CDA Journal - July 2021: Dentistry Takes a Shot at COVID-19 by California Dental Association

Journa C A L I F O R N I A

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July 2021 Dental Prosthesis Design Geospatial Health TMJ Disorders

A S S O C I AT I O N

Dentistry Takes a Shot at COVID-19

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Vol 49 Nº 7

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d e pa r t m e n t s

421 The Editor/Critical Thinking Is Not a Spectator Sport 423 Impressions 465

RM Matters/Improving Patient Safety With a Timeout Policy

467 Regulatory Compliance/Expanding Patient Access to Their Health Information

469 Tech Trends

f e at u r e s

427 Dentistry Takes a Shot at COVID-19 CDA developed a COVID-19 vaccine toolkit to compile multiple COVID-19 vaccine resources on behalf of our members.

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443 Functional and Aesthetic Rehabilitation With Porcelain Veneers and Attachment-Retained RPD: 40 Months of Follow-Up This clinical report addresses indications, selection and procedures for the rehabilitation of a partially edentulous maxilla, involving laminate veneers, fixed and removable prostheses. Rodrigo Melim Ferreira, DDS; Thais Patricia dos Santos; Renata de Paula Cortati Rabelo; Aline Akemi Mori, DDS, PhD; and Fernanda Ferruzzi, DDS, PhD

449 Local Geographic Variation of Periodontitis and Self-Reported Type 2 Diabetes Mellitus This study confirms local health disparities in the Inland Empire to the ZIP code level. Tobias K. Boehm, DDS, PhD; Dalia Seleem, DDS, PhD; and Finosh G. Thankam, PhD

459 Temporomandibular Joint ‘Mice:’ Report of Two Cases This paper discusses two cases with radiological loose and detached bone bodies in the TMJ suggestive of osteochondritis dissecans. Tarun Mundluru, BDS, MSc; Fariba Farrokhi, DMD, MAGD; Melika Shahsavar Haghighi, DDS; and Mariela Padilla, DDS, MEd

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Journa C A L I F O R N I A

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

CDA Officers Judee Tippett-Whyte, DDS President president@cda.org Ariane R. Terlet, DDS President-Elect presidentelect@cda.org John L. Blake, DDS Vice President vicepresident@cda.org Carliza Marcos, DDS Secretary secretary@cda.org Steven J. Kend, DDS Treasurer treasurer@cda.org Debra S. Finney, MS, DDS Speaker of the House speaker@cda.org Richard J. Nagy, DDS Immediate Past President pastpresident@cda.org

D E N TA L

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

Volume 49 Number 7 July 2021

A S S O C I AT I O N

Robert E. Horseman, DDS Humorist Emeritus

Permission and Reprints

Journal of the California Dental Association Editorial Board

Production

Andrea LaMattina, CDE Publications Manager Andrea.LaMattina@cda.org 916.554.5950

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

Shelly Peppel Senior Visual Designer

August/E-cigarettes

Manuscript Submissions

September/ Chronic Conditions

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November/ Health Literacy II

Letters to the Editor

Ruchi K. Sahota, DDS, CDE Associate Editor

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Brian K. Shue, DDS, CDE Associate Editor

Sue Gardner Advertising Sales Sue.Gardner@cda.org 916.554.4952

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

Gayle Mathe, RDH Senior Editor

Upcoming Topics

Andrea LaMattina, CDE Publications Manager Kristi Parker Johnson Senior Communications Specialist Blake Ellington Tech Trends Editor Jack F. Conley, DDS Editor Emeritus

The Journal of the California Dental Association (ISSN 1942-4396) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. The California Dental Association holds the copyright for all articles and artwork published herein.

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

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

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

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

Visit cda.org/journal for the Journal of the California Dental Association’s policies and procedures, author instructions and aims and scope statement.

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

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

Editor

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Critical Thinking Is Not a Spectator Sport Kerry K. Carney, DDS, CDE

here is a scene in the 1976 film “All the President’s Men” set in an editorial meeting at The Washington Post. The repartee is fast and clipped. One journalist reminds another of the reporter’s duty to check and confirm all facts even if they seem obvious. “If your mother tells you she loves you, check it out.” That need to fact-check is even more important today than it was in the last century. Institutions of journalism have been disrupted by free, trending internet information, untrained citizen reporters and social media algorithms. We are presented with more of what we like, and the information steered our way is ever more extreme. I do not “do” Facebook. Probably a handful of people and I will go to our graves never having had a Facebook ID/profile/whatever. Even with that deficiency, I am still able to receive email and text messages from friends who forward comments, blogs or other internet communications. Occasionally, something is forwarded because my correspondent wants to share some infuriating communication with me. Primarily, they want me to share their infuriation and indignation. To adapt an old adage: A sorrow shared is a sorrow halved. A joy shared is a joy doubled. An indignation shared is an indignation exponentially intensified. During the last election cycle, a friend of 30 years texted me about what she was reading on social media about the candidates. She had allowed herself to become wound up by exchanges with others online. Her diatribes about some postings were shocking. What had happened to the person I had

Institutions of journalism have been disrupted by free, trending internet information, untrained citizen reporters and social media algorithms.

known for over three decades? She was so possessed by anger that she could not have a civil exchange of opinions. It was dismaying and alarming. If my friend walked down the street, picked up a note skittering across the path and read it, she would have no reason to believe the information on that paper. For the scrap of paper to have any informational value, she would need to know the source, corroborate the information and evaluate if it made logical sense. However, for some folks, information communicated online is imbued with an aura of truth. It is not critically assessed. It is welcomed into that collection of things they believe. Things that confirm what we already believe tend to make our belief even stronger. Simply believing something is true is easier than doing the hard work of critical thinking. In the past, a patient told me that all of her son’s behavior problems were the result of his allergic reactions to certain common environmental stimuli. She told me it was all scientifically tested and proven. I asked how this had been determined and she related how she had read about it online and communicated with the doctor who had a clinic in another state. I asked what had happened during their visit to the clinic. What tests had been performed and what were the results of those tests? She was

very animated and told me, “That’s the best part. We did the whole exam over the phone.” I was underwhelmed. Sometimes when I ask a patient why they are taking a certain homeopathic substance, they say they heard about it from a (trusted) friend or read about it on a website they trusted. That “trusted source” trumps their need for a critical analysis of the claimed benefits or an evaluation of the quality of supporting evidence. There is an understandable allure to a solution as simple as a pill, a lotion or an elixir to solve a problem. That allure and simplicity are the very basis of the success of “snake oil” sales in the past and their “snake oil 2.0” versions of today. The easy way to take in information on the internet is to read it uncritically. Then we ignore conflicting information and forward the information that confirms what we already believe or suspect. Taking information at face value relieves us of the need to critically analyze what we read or carefully fact-check and verify the information being offered. However, as the old reporter’s adage advises, we should be especially critical of information that seems to confirm what we already feel to be true. If your mother tells you she loves you, check it out. At lunch with a colleague recently, the question arose as to how one could verify JULY 2 0 2 1

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the truth of something one had heard or read. His conclusion was, “How can you fact-check when you cannot trust any source on the internet?” I was surprised at his resignation. There are many organizations dedicated to fact-checking and winnowing truth from fiction. It just takes a little effort to find and vet them. As dentists, we are trained to critically analyze the data we are presented. When we review an article, it is imperative that we consider the source of the data, the quality of the data and the appropriateness of the conclusions. Why should anyone abandon those critical imperatives when considering anything from the internet? During this pandemic, friends and colleagues have forwarded spurious “facts” or anecdotal evidence as real and true and meaningful. This was dismaying. It is in times like these that our professional training should bolster our reliance on fact-checking, critical analysis and logical consideration. It is even worthwhile to convey the importance of critical thinking to others, including those

without scientific training. A little dab of skepticism could do us all some good. The fundamental lesson is: Critical thinking is not a spectator sport. Factchecking, source-vetting and logical evaluation of information does not stop at the end of a formal education. We are all participants in life’s competition for hearts and minds. Critical thinking is a sport we cannot afford to play poorly. n

The Journal welcomes letters We reserve the right to edit all communications. Letters should discuss an item published in the Journal within the last two months or matters of general interest to our readership. Letters must be no more than 500 words and cite no more than five references. No illustrations will be accepted. Letters should be submitted at editorialmanager. com/jcaldentassoc. By sending the letter, the author certifies that neither the letter nor one with substantially similar content under the writer’s authorship has been published or is being considered for publication elsewhere, and the author acknowledges and agrees that the letter and all rights with regard to the letter become the property of CDA.

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Impressions

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Study Examines Baby Teeth From Historic Cold War Survey A cache of donated baby teeth that had been hidden away in an old ammunition bunker at a university until about 20 years ago will now be used to study cognitive decline in older age. The teeth are left over from a famous radiation exposure study, the Baby Tooth Survey, from the 1950s. The study, led by Marc Weisskopf, PhD, of Harvard University’s T.H. Chan School of Public Health, will use the baby teeth to examine how early exposure of heavy metals may be linked to neurodegeneration. The approximately 100,000 teeth left over from the Baby Tooth Survey were found in a closet in an ammunition bunker at Washington University in St. Louis in 2001. The survey helped change history and likely saved numerous lives. In 1956, the U.S. Public Health Service issued a report suggesting that the St. Louis area was a hotbed for radioactivity due to above-ground nuclear weapons testing during the early years of the Cold War. This alarmed the community, leading faculty members at Washington University to create the Commission for Nuclear Information. In 1958, the committee created the Baby Tooth Survey following earlier evidence that showed the isotope strontium-90 — a byproduct of nuclear fallout — followed the typical pathways of calcium collected in cow’s milk, which children drank while their baby teeth were developing. Researchers collected hundreds of thousands of baby teeth from children born in the 1950s and 1960s and measured the teeth for exposure to radiation. Research revealed that children born in 1963 had 50 times more strontium-90 in their teeth than those born in 1950, which is before most atomic bomb testing occurred. Finding the teeth as well as donor information cards in 2001 was a major discovery. The university donated the teeth to the organization Radiation and Public Health Project, which was conducting a study of in-body radioactivity near nuclear plants. About 80% of the teeth are from people born in the St. Louis area. The rest are from those born in each of the 50 U.S. states, plus 45 foreign countries. About two dozen researchers will study how exposure to hazardous substances, such as industrial solvents and heavy metals, including lead, mercury and arsenic, affect cognitive aging. Additionally, they will study how to protect the public from these metals and substances that are found in contaminated water, soil and air at hazardous waste sites throughout the U.S. The study will require finding 1,000 adults who participated in the St. Louis study. Read more about the Baby Tooth Survey and Dr. Weisskopf’s study in the St. Louis Post-Dispatch. n JULY 2 0 2 1

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Side and oral views of a virtual model of the ischnacanthid acanthodian jaw showing the toothrows and reconstruction of the tooth replacement. (Credit: Martin Rücklin, Naturalis Biodiversity Center.)

Study Explores Evolutionary Origins of Vertebrate Dentitions New research led by the University of Bristol and the Naturalis Biodiversity Center published in the journal Nature Ecology and Evolution reveals that the dentitions of living shark relatives are entirely unrepresentative of the last shared ancestor of jawed vertebrates. The study also found that while teeth evolved once, complex dentitions have been gained and lost many times in evolutionary history, and tooth replacement in living sharks is not the best model in the search for therapeutic solutions to human dental pathologies. The origins of a pretty smile have long been sought in the jaws of living sharks, which have been considered living fossils reflecting the ancestral condition for vertebrate tooth development and inference of its evolution. However, this view ignores real fossils that more accurately reflect the nature of ancient ancestors, according to the study. Lead author Martin Rücklin, PhD, from the Naturalis Biodiversity Center in Leiden, The Netherlands, said the research team used high-energy X-rays to study tooth and jaw structure and development among shark ancestors. “These ischnacanthid acanthodians possessed marginal dentitions composed of multiple, successional tooth rows that are quite unlike the tooth whorls that occur in front of the jaw in acanthodians and across the jaws of 424 JULY

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Asymptomatic Pediatric Dental Patients Test Positive for COVID-19 A study by a University of Illinois Chicago (UIC) pediatric dentist has shown a novel way to track potential COVID-19 cases — testing children who visit the dentist. The study also showed a more than 2% positivity rate for the asymptomatic children tested. The study, which appeared in the April 2021 issue of the Journal of the American Dental Association, looked at pediatric patients who visited UIC dental clinics for emergency dental procedures from April 1 to Aug. 1, 2020. Children with COVID-19 are typically asymptomatic but have the potential to carry substantial viral loads and be a source of infection. The patients, who were between the ages of 2 and 18 with a median age of 6, were screened over the phone prior to their scheduled visits and were asymptomatic when they arrived for their appointments. They were given a polymerase chain reaction, or PCR, test for SARS-CoV-2 infection at their visit, said author Flavia Lamberghini, DDS, MS, MPH, from UIC. Sociodemographic characteristics were abstracted and positivity rates were calculated. With the sample size of 921 patients, the overall SARS-Co-V-2 positivity rate was 2.3%. Positivity rates were statistically higher for Latino patients (3.1%), and 63% of the children studied were Latino. Dr. Lamberghini notes the study did not extend to include variables, and questions about social distancing and exposure to the virus were not asked. However, when a child tested positive for COVID-19, researchers followed up with the child’s pediatrician and caregivers and encouraged them to follow recommended advice. The study concluded that PCR testing for COVID-19 of asymptomatic patients in pediatric dentistry adds value to the use of screening questionnaires for the identification of infected people who could be contagious. Researchers did not observe transmission to clinic staff, supporting the notion that personal protective equipment works, according to the authors. Read more of this study in the Journal of the American Dental Association (2021); doi.org/10.1016/j.adaj.2021.01.006.

crown-chondrichthyans,” Dr. Rücklin said. The authors found that dentitions of vertebrates are characterized by an organized arrangement to enable occlusion and efficient feeding over the lifetime of an animal. This organization and patterning of teeth is thought to originate in a universal

development mechanism, the dental lamina, seen in sharks. The condition seen in the successional tooth rows cannot be explained by this mechanism. Learn more about this study in Nature Ecology and Evolution (2021); doi.org/10.1038/s41559-021-01458-4.

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Gum Bacteria Imbalance Linked to Alzheimer’s Biomarker Older adults with more harmful than healthy bacteria in their gums are more likely to have evidence for amyloid beta — a key biomarker for Alzheimer’s disease — in their cerebrospinal fluid (CSF), according to new research from the NYU College of Dentistry and Weill Cornell Medicine. However,

this imbalance in oral bacteria was not associated with another Alzheimer’s biomarker called tau. The study, published in the journal Alzheimer’s and Dementia: Diagnosis, Assessment and Disease Monitoring, adds to the growing evidence of a connection between periodontal disease and Alzheimer’s.

Single-Cell Atlas of Human Teeth Created by Researchers A team of researchers in Zurich has created the first-ever single cells atlas of the human teeth. By using advanced single-cell sequencing technology, they were able to distinguish every single cell that is part of the dental pulp and the periodontium. The study, published in the journal iScience, identified great cellular heterogeneity in the dental pulp. Unexpectedly, the research team found that the molecular signatures of the stem cell populations were very similar. The findings suggest that the microenvironmental specificity is the potential source of the major functional differences of the stem cells located in the various tooth compartments. The study demonstrates the complexity of dental tissues and represents a major contribution to a better understanding of the cellular and molecular identity of human dental tissues. “Single-cell approaches can help us understand the interactions of dental pulp and periodontal cells involved in immune responses upon bacterial insults. Therefore, single-cell analysis could be useful for diagnostic purposes to support the early detection of dental diseases,” said author Thimios Mitsiadis, PhD, DDS. Thus, the findings open up new avenues for cell-based dental therapeutic approaches. These advances in dental research can lead to more appropriate therapies, successful regeneration of damaged parts of the teeth and even more precise diagnostic tools in case of dental pathologies. “These innovations are the consequence of the fusion between bioinformatics and modern dentistry,” Dr. Mitsiadis said. Learn more about this study in iScience (2021); doi.org/10.1016/ j.isci.2021.102405. (Credit: Pagella P, et al. Licensed under Creative Commons CC BY-NC 4.0.)

Alzheimer’s disease is characterized by two hallmark proteins in the brain: amyloid beta, which clumps together to form plaques and is believed to be the first protein deposited in the brain as Alzheimer’s develops, and tau, which builds up in nerve cells and forms tangles. The researchers studied 48 healthy, cognitively normal adults ages 65 and older. Participants underwent oral examinations to collect bacterial samples from under the gumline, and lumbar puncture was used to obtain CSF in order to determine the levels of amyloid beta and tau. To estimate the brain’s expression of Alzheimer’s proteins, the researchers looked for lower levels of amyloid beta (indicating higher brain amyloid levels) and higher levels of tau (reflecting higher brain tangle accumulations) in the CSF. Analyzing the bacterial DNA of the samples taken from beneath the gumline, the researchers quantified bacteria known to be harmful to oral health and pro-oral health bacteria. The results showed that individuals with an imbalance in bacteria, with a ratio favoring harmful to healthy bacteria, were more likely to have the Alzheimer’s signature of reduced CSF amyloid levels. The researchers hypothesize that because high levels of healthy bacteria help maintain bacterial balance and decrease inflammation, they may be protective against Alzheimer’s. The researchers did not find an association between gum bacteria and tau levels in this study, so it remains unknown whether tau lesions will develop later or if the subjects will develop the symptoms of Alzheimer’s. Read more of this study in Alzheimer’s and Dementia: Diagnosis, Assessment and Disease Monitoring (2021); doi.org/10.1002/dad2.12172. JULY 2 0 2 1

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vaccine toolkit C D A J O U R N A L , V O L 4 9 , Nº 7

Dentistry Takes a Shot at COVID-19 EDITOR ’S N OTE

It has been a year of challenge and change for dental professionals. CDA and the State Office of Oral Health have worked together to support dental practices and patients to deliver and receive dental care safely, to interpret guidance from authorities, to develop essential resources and to communicate using every tool at our disposal. This month’s Journal brings you one of the resources designed as a toolkit: turn-key materials published in easyto-access formats, intended for dental professionals to use in their offices and clinics. Please use and share this, and look for additional toolkits in upcoming Journal issues. This is CDA and your State Office of Oral Health working for you!

