CDA Journal - August 2022: Embracing Precision and Data Science in Dentistry

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August 2022

C D A J O U R N A L , V O L 5 0 , Nº 8

d e pa r t m e n t s

435 Associate Editor/The Great Resignation 437 Impressions 481 RM Matters/When Patients Are Angry: De-escalation and Risk Mitigation Are Vital Tools

485 Regulatory Compliance/Avoid Problematic Social Media, Marketing Activities

489 Tech Trends

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f e at u r e s C.E. Credit

441 Embracing Precision and Data Science in Dentistry This article discusses some of the ongoing and projected developments in health information technology, clinical diagnosis frameworks, biomedicine and biotechnology and highlights their current and future applications in precision dentistry.

Nam Nguyen, BS; Andrew H. Jheon, PhD, DDS; and Michael S. Reddy, DMD

453 How Do We Protect a Child’s Psychological Health During Procedures That Use Protective Stabilization?

This article covers three practice recommendations proposed to improve pain outcomes and protect the psychological health of children during potentially painful procedures, especially those involving the use of protective stabilization. Drs. Casamassimo, Meyer and Townsend offer additional perspectives on protective stabilization in their article “Pain, Psyche and Protective Stabilization.”

Dennis Paul Nutter, DDS

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Pain, Psyche and Protective Stabilization This paper submitted as a companion piece to the article “How Do We Protect a Child’s Psychological Health During Procedures That Use Protective Stabilization?” reviews the role of medical immobilization (MI) and protective stabilization (PS), offers qualifiers before their use, builds on some of the concepts in Dr. Nutter’s article, suggests an algorithm for application of PS in today’s pediatric dentistry environment and offers illustrations of PS and MI use and better-advised alternatives.

Paul S. Casamassimo, DDS, MS; Beau Meyer, DDS, MPH; and Janice A. Townsend, DDS, MS

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Missed Dental Care Appointments in an Urban Safety Net Hospital This pilot study assesses the factors associated with missing dental care appointments among pediatric patients visiting a hospital-based dental clinic.

Katheryn Goldman, DMD, MPH, ABD; Muath A. Aldosari, BDS, MPH, DMSc; and Keri Discepolo, DDS, MPH

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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 Ariane R. Terlet, DDS President president@cda.org John L. Blake, DDS President-Elect presidentelect@cda.org

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Editorial Kerry K. Carney, DDS, CDE Editor-in-Chief Kerry.Carney@cda.org Ruchi K. Sahota, DDS, CDE Associate Editor Marisa Kawata Watanabe, DDS, MS Associate Editor

Max Martinez, DDS Secretary secretary@cda.org

Gayle Mathe, RDH Senior Editor

Debra S. Finney, MS, DDS Speaker of the House speaker@cda.org Judee Tippett-Whyte, DDS Immediate Past President pastpresident@cda.org

A S S O C I AT I O N

Management

Carliza Marcos, DDS Vice President vicepresident@cda.org

Steven J. Kend, DDS Treasurer treasurer@cda.org

D E N TA L

Volume 50 Number 8 August 2022

September/Dental Radiology October/Diversity in Dentistry November/Dental Student Research

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

Permission and Reprints

Journal of the California Dental Association Editorial Board

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

Manuscript Submissions www.editorialmanager. com/jcaldentassoc

Letters to the Editor www.editorialmanager. com/jcaldentassoc

Andrea LaMattina, CDE Publications Manager Kristi Parker Johnson Communications Manager Blake Ellington Tech Trends Editor Jack F. Conley, DDS Editor Emeritus Robert E. Horseman, DDS Humorist 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.

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.

Copyright 2022 by the California Dental Association. All rights reserved.

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 , interim vice president research & biotechnology, 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 Avishai Sadan, DMD, dean, Herman Ostrow School of Dentistry of USC, Los Angeles 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

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

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

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

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Assoc. Editor

C D A J O U R N A L , V O L 5 0 , Nº 8

The Great Resignation Ruchi K. Sahota, DDS, CDE

I

n one of Aesop’s fables, a mighty oak tree stood tall in the middle of a forest.

Next to it was a brook. Daily, the oak tree would admire its reflection in the water and beam with satisfaction.

Around the periphery of the water were tiny reeds. They would bend and move as the wind blew, while the mighty oak stood tall and strong. The mighty oak was proud that it did not need to bend. It did not succumb to the wind. The mighty oak would direct the reeds to do the same. The reeds would politely decline.

The mighty oak would still scoff at this and tell them to be “strong” like it. This went on for years. One day, the reeds grew tired and piped back. They warned the mighty oak that its ego would get the best of it one day. Soon thereafter, a strong windstorm blew through the forest. The oak tried and tried to fight through the gusts but was ultimately toppled and landed next to the reeds. The reeds survived, proving that flexibility and a willingness to find a solution would help endure the toughest storm.

The pandemic proved to be quite the storm for our dental offices. Many realized that they could shut down for six weeks and still have a very productive year. Many survived because of government funded grants. Some dentists retired. And others grappled with the added pressures the pandemic presented to our profession. Some became nimble. Some fell.

During the early shutdowns, many offices laid off personnel. Offices reopened.

They rehired employees. Many months later, offices revved up their schedules to match pre-pandemic times. The storm was starting to weaken, but many of the roots of the offices had been shaken. If trees did not fall, many of their branches did. Staff

CDA will continue to identify the potential moments for us to bend and bow and help our practices endure as we deliver excellent oral health care to our patients.

members began to resign.

A high number of resignations did not plague only dentistry. In fact, our nation hit a 20-year high in the “quit” number last November when 4.5 million workers left their jobs. Schools are seeing teacher shortages. Hospitals are enduring nursing shortages. Help-wanted signs are browning as they weather the storms of the many months since they were posted.

The Great Resignation is upon us. After the stock market crash of 1929, our country endured the Great Depression. After the subprime mortgage crisis in 2006, our country suffered through the Great Recession. Small businesses are now braving through an incredible shift in the labor market labeled the Great Resignation.

Data elucidates that the labor issues had started to spark even before the pandemic.

But the fireworks went off more recently in our dental offices. Not only are hiring and recruitment more difficult, but retention is also challenging. CNN Business notes that employers are increasing wages but still struggling to find staff.

