Newsletter
Issue 36 | September 2017
The Cancer Crusade Continues [pg 4] Trends in Dentistry [pg 10] The Importance of Early Oral Cancer Detection [pg 20]
“The entire construction process was completed in 60 days as promised. There were no hidden surprises and no unexpected costs. The finish of my office is exceptional and truly reflects my style. The whole experience was a lot less stress than I expected and there was never a moment I felt things were not right” —David Buck, DDS LVIM
C O N S TA N T I N E B U I L D E R S . C O M 2 Washington AGD Newsletter | September 2017
What’s in this Issue The Cancer Crusade Continues ........................................................................................ 4 Preparing Your Practice to Sell .......................................................................................... 9 Trends in Dentistry ................................................................................................................. 10 Back to basics: Why good chart documentation matters ........................................ 12 Is clindamycin dangerous? ................................................................................................. 13 Dental Affiliates, Are you looking for the perfect dental space??? .................................. 18 Biographical Data ................................................................................................................19 Congrats to the 2017 Class of Fellows, Masters & LLSR Recipients ...........................19 The Importance of Early Oral Cancer Detection .............................................................. 20 Cancer Facts and Figures from the American Cancer Society ................................ 21 Henry Schein Donates Medical Supplies ......................................................................... 22 Preventing Cancer Just Got Easier ........................................................................................ 24 2017-2018 MasterTrack Program ...................................................................................... 24 Cervical-thoracic necrotizing fasciitis of odontogenic origin in a diabetic patient . 26 White Paper: Human Papilloma Virus (HPV) and Oropharyngeal Cancer ................ 31 Esthetic Dentistry - Redefine the Cliche .......................................................................... 34 Oral Surgery for the General Dentist ................................................................................ 35 Two Courses on Medical Billing for Dental Practices featuring Dr. Chris P. Farrugia .. 36 Green Dentistry: Marijuana, Opioids and the Effects on Oral Health...................... 37 Introduction to Medical Billing for Dental Practices ..................................................... 38 2017 AGD Membership Application................................................................................... 39 Continuing Dental Education Courses & Events Organization ...............................40-41 AGD Member Benefits ........................................................................................................ 42
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ARTICLES
The Cancer Crusade Continues By: Vicki Munday, RDH, BS
I have long been a crusader for better and early oral/ oropharyngeal cancer screenings. Over the last several years, I have not only been involved with WDHA/ADHA activities, OCF activities, but I have been a product representative for 2 oral cancer early detection companies, all while still practicing clinical dental hygiene 2 days a week. I believe in early detection, proactive referral and patient advocacy. Keep reading and you will understand why.
have seen his hygienist during his treatment. He now must use a high fluoride toothpaste every time he brushes and several oral hygiene aids. He has also lost some teeth. Cause of cancer is unknown. Figure A, is his radiation mask. Figure B is the incision where his fibula was removed. Figure C is the incision to insert the fibula to replace the portion of his mandible that had to be removed. A. B.
About two years ago, I began interviewing oral cancer survivors, mostly to see what we dental health care providers were not doing or what we could do better to serve these cancer patients. What I found out was shocking, not just in what we don’t know or do, but in what the medical world needs to do as well. I will share some of their stories with you to illustrate. These cancer survivors are true warriors in the fight against oral/oropharyngeal cancers. They have been through hell and lived to tell about it. For several of these amazing warriors, it was very difficult for them to share their story. I have tried to honor their words and feelings by not making too many changes. Some of the survivors who shared their journey with me had not been regular dental patients, others had. Granted we can’t find it if they are not in our offices, but we should be reaching out and not only participating in oral cancer run/walks, but be involved in community health fairs. Public education is going to make a huge difference in saving lives. Grab some tissues, these stories might get to you. Patient #1: Male, had regular 6 month hygiene appointments. No history of decay and he was periodontally healthy and stable. His cancer began as a lesion on the lateral border of the tongue, one of the most common places. He had recently started wearing a night guard and thought it was just rubbing his tongue. He was diagnosed at stage II, but the cancer progressed to stage III before treatment started. He was referred to a surgeon at the local school of dentistry and also an oncologist. A tumor board at the university outlined two courses of treatment and gave the patient his choice. Option #1 was surgery with a small amount of radiation or option #2, chemo and radiation. He was told that the outcome would be the same either way. He opted for the non-surgical route. Remember, this patient has never had a cavity. He was never told by his medical team to continue regular dental care during his treatment. He had more than 30 cavities during the first 2 years after his treatment. This patient also had a reoccurrence of cancer 6 months after completing radiation therapy. To date, he has had 4 surgeries, including a mandibulectomy with fibula free flap. So, what this means is that they replaced a portion of his lower jaw with part of his fibula. The surgeon who pioneered the fibula free flap misdiagnosed the reoccurrence, per the patient. When asked how his life has changed, he responded that he used to dream about eating a hamburger or a sandwich. He can only eat moist foods that are the consistency of whipped potatoes. This makes dining out very difficult. He can’t enjoy spicy foods, because of the side effects of radiation. He also misses kissing his wife like he once did. If he could do anything different, he would have had surgery the first time and less radiation, plus he would 4 Washington AGD Newsletter | September 2017
C.
Patient #2: Local car salesman, ignored a chronic sore throat with a cough. He was not regular in his dental visits. When he started coughing up blood, he went to the doctor. Stage III oropharyngeal cancer. Cancer was HPV positive related. Had this man been seen for regular six month care, his cancer still might have slipped by, unless his dental office was performing oral HPV testing. Oral HPV testing has been around for a few years, but until recently it has not gained much traction in the dental world. A new company in Seattle is providing Oral HPV testing for HPV 16 and 18, the two known HPVs to be associated with oropharyngeal cancer. Dr. Quinne Feng is the research scientist behind this test. She earned her PhD. In molecular biology/genetics from Johns Hopkins University School of Medicine and did her Postdoctoral Fellow at Whitehead Institute/ MIT. Her focus was HPV related cervical cancer while at the University of Washington in Seattle. Her saliva assay is specific for HPV 16 and 18. It not only shows if there is HPV 16 or 18, but how much viral load is present down to 10 particles of DNA. For more information: www.Fidalabus.com. HPV testing does not indicate a lesion, but a persistently positive test result for HPV does indicate an increased risk of developing oral cancer. Intensive monitoring and screenings are even more important to detect a lesion at a pre-cancerous stage, where it is almost 100% treatable. (1) (continued on page 6)
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ARTICLES (continued from page 4)
There are nearly 200 types of HPV, but so far, only 16 and 18 are associated with oropharyngeal cancer. 85% of sexually active individuals will be exposed to HPV at some point of their lives. In the United States, more than 1 in 5 adults has cancer causing HPV according to the CDC. (2)
HPV encodes two oncogenes, E6 and E7, that inactivate tumor suppressor genes p53 and pRb to initiate a malignant transformation. HPV is the etiological agent for cervical, anal, vaginal, vulva, penile and oropharyngeal cancers. HPV is site specific, you can have oral HPV but not have it below the waist. HPV can also lay dormant in the body for years or even decades, similar to the chicken pox virus that causes shingles in older adults.
HPV is transmitted:
(3)
Signs and symptoms of oropharyngeal (throat) cancer are: chronic sore throat, the need to clear the throat often, a change in voice from normal to raspy, difficulty swallowing, ear pain, cough and weight loss, per the Mayo Clinic. Patients should know their risk factors. Oral sex is a huge risk factor, with 80% of sexually active people will admit to having had oral sex at some point. We have known for years, and it is well documented that tobacco smoking increases the risk of oral cancer 3 times over a non-smoker. This is also true of marijuana smoking. Excess alcohol consumption increases the risk of oral cancer 2 times over those that do not over consume. Persistent oral HPV infection increases the risk of oral cancer 22 times over. We can’t see it, but we can screen for it. If oropharyngeal cancer is suspected, the Mayo Clinic indicates that an endoscope and or laryngoscope may be used to look for lesions, then a simple tissue biopsy should be performed should lesions be found. MRI, PET and CT scans may also be ordered. (4) 6 Washington AGD Newsletter | September 2017
(5) Patient #3: Female age 39 noticed a white patch under her tongue. Her primary care physician referred her to and oral surgeon who removed it. The biopsy came back negative for cancer but positive for leukoplakia. It reoccurred 7 times with 7 more biopsies. Two years later, with the eighth reoccurrence, she went for a second opinion. It was squamous cell carcinoma in situ, and was removed with clean margins. 8 years later, a red irritation spot developed under her tongue, she was told she had bitten herself and was given a steroid injection. In three months, it developed into a lump and an indurated ulcer. She was then told by the oral surgeon that it was from the tonsillitis she had just recovered from, and it would take several months to heal. The next 3 months were nearly unbearable. Finally, she got another biopsy, and another diagnosis of SCC. The was referred to an ENT with fellowship training in head and neck oncology and microvascular reconstruction. He asked why she waited so long for treatment, that the cancer had been there all along. HPV related cancer 8 years after removal of SCC lesion with clean margins. She had a neck dissection, partial glossectomy, radiation and chemo. She now lives every day to the fullest. Please remember, that Leukoplakia is a clinically descriptive term used for a white patch that does not rub off. The significance of it is determined by the histological findings, which can range from hyperkeratosis to an early stage of invasive cancer or maybe a fungal infection, lichen planus, or other benign oral disease. (6) If you were the hygienist seeing this patient what would you have done for her during her treatment for her mouth pain? There are some new products on the market for patients to swish with for pain control. Forward Science technology, the makers of OralID also have Saliva MAX and SalivaCAINE that can help with lack of saliva and oral pain. SalivaCAINE is a topical rinse containing 5%Benzocaine. Many oral cancer patients have been very happy with the pain relief this offers. www.forwardsciencetechnologies. (7) Patient #4: Female age 46 Dental Hygienist had a lump on the right side of neck below the jaw, that felt like a popcorn hull in her throat. No pain. Patient had been a smoker, and had stopped at age 28. She took vitamins, exercised and lived a healthy lifestyle. Her treatment was robotic laser surgery (continued on page 7)
ARTICLES (continued from page 6)
followed by radiation, but no chemo. Her diagnosis was made after only 3 months because she was persistent. Her cancer was HPV positive related. HPV positive associated oropharyngeal cancer patients have a significantly improved rate of survival. (8) Again, know your HPV status. With HPV testing she might have been able to avoid having her tumor suppressor cells turned off with early intervention. Believe it or not, there has been a decrease in smoking in the US. HPV negative smoking related oropharyngeal cancer is decreasing; however, HPV positive oropharyngeal cancer is increasing. According to the Surveillance, Epidemiology, and End Results (SEER) program’s tissue repository data from 1988 to 2004, the prevalence of HPV negative cancer declined by 50% and HPV positive oropharyngeal cancers increased by 225%. (9) So, great job with your smoking cessation campaigns, but now we need to work on HPV positive cancers. Patient #5: Male, not a regular dental patient, was first diagnosed in 1980 with a tumor on the right side of his mandible. He had surgery and radiation from “cheek bone to breast bone”. During that same year, a tumor was found in a neck lymph node and radical neck surgery was performed. 25 years later, a lesion was detected in his right cheek while seeking the reason his thrush infection was resisting treatment. He had surgery in January 2014. In July of 2015 a lesion under his tongue was found, again on the right side of the patient’s mouth. This gentleman has had some reconstruction, however due to a history of periodontal disease and bone loss he was not a good candidate for maxillary implants, but he does have some in the mandible. When asked if he felt he received good nutritional information, he said in hindsight is was maybe 50/50. He stated that he felt like he recovered quickly from the first surgery and radiation back in 1980, returning to work as a technical writer at Boeing until his retirement at age 64. He also was very involved with a local classic car club for 20 years, editing their newsletter. After the January 2014 surgery, eating became a challenge, as choking was a big issue. Rehab exercises to his atrophied muscles resulted in neck spasms that limited his ability to rehab and increase his opening abilities. Today he chops or purees all his meals. He also relies on supplements to try and rebuild his body and gain some weight back. He went from 128 pounds down to 114. He is now 88 years young and avoids social situations where meals are involved. He no longer works on classic cars. Risk factor for reoccurrence is his history of head and neck cancer. More and more celebrities are coming forward to share their diagnosis of oral and oropharyngeal cancer. In addition to Michael Douglas, Iron Maiden lead singer Bruce Dickinson has shared that his cancer was HVP related. Other names you will recognize that have had various head and neck cancers are: Babe Ruth, Roger Ebert, Eddie VanHalen, George Harrison, Sean Connery, Rod Stewart, Jack Wild, Susan Buffett and Bruce Paltro. I am sure this list could even be longer. As you can see, oral and oropharyngeal cancers are not always easy to detect early with the naked eye. It also seems that there is a reluctance to diagnose it. Many in our dental world, still are not performing Extraoral and Intra-oral cancer screenings. “Published studies, (Horowitz et.al. in two studies ten years apart) show that
currently less than 15-25%of those who visit a dentist regularly report having had an oral cancer screening.” (10) Are you doing an EO/IO on every patient? If not, WHY? Is it to “stay on time”, is it because you have “healthy not at risk patients”, or is it because you are just going to pretend you are a great hygienist and have your patients’ best interest at heart? Or is it that your employer, the dentist is doing his or her version of a thorough and complete oral cancer exam? Think about the stories you have just read. These are but a few of the stories out there about oral cancer survivors. Take a moment to think about the ones who don’t make it. Could you have saved a life if you had taken the time to look? We have the ability and the technology to save lives. We need to stop for a moment and put ourselves in the shoes of the patient, and the family members, who become the care givers and cheerleaders for cancer patients. Cancer happens, it does not care who you are, what you do for a living or how old you are. Early detection, find those small lesions, grain of rice size abnormality, hard, fixed lymph node. Use fluorescent technology to find lesions before you can see them with the naked eye. Take a photo of it under fluorescence and email it to the oral surgeon. Diagram out exactly where the suspected lesion is. Help them to find it. The National Cancer Institute states that the risk factors for Oropharyngeal squamous cell carcinoma (SCC) are: a history of smoking more than 10 packs per year and other tobacco use, which includes Marijuana. Heavy alcohol use. HPV positive, especially HPV-16. A history of head and neck cancer and Betel quid chewing (commonly known as Betel Nut). (11) Use HPV saliva testing to find HVP 16 or 18 that are known to cause oropharyngeal cancer. The saliva test shows DNA of HVP before you can find a lesion. The lesions, however, are not in areas that we as clinicians can typically see, so this is our only way to find the potentially cancer causing HPV lesions. Remember, HPV like chicken pox can lay dormant in the body for years and decades. Just because someone has been married for 30 plus years does not mean they did not contract HPV as a younger person being sexually active. Today, over 90% of oropharyngeal cancers are caused by HPV 16 or 18, compared to just 40% just over 30 years ago. The lifetime risk of having an HPV infection in the population is over 90%. HPV is transmitted via skin to skin, digitally, orally, and vertically during child birth. HPV is not a female disease. Men are 3 times more likely to develop HPV related cancer as women are. Remember there are over 200 types of HPV. We, you and I can save lives; the lives of our patients, the lives of our friends and family. The life you save is more important than staying on time! Anyone at any age can get oral/oropharyngeal cancer. Trust me, you find oral cancer, your patient will thank you; mine did. Resources: 1, 3, 5, Qinghua Feng PhD., Fidalabus.com 2. The Center for Disease Control 4. Mayo Clinic website – oropharyngeal cancer 6. Neville BD, Day TA; Oral Cancer and precancerous lesions. CA Cancer J Clin 52 (4):195-215 2002 July-Aug. [PUBMED Abstract] 7. Forward Science Technologies 8. Ang KK, Harris J, Wheeler R, et al.: Human Papilloma virus infection and survival in oral SCC: Otolaryngeal Head (continued on page 8) washingtonAGD.org
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ARTICLES (continued from page 7) Neck Surg. 125 (1) 1-9 2001 [PUBMED Abstract] 9. Surveillance, Epidemiology and End Results (SEER) data 1998-2004. 10. Oral Cancer Foundation Website 11. National Cancer Institute Website The Cancer Crusade Continues Authored by: Vicki Munday, RDH, BS Regional Coordinator Oral Cancer Foundation Contact at: vicki.ocf.wa@gmail.com
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ARTICLES
Preparing Your Practice to Sell By Rod Johnston, MBA, CMA
Whether you are approaching retirement age or just thinking about a transition, there are several things you can do to prepare your practice for sale. Doing these things may help eliminate headaches, increase your sales price, and make your transition smoother. Here are a few tips: 1. Assess your equipment. Upgraded practices sell faster. If you are more than five years away from retirement, I recommend a few upgrades such as digital x-rays, recover your chairs if needed and freshen up the paint. If you’re closer than five years, you will not get the tax benefit of major upgrades, so stick to the paint and carpet. 2. Clean up your accounts receivable. Reimburse patient credits, collect old accounts and keep the A/R current. 3. If you have an associate, make sure you have an associate agreement with a non-compete. 4. If you have an employment agreement with your corporation and you are a C-Corporation, you may need to change your corporation a few years before retiring. Consult your tax accountant. 5. Consult your financial advisor and tax accountant. How much do you need to retire? How much do you have? What are the tax consequences? 6. Get a practice valuation to see what proceeds you will get from the sale. 7. Be realistic in the time it takes to sell. In remote areas, it can take a year or two or more. Metro areas, typically can sell 6 to 9 months and even faster in good economic times. 8. Keep your production up or increase it. I see dentists slow down all the time in their last few years. Buyers and banks don’t like to see a practice where production goes down every year. 9. Assess your staff. Do you have too many staff? Do you have one that should have been let go seven years ago? 10. Have a practice assessment performed by a qualified consultant. Many will do it for free or a small fee. This may help show you some areas to improve over the next few years. We have a consultant on staff who can do a free assessment and snapshot valuation. By focusing on these items in the coming years as you near retirement, you will avoid having your practice production and thus the price of your practice go down in your later years.