At the close of 2020, the U.S. Food and Drug Administration began issuing the first emergency use authorizations for COVID-19 vaccines. In January 2021, CDA began assembling resources to assist our member dentists with information for them, their dental team and their patients, as the swift rollout of the vaccines raised many questions for those who were considering the vaccine and eligible to receive them. CDA developed a COVID-19 vaccine toolkit to compile multiple COVID-19 vaccine resources on behalf of our members, including an overview of the vaccines and how they were developed and approved; information on vaccine distribution; employer resources; vaccine administration; registration and training; and, more recently, vaccine confidence materials to assist with addressing patient and staff hesitancy. CDA partnered with several outside sources including HealthNet to create a vaccine discussion guide and the California Department of Public Health to host a volunteer vaccinator webinar. The information provided in the toolkit in this month’s Journal is a “snapshot in time” of the resources provided over the past six months. Due to production timeframes for this publication, the information shared in this issue does not reflect the most current evidence or recommendations, as the environment surrounding COVID-19 vaccines is comparable to the virus itself — incredibly fluid and everchanging. We encourage readers to visit cda.org for the most current information and resources offered by CDA as well as the websites of the Centers for Disease Control and Prevention, the California Department of Public Health and the California Division of Occupational Safety and Health, better known as Cal/OSHA, for the most current standards and recommendations.

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Vaccine Administration FAQ Get answers to commonly asked questions regarding the emergency public health waiver issued by the Department of Consumer Affairs. Below are answers to commonly asked questions regarding the emergency public health waiver issued by the Department of Consumer Affairs (DCA) on Jan. 4, 2021 (amended Jan. 21), allowing dentists to administer COVID-19 vaccines to people age 16 and over. This FAQ will be updated as new information develops.

What do I have to do before I can start administering the COVID-19 vaccine?

Dentists who wish to begin administering the COVID-19 vaccine must complete the required training, comply with all federal and state recordkeeping and reporting requirements and adhere to the administration requirements in accordance with the FDA emergency use authorization. Please note, dentists are unable to administer vaccines in-office at this time and may only administer as a volunteer vaccinator at local community sites.

How do I receive proof of completion of the trainings?

Print or save certificates to keep in your records similarly to other C.E. course certificates. At this time, you will not need to submit the certificates to any state agency. A few tips for completing the training: ■ Registration is required to receive a certificate of completion. ■ Take a screenshot of your completion as a backup record. Many dentists may experience technical difficulties registering with the various systems the CDC is utilizing to host their trainings. Please use this troubleshooting guide that illustrates how to complete the trainings and print certificates of completion for the trainings that provide one. 428 JULY

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Who can I administer the vaccine to?

Dentists may vaccinate individuals 16 years of age or older. In cases of severe allergic reaction, dentists are also permitted to administer epinephrine or diphenhydramine by injection. The waiver is limited to any FDA-approved or Emergency Use Authorized COVID-19 vaccine.

Why does the waiver allow for the administration of the vaccine to people age 16 and older?

While the DCA waiver allows for dentists to administer the vaccine to people as young as 16, dentists must also adhere to the limitations of each approved vaccine. The Moderna vaccine has only been approved for individuals aged 18 and over. However, the Pfizer vaccine has been approved for individuals aged 16 and over.

How do I sign up for the required state and federal vaccine registries? An overview of immunization information systems (IISs), also known as “vaccine registries,” can be found here. However, until vaccine supply increases, registration for state vaccine registries for new providers, including dentists, is currently closed.

Where can I learn more about the storage and handling requirements?

While these topics will be covered in the mandated trainings, the following links provide brief but detailed overviews of the storage and handling requirements for the Pfizer and Moderna vaccines: ■ CDC Pfizer Storage and Handling Summary ■ CDC Moderna Storage and Handling Summary

■

CDC Johnson & Johnson Storage and Handling Summary

Where can I learn more about the emergency use authorizations (EUAs) and administration requirements for the Pfizer, Moderna and Johnson & Johnson vaccines?

The CDC has developed the following in-depth resources on the FDA EUAs, vaccine administration, interim clinical considerations, Advisory Committee on Immunization Practices (ACIP) recommendations and FAQs for both vaccines: ■ Pfizer Vaccine Resource ■ Moderna Vaccine Resource ■ Johnson & Johnson Vaccine Resource

What materials do I need to provide to individuals who I vaccinate?

Vaccine information sheets (VIS) have not been developed for the COVID-19 vaccines at this time. The appropriate FDA emergency use authorization fact sheets for recipients listed below should be provided to patients at the time of vaccination: ■ Moderna Fact Sheet ■ Moderna Fact Sheet Translations ■ Pfizer Fact Sheet ■ Pfizer Fact Sheet Translations ■ Johnson & Johnson Fact Sheet ■ Johnson & Johnson Fact Sheet Translations

How do I notify individuals’ physicians about vaccines that I have administered?

As more vaccination clinics are established throughout the state, we expect to be provided with additional guidance on what, if anything, dentists will need to do aside from inputting data into the state vaccine registry in

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order to inform individuals’ physicians about receiving a COVID-19 vaccine.

How do I bill for the vaccine?

CDA is engaged in active discussions with health plans, including dental benefit plans, to determine the most appropriate code to use when billing for the administration of the COVID-19 vaccine. CDA will keep members updated on these discussions in the CDA Newsroom.

Where can I administer the vaccine?

The DCA waiver does not specify in which settings a dentist can administer the vaccine. However, the dentist should ensure that all appropriate emergency response supplies are readily available and that the patient can be monitored for adverse reactions or side effects for 15 minutes after the injection. It is unlikely that dentists will be able to administer vaccines from their dental offices at this time due to storage requirements, outstanding billing questions and lack of finalized vaccine administration plans in most counties. Dentists wishing to participate in vaccination efforts will likely be able to do so through efforts organized by government entities or local health systems and hospitals.

How can I participate if I haven’t yet received the vaccine?

CDA and local dental societies are working closely with health departments and emergency medical services authorities to learn how your county is deploying health professionals to administer the vaccine in your area. CDA is continuing to advocate at the state and local levels for dentists and

their staff to be elevated in priority to access the vaccine and should receive at least their first dose prior to vaccinating community members.

When does the waiver expire?

The waiver does not have an expiration date but is expected to stand for the duration of the declared state of emergency due to the COVID-19 pandemic.

When can I start vaccinating my patients?

At this time, it is unlikely that dentists will be able to vaccinate individuals within their dental office due to vaccine storage requirements. It is likely for the indefinite future that dentists will be able to administer vaccines in hospital, clinic and mass vaccination sites. Additionally, because state and local vaccine rollout plans are still in flux, there is no estimated time for when vaccines will be available to the general public. Please note that the information and any suggestions contained in this resource represent the experience and opinions of CDA. This communication does not constitute and should not be considered a substitute for legal, financial or other advice provided by licensed professionals. For that, you must consult your own attorney, accountant or other professional advisor.

If you are covered by a different carrier, we recommend you inquire about temporary extended coverage and provide a copy of the DCA waiver. For dentists who have reactivated their inactive or retired license or are retired with an active license and no liability insurance, in order to help with state vaccination efforts, TDIC offers a volunteer policy where coverage can be purchased if volunteering for an organization without compensation, less any expenses. The statutory immunities cannot prevent a claim or lawsuit from being filed against you, but can provide you with a legal defense against any such claims. In other words, the broad immunities are designed to protect you from being held liable for any claims based on administering the vaccine, so long as you are practicing within the standard of care. This includes taking the appropriate training and following all manufacturer guidance on storage and administration of the vaccine. The advantage of having a policy that specifically covers the administration of the COVID-19 vaccine is that should a claim be filed against you, the liability carrier would provide your legal defense as opposed to you finding an attorney on your own. n

Will the administration of vaccines be covered by TDIC?

For as long as the DCA waiver is in effect, the administration of the COVID-19 vaccine when provided in accordance with the waiver requirements will be considered within the scope of practice and therefore covered under a TDIC policy. JULY 2 0 2 1

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Employer Best Practices and Policies Understand best practices regarding employee vaccination, including vaccine policies, employer mandates and employee vaccine reactions. Check for updates on cda.org.

For dentists who are also employers, there are considerations and best practices regarding employee vaccination, including vaccine policies, employer mandates and employee vaccine reactions. Find answers to common questions here.

If all of my employees are vaccinated, do I still have to implement the extra COVID-19 precautions (i.e., N95/ face shield/HEPA filters/staggered lunch breaks)?

Yes. Even with vaccinated employees, or patients, existing COVID-19 prevention precautions remain necessary until further notice. Cal/OSHA requirements remain in place regardless of the vaccine.

How can I encourage my staff to become vaccinated for COVID-19? There are multiple resources available, but the CDC does offer a tipsheet to help bolster vaccine confidence — How to Build Healthcare Personnel Confidence in COVID-19 Vaccines.

Should I make the vaccine mandatory for my employees?

Employers in health care settings have the right to establish legitimate health and safety standards, policies and requirements so long as they are job-related and consistent with business necessity. However, CDA recommends as a best practice that employers encourage, but not require, employees to receive the COVID-19 vaccine. Policies mandating vaccinations are more likely to be appropriate for employers in the health care industry. But legal risk and complications, including the potential for side effects from the COVID-19 vaccine and the need to consider medical and sincerely held religious objections can 430 JULY

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make encouraging and facilitating an employee vaccination a better option for businesses than requiring it. Even if an employer’s vaccination policy is mandated to meet county requirements or qualifies as a legitimate health and safety requirement for the business, under certain circumstances, some employees may nonetheless be exempt from complying. If employers feel strongly about requiring employees to be vaccinated, CDA Practice Support recommends speaking with an employment law attorney before implementing a mandatory policy.

What circumstances would allow for an employee exemption from vaccination?

Employees may be exempt from compliance with a mandatory vaccination policy if they have a sincerely held religious objection or a qualifying disability under the federal Americans with Disabilities Act (ADA) or California Fair Employment and Housing Act (FEHA) that prevents them from safely receiving the vaccine. Specific to the Pfizer and Moderna COVID-19 vaccines, this includes factors such as whether the employee is pregnant, nursing or allergic to ingredients of the vaccine or has a compromised immune system. Upon receiving a request to be excluded from a vaccination requirement as an accommodation, whether due to disability or religiousrelated reasons, an employer must engage in an interactive process with the objecting employee to determine if they can provide the employee with a reasonable accommodation that does not pose an undue hardship for the employer.

Do I need to pay my employees for their time and costs associated with receiving the COVID-19 vaccine?

As of April 1, employers of more than 25 employees must comply with the 2021 California Supplemental COVID-19 Paid Sick Leave law (SB 95), which mandates that employees who are unable to work or telework in order to obtain a COVID-19 vaccine or who are recovering from complications of the vaccine be paid up to a maximum of 80 hours (or equivalent to their normal two-week work schedule). Employers cannot require an employee to use other paid or unpaid leaves before using COVID-19 supplemental paid sick leave. SB 95 took effect March 29 but applies retroactively to Jan. 1, 2021. This means employers are required to make retroactive payments for leave taken for any of the qualifying reasons between Jan. 1 and March 28 upon oral or written request of the employee. For more information visit dir.ca.gov. Employers with fewer than 25 employees who have voluntary policies are not required to pay employee costs associated with the vaccine or time spent obtaining the vaccine. Most health insurers are covering the cost of the vaccine. However, employers who encourage employees to obtain the vaccine may consider reimbursement of costs (when applicable) and compensation of time to obtain it in order to remove any barriers for employees who may be reluctant to receive the vaccine. If you require employees to obtain the vaccine, then you are required to compensate your employees for their time and costs not covered by their health insurance associated with obtaining the vaccine.

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What is an employer’s legal exposure if an employee refuses to be vaccinated?

Currently, there is no law that requires employers to vaccinate all employees with the COVID-19 vaccine. It is still too early to fully provide a legal liability response. Theoretically, it may be possible that, in the future, failure to provide or offer the vaccine to employees could be a workplace safety violation – but this is purely speculation. There is still much to be known. Some states are introducing bills to prohibit mandating vaccinations. If passed, that will change the liability exposure for employers. It is possible that an employer may never have 100% of their employees vaccinated. Having a fully vaccinated staff does not completely reduce an employer’s liability or obligations to maintain workplace safety standards. Can I have my employee, who refuses the vaccine, sign a waiver to release my liability if that employee transmits COVID-19 to a patient or another employee? A waiver signed by an employee who refuses the vaccine may not provide an employer with liability protection from patients or other employees. Continue to follow standard COVID-19 prevention precautions regardless of employee vaccinations until further notice. I’ve heard many people feel sick for several days after receiving the vaccine. Will my employees need sick time off following the vaccine? Do I pay them for the time off? Do they qualify for the COVID-19 FFCRA paid time off? First, CDA recommends staggering the distribution of the vaccine among the dental team in the event that team members experience adverse reactions within the same window of time. Consider asking your front office team to stagger the

days in which they receive the vaccine and the same for your back office team. This will help the practice maintain staff coverage. Employees who request time off due to the vaccine side effects may request to use any available employerprovided paid sick leave or vacation time, if approved by the employer. Any reactions to the COVID-19 vaccine must be reported to the employee’s medical care provider or to local public health department if the individual does not have a medical care provider. In the event that an employee experiences long-term health effects and requires a leave of absence, as of April 1, California employers have two supplemental COVID-19 paid sick leave laws to consider depending on the number of employees in the practice. The American Rescue Plan Act (ARPA) does not require employers to provide paid and emergency family leave under the Families First Coronavirus Response Act (FFCRA); however, it does extend tax credits for employers who continue to voluntarily offer FFCRA leave. The ARPA resets the allotted amount of emergency paid sick leave an employee has, meaning employees who previously exhausted their leave prior to April 1 are now entitled to an additional 80 hours of EPSL. The act further expanded the qualifying reasons to include coverage for time an employee may use to obtain the vaccine a vaccine and time the employee may use to recover from complications due to receiving the vaccine. If an employer chooses to voluntarily offer leave, it must be used for the same purposes and subject to the same conditions as originally outlined in the FFCRA and must be provided fairly to all employees.

As previously noted, under the expanded Supplemental COVID-19 Paid Sick Leave legislation (SB 95), California employers of 26 or more employees are required to provide COVID-19 supplemental paid sick leave. All employees working for covered employers are eligible to take paid sick leave if they are attending an appointment to receive a COVID-19 vaccine or are experiencing symptoms related to a COVID-19 vaccine that prevent the employee from being able to work or telework. If an employer has already provided supplemental paid leave after Jan. 1 to an employee for any of the qualifying reasons and if the amount of leave is equal to or greater than the required amount, the employer is allowed to count those hours toward the new leave requirements. Additionally, if an employee has exhausted their SPSL under SB 95 and requires additional covered leave for a qualifying reason after April 1, covered employers may choose to voluntarily provide leave under the new ARPA revisions as noted above and receive payroll tax credits. Both the ARPA and California’s COVID-19 supplemental paid sick leave under SB 95 expire Sept. 30. n

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Proven Strategies Help Shorten Talks about the COVID-19 Vaccines Dentists are an important part of a patient’s overall health care, and that includes talking to patients about recommended vaccines. The following strategies and tips will help make it easier for you to discuss vaccines – especially the COVID-19 vaccines – with your patients. Evidence-based strategies have been used with positive results when talking to patients about vaccines. Once you learn how to use them, it takes four minutes or less of your time. The table below shows the order of strategies to use based on the level of acceptance or hesitancy.

Accepting patients

1 2

Hesitant patients

Presumptive recommendations

Motivational interviewing

Blanket recommendations

Debunking myths

1. Start with a presumptive recommendation. Announce that a COVID-19 vaccine is recommended instead of asking how a patient feels about receiving it.

PROVIDER COMMUNICATIONS

Example:

“With COVID-19 continuing to be a big concern in our community, let’s get you vaccinated as soon as you are eligible.”

2. Follow with a strong blanket recommendation. Sound matter-of-fact, confident. Recommend the COVID-19 vaccine the same way you would with any other form of dental treatment. Example: “You need the COVID-19 vaccine as soon as you are eligible.” Be prepared for questions and reply with brief facts about the vaccine. Keep it simple. (continued)

* Health Net of California, Inc., Health Net Community Solutions, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, LLC and Centene Corporation. Health Net is a registered service mark of Health Net, LLC. All other identified trademarks/service marks remain the property of their respective companies. All rights reserved. 21-227/FLY110102EH01w (3/21)

Coverage for every stage of life™

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Coverage forfor every stage ofof life™ Coverage every stage life™

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3. Change tactics to motivational interviewing. Switch to motivational interviewing (MI) when a patient is not sure about the COVID-19 vaccine to reconnect with them. Leverage their basic motivation for a behavior. MI has four principles: empathy, collaboration, evocation and support for autonomy. To help manage concerns, these principles include micro skills: • Ruler

• Open-ended questions

• Elicit, provide, elicit (EPE)

• Affirmation

• Reflection

• Summaries

Example

A patient comes in for an appointment. At the end of the visit, you offer a presumptive, strong blanket recommendation for the COVID-19 vaccine. Your patient is hesitant about the vaccine. You pivot to MI as follows:

Dentist asks…

Patient replies…

“I see. So, on a scale of one to 10, with one never “About a three.” getting the vaccine and 10 definitely getting it today, where are you at?” (Ruler) “Okay, can you tell me more about why you are a three and not a one?” (Elicitation, Evocation)

“Well, I definitely don’t want to get COVID-19. I’m open to the idea of the vaccine, but I’m scared it’s not safe.”