Historically, local dental society executive directors have helped with staff shortage issues. For many years, they teamed up with local dental assisting and hygiene schools. The dental societies housed graduates’ resumes. They were the hub of connection — creating a network of internships in member-dentists’ offices for

the schools. However, just before the pandemic, a heavy storm hit. Budget cuts shut down many of the local dental assisting and hygiene schools or decreased their enrollment.

Early in the pandemic, CDA identified helping fill staff shortages as a priority. For many years, local component executive directors had proven to be like the reeds of the forest. They had nimbly and patiently aided in connecting dental assisting schools with member-dentists. In 2021, the component executive directors connected pathway programs like the Jewish Vocational Services (JVS) and CDA. The Smile Crew of CA bootcamps, in partnership with JVS and local workforce boards, has been rolled out in locations in Northern and Southern California regions.

The online self-led didactic program, in-person training and local internships are a conduit for new dental assistants to go directly into CDA members’ offices. The Smile Crew CA campaign was marketed to specific service workers who had resigned from other industries. An expanded online career center was launched to connect CDA member-dentists to job-seeking auxiliary staff.

How else can we be nimble and bend like the reeds in the forest? CDA’s practice management analysts have pointed out a few key strategies to add glitter to a help-wanted notice: Consider a hiring AUGUST 2 0 2 2

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bonus, extra vacation days or even paying for C.E. and licensure fees. A recent CDA online article notes, “The Society for Human Resource Management estimates that employers spend an average of $4,425 per job in hiring costs.” Perhaps many of us can attest that we have spent an aboveaverage amount of time stressing about hiring and training new employees. The stress is often much more costly than dollars spent.

A trophic cascade occurs when a series of indirect interactions ultimately impact an entire ecosystem. For example, in the mid-90s, there was only one beaver colony in the Yellowstone ecosystem. After the grey wolf was introduced, nine beaver colonies emerged. How? When the wolves disappeared in the 1930s, the elk had a chance to breathe. One of their major predators was gone. The elk multiplied.

And because of their newfound freedom, the elk grew lazy and loitered around willow plants. The beaver depends on the willow plants to survive. With less willow to feed upon, the beaver colonies dwindled. Once the wolf was reintroduced, the elk spent less time in one place. Vegetation started to return, The beavers got their willows back and the ecological system of Yellowstone was rebuilt.

What will be the tipping point of the trophic cascade in dentistry? Will former restaurant staff who sought benefits and more predictable schedules fill the employment holes in dentistry? Will former teachers who thrive with human connection find their way to dentistry? A recent Pew Research article noted that over half of adults who quit their job last year switched professions — especially those who were younger and did not have a postgraduate degree. In fact, this mixing is so common that some economists say the Great Resignation may be a misnomer; the Great Reshuffle may be more accurate. The

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millennial and Generation Y populations seek purpose at their workplaces. They desire autonomy. They want to see a path to promotions before starting. Dentistry has a chance to weather this storm. Not only does our profession provide purpose and a sense of service toward the greater good, it also features various channels of certifications that provide various stages of autonomy.

Where will dentistry end up on the other side of the Great Resignation? Will we be able to bow and bend through this latest economic era? Perhaps more of our staff’s day-to-day activities will become automated. A superbly intuitive virtual assistant may be able to navigate phone calls, reimbursement follow-ups and schedule management. A robot may be able to suction, assist and take X-rays, while a drone completes pickup and delivery of sterilization of our instruments.

While we move through the Great Resignation, CDA will continue to identify the potential moments for us to bend and bow and help our practices endure as we deliver excellent oral health care to our patients. n Ruchi K. Sahota, DDS, CDE, practices family dentistry in Fremont, California, and serves on the Southern Alameda County Dental Society Board of Directors. She is a certified dental editor, a consumer advisor for the American Dental Association, past president of the Southern Alameda County Dental Society and a fellow of the American College of Dentists, International College of Dentists and the Pierre Fauchard Academy.

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.

Impressions

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Shapeshifting Microrobots Can Brush, Floss Teeth

Scanning electron microscope image (pseudocolored) showing intact C. albican (in cyan) and S. mutans (in green) cells entrenched by the superstructure (in gray).

(Credit: ACS Nano 2022.)

A shapeshifting robotic microswarm developed by a multidisciplinary team at the University of Pennsylvania is poised to offer a new and automated way to perform the critical daily tasks of brushing and flossing, which would be particularly valuable for those who struggle with manual dexterity.

The building blocks of these microrobots are iron oxide nanoparticles that have both catalytic and magnetic activity. Using a magnetic field, researchers could direct their motion and configuration to form either bristle-like structures that sweep away dental plaque from the broad surfaces of teeth or elongated strings that can slip between teeth like a length of floss. In both instances, a catalytic reaction drives the nanoparticles to produce antimicrobials that kill harmful oral bacteria on-site.

In developing the microrobots, the Penn researchers constructed a platform to electromagnetically control them, enabling the microrobots to adopt different configurations and release antimicrobials on-site to effectively treat and clean teeth. The microrobots adapt to different surfaces, including both straight and misaligned teeth, and can adjust to all the nooks and crannies in the oral cavity.

The researchers optimized the motions of the microrobots on a small slab of tooth-like material. Next, they tested the microrobots’ performance adjusting to the complex topography of the tooth surface, interdental surfaces and the gumline using 3D-printed tooth models based on scans of human teeth from the dental clinic. Finally, they trialed the microrobots on real human teeth that were mounted in such a way as to mimic the position of teeth in the oral cavity.

On these various surfaces, the researchers found that the microrobotics system could effectively eliminate biofilms, clearing them of all detectable pathogens. The iron oxide nanoparticles have been FDA approved for other uses, and tests of the bristle formations on an animal model showed that they did not harm the gum tissue.

The system is also fully programmable; the team’s roboticists and engineers used variations in the magnetic field to precisely tune the motions of the microrobots as well as control bristle stiffness and length.

The researchers found that the tips of the bristles could be made firm enough to remove biofilms but soft enough to avoid damage to the gums.

The customizable nature of the system could make it gentle enough for clinical use, but also personalized and able to adapt to the unique topographies of a patient’s oral cavity. To advance this technology to the clinic, the Penn team is continuing to optimize the robots’ motions and considering different means of delivering the microrobots through mouth-fitting devices.