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ARTICLES
TRENDS IN DENTISTRY Authored by Rodney D. Johnston, MBA, CMA In the investing world, there is a saying that says “the trend is your friend”. If you know where the market is trending, you will improve the returns on your investments. Go against the trend and you end up broke. In this article, we will take a look at the dental industry and how it has changed from year 2000 to where we are today. We start by looking at the demographic of the average dentist in the United States. In 2000, 75% of dentists were under the age of 55. Dentists’ average retirement age was 62 years old. Approximately 98% of all dental practices were solo practices. The corporate practice concept was in its infancy at the beginning of this century. Within the dental practice itself, the average patient spent $200 per year on dental treatment. Digital x-rays were not common in a practice and crown milling machines like cerec and E4D were in their infancy and not too reliable. Fast forward to the year 2017, we have 50% of dentists over the age of 55. The average retirement age is up to 68. Solo practices make up 83% of all practices with corporate
practices growing steadily. There are approximately 7,000 practices that are classified as group practices. On a local note, Washington State has been working on legislation to allow non-licensed dentists to own dental practices. If this passes, corporate practices will continue to grow. Another interesting trend is that in 2016 there were 5,000 retiring dentists across the United States. Also, in 2015, there were 4,000 students who graduated from dental school. Average school debt has gone from $140,000 in 2000 to nearly $260,000 in 2016. Of the graduating dental students, 51% were female. According to an ADA poll of dental students, approximately 50% of female students said they do not want to work full time as a dentist throughout their entire dental career. Another statistic found that 60% of dentists under the age of 44 are female. Taking a look at practice and profitability trends, we find that practice gross production is up since 2000, collections are down and overhead has gone up. Much of this can be attributed to insurance reimbursements going down. (continued on page 11)
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10 Washington AGD Newsletter | September 2017
ARTICLES (continued from page 12)
The average dental patient now spends $351 per year on dental treatment. Technology has greatly improved with reliable milling machines, digital x-rays and practice management systems. On a more positive note, if you are a graduating dentist, the job outlook is excellent. Especially with the number of dentists now reaching retirement age. Also, practice values are at an all-time high with low interest rates and not many practices currently on the market. Studying these and other trends will help you in growing your practice. Knowing which way certain trends are going will also help you in making career decisions whether you are a new graduate, early career dentist, or nearing retirement. Rodney D. Johnston, MBA, CMA Omni Practice Group 6513 132nd Ave NE #200 | Kirkland, WA 98033 | Office: 206-979-2660
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ARTICLES
Back to basics: Why good chart documentation matters By: Melissa Moore Sanchez, CIC There are many good, even compelling reasons to properly document your patient’s visits to your practice. Memorializing conversations, treatment plans, patient compliance, and patient consent are just a few. Poor chart documentation can set a dentist up for significant challenges if they’re named in a lawsuit, if a subsequent dentist is now providing care to the patient and is trying to understand the previous treatment plan, or if the patient has requested to view their records.
attorney will have a field day and it’s not going to go well for the dentist. Ask yourself what meets the standard of care and if your treatment falls within those guidelines. If it doesn’t, don’t do it.
Your chart notes should always include your observations when examining your patient and their radiographs. This should be followed with a diagnosis, which then correlates with your treatment plan and what comes next. All prescription or over-the-counter medications must be documented, including the dental nexus for why you’re prescribing. Your discussions with the patient about their treatment plan or any concerns they have should also be documented using PARQ (Procedures, Alternatives, Risks, Questions), SOAP, or whatever acronyms you use. It is not necessary to repeat the PARQ discussion for each visit unless your treatment plan has changed, then you need to have another discussion. However, it is necessary that you consistently practice the same routine with each of your patients.
Patients that are threatening or using profanity should be quoted. If you’re uncomfortable placing the language in your chart, use the first letter, the appropriate number of blanks, and then the last letter for each word used.
Some of the most common documentation errors are: not charting the PARQ discussion, leaving out the diagnosis or the diagnosis is apparent from the radiograph but isn’t noted in the record, no treatment plan, failure to document prescriptions or OTC medications and why they’re prescribed, and not documenting shortfalls in the treatment and subsequent follow-up efforts by the dentist. And what about the noncompliant patient? No shows, frequent cancellations, or patients trying to dictate their own care should be documented in minute detail. One of the most common examples we see is patients who refuse radiographs but want the dentist to continue treating them. What very often happens is, even if the patient has signed a release form, and even if the dentist warns of risks associated with the inability to properly diagnose, eventually an issue will materialize that could’ve been caught with radiographs, and the patient will have a limited memory of the dentist’s earlier warnings as they prepare to sue the dentist. And consider for a moment; how do you think that would play out in a court of law? The patient, who is not a dental expert, has been allowed to dictate their care. And the dentist, who is the expert, has allowed it. Hint – the plaintiff 12 Washington AGD Newsletter | September 2017
If you’re not currently charting patient quotes with quotation marks, begin that new habit today; it’s one of the easiest and best tools in your risk management arsenal! Patient quotes carry a high degree of credibility with a jury if you get sued.
Other examples where charting quotes is appropriate: patients that don’t want to follow your recommended treatment plan, e.g. “I can’t afford that right now. Is there something else we can try?” Or when a patient is pleased with their dental care, e.g. “I just love my new dentures; they feel great!” If the patient changes their tune later, you’ve created a credible history of the patient’s own comments in your dental record. HIPAA gives your patients the right to view their dental records, so please avoid making disparaging remarks in the record. I once worked in a teaching hospital and came across a surgery report that had been dictated by the surgeon. He described his patient as having “thighs the size of a baby whale.” Can you imagine how that patient would’ve felt if they had read their doctor’s remarks? Lawsuits have been lost, not because the dentist didn’t meet the standard of care, but because of inappropriate comments in the dental record. And finally, if you work in a private dental group setting, provide your services in a volunteer clinic, or work for a tribal clinic, it is imperative that you be particularly diligent with your documentation. In these situations it’s not unusual for multiple dentists to see the same patient. You must always be in compliance with Washington State laws and provide treatment that meets the standard of care. Your progress notes and observations should be as detailed and explicit as possible. If you get sued, how thoroughly you document your records could make all the difference between winning a defense verdict or losing to a plaintiff verdict. Sounds like a compelling reason to practice good chart documentation, doesn’t it?
ARTICLES
PHARMACOLOGY
Is clindamycin dangerous? Mark Donaldson, BSP, ACPR, PHARMD, FASHP, FACHE ¢ Jason H. Goodchild, DMD
T
his year marks the 40th anniversary of the World Health Organization’s WHO Model List of Essential Medicines.1 This list denotes the most effective and safe medicines required to address priority conditions and diseases in a health system, and clindamycin has been on this list since its inception. The American Heart Association has recommended prophylactic antibiotic regimens for dental and respiratory tract procedures since 1955, and clindamycin has been a core component of these recommendations since 1977.2,3 Given these endorsements and others, clindamycin may be considered one of the most important antibiotics in the anti-infective armamentarium, yet concerns around its safety and efficacy persist.
The good
Clindamycin is a lincosamide antibiotic that was first synthesized in 1967 and is approved by the US Food and Drug Administration (FDA) for the treatment of anaerobic, streptococcal, and staphylococcal infections. Clindamycin achieves high intracellular levels in bone and phagocytic cells and is able to reduce toxin production in toxin-eluting strains of streptococci and staphylococci pathogens (ie, staphylococcal toxin associated with toxic shock syndrome).4 This antibiotic has been especially useful in treating infections of the submandibular space (Ludwig angina), peritonsillar cellulitis, and peritonsillar abscess and is considered a drug of choice for many other odontogenic infections.
Clindamycin’s mechanism of action involves binding to the 50s ribosomal subunit of bacteria, disrupting protein synthesis by interfering with the transpeptidation reaction and thereby inhibiting early chain elongation. Even at subinhibitory concentrations, clindamycin may potentiate the phagocytosis and opsonization of bacteria.5,6 By disrupting bacterial protein synthesis, clindamycin causes changes in the cell wall surface, reducing adherence of bacteria to host cells and increasing intracellular killing of susceptible organisms. The medication also exerts an extended postantibiotic effect against some bacteria, which may be attributed to persistence of the antibiotic at the ribosomal binding site.
Fig 1. Buccal swelling associated with the maxillary right first molar.
Fig 2. Periapical radiolucency at the maxillary right first molar.
Clinical challenge A 56-year-old man who is a new patient presents to your office with a complaint of “pain from a swelling in my mouth.” You complete a limited intraoral examination and note a buccal swelling associated with the maxillary right first molar (Fig 1). You take a periapical radiograph and identify a periapical radiolucency at the first molar (Fig 2). A review of the patient’s medical history reveals only an allergy to penicillin and reported gastrointestinal intolerance to azithromycin. The restorability of this tooth may be questionable, but, to mitigate the acute infection at this time, which antibiotic would you prescribe and at what dose?
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GENERAL DENTISTRY July/August 2017
(continued on page14)
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Table 1. Spectrum of activity of clindamycin.
Table 2. Dosing of clindamycin for adults.
Susceptible microorganism
MIC50 (mg/L)
Indication for use
Formulation and dose 150-300 mg orally 3 times a day
Staphylococcus aureus
< 0.25
Staphylococcus epidermidis
< 0.25
Odontogenic infections
Streptococcus pyogenes
< 0.40
Acne rosacea
Streptococcus pneumoniae
< 0.25
1% lotion applied to affected area twice daily
Viridans streptococci
< 0.12
Acne vulgaris
Corynebacterium diphtheriae
< 0.20
1% lotion applied to affected area twice daily
Pneumocystis carinii pneumonia
900 mg IV every 8 hours initially; followed by 450 mg orally every 8 hours (plus primaquine, 30 mg, orally once daily)
Babesiosis
300-600 mg IV or IM every 6 hours (plus quinine, 650 mg, every 4-6 hours)
Pelvic inflammatory disease
900 mg IV every 8 hours (plus gentamicin); followed by 450 mg orally every 6 hours for a total of 14 days
Bacterial vaginosis (nonpregnant women)
2% cream, one full applicator intravaginally at bedtime for 7 days; or 300 mg orally twice daily for 7 days
Non-enterococcal group D (Streptococcus bovis)
Most are susceptiblea
Neisseria gonorrhoeae
< 3.1
Peptococcus spp
< 0.125
Peptostreptococcus spp
< 0.125
Propionibacterium spp
< 0.03
Campylobacter fetus
< 3.1
Clostridium perfringens
< 1.0
Clostridium tetani
< 1.0
Bifidobacterium and Lactobacillus spp
Most are susceptiblea
Chlamydia trachomatis
< 1.0
Actinomyces spp and Eubacterium spp
Most are susceptiblea
Bacteroides fragilis group
< 1.0
Prevotella/Porphyromonas spp
< 4.0
Fusobacterium spp (one third of F varium are resistant)
0.015-16
Veillonella spp
Most are susceptiblea
Gardnerella vaginalis
< 0.5
Clostridium ramosum, C novyi, C sordelli, C bifermentans, C difficile, C sporogenes
< 4.0
Abbreviation: MIC 50 , minimum inhibitory concentration of the antibiotic at which 50% of the isolates were inhibited. a Minimum inhibitory concentrations were too low to measure, and the antibiotic is highly effective against the organism.
Clindamycin is a bacteriostatic antibiotic but is bactericidal against some strains of Staphylococcus, Streptococcus, and anaerobes (eg, Bacteroides fragilis), although killing activity varies with drug concentration, inoculum, and bacterial species. A more complete list of susceptible microorganisms is provided in Table 1. About 90% of an oral dose of clindamycin is absorbed after oral administration. Absorption from the gut is rapid, and the rate but not the extent of absorption can be delayed by food. It does penetrate well into bone. Since the drug is actively transported into polymorphonuclear leukocytes and macrophages, it may
Bacterial 300 mg orally twice daily for vaginosis 7 days; topical cream should (pregnant women) not be used in pregnant women Surgical prophylaxis, head and neck
600 mg IV 1-2 hours preoperatively and continued every 8 hours for 4 doses
Bacterial endocarditis prophylaxis
600 mg orally 1 hour prior to the procedure or 600 mg IV within 30 minutes of the procedure
Abbreviations: IM, intramuscularly; IV, intravenously.