“Would you mind telling me what safety issues you are worried about?” (Open-ended question)

“I’ve heard that some people have had adverse reactions and it could make me really sick.”

“There are many rumors about the COVID-19 vaccines on the internet. Severe adverse events from the COVID-19 vaccines are rare and more treatable compared to the adverse events from full-blown infection of the novel coronavirus.” “The COVID-19 vaccines are safe and have been well studied. The vaccines are up to 95% effective at preventing COVID-19, and up to 100% effective at preventing hospitalization and death from COVID-19.” “I think it’s an important vaccine. I and my entire staff have received it.” “That said, this is a decision only you can make. What do you think?” (Autonomy, EPE) (continued)

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4. Debunk myths with brief facts. Take the mystery out of it. Always state a myth is false before you talk about it. This removes the myth in a person’s mind and creates a gap. It is vital you fill the gap with brief, simple facts. Example Your next patient is a man who comes in for a visit. He is in a category eligible for the COVID-19 vaccine. Dentist asks…

Patient replies…

You give your presumptive, blanket recommendation.

“My cousin told me I shouldn’t get the COVID-19 vaccines because there are toxins in them.“

Summarize what you heard. Ask permission to make a recommendation. “So, you seem concerned about potential effects of the ingredients in the vaccines.” (MI – reflection) “I get that – you want to make sure you only take things that are good for you. I’ve looked into this a great deal. Would it be okay to share what I’ve learned about the COVID-19 vaccines?” (MI – ask permission) Briefly share what you learned, then pivot to the importance of the vaccines. “It’s actually a myth about the COVID-19 vaccines containing toxins.” (Preceding explicit warning) “The ingredients in vaccines are in tiny quantities. Vaccines are made to be safe.” (Alternative explanation) “I feel better knowing my patients get the vaccines they need. COVID-19 is serious. It can lead to hospitalization and possibly death.” (Focus on core facts and positives of action) “That said, this is your decision. What do you think?” (MI – autonomy)

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Residents can visit https://covid19.ca.gov/get-localinformation/for county- or city-specific COVID-19 vaccination locations and eligibility.

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California Dental Association 1201 K Street, Sacramento, CA 95814 800.232.7645 | cda.org

Instilling Vaccine Confidence Why dentists should speak with their patients about COVID-19 vaccination You’re an influencer As a health care professional, you are a trusted advisor and influencer of vaccination decisions,1 and the public generally trusts public health bodies when it comes to COVID-19 vaccine information. A recommendation from a health care provider is one of the strongest determinants of vaccine acceptance.2 Flex your muscle However, dentists often underestimate the importance of their recommendations. A strong recommendation to get vaccinated, assuming the person is willing to be vaccinated, has been shown to increase uptake.3,4 If you include a question about COVID-19 vaccination to your patient intake, it provides advance information and allows you to address it with the patient at the visit. For example: “I can see from today’s intake form that you have not received your COVID-19 vaccine.” Such announcements signal your confidence in the vaccine and help establish vaccination as the norm. This is more effective at increasing uptake than more hesitant language (such as “What do you think about getting the COVID-19 vaccine today?”).3

Nine communication strategies for ensuring demand for and promoting acceptance of COVID-19 vaccines5 1. Meet People Where They Are and Don’t Try to Persuade Everyone Empathy is key to interacting with those who may be vaccine hesitant or skeptical. 2. Provide a Factual Alternative to Misinformation Utilize a pivot approach to divert the listener to consider the concerns about the risks of the disease. 3. Tailor Messages to Specific Audiences Messages will be received differently by different groups. An understanding of the targeted audiences’ concerns and motivations will drive the communication. 4. Adapt Messaging as Circumstances Change Recognizing the fluidity of the situation and monitoring of the research is key to appropriate messaging. 5. Respond to Adverse Events in a Transparent, Timely Manner Communicate what is known, unknown and what should be done. Employ postvaccination surveillance to identify rare adverse outcomes that may be vaccine related. 6. Identify Trusted Messengers to Deliver Messages See note above about dentists’ role in messaging. 7. Emphasize Support for Vaccination Instead of Focusing on Naysayers Making vaccine uptake visible will encourage a social norming of COVID-19 vaccine acceptance.

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8. Leverage Trusted Vaccine Endorsers Use of thought leaders, community champions and celebrities can encourage the public to get vaccinated. 9. Pay Attention to Delivery Details That Also Convey Information Note the public experience in the provision of the vaccine and ensure it’s positive (e.g., clean clinic sites, manageable wait times, easily accessible online sign-up portals).

Vaccination hesitancy talking points for the dental profession6 COVID-19 vaccine went through thorough scientific review and was found to be safe and effective. • COVID-19 vaccines approved by the FDA, including the Pfizer, Moderna and Johnson & Johnson vaccines have been proven to be safe and effective. Many clinical trials were conducted and the efficacy of COVID-19 vaccine has been verified. • There may be minor side effects after vaccination. • The safety of COVID-19 vaccine will continue to be the nation’s top priority. California is working aggressively to expedite the distribution process equitably. • The COVID-19 vaccine is being made available on a phased basis that is determined by health professionals, community groups and stakeholders and according to identified urgent-need groups and vaccine supply levels. Despite the rollout of COVID-19 vaccines, Californians must remain vigilant in the effort to Stop the Spread. • All individuals, including those who have been vaccinated, should keep wearing masks, washing their hands and practicing social distance until infectious disease experts determine there is herd immunity and these precautions are no longer needed. Following the 5Ws is the best way to protect others and help bring an end to the pandemic. • Wear a mask whenever outside your home (CDC says it’s best to layer masks) • Wash your hands frequently • Watch your distance • Wait to see loved ones or attend social gatherings • When it’s your turn, get vaccinated Now more than ever, everyone’s actions can make a measurable difference in getting all of us through the pandemic. The best thing each of us can do is to not let our guard down.

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Addressing the 3 C’s to bridge toward normalcy: Conviction, Convenience and Costlessness Objections

Talking points Conviction One approach (primarily used for social media): • Do not engage. Don’t debate. Don’t respond at all. • Don’t try to convince or counter them with science or data or resource materials or peer-reviewed research. Another approach:

Conspiracy theories (not a pandemic, anti-vaxxers, fake injections)

• Provide a factual alternative to the misinformation. State a clear fact, such as “The vaccine is safe.” • Avoid scientific jargon or complex, technical language. • Provide facts, but don’t overwhelm. Discuss ways to fact-check and how to identify reliable sources of information. • Finish by reinforcing the fact, multiple times if possible. Additional resources: COVID Vaccine Fact Sheet - English COVID Vaccine Fact Sheet - Spanish Myths and Facts about COVID-19 Vaccines

Science-based

• COVID-19 is not like the flu. It is more contagious and more deadly. • Vaccines provide a path out of the COVID-19 pandemic. • The current COVID-19 vaccines approved by the FDA are up to 95% effective at inducing immune response to COVID-19. Pfizer and Moderna vaccines both require two doses, while the Johnson & Johnson vaccine is one dose. • These vaccines have been tested with more participants than many earlier vaccines for other diseases. Resources: CDC and COVID19.ca.gov for up-to-date statistics and additional vaccine resources. COVID Vaccine Fact Sheet - English COVID Vaccine Fact Sheet - Spanish Myths and facts about COVID-19 Vaccines

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Addressing the 3 C’s to bridge toward normalcy: Conviction, Convenience and Costlessness Objections

Talking points Conviction

Testimonial

My “why” for COVID vaccination (e.g. safety, family, economic, etc.) Convenience

Sign up at myturn.ca.gov or call 833.422.4255 and schedule your appointment or get notified when appointments are available in your area. Cost COVID-19 vaccines, including their administration, are free.

1. Lewandowsky S, et al. The COVID-19 Vaccine Communication Handbook. 2021. Chung Y, et al. Influences on Immunization Decision-Making among US Parents of Young Children. Matern Child Health J 2017 Dec;21(12):2178–2187. doi: 10.1007/s10995-017-2336-6. 2. Lewandowsky S, et al. The COVID-19 Vaccine Communication Handbook. 2021. Brewer NT, et al. Increasing vaccination: Putting doi.org/10.1177/ 1529100618760521psychological science into action. Psychol Sci Public Interest 2017 Dec;18(3):149–207. doi: 10.1177/1529100618760521. 3. Lewandowsky S, et al. The COVID-19 Vaccine Communication Handbook. 2021. Attwell K, et al. Vaccine acceptance: Science, policy and practice in a ‘post-fact’ world. Vaccine 2019 Jan 29;37(5):677–682. doi: 10.1016/j.vaccine.2018.12.014. Epub 2019 Jan 4. 4. Lewandowsky S, et al. The COVID-19 Vaccine Communication Handbook. 2021. Jacobson RM, et al. How health care providers should address vaccine hesitancy in the clinical setting: Evidence for presumptive language in making a strong recommendation. Hum Vaccin Immunother 2020 Sep 1;16(9):2131–2135. doi: 10.1080/21645515.2020.1735226. Epub 2020 Apr 3. 5. Brunson E, et al. Strategies for Building Confidence in the Covid-19 Vaccines. Box 2, p. 3. nap.edu/catalog/26068/strategies-for-building-confidence-inthe-covid-19-vaccines 6. Vaccinate All 58 Talking Points. 7. Lewandowsky S, et al. The COVID-19 Vaccine Communication Handbook. 2021

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Vaccine Confidence FAQs Find answers to frequently asked questions regarding vaccination.

Your patients are likely asking a lot of questions about the vaccine. Here are answers to some of those questions and resources to help you talk to your patients.

Why dentists should speak with their patients about COVID-19 vaccination How can I talk to patients about the COVID-19 vaccine?

Prepare to answer questions about the vaccine from dental team members and patients. Most importantly, give your personal strong recommendation to get vaccinated. Learn more about engaging with patients on the COVID-19 vaccine from the CDC.

Benefits of Getting a COVID-19 Vaccine

Additional suggestions on how to discuss vaccination may be found in the following document: Discussion guide: HealthNet and CDA offer a resource to assist with discussing COVID-19 vaccination with your patients. ■ Discussion guide (color) ■ Discussion guide (b&w)

How do I speak with patients who have religious concerns about vaccination?

In general, religions around the world support immunization. The Immunization Action Coalition offers several resources and suggestions for health care professionals who see patients with religious concerns about vaccination.

What is the best way for patients to manage their side effects post-vaccination? Where should those be reported? Patients and staff can track any side effects from the COVID-19 vaccine by enrolling in V-safe, a smartphonebased tool that uses text messaging and web surveys to provide personalized

health check-ins after someone receives a COVID-19 vaccine. Utilizing V-safe is a quick way to inform the CDC of any side effects and offers reminders for second vaccine doses.

My patient informed me he received the COVID-19 vaccine. Do I still need to implement the same precautions as I do for other patients without the vaccine?

Yes. Until further notice, it is important that you maintain the same COVID-19 prevention precautions in the practice consistently among all patients. According to the CDC, experts need to understand more about the protection that COVID-19 vaccines provide before deciding to change recommendations on steps everyone should take to slow the spread of the virus that causes COVID-19. Researchers are still conducting studies on how long the vaccine is efficacious for and whether booster vaccines are necessary. Other factors, including when the vaccine was received, whether the patient has received the second dose, how many people become vaccinated and how the virus is spreading in communities, will also affect this decision.

that our dental practice is continuing to do all it can to ensure patient safety.” Further, explain to the patient the protections (such as PPE, staggering of patient appointments, patient and employee daily screenings, social distancing and additional patient barriers) your practice has put in place to mitigate COVID-19 exposure and keep patients safe.

Additional Resources ■ ■

Instilling Vaccine Confidence Vaccine Literacy — Helping Everyone Decide to Accept Vaccination n

My patient asked if I’m requiring all employees of the practice to receive the vaccine. The patient doesn’t want treatment until all employees receive the vaccine. What should I tell this patient?

As the employer, it is important that you protect and keep your employees’ health and health status information confidential, therefore, disclosing whether your employees have or will receive the vaccine is not information you can, nor should share with patients. A sample response to the patient who asks this question is, “Employee health and medical information is protected by the right to privacy, but please be assured JULY 2 0 2 1

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California Dental Association 1201 K Street, Sacramento, CA 95814 800.232.7645 | cda.org

Dentists may customize this email template for distribution to their patients via email. Dear [Patient], Across the country, the COVID-19 pandemic is having devastating effects. Here at {INSERT YOUR PRACTICE NAME }, we have felt the pain and loss in our own community. We’ve supported families who have been affected and mourned those we have lost. While the pandemic has kept us apart, there is new hope—vaccines are here. They will help us move closer to ending the pandemic. We want everyone in our community to be safe and get back to hugging our families and friends and shaking hands with our neighbors. Getting the COVID-19 vaccine adds one more layer of protection for you, your family and your loved ones. Here is what you should know about the COVID-19 vaccine: • All COVID-19 vaccines currently available in the United States are very effective at preventing the disease. • The most common side effects are pain in the arm where you got the shot, feeling tired, headache, body aches, chills and fever. • Stopping a pandemic requires using all the tools we have available—wearing masks, staying at least 6 feet apart from people who don’t live with you, avoiding crowds and poorly ventilated spaces, washing your hands frequently and getting vaccinated. We all play a part in this effort, and you are key. Please sign up to get your COVID-19 vaccination at myturn.ca.gov. If you have questions about vaccination clinics in {INSERT NAME OF TOWN OR COUNTY }, please contact {INSERT COUNTY COVID-19 CONTACT INFORMATION (website URL or telephone number)}. Despite the rollout of COVID-19 vaccines, Californians must remain vigilant in the effort to “Stop the Spread” The 5Ws are the best way to protect others and help bring an end to the pandemic: • Wear a mask when outside your home (CDC says it’s best to layer masks). • Wash your hands frequently. • Watch your distance. • Wait to see loved ones or attend social gatherings. • When it’s your turn, get vaccinated. If you want to know more about COVID-19 vaccines, visit cdc.gov/coronavirus/2019-ncov/vaccines.

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Making your transition a reality.

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PRACTICE SALES • VALUATIONS/APPRAISALS • TRANSITION PLANNING • PARTNERSHIPS • MERGERS • ASSOCIATESHIPS NORTHERN CALIFORNIA ALAMEDA: 4 Ops in busy shopping center. 29 yrs Goodwill. 2019 GR $246K on 27 hrs/ wk. Room to grow!#CA1268 DAVIS/WOODLAND: GP practice/Condo with 37 yrs. Goodwill. 2019 GR $770K. 7 Ops, 5 Equipped, Digital Sensors and Pano in sought-after area. #CA1732 EAST BAY AREA PEDO: New Listing! Well-established with 8 Ops, Digital, plumbed for Nitrous, and high NP count. Associatedriven with Delta PPO. 2019 GR $832K on 3-4 days/wk., 2020 Production $523K. #CA2523 FAIR OAKS/CITRUS HEIGHTS AREA: Successful practice w/ 38 yrs. Goodwill. Nice décor, Digital, 6 hyg days/wk. Growth potential with Ortho/Implants. 4 Ops in 1,100 sf. 2019 GR $970K+ on 32 hrs/wk. #CA656 GREATER SACRAMENTO: Paperless, hiend retail area, 5 Ops, 30 yrs Goodwill. Most Specialties referred. 2020 GR$781K on 32 hrs/ wk. Seller can work back post-sale. #CA2465 GREATER SONORA AREA: Rural lifestyle GP/Real Estate, 5 Ops, Dentrix, Strong hyg prog in stable community. 2019 GR $698K. #CA1713 LAKE TAHOE AREA: 4 Ops, 37+ yrs Goodwill. Rural lifestyle GP in growing resort community. 2019 GR $760K. #CA1715 LAKE TAHOE AREA: GP practice with 5 Ops w/ 6th Open, Operatory views of Lake Tahoe, only 34 Delta Premier patients, 2,100 sf. 2019 GR $579K on 22 avg. Dr. hrs/wk. #CA608 MILLBRAE: Role Reversal, 5 Ops. 2019 GR $1M+ on 4 days/wk. and 6 hyg days. Seller offering 6 mo. employment and work back 6 mo. after sale. Digital, Pano, Waterlase & Periolase. #CA1139 NORTHERN CA PERIO: 4 Ops, Consult Rm, Upgraded Tech with Digital, LANAP, Paperless. 2019 GR $900K+. Draws from lg area with little competition. #CA1553 NORTHERN SACRAMENTO: Busy location, Paperless, 3 Ops+4th shared, CEREC, Digital Pano. 2019 GR $671K on 24-32 hrs/wk. #CA1745 NORTHERN SACRAMENTO: 5 Ops, busy retail shopping center. Digital, strong hygiene, and high NP count. Room for growth with specialties. 2020 GR $900K. #CA2464 OAKLAND: 3 Ops, Room to expand, Digi Xrays, Paperless, 40+ yrs Goodwill. 2019 GR $675K w/ room to grow Specialties. Prime location, retiring doctor will help with a smooth transition. Seller-owned RE to purchase or lease. #CA1380 REDDING AREA: Modern office with 5 Ops, 4 Eq., Digital, Newer CEREC, 23 NP/mo with no marketing. Strong Hygiene, specialties referred. 2019 GR $558K. #CA1742 SACRAMENTO: New Listing! 5 Ops+RE in a busy medical/dental/retail area. Digital, 50 yrs Goodwill, 6 hyds/wk. and 3.5 Dr. days/wk. 2019 GR of $697K with specialties referred. #CA2620 SAN JOSE: Practice+RE, 3 Ops, Modern design in open concept in desirable location. 2019 GR $374K. #CA2613 SAN JOSE: 6 Ops, Paperless, Digital, CAD/ CAM, Digital Pano. Seller will stay on P/T, if desired. 2019 GR $1.3M+. #CA1140

