone, his mother began to explain his troubled history. It started some days prior with a lack of appetite and increased irritability. Stewart’s pediatrician noted an eight-millimeter circular opening in the roof of his mouth that seemed new. A subsequent exam by a pediatric ear, nose, and throat specialist revealed an aperture mid-palate with an irregular pustulus perimeter. Blood tests and radiographs were unremarkable for the idiopathic problem. A Computerized Axial Tomography scan was scheduled and the mother was becoming concerned at a suggestion of a history of 80 | January/February 2024

Common things are common except in the rare diagnosis.

syphilis. As I listened to this history, I hoped to have a Dr. Albert Schweitzer moment and instantly recall some rare but long-forgotten Latin-laden syndrome. I must admit I was only half listening. She had lost me at the polymorphonuclear leukocyte count and atypical rhinolithiasis. Fortunately, the long story bored Stewie to the point of a world-class yawn. I was able to get a glimpse and a small finger in to circumvent the hole. Palpation of the perimeter revealed four nodules near the center, raised in a Braille-like fashion. Ah-hah, I knew what this was; Dr. House would have been proud. My boys had the same thing. They had hundreds of them, but never at this location. Dipping in my small curved hemostat, I was able to “extract” the “hole.” The hole was, in fact, a black, circular LEGO®.

Apparently, an attempt at a LEGO® sandwich had forced the plastic part into a fold of the palate, where it planted and grew roots. It was my first LEGO®-ectomy! Suddenly, I did recall some Latin from a pathology class — Clamo, clamatis, omnes clamamus, pro glace lactis. Ok, maybe that Latin did not apply here, but I remember the message: Common things are common except in the rare diagnosis. If you hear hoof beats, think horse, not zebra.

In dentistry, parsimony is the preference for the least complex explanation for an observation. So, the thinking is that if one diagnosis can explain all of a person’s signs and symptoms, then it must be the correct diagnosis, and that rare case of congenital syphilis might, in fact, be a common case of LEGOitis.

FDA Editor Dr. Hugh Wunderlich can be reached at hwunderlich@bot.floridadental.org.

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