also achieve excellent penetration into abscesses. Clindamycin is metabolized in the liver to active and inactive metabolites. The half-life in patients with normal renal function is 2.4 hours, but it is extended to approximately 6 hours in those with renal insufficiency. The half-life of the drug is also extended in patients with hepatic failure. Despite clindamycin’s relatively short half-life, given the drug’s postantibiotic effect, there is no pharmacokinetic reason to prescribe the medication more often than 3 times a day.7,8 In fact, the Infectious Diseases Society of America recommends that clindamycin be administered every
8 hours for most infections, including methicillin-resistant Staphylococcus aureus (MRSA)–associated cellulitis (Table 2).9-11 Clindamycin is safe for adults and children as well as in pregnancy, where no reports linking clindamycin with congenital defects have been published to date, and animal studies have failed to demonstrate fetal risk with clindamycin therapy (FDA pregnancy risk category of B). Clindamycin is excreted in breast milk, but the American Academy of Pediatrics considers clindamycin administration compatible with breastfeeding.12-14 (continued on page15) 13
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ARTICLES Is clindamycin dangerous? (continued from page14)
The bad
Mycoplasma pneumoniae and aerobic gram-negative bacilli are usually resistant to clindamycin due to poor permeability of the cellular outer envelope to the drug. Increasing rates of resistance among B fragilis have limited its effectiveness against these organisms in the United States; the frequency of clindamycin resistance in B fragilis increased from 3% in 1987 to 26% by 2004.15,16 The most recently published national survey for the susceptibility of B fragilis reported clindamycin resistance rates to be as high as 60%.17 Bacteroides fragilis is a common pathogen in orofacial infections, and certain strains have also been associated with clinical failures of penicillin treatment. The most common adverse effects associated with clindamycin are allergic reactions (maculopapular skin rash has been noted in up to 10% of patients receiving clindamycin) and diarrhea (incidence of 2%-20%). Typically, the diarrhea is mild and self-limited and resolves on discontinuation of the drug; however, clindamycin, like many other antibiotics, has been implicated in antibiotic-associated diarrhea due to the overgrowth of Clostridium difficile.18,19 Clostridium difficile is a gram-positive, spore-forming bacteria that is a normal part of the intestinal flora. Appropriate antibiotic use can disrupt the equilibrium of bacterial species in the human intestine and allow for overgrowth of C difficile, which can lead to asymptomatic carriage, mild diarrhea, colitis, or pseudomembranous colitis.20 In severe cases, resection of the colon and death can occur. Clostridium difficile infection is largely nosocomial and rarely occurs in the outpatient setting; however, the 2 most significant risk factors are exposure to antibiotics and exposure to the bacteria. The primary mode of transmission for C difficile is the fecal-oral route; cross-contamination between the hands of healthcare workers and patients is often implicated.21 Pseudomembranous colitis caused by overgrowth of C difficile has been reported in 0.1%-10% of patients receiving clindamycin and can be severe or life-threatening.19 Although this condition has been documented with almost all antibiotics, specific medications such as ampicillin, amoxicillin, 14
the cephalosporins, and clindamycin are most frequently implicated. A systematic review and meta-analysis on this subject by Bignardi established that antibiotic exposure was a strong and statistically significant risk factor associated with both C difficile diarrhea and C difficile carriage.18 Other identified risk factors included increasing age, severity of underlying disease, nonsurgical gastrointestinal procedures, presence of a nasogastric tube, concurrent antiulcer medications, duration of hospital stay, duration of antibiotic course, and use of multiple antibiotics. While the metaanalysis approach enabled the ranking of individual antibiotics in relation to the risk of C difficile infection, the 95% confidence intervals were often wide and overlapping, indicating similar risk with antibiotics such as metronidazole, quinolones, cefuroxime, third-generation cephalosporins, and amoxicillin/clavulanic acid.18 Two more recent meta-analyses suffered similar limitations; however, based on odds ratios calculations, researchers concluded that exposure to cephalosporins or clindamycin had a higher association with hospital-acquired C difficile infection than did no exposure.19,22 Antibiotic-associated diarrhea can occur during antibiotic therapy or even several weeks after the cessation of therapy. Topical and vaginal preparations of clindamycin have also been implicated in this disease, which may be attributable to systemic absorption of the drug.23,24 Caution should be exercised in prescribing clindamycin to patients with inflammatory bowel disease, since antibiotic-associated diarrhea in this patient population can be particularly intolerable.
The ugly
In 2004, several Canadian hospitals reported C difficile outbreaks.25 The infection caused at least 83 patient deaths in institutions located in Montreal and Calgary. The infection occurred in some patients who had received clindamycin, which was thought to reduce the normal bacterial flora of the small intestine, allowing C difficile overgrowth and the production of cytotoxin B. Damage to the colon resulted in diarrhea, which progressed, in severe cases, to colectomy or death.25 Clostridium difficile spores are resistant to common hospital
GENERAL DENTISTRYâ&#x20AC;&#x201A;July/August 2017
disinfectants and can survive for long periods outside the body. The hospital environment is unfortunately ideal to spread C difficile, and in these cases, the bacteria was thought to have been passed through hand-to-hand contact between patients and healthcare providers. These reports and others were picked up by the mainstream media and quickly clindamycin began to be touted as a dangerous drug. Unfortunately, the specific details of these cases tended to be overlooked, and prescribers began to stop prescribing clindamycin. A look at the specifics shows that many of these patients had received 600-900 mg of intravenous clindamycin every 6 hours for more than 10 days: These were heroic doses for very sick individuals who were often residing in the intensive care unit.25 What the lay media neglected to emphasize was the safety of clindamycin, certainly in comparison to other antibiotics, when administered at the typical dose of 150-300 mg orally, 3 times a day, for odontogenic infections. This was something that Bignardi emphasized back in 1998.18
Strategies to prevent antibiotic-associated diarrhea and adverse events
Recognizing and minimizing risk factors for the development of C difficileâ&#x20AC;&#x201C; induced colitis should be every prescriberâ&#x20AC;&#x2122;s first line of defense in mitigating this iatrogenic complication, if possible. Specific attention to the right drug, at the right dose, for the right patient and the right indication should help minimize any potential collateral damage and the development of adverse reactions, medication side effects, antimicrobial resistance, and suprainfections, including secondary fungal infections. The coprescribing of probiotics with antibiotic prescriptions is sometimes considered another line of defense in avoiding potential adverse events associated with antimicrobial agents. A recent metaanalysis on this subject again concluded, however, that the routine use of probiotics is not recommended.26 Probiotics could be beneficial for the maintenance of oral health, given their ability to decrease the colony-forming unit counts of oral pathogens, but randomized clinical trials with long-term follow-up periods are needed to confirm their efficacy in (continued on page16) washingtonAGD.org
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reducing the prevalence and incidence of oral infectious diseases. Furthermore, the recognition of specific strains with probiotic activity for each infectious oral disease is required to determine the exact dose, treatment time, and ideal vehicles for administration. Finally, the medical and pharmacologic history of each patient must be carefully reviewed before any medication is prescribed. Close attention to previous medication reactions and allergic reaction history will help avoid potential adverse outcomes. Accurate and complete charting, beyond simply writing “penicillin allergic,” should detail the specifics of the reaction (eg, development of hives, tongue swelling, or airway compromise) to help guide future prescribing.
Conclusion
Clindamycin is an excellent antibiotic for odontogenic infections; its mechanism of action, spectrum of activity, and pharmacokinetic profile make it particularly advantageous. It is an integral component of many antibiotic prophylaxis and treatment guidelines, as supported by international scientific authorities such as the World Health Organization, American Heart Association, and the American Dental Association. The concern that clindamycin is a “dangerous” drug, highly associated with the development of Clostridium difficile infection, is the result of data extrapolated from unfortunate cases in which heroic, intravenous doses were administered every 6 hours to hospitalized patients for greater than 10 days. When appropriately prescribed for odontogenic infections at the usual dose of 150-300 mg orally, 3 times a day, clindamycin should continue to be considered as one of the most effective
Clinical challenge answer Clindamycin, 300 mg, taken every 8 hours (ie, 3 times a day) for 5-7 days, is an appropriate treatment for this odontogenic infection.
and safe medicines required to meet the most important needs in the health system and in ambulatory patients.
10.
Author information
Dr Donaldson is a senior executive director, Vizient Pharmacy Advisory Solutions, Irving, Texas; a clinical professor, Skaggs School of Pharmacy, University of Montana, Missoula; and a clinical assistant professor, School of Dentistry, Oregon Health & Science University, Portland. Dr Goodchild is an associate professor and chair, Department of Diagnostic Sciences, Creighton University School of Dentistry, Omaha, Nebraska; a clinical associate professor, Department of Oral Medicine, University of Pennsylvania, School of Dental Medicine, Philadelphia; and in private practice in Havertown, Pennsylvania.
Disclaimer
The authors report no potential conflicts of interest. The views expressed in this column are those of the authors and do not necessarily reflect those of Creighton University School of Dentistry or Vizient Inc.
11. 12.
13. 14. 15.
16.
17.
18. 19.
References
1. World Health Organization. WHO Model List of Essential Medicines. http://www.who.int/medicines/publications/ essentialmedicines/en/. Accessed April 15, 2017. 2. Jones TD, Baumgartner L, Bellows MT, et al. Prevention of rheumatic fever and bacterial endocarditis through control of streptococcal infections. Circulation. 1955;11(2):317-320. 3. Kaplan EL, Anthony BF, Bisno A, et al. Prevention of bacterial endocarditis. Circulation. 1977;56(1):139A-143A. 4. Schlievert PM, Kelly JA. Clindamycin-induced suppression of toxic-shock syndrome–associated exotoxin production. J Infect Dis. 1984;149(3):471. 5. Veringa EM, Verhoef J. Influence of subinhibitory concentrations of clindamycin on opsonophagocytosis of Staphylococcus aureus, a protein-A-dependent process. Antimicrob Agents Chemother. 1986;30(5):796-797. 6. Veringa EM, Lambe DW Jr, Ferguson DA Jr, Verhoef J. Enhancement of opsonophagocytosis of Bacteroides spp. by clindamycin in subinhibitory concentrations. J Antimicrob Chemother. 1989;23(4):577-587. 7. Frighetto L, Nickoloff D, Martinusen SM, Mamdani FS, Jewesson PJ. Intravenous-to-oral stepdown program: four years of experience in a large teaching hospital. Ann Pharmacother. 1992;26(11):1447-1451. 8. Bunz DM, Frighetto L, Gupta S, Jewesson PJ. Simple ways to promote cost containment. DICP. 1990;24(5):546. 9. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious
20. 21.
22.
23. 24. 25. 26.
Diseases Society of America. Clin Infect Dis. 2012;55(10): 1279-1282 [erratum: 2014;58(10):1496]. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011; 52(3):e18-e55 [erratum: 2011;53(3):319]. Guay D. Update on clindamycin in the management of bacterial, fungal and protozoal infections. Expert Opin Pharmacother. 2007;8(14):2401-2444. Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2011: xvii, 406-408, 497. American Academy of Pediatrics. AAP issues policy statement on the transfer of drugs and other chemicals into human milk. Am Fam Physician. 1994;49(6):1527-1529. American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001;108(3):776-789. Snydman DR, Jacobus NV, McDermott LA, et al. National survey on the susceptibility of Bacteroides fragilis group: report and analysis of trends for 1997-2000. Clin Infect Dis. 2002;35(Suppl 1):S126-S134. Snydman DR, Jacobus NV, McDermott LA, et al. National survey on the susceptibility of Bacteroides fragilis group: report and analysis of trends in the United States from 1997 to 2004. Antimicrob Agents Chemother. 2007;51(5): 1649-1655. Snydman DR, Jacobus NV, McDermott LA, et al. Update on resistance of Bacteroides fragilis group and related species with special attention to carbapenems 2006-2009. Anaerobe. 2011;17(4):147-151. Bignardi GE. Risk factors for Clostridium difficile infection. J Hosp Infect. 1998;40(1):1-15. Vardakas KZ, Trigkidis KK, Boukouvala E, Falagas ME. Clostridium difficile infection following systemic antibiotic administration in randomised controlled trials: a systematic review and meta-analysis. Int J Antimicrob Agents. 2016;48(1):1-10. Surawicz CM, Brandt LJ, Binion DG, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108(4):478-498. Deshpande A, Pimentel R, Choure A. Antibiotic-Associated Diarrhea and Clostridium Difficile. The Cleveland Clinic Foundation. June 2014. http://www.clevelandclinic meded.com/medicalpubs/diseasemanagement/ gastroenterology/antibiotic-associated-diarrhea/. Accessed April 28, 2017. Slimings C, Riley TV. Antibiotics and hospital-acquired Clostridium difficile infection: update of systematic review and meta-analysis. J Antimicrob Chemother. 2014;69(4): 881-891. Parry MF, Rha CK. Pseudomembranous colitis caused by topical clindamycin phosphate. Arch Dermatol. 1986; 122(5):583-584. Meadowcroft AM, Diaz PR, Latham GS. Clostridium difficile toxin-induced colitis after use of clindamycin phosphate vaginal cream. Ann Pharmacother. 1998;32(3):309-311. Eggertson L, Sibbald B. Hospitals battling outbreaks of C. difficile. CMAJ. 2004;171(1):19-21. Seminario-Amez M, López-López J, Estrugo-Devesa A, Ayuso-Montero R, Jané-Salas E. Probiotics and oral health: a systematic review. Med Oral Patol Oral Cir Bucal. 2017; 22(3):e282-e288.
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ARTICLES Dental Affiliates, Are you looking for the perfect dental space??? Look no further the Washington AGD Educational Center for your next CE programs!
Washington Academy of General Dentistry “New” Educational Center has been established to fulfill continuing dental education needs for the dental professionals. The center itself is very comfortable and convenient; every consideration was given to create for participants and our members the most optimal, state-of-the-art technological and audio-visual advantages. With the educational center central location within minutes of the Seattle-Tacoma International Airport and hotels, you won’t find a better educational facility in Seattle. The goals of the Washington Academy of General Dentistry Center for Dental Education are: • Educate dental professionals with outstanding knowledge and skill, for lifelong learning. • Serve as the regional educational center for dental professionals & affiliate organizations. • Establish through education the implementation of affiliate partnerships and professional collaborations. • Foster an educational environment where creativity, collaboration, diversity and respect are embraced. Develop nationally recognized, multi-disciplinary educational programs in Washington state. Dental affiliates and our members are welcome to use this space for your study clubs or dental meetings. Please contact our Washington Academy of General Dentistry Conference Center Director, Jennifer Murphy, Cell #206-948-5611 or Email: conferencecenterwashingtonagd@gmail.com for more details. Welcome to the “New” Educational Center for the Washington Academy of General Dentistry! 19415 International Blvd, Floor 4-Suite #410, SeaTac, WA 98188
We hope you will visit us soon! Valerie Bartoli, Washington AGD Executive Director
18 Washington AGD Newsletter | September 2017
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Biographical Data Vicki L. Munday, RDH, BS Vicki Munday, RDH, BS graduated from Shoreline C.C. Dental Hygiene Program in 1992 and from O’Hehir University in 2015. She has been a member of ADHA/WDHA all of her professional life. Vicki was co-recipient of the Most Inspirational Award as voted on by her classmates at Shoreline. Vicki was president of WDHA (Washington State Dental Hygienist’s Assoc.) in 2000, served as a delegate to ADHA for many years and was elected to serve on both the Ethic and Finance Committees for ADHA. She has had 5 articles published in RDH, and Op-Ed in Access and digitally in DPR. Vicki has a passion for making a difference. She is the founder of Smiles for Veterans, which has provided nearly $75,000.00 in care over the last 5 years. She is the regional coordinator for the Oral Cancer Foundation. Vicki was one of the 2014 Sunstar/RDH Distinguished Hygienist Award winners. She also received the 2015 ADHA/Colgate Community Service Award and the Young Caring Clinician Award. Vicki sits on the advisory boards of both the Pima Dental Hygiene program and Seattle Central Dental Hygiene Program. She recently joined the team at Fidalab to provide education, marketing and sales from a dental hygiene point of view. Vicki practices clinical dental hygiene 2 days a week, and states that she loves the ability to do both clinical hygiene and educate her colleagues about oral cancer. Prior to her position at Fidalab Vicki was in sales with OralID and PDT.
Congrats to the 2017 Class of Fellows, Masters & LLSR Recipients On behalf of the Washington AGD board of directors, we would like to offer our most heartfelt congratulations to the following doctors for their accomplishment in receiving either their Fellowship or Mastership in Las Vegas Saturday, July 15, 2017! Please join us for an opportunity to congratulate them!