SAN MATEO: New Listing! 5 Ops, Digital, iTero Scan, CEREC, Laser, Paperless, Microscope. Seller-owned stand-alone building to lease. $1.4M GR on 4 days/wk. #CA2596 SAN RAMON FACILITY ONLY: New Listing! Desirable Bishop Ranch location. 5 Ops with great exposure. Digital, Laser, Digital Pano, Open Dental w/ 10 computers, bright, modern design. #CA2588 SONOMA COUNTY: New Listing! 4 Ops in spacious layout in heart of the area off main highway. Est 22 yrs with 5 star Google reviews, Paperless with CEREC, Scope, Laser, Strong Hyg. Retiring seller. 2019 GR $782K with good post-COVID recovery. #CA2594 SONOMA COUNTY: Stand-alone 3,000 sf, 72 NP/mo. & 10 hyg days. 6 Ops, Pano, Dexis, Cameras, Laser, Dentrix. Business & RE for sale or Lease. Doctor Retiring. 2019 GR $2.3M+. #CA544 VACAVILLE AREA: Centrally-located & hitraffic location with 25+ yrs Goodwill. 5 Ops in 1,700 sf. 2019 GR $556K on 32 hrs/wk. #CA645 VALLEJO/BENICIA/MARTINEZ: Downtown practice+RE with add’l tenants. 3 Ops with 4th available. Digital Pano, Laser. Most Specialties referred. #CA321

CENTRAL CALIFORNIA CENTRAL COAST: 5 Ops, digital, 25+ yrs Goodwill. Newly renovated, practice sees 30 NP/mo. Strong hyg prog. 2019 GR $1.1M+. #CA1218 CENTRAL VALLEY/MODESTO: New Listing! 8 Ops, high visibility retail, Open 20+ yr, Digital, soft/hard tissue lasers, 3,300+ active pts., 24+ NP/mo., 4 hyg days/wk., 18.5 hour Dr. work week. 2019 GR $852K, 2020 84% of 2019. #CA2721 MODESTO AREA: Est. area with 60+ yrs. goodwill. 5 Ops, 2019 GR $1.1M+ on 3 days/ wk. Dental Condo also available for purchase or lease, Seller may consider financing. #CA635 MONTEREY: New Listing! 4 Ops, Paperless, Digital, Pano. 2019 GR $1.1M with Adj. Net over $450K. Post-COVID revenue has grown even more! RE for sale, non-Delta Premier office, FFS and some PPOs. #CA2614 STOCKTON: 1/3-2/3 share of 3 GP partner practice. 2019 GR $508K on 32 hrs/wk. Digital, paperless. Most specialty referred. Add’l 1/3 ownership of separately listed practice in group also avail, allowing 2/3 ownership. #CA1389 STOCKTON: Practice+RE available, 5 Ops, 5 Hyg. Days/wk. 2019 GR $812K on 32 hr. week. High level of Ortho, seller can work back. #CA2006

SOUTHERN CALIFORNIA ANTELOPE VALLEY: New Listing! 7 Ops in fast-growing community. Paperless with Dentrix, digital x-rays, 8 days of hyg./week and dedicated staff. Room to grow with specialties! #CA2612 ARCADIA: New Listing! 4 Ops and 1-2 hyg days/wk. 2020 GR of $300K, with upside potential. Office has older equipment, ready for a buyer to modernize it to their liking. Retiring seller. #CA2642 BAKERSFIELD: 6 Ops, 40 yrs Goodwill, great reputation in the area. 6 hyg days/wk. Most Specialty referred. Digital pano, digital X-rays. 2019 GR $600K. RE also for sale. #CA1274

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BAKERSFIELD: New Listing! 6 Ops, 5 Equipped, Digital, 2020 Collections $1M+ with 6 days hygiene and 2 P/T associates. #CA2587 COASTAL LA COUNTY: New Listing! 3 Ops on major road in beautiful location. Modern design in bright space. Paperless with Digital Pan/Ceph and refers out specialties. No Delta Premier. 2019 GR $863K. #CA2489 CORONA: 4 Ops, Digital, excellent growth opportunity. Main street location in small strip center. 2019 GR $280K. #CA2002 HUNTINGTON BEACH: PRICE REDUCED FOR QUICK SALE! 5 Ops, desirable loc, Digital, Strong hyg prog. 2019 GR $604K. #CA685 HUNTINGTON BEACH: 4 Ops, located in a busy retail center with great visibility. Practice utilizes Digital X-rays and Easy Dental PMS. 2019 GR $466K. #CA673 INDIO: New Listing! 4 Ops, single-story medical/retail center. Digital, CEREC w/ milling unit and oven. GR $764K in 2019 and $535K in 2020. 7 Hyg days/wk. Great Opportunity. #CA2619 LONG BEACH: RE Ownership an option! Upper middle-class residential practice est. in 1950. Existing 4 Ops, 3 Equipped, easy expansion next door to add another 3 Ops, 2 are equipped. Digital.most specialties referred. Strong post-COVID production. 2019 GR $696K. #CA671 LOS ANGELES: New Listing! Cash/PPO office in great DTLA Location. 3 Ops with low rent. Digital with scanner and lasers. 2020 GR $299K on 2 days/wk. #CA2493 ORANGE COUNTY: Price Reduced! 5 Ops, Digital, Retiring seller. Excellent reputation, affluent area, high quality care. Modern, welcoming office with strong hyg prog. Room to grow specialties. 2019 GR $642K. #CA1676 ORANGE COUNTY: Strip center location at a major intersection. 2019 GR $329K with low overhead and great take-home Net. 5 Ops, 3 equipped, seller works average 25 hrs./wk. Great potential, low asking price of $175K. A must-see! #CA1728 OXNARD: 7 Ops, nice office, paperless, digital, 11 days of hygiene/wk. 2019 GR $1.55M. #CA1829 OXNARD: 4 Ops, Digital X-rays, Est. 35+ yrs ago. Seller owned it for 3 yrs and has a primary office in LA. 2019 GR $662K. #CA1164 PALM DESERT: 4 Ops 27 yrs Goodwill. Strong hyg prog w/ hi-end patient base of locals/snowbirds. 2019 GR $809K on only 16 days/mo. with low overhead. Call today! #CA691 PALM SPRINGS AREA MULTISPECIALTY: Priced to sell @ $775K! 5 Ops, lecture room, 28 yrs Goodwill. Hi-end, mostly cash patient base. Dentrix, Digital, CT Scan & Gemini Dual Wave Laser. History of $1.2M+/yr on 4 days/wk. #CA604 SAN GABRIEL VALLEY: 4 Ops, Digital Xrays, 65 yrs Goodwill. Most specialty work referred out, most PPO plans are accepted. Busy road with great visibility, open 4 days/wk. Nicely appointed; excellent opportunity. #CA596 SOUTH BAY LOS ANGELES: Ready to retire! 7 Ops, RE for sale. 50% Denti-Cal, some HMO/PPO. 2019 GR $568K. #CA1050

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SOUTH ORANGE COUNTY PERIO: 4 Ops, 3 Equip, Coastal Community, Modern, Busy strip center location near hi-end residential. 2019 GR $845K. #CA643 SANTA BARBARA: New Listing! 4 Ops in beautiful setting. Digital, FFS, strong hygiene, and room to grow with specialties. Consistently collects $1M+/yr. with manageable overhead. #CA2531 SANTA BARBARA: New Listing! 4 Ops with Digital x-rays, 5 hygiene days/wk. Most specialties referred, beautiful area. 2019 GR $790K with attractive net. #CA2722 VALENCIA: New Listing! 4 Ops, digital X-Ray, Pano, 5 y/o equipment, 2019 GR $605K and 2020 $507K, 30+ years of goodwill.Retiring seller, priced to sell! #CA2691

SAN DIEGO DEL MAR: New Listing! 4 Ops, Digital, Open Dental, Conservative Practitioner who refers out specialties. 4 days of hygiene per week. Seller is eager for a quick sale. Excellent opportunity in a very desirable location. #CA2724 LA MESA: 7 Ops, 4 Equip, Digital, Stand-alone office w/ freeway access. Room to grow with specialties. 2019 GR $696K. #CA1915 NATIONAL CITY: 6 Ops, 14 yrs Goodwill, strip mall with high visibility, Digital, loyal staff and patients. 2019 GR $754K. #CA1465 SANTEE: New Listing! Practice+RE – 7 Ops, Digital, Pan, in excellent location with parking. Growing area with many years of goodwill. #CA2549

OUT OF CALIFORNIA BIG ISLAND, HAWAII: New Listing! 3 Ops, non-digital, excellent location plus rare option to purchase office space. Room to grow! #HI1929 SOUTHWEST PORTLAND, OR: 7 Ops, 6 Equip, Dentrix, Digital, Pano. Well-maintained leased space. 2019 GR $598K. #OR115 SOUTH OF PORTLAND, OR - ORTHO: New Listing! Growing community outside “Big City”. Well-estab near referring doctors. Updated, spacious, turnkey! 2019 GR $1.3M+ #OR1550 SOUTHERN OREGON: New Listing! 5 Ops, Paperless, CEREC, Laser, and much more. Doctor is available to stay on for transition, if desired. Turn-key office. 2020 GR $1.5M. #OR2688 SOUTHERN OREGON: New Listing! Quaint GP in ideal location in desirable town. 4 Ops with room to grow adding days and specialties. Open 31 yrs. Digital with EagleSoft. $276K GR in 2020. #OR2574 TRI-CITIES, WASHINGTON: New Listing! Small modified start up, fully equipped! Access to 1500 patient records, Open Dental software, laser, x-ray sensors. Desirable location, affordable rent. #WA2639

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veneers and prostheses C D A J O U R N A L , V O L 4 9 , Nº 7

Functional and Aesthetic Rehabilitation With Porcelain Veneers and Attachment-Retained RPD: 40 Months of Follow-Up Rodrigo Melim Ferreira, DDS; Thais Patricia dos Santos; Renata de Paula Cortati Rabelo; Aline Akemi Mori, DDS, PhD; and Fernanda Ferruzzi, DDS, PhD

abstract Background: Distal edentulous spaces can be challenging when rehabilitation with dental implants is limited. Attachment-retained removable partial dentures (RPD) work as a therapy that can compensate rotational movements and reduce the number of abutments. Case description: This clinical report addresses indications, selection and procedures for the rehabilitation of a partially edentulous maxilla, involving laminate veneers, fixed and removable prostheses. Practical implications: Attachment-retained RPDs provide sufficient retention and improved aesthetics compared to clasp-retained partial dentures. Careful aesthetic and functional planning and periodic follow-up are essential for patients’ satisfaction. Keywords: Denture, partial, removable, denture precision attachment, dental prosthesis design, dental veneers

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AUTHORS Rodrigo Melim Ferreira, DDS, is a master’s student in the department of dentistry at Ingá University Center-UNINGÁ in Maringá, Brazil. Conflict of Interest Disclosure: None reported.

Aline Akemi Mori, DDS, PhD, is an assistant professor in the department of dentistry at Ingá University Center-UNINGÁ in Maringá, Brazil. Conflict of Interest Disclosure: None reported.

Thais Patricia dos Santos is an undergraduate student in the department of dentistry at Ingá University Center-UNINGÁ in Maringá, Brazil Conflict of Interest Disclosure: None reported.

Fernanda Ferruzzi, DDS, PhD, is an assistant professor in the department of dentistry at Ingá University Center-UNINGÁ in Maringá, Brazil. Conflict of Interest Disclosure: None reported.

Renata de Paula Cortati Rabelo is an undergraduate student in the department of dentistry at Ingá University CenterUNINGÁ in Maringá, Brazil Conflict of Interest Disclosure: None reported.

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lthough complete edentulism is decreasing due to improvement in the oral health of individuals and better understanding of the oral diseases, the proportion of partial edentulism is increasing because life expectancy has risen and more teeth are being retained by this population.1,2 Dental implants are a conservative and comfortable treatment modality, however, surgical procedures are needed that might increase complexity, time and cost. Removable partial dentures (RPDs) can be indicated to overcome surgical limitations, biomechanical and aesthetic issues related to implants, such as excessive bone resorption, that demand bone augmentation or the need for a flange to provide aesthetics.1,2 When dental implants and/or conventional fixed dental prostheses (FDPs) are not indicated or not desired by the patient, removable partial dentures are a treatment alternative that can yield excellent clinical results.2–6 RPDs can be easily removed, which facilitates oral hygiene and favors the survival of abutment teeth; however, poor retention and stability can result in treatment failure.5 The retention, aesthetics and biomechanics of RPDs can be improved by means of attachments.7 Attachments are mechanical devices for the fixation, retention and stabilization of a prosthesis.8 They consist of two parts that relate to each other in a patrix-matrix system. The matrix is positioned inside or outside the contours of the crown of the abutment teeth, while the patrix is attached to the denture framework or base.8 The primary indication of attachments is aesthetics because retention arms are not present at the facial surface.7,9 Biomechanical advantages may be obtained, depending on the type of attachment used, the design and adaptation of the framework and the characteristics of abutment teeth and the edentulous space.5,10

Attachments are classified as intracoronal or extracoronal depending on if they are positioned within the contours of the abutment teeth or not.7,8 They can also be rigid or resilient depending on the material and amount of movement they provide to the prostheses.7,8 Considerations for attachment selection are based in 1B basic prosthodontic principles, including rotation movements and the possibility of torque on abutment teeth as well as the size and location of the edentulous space. It is important that the removable partial denture framework is closely adapted to the teeth and the edentulous ridge. Attachments should be passive when the prosthesis is in its terminal position.9,10 In this way, careful planning of the clinical steps is essential to treatment success as well as high-quality impressions, proper axis of insertion and guiding planes and precise laboratory procedures. This clinical report aims to discuss the fabrication of an attachment-retained free distal extension RPD, fixed prosthodontics and porcelain laminate veneers to meet the aesthetic and functional expectations of a partially edentulous patient.

Case Report

A 67-year-old woman presented at a private dental clinic for rehabilitation of edentulous bilateral posterior spaces in the maxilla (from first premolar to second molars) and replacement of provisional crowns on the canines and lateral incisors to improve aesthetics. She wore a conventional RPD and was unhappy with the appearance of the clasps (FIGURE 1 ). At clinical examination, the maxillary right canine and both lateral incisors were treated endodontically and restored with metal post and cores. The maxillary left canine was vital and prepared for a full crown restoration. Central incisors presented with facial composite resin restorations with marginal discoloration that did not

C D A J O U R N A L , V O L 4 9 , Nº 7

match the shade of the unprepared tooth structure (FIGURE 2 ). The patient had been treated previously with extraction of the remaining five mandibular teeth and an implant-supported full arch metalacrylic fixed dental prostheses. Treatment with dental implants was planned for the maxillary edentulous spaces; however, the cone beam computerized tomography showed insufficient bone height and width in the edentulous area, requiring bone augmentation procedures for implant placement. The patient desired to keep the six remaining teeth in the maxilla and rejected the treatment plan that included bone augmentation surgery due to the extended time of the treatment. Considering the therapeutic options, the proposed treatment plan was to restore the central incisors with porcelain laminate veneers and lateral incisors and canines with a splinted metal-ceramic FPD that would support an attachment-retained RPD to replace posterior edentulous spaces. Treatment was started by mounting diagnostic casts on a semi-adjustable articulator (A7 Plus, Bio-Art, São Carlos, Brazil), the maxillary cast was oriented by a facebow record (Elite, Bio-Art) and occlusal relationship was recorded with a wax rim. Acrylic teeth were positioned over an acrylic base in the edentulous areas and a preoperative wax try-in was performed over the anterior teeth for an aesthetic and functional clinical evaluation. A mock-up in bis-acrylic resin (Structur 3, VOCO GmbH, Cuxhaven, Germany) was positioned over the anterior teeth and the position of the artificial teeth was clinically evaluated. This is a key step that allows the patient and the dentist to predict the final result and determine achievable treatment goals. After the patient’s approval, the prepared anterior teeth were refined and polished. An impression using acrylic copings and low-viscosity polyether

FIGURE 1. Pretreatment frontal view. Notice the provisional crowns and unsatisfactory restorations.

FIGURE 2 . Prepared maxillary tooth with retraction

cords, prior to impression.

FIGURE S 3 . Impression with acrylic copings for fabrication of fixed dental prostheses (FDPs) (3A ). Impression for fabrication of laminate veneers and applying veneering ceramics on the FDPs (3B ). Impression of edentulous

area (after border molding) and transferring of finished FDPs for fabrication of RPD’s infrastructure and acrylic base (3C ).

(Impregum, 3M ESPE, St Paul, Minn.) was taken (FIGURE 3A ). Splinted FPDs were waxed and recontoured with the aid of a dental surveyor to determine the most suitable path of insertion and removal of the RPD. A combination of attachments was planned: semi-precision rigid intracoronal attachments (interlock type) and rigid extracoronal semi-precision attachments (SR 3.0, CNG, São Paulo, Brazil). The intracoronal attachments were contoured during waxing of the FDPs’ metal structures between the lateral incisors and the canines. The rigid attachments consisted of prefabricated acrylic patterns (patrix) positioned at the distal surface of canines and cast with the FDP framework, and

metallic retainers (matrix) were embedded in the acrylic base of the RPD. Rest seats and guiding planes for reciprocal clasps were designed to guide insertion and removal. The FPDs’ frameworks were cast in a cobalt-chromium alloy (FIGURE 4 ). The FPDs’ framework’s shape and fit were clinically examined and bite registration was performed with acrylic resin (Pattern, Kota, Cotia, Brazil). Maxillary central incisors received chamfer veneer preparations according to biomechanical and aesthetic principles. The shade of the teeth was determined with photographs and the aid of the shade guide of the selected ceramic system (FIGURE 5 ). A full-arch impression was taken using retraction cords JULY 2 0 2 1

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FIGURE 4 . FDPs cast in cobalt-chromium alloy. Interlock intracoronal attachments/precision rests were contoured between lateral incisors and canines. Note the patrix connector at the distal surface of canines.