The researchers shared their findings establishing a proof-ofconcept for the robotic system in the journal ACS Nano. n

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Oral Lesions After COVID Vaccine May Be Tied To Immune Response

New Fluoridation Tablet System Deployed in U.S. The water utility board of Marathon City, Wisconsin, was on the cusp of terminating the community’s water fluoridation program due to cost issues earlier this year. But in the end, the board decided to sign off on a tablet feeder system that advocates are calling the first advancement in water fluoridation technology in decades, as reported by the American Dental Association (ADA).

“This is a solution at a much lower cost,” said Andrew R. Kurtz, Marathon City administrator, after the decision. “It’s geared for a small community.”

The sodium fluorosilicate tablet system, developed by Florida-based KC Industries and contracted by the Centers for Disease Control and Prevention, received NSF Standard 61 approval in late 2020.

NSF Standard 61 is a set of national standards that relates to water treatment and was developed by the National Sanitation Foundation.

The new tablet system is a more cost-effective way to distribute fluoride into drinking water and offers an opportunity to distribute fluoride to smaller communities that did not have the previous infrastructure to do so. The feeder system works through 438

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A study by researchers at the Mazandaran University of Medical Sciences in Iran found orofacial adverse reactions are reported increasingly after COVID-19 vaccination, including facial paralysis, oral mucosa ulcers, posterior palatal swelling and pain, pain on lips, gingiva, tongue or palatal area of the central incisor, and may be tied to the triggered immune response of the body after receiving the vaccine. The study was published in the journal Infectious Medicine.

For the study, researchers performed a narrative literature review by searching electronic databases including PubMed, Scopus and Web of Science to investigate the oral lesions after COVID-19 vaccination. The inclusion criteria were original studies, including the case reports, case series, letters to the editor and cross-sectional studies. The exclusion criteria included the studies that examined the oral lesions caused by COVID-19 infection.

The results of this review showed that some vaccines had side effects with oral involvement such as pemphigus vulgaris, bullous pemphigoid, herpes zoster, lichen planus, Stevens-Johnson syndrome and Behçet’s disease. Researchers found that the vaccines developed for COVID-19 serve as T‐cell‐mediated immunity triggers, and T-cell activation following inflammatory cytokines secretion can cause possible adverse effects. Extensive vaccination of individuals and increasing the number of doses administered could be another justification for the high incidence rate of oral adverse reactions, according to the study.

“Future research needs to elucidate the physiopathy of oral manifestations after the COVID-19 vaccination and better understand the risk factors associated with such responses,” the study’s authors concluded.

The authors urge physicians and dentists to be aware of oral lesions as a potential complication of COVID-19 infection or vaccination.

the erosion of sodium fluorosilicate tablets in the patented New Wave Fluoridation Feeder, much like how chlorine is distributed into swimming pools. Currently, most water systems use a water-based fluoride solution or a dry salt additive that must be dissolved into a solution before being added to the water.

The approval and deployment of the new feeder system will soon be complete and can be utilized across the country.

California State Dental Director

Jayanth Kumar, DDS, a member of the National Fluoridation Advisory Committee, said he was pleased to see the approval and deployment of the new system throughout the nation.

“This system will expand the benefits of community water fluoridation to many more communities that before were unable to offer community water fluoridation to its residents,” Dr. Kumar said. “Community water fluoridation is one of the best population-based interventions.”

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Study: Diabetes May Weaken Teeth A new study from Rutgers University found that reduced strength and durability of enamel and dentin may be why people with both Type 1 and Type 2 diabetes are prone to tooth decay. The study was published in the Archives of Oral Biology.

Researchers induced Type 1 diabetes in 35 mice and used a Vickers microhardness tester to compare their teeth with those of

35 healthy controls over 28 weeks.

Although the two groups started with comparable teeth, enamel grew significantly softer in the diabetic mice after 12 weeks, and the gap continued to widen throughout the study. Significant differences in dentin microhardness arose by week 28.

“We’ve long seen elevated rates of cavity formation and tooth loss in patients with

Influence of Free-Sugar Intake on Dental Caries A study investigating the relationship between free-sugar intake in early childhood and dental caries found that between ages 18 months and 4 years, freesugar consumption increased markedly in two-thirds of the children studied, increasing the risk of dental caries at ages 4-6 years.

Free sugar is any sugar added to a food or drink or the sugar that is already in honey, syrup and fruit juice. These are free because they’re not inside the cells of the food we consume.

For the study, free-sugar consumption was measured in children enrolled in the Barwon Infant Study at ages 18 months and 4 years. The exposure, free-sugar intake, was quantified as continuous and binary variables indicating less than 5% of total energy intake (TEI) at ages 18 months and 4 years. The prevalence of dental caries was obtained from dental records, and multiple logistic regression estimated the effect of the exposure variables on the presence of dental caries at ages 4 to 6 years, adjusting for potential confounders.

Of the original birth cohort, dietary data and dental caries data were available.

Of the participants studied, 70.4% and 36.7% consumed less than 5% TEI from free sugars at ages 18 months and 4 years, respectively. Dental caries affected 46.7% of children. In fully adjusted models, free sugar at age 18 months increased dental caries risk at ages 4-6 years.

The study was presented by Australian researchers at the recent 100th General Session and Exhibition of the IADR, held in conjunction with the 5th Meeting of the IADR Asia Pacific Region.

diabetes, and we’ve long known that treatments such as fillings do not last as long in such patients, but we did not know exactly why,” said Mohammad Ali Saghiri, PhD, an assistant professor of restorative dentistry at the Rutgers School of Dental Medicine.

The study advances a multiyear effort by Dr. Saghiri and other researchers to understand how diabetes affects dental health and to develop treatments that counter its negative impact.

Previous studies have established that people with both types of diabetes have significantly elevated rates of most oral health issues, both in the teeth and the soft tissues that surround them.

Researchers also have demonstrated that diabetes can interfere with the ongoing process of adding minerals to teeth as they wear away from normal usage.

“This is a particular focus of mine because the population of people with diabetes continues to grow rapidly,” Dr. Saghiri said. “There is a great need for treatments that will allow patients to keep their teeth healthy, but it has not been a major area for research.”