Fellowship: *Dr. Sue Kim Vetter *Dr. Keerti Sahasrabudhe *Dr. Jennifer Miranda Domagalski *Dr. Vernon Beck *Dr. Jonathan Su *Dr. Senan Ahmed *Dr. Man Sunwoo *Dr. Steven Karmy *Dr. Steven Haws *Dr. Kianoosh Behshid Mastership: *Dr. Cynthia V. Feleppa *Dr. Phillippe Freeman *Dr. Laura Schoening Howrey *Dr. Eugene Hsu *Dr. Christine Vuong *Dr. Carl Youngquist
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The Importance of Early Oral Cancer Detection By Linda J. Edgar, DDS, MEd, MAGD, AGD Foundation Vice President, AGD Past President
About a year and a half ago, I was experiencing one of the most stressful periods in my life. I had been caring for my mother and was traveling back and forth from Seattle to Portsmouth, Virginia, every two weeks to orga-nize and provide care, as I was her medical power of attorney. I was also practicing dentistry during this time and really felt as if I had a 24/7 job with everything combined. In September 2015, I developed a fever blister on my inner lower lip. I thought it was probably due to stress, poor diet from traveling and lack of sleep. I purchased over-thecounter medications that did not help and then went to a dermatologist in December. She gave me a cream that was painful to use and made no difference. The sore would ulcerate, then crust and fall off, and then ulcerate again. The area never fully healed. My husband, who is also a dentist, examined the sore and recom-mended a biopsy, which I had done in January 2016. The oral surgeon was a friend and rushed the report, which came back a week later with a diagnosis of squamous cell carcinoma of the lower lip. This diagnosis left me feeling very anxious because the determination of how much lip, face or jaw would have to be removed is not made until the surgery actually occurs. I left the oral surgeon’s office shaking and called my office to cancel my afternoon appointments with patients. I met with a well-known head and neck surgeon at the University of Washington, as well as the head of the oral medicine department, Dr. Edmond Truelove. He looked at the lesion and determined that a Mohs surgery could be done if it hadn’t spread, and it hadn’t. In March, the Mohs surgery was done, and the cancer cells were removed with two cuts. The second cut removed most of the lower lip, but they were able to save most of the vermillion border. The next day was the reconstruction surgery, which took about five hours. Forty-two stitches later, I woke up in the recovery room with a large bandage across my whole lower lip that I had to wear for 10 days. After the surgery, I wore a surgical mask at work and at home. I took about a week off from work. My lower lip remained swollen for about six weeks. My diet consisted of Jell-O, pudding, lukewarm soup and ice cream for about a month. My lower lip is still numb; it was painful to brush my teeth for about six months, and I often used a cotton swab. It still hurts to touch the area and apply lipstick. The area also is very sensitive to spices and sugar. I am constantly aware of the tingling in my lower lip. So, why did this happen to me? The biggest reason probably was because I was a serious competitive runner and triathlete from ages 28 to 38, often running 120 miles a week and biking several 100-mile rides out in the sun. I have never smoked, rarely drink alcohol and have been with the 20 Washington AGD Newsletter | September 2017
same marriage partner for more than 50 years. I have never had Botox or anything injected into my lips or face. I have been encouraged to tell my story as a reminder for dentists to screen more often and refer for biopsies for areas that are not healing in our patients’ mouths. I also want to show how scary this positive diagnosis can be and the importance of early diagnosis. The Academy of General Dentistry (AGD) Foundation’s mission is to promote oral cancer awareness and education, as well as provide screenings. Of course, this mission has become much more personal for me. It would be my vision to see AGD take the lead in the country and have proactive action and education in every state to help prevent this disease. If each member donated $25 to the foundation, we could accomplish this vision.
Linda J. Edgar, DDS, MEd, MAGD
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Cancer Facts and Figures from the American Cancer Society Authored by Cynthia Eichner In the 2017 edition of Cancer Facts and Figures from the American Cancer Society, it is estimated 1,120 people will be diagnosed and 250 people will die in Washington from oropharyngeal cancers. Of those new cases, 70% of these cancers are linked to the HPV virus. Washington Dentists can play a critical role in talking with parents and young adults about the importance of getting vaccinated for HPV-related cancers. Recommended ages for HPV vaccinations is between 11-12 and is usually accompanied by vaccinations for Tdap and MenACWY. Currently the HPV vaccination rates for children 11-12 who have completed the series of HPV vaccinations hovers between 30-40%. Some populations within the state have significant lower rates; with vaccination rates significantly lower among boys than girls. As dentists and hygienists, it’s likely that children and young adults spend more time at your office and in your chairs than at a doctor’s office – making your communication about HPV vaccination even more important. To help you get started, we encourage you to review this tip sheet specifically developed for dentists. We are partnering with the American Cancer Society as part of our commitment to Oral Cancer Awareness to provided additional resources and training. Contact Cynthia Eichner for more information about their HPV Cancer program. Please save the date for the 2017 Washington AGD Membership Appreciation “Mad Hatter’s Gala”, Saturday, October 7, 2017 at the Four Seasons. We are currently seeking Gala volunteers as well as silent and live auction items. Sponsorship opportunities are available. Please contact Washington AGD, Executive Director, Valerie Bartoli at washingtonagd1@yahoo. com for more information We look forward to seeing all our members at next year’s event! Email: Cynthia.eichner@cancer.org
We are proud to support the Washington AGD and its members.
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Henry Schein Donates Medical Supplies In Support of Free Oral Cancer Screening Events throughout the United States By Jackie Ulasewich
Company’s Donation to Support 77 Screening Events in 2016 and 2017 by the Oral Cancer Foundation Press Release – MELVILLE, N.Y.,– Henry Schein, Inc. (Nasdaq: HSIC) announced today that it is donating more than $10,000 in medical supplies to the Oral Cancer Foundation (OCF) in support of 77 free oral cancer screening events being held throughout the United States in 2016 and 2017. Each OCF-hosted event aims to boost awareness of the disease and increase early detection. The Company’s donation of gauze, tongue depressors, and disposable dental mirrors, facemasks, and gloves is an initiative of Henry Schein Cares, the Company’s global corporate social responsibility program, and continues the Company’s support of OCF’s screening events. OCF hosts the events in a range of locations, including pharmacy parking lots, health fairs, farmer’s markets, colleges, and OCF Walk/Run for Awareness events. “The health of our mouths greatly impacts our ability to eat and drink, communicate thoughts and ideas, and express feelings for loved ones,” said Brian Hill, Founder of the Oral Cancer Foundation. “When cancer affects our mouths, it does more than take away these everyday functions, it too often takes our lives. Our screening events are designed to identify signs of oral cancer before it ever gets that far, and we thank Henry Schein for this generous donation and its continued support of oral cancer awareness and early detection efforts.” The donation comes at a time when nearly 500,000 people worldwide are diagnosed annually with oral and oropharyngeal cancer, according to data from the International Agency for Research on Cancer’s Globocan 2000 database and the World Health Organization’s Mortality Database. Of that number, between one-third and one-half lose their lives annually while many more suffer from the complications of treatment. Despite the easy accessibility to these body sites by health care providers and the overall impact early detection can have on a person’s overall health, more than two-thirds of these patients are diagnosed in advanced stages where the cancer has already spread to regional lymph nodes or beyond. “Regular oral cancer screening events raise awareness and enhance early detection and prevention efforts, which are critical to reducing the disease’s incidence and impact,” said Steven W. Kess, Vice President of Global Professional Relations at Henry Schein. “Oral cancer is a stark reminder of the vital importance of good oral health in relation to a person’s overall health, and that’s why Henry Schein is pleased to support the Oral Cancer Foundation.” Henry Schein’s donation continues the Company’s long-standing commitment to exploring ways of reducing the disease’s global impact. Earlier this year, the Henry Schein Cares Foundation, Inc.—an independent 501(c)(3) organization founded by the Company to foster, support, and promote dental, medical, and animal health by helping to increase access to care in communities around the world—funded the Global Oral Cancer Forum. The Forum gathered many of the world’s foremost experts on oral cancer, as well as clinicians, scientists, epidemiologists, activists, public health experts, nonprofit organizations, government agencies, and other stakeholders who are working to understand how to reduce the global oral cancer burden.
About Henry Schein Cares Henry Schein Cares stands on four pillars: engaging Team Schein Members to reach their potential, ensuring accountability by extending ethical business practices to all levels within Henry Schein, promoting environmental sustainability, and expanding access to health care for underserved and at-risk communities around the world. Health care activities supported by Henry Schein Cares focus on three main areas: advancing wellness, building capacity in the delivery of health care services, and assisting in emergency preparedness and relief. Firmly rooted in a deep commitment to social responsibility and the concept of enlightened self-interest championed by Benjamin Franklin, the philosophy behind Henry Schein Cares is a vision of “doing well by doing good.” Through the work of
22 Washington AGD Newsletter | September 2017
(continued on page22)
ARTICLES (continued from page21) Henry Schein Cares to enhance access to care for those in need, the Company believes that it is furthering its long-term success. “Helping Health Happen Blog” is a platform for health care professionals to share their volunteer experiences delivering assistance to those in need globally. To read more about how Henry Schein Cares is making a difference, please visit our blog: www.helpinghealthhappen.org. About Henry Schein, Inc. Henry Schein, Inc. (Nasdaq: HSIC) is the world’s largest provider of health care products and services to office-based dental, animal health and medical practitioners. The Company also serves dental laboratories, government and institutional health care clinics, and other alternate care sites. A Fortune 500® Company and a member of the S&P 500® and the Nasdaq 100® indexes, Henry Schein employs nearly 19,000 Team Schein Members and serves more than one million customers. The Company offers a comprehensive selection of products and services, including value-added solutions for operating efficient practices and delivering high-quality care. Henry Schein operates through a centralized and automated distribution network, with a selection of more than 110,000 branded products and Henry Schein private-brand products in stock, as well as more than 150,000 additional products available as special-order items. The Company also offers its customers exclusive, innovative technology solutions, including practice management software and e-commerce solutions, as well as a broad range of financial services. Headquartered in Melville, N.Y., Henry Schein has operations or affiliates in 33 countries. The Company’s sales reached a record $10.6 billion in 2015, and have grown at a compound annual rate of approximately 15 percent since Henry Schein became a public company in 1995. For more information, visit Henry Schein at www.henryschein.com, Facebook.com/HenrySchein and @ HenrySchein on Twitter. *This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy. Henry Schein Donates Medical Supplies In Support of Free Oral Cancer Screening Events throughout the United States Source: www.mysocialgoodnews.com Author: Api Potter
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Preventing Cancer Just Got Easier HPV vaccine protects against cancers and other diseases caused by human papillomavirus (HPV). Follow the chart below to determine whether your patient needs two or three doses of HPV vaccine.
IS THE PATIENt AGE 11–12?
NO
See FAQs on reverse side for patients outside this age range.
YES
Has the patient received any doses of HPV vaccine?
NO
VACCINATE
CDC recommends 11- to 12-year-olds receive two doses of HPV vaccine 6–12 months apart.
NO
VACCINATE
The patient should receive the second dose of HPV vaccine 6–12 months after the first dose to complete the series.
YES
More than one?
YES
Two doses or three doses?
Two doses
YES
Three doses*
YES
Administered at least 5 months apart?
YES
THE SERIES
IS COMPLETE
THE SERIES
IS COMPLETE
NO *All minimum intervals must be met: second dose at least 4 weeks after first dose; third dose at least 12 weeks after second dose and at least 5 months after first dose.
24 Washington AGD Newsletter | September 2017
VACCINATE
The patient should receive a third dose of HPV vaccine 6–12 months after the first dose to complete the series.*
ARTICLES
CDC RECOMMENDS TWO HPV DOSES FOR YOUNGER ADOLESCENTS The Centers for Disease Control and Prevention (CDC) now routinely recommends two doses of HPV vaccine for 11- or 12-year-olds to prevent HPV cancers. This recommendation makes it easier for parents to protect their children by reducing the number of doses and trips to the doctor. HPV vaccination is an important cancer prevention tool and two doses of HPV vaccine will provide safe, effective, and long-lasting protection. Some specifics of the recommendation include:
than 5 months apart will require a third dose. The third dose should be given 6–12 months after the first dose to complete the series. • A three-dose schedule is recommended for teens and young adults who start the series at ages 15 through 26 years. Under this schedule, the second dose of HPV vaccine should be given 1–2 months after the first dose, and the third dose should be given 6 months after the first dose.
• A two-dose schedule is recommended for adolescents starting the schedule at ages 9 through 14 years. For this age group, follow the decision tree on the reverse side.
• Three doses are recommended for people aged 9–26 years with certain immunocompromising conditions.
• Adolescents aged 9 through 14 years who have already received two doses of HPV vaccine less
Read the full policy note: www.cdc.gov/mmwr/volumes/65/wr/mm6549a5.htm
TALKING TO PATIENTS AND THEIR PARENTS ABOUT 2-DOSE SCHEDULES FOR HPV VACCINATION With patients aged 11–12 years, start the vaccine discussion with their parents by making the following recommendation: "Now that your child is 11 (or 12) years old, they are due for three vaccines today to help protect them from the infections that cause meningitis, HPV cancers, and pertussis—or whooping cough." Many parents are accepting of this bundled recommendation because it demonstrates that HPV vaccination is a normal part of adolescent vaccination. Parents may be interested in vaccinating, yet still have questions. Some parents might just need additional information from you, the clinician they trust. Clarify the parent’s question or what additional information they need. For parents who have a question or need more information about “why now/why 11–12?” “As with all vaccine-preventable diseases, we want to protect your child early. If we start now, it’s one less thing for you to worry about. Also, your child will only need two doses of HPV vaccine at this age. If you wait, your child may need three doses in order to get complete protection. We’ll give the first dose today and then you’ll need to bring your child back in 6 to 12 months from now for the second dose.”
If a parent asks, or needs more information about “How long can we wait and still give just two doses?” “The two-dose schedule is recommended if the series is started before the 15th birthday. However, I don’t recommend waiting to give this cancer-preventing vaccine. As children get older and have busier schedules, it becomes more difficult to get them back in. I’d feel best if we started the series today to get your child protected as soon as possible.” For patients aged 9–14 who have already had two doses given less than 5 months apart “The recommended schedule is two doses given 6 to 12 months apart. The minimum amount of time between those doses is 5 months. Because your child received two doses less than 5 months apart, we’ll need to give your child a third dose.” For parents asking about the duration of protection or how well the vaccine will work with just two doses "Studies have shown that two doses of HPV vaccine work very well in younger adolescents and we expect the same long-lasting protection with two doses that we expect with three doses." You can also access guidance on answering parents’ questions about HPV vaccine by using our tip sheet, Talking to Parents about HPV Vaccine, at www.cdc.gov/HPV.
vaccine
is CANCER PREVENTION
MARCH 2017
washingtonAGD.org
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ARTICLES
Cervical-thoracic necrotizing fasciitis of odontogenic origin in a diabetic patient: a case report Mateus Barros Cavalcante, DDS ¢ Amanda Laísa de Oliveira Lima, DDS ¢ Raphael Teixeira Moreira, DDS Emanuel Dias de Oliveira e Silva, PhD ¢ Bruno de Lira Castelo Branco, DDS Necrotizing fasciitis (NF) is a severe bacterial infection with rapid and aggressive progression. The infection generally affects individuals with comorbid conditions that lead to immunologic and microvascular deficiencies. It is characterized by necrosis of tissues, mainly in the extremities, trunk, and perineum, and is rarely found in the head and neck. This case report describes the course of NF in a 55-year-old man, highlighting diagnosis, surgical treatment, drug therapy, and supportive measures. The patient, who had chronic alcoholism, systemic arterial hypertension, a smoking habit, and decompensated diabetes (glucose level of 490 mg/dL), was admitted to the hospital with a volume increase in the cervical and thoracic areas with a duration of about 7 days. He presented with fever, dyspnea, and inflammatory signs bilaterally in the submandibular, submental, and superior thoracic regions as well as severe trismus. The patient underwent a surgical procedure to drain the infectious process and to place drains. The patient developed cutaneous necrosis in the cervical and superior thoracic regions, diagnosed as NF. Surgical debridement of all affected tissue was performed. After resolution of the infection, the patient underwent skin grafting with a satisfactory outcome. Received: October 29, 2016 Accepted: December 6, 2016 Key words: bacterial infections, neck injuries, necrotizing fasciitis
Published with permission of the Academy of General Dentistry. © Copyright 2017 by the Academy of General Dentistry. All rights reserved. For printed and electronic reprints of this article for distribution, please contact jkaletha@mossbergco.com.