FIGURE 6 . Infrastructure of RPD attached to finished

FDPs in cast model obtained after cementation of veneers. Matrix retainers are connected to the RPD with pattern resin and covered with wax. They were embedded to acrylic base after processing.

(Ultrapak, Ultradent, South Jordan, Utah) and polyvinyl siloxane (Express XT, 3M ESPE) (FIGURE 3B ) to obtain a definitive cast for fabrication of ceramic veneers for the central incisors and porcelain application for the FPD frameworks. The same feldspathic ceramic (IPS d.Sign, IvoclarVivadent AG, Schann, Switzerland) was used to ensure the different prosthetic options would match in shade (the desired final shade was A2, Ivoclar shade guide). At the next clinical appointment, laminate veneers and FPDs were examined for fit, shade match and aesthetics. The feldspathic laminate veneers were prepared for adhesive bonding with 5% hydrofluoric acid for 60 seconds, rinsed and treated with 37% phosphoric acid for 30 seconds to remove residues from the hydrofluoric acid etching that could jeopardize the bond strength to the resin materials. A silane coupling agent was actively applied to the intaglio surface for 20 seconds and left to react for 60 seconds. Modified 446 JULY

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FIGURE 5 . Central incisors with chamfer preparation

for laminate veneers, registration of dentin’s shade.

rubber dam isolation was performed and a conventional total-etch adhesive technique was carried out. Most of the margins were located in the enamel, thus central incisors were etched with 37% phosphoric acid for 30 seconds. In cervical areas with exposed dentin, acid etch was performed for 15 seconds followed by application of a primer (Adper Scotchbond Multi-Purpose, 3M ESPE). Veneers received a layer of hydrophobic adhesive (Adper Scotchbond Multi-Purpose, 3M ESPE) and composite resin shade A2 (Z100, 3M ESPE) thermally modified in a composite warmer (Calset, AdDent, Danbury, Conn.). After removal of excess composite, 60 seconds of polymerization time was carried out for each tooth. An acrylic custom tray was made and border molding with impression compound (Kerr, Brea, Calif.) was performed in the edentulous area. Metal ceramic crowns were set in position and an impression was taken with medium viscosity polyether (Impregum, 3M ESPE) in order to transfer the position of the RPD and obtain a selected pressure impression of the edentulous areas (FIGURE 3C ). The definitive cast was used for waxing and casting the framework in a cobaltchromium alloy over the metal-ceramic FPDs (FIGURE 6 ) and also for processing the acrylic portion of the RPD. Afterward, the relationship between the RPD framework and the FPDs was clinically evaluated. Occlusal relationship and aesthetic arrangement of the acrylic teeth (Pala, Kulzer GmbH, Hanau, Germany) were positioned over the RPD framework

with wax and evaluated. Finally, the RPD was processed and its gingival portion was characterized using an acrylic resin staining system (STG Tomaz Gomes, Vipi, Pirassununga, Brazil). The passive seating of the RPD was checked prior to cementation of the FPDs; subsequently, the patient was asked about any pressure, pain or discomfort during the final insertion of the RPD. FPDs were cemented with resin self-adhesive cement (RelyX U200, 3M ESPE). The RPD was adapted, an occlusal adjustment was performed and the patient was instructed not to remove the prosthesis for the next 24 hours to allow the final set of the cement. The next day, the RPD was removed and the cervical areas around the FPDs were carefully inspected for excess cement. The adjusted occlusal surfaces were polished. Occlusion, hygiene and comfort were checked in the seven- (FIGURE 7 ) and 30day follow-up appointments. The patient was taught how to clean and take care of the prosthesis and was instructed to return every six months. During the 40 months of followup, the patient had no complaints and there was no need for repair or rebase. The patient reported improvement in masticatory function and satisfactory aesthetics after rehabilitation treatment (FIGURE 8 ).

Discussion

In this clinical report, porcelain laminate veneers, metal ceramic FPDs and an attachment-retained RPD were proposed to rehabilitate a patient with a Kennedy Class I edentulous maxilla. This treatment provided retention, comfort and aesthetics with no need for surgical procedures. Although the main advantage of attachments is aesthetics, they may also provide some increase in retention and comfort, considering that they are independent of the size and shape of the abutment tooth and present less volume.7,9,10 The main negative aspect of

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attachments is the need for placing full crowns on the abutment teeth, which requires removal of tooth structure and also increases the treatment’s complexity and cost.7 In this case, an attachmentretained RPD was considered as the first nonsurgical option, as the abutment teeth had already been endodontically treated and/or prepared prior to the patient seeking definitive treatment.9,11 Distal extension removable prostheses are challenging because they are supported by both hard and soft tissues. The main concern when designing an RPD is minimizing distal rotation and torque of the abutment teeth during function.8,9 In the present case report, intracoronal attachments positioned at the canines would favor stress distribution in the long axis of the tooth; nevertheless, they require extensive preparation that would probably demand endodontic treatment of the left canine. Thus, extracoronal attachments were planned for both canines to allow symmetric forces distribution in this Kennedy Class I RPD. Extracoronal attachments, however, represent a lever arm that could increase torque forces in abutment teeth. To reduce these forces, it is recommended to place rigid extracoronal attachments over splinted crowns and ensure that forces are distributed to the residual ridge by means of a well-fitted extended denture base, as performed in this case.8,10,12 Intracoronal attachments between canines and lateral incisors were designed to provide the most stability possible, reducing distal movement and torque in the abutment teeth that might occur. Although there are no guidelines on the exact number of retainers that should be designed for an RPD, the authors believe that additional intracoronal attachments could act as highly functional indirect retainers in an attempt to compensate the reduced number of abutment teeth. Guiding planes were also designed to

FIGURE 7. Smile view at seven days follow-up.

FIGURE 8 . Frontal view at 40 months follow-up. Patient is satisfied with retention and aesthetics.

increase the contact area of the framework and abutment teeth and guide insertion and removal, contributing to bracing and stability of the abutment teeth.9,10 When a combination of FPD and RPD is planned, metal-ceramic prostheses are recommended for both short- and longspan reconstructions because they have high success rates in the long term, and the attachments can be cast or welded to the metal structure.13,14 Considering the main complaint of this patient was aesthetics, the central incisors received laminate veneers assuming a pleasant shape, shade and size to fulfill the patient’s expectations. This restorative option requires minimal preparation and presents excellent longterm results and patient satisfaction.15 Oral rehabilitation with combined FPD and attachment-retained RPD, however, is more complex. Thus, the clinical steps must be carefully planned to prevent any minor distortions that could culminate in misfit of the RPD.11,16 In the present case, three different impressions were performed to produce different working casts (FIGURE 3 ). The first provided a working cast for the fabrication of the FPDs’ metal framework. Later, the second cast allowed the fabrication of laminate veneers and ceramic veneering of the FPDs using the same feldspathic ceramic to ensure color match. Considering that forces must be widely distributed to all available tissues in distal extension RPDs, the denture base should be extended to cover all of the residual ridge within the limitation of functional muscle movements.9,10 The third impression transferred the position of the FPDs and provided an accurate reproduction of the

edentulous area. Even minimal errors during impression and cementation of the FPDs might compromise the seating of the RPD.11 However, in this case, the accurate impressions resulted in excellent clinical fit and only occlusal adjustments were necessary. Although some controversy may arise with the use of attachments in Class I RPDs, in particular, the influence on stress distribution and the consequences to abutment teeth, there were no complications reported for soft tissues and abutment teeth. In a multicenter randomized clinical trial, Walter et al.6 evaluated tooth loss in patients wearing attachment-retained RPDs or no removable prostheses or FPD with a distal cantilever in the second premolar (shortened dental arch (SDA) concept) after 10 years. The authors concluded that attachment-retained RPDs are not capable of causing tooth loss at a higher rate than the SDA concept.6 A systematic review on the clinical performance of RDPs concluded that attachments are unsuitable for Kennedy’s Class II; however, for attachment-retained Class I RPDs, failure rates vary from 11% to 30% and are comparable to conventional RPDs.5 The possibility of retention loss attributed to the attachments’ wear is a concern. If repairs or replacements are necessary, the procedure might be technically difficult.16–18 In the present report, no complications were reported and no repair was needed. Although the wear by attrition might occur, clinical studies show these prostheses seem to be less prone to repair and technical complications than JULY 2 0 2 1

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conventional clasp-retained RPDs.5,18 In fact, the attachments provide additional comfort and confidence to patients because treatment failure due to nonwearing is reported for conventional RPDs, but not for attachment-retained RPDs.5

Summary

In the present clinical report, oral rehabilitation with removable prosthesis is a conservative therapeutic modality for distal extension edentulous space with excellent clinical results in the short term. Using a combination of intra- and extracoronal attachments as retentive devices provided an RPD with retention

and stability. By eliminating conventional facial retention arms, the overall treatment with laminate veneers, FPDs and an attachment-retained RPD provided the patient a highly aesthetic result. n AC KN OW LE DG M E N T The authors thank Frank Kaiser, dental technician, for superbly performing all laboratory procedures involved in this case. RE FE RE N CE S 1. Bohnenkamp DM. Removable partial dentures: Clinical concepts. Dent Clin N Am 2014 Jan;58(1):69–89. doi: 10.1016/j. cden.2013.09.003. 2. Campbell SD, Cooper L, Craddock H, Hyde TP, Nattress B, Pavitt SH, Seymour DW. Removable partial dentures: The clinical need for innovation. J Prosthet Dent 2017 Sep;118(3):273–280. doi: 10.1016/j.prosdent.2017.01.008. Epub 2017 Mar 23. 3. Viennot S, Dalard F, Malquarti G, Grosgogeat B. Combination

fixed and removable prostheses using a CoCr alloy: A clinical report. J Prosthet Dent 2006 Aug;96(2):100–3. doi: 10.1016/j. prosdent.2006.04.013. 4. Stegelmann K, Dirheimer M, Ludwig E, Moldovan O, Rudolph H, Luthardt RG, Just BA. Case-control study on the survival of abutment teeth of partially dentate patients. Clin Oral Invest 2012 Dec;16(6):1685–91. doi: 10.1007/s00784-011-0661-5. Epub 2011 Dec 28. 5. Moldovan O, Rudolph H, Luthardt RG. Clinical performance of removable dental prostheses in the moderately reduced dentition: A systematic literature review. Clin Oral Invest 2016 Sep;20(7):1435–47. doi: 10.1007/s00784-016-1873-5. Epub 2016 Jun 9. 6. Walter MH, Dreyhaupt J, Hannak W, Wolfart S, Luthardt RG, Stark H, et al. The randomized shortened dental arch study: Tooth loss over 10 years. Int J Prosthod Jan/Feb 2018;31(1):77–84. doi: 10.11607/ijp.5368. 7. Burns DR, Ward JE. A review of attachments for removable partial denture design: Part 1. Classification and selection. Int J Prosthodont Jan–Feb 1990;3(1):98–102. 8. Ferro KJ, Morgano SM. The Glossary of Prosthodontic Terms. 9th ed. J Prosthet Dent 2017; 117:(5S), e12. 9. Carr AB, Brown DT, eds. McCracken’s removable partial denture prosthodontic. 13th ed. St. Louis: Mosby; 2011. 10. Burns DR, Ward JE. A review of attachments for removable partial denture design: Part 2. Treatment Planning and Attachment Selection. Int J Prosthodont Mar–Apr 1990;3(2):169–174. 11. dos Santos Nunes Reis JM, da Cruz Perez LE, Alfenas BFM, de Oliveira Abi‐Rached F, Filho JNA. Maxillary rehabilitation using fixed and removable partial dentures with attachments: A clinical report. J Prosthod 2014 Jan;23(1):58–63. doi: 10.1111/ jopr.12069. Epub 2013 May 31. 12. Kratochvil FJ, Thompson WD, Caputo AA. Photoelastic analysis of stress patterns on teeth and bone with attachment retainers for removable partial dentures. J Prosthet Dent 1981 Jul;46(1):21–8. doi: 10.1016/0022-3913(81)90129-3. 13. Sailer I, Makarov NA, Thoma DS, Zwahlen M, Pjetursson BE. All-ceramic or metal-ceramic tooth-supported fixed dental prostheses (FDPs)? A systematic review of the survival and complication rates. Part I: Single crowns (SCs). Dent Mater 2015 Jun;31(6):603–23. doi: 10.1016/j.dental.2015.02.011. Epub 2015 Apr 2. 14. Pjetursson BE, Sailer I, Makarov NA, Zwahlen M, Thoma DS. All-ceramic or metal-ceramic tooth-supported fixed dental prostheses (FDPs)? A systematic review of the survival and complication rates. Part II: Multiple-unit FDPs. Dent Mater 2015 Jun;31(6):624–39. doi: 10.1016/j.dental.2015.02.013. Epub 2015 Apr 30. 15. Gresnigt MMM, Kalk W, Özcan M. Clinical longevity of ceramic laminate veneers bonded to teeth with and without existing composite restorations up to 40 months. Clin Oral Invest 2013 Apr;17(3):823–32. doi: 10.1007/s00784-012-0790-5. Epub 2012 Jul 21. 16. Renner RP. Semi-precision attachment-retained removable partial dentures. Quintessence Dent Technol 1994;17:137–144. 17. Owall B. Precision attachment-retained removable partial dentures. Part 1. Technical long-term study. Int J Prosthodont May– Jun 1991;3:249–257. 18. Hedzelek W, Rzatowski S, Czarnecka B. Evaluation of the retentive characteristics of semi‐precision extracoronal attachments. J Oral Rehabil 2011 Jun;38(6):462–8. doi: 10.1111/j.13652842.2010.02153.x. Epub 2010 Sep 15. T HE CORRE S P ON DIN G AU T HOR , Fernanda Ferruzzi, DDS, PhD, can be reached at Fer.ferruzzi@gmail.com.

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Local Geographic Variation of Periodontitis and Self-Reported Type 2 Diabetes Mellitus Tobias K. Boehm, DDS, PhD; Dalia Seleem, DDS, PhD; and Finosh G. Thankam, PhD

abstract Tooth loss, periodontitis, Type 2 diabetes mellitus, age, race/ethnicity and gender are all correlated, and previous researchers developed mathematical models suggesting geographic disparities for these conditions for the Inland Empire region of California. By performing geospatial analysis of the medical charts from patients attending the dental center of the Western University of Health Sciences, the researchers provide further evidence for geographic health disparities to the ZIP code level in the northern half of the Inland Empire. Key words: Geospatial health, periodontitis, Type 2 diabetes mellitus, tooth loss, demographics

AUTHORS Tobias K. Boehm, DDS, PhD, is an associate professor and periodontist at the Western University of Health Sciences College of Dental Medicine. Conflict of Interest Disclosure: None reported. Dalia Seleem, DDS, PhD, is an assistant professor at the Western University of Health Sciences Colleges of Dental Medicine. Conflict of Interest Disclosure: None reported.

Finosh G. Thankam, PhD, is an assistant professor in tissue engineering and regenerative medicine at the department of translational research at the Western University of Health Sciences. Conflict of Interest Disclosure: None reported.

eriodontitis is a chronic inflammatory condition caused by a reciprocally reinforced interaction between polymicrobial communities inside periodontal sulci and a dysregulated host inflammatory response.1 Type 2 diabetes mellitus (T2DM) is characterized by multiple disturbances in glucose homeostasis, including impaired insulin secretion, insulin resistance and splanchnic glucose uptake leading to chronic hyperglycemia.2 Generally, hyperglycemic individuals exhibit 1.86 times more likely to develop periodontitis compared to nondiabetic individuals.3 In turn, periodontitis is associated with poorer glycemic control in T2DM and with higher insulin resistance as determined by the homeostatic model assessment of insulin resistance (HOMA-IR) levels.4 Potential mechanisms of uncontrolled T2DM exacerbating periodontitis include an altered periodontal microflora and immune

dysfunction and periodontal extracellular matrix mineralization disorganization triggered by diverse pathological mediators including advanced glycosylation end products, oxidative stress and adipokines. Likewise, it is thought that bacterial irritants released from periodontal tissues and the chronic elevation of inflammatory mediators such as interleukin 6 (IL-6), tumor necrosis factor alpha (TNF-α), C-reactive protein (CRP) and oxygen radicals exacerbate diabetes in untreated periodontitis.5 Periodontitis experience and T2DM are common in males, Hispanics and older individuals in the U.S. as reported respectively by National Health and Nutrition Examination Surveys and National Center of Health Statistics at the Centers for Disease Control and Prevention.6,7 Self-reported T2DM status is a valid and reliable substitute for clinical diagnosis of diabetes in epidemiologic studies, with self-reported diabetes matching JULY 2 0 2 1

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the clinical diagnosis of diabetes more than 92% over repeated visits.8 Given that demographics vary geographically, Eke et al. developed a model to predict prevalence of periodontitis down to census tract level, predicting possible local hot spots of severe periodontal disease in Los Angeles and San Bernardino counties.9 Similarly, national epidemiologic data on diabetes risk factors have been used to predict local variations in overall T2DM experience; however, it was limited only to the county level.10 Therefore, the researchers aimed to test the prediction of local variations of disease experience by mapping self-reported T2DM and clinically diagnosed periodontal status of patients attending a dental school clinic.

Methods Subjects

The researchers collected demographics, ZIP codes of patients’ mailing addresses, self-reported T2DM status and clinical periodontal diagnoses from the AxiUm patient record of all patients seen at the dental center of the Western University of Health Sciences between 2010 and 2013, and obtained 1,991 records with the complete dataset. Periodontal exams including radiographs were conducted by third- and fourth-year dental students supervised by a general dentist faculty according to the parameters published by the American Academy of Periodontology.11 Demographics were recorded as provided by the patient for age, gender identification (coded as “male” if identifying as such for this study) and ethnicity (coded as “Hispanic” or “Caucasian,” not Hispanic for this study). For each of these patients, a periodontal diagnosis was assigned by a board-certified periodontist (TB) according to the 1999 International Workshop for a Classification of Periodontal Diseases and Conditions12 at the time of the patient visit. Because no other periodontist was available for calibration at the time, 450 JULY

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calibration was achieved with comparison of diagnoses provided by the student/ general dentist teams. The researchers coded “periodontitis” for cases meeting the 1999 criteria for “chronic periodontitis” and “severe periodontitis” as cases where the interproximal clinical attachment level equaled or exceeded 5 mm. The observed kappa for periodontal disease severity (no periodontitis; mild, moderate, severe chronic periodontitis) was 0.936 (standard error, 0.012) and the Pearson correlation coefficient was 0.968 (95% confidence interval (CI), 0.962–0.972).