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precision medicine C D A J O U R N A L , V O L 5 0 , Nº 8

C.E. Credit

Embracing Precision and Data Science in Dentistry Nam Nguyen, BS; Andrew H. Jheon, PhD, DDS; and Michael S. Reddy, DMD

abstract The National Institutes of Health (NIH) defines precision medicine (previously referred to as personalized medicine) as “an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment and lifestyle.” Advances in precision medicine presage similar progress in dentistry and will be increasingly harnessed to improve dental care. This article discusses some of the ongoing and projected developments in health information technology, clinical diagnosis frameworks, biomedicine and biotechnology and highlights their current and future applications in precision dentistry. Innovations in artificial intelligence, machine learning, high-throughput sequencing and other molecular techniques (e.g., genomics, metabolomics, pharmacogenomics and transcriptomics) may be fully incorporated into the clinic within the next few decades. Nevertheless, it is imperative to understand that while technology usage can enhance the rate at which clinical success can be achieved, it does not equate to or guarantee clinical success. As dentistry transitions toward a data-augmented model that customizes treatment options, including preventive care, precision dentistry will continue to benefit from advances in many fields to improve health care delivery and clinical outcomes.

Keywords: Precision dentistry, periodontics, orthodontics, oral cancers, big data

AUTHORS Nam Nguyen, BS, is a third-year predoctoral student at the University of California, San Francisco, School of Dentistry. He is a past John C. Greene Society research fellow at the UCSF Biomaterials and Bioengineering Correlative Microscopy Core and currently conducting active research for the UCSF Program in Craniofacial Biology.

Conflict of Interest Disclosure: None reported.

Andrew H. Jheon, PhD, DDS, is an orthodontist and assistant professor in the University of California, San Francisco, School of Dentistry program of orthodontics and orofacial sciences. As a clinician-scientist, he is always looking to translate knowledge from the laboratory into the clinic.

Conflict of Interest Disclosure: None reported.

Michael S. Reddy, DMD, is an educator, clinician and researcher currently serving as dean and professor at the University of California, San Francisco, School of Dentistry.

Conflict of Interest Disclosure: None reported.

I

n the 2021 executive summary “Oral Health in America: Advances and Challenges,” the National Institutes of Health (NIH) states that “although microbial infections continue to be the primary cause of the most prevalent oral diseases, profound disparities in the experience of these diseases persist and can be explained only in terms of a complex interplay among risk factors and social determinants.” Precision dentistry (also referred to as augmented or individualized dentistry) is an emerging AUGUST 2 0 2 2

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revolutionary model of treatment that proposes to customize oral health care based on the individual’s unique genetic, environmental and behavioral profiles.1 The precision dentistry model goes beyond traditional patient care with similar clinical exams or phenotypes by attempting to understand the patient as a whole. Thus, a successful clinical outcome applying precision dentistry results from a combination of the patient’s treatment delivery, genetics, social and physical environment and behavior/ compliance. Given the advances in health information technology, computational power and versatility, innovative highthroughput sequencing and “omic” analyses (i.e., genomics, metabolomics, pharmacogenomics and transcriptomics) and an improved understanding of periodontal and craniofacial bone biology beyond phenotypic representation, precision dentistry is fast becoming a reality. This article discusses some of the ongoing and projected developments in health information technology, clinical diagnosis frameworks, biomedicine and biotechnology as well as highlighting the current and future applications in precision dentistry.

Data-Derived Dentistry

Dental appointments are primarily viewed as wellness checks, and recurring, nonemergency visits help establish and collect background information on the patient’s oral and overall health.1 Dentistry is a dynamic network for data (FIGURE 1 ).

Optimal treatments based on the patient’s medical history, genetics, environment and lifestyle can then be generated.

Clinical head, neck and oral diagnostic exams open a window into the patient’s systemic health information based on signs of “pre-diseases” and ongoing oral health issues.1 Chairside oral and systemic health tests (e.g., SARS CoV-2 diagnostic 442

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test, subgingival microbiome analysis) use saliva and oral fluids such as gingival crevicular fluid to establish dynamic biomarker profiles, which may enable early detection of disease and further provide decision-making information to improve upon current diagnostic, prognostic and management of care.2 Other sources of data include eHealth records, surveys, lab tests, social media and even datagenerating devices, such as wearables or sensors.3 When dentists collect and factor health data into their clinical care decisions, clinical success rates will

Comprehensive and continuous monitoring of a patient’s health involving different medical and dental disciplines enhances the clinical success of a planned treatment procedure. increase because a comprehensive realtime assessment of the patient’s dynamic health profile can be readily performed.

Thus, shared health care data will aid in delivering optimal, individualized care.

The evolution of economic, demographic and epidemiologic facets and advances in technology in the past century have shifted the population toward preventive measures and personalized care.3 As population health transforms into precision health and dentistry, availability and access to records among all health care providers for one patient become increasingly necessary for optimal treatment decisions. Comprehensive and continuous monitoring of a patient’s health involving different medical and dental disciplines enhances the clinical success of a planned treatment procedure.4

However, while the concept of precision dentistry holds incredible potential, there is an educational divide that makes its application difficult for most practicing dentists. Many dentists are not formally trained in “omics” analysis or the practice of caries management by risk assessment (CAMBRA) that factor social health determinants into clinical care decisions.5,6 As dental care transitions from a surgical, population-based model toward a medical, personalized model that customizes treatment options and enhances the opportunity for preventive care, it is imperative that teaching institutions consider further or additional training in some areas as well as switching to a centralized health care management platform where providers from different major health care systems can readily access the same health information data (e.g., Epic, Epic Systems Corporation).

Implementing a comprehensive, dynamic network of data will facilitate the exchange of data between providers for improved patient care and leverage datadriven research into links between dental and systemic health.3

Examples of Precision Dentistry in Clinical Success

Precision dentistry is not a new concept. Some current examples of precision dentistry in periodontics, orthodontics and oral medicine/oncology are discussed.

Periodontics

Tonetti et al. (2018) proposed a case definition that appropriately defined an individual’s periodontitis based on stage and grade.7 The new framework extended beyond the 1999 classification based on severity to include the disease’s biological characteristics in diagnosis, prognosis and treatment planning.7 The newly proposed framework splits

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Socioeconomic and physical environment

Behavior, attitude, lifestyle

Medical, dental history Caries management by risk assessment (CAMBRA) Protective Factors Favorable

Saliva flow and composition Diet (composition, frequency) ✓ Fluoride use, oral hygiene ✓ Microbial composition ✓ Systemic health ✓ Others (xylitol gum, etc.)