F
irst described by Hippocrates in the 5th century bce and cited again in 1952 by Wilson, necrotizing fasciitis (NF) is a rare and severe microbial infection that mainly affects the extremities of the trunk and perineum.1-3 Necrotizing fasciitis can result from progressive odontogenic infection, usually in relation to the mandibular molars.4 It is characterized by formation of gases in the subcutaneous tissue and superficial fascia.5 The infection can evolve to extensive necrosis that advances rapidly along superficial layers of the tissue and may necessitate limb amputation or result in death.6-9 Necrotizing fasciitis rarely occurs in the head and neck (3%-4% of cases).4,10 The infection does not show any predilection for either sex or for any age group.4,11 When NF affects the head and neck region, it generally originates from an odontogenic or pharyngeal infection.12 Necrotizing fasciitis can occur more frequently in diabetic, immunosuppressed, alcoholic, or severely malnourished individuals; intravenous opiate drug users; patients with peripheral vascular or neoplastic diseases; and pregnant women, principally during the second and third trimesters and after birth.4,10 Laboratory investigations have demonstrated an association between diabetes and NF.13 Patients with diabetes exhibit depressed activity of polymorphonuclear cells (neutrophils) related to hyperglycemia in the presence of acidosis; immune system deficiency resulting from impaired neutrophil adhesion; dysfunction of the inflammatory system, resulting in a delayed response to harmful agents; altered antioxidant systems; and lower production of interleukins.13 Edema, pain, fever, erythema, crepitation, skin desquamation, bullous formation, and purulent accumulations are common clinical signs in patients with NF.7,8 With the evolution of the disease, there are more evident signs, such as dark skin color; small purpuric plaques with ill-defined borders; formation of vesicles or bubbles; exposure of the subcutaneous adipose tissue; necrosis of the fascia; gangrene of the subjacent skin; and the presence of the characteristic putrid odor associated with anaerobic infection.14 The main complications that significantly increase morbidity and mortality are mediastinitis, pericarditis, septic shock, respiratory obstruction, arterial erosion, and jugular vein thrombosis.15 Laboratory findings in patients with NF may include leukocytosis with a left shift, anemia, increased erythrocyte sedimentation rate, elevated levels of C-reactive protein, hyperglycemia, hypocalcemia, and increased levels of creatine phosphokinase, suggesting the extent of the infection in the muscles. Computed tomography can assist in determining the presence and extent of the infectious process.16 However, imaging methods by themselves are considered insufficient for diagnosis; biopsy of the fascia is considered the gold standard for diagnosis of this disease.17-20 www.agd.org/generaldentistry (continued
26 Washington AGD Newsletter | September 2017
25 27) on page
ARTICLES (continued from page 26) Cervical-thoracic necrotizing fasciitis of odontogenic origin in a diabetic patient: a case report
A
Fig 1. Initial appearance of the patient with evidence of edema bilaterally in the submandibular region and hyperemia in the thoracic region.
Fig 3. Postoperative appearance immediately after drainage surgery and placement of drains.
Fig 2. Computed tomographic evaluation. A. Tomogram suggesting the presence of a vertical fracture in the mandibular first premolar. B. Sagittal tomogram evidencing Ludwig angina in the submental region.
Fig 4. Evolution to necrotizing fasciitis 72 hours after initial drainage.
NF is classified into 2 types. Type 1, also called necrotizing cellulitis, is more common in patients with diabetes and/or peripheral vascular disease.21 Type 1 NF is polymicrobial, characterized by the presence of at least 1 species of obligate anaerobic bacterium in combination with 1 or more facultative anaerobic organisms and enterobacteria.22 Type 2 NF, also called hemolytic streptococcal gangrene, is a monomicrobial infection that occurs mainly in sites of penetrating injuries, surgical procedures, burns, and trauma.21 Pathogens isolated from type 2 NF consist of group A β-hemolytic streptococci (usually Streptococcus pyogenes) alone or in association with Staphylococcus aureus or other Staphylococcus sp.21,23 Treatment of NF consists of radical surgical debridement of all necrotic tissue, parenteral administration of broad-spectrum antibiotics, and general supportive measures, such as fluid volume restoration, analgesia, hyperbaric therapy, nutritional support with a high-protein, high-calorie diet, and psychological support.7,24 After surgical debridement and establishment 26
B
GENERAL DENTISTRY July/August 2017
Fig 5. Results 1 day after debridement of necrotic tissue.
of the integrity of tissue planes, reconstruction and skin grafts must be provided.25 The objective of this case report is to describe treatment of a diabetic patient presenting with extensive cervical-thoracic NF potentiated by diabetic ketoacidosis.
Case report
A 55-year-old man with chronic alcoholism, systemic arterial hypertension, a smoking habit, and decompensated diabetes (glucose level of 490 mg/dL) was referred to the General Hospital of the State of Alagoas, Maceió, Brazil, complaining of a swelling in the cervical region that had a duration of 7 days (Fig 1). During initial treatment, the patient was lucid, oriented, tachypneic (35 beats per minute), normal colored, and febrile (37.9°C). Examination revealed a significant increase in the fluid volume, without spontaneous drainage, in the submandibular and submental regions bilaterally; hyperemia in the upper thoracic region; and severe trismus. (continued on page 28) washingtonAGD.org
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ARTICLES (continued from page 27) A
B
Fig 6. Clinical progress of the injured area. A. Site 3 weeks after debridement. B. Site 40 days after debridement. Note the presence of retractile scar tissue.
Fig 8. Satisfactory healing 6 months after skin grafting.
The patient was submitted to laboratory examinations of urea (51.5 mg/dL), creatine (0.82 mg/dL), C-reactive protein (182.88 mg/L), Îł-glutamyl transferase (70 U/L), and lysosomal acid lipase (1.8 U/L) levels as well as imaging examinations (computed tomography). The diagnosis was Ludwig angina originating from a fractured mandibular first premolar (Fig 2). A diagnosis of descending necrotizing mediastinitis was ruled out, and surgical drainage of the infectious process under general anesthesia was planned. The drains were positioned bilaterally in the submandibular, submental, and lower cervical regions (Fig 3). Drug therapy consisted of intravenous piperacillin-tazobactam antibiotic, 4.5 mg; dexamethasone, 10 mg; dipyrone (metamizole), 1 g; ranitidine, 50 mg; and insulinization (insulin pump) for glycemic control. He received supportive therapy of intravenous normal saline, 0.9%, plus vitamin C, 1 g, for hydration. Seventy-two hours after initial surgical drainage of the abscess, the clinical condition of the patient worsened with the appearance of cutaneous necrosis in the cervical and upper thoracic regions (Fig 4). Laboratory testing revealed leukocytosis
Fig 7. Placement of a skin graft 40 days after initial debridement.
(26,000 cells/mm3) and a negative culture within 24 hours. The clinical signs of the disease have been well characterized, and the definitive diagnosis was NF. After 5 days, a second laboratory analysis was performed. Results indicated the presence of Staphylococcus sp with resistance to cephalexin, clindamycin, erythromycin, oxacillin, ciprofloxacin, and amoxicillin with clavulanic acid as well as sensitivity to sulfamethoxazole/trimethoprim and teicoplanin. Surgical intervention was necessary to accomplish debridement of all affected tissue (Fig 5). The multidisciplinary wound care team of the hospital followed the patient with due care, and the patient progressed well, showing clinical improvement and resolution of the infectious process (Fig 6). Forty days after initial debridement, after the infectious process had resolved and the underlying diseases had been controlled, the patient was submitted to a second surgical debridement for removal of all nonviable tissue, including skin and all fascia of scar tissue. Tissue grafting was performed immediately. Partial-thickness skin grafts were collected from the anterior thigh with a dermatome, and a pedunculated rotation flap was repositioned from the shoulder and arm (Fig 7). The patient was monitored carefully for any complications associated with the grafted tissues. The patient demonstrated favorable recovery and was discharged after 60 days of hospitalization. The patient returned for evaluation after 6 months and showed signs of healing with a good prognosis (Fig 8).
Discussion
Necrotizing fasciitis is more prevalent in immunocompromised patients than in healthy patients.26 In the present case, immunosuppression resulting from decompensated diabetes favored the rapid progression and hindered the control of the disease, allowing the development of NF.4,26
Diagnosis
Although biopsy of the fascia is considered the gold standard for the diagnosis of NF, the hospital in the present case did not have that diagnostic capability.17 The clinical disease conditions were very clear, including edema, pain, fever, erythema in www.agd.org/generaldentistry (continued
28 Washington AGD Newsletter | September 2017
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ARTICLES (continued from page 28) Cervical-thoracic necrotizing fasciitis of odontogenic origin in a diabetic patient: a case report
the chest and neck, and concomitant cutaneous necrosis, and these signs have been well described in the literature.7,8,14,27 A finding of leukocytosis with a left shift, as described by other authors, provided conclusive evidence of NF.4,20,26,28-31 The diagnosis was confirmed by surgical exploration and the presence of necrosis of the fascia, features that characterize a definitive diagnosis of NF.10,15,16,22,28,30 Some authors contend that imaging tests such as computed tomography are of the utmost importance for the evaluation of potential infiltration of the lesion and the presence of gas.12,16,27,32 The examination prior to surgical procedures excluded the possibility of invasion to the mediastinum, a development that would have aggravated the disease. Other complications, such as aspiration, adult respiratory distress syndrome, pericarditis, sepsis, and multiple-organ failure, could greatly increase morbidity and mortality.33
Treatment
The hospitalization proposed by the staff to resolve the initial injury contributed to the rapid diagnosis and successful treatment proposed for the secondary problem (NF), as has been suggested by Muhammad et al.28 Although nasofibroscopic examination of the nasopharyngeal region can reveal a variety of etiologic factors that cause diseases that can lead to airway obstruction, the hospital did not have the equipment.34 Therefore, in the present case, orotracheal examination was used. The examination was performed after mouth opening was improved with muscle relaxant injection and sedation, since airway involvement and trismus are common in odontogenic neck infections.32,35 Success is influenced by early diagnosis, use of the appropriate surgical approach, and control of underlying diseases. The mortality rate of NF can range from 6% to 89%.29,30,33 The mortality rate is 100% when NF is untreated or when myositis is present.36 When the surgical procedure is performed within 24 hours of diagnosis, the mortality rate is reduced to 19.6%; the rate is more than 50.0% when surgery is performed after this period.28 A number of authors have proposed treatment with radical surgical debridement of necrotic tissue in conjunction with antibiotic therapy that is specific to the detected microorganism.29-31 However, the polymicrobial form of NF accounts for 80% of cases, justifying broad-spectrum antibiotic therapy, which has been shown to improve prognosis and reduce relapse rates.17 After surgical debridement and removal of necrotic tissue, the wound should remain open to reduce the risk of reinfection through the residual tissue. Reconstruction of the site of injury should occur later, when the underlying disease is more controlled and no signs of infection remain. The tissue repair process, evidenced by the deposition of granulation tissue, must be initiated before reconstruction is performed.37 Techniques such as skin grafts or rotation flaps may be preferred rather than simple reapproximation of borders or healing by secondary intention. Reconstructions minimize the esthetic and functional problems resulting from the retractile scar tissue. Hyperbaric therapy has been reported in the literature as an adjuvant treatment, but its usefulness is controversial.38,39 28
GENERAL DENTISTRY July/August 2017
In the present case, due to the loss of a considerable amount of tissue, reconstruction was performed via 2 separate grafts. A partial-thickness graft from the anterior part of the thigh, with preservation of the dermis in the donor area to allow reepithelialization, was placed in the lower half of the wound, up to the sternal notch.38 A full-thickness rotation flap from the shoulder and arm, including epidermis and dermis, was placed from the sternal notch to the edge of the submandibular wound.25 During resolution of NF, the patient remained hospitalized, receiving volume replacement and analgesia as well as nutritional support from a high-protein, high-calorie diet to ensure diabetic control. Hospitalization also facilitated close monitoring and care of potential new complications.
Conclusion
Necrotizing fasciitis is a rare and severe infection with a rapid progression, especially when associated with predisposing factors. Because the mortality rate of NF is high, early diagnosis is essential to initiating treatment with broad-spectrum antibiotic therapy and radical surgery carried out by a multidisciplinary team.
Author information
Dr Cavalcante is an oral and maxillofacial surgery student, State University of Pernambuco, Recife, Brazil, where Dr de Oliveira e Silva is an adjunct professor. Dr Lima is a postgraduate student, Prosthodontics Specialization Course, State University of São Paulo, Brazil. Dr Moreira is an associate professor, UNINASSAU, and an oral and maxillofacial surgeon, General Hospital of the State of Alagoas, Maceió, Brazil, where Dr Branco is an oral and maxillofacial surgeon.
References
1. Martínez AY, McHenry CR, Rivadeneira AM. Cervicofacial necrotizing fasciitis: a rare disease with a high mortality requiring early debridement for survival. Rev Esp Cir Oral Maxilofac. 2016;38(1):23-28. 2. Wilson B. Necrotizing fasciitis. Am Surg. 1952;18(4):416-431. 3. Soares TH, Penna JT, Penna LG, et al. Necrotizing fasciitis (NF) diagnosis and treatment: two cases report [in Portuguese]. Rev Med Minas Gerais. 2008;18(2):136-140. 4. Medeiros Júnior R, Melo Ada R, Oliveira HF, Cardoso SM, Lago CA. Cervical-thoracic facial necrotizing fasciitis of odontogenic origin. Braz J Otorhinolaryngol. 2011;77(6):805. 5. Umeda M, Minamikawa T, Komatsubara H, Shibuya Y, Yokoo S, Komori T. Necrotizing fasciitis caused by dental infection: a retrospective analysis of 9 cases and a review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95(3):283-290. 6. Lancerotto L, Tocco I, Salmaso R, Vindigni V, Bassetto F. Necrotizing fasciitis: classification, diagnosis, and management. J Trauma Acute Care Surg. 2012;72(3):560-566. 7. Sprovieri SR, Salles MJ, Lee FD, Golin V. Necrotizing fasciitis [in Portuguese]. Rev Bras Clin Ter. 1998;24;206-210. 8. Roje Z, Roje Z, Matić D, Librenjak D, Dokuzović S, Varvodić J. Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs. World J Emerg Surg. 2011;6(1):46 [expression of concern: 2012;7(1):33]. 9. Morgan MS. Diagnosis and management of necrotizing fasciitis: a multiparametric approach. J Hospital Infect. 2010;75(4):249-257. 10. Yadav S, Verma A, Sachdeva A. Facial necrotizing fasciitis from an odontogenic infection. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;113(2):e1-e4. 11. Lazow SK. Orofacial infections in the 21st century. N Y State Dent J. 2005;71(6):36-41. 12. Leyva P, Herrero M, Eslava JM, Acero J. Cervical necrotizing fasciitis and diabetic ketoacidosis: literature review and case report. Int J Oral Maxillofac Surg. 2013;42(12):1592-1595. 13. Rocha JL, Baggio HC, da Cunha CA, Niclewicz EA, Leite SA, Baptista MI. Relevant issues in the interaction between diabetes mellitus and infection [in Portuguese]. Arq Bras Endocrinol Metab. 2002;46(3):221-229. 14. Hupp JR. Infections of soft tissues of the maxillofacial and neck regions. In: Topazian RG, Goldberg MH, Hupp JR, eds. Oral and Maxillofacial Infections. 4th ed. Philadelphia: Saunders; 2002:294-312.