The researchers aimed to test the prediction of local variations of disease experience by mapping self-reported T2DM and clinically diagnosed periodontal status of patients. They also recorded the worst probing depth and the number of missing teeth excluding third molars for these patients. The patient’s diabetes status was recorded by third- or fourth-year dental students during the initial visit following a questionnaire asking if patients had diabetes or blood sugar anomalies. Students further questioned patients if the answer was yes, checking a box for Type 1 or Type 2 diabetes if the patient was able to confirm a previous diagnosis of these conditions and “other” if the response did not specifically indicate either condition. Examples of “other” conditions that students listed were “unknown,” “don’t know,” “pregnancy related” or “gestational.” These “other” conditions were omitted in further analysis. This study was approved by the Western University of Health Sciences Institutional

Review Board as exempt (12/IRB/019 and the addition of geographic analysis was approved April 21, 2015.)

Statistical Analysis

Data were tabulated using Microsoft Excel (Redmond, Wash.) and reformatted as needed for statistical analysis for the R statistical package (Vienna). Correlation of periodontitis with diabetes was evaluated using chi square analysis. Differences in proportions of males, Caucasians, Hispanics, periodontitis and severe periodontitis were evaluated with the proportion test. Age, pocket depths and missing teeth were found to be nonparametrically distributed as visualized using histograms and determined by the Shapiro-Wilk test. Consequently, the Mann-Whitney U test was used to assess whether nondiabetic and diabetic groups were different. Geographic distribution of periodontitis and diabetes was mapped according to percentage of patients with these conditions for ZIP codes (based on 2015 census zoning data as found in the file cb_2015_us_zcta510_500k published by the U.S. Census Bureau). A choropleth (heat map) was produced using the dlpyr, rgdal, ggplot2, ggmap,13 rgeos, maptools, RColorBrewer and scales packages in R and the U.S. Census Bureau’s ZIP Code Tabulation Areas. The researchers set a limit of a minimum of 10 patients from each displayed ZIP code tabulation area disease average, as a power calculation indicated that nine individuals would be sufficient to detect a fivefold increase in severe periodontitis (alpha 0.05, power 80%). Logit regression was performed using the glm function of the “aod” package in R after transforming the data in the following fashion for a model that regarded the following as risk factors for severe periodontitis: age, identifying as male, Hispanic or Type 2 diabetic and reporting a residence in a ZIP

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TABLE 1

Patient Characteristics Parameters

No Diabetes

T2DM

Total number

1,830

161

Average age +/– SD (years)

44.7 +/– 16.9

60.4 +/– 11.0**

code where more than 20% of patients experienced severe periodontitis. Different permutations of risk factors were also tested and the same approach for modeling the risk for periodontitis was used.

% males

41.0

45.3

% Caucasian

39.5

28.0**

% Hispanic

30.8

39.8**

% periodontitis

52.3

86.3**

% Severe periodontitis

12.5

22.4**

Results

Average worst probing depth +/– SD (mm)

4.92 +/– 2.14

5.67 +/– 1.99**

Average missing teeth* +/– SD

2.85 +/– 4.13

4.87 +/– 4.90**

Risk ratio of periodontitis (95% CI)

1.00 (reference)

1.66 (1.54–1.79)**

Risk ratio of severe periodontitis (95% CI)

1.00 (reference)

1.80 (1.31–2.46)**

To study whether the sample provided by the dental school clinic population could provide a useful test for the predicted local variation, the researchers determined whether the sample followed the known periodontitis-diabetes correlation (TA BLE 1 ). The dental school clinic patient population is generally older and more female than the average demographics reported by the U.S. Census Bureau for Los Angeles, Riverside and San Bernardino counties, and the ethnic composition is similar to the ranges reported for these counties (male 49% to 50%, Hispanic 49% to 55%, white alone, non-Hispanic 26% to 35%).14 As displayed in TA BLE 1, the clinic population follows the known epidemiologic pattern for T2DM, with an increase in males and a significantly older age and a larger number of Hispanic patients. As expected, patients with T2DM experienced significantly more periodontitis, severe periodontitis and tooth loss excluding third molars and displayed worse probing depths. Not adjusting for age and other risk factors, self-reported Type 2 diabetics in these patient populations were 1.7-fold more likely to experience periodontitis and 1.8-fold more likely to experience severe periodontitis, which is in accordance with the risk ratios published in the literature. Because the clinic population exhibited the typical periodontitis-diabetes comorbidity and demographics-disease relationships, the researchers first mapped demographic patient characteristics for ZIP code tabulation areas and noted whether these corresponded to the publicly available demographic maps for the same areas (FIGURE 1 ). They noted that the pattern for age (FIGURE 1 A ), gender (FIGURE 1B )

SD: standard deviation; CI: confidence interval * Excluding third molars ** p < 0.05 (Risk ratio: Fisher’s exact test, Wald method; proportion test for percentages; Mann-Whitney U test for age, worst probing depth, missing teeth)

and either self-identified Caucasian or Hispanic identity (FIGURES 1C and D ) resembled census bureau data maps, suggesting that the dental school clinic population captured a reasonable snapshot of the surrounding communities. To determine whether the prediction of local variances of diabetic prevalence was supported by our data, they mapped the self-reported condition of “T2DM” to ZIP code tabulation areas (FIGURE 2 ). As seen in this map, experience of T2DM varied widely, supporting the hypothesis that T2DM prevalence may differ significantly between geographic locations. Even though the diabetes map does not precisely match any demographic map, it resembled the map for age, confirming the relationship between age and T2DM. To understand whether the prediction of local variance of periodontitis prevalence was supported by our data, they mapped diagnoses of “(chronic) periodontitis,” “severe periodontitis,” average worst probing depth and the number of missing teeth (FIGURE 3 ). The geographic diversity in disease experience of our patients was readily visible, with clusters of severe periodontitis (FIGURE 3A ), periodontitis in general (FIGURE 3B ), pocketing (FIGURE 3C ) and tooth loss (FIGURE 3D )

in all neighborhoods. The patterns that do not match suggest that occurrence of pocketing, periodontitis diagnosis, severe periodontitis and tooth loss are not related in our patient population. Similarly, none of these patterns match the T2DM pattern, suggesting that there is no relationship contrary to the rough correlation between T2DM and periodontal findings displayed in TA BLE 1 . This suggests that the difference in periodontitis experience between T2DM and nondiabetics is likely not predicted by self-reported diabetes status. The logit regression analyses identified that 15 ZIP codes where more than 20% of patients experienced severe periodontitis of demographic factors and considered a mailing address of these ZIP codes a risk for (severe) periodontitis as well as age, identifying as male, Hispanic or having T2DM (TA BLE 2 ). For severe periodontitis, age and being male were the strongest predictors for a diagnosis of severe periodontitis. “Hispanic” and the ZIP code were also predictive to a significant degree, whereas self-reported T2DM was not (TA BLE 2A ). For diagnosis of periodontitis, age was most predictive and being male and Hispanic were other significant predictors. In contrast, ZIP code or self-reported T2DM were not predictive. This suggests JULY 2 0 2 1

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that the difference in periodontal disease activity seen among nondiabetic patients of the dental center and self-reported T2DM can be predicted by age and ethnicity alone.

Discussion

FIGURE 1A . Age distribution of patients from local ZIP codes reveals a great diversity of geographic patient

populations.

FIGURE 1B . Age distribution of patients from local ZIP codes reveals a great diversity of geographic patient

populations.

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The present study confirmed the possibility of local variations in the prevalence of T2DM and periodontal status. The researchers demonstrated that the dental school clinic patients reporting a history of T2DM were likely to be older and experience periodontitis of increased severity, worse probing depths and increased tooth loss. However, it appears that the effect of T2DM on the clinical presentation is easily masked by age and ethnicity and that clinical studies evaluating the relationship between periodontitis and diabetes may benefit from an age and ethnicity matched case-control setup. However, understanding the existence of local variations in disease prevalence warrants further investigations involving representative sample populations from local areas. Also, the researchers are not aware of any obvious demographic or environmental risk factor that could explain the wide variance in observed disease prevalence, and this needs further research. Moreover, it is possible that small sample sizes (10 or more) could exacerbate disease prevalence by chance, although it seems likely that the extremes of periodontal disease prevalence were based on power analysis. Studies reporting the relationship of periodontitis to T2DM often report odds ratios. The odds ratio of periodontitis in T2DM in this study is 6.02 (95% CI 3.77 to 9.61) and that of severe periodontitis is 2.03 (95% CI 1.37 to 3.01). This odds ratio is similar to the odds ratio of periodontitis observed in diabetic Pima Indians of Arizona (2.81, 95% CI1.91–4.13),15 where diagnosis of periodontitis was determined by attachment loss as in this study. Increased odds for periodontal disease

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were reported in multiple studies that used different measures such as the Community Index of Periodontal Treatment Needs, probing depths only or combinations of bleeding on probing, probing depths and attachment loss.16–19 Regarding tooth loss, our data replicates earlier findings of increased tooth loss in T2DM.20–25 The odds ratio reported in this study for T2DM is comparable to the odds ratios reported for other well-known risk factors such as smoking and risk indicators such as age and gender. Generally, odds ratios are adjusted for each risk factor to remove influences from other risk factors or indicators. For example, Tomar et al. (2000) reports an adjusted odds ratio of 3.97 for periodontitis in current cigarette smokers, 5.88 in heavy cigarette smokers and 1.68 in former smokers (TA BLE 3 ).26 It is difficult to compare odds ratios, as they are directly comparable across studies because the adjustment mechanisms are different. For example, the NHANESbased studies16,26 adjust for education level and income, which was not possible in this study. Moreover, the NHANES subject population is selected to mimic national averages, whereas the local dental school patient population has higher levels of periodontitis (52%) compared to the national average, which also makes odds ratios less comparable. Last, periodontitis definitions vary across studies,16,26,27 which adds to the observed variance between previously reported odds ratios. A limitation of this study is that the researchers chose to limit the data from 2010 to 2013 because changes in clinic protocols resulted in a much larger number of providers entering periodontal diagnoses. This resulted in much increased heterogeneity in data, as some providers did not determine attachment levels, lacked calibration in periodontal diagnosis or did not utilize the clinic form used to collect diagnostic data.

FIGURE 1C . The number of patients who identify as “Caucasian” varies widely between ZIP codes and

generally reflects the ethnic makeup of different ZIP codes.

FIGURE 1D. The number of patients who identify as “Hispanic” also varies widely between ZIP codes and

generally reflects the ethnic makeup of different ZIP codes.

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FIGURE 2 . The prevalence of Type 2 diabetes mellitus as reported by patients from different ZIP codes differs

widely. This pattern does not match well the previous demographic patterns, indicating that there is no strong relationship of diabetes with demographic factors among patients at the dental center.

FIGURE 3A . Prevalence of severe periodontitis in patients differs widely and follows a unique distribution. There is a cluster of patients with severe periodontitis from the northeastern corner of Rancho Cucamonga, with a prevalence nearly four times higher than the national average.

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Heterogeneity was a problem also for attempting to correlate radiographic bone level with diabetes, demographic characteristics and ZIP codes. In most cases, periodontal exams included a full-mouth radiographic series, and only occasionally were vertical bitewings ordered. Therefore, it was not possible to obtain reliable radiographic bone level measurements for all subjects. Likewise, HbA1c data was too heterogenous to be useful for this study, as routine HbA1c testing on the day of the dental exam is not part of our comprehensive oral exam protocol at the dental center. While a significant number of patients could report their latest HbA1c level, we felt that the self-reported data was not reliable and of questionable validity because the testing date and reporting accuracy varied widely. For the values that were reported by patients, it appeared that most patients in our clinic were able to achieve a modest control of their glucose levels with HbA1c levels below 9% and glucose levels below 200 mg/dL. This corresponds to the observed odds ratio for T2DM in this study, similar to the odds ratio of 1.56 reported by Tsai et al.16 for “better controlled” diabetics. It is unknown how much socioeconomic status played a role as risk indicator in our study population because income level and education level are never recorded during the patient intake process at the dental center. Previous studies16,27 indicate that there is an inverse relationship between severe periodontitis and attained education level and income. A standard classification scheme for periodontitis has been endorsed by the American Academy of Periodontology and the European Federation of Periodontology.28 Consequently, the periodontitis definition in this study does not precisely match the current classification scheme of periodontitis stages. In this study, the “severe periodontitis”

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approximates Stages III and IV in the new disease classification and may include cases of periodontally healthy, but reduced periodontium. Likewise, the “periodontitis” definition in this study includes Stage I type of periodontitis, along with cases that are now considered “healthy” if the bleeding-on-probing percentage of sites is less than 10%. This study suggests that the geographical disparities in oral health extrapolated from national epidemiological data likely reflect reality. With a network of calibrated dental practices, it may be possible to chart oral diseases and health conditions to the neighborhood level in real time for the entire state of California or beyond. Data of this type could assist dentists in selecting locations for practice. Moreover, this type of data could assist development of initiatives that could address public health disparities at locations where market mechanisms are not supportive of conventional private practice.

FIGURE 3B . When accounting for all diagnoses of “periodontitis,” the geographic distribution shifts to a much

broader area.

Conclusion

This study provides evidence that patients with a history of T2DM exhibited worse levels of periodontal disease and tooth loss compared to a general nondiabetic patient population, and identifies age, gender and ethnicity as risk indicators for periodontitis. In addition, the data in this study provides evidence for geographic variations in periodontal disease and suggests that a patient’s mailing address ZIP code may be used by dentists as a risk indicator for diagnosis of periodontitis in portions of the Inland Empire of California. However, the study also emphasizes the importance of adjusting for age, gender and ethnicity when determining the effect of T2DM on periodontal disease. n RE FEREN CE S 1. Lamont RJ, Koo H, Hajishengallis G. The oral microbiota: Dynamic communities and host interactions. Nat Rev Microbiol 2018;16(12):745–759.

FIGURE 3C . When mapping the average worst probing depth, several ZIP codes exhibit worse probing depths

including the cluster of severe periodontitis patients noted in figure 3A, but also including other areas.

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FIGURE 3D. The distribution of patients with the greatest number of missing teeth excluding third molars does not

match the one for periodontitis or probing depth, indicating that the number of missing teeth does not correlate with a diagnosis of periodontitis. TABLE 2A

Model Outcomes for Severe Periodontitis Parameters

Coefficient estimate

Std. error

z value

p-value

Odds ratio (95% CI)

Age

0.057185

0.004469

10.559

< 0.001*

1.048 (1.039–1.057)

Male

0.645272

0.138614

4.655

< 0.001*

1.907 (1.453–2.504)

Hispanic

0.326568

0.144877

2.254

0.0242*

1.386 (1.041–1.839)

T2DM

0.027497

0.213359

0.129

0.8975

1.028 (0.669–1.547)

ZIP code

0.430602

0.147927

2.911

0.0036*

1.538 (1.148–2.051)

Model

Severe periodontitis risk ~ age + male + Hispanic + Type 2 DM + ZIP code

* Significant contribution to risk of diagnosis for severe periodontitis. ZIP code: Having a mailing address belonging to a ZIP code that contains more than 20% of patients with severe periodontitis. Age, identifying as male and Hispanic and having a mailing address from a ZIP code that produces a high number of severe periodontitis patients are predictive for a diagnosis of severe periodontitis, while reporting Type 2 diabetes is not. 2. DeFronzo RA. Pathogenesis of type 2 diabetes mellitus. Med Clin North Am 2004 Jul;88(4):787–835, ix. doi: 10.1016/j. mcna.2004.04.013. 3. Nascimento GG, Leite FRM, Vestergaard P, et al. Does diabetes increase the risk of periodontitis? A systematic review and meta-regression analysis of longitudinal prospective studies. Acta Diabetol 2018 Jul;55(7):653–667. doi: 10.1007/s00592-018-

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1120-4. Epub 2018 Mar 3. 4. Sanz M, Ceriello A, Buysschaert M, et al. Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the International Diabetes Federation and the European Federation of Periodontology. J Clin Periodontol 2018 Mar;137:231–241. doi: 10.1016/j.