Risk Factors Unfavorable Inadequate saliva flow Abnormal salivary composition ✗ Frequent acidic/sugary diet ✗ Microbial dysbiosis, visible plaque ✗ Predisposing factors (deep pits/ fissures, systemic diseases, medications, etc.)

✓

✗

✓

✗

Genetics, biomarker profiles

HEALTH

DISEASE

Treatment delivery preferences

Ambient data (wearables sensors displaying heart rate, Hb1Ac, exercise, etc.)

FIGURE 1. Sources of health data generated during a dental visit. Modified from the UCSF-developed CAMBRA protocol.6

periodontitis classification into four stages, each of which corresponds to the disease severity and complexity of management (FIGURE 2 ). Similar to how the “staging” concept is used in precision oncology to determine the precise condition of a malignant tumor, periodontal staging will transform how oral health clinicians communicate the current extent of periodontitis and more accurately define the state and progression of the disease at different points in time. Staging not only applied the traditional method of classification based on severity and extent of past periodontal destruction and tissue damage, but it also factors in the multidimensional complexity of shortterm suppression of symptoms, long-term management and permanent impacts on functional and aesthetic aspects of the patient’s dentition.7 Periodontitis staging, therefore, enables individualized patient care and represents a crucial step toward precision care in dentistry.

Within each periodontitis staging, each individual’s level of severity and complexity of management may progress at different rates, have different risk factors for progression and may or may not affect the patient’s systemic health.7,8 Thus, the 2018 periodontal framework proposed that each “stage” of periodontitis be further classified into “grades” that contain information about the inherent biological nature of the disease. Within each stage, the seriousness and complexity of the disease are greater as the grade increases. Grading a stage of periodontitis helps oral health clinicians estimate the risk of progression and impact on systemic health and guide the appropriate therapeutic approach.

Grading also lays the foundation for implementing biomarkers and soft tissue imaging technologies, in conjunction with periodontal probing, to improve early detection of stage I periodontitis, guide selection of stage- and grade-specific

drug therapies and ultimately improve the patient’s oral health-related quality of life.9 Overall, the framework of staging and grading of periodontitis represented one of the critical implementations of precision dentistry in periodontics. This framework goes beyond the traditional classification of disease based on the severity of periodontal damage by also including the risk and prognosis of future complications. By enabling practitioners to use more signs, symptoms and other associated factors when placing a patient in a diagnostic category, the framework promoted more personalized care for patients and may result in a more favorable clinical outcome. In the context of dentistry as a dynamic network of data, a matrix of periodontitis stage and periodontitis grade will assist oral health clinicians in communicating better with other health professionals and third parties’ eHealth platforms that have had much success with the conceptual use of staging and grading in cancer diagnosis, prognosis and management.3,10

Orthodontics

Jheon et al. (2017) presented emerging advances in digital technology and biomedicine in the promise of customized orthodontic treatment (FIGURE 3 ).1 Briefly, innovations in digital hardware and software, as well as 3D imaging and printing, are currently being applied to fabricate aligners, retainers and customized orthodontic brackets. As well, smart devices (e.g., to remotely document patient’s retainer wear) are gaining some traction, although it is unclear whether the benefits offset the effort and cost.

Furthermore, the oral microbiome differs dramatically between individuals and even within each individual’s tooth before and during orthodontic treatment.1 Biomedical research is advancing the understanding of cartilage growth and bone biology, which will be utilized to modify mandibular growth and modulate tooth movement in animal models.

This is an exciting time in the field of orthodontics.

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Factors influencing staging classifications

Factors influencing grading classification

Degree of severity Degree of complexity Extent and distribution

Evidence or risk of rapid progression Other modifiers (smoking, diabetes)

Stage I

Stage II

Initial periodontitis

Moderate periodontitis

Stage III Severe periodontitis with potential additional tooth loss

Stage IV Advanced periodontitis with extensive tooth loss and potential for loss of dentition

Grade A: Slow progression Grade B: Moderate progression

Individual stage and grade assignment

Grade C: Rapid progression

FIGURE 2 . A brief overview of periodontitis classification based on staging and grading. Modified from the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.7

Oral Cancers

In 2020, 377,713 new oral cancer cases were diagnosed globally, with 177,757 deaths and a five-year mortality rate of 39% to 65%, making oral cancer the sixth most common cancer.11 Between 80% and 90% of all oral cancers were squamous cell carcinomas that appeared most frequently around the tongue, followed by the floor of the mouth, buccal mucosa, alveolar mucosa and hard palate. And 10% to 20% of oral cancers were human papilloma virus (HPV)associated carcinomas that manifested on the tonsil and the oropharynx. In the U.S., oropharyngeal cancer has now surpassed cervical cancer as the most common site of HPV-induced cancer.11,12 Despite being a significant risk factor, HPV-16 infection alone does not warrant the development of oropharyngeal and tonsil cancer in all individuals.13 Conversely, despite the success of 444

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campaigns for tobacco cessation, a known significant risk factor in the development of oral squamous cell carcinomas, there remains a significant trend of increased tongue and oropharyngeal cancers with unknown or unclear causes.13,14 Zhu et al. (2018) performed meta-analysis and confirmed that patients with clinically similar head and neck tumors have different responses to treatment and different clinical outcomes.15 Thus, oral cancers possess complex growth, regulation and metastatic processes that are dependent on each individual’s unique environmental background and genetic predisposition.16,17 A comprehensive oral and head examination is essential for health care.

Many suspicious lesions are identified through visualization via incisional or excisional biopsy. To date, surgical biopsies are the most common diagnostic methods for oral cancers despite ~20% of these biopsies being unusable due to technical

errors.18 Moreover, tissue damage created by the biopsy may promote inflammation, which alters the microenvironment and may enhance the invasive nature of oral cancers.19 Thus, many noninvasive biopsies are being considered, such as liquid and radiologic imaging.

Liquid biopsies in oral cancers show much promise. Biomarkers in oral cavity fluids such as saliva have been associated with a tumor’s unique characteristics (e.g., tumor dimension, pattern, degree of invasion).20 Salivary biopsy can show the dynamics of specific biomarkers over time, which in turn can be used by clinicians to diagnose, monitor and customize treatment. For example, the Viome saliva test was developed and approved by the Food and Drug Administration to screen for oral squamous cell carcinoma and oropharyngeal cancer. Using machine learning and an RNA signature that incorporates taxonomic and functional oral microbiomes related to oral cancer,

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Initial data acquisition; chief complaint; treatment history; 3D data of skeletal, facial and dental morphology captured.