(continued on page 30) washingtonAGD.org
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ARTICLES (continued from page 29) 15. Brunworth J, Shibuya TY. Craniocervical necrotizing fasciitis resulting from dentoalveolar infection. Oral Maxillofacial Surg Clin North Am. 2011;23(3):425-432. 16. Sandner A, Moritz S, Unverzagt S, Plontke SK, Metz D. Cervical necrotizing fasciitis—the value of the Laboratory Risk Indicator for Necrotizing Fasciitis score as an indicative parameter. J Oral Maxillofac Surg. 2015;73(12):2319-2333. 17. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis. 2014;59(2):147-159 [erratum: 2015;60(9):1448]. 18. Kuncir EJ, Tillou A, St Hill CR, Petrone P, Kimbrell B, Asensio JA. Necrotizing soft-tissue infections. Emerg Med Clin North Am. 2003;21(4):1075-1087. 19. Hasham S, Matteucci P, Stanley PR, Hart NB. Necrotising fasciitis. BMJ. 2005;330(7495):830833 [erratum: 2005;330(7500):1143]. 20. Schütz P, Joshi RM, Ibrahim HH. Odontogenic necrotizing fasciitis of the neck and upper chest wall. J Oral Maxillofac Surg Med Pathol. 2012;24(1):32-35. 21. Suárez A, Vicente M, Tomás JA, Floría LM, Delhom J, Baquero MC. Cervical necrotizing fasciitis of nonodontogenic origin: case report and review of literature. Am J Emerg Med. 2014; 32:1441.e5-1441.e6. 22. Sahoo NK, Tomar K. Necrotizing fasciitis of the cervico-facial region due to odontogenic infection. J Oral Maxillofac Surg Med Pathol. 2014;26(1):39-44. 23. Schneider JI. Rapid infectious killers. Emerg Med Clin North Am. 2004;22(4):1099-1115. 24. Costa IM, Cabral AL, Pontes, SS, Amorim JF. Necrotizing fasciitis: new insights with a focus on dermatological aspects. An Bras Dermatol. 2004;79(2):211-224. 25. Neto NT, Chi A, Paggiaro AO, Ferreira MC. Surgical treatment of complex wounds [in Portuguese]. Rev Med (São Paulo). 2010;89(3/4):147-152. 26. Murray M, Dean J, Finn R. Cervicofacial necrotizing fasciitis and steroids: case report and literature review. J Oral Maxillofac Surg. 2012;70(2):340-344. 27. Sarna T, Sengupta T, Miloro M, Kolokythas A. Cervical necrotizing fasciitis with descending mediastinitis: literature review and case report. J Oral Maxillofac Surg. 2012;70(6):1342-1350. 28. Muhammad JK, Almadani H, Hashemi BA, Liaqat M. The value of early intervention and a multidisciplinary approach in the management of necrotizing fasciitis of the neck and anterior mediastinum of odontogenic origin. J Oral Maxillofac Surg. 2015;73(5):918-927. 29. Swartz MN, Pasternack M. Cellulitis and subcutaneous tissue infectious. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. Vol 1. 6th ed. New York: Churchill Livingstone; 2005:1172-1194. 30. Zhang WJ, Cai XY, Yang C, et al. Cervical necrotizing fasciitis due to methicillin-resistant Staphylococcus aureus: a case report. Int J Oral Maxillofac Surg. 2010;39(8):830-834. 31. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535-1541. 32. Neto NT, Giacchetto E, Kamamoto F, Ferreira MC. Severe infections of soft tissue: case report of face necrotizing fasciitis using vacuum dressing and literature review [in Portuguese]. Rev Bras Cir Plast. 2011;26(2):353-359. 33. Cordero L, Torre W, Freire D. Descending necrotizing mediastinitis and respiratory distress syndrome treated by aggressive surgical treatment. J Cardiovasc Surg (Torino). 1996;37(1): 87-88. 34. Jorge EP, Santos-Pinto A, Gandini Júnior LG, Guariza Filho O, Castro AB. Evaluation of the effect of rapid maxillary expansion on the upper airway using nasofibroscopy: case report and description of the technique. Dental Press J Orthod. 2011;16(1):81-89. 35. Filho DI, Raveli DB, Raveli RB, de Castro Monteiro Loffredo L, Gandin LG Jr. A comparison of nasopharyngeal endoscopy and lateral cephalometric radiography in the diagnosis of nasopharyngeal airway obstruction. Am J Orthod Dentofacial Orthop. 2001;120(4):348-352. 36. Kaul R, McGeer A, Low DE, Green K, Schwartz B. Population-based surveillance for Group A streptococcal necrotizing fasciitis: clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario Group A Streptococcal Study. Am J Med. 1997; 103(1):18-24. 37. Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009;208(2):279-288. 38. Flanagan CE, Daramola OO, Maisel RH, Adkinson C, Odland RM. Surgical debridement and adjunctive hyperbaric oxygen in cervical necrotizing fasciitis. Otolaryngol Head Neck Surg. 2009;140(5):730-734. 39. Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am. 2003; 85-A(8):1454-1460.
AGDPODCAST Oral Medicine, Oral Diagnosis, Oral Pathology
www.agd.org/generaldentistry
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ARTICLES White Paper: Human Papilloma Virus (HPV) and Oropharyngeal Cancer Association of State and Territorial Dental Directors (ASTDD) Adopted July 10, 2017
Problem Cancers of the head and neck occur in a number of anatomical areas including the oral cavity, pharynx, larynx, the paranasal sinuses, nasal cavity, and salivary glands.1 The main causes of head and neck cancers are from one or more of an array of behavioral, environmental, cultural, and viral factors with the majority (approximately 75%) of these attributed to tobacco and alcohol use.1 Recent studies show that an increasing proportion (approximately 60% to 70%) of oropharyngeal cancers (OPC) may be linked to the Human Papilloma Virus (HPV).1,2,3,4,5 Cancers of the oropharynx, the middle part of three anatomical areas comprising the pharynx, impact the back of the throat, which includes the soft palate, base of the tongue, and tonsils;1 HPV-related OPC mainly affect the base of the tongue and tonsils.1 However, it remains unclear whether HPV is linked to other head and neck cancer areas including the oral cavity.6,7 HPV is the most common sexually transmitted virus and infection in the U.S.5 A person can have HPV for many years, even decades, before it is detected or develops into cancer.2 The vast majority of infected people, even those with a high risk strain of HPV, will not develop cancer.8 In the US, estimates show an average of 15,738 new cases of HPV-associated OPC are diagnosed each year in sites where HPV is found, with 3,100 new cases in women and 12,638 in men. 3,4,Error! Bookmark not defined.,9 Findings from the National Health and Nutrition Examination Survey (NHANES) indicate that on any given day, approximately 26 million Americans have an oral HPV infection, with approximately 2,600 of these individuals infected with a high-risk cancer-causing strain.9 According to the CDC, the highest prevalence of HPV-associated OPC is found in non-Hispanic males.10 The fastest growing segment of the HPVrelated OPC population is healthy, non-smokers in the 25-50 age range.Error! Bookmark not defined. White, nonsmoking males age 35 to 55 are most at risk, four to one over females.2 Because of an array of non-traditional risk factors associated with HPV-related OPC, including a younger age cohort and no history of significant tobacco and alcohol use, diagnosis may be delayed since both patients and practitioners may not readily be considering and looking for such oral pathology. HPVrelated OPCs may also be more difficult to detect than tobacco-related cancers because the symptoms are not always obvious to the individual or to the professionals.2 As with most head and neck cancers, the symptoms may be subtle and painless. Because the affected areas for OPC are approximate to the back of the throat, OPC, including those caused by HPV, are generally more difficult to detect and diagnose early when compared to other oral cavity cancers.3 According to the Oral Cancer Foundation, the best way to screen for head and neck cancers, including HPV-related OPC, is through a visual and tactile exam given by a medical or dental professional.2 However, traditional screening techniques may not always be effective for OPC since the oropharynx is located deep inside the neck and cannot be easily visualized or palpated. The exam should be accompanied by a thorough medical history asking about signs and symptoms of OPC along with possible exposure specific to HPV. If the practitioner suspects possible pathology based on the history, a follow-up exam using mirrors (indirect pharyngoscopy) or special fiber-optic scopes (direct pharyngoscopy) will likely be needed to thoroughly examine the oropharynx.11 An oral health professional or physician should (continued on page 32) washingtonAGD.org
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ARTICLES (continued from page 31)
evaluate any symptoms that persist for two or more weeks including a sore in the mouth that does not heal, pain that doesnâ&#x20AC;&#x2122;t go away, a white or red patch, persistent sore throat or lump/swelling of unknown origin. Persistent problems should be assessed for a definitive diagnosis. According to the Oral Cancer Foundation, about 12,000 people between the ages of 15 to 24 are infected with HPV every day in the U.S.2 Yet despite the availability of a vaccine for young boys and girls, HPV OPC rates have increased in recent years. Many factors may pose barriers to receiving the vaccine in healthcare settings including the hesitancy of healthcare providers to discuss HPV in a clinical setting. It is likely that dental professionals, while routinely screening for oral cancer, may not be recommending the HPV vaccine to their patients because: (1) they may be unaware of HPV-related OPC; (2) they may be aware of HPV-related OPC but not about the vaccine and its purported use and effectiveness; and (3) perhaps the most likely reason, dental professionals may feel uncomfortable discussing HPV since it is a sexually transmitted disease. Method The Advisory Committee on Immunization Practices (ACIP) recommends routine HPV vaccination for girls and boys ages 11 and 12.12 Vaccination is also recommended for females ages 13 through 26 and for males ages 13 through 21 who have not been vaccinated previously or who have not completed the recommended series.13 Vaccination is also recommended through age 26 for men who have sex with men and for immunocompromised persons (including those with HIV infection) if not vaccinated previously.13 These vaccines are most effective if given to children before they become sexually active. Given the intricacies in effectively diagnosing HPV-related OPC in a timely manner, receiving the HPV vaccine at a young age by both boys and girls becomes ever more critical. Integrating effective communication strategies to discuss HPV and the HPV vaccine in a clinical setting can build awareness for the possible risk of HPV-related OPC. Healthcare professionals must feel comfortable discussing HPV and the HPV vaccine in their practices. At times it is difficult discussing sexual concerns in a healthcare setting, but rephrasing the message as a cancer prevention strategy can help encourage conversations with patients. If healthcare providers, particularly dentists and dental hygienists, are uncomfortable discussing the subject of sexually transmitted diseases, emphasizing how the HPV vaccine can reduce the risk of OPC and other cancers may be the most prudent tactic to encourage more providers to discuss this topic. Webinars and continuing education courses can help healthcare providers learn the most effective communication tools to implement in their practice. State oral health programs (SOHP) can play an important role in communicating information regarding HPV and the HPV vaccine. SOHPs can facilitate partnerships, including referral relationships among stakeholders. Because of their positioning with external as well as internal partners, SOHPs have the opportunity to work with private and public health medical and dental clinical professionals and their professional associations to craft messages that clinicians can use in discussing HPV and promoting the HPV vaccine. Such messages can include the importance of referrals to primary care medical and dental providers for HPV vaccination, depending on what individual state practice acts allow. These messages might also form the basis of broader, community-based campaigns employing public health approaches, using risk communications techniques and framing appropriate to the intended audiences. Similarly, SOHPsâ&#x20AC;&#x2122; relationships with state health department colleagues in programs such as Chronic Disease and Cancer Prevention enable them to discuss HPV-related oral cancers and for the programs to make their own networks aware of the OPC risk due to HPV. In both situations, the SOHP can help develop messages for dissemination on how best to promote use of HPV vaccination in preventing OPC.
2 32 Washington AGD Newsletter | September 2017
(continued on page 33)
ARTICLES The primary focus of HPV vaccines has been on reducing cervical cancer. However, increased awareness 14 (continued 32)prevention of OPC in males and females as well. The SOHP and other public health should from focuspage on the programs canfocus address HPV-related through the establishment of collaborative resulting The primary of HPV vaccinesOPC has been on reducing cervical cancer. However,partnerships increased awareness 14 in an interprofessional workforce that encompasses healthcare professionals and includes immunization should focus on the prevention of OPC in males and females as well. The SOHP and other public health staff. Together, they can help raise public awareness signs, symptoms, risk factors and changes in programs can address HPV-related OPC through the about establishment of collaborative partnerships resulting the of head and neck cancer, includinghealthcare OPC. Further, this integrated workforce can counsel in andemographics interprofessional workforce that encompasses professionals and includes immunization patients about the HPV vaccine and how it can help reduce the risk of HPV-related OPCs. Offering head staff. Together, they can help raise public awareness about signs, symptoms, risk factors and changes in primary of HPV has been on reducing cervical However, awareness and neck The cancer screenings forvaccines targeted, high risk populations during an increased immunization clinic also might the demographics offocus head and neck cancer, including OPC.cancer. Further, this integrated workforce can counsel should focus on the prevention of OPC in males and females as well.14 The SOHP and other public health create important opportunity to discuss trends of OPC and HPV. OPCs. Offering head patientsanabout the HPV vaccine and how itthe canincreasing help reduce the risk of HPV-related programs can address HPV-related OPC through the establishment of collaborative partnerships resulting and neck in cancer screeningsworkforce for targeted, high risk populations during an immunization an interprofessional that encompasses healthcare professionals and includes immunization clinic also might staff. Together, they can help raise public awareness about symptoms, risk factors and changes Finally, perhaps most important, integrating HPVsigns, andtrends OPC of education dental,in dental hygiene and create anand important opportunity to discuss the increasing OPC andinto HPV. the demographics of head and neck cancer, including OPC. Further, this integrated workforce can counsel other health professions curricula can increase the comfort level of healthcare providers in addressing patients about the HPV vaccine and how it can help reduce the risk of HPV-related OPCs. Offering head HPV andand theperhaps HPV vaccine in aforclinical setting. The next generation of healthcare professionals needs and to Finally, most important, integrating HPV and OPC education into also dental, and neck cancer screenings targeted, high risk populations during an immunization clinic might dental hygiene create an important opportunity to discuss the increasing trends of OPC and HPV. be well versed in the emerging evidence as it relates to HPVlevel andof OPC. other health professions curricula can increase the comfort healthcare providers in addressing HPV and Finally, the HPV vaccine inimportant, a clinical setting. The generation of healthcare professionals needs to and perhaps most integrating HPV andnext OPC education into dental, dental hygiene and be well versed in the emerging evidence as ittherelates HPV and OPC. other health professions curricula can increase comfortto level of healthcare providers in addressing HPV and the HPV vaccine in a clinical setting. The next generation of healthcare professionals needs to be well versed in the emerging evidence as it relates to HPV and OPC.
Concluding Statement: The Association of State and Concluding Statement : :Territorial Dental Directors (ASTDD) endorses promotion of the HPV vaccine toConcluding reduce theStatement risk of HPV-related oropharyngeal cancer. State oral health programs (SOHPs) can The Association of State Territorial Dental Directors endorses promotion of the HPV play a critical roleofinState facilitating evidence-based state(ASTDD) and(ASTDD) community practice interventions andHPV The Association andand Territorial Dental Directors endorses promotion of the vaccine to reduce the risk of HPV-related oropharyngeal cancer. State oral health programs (SOHPs) can messaging campaigns aimed at effectively promoting the HPV vaccine. Through external and internalcan vaccine toplay reduce the risk of HPV-related oropharyngeal cancer. State oral health programs (SOHPs) a critical role in facilitating evidence-based state and community practice interventions and partners, SOHPs help aimed develop collaborative and referral networks that can empower an play a critical rolecan in facilitating state andvaccine. community practice and messaging campaigns at evidence-based effectively promotingpartnerships the HPV Through external andinterventions internal partners, SOHPs can help develop collaborative partnerships and referral networks that can empower an interprofessional workforce and medical practitioners to promote use of external the HPVand vaccine for messaging campaigns aimedofatdental effectively promoting the HPV vaccine. Through internal interprofessional workforce of dental and medical practitioners to promote use of the HPV vaccine for their patients and increase the rates of completion of the HPV vaccination series. A cost-effective partners, SOHPs can help develop collaborative partnerships and referral networks that can empower an their patients and increase the rates of completion of the HPV vaccination series. A cost-effective approach to promoting overall in evidence-based state and interventions is to interprofessional of health dental and medical practitioners to community promote usepractice of the HPV vaccine for approach toworkforce promoting overall health in evidence-based state and community practice interventions is to incorporate HPV-related oropharyngeal cancer awareness strategies into oral health promotion efforts and incorporate cancer awareness strategies into oral health promotion efforts and their patientsHPV-related and increaseoropharyngeal the rates of completion of the HPV vaccination series. A cost-effective healthcare professional academic curricula. healthcare professional academic curricula. approach to promoting overall health in evidence-based state and community practice interventions is to incorporate HPV-related oropharyngeal cancer awareness strategies into oral health promotion efforts and healthcare professional academic curricula. The ASTDD Dental Public Health Resources Committee is pleased to acknowledge Christina Demopoulos, DDS, MPH, for her assistance in preparing this paper.