diabres.2017.12.001. Epub 2017 Dec 5. 5. Polak D, Shapira L. An update on the evidence for pathogenic mechanisms that may link periodontitis and diabetes. J Clin Periodontol 2018 Feb;45(2):150–166. doi: 10.1111/ jcpe.12803. Epub 2017 Dec 26. 6. Xu G, Liu B, Sun Y, et al. Prevalence of diagnosed Type 1 and Type 2 diabetes among U.S. adults in 2016 and 2017: Population-based study. BMJ 2018 Sep 4;362:k1497. doi: 10.1136/bmj.k1497. 7. Eke PI, Wei L, Thornton-Evans GO, et al. Risk indicators for periodontitis in U.S. adults: NHANES 2009 to 2012. J Periodontol 2016 Oct;87(10):1174–85. doi: 10.1902/jop.2016.160013. Epub 2016 Jul 1. 8. Schneider AL, Pankow JS, Heiss G, et al. Validity and reliability of self-reported diabetes in the Atherosclerosis Risk in Communities Study. Am J Epidemiol 2012 Oct 15;176(8):738–43. doi: 10.1093/aje/kws156. Epub 2012 Sep 25. 9. Eke PI, Zhang X, Lu H, et al. Predicting periodontitis at state and local levels in the United States. J Dent Res 2016 May;95(5):515– 22. doi: 10.1177/0022034516629112. Epub 2016 Feb 4. 10. Li X, Staudt A, Chien LC. Identifying counties vulnerable to diabetes from obesity prevalence in the United States: A spatiotemporal analysis. Geospat Health 2016 Nov 21;11(3):439. doi: 10.4081/gh.2016.439. 11. Parameter on comprehensive periodontal examination. American Academy of Periodontolgy. J Periodontol 2000 May;71(5 Suppl):847–8. doi: 10.1902/jop.2000.71.5-S.847. 12. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999 Dec;4(1):1–6. doi: 10.1902/annals.1999.4.1.1. 13. Kahle D, Wickham H. ggmap: Spatial Visualization with ggplot2. The R Journal 2013;5(1):144–161. 14. QuickFacts Riverside County, California; San Bernardino County, California; Los Angeles County, California. United States Census Bureau 2019. www.census.gov/quickfacts/ fact/table/riversidecountycalifornia,sanbernardinocountycalifornia, losangelescountycalifornia/PST045219. Accessed May 26, 2020. 15. Emrich LJ, Shlossman M, Genco RJ. Periodontal disease in non-insulin-dependent diabetes mellitus. J Periodontol 1991 Feb;62(2):123–31. doi: 10.1902/jop.1991.62.2.123. 16. Tsai C, Hayes C, Taylor GW. Glycemic control of type 2 diabetes and severe periodontal disease in the US adult population. Community Dent Oral Epidemiol 2002 Jun;30(3):182–92. doi: 10.1034/j.1600-0528.2002.300304.x. 17. Persson RE, Hollender LG, MacEntee MI, et al. Assessment of periodontal conditions and systemic disease in older subjects. J Clin Periodontol 2003 Mar;30(3):207–13. doi: 10.1034/j.1600051x.2003.00237.x. 18. Demmer RT, Jacobs DR Jr., Desvarieux M. Periodontal disease and incident Type 2 diabetes: Results from the First National Health and Nutrition Examination Survey and its epidemiologic follow-up study. Diabetes Care 2008 Jul;31(7):1373–9. doi: 10.2337/ dc08-0026. Epub 2008 Apr 4. 19. Wang TT, Chen TH, Wang PE, et al. A population-based study on the association between Type 2 diabetes and periodontal disease in 12,123 middle-aged Taiwanese (KCIS No. 21). J Clin Periodontol 2009 May;36(5):372–9. doi: 10.1111/j.1600051X.2009.01386.x. 20. Campus G, Salem A, Uzzau S, et al. Diabetes and periodontal disease: A case-control study. J Periodontol 2005 Mar;76(3):418– 25. doi: 10.1902/jop.2005.76.3.418. 21. Tanwir F, Altamash M, Gustafsson A. Effect of diabetes on periodontal status of a population with poor oral health. Acta Odontol Scand 2009;67(3):129–33. doi: 10.1080/00016350802208406.

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TABLE 2B

Model Outcomes for Periodontitis

22. Demmer RT, Desvarieux M, Holtfreter B, et al. Periodontal status and A1C change: Longitudinal results from the study of health in Pomerania (SHIP). Diabetes Care 2010 May;33(5):1037–43. doi: 10.2337/dc09-1778. Epub 2010 Feb 25. 23. Susanto H, Nesse W, Dijkstra PU, et al. Periodontitis prevalence and severity in Indonesians with Type 2 diabetes. J Periodontol 2011 Apr;82(4):550–7. doi: 10.1902/ jop.2010.100285. Epub 2010 Oct 8. 24. Apoorva SM, Sridhar N, Suchetha A. Prevalence and severity of periodontal disease in type 2 diabetes mellitus (non-insulin-dependent diabetes mellitus) patients in Bangalore city: An epidemiological study. J Indian Soc Periodontol 2013 Jan;17(1):25–9. doi: 10.4103/0972-124X.107470. 25. Khanuja PK, Narula SC, Rajput R, et al. Association of periodontal disease with glycemic control in patients with Type 2 diabetes in Indian population. Front Med 2017 Mar;11(1):110– 119. doi: 10.1007/s11684-016-0484-5. Epub 2017 Mar 2. 26. Tomar SL, Asma S. Smoking-attributable periodontitis in the United States: Findings from NHANES III. National Health and Nutrition Examination Survey. J Periodontol 2000 May;71(5):743–51. doi: 10.1902/jop.2000.71.5.743. 27. Grossi SG, Zambon JJ, Ho AW, Koch G, Dunford RG, Machtei EE, Norderyd OM, Genco RJ. Assessment of risk for periodontal disease. I. Risk indicators for attachment loss. J Periodontol 1994 Mar;65(3):260–7. doi: 10.1902/jop.1994.65.3.260. 28. Papapanou PN, Sanz M, Buduneli N, et al. Periodontitis:

Parameters

Coefficient estimate

Std. error

z value

p-value

Odds ratio (95% CI)

Age

0.117641

0.004977

23.638

< 0.001*

1.125 (1.114–1.136)

Male

0.317914

0.126941

2.504

0.0123*

1.374 (1.072–1.764)

Hispanic

0.470542

0.130843

3.596

0.0003*

1.601 (1.240–2.071)

Type 2 DM

0.249000

0.271160

0.918

0.3585

1.283 (0.768– 2.232)

ZIP code

–0.06200

0.141839

–0.437

0.6620

0.940 (0.712–1.241)

Model

Severe periodontitis risk ~ age + male + Hispanic + Type 2 DM + ZIP code

* Significant contribution to risk of diagnosis for severe periodontitis. ZIP code: Having a mailing address belonging to a ZIP code that contains more than 20% of patients with severe periodontitis. Age, identifying as male and Hispanic are predictive for a diagnosis of severe periodontitis, while ZIP code and reporting Type 2 diabetes are not.

Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol 2018 Jun;89 Suppl 1:S173–S182. doi: 10.1002/JPER.17-0721.

T HE CORRE S P ON DIN G AU T HOR , Tobias K. Boehm, DDS, PhD, can be reached at tboehm@westernu.edu.

TABLE 3

Previously Reported Odds Ratios for Periodontitis Condition

Subcategory

Odds ratio (95% CI)

Adjusted OR (95% CI)

Study population

Reference

Cigarette smoking

Current

3.58 (2.94–4.36)

3.97† (3.20–4.93)

4.78 (3.32–6.89)

5.88† (4.03–8.58)

Former

2.26 (1.83–2.78)

1.68† (1.31–2.17)

NHANES III (18+ years, dentate, N = 12,329); Periodontitis: > 3 mm CAL and PD

Tomar et al. 2000

Current, >30 cigs/day Glycemic control

HbA1c ≤ 9%

1.65 (1.13–2.43)

1.56† (0.90–2.68)

Tsai et al. 2002

HbA1c > 9%

3.22 (2.12–4.87)

Education

Less than H.S.

NHANES III (45+ years, dentate, N = 4,343); Periodontitis: > 5 mm CAL and PD

Erie County (25–74 years, N = 1,426)

Grossi et al. 1994

2.9† (1.40–6.03) Referent

H.S. diploma

0.49 (0.37–0.66)

1.00† (0.63–1.58)

Some college

0.35 (0.23–0.55)

0.80† (0.37–1.71)

College degree

0.27 (0.14–0.52)

0.35† (0.13–0.96)

Subgingival calculus

More than average

16.6 (9.05–30.3)

1.03† (1.03–1.04)

Gender

Male

N/A

1.36‡ (1.06–1.76)

Age

35–44 years

N/A

1.72‡ (1.18–2.49)

65–74 years

N/A

9.01‡ (5.86–13.89)

Detected

N/A

0.60⁺ (0.43–0.84)

Capnocytophaga sp. P. gingivalis

Detected

N/A

1.59⁺ (1.11–2.25)

T. forsythia

Detected

N/A

2.45⁺ (1.87–3.24)

† Adjusted for gender, age, race/ethnicity, education level and income:poverty ratio ‡ Adjusted for age, socioeconomic status, microflora and occupational hazards ⁺ Adjusted for smoking, plaque and calculus N/A: Grossi et al. did not provide unadjusted odds ratios or provide the data to calculate odds ratios. JULY 2 0 2 1

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tm j C D A J O U R N A L , V O L 4 9 , Nº 7

Temporomandibular Joint ‘Mice:’ Report of Two Cases Tarun Mundluru, BDS, MSc; Fariba Farrokhi, DMD, MAGD; Melika Shahsavar Haghighi, DDS; and Mariela Padilla, DDS, MEd

abstract Background: The temporomandibular joint (TMJ) is subject to frequent loading, related mostly to its functional capabilities, and it commonly exhibits bone remodeling. The physiological adaptability and tolerance might be compromised and signs of degenerative change will appear. The presence of loose calcified bodies in the TMJ space might suggest osteochondritis dissecans or synovial chondromatosis, and patients may have symptoms of pain, joint sounds and limitation in the range of motion of the jaw. Methods: In this paper, two cases with radiological loose and detached bone bodies in the TMJ suggestive of osteochondritis dissecans are discussed, including medical history, clinical findings, radiological appearance and treatment. Results: The first case is a 66-year-old female with systemic conditions who presented with TMJ crepitus. The second case is a 55-year-old female with a previous diagnosis of rheumatoid arthritis who has jaw clicking and facial pain. Panoramic imaging in both cases revealed joint loose bodies, and conservative treatment was implemented. Conclusions: The use of panoramic imaging as a preliminary diagnostic approach is useful to identify the presence of TMJ alterations. The management for these “joint mice” ranges from conservative treatment to surgical options. Practical implications: A conservative approach includes physical therapy and activity modification to improve muscle mobility and increase range of motion of the TMJ. Close monitoring will identify the need to intervene with a surgical procedure. Keywords: TMJ disorders, joint loose bodies, osteochondritis dissecans, synovial chondromatosis, TMJ mice

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AUTHORS Tarun Mundluru, BDS, MSc, is an orofacial pain and oral medicine resident at the Herman Ostrow School of Dentistry of USC. Conflict of Interest Disclosure: None reported. Fariba Farrokhi, DMD, is the associate director of temporomandibular disorders at Newark Beth Israel Medical Center in Newark, N.J. She is a master of the Academy of General Dentistry. Conflict of Interest Disclosure: None reported.

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Melika Shahsavar Haghighi, DDS, is a general dentist and practices dentistry at two private practices in Los Angeles and Orange County. Conflict of Interest Disclosure: None reported. Mariela Padilla, DDS, MEd, is an associate professor of clinical dentistry, orofacial pain, at the Herman Ostrow School of Dentistry of USC. Conflict of Interest Disclosure: None reported.

he temporomandibular joint (TMJ) is subject to frequent loading, related mostly to its functional capabilities, and it commonly exhibits bone remodeling. In some instances, the physiological adaptability and tolerance might be compromised and signs of degenerative change will appear, including condylar flattening and erosion.1 Campos et al. (2008) reported a series of TMJ magnetic resonance imaging characteristics, and even though they were not able to correlate the condylar changes with clinical symptoms, they documented the most common alterations as: osteophytes, erosion, avascular necrosis, subchondral cyst and intra-articular loose bodies.2 Intra-articular loose bodies are not a common finding in the TMJ, but their appearance in other parts of the body has been related with diseases such as osteochondritis dissecans, intracapsular fractures, osteoarthritis, synovial chondromatosis and rheumatoid arthritis.3 Osteochondritis dissecans is an idiopathic bone anomaly, which appears as a detached bone fragment, as a result of bone modeling beneath the surface of the lesion. The diagnosis is often achieved with a 2D radiographic image (such as a panoramic X-ray) and four stages have been reported, depending on the progression of the condition.4 One of the radiological characteristics in the TMJ is the presence of loose bodies on the condylar heads, and the patient might report pain, joint sounds and limitation of oral movement.5 Possible causes include trauma, abnormal ossification, genetic alterations and endocrine factors. The management is controversial and ranges from conservative treatment, such as activity modification and physical therapy, to surgical approaches including fragment excision and remodeling.6

Synovial chondromatosis of the TMJ is characterized by chondrometaplasia of the synovial membrane, a process in which cartilaginous nodule formation is followed by detachment, forming loose bodies in the joint space. Although there are radiological findings, a definitive diagnosis requires a histopathologic examination.7 This condition is considered benign and affects mostly large synovial joints such as knees and elbows; it is very rare in the TMJ, showing predilection for the upper articular space.8 A challenge in the diagnosis is the inconsistencies because in some cases the nodules are not calcified enough to be evident and observable.9 The most common signs and symptoms of synovial chondromathosis of the TMJ are pain, swelling and restricted mouth opening; however, in some cases this is an incidental finding.10 This is a report of two cases of joint mice of TMJ diagnosed based on the preliminary findings observed in the panoramic radiograph. Calibrated practitioners in orofacial pain from the advanced training program at the Herman Ostrow School of Dentistry of USC performed medical history and clinical examination. Once the cases were identified, the patients signed the authorization to use protected health information for education and instruction form. The first case is a 66-year-old female whose condition was an incidental finding. The second case is a 55-year-old female with jaw clicking and mild pain.

Case One

A 66-year-old female presented with a medical history significant for ulcerative colitis, high blood pressure, high cholesterol, osteoarthritis, depression and insomnia. The patient’s medications include carvedilol, budesonide, rosuvastatin and escitalopram. She visited the clinic for routine dental care

C D A J O U R N A L , V O L 4 9 , Nº 7

FIGURE 1. Loose bone bodies observed in the front of both condylar heads (panoramic taken with open mouth to reduce overlap of the condyle and the temporal bone). Arrows show the “mice” or loose bone.

and had no complaints of facial pain. Clinical examination showed normal range of motion of TMJ with an active interincisal opening of 48 mm and lateral movements of 8 mm. Muscle palpation revealed tenderness in the superficial and deep masseter muscles bilaterally with no referral pattern. Joint palpation was unremarkable, but crepitus was present in both joints. The presence of joint mice was an incidental finding on her panoramic radiograph (FIGURE 1 ).

Case Two

A 55-year-old female presented with a chief complaint of jaw clicking and facial pain. The patient has a history of rheumatoid arthritis and is taking hydroxychloroquine and etanercept. Clinical examination showed a normal range of motion of TMJ, with an active opening of 46 mm and lateral movements of 10 mm on each side. Muscle palpation revealed tenderness in the superficial and deep masseter muscles bilaterally. Mild tenderness was noted on the left TMJ on palpation. Clicking sounds were observed on both the TMJ upon wide opening of the jaw; however, no pain was associated with the clicks. On radiographic examination of the TMJ, irregular bone fragments were noticed related with the right TMJ (FIGURE 2 ). The radiological characteristics in both cases were consistent with osteochondritis dissecans, stage IV, where the fragments

FIGURE 2 . Loose bone bodies observed in relationship with the right condylar

head. Arrow shows the “mice” or loose bone.

are not attached to the bone surface. Both patients had findings suggesting localized myalgia; the second patient exhibited mild capsulitis. No functional limitations were identified. The followup plan included further imaging and monitor evolution. Physical therapy was included for the muscle pain and anti-inflammatories for the capsulitis.

Discussion

As discussed by Misirlioglu (2014)5, the follow-up in cases with degenerative changes includes volumetric imaging in order to have spatial information and to monitor evolution. The use of panoramic imaging as a preliminary diagnostic approach is useful to identify the presence of TMJ alterations such as joint mice; however, cone beam computed tomography provides better diagnostic information of the morphology of the osseous structures of the TMJ, including cortical bone integrity and subcortical bone destruction/production. If an evaluation of soft tissues is required, magnetic resonance imaging is to be considered.11 For loose bone bodies, the use of volumetric images will provide adequate information regarding location and relationship with the cortical bone. We selected a conservative approach, including physical therapy and activity modification as a therapeutic alternative, because the use of passive stretching improves muscle mobility and increases

the range of motion of the TMJ.12 It is important to consider that in cases with loose bone bodies, close monitoring will identify the need to intervene with a surgical procedure. Orhan (2006)6 has suggested considering age, presentation, fragment size and fragment stability to decide the required intervention. The use of comprehensive clinical examination including range of motion, palpation and auscultation of TMJ and evaluation of masticatory muscles as well as an appropriate protocol for imaging will provide the clinician the information needed to identify conditions such as alterations that might have clinical symptomology but require follow-up and monitoring. n RE F E RE N C E S 1. Roberts WE, Stocum DL. Part II: Temporomandibular joint (TMJ)-regeneration, degeneration and adaptation. Curr Osteoporos Rep 2018 Aug;16(4):369–379. doi: 10.1007/ s11914-018-0462-8. 2. Campos MI, Campos PS, Cangussu MC, et al. Analysis of magnetic resonance imaging characteristics and pain in temporomandibular joints with and without degenerative changes of the condyle. Int J Oral Maxillofac Surg 2008 Jun;37(6):529–34. doi: 10.1016/j.ijom.2008.02.011. Epub 2008 Apr 28. 3. Blenkinsopp PT. Loose bodies of the temporomandibular joint, synovial chondromatosis or osteoarthritis. Br J Oral Surg 1978 Jul;16(1):12–20. doi: 10.1016/s0007117x(78)80050-x. 4. Accabled F, Vial J, Sales de Gauzy J. Osteochondritis dissecans of the knee. Orthop Traumatol Surg Res 2018 Feb;104(1S):S97–S105. doi: 10.1016/j.otsr.2017.02.016. Epub 2017 Nov 29. 5. Misirlioglu M, Zahit M, Yilmaz S. Radiographic diagnosis of osteochondritis dissecans of the temporomandibular joint: Two cases. Med Princ Pract 2014;23(6):580–3. doi: 10.1159/000363572. Epub 2014 Jul 5. JULY 2 0 2 1

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6. Orhan K, Arslan A, Kocyigit D. Temporomandibular joint osteochondritis dissecans: Case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006 Oct;102(4):e41–6. doi: 10.1016/j.tripleo.2006.01.002. Epub 2006 Jul 14. 7. Boffano P, Viterbo S, Bosco G. Diagnosis and surgical management of synovial chondromatosis of the temporomandibular joint. J Craniofac Surg 2010 Jan;21(1):157–9. doi: 10.1097/SCS.0b013e3181c50dc8. 8. Chen M, Yan Ch, Zhang X, Qiu Y. Synovial chondromatosis originally arising in the lower compartment of temporomandibular joint: A case report and literature review. J Craniomaxillofac Surg 2011 Sep;39(6):459–62. doi: 10.1016/j.jcms.2010.10.012. Epub 2010 Nov 20. 9. Meng J, Guo G, Yi B, Zhao Y, et al. Clinical and radiologic findings of synovial chondromatosis affecting the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010 Mar;109(3):441–8. doi: 10.1016/j.tripleo.2009.09.036. Epub 2010 Jan 22. 10. Pappot TWF, Brouns JA, Joosten J. Unusual extensive synovial chondromatosis of the temporomandibular joint. J Craniofac Surg 2017 Mar;28(2):e172–e173. doi: 10.1097/ SCS.0000000000003212. 11. Larheim TA, Abrahamsson AK, Kristensen M, et al. Temporomandibular joint diagnostics using CBCT. Dentomaxillofac Radiol 2015 Jan;44(1):20140235. doi: 10.1259/dmfr.20140235. 12. List T, Jensen RH. Temporomandibular disorders: Old ideas and new concepts. Cephalalgia 2017 Jun;37(7):692–704. doi: 10.1177/0333102416686302. Epub 2017 Jan 9. T HE CORRE S P ON DIN G AU T HOR , Mariela Padilla, DDS, MEd, can be reached at marielap@usc.edu.