Molecular analysis Via cheek swab or fluid diagnosis to determine patient’s expected responses to therapy.

Clinicians determine treatment objectives.

Technology Software built from data-mined algorithms provides treatment options, suggests modification (e.g., extraction), biomechanics of tooth movement and treatment sequence.

Personalized care delivery Specific biological or pharmacological agents prepared and provided in appropriate doses in smart delivery system.

Clinicians decide the treatment plan that best optimizes treatment duration without compromising health.

Personalized care delivery Custom smart appliances are generated based on treatment plan, patient’s environmental, behavioral and compliance profile.

Personalized treatment is delivered according to a patient’s unique genetics, social and physical environment, behavior and compliance profiles.

FIGURE 3 . Moving toward precision orthodontics. A modified, proposed vision for the integration of technology and biomedicine toward precision orthodontics.1

this test can spot early signs of stage 1 oral cancer with a sensitivity of over 93% and a specificity of 97.9%.21 Another noninvasive, diagnostic modality called radiomics uses mathematically defined parameters to generate quantitative diagnostic and prognostic biomarkers from clinical images (e.g., computed tomography, positron emission tomography, magnetic resonance imaging).22 When combined with traditional clinical predictors, radiomics can help advance oral cancer diagnosis toward more personalized precision care. In particular, radiomics utilizes recent advancements in computational power, machine learning and artificial intelligence to capture various properties of head and neck squamous cell carcinomas. This information predicts the current and future morphologic, metabolic and spatial aspects of the primary tumor and metastatic lymph nodes, ultimately increasing the chance for favorable

treatment outcomes. To date, only a handful of studies on the application of radiomics in oral cancer have been published, as radiomics is still being evaluated and validated.23

Advancing Treatment of Oral Cancers

Current treatment options for patients with oral cancer mainly consist of initial surgeries followed by radiation and chemotherapy.24 Each of these therapies has several side effects, and even when combined, a significant number of patients still experience disease recurrence and metastasis with mortality in less than 12 months.25 Oral cancer tumors eventually resist available pharmacological regimens.26 To more effectively prevent and treat oral squamous cell carcinoma and oropharyngeal cancers, scientists and clinicians have been investigating novel pharmacogenomic therapy targets, alternative treatment modalities and expanding the role of oral health primary

care clinicians in HPV vaccination and HPV-related oral cancer protection.

Epidermal growth factor receptor (EGFR) is often expressed in oral squamous cell carcinoma and is one of the most popular targets for antitumor pharmacology. However, as discussed previously, many tumors inevitably become resistant to anti-EGFR therapy over time.26 The search for novel targets for pharmacogenomic therapy becomes more crucial than ever. A tumor sequencing effort by The Cancer Genome Atlas (TCGA) program remarkably revealed a few conserved molecular signaling networks among cells affected by oropharyngeal and oral squamous cell carcinomas; one of such is the downstream PI3K/mTOR signaling pathway.27 This discovery provides the rationale for further studies in the clinical effectiveness of PI3K/mTOR inhibitors.

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mTOR activity and shrinks the tumor before physical removal by surgery.28 Another ongoing study investigates the use of metformin, which indirectly blocks mTOR activities and prevents the progression of premalignant lesions to full-blown oral squamous cell carcinoma.29 In addition to finding novel molecular targets, a new alternative treatment modality known as immunotherapies draws on the potential reactivation of the patient’s antitumor immune response. Head and neck squamous cell carcinoma cells, in particular, often avoid immune recognition and antitumor immune response through manipulation of their immunogenicity, production of immunosuppressive mediators (e.g., IL-6, IL-10 and TGF-ß) and promotion of immunomodulatory cell types (e.g., immunosuppressive T-regs and M2 tumorassociated macrophage).30 The recent development of new immunotherapeutic agents, such as pembrolizumab and nivolumab, has demonstrated the capability of inhibiting tumor activity by reactivating the patient’s T-cell antitumor response in 13% to 20% of head and neck cancer patients.31 The full potential of precision care using immunotherapy may become a reality in only a few years, as more and more biomarkers and their associated molecular mechanisms are identified.

Genome Editing

HPV-16 is responsible for more than 80% of HPV-induced new cases of oropharyngeal cancer per year.32 Continuous efforts in investigating the molecular alterations in HPV-induced oropharyngeal cancer revealed that the virus replicates differently in oral keratinocytes compared to the cervical site of infection.33 Specifically, > 70% of HPV-16+ head and neck cancer cells 446

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replicate autonomously as an episomal genome. In contrast, the viral genome often integrates into the host’s genome in HPV-16 positive cervical cancer.33 Specific alternative transcripts, such as the dominant variant E6*I, are responsible for the induction of cellular oxidative stress, uniquely expressed in HPV-related cancer, and not observed in any other types of tumors.33 Such findings pave the way for the development of new pharmacologic and genome editing therapies, which directly target these unique regions and either reduce the viral

Vaccinations are the primary prevention method to protect patients against HPV infection and HPV-induced oral cancers.

load by promoting apoptosis in HPVinfected head and neck cancer cell lines or enhancing the sensitivity of these cells to available pharmacogenomic and immunotherapies. One extensively used genome editing technology is the clustered regularly interspaced short palindromic repeats (CRISPR) and their associated proteins (Cas proteins). Yee et al. used CRISPR/Cas9 technology to discover new signature regions of the Hippo signaling pathway associated with biomarkers of favorable response toward PI3K/mTOR immunotherapy in oral carcinoma cell lines.34 Zeng et al. (2022) used CRISPR/ Cas9 to screen for genomic regions, also in cell lines, that can compensate and enhance the sensitivity of previously tumor-resistant EGFR-targeting

pharmacogenomic therapies.35 Efforts will be made to utilize these data to improve upon current clinical treatment.