The ASTDD Dental Public Health Resources Committee is pleased to acknowledge Christina Demopoulos, DDS, MPH, for her assistance in preparing this paper. 1
The ASTDD Dental Public Health Resources Committee is pleased to acknowledge Christina Demopoulos, DDS, MPH, for her assistance in preparing this paper.
National Cancer Institute. https://www.cancer.gov/types/head-and-neck/head-neck-fact-sheet#q2. Accessed 5/13/17. Saraiya M, Unger ER, Thompson TD, et al. U.S. Assessment of HPV types in cancers: implications for current and 9-valent HPV vaccines. Journal of the National Cancer Institute. 2015 June 29: 107(6): djv086. 3 Chaturvedi AK, Engels EA, Pfeiffer RM. HPV and rising oropharyngeal cancer incidence in the United States. Journal of Clinical Oncology. 2011 Nov 10: 29(3): 4294-301. 1 4 GillisonInstitute. ML, Chaturvedi AK, Lowy DR. HPV prophylactic vaccines and the potential prevention of noncervical cancers in both 5/13/17. National Cancer https://www.cancer.gov/types/head-and-neck/head-neck-fact-sheet#q2. Accessed 2 and women. Cancer. 2008 Nov Suppl): 3036-46. Saraiya M,5men Unger ER, Thompson TD,15;et113(10 al. U.S. Assessment of HPV types in cancers: implications for current and 9-valent Oral Cancer Foundation. HPV Oral Cancer Facts. http://oralcancerfoundation.org/understanding/hpv/hpv-oral-cancer-facts/. HPV vaccines. Journal of the Cancer Institute. 2015 June 29: 107(6): djv086. Accessed November 21,National 2016 31 6 National Cancer Institute. https://www.cancer.gov/types/head-and-neck/head-neck-fact-sheet#q2. Accessed 5/13/17. Hubbard CU, Akgul B. Pfeiffer HPV and cancer of the oral cavity. Virulence. 2015 Apr;6(3):244-248. Chaturvedi AK, Engels EA, RM. HPV and rising oropharyngeal cancer incidence in the United States. Journal of 7 2 W, Schmitt A, et al. Low etiology fraction in high-risk human papilloma virus in oral cavity squamousfor cellcurrent and 9-valent SaraiyaOncology. M, Lingen UngerMW, ER,Xiao Thompson TD, et al. U.S. Assessment of HPV types in cancers: implications Clinical 2011 Nov 10: 29(3): 4294-301. carcinomas. Oral Oncology, 2013; 49:1-8. 4 2
HPV vaccines. Journal of the Cancer 2015 vaccines June 29: 107(6): djv086. prevention of noncervical cancers in both Gillison ML, Chaturvedi AK,National Lowy DR. HPVInstitute. prophylactic and the potential 3 Chaturvedi AK, Cancer. Engels EA, Pfeiffer RM. HPVSuppl): and rising oropharyngeal cancer incidence in the United States. Journal of men and women. 2008 Nov 15; 113(10 3036-46. 8 5 Centers for Disease Control and Prevention. Epidemiology and 3Prevention of Vaccine-Preventable Diseases. Hamborsky J, Clinical Oncology. 2011 Nov 10:Oral 29(3): 4294-301. Oral Cancer Foundation. HPV Cancer Facts. http://oralcancerfoundation.org/understanding/hpv/hpv-oral-cancer-facts/. Kroger A, Wolfe S, eds. 13th ed. Washington D.C. Public Health Foundation, 2015. Also at 4 Gillison ML, Chaturvedi AK, Lowy DR. HPV prophylactic vaccines and the potential prevention of noncervical cancers in both Accessed November 21, 2016 https://www.cdc.gov/vaccines/pubs/pinkbook/hpv.html. 6 9 men and women. Cancer. 2008 Novcancer 15; Suppl): 3036-46. Gillison ML, B. Broutian T,and Pickard RK, 113(10 etof al. the Prevalence of oral HPV infection in 2015 the United States, 2009- 2010. JAMA. 2012 Hubbard CU, Akgul HPV oral cavity. Virulence. Apr;6(3):244-248. 57 Feb Foundation. 15: 307(7) Oral Cancer HPV A, Oral http://oralcancerfoundation.org/understanding/hpv/hpv-oral-cancer-facts/. Lingen MW, Xiao W,693-703. Schmitt et Cancer al. LowFacts. etiology fraction in high-risk human papilloma virus in oral cavity squamous cell 10 Centers for Disease Control and Prevention. HPV-associated oropharyngeal cancer rates by race and ethnicity. Accessed November 21, 2016 carcinomas. Oral Oncology, 2013; 49:1-8. http://www.cdc.gov/cancer/hpv/statistics/headneck.htm. Accessed November 21, 2016. 6 11 Hubbard CU, AkgulCancer B. HPV and cancer of the oral cavity. Virulence. 2015 Apr;6(3):244-248. American Society, https://www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/detection-diagnosis7 staging/how-diagnosed.html. Accessed Lingen MW, Xiao W, Schmitt A, et al. 5/14/17. Low etiology fraction in high-risk human papilloma virus in oral cavity squamous cell 12 Markowitz LE, Dunne EF, Saraiya M, et al. Centers for Disease Control and Prevention (CDC). Human papillomavirus carcinomas.vaccination: Oral Oncology, 2013;of49:1-8. recommendations the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep
3
2014;63(No. RR-05):1â&#x20AC;&#x201C;30. 13 Petrosky E, Bocchini JA, Hariri S, et al. Centers for Disease Control and Prevention (CDC). Use of 9-Valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the advisory committee on immunization practices (ACIP). MMWR 2015:64(11);300-304. 14 Kreimer, AR. Prospects for prevention of HPV-driven oropharynx cancer. Oral Oncol. 2014 June ; 50(6): 555â&#x20AC;&#x201C;559. doi:10.1016/j.oraloncology.2013.06.007.
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washingtonAGD.org
33
CONTINUING EDUCATION Washington AGD Educational Center Heyamoto Conference Room 19415 International Blvd, #410 SeaTac, WA 98188 Office: 253-306-0730 Fax: 206-212-4969
2-Day Hands On Workshop! Speaker: Dr. Foroud Hakim & Dr. Marc Geissberger Date: Time: Tuition:
Dr. Marc Geissberger
December 1-2, 2017 8:00 AM - 5:00 PM Friday & Saturday Tuition: Dentist: $595, Active Military Dentist: $535 and Staff with Dentist: $350 Friday (Lecture Only): Dentist, Military Dentist and Staff with Dentist: $199 Credits: 14 Lecture & Participation Subject Code: 250 Operative Location: Washington AGD Educational Center 19415 International Blvd, #410, SeaTac, WA 98188
Course Outline: essential to contemporary practice. Special emphasis will be placed on modern techniques and ancillary products that allow practitioners to design and deliver restorative treatment with precision - leading to optimal esthetics, efficiency, productivity and doctor and patient satisfaction.
Topics covered:
• Adhesive advancements and bonding. • Impressions yesterday, today and tomorrow • Direct resin restorations. • Indirect ceramic options. • Treatment planning and design. • Latest product entries and technologies costing under 10K. • Pre prosthetic orthodontics to optimize restorative results (Invisalign). • Developing esthetic restorations while respecting tooth structure. To register go to www.washingtonagd.org or call 253-306-0730
Dr. Foroud Hakim
Washington AGD Approved PACE Program Provider #219331 FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry, AGD or WAGD endorsement. Washington AGD PACE Provider /1/2014-5/31/2018
(Light Breakfast, Lunch, Parking & all materials included with Registration) 34 Washington AGD Newsletter | September 2017
CONTINUING EDUCATION Washington AGD Educational Center Heyamoto Conference Room 19415 International Blvd, #410 SeaTac, WA 98188 Office: 253-306-0730 Fax: 206-212-4969
Oral Surgery for the General Dentist Making it Easier, Faster & More Predictable Speaker: Dr. Karl Koerner Date: Time: Tuition:
March 2-3, Friday and Saturday
8:00 AM - 5:00 PM AGD Member Dentist: $795, Non-AGD Dentist: $895, Military Dentist: $715.50 Credits: 16 Lecture & Participation Subject Code:310 Location: Washington AGD Educational Center 19415 International Blvd, #410, SeaTac, WA 98188 Course Outline:
Lecture and Hands-on Workshop Oral Surgery: Faster, Easier, and More Predictable. karlrkoerner@comcast.net | Work: 801-502-8585 | 2602 S. 150 E., Bountiful, UT 84010 website: www.oralsurgeryservices.com Didactic part: Many extractions look easy but can soon become difficult, time consuming, and lead to complications. This course reviews the best techniques and instruments to remove “surgical” extractions easily and quickly while conserving bone. From that primary emphasis, Dr. Koerner branches to other related surgery subjects that use many of the same instruments and principles.
These include:
The most common suturing techniques and materials, avoiding sinus problems, predictable socket grafting techniques ( without company hype), ridge preparation for immediate dentures, bleeding management during surgery, a review of moderate third molar impaction essentials (anatomy and step-by-step guidelines). Review of mini-implants for denture stabilization. anxiety control for apprehensive surgery patients, I&D in general practice, discussion of antibiotic usage incisional/excisional biopsies, bisphosphonates, other discussions as time permits. Workshop part: This part of the course (intermittent with the lecture) uses life-like dentoform models on which surgical procedures are performed. The following procedures will be done on the models: full-thickness mucoperiosteal flaps (envelope and triangular), suturing (interrupted/surgeon’s knot, cross-suture, continuous-lock), surgical extractions (multiple root-tip removals with several different methods), alveoplasty, socket grafting (bone graft and barrier membrane) moderate third molar impaction (mesioangular), excisional biopsy incision and drainage,
Course objectives:
As a result of attending this course, the dentist will be able to: 1. More easily do “surgical” or difficult extractions that frequently occur in general practice. 2. Be more proficient at ridge preparation for immediate dentures. 3. Select appropriate socket grafting cases and have the knowledge to do them successfully. 4. Prevent and/or manage bleeding problems that can occur during oral surgery.
5. Better understand patient selection and risks of third molar surgery along with step-by-step - how to do moderate third molar impactions. 6. Perform oral surgery according to current standards of care.
Washington AGD Approved PACE Program Provider #219331 FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry, AGD or WAGD endorsement. Washington AGD PACE Provider /1/2014-5/31/2018
(Light Breakfast, Lunch, Parking & all materials included with Registration) washingtonAGD.org
35
CONTINUING EDUCATION
Two Courses on Medical Billing for Dental Practices featuring Dr. Chris P. Farrugia Friday, October 13, 2017 8:30 am – 4:30 pm Credits: 7 Emerald Queen Conference Center 5700 Pacific Highway E., Fife, WA 98424
FRIDAY CLASS Medical Billing for Dental Practices
Dental practices are filled with patients that pay premiums for medical insurance policies that have benefits available for services they render. Accessing medical benefits requires the dental office to step out of their “dento-centric” view of their practice and into a medical view. In this course, dental practices will learn to separate the medical portion of their services from the dental, identify when to file for medically necessary services and the basics of medical claim submission. Understand the basis for medical billing for dental practices Learn basic medical insurance terminology and concepts Understand the medical claims cycle and how it works Understand medical necessity for claims Learn ICD and CPT coding basics Learn what can be billed to medical insurance Learn how to complete the CMS1500 claim form
Coding For Medical and Dental Claims
ICD 10 replaced ICD-9 in October 2015. Changes to the ADA claim form require the use of ICD-10 diagnosis codes as does the CMS1500 medical claim form; thus, a working knowledge of ICD-10 is important for dental practices that file dental AND medical claims. This course will prepare the practitioner and staff for medical and dental claims using ICD-10. Learn the contents, organization, conventions and structure of ICD-10-CM Learn how to locate and assign a code with ICD-10-CM Learn how to prioritize your diagnosis codes for successful claims Learn how to code various clinical situations (ICD and CPT) including exam, consultation, radiographs, CT, emergencies, TMD, sleep apnea appliance and surgical removal of wisdom teeth
Saturday, October 14, 2017 9:00 am – 4:00 pm Credits: 6 AGD Educational Center
19415 International Blvd, Ste 410, SeaTac WA 98188
SATURDAY CLASS Advanced Medical Dental Billing Workshop
This course will focus on adding dental medical billing to your practice and navigating the dental medical billing world. Once dental practices are fundamentally sound in the claims process, medical claims may be successfully submitted for "beyond the basics" services. This is the ultimate in-depth coding course for surgeries, appliances, and trauma claims plus more! Basic medical billing concepts are not covered in this course. A working knowledge of the medical claim form and the claims process is a prerequisite for registration. This course is not appropriate for practices with little or no medical claims experience. This course is designed as a follow-up to Friday’s class. It is strongly encouraged that both the dentist and the staff attend together. There is a discount if you register for this bundled class th before Friday, October 13 .
Course Prerequisites: Billing for Dental Practices
About our Presenter: Dr. Chris P. Farrugia is a speaker, teacher and leader in digital dentistry. An early adopter of digital CAD/CAM technology, Dr. Farrugia added CT to his practice in 2011. He trains dentists nationwide who want to advance their practices with CAD/CAM digital restorative techniques, digital imaging and successfully access medical benefits for their services. Dr. Farrugia is a graduate from the Emory University of Dentistry and an alumnus of LD Pankey Institute. He has been a CEREC Chair side user since 2000, a CEREC in Lab user since 2009 and a Patterson Certified CEREC Basic, Intermediate and Advanced Trainer. Dr. Farrugia is the owner of Artistic Dental Laboratory Services and author of multiple articles on medical billing for dentists. Academy of General Dentistry Approved PACE Program Provider. FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. 2017 to 2021 AGD Provider 3193
36 Washington AGD Newsletter | September 2017
1111 Harvard Avenue Seattle, WA 98122 206.448.6620 FAX 206.443.9308
CONTINUING EDUCATION Green Dentistry: Marijuana, Opioids and the Effects on Oral Health
featuring Dr. Barry Taylor and Dr. Caroline DeVincenzi
Marriott – Seattle Airport 3201 South 176th Street Seattle, WA 98188 206.241.2000
Friday, May 18, 2018 8:30 am – 4:30 pm Credits: 7 Marijuana is the most commonly used recreational drug in the United States. Twenty-three states currently have some form of legalized marijuana; eight states have legalized it for recreational use. It is estimated that over 10% of the US population uses it at least once a year. In addition to marijuana usage, our Nation is experiencing a deadly drug epidemic due to opioid medications being prescribed at an alarming rate. Over 600,000 opioids related prescriptions are written every day in the U.S.