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RM Matters

C D A J O U R N A L , V O L 4 9 , Nº 7

Improving Patient Safety With a Timeout Policy TDIC Risk Management Staff

atient safety remains a top priority for practice owners and dental teams; however, the dental office can often be a fast-paced working environment with various distractions that can impede best safety practices. Dental teams should be reminded that taking shortcuts often come at a high cost. Taking the time to check procedure details protects the patients and practice and minimizes the risk for liabilities. In an effort to better prevent mishaps, the Joint Commission requires accredited dental practices to implement a timeout before all surgical procedures. A timeout is the last in a series of steps established by the Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery and is defined as an immediate pause by the entire surgical team to confirm the correct patient, procedure and site. Even if it’s not required for some dental offices, all practices should strongly consider implementing a timeout policy to help avoid the wrong teeth from being treated or extracted. A case reported to The Dentists Insurance Company’s Risk Management Advice Line illustrates the need for consistent timeouts to confirm procedure details. The dentist had referred a patient to an endodontist for an evaluation on teeth Nos. 14 and 15. After taking the necessary diagnostic radiographs and conducting further testing, the endodontist identified tooth No. 14 as the source of her complaint and recommended root canal therapy. The patient returned the following day for the treatment. Halfway through the procedure, the endodontist realized that he had accessed the wrong tooth and was working on tooth No. 15 instead of tooth No. 14. He immediately completed a root canal on tooth No. 15 to repair his mistake and

then began the root canal on the correct tooth. After completing the procedure, the endodontist informed the patient of the incident and offered to waive the fee for treatment on both teeth. He also promised to take care of tooth No. 15 should it require treatment in the future. A few days later, the office received a demand letter from the patient regarding the “mistake of drilling” the wrong tooth, asking the endodontist to make restitution for his error. The endodontist was dealing with health complications at the time and did

not want to risk the patient involving an attorney and adding more to his stress levels, so he contacted TDIC for assistance with resolving the issue. After multiple discussions, the TDIC claims representative and the insured were able to reach a settlement with the patient in exchange for signing a release of liability form.

Conducting a Timeout With the Dental Team

Prior to invasive or irreversible treatment, a timeout is a vital step in ensuring the correct patient receives the intended treatment at the proper site. All

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JULY 2021

RM MAT TERS C D A J O U R N A L , V O L 4 9 , Nº 7

team members, including the dentists, dental assistants and front desk staff, play a significant role in conducting a timeout. The timeout is initiated by a designated member of the treatment team, usually the dentist, and begins with a preprocedure verification of the patient, the procedure and the site of the procedure to be performed. It also involves interactive verbal communication with the patient, if possible, and all team members. Any team member is able to express concerns about the procedure verification. The timeout is conducted in a fail-safe mode, meaning that the procedure is not initiated until all questions or concerns have been resolved. It also includes a process for reconciling differences in responses among team members. The completed components of the timeout should be clearly documented in the patient’s records. The Joint Commission does not require providers to individually document each step of the timeout. One check box or a brief note regarding the successful completion of the timeout, located in a consistent location in the patient record, is adequate documentation as long as the full content of the timeout is specified elsewhere, such as a policy handbook, according to the Joint Commission. The Joint Commission’s Universal Protocol also includes surgical site marking; however, surgical site marking is not a feasible method for dental procedures. Therefore, dental professionals are considered exempt from the sitemarking requirement. The Joint Commission recommends dentists and oral specialists complete the following steps: ■ Review the dental record including the medical history, laboratory findings, appropriate charts and dental radiographs. Indicate the tooth numbers or mark the tooth site or surgical site on the odontogram or radiograph to be included as 466 JULY

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■

part of the patient record. Ensure that radiographs are properly oriented and visually confirm that the correct teeth or tissues have been charted. Verify completion of the informed consent process, ensuring any questions or concerns from the patient are addressed. Conduct a timeout to verify patient, tooth and procedure with an assistant present at the time of the extraction. For patients referred to a specialist, review the referral slip to verify the tooth for which the patient was referred.

Employers Could Be Held Liable for Employee Negligence

In addition to conducting a timeout before treatment, practice owners and dental teams should undergo the verification process anytime the responsibility of care for the patient is transferred to another dentist within the practice or when the patient is being referred to another provider for treatment. In many cases, the practice owner could be held vicariously liable for the negligence of their employees. In another case reported to the TDIC Risk Management Advice Line, a patient arrived at the dental office for a tooth extraction that had previously been diagnosed by the practice owner. The extraction was performed by an associate dentist who was not involved in the initial consultation with the practice owner. The patient returned to the dental office a few days later for fillings on a different quadrant with a different associate dentist. After reviewing the patient’s treatment plan, the dentist noticed that the subsequent associate had extracted the wrong tooth. The dentist informed the patient and recommended a consultation

with the practice owner. After learning about the issue, the practice owner reassured the patient that he would do whatever it took to fix the problem. A short time later, the dental office received an intent to commence litigation notice from the patient’s attorney. In this case, the treating dentist was not insured with TDIC and the outcome of the case is not available; however, this case underscores how easily a wrong site procedure can occur without the implementation of a timeout and how quickly these incidents can escalate. Had the associate dentist verified the details of the procedure prior to beginning treatment, this incident could have been easily avoided. Even though the practice owner is not the one who performed the procedure, they could be held liable. Employers are considered responsible for their employees’ actions while they are on the job and are considered to be able to prevent and/or limit any negligence by the employees. It is in the practice owner’s best interest to exercise reasonable care to prevent negligent behavior. A timeout policy promotes a patient-centered safety environment of team members who are all empowered to work on behalf of the patient. By implementing a timeout policy in the dental office, the practice owner is opening the lines of communication between all members of the team and creating a safe space for team members to feel comfortable enough to speak up before, during or after a procedure. n The Dentists Insurance Company’s Risk Management Advice Line is a benefit available at no cost to CDA members, as well as to policyholders protected by TDIC. To schedule a consultation, visit tdicinsurance.com/RMconsult or call 800.733.0633.

Regulatory Compliance

C D A J O U R N A L , V O L 4 9 , Nº 7

Expanding Patient Access to Their Health Information CDA Practice Support

n a year and a half, the U.S. Department of Health and Human Services (HHS) Office for Civil Rights reached settlement agreements with 18 covered entities that were investigated for failing to provide patients with access to their records in accordance with HIPAA. Seven of those settlements were with physician practices, and the settlement fees paid by those practices ranged from $3,500 to $36,000. Settlements were reached between September 2019 and March 2021.1 This news should not be surprising. Since the HHS began taking privacy complaints in 2003, patient access to their records has been one of the top five public complaints investigated by the HHS.2 Dental practices should review their policy and practices for providing patients with access to their records to ensure they comply with both HIPAA and state law. Practices also should be aware of two new initiatives by the federal government to further expand the ability of patients to access their health information. One is the information blocking rule that is part of the 21st Century Cures Act and the second is proposed amendments to the HIPAA privacy rule.

Current Access Rules

A patient’s right to access their health record is governed by federal HIPAA law and state law. There are a few differences in the two laws; and where the two conflict, the prevailing provision is the one that provides the greatest benefit to the public. State law does not address electronic versions of the patient record and only allows 15 days to provide a patient with a copy of their record instead of the 30 days permitted by HIPAA. HIPAA requires that patients be provided with the option of receiving electronic copies of their

records if that is readily achievable and sets limits on what covered entities may charge a patient for access. HIPAA-covered entities are required to have written policies and procedures, which some of the investigated entities did not have. A patient may not be denied access to their record due to an unpaid bill or be required to present at the office to make the access request or receive the copy. If a covered entity charges for providing a copy of records, they may not charge more than what it costs to produce a copy and must provide a cost estimate to the patient in advance. A CDA Practice Support resource, “Patient Request for Access to Records (Records Release) Form and Q&As,” details the rules for providing a patient with access to their records. A dental practice that wants to help a new patient obtain their records from their previous dentist may suggest the patient use “Patient Records,” an oral health fact sheet available on cda.org, when communicating with the previous dental practice.

Information Blocking Rule

The 21st Century Cures Act was enacted in 2017 with the goal of supporting seamless secure access, exchange and use of electronic health information. Part of that goal is to make the patient in charge of their own health information and doing so means removing barriers to obtaining their information. Envision accessing your own health information and that of your family through a single application that pulls the information from health care providers. The information blocking rule of the 21st Century Cures Act, which became effective April 5, 2021, defines information blocking, prohibits it and establishes exceptions to the definition. It focuses

on electronic health information. The rule applies to all health care providers whether or not they use certified health information technology or are subject to HIPAA. The rule also applies to health information technology developers and health information networks or information exchanges. Penalties will be assessed on “actors” — those subject to the rule — who engage in practices that interfere with the access, exchange and use of electronic health information. A health care payer organization is not excluded as an actor and will be subject to the rule if it undertakes activities that fall under the rule’s definition of “health care provider,” “health IT developer of certified health IT” or “health information network or health information exchange.” Health care payer organizations are subject to the interoperability rules promulgated by the Centers for Medicare and Medicaid Services. As of April 5, an actor must respond to a request to access, exchange or use electronic health information. The applicable electronic health information is limited for 18 months to specified data elements in the United States Core Data for Interoperability. The limit on applicable electronic health information will end Oct. 6, 2022. The Office of the National Coordinator (ONC) for Health Information Technology considers the 18 months as a time for actors to become educated on the rule. The ONC will conduct outreach. Webinars, fact sheets, blogs and FAQs are available on the ONC website. An enforcement rule with civil monetary penalties is expected to become effective sometime after Oct. 6. The rule does not require actors to have or use ONC-certified health IT or to proactively make electronic health JULY 2 0 2 1

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information available through use of patient portals or application programming interfaces (APIs). The rule is expected to work with HIPAA and interoperability rules. Eight exceptions are permitted for an actor who cannot fulfill a request for electronic health information. The rule sets an expectation that an actor will not charge patients who access their electronic health information with an API. The ONC has an online portal to take information blocking complaints.

Proposed Amendments to HIPAA Privacy Rule

The HHS has proposed amendments to the privacy rule to overcome what it views as impediments to care coordination and to value-based health care. Simply put, the changes will remove some obstacles to the flow of patient information necessary to provide care to a patient, and patients should have improved access to their information. Some of the proposed changes include:

Permitting patients to use their own devices to view and capture their information. ■ Allowing record inspection at time of appointment. ■ Requiring covered entities who charge for copies of records to place a fee schedule on their websites. ■ Permitting the use of APIs but not requiring a covered entity to have an electronic health record system with specific API capabilities. The HHS currently is reviewing the comments it received during the comment period that ended May 6. Although there is no timeline for publishing the amendments, the HHS has set the compliance date to be approximately six months after the amendments are published and have become effective. When the amendments are published, covered entities can expect to be required to update their notice of privacy practices. CDA will provide members with information on the new requirements and compliance guidance after amendments are published. n ■

RE F E RE N C E S 1. U.S. Health and Human Services. Resolution Agreements, www.hhs.gov/hipaa/for-professionals/complianceenforcement/agreements/index.html. Accessed April 7, 2021. 2. U.S. Health and Human Services. Enforcement Highlights, www.hhs.gov/hipaa/for-professionals/complianceenforcement/data/enforcement-highlights/index.html. Accessed April 7, 2021.

Regulatory Compliance appears monthly and features resources about laws that impact dental practices. Visit cda.org/ practicesupport for more than 600 practice support resources, including practice management, employment practices, dental benefit plans and regulatory compliance.

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Tech Trends

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

Cloud-Based Virtual Tour Software (Free and up to $15 per user per month, Lapentor)

Creating images for virtual tours is remarkably achievable now. With a tripod and a mobile phone, most people can take rudimentary 360-degree pictures and share them with others. Though achievable, sharing 360 pictures in this way removes the interactive element of virtual tours, which is a primary selling point. Many products have sprung up to organize, customize and host virtual tours, and Lapentor is among the few free, cloud-based, all-in-one solutions on the market today. Based in Vietnam, Lapentor states on its website that it is a virtual tour “publishing service for all” with an emphasis on simplicity. Lapentor relies exclusively on a web interface, which means that users do not need to download or install any applications. In testing, Lapentor seemed to respond well to Chrome but had bugs — blank screens, missing customized elements — when Safari or Firefox were used in both content creation and viewing. The workflow is elegant in that it asks users to upload images, add interactive “hotspot” points and other customizations then deploy as a simple link or as an iFrame. The customization interface is written plainly and the objects are all drag-and-drop. It has three tiers of service: free, cloud-hosted and self-hosted. Each virtual tour is called a “project,” and the free tier limits users to sharing three projects at a time while the cloud-hosted tier allows for unlimited projects. The self-hosted tier allows more advanced users to make use of Lapentor’s webtools then download the entire project so they can deploy on their own servers. At $10 per project, those who are adept with virtual tours may find this price on the expensive side compared to competitors. For the private practitioner looking to start incorporating virtual tours into their online presence, Lapentor is an easy-to-use and affordable solution. For those already using this technology, Lapentor’s bugs in some browsers should be taken into consideration before moving platforms. — Alexander Lee, DMD

AirTag (Starting at $29, Apple) AirTag is a great way to keep track of everyday items for those with an iPhone or iPad. The AirTag is a small, disc-shaped device that is slightly larger than a quarter in diameter and operates using Bluetooth to connect to any mobile device with iOS or iPadOS 14.5 or later. Accessories sold separately can be purchased to attach the AirTag to an item that needs tracking. It is powered through an installed user replaceable CR2032 coin battery, which lasts up to a year. Setup is extremely easy — users simply remove the packaging, which activates the battery, and place the AirTag near their iPhone or iPad. The AirTag is recognized immediately, and users are prompted to name and add it to their Apple ID account. Through the Items tab in the Find My app, users can see their AirTag location on a map. For AirTags that are not in proximity, the Find My network utilizes other Apple devices from around the world to anonymously track their location. Users can choose Play Sound in the app for AirTags in range to find their location through an audible sound. For users with iPhone 11 or newer, users can activate Precision Finding in the app, which provides distance and direction to the missing AirTag in range using Ultra Wideband technology. Users can also place an AirTag in Lost Mode, which provides notifications whenever the item is found in the Find My network and allows for a custom message to be displayed when someone taps it on their NFC-enabled smartphone. Apple states that privacy measures have been built in to the Find My network. Devices that report AirTag locations are anonymous and encrypted. Any AirTag separated from its owner and following another iPhone for an unspecified period will trigger an alert and play a sound. Users can then locate the unknown AirTag and disable it following instructions displayed on their smartphone. AirTag location updates using the Find My network could take minutes or longer depending on its proximity to other iPhone or iPad devices. AirTag is water resistant and up to 16 can be linked to an Apple ID account. — Hubert Chan, DDS

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W O R T H T H E WA I T ®

Your convention, your way. CDA Presents The Art and Science of Dentistry is back. Your profession’s favorite convention is coming to San Francisco this fall — and right to you as a live, virtual event. Get ready to reconnect with your dental community and rediscover hands-on learning. Sharpen skills at new workshops, earn C.E. while being inspired by leading speakers and check out a full hall of innovative exhibitors. Plus, plan time for all the after-hours fun. Choose the in-person or virtual experience that works for you. Or both! Discover practice-changing education to fuel your entire dental team at cda.org/cdapresents.

San Francisco, California September 9–11, 2021 #cdaPresents 470 JULY

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Anaheim, California May 12–14, 2022 #cdaPresents

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CDA Journal - July 2021: Dentistry Takes a Shot at COVID-19

Articles inside

Tech Trends: A look into the latest dental and general technology on the market

Regulatory Compliance: Expanding Patient Access to Their Health Information

RM Matters: Improving Patient Safety With a Timeout Policy

Temporomandibular Joint 'Mice:' Report of Two Cases

Local Geographic Variation of Periodontitis and Self-Reported Type 2 Diabetes Mellitus

Functional and Aesthetic Rehabilitation With Porcelain Veneers and Attachment-Retained RPD: 40 Months of Follow-Up

Introduction: Dentistry Takes a Shot at COVID-19

Editorial: Critical Thinking Is Not a Spectator Sport