HPV Vaccinations by a Dental Professional

Vaccinations are the primary prevention method to protect patients against HPV infection and HPV-induced oral cancers. Bleacher et al. (2016) confirmed that vaccination against HPV is 83% effective among women with no prior HPV exposure, 58% among women with previous HPV exposure and 25% among women with active cervical HPV16/18.36 The Centers for Disease Control and Prevention (CDC) recommends two doses of vaccines between six to 12 months apart before age 15 for maximum preventive effectiveness. For older teens and adults, the CDC guidelines recommend three doses.37 Unfortunately, the overall vaccination rate in U.S. adolescents with the two- or three-dose series remains relatively low at 48.6%.38 Strauss et al. (2012) indicated that of the children and adults who did not visit a primary care practitioner in 2008, approximately 34.7% of these children and 23.1% of adults did visit a dental health provider in the same year.39 For these reasons, dentists should be crucial providers recommending up-to-date HPV vaccination and discussing the risk of HPV-related oral cancers. To support this cause, the American Dental Association (ADA) recently published guidelines suggesting an expanded role for dental professionals in HPV vaccination and HPV-related oral cancer education and counseling.40 We included this discussion on vaccinations because the next “golden age” in vaccinology will be to personalize vaccinations based on the subject’s age, sex, comorbidity, immune system and genetic background rather than a one-size-

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Redefining clinical dentistry success Fluid biopsy and molecular analysis Genomics

Gingiva

Epigenomics

Pathogenic bacteria

Transcriptomics, proteomics, metabolomics

Microbiomics, metagenomics Dysbiosis

Environmental stimuli Infection, nutrition, smoking, oral hygiene

Epidemiology

Extrinsic

FIGURE 4 . Some examples of precision dentistry applications that may optimize treatment duration and/or improve clinical outcomes. Modified from the UCSF workshop “Embracing Precision and Data Science in Dentistry.”

fits-all approach.41

The Mouth Is the Window Into Overall Health42

The oral cavity is the point of entry of nutrients and many toxins and pathogens.43 It is bathed in fluids, such as saliva and gingival crevicular fluid, and houses > 700 bacterial species of bacteria, viruses, fungi and protozoa.44 Collecting and acting on the data available in the oral cavity could be a game changer for a patient’s health (FIGURE 4 ). The presence of specific, dynamic, liquidbased biomarkers secreted by tissues and resident microbes, such as active MMP-8 signifying the beginning of inflammation in gingival tissues, can help identify the critical transition from health baseline to a diseased state.45 Additionally, dysbiosis of the oral ecosystem can serve as early warning signs of oral pathosis, cancer and other systemic health complications.

An example is the distinctive and predictive nature of the oral microbiota in individuals with colorectal cancer who show increased abundance of specific pathogenic oral bacteria (e.g., F. nucleatum, Streptococcus, Peptostreptococcus stomatis, Actinomyces).46 Additionally, the concentration of Fusobacterium nucleatum is more abundant in individuals with inflammatory bowel disease.47 Current tests that screen for colorectal cancer, including the fecal immune test and the fecal occult blood test, have low sensitivity for early detection.48 Oral bacteria may infect the brain via branches of the trigeminal nerve.49 The presence of oral bacteria such as P. gingivalis and their associated byproduct secretions in the brain may result from septic infections where bacteria successfully cross the blood-brain barrier to affect brain function and promote the

pathogenesis of brain-related diseases such as Alzheimer’s.50 Mechanisms into how dysbiosis of the oral microbiome can affect the development of systemic diseases are currently being uncovered.

With such knowledge, many therapies that alter the oral microbiome, such as phototherapy and prebiotic/probiotic therapies, can improve the prognosis and treatment outcome of these pathologies.50 The bidirectional relationship between oral pathologic conditions and overall health is often overlooked. Many systemic diseases such as AIDS and Sjögren’s syndrome may first manifest as mouth lesions or conditions such as dry mouth and gingivitis.51 Moreover, periodontitis is significantly linked to other systemic health problems, such as diabetes and cardiovascular disease.52 Pregnant people with periodontitis have shown a higher risk of premature birth and/or delivery of infants with lower birth weight.53 AUGUST 2 0 2 2

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Oral epidemiologic surveillance data is a cost-effective and noninvasive way to identify social determinants of health, like poverty, health literacy and access to care, which manifest in predictive overall health outcomes.54 Thus, all primary care providers, including dentists, should collaborate to identify all possible risk factors or early warning signs of disease to maximize the preventive aspects and deliver the care patients need.

The Promise of Artificial Intelligence

The past 10 years have marked the spectacular development and breakthrough of artificial intelligence (AI) and machine learning (ML), from how data is acquired to the methodology of data storage, processing and analysis.55 AI and ML have tremendous potential to optimize patient care by revolutionizing dental diagnostic and treatment approaches. For example, AI and ML have shown great potential in detecting caries, abnormal lesions and identifying abnormal anatomical structures from radiographs.55 Another promising application of AI and ML is to guide the clinical decision-making process.

Orthodontists, for example, can utilize AI and ML in their treatment planning strategies to accurately determine the need for tooth extractions before orthodontic therapy.56 Likewise, endodontists can optimize clinical outcomes of endodontic treatment by considering trends of morphological variations identified by deep-learning algorithms.57 While technology can enhance the rate at which clinical success can be achieved, the actual clinical decision still needs to be made by the clinician.

This is due to safety and accountability, the potential lack of AI algorithm transparency and confidentiality and privacy rules. To ensure the safety of 448

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patients, the FDA recently formulated a new drug category, Software as Medical Device, to regulate medical service companies that use AI and ML to make or suggest clinical decisions.58 This is necessary because the laws are unclear about who will be held responsible for the consequences of decisions made by AI technology. Transparency of AI algorithms and data may also lead to problems, as the intentional lack of transparency of AI algorithms from the software providers, called black-box AI, coupled with poorly processed and/or analyzed data by the AI system can repeatedly result in poor clinical decisions and place the blame on clinicians who utilize these services.59 Lastly, AI algorithms must be trained with personal data from patients.

However, because of confidentiality and privacy concerns, these data must be anonymized, which prompts incertitude in the health care community about secure data sharing and the validity of the data sets used.60 AI and ML should always be complementary and not replace the health providers’ clinical decisions. Thus, rather than “artificial” intelligence, health care professionals, including dentists, should start considering these systems as “augmented decision-making” intelligence.