THANKS TO OUR CO-PRESENTERS:
This course will be an unbiased and evidence based presentation of marijuana, opioids and their role in dentistry. At the end of this course participants will: 1. Understand the pharmacology and pharmacokinetics of marijuana and opioids; 2. Understand how marijuana and opioid usage by patients effects their oral health; specific focus on oral pathology, caries risk and periodontal disease; 3. Understand interactions of THC with commonly used prescribed medications and be familiar with medical emergencies related to THC; 4. Learn how to communicate with your patients regularly using cannabis; 5. Explore future areas of research in regards to periodontal health, wound healing and caries control; and, 6. Have an introduction to ‘medical marijuana’ and cannabinoid.
This course is suitable for doctors, hygienists, assistants and front office staff.
Type
Before May 4, 2018
After May 4, 2018
Dentists
$245
$270
Retired Members/Staff
$160
$185
About our Presenters: Dr. Barry Taylor, DMD, FAGD, FACD, CDE, is an Assistant Professor in Restorative Dentistry at the Oregon Health & Science University’s School of Dentistry. He also is a part-time associate in private practice at Woodburn Community Dental. Prior to attending the OHSU School of Dentistry, he worked as a research assistant for two year in the field of neuropsychopharmacology at the U.S. Veteran’s Hospital in Portland. Dr. Taylor has served as the Oregon Dental Association’s Editor for ten years in addition to leadership positions with the Oregon Academy of General Dentistry, American College of Dentists, Academy of General Dentistry, Delta Sigma Delta and the American Dental Association. Dr. Taylor has been awarded the “Dentist of the Year” from both the Oregon AGD and the Washington County Dental Society. Dr. Caroline DeVincenzi, DMD, MS candidate in Periodontics 2019 at OHSU. She graduated from the OHSU School of Dentistry in 2016 and was awarded both the Academy of Operative Dentistry Award and the American Academy of Periodontology Award. Dr. DeVincenzi completed a global health study in rural Kenya, winning a Predoctoral Dental Student Merit Award for Outstanding Achievement in Community Dentistry given by the American Association of Public Health Dentistry. She has provided basic literature reviews for the OHSU School of Dentistry CaseCAT poster presentations reviewing the relationships of type II diabetes and cannabis use with periodontal disease. Dr. DeVincenzi is currently planning to assess the incidence of periodontal disease among adult cannabis users in the Portland area. 1111 Harvard Avenue Seattle, WA 98122 206.448.6620 FAX 206.443.9308 washingtonAGD.org
37
CONTINUING EDUCATION
REGISTRATION FORM Friday and/or Saturday, October 13 and/or 14, 2017 Introduction to Medical Billing for Dental Practices
Speaker: Chris Farrugia, DDS Credit Hours: 7 credits Friday and 6 credits Saturday Times: 8:30am - 4:30pm Friday; 9:00am - 4:00pm Saturday Location: Friday: Emerald Queen Conference Center - 5700 Pacific Highway E. - Fife, WA 98424 Saturday: Washington AGD Educational Center - 19415 International Blvd, #410 - Seatac, WA 98188
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[ ] WORK
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DIETARY RESTRICTIONS: [ ] Vegetarian
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METHOD OF PAYMENT PRICE FOR BOTH DAYS: On or before October 6, 2017 [ ] DENTIST $575 [ ] RETIRED DENTIST/STAFF $430 After October 6, 2017 [ ] DENTIST $600 [ ] RETIRED DENTIST/STAFF $455 PRICE FOR FRIDAY ONLY: On or before October 6, 2017 [ ] DENTIST $245 [ ] RETIRED DENTIST/STAFF $150 After October 6, 2017 [ ] DENTIST $270 [ ] RETIRED DENTIST/STAFF $175 PRICE FOR SATURDAY ONLY (if you have attended intro class through the WAGD previously): On or before October 6, 2017 [ ] DENTIST $350 [ ] RETIRED DENTIST/STAFF $299 After October 6, 2017 [ ] DENTIST $400 [ ] RETIRED DENTIST/STAFF $330 Dentist(s):
_____ X $575 = $_______; _____ X $245 = $_______; _____ X $350 = $_______
Retired Dentist/Staff: _____ X $430 = $_______; _____ X $150 = $_______; _____ X $299 = $_______ [ ] VISA [ ] MasterCard [ ] American Express [ ] Check enclosed
TOTAL DUE: $___________ (Checks should be made out to Seattle-King County Dental Society) CARD ACCOUNT NUMBER
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Please send this form to: Seattle-King County Dental Society 1111 Harvard Ave Seattle, WA 98122 38 Washington AGD Newsletter | September 2017
Or fax to: Seattle-King County Dental Society (206) 443-9308
CONTINUING EDUCATION Promotional code:_______________________
2017 AGD Membership Application
Referral Information If you were referred to the AGD by a current member, please note his or her information below:
For more information: Join online at www.agd.org. Call us at 888.243.3368 or 312.440.4300.
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Do you currently hold a valid dental license in your country of practice? q No q Yes: ____________________________________________________________________________________________ License number State/province Country Date renewed (mm/yyyy) Type of membership (See back page for definitions.): (Check one.) ❑ Active general dentist ❑ Associate (dental specialist) ❑ Resident ❑ Dental student ❑ Affiliate If you are not in general practice, please indicate your specialty: _______________________________ Current dental practice environment: (Check one.) ❑ Solo ❑ Associateship ❑ Group practice ❑ Hospital ❑ Resident ❑ Corporate ❑ Other____________________________ ❑ Faculty _________________________________________________________________ Please indicate institution
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Are you a graduate of an accredited* U.S./Canadian dental school? ❑ Yes ❑ No ❑ Currently enrolled
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Are you a graduate of (or resident in) an accredited* U.S. or Canadian postdoctoral program? ❑ Yes ❑ No ❑ Currently enrolled Type: ❑ AEGD ❑ GPR ❑ Other ________________________ *See back of form.
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❑ Active General International (in Canadian dollars) Dentist ..................... $386 ..................$427 ................ $324 ❑ Associate ..................... 386 ....................427 .................. 324 ❑ Affiliate ....................... 193 ....................214 .................. 162 ❑ Resident ....................... 77 ......................86 .................... 65 ❑ 2016 Graduate ............. 77 ......................86 .................... 65 ❑ 2015 Graduate ........... 154 ....................171 .................. 130 ❑ 2014 Graduate ........... 231 ....................256 .................. 194 ❑ 2013 Graduate ........... 308 ....................341 .................. 259 ❑ Dental Student .............. 17 ......................22 .................... 17
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___________________________________
Expiration date (mm/yyyy) Please print name as it appears on the card. I hereby certify that all of the above information is correct, and that by signing this application agree to all terms of membership, including completion of 75 hours of continuing education every three years for active general dentist and associate members.
1. AGD Headquarters Dues: ............................. _________ 2. AGD Constituent Dues: ............................... _________ Please refer to back side for constituent dues.
Signature
Date
Total Amount Enclosed: ............................. _________
Return this application with your payment to: Academy of General Dentistry, 560 W. Lake St., Sixth Floor, Chicago, IL 60661-6600, USA.
Dues rates effective through Sept. 30, 2017.
If paying by credit card, fax to 312.335.3443.
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CONTINUING EDUCATION
Continuing Dental Education Courses & Events Organization SEPTEMBER 2017 September 8: “Washington AGD Orthodontic Hands-On Program”, Dr. Binh Tran Washington AGD September 15: Clinical Records Prevent Criminal Records: Do Dentistry, Not Time”, Dr. Roy Shelburne
Henry Schein Dental & Washington AGD
September 20: “Medical Management of Dental Caries”, Dr. Joel Berg
SCDS
September 21: “Dental Materials”, Dr. George Holzer
Washington AGD
September 22: “Learning from My Endodontic Failures”, Dr. Rodrigo Cunha (Day 1)
Washington AGD
September 23: “Simplifying Endodontics”, Dr. Rodrigo Cunha (Day 2)
Washington AGD
September 23: “Dental Materials”, Dr. George Holzer
Washington AGD
September 22-23: “Ultrasonics “Olympic Gold” in Patient Health & Wellness Workshop” Ms. Janet Press September 29: “Update in Pharmacology” Dr. Hal Crossley September 29: “Medical Billing for the GP”, Dr. Chris Farrugia
UWSOD
UWSOD PCDS, SKCDS & UWSOD
September 30: “Street Drugs – What the Dentist Needs to Know” Dr. Hal Crossley
UWSOD
OCTOBER 2017 October 3-8: “Oral Surgery for the General Dentist” Dr. Maria B. Papageorge, Destination Iceland UWSOD October 6: “Washington AGD Orthodontic Hands-On Program”, Dr. Binh Tran
Washington AGD
October 7: “Washington AGD Membership Appreciation Gala” Mad Hatter’s Ball
Washington AGD
October 18: Avoiding Anesthesia & Sedation issues, malpractice suits”, Dr. Fred Quarnstrom
SCDS
October 19-24: “ADA National Conference—Atlanta”
ADA
October 27: “BLS for Healthcare Providers & First Aid Courses, Everett
SCDS
NOVEMBER 2017 November 3: “Washington AGD Orthodontic Hands-On Program”, Dr. Binh Tran Washington AGD November 3: “Business & Communication – How to Produce a Memorable Daily Show and Whole Health: The Mouth and Its Messages: An Oral & Systemic Health Review” Dr. Lisa Knowles WSDHA & UWSOD November 4: “SKCDS Auction & Gala”
SKCDS
November 10-11: “Revolutionary Prevention Protocols” Dr. Brian Novy
Oregon AGD
November 16: “Esthetics & Function in all Ceramics and Composites”, Dr. Joyce Bassett
Washington AGD
November 16: Annual Social & Foundation Fundraiser, team building, dinner & entertainment
SCDS
November 17: “Mastering Posterior Bulk Full & Direct Composite Veneer”, Dr. Joyce Bassett
Washington AGD
November 18: “Pathology & Trauma”, Dr. Jasjit Dillon
Washington AGD
REGISTER ONLINE: WASHINGTONAGD.ORG OR CALL: 253-306-0730 (continued on page 41 40 Washington AGD Newsletter | September 2017
CONTINUING EDUCATION
Continuing Dental Education Courses & Events Organization DECEMBER 2017 December 1: “Washington AGD Orthodontic Hands-On Program”, Dr. Binh Tran Washington AGD December 1: “Topic TBD”
PCDS & Washington AGD
JANUARY 2018 January 12: “Washington AGD Orthodontic Hands-On Program”, Dr. Binh Tran Washington AGD January 25: “Confident Implant Placement Through Digital Planning”, Dr. Armen Mirzayan
Washington AGD
January 26: “Growth Opportunities for your Dental Practice”, Dr. Armen Mirzayan
Washington AGD
January 27: “Soft Tissue Concepts for the General Dentist”, Dr. Gordon Fraser
Washington AGD
January 26-27: “Pediatric Dentistry and Patient Behavior” Dr. Gregory Psaltis Oregon AGD FEBRUARY 2018 February 2: “Washington AGD Orthodontic Hands-On Program”, Dr. Binh Tran Washington AGD February 21: SCDS General Meeting, TBA
SCDS
MARCH 2018 March 9: Annual Seminar at Lynnwood Convention Center, TBD SCDS, UWSOD, SKCDS March 21: SCDS General Meeting, TBA
SCDS
APRIL 2018 April 13: Stay out of Jail: Avoid Coding Errors & Excel in Insurance Administration, Dr. Charles Blair Henry Schein Dental & Washington AGD April 18: SCDS General Meeting, TBA
SCDS
April 26: “Practical Pediatric Dentistry for the General Practitioner”, Dr. Carla Cohn
Washington AGD
April 27: “The Walletectomy: Embezzlement in the Dental Office”, Dr. Pat Little
Washington AGD
April 27: BLS for Healthcare Providers & First Aid Courses, Everet
SCDS
April 28: “Assessment & Diagnosis of Oral Facial Pain”, Dr. Henry Gremillion
Washington AGD
April 28: “The Walletectomy: Embezzlement in the Dental Office”, Dr. Pat Little
Washington AGD
May 2018 May 16: SCDS General Meeting, TBA SCDS May 18: Topic TBA “William Howard Memorial Lecture
SKCDS, UWSOD & Washington AGD
Organization Contacts Contact: Henry Schein Dental: 253-395-8039 Contact: Oregon Academy of General Dentistry (Oregon AGD) Phone #503-228-6266 Contact: Pierce County Dental Society (PCDC) #253-274-9722 Contact: Region 11 Academy of General Dentistry #253-306-0730 Contact: Seattle-King County Dental Society (SCKDS) # 206-448-6620 Contact: Snohomish County Dental Society (SCDS) #360-419-7444 Contact: University of Washington School of Dentistry (UWSOD) #206-543-5448 Contact: Washington Academy of General Dentistry (Washington AGD) #253-306-0730
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AGD Member Benefits The Academy of General Dentistry (AGD) is the only organization that exclusively represents the interests and serves the needs of the general dentist. Start taking advantage of our member benefits today—join the AGD by visiting www.agd.org or calling 888.AGD.DENT (888.243.3368).
Continuing Education
Discover quality continuing education (CE) opportunities—at both the local and national level, and in a variety of formats—to help you provide the best patient care, learn about the latest technologies and procedures, and emerge as the educated voice of general dentistry. Plus, you can submit CE to the AGD in a variety of convenient ways—via the Web, email, mail, or fax—and we’ll track your courses with our members-only CE transcripts.
Achievement Awards
Stand out among the competition, gain instant credibility in your profession, and establish your commitment to lifelong learning and quality patient care with the prestigious AGD Fellowship and Mastership awards, the only achievement-based awards in general dentistry.
Advocacy and Representation
Join the organization that serves as the voice of general dentistry. The AGD ensures that general dentists and supporters of the profession can speak up when it matters most, helping members unite their voices on legislative and regulatory activities affecting their right to practice within the United States.*
Annual Meeting
Take advantage of discounted registration to the AGD’s annual meeting, where you can earn CE, checkout the latest products and technology, and network with your colleagues.
Practice Tools
Access a variety of tools to help you manage your practice more efficiently: Check the AGD Product Review Directory before you buy, download sample consent, employee, and practice policy forms from the AGD’s Practice Management Library, and get personalized assistance with third party payer problems, as well as free insurance contract analysis.
888.AGD.DENT
Career Tools
Take advantage of the AGD Marketplace & Career Center, where dental connections are made. Search available job listings, buy a practice or equipment, post your own résumé at no cost, and find additional resources to help you plan for your next career move.
Patient Resources
Get enrolled in the Find an AGD Dentist directory, which is searchable by prospective patients through KnowYourTeeth. com, the AGD’s consumer-facing website. You also may direct your current patients to learn more about their oral health through www.2min2x.org, an educational website created by the Partnership for Healthy Mouths, Healthy Lives—of which the AGD is a proud member—and the Ad Council. Plus, offer educational reading materials in your waiting room with AGD oral health fact sheets, which cover a range of topics and are customized with your practice information.
Publications and Media
Stay informed on the latest general dentistry news and research with complimentary subscriptions to the AGD’s awardwinning print publications, AGD Impact and General Dentistry, along with extra content available exclusively in the digital editions. You also can listen to the AGD Podcast series and read our blog, The Daily Grind.
Member Savings
Receive immediate access to the AGD Member Savings & Offers program, which provides you with exclusive savings and special offers on the personal and professional products and services you need most. *Canadian dues rates reflect limited advocacy benefits.
membership@agd.org
www.agd.org
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Constituent of the Academy of General Dentistry Valerie A. Bartoli, Executive Director 19415 International Blvd, #410, SeaTac, WA 98188 p 253-306-0730 | f (206) 212-4969
Washington AGD Mission: â&#x20AC;&#x153;The Washington AGD provides its membership professional development through quality education for comprehensive patient care.â&#x20AC;?
www.washingtonAGD.org 44 Washington AGD Newsletter | September 2017
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