Conclusion

Precision dentistry is an emerging revolutionary model of treatment that proposes to customize oral health care based on the individual’s unique genetic, environmental and behavioral profiles. By considering each patient’s biology, historical records, current systemic conditions, socioeconomic status and compliance, the delivery of dental care will be customized and optimized. Dentistry will play an important and expanded role in precision health care delivery. n

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42. Kane SF. The effects of oral health on systemic health.

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43. Butler AJ, Thomas MK, Pintar KDM. Expert elicitation as a means to attribute 28 enteric pathogens to foodborne, waterborne, animal contact and person-to-person transmission routes in Canada. Foodborne Pathog Dis 2015 Apr;12(4):335–44. doi: 10.1089/fpd.2014.1856.

44. Subbarao KC, Nattuthurai GS, Sundararajan SK, Sujith I, Joseph J, Syedshah YP. Gingival crevicular fluid: An overview.

J Pharm Bioallied 2019 May;11(Suppl 2):S135–S139. doi: 10.4103/JPBS.JPBS_56_19. PMCID: PMC6555362.

45. Scheff JD, Calvano SE, Androulakis IP. Predicting critical transitions in a model of systemic inflammation. J Theor Biol 2013 Dec 7;338:9–15. doi: 10.1016/j.jtbi.2013.08.011.

Epub 2013 Aug 21.

46. Flemer B, Warren RD, Barrett MP, Cisek K, Das A, Jeffery IB, et al. The oral microbiota in colorectal cancer is distinctive and predictive. Gut 2018 Aug;67(8):1454–1463. doi: 10.1136/gutjnl-2017-314814. Epub 2017 Oct 7.

47. Swidsinski A, Dörffel Y, Loening-Baucke V, Theissig F, Rückert JC, Ismail M, et al. Acute appendicitis is characterised by local invasion with Fusobacterium nucleatum/necrophorum.

Gut Jan;60(1):34–40. doi: 10.1136/gut.2009.191320. Epub 2009 Nov 18.

48. Li JN, Yuan SY. Fecal occult blood test in colorectal cancer screening. J Dig Dis 2019 Feb;20(2):62–64. doi: 10.1111/1751-2980.12712. Epub 2019 Mar 5.

49. Riviere GR, Riviere KH, Smith KS. Molecular and immunological evidence of oral Treponema in the human brain and their association with Alzheimer’s disease. Oral Microbiol Immunol 2002 Apr;17(2):113–8. doi: 10.1046/j.09020055.2001.00100.x.

50. Maitre Y, Mahalli R, Micheneau P, Delpierre A, Amador G, Denis F. Evidence and Therapeutic Perspectives in the Relationship between the Oral Microbiome and Alzheimer’s Disease: A Systematic Review. Int J Environ Res Public Health 2021 Oct 24;18(21):11157. doi: 10.3390/ ijerph182111157. PMCID: PMC8583399.

51. Błochowiak K, Olewicz-Gawlik A, Polańska A, NowakGabryel M, Kocięcki J, Witmanowski H, et al. Oral mucosal manifestations in primary and secondary Sjögren syndrome and dry mouth syndrome. Postepy Dermatol Alergol 2016 Feb;33(1):23–7. doi: 10.5114/pdia.2016.57764. Epub 2016 Feb 29. PMCID: PMC4793060.

52. Liccardo D, Cannavo A, Spagnuolo G, Ferrara N, Cittadini A, Rengo C, et al. Periodontal disease: A risk factor for diabetes and cardiovascular disease. Int J Mol Sci 2019 Mar 20;20(6):1414. doi: 10.3390/ijms20061414.

53. Saini R, Saini S, Saini SR. Periodontitis: A risk for delivery of premature labor and low birth weight infants. J Nat Sci Biol Med 2011 Jan;2(1):50–2. doi: 10.4103/0976-9668.82321.

54. Aldoory L, Macek MD, Atchison KA, Chen H. Comparing Well-Tested Health Literacy Measures for Oral Health: A Pilot Assessment. J Health Commun 2016 Nov;21(11):1161– 1169. doi: 10.1080/10810730.2016.1233308. Epub 2016 Oct 11.

55. Tandon D, Rajawat J. Present and future of artificial AUGUST 2 0 2 2

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intelligence in dentistry. J Oral Biol Craniofac Res Oct–Dec 2020;10(4):391–396. doi: 10.1016/j.jobcr.2020.07.015.

Epub 2020 Jul 24.

56. Al-Ani MH, Mageet AO. Extraction planning in orthodontics. J Contemp Dent Pract 2018 May 1;19(5):619– 23.

57. Suebnukarn S, Rungcharoenporn N, Sangsuratham S. A Bayesian decision support model for assessment of endodontic treatment outcome. Oral Surg Oral Med Oral Pathol Oral

Radiol Endod 2008 Sep;106(3):e48–58. doi: 10.1016/j. tripleo.2008.05.011. Epub 2008 Jul 7.

58. Jotterand F, Bosco C. Artificial intelligence in medicine: A sword of Damocles? J Med Syst 2021 Dec 11;46(1):9. doi: 10.1007/s10916-021-01796-7.

59. Poon AIF, Sung JJY. Opening the black box of AI-Medicine.

J Gastroenterol Hepatol 2021 Mar;36(3):581–584. doi: 10.1111/jgh.15384.

60. Bani Issa W, Al Akour I, Ibrahim A, Almarzouqi A, Abbas

S, Hisham F, et al. Privacy, confidentiality, security and patient safety concerns about electronic health records. Int Nurs Rev 2020 Jun;67(2):218–230. doi: 10.1111/inr.12585. Epub 2020 Apr 21.

T HE CORRE S P ON DIN G AU T HOR , Michael S. Reddy, DMD, can be reached at michael.reddy@ucsf.edu.

C .E. CREDIT QUESTIONS

August 2022 CDA Continuing Education Worksheet This worksheet provides readers an opportunity to review questions about the article “Embracing Precision and Data Science in Dentistry” before taking an online quiz to earn C.E. To take the quiz, you must first sign in or set up an Online Learning account at cdapresents360.com. Earn 1.0 of Core C.E. credit through this activity. To take the test online, click here.

1. Which of the following statements applies to “precision dentistry?” (mark all that apply) a. It has also been referred to as augmented or individualized dentistry. b. It goes beyond methodologies used in traditional patient care. c. It recognizes the complex interplay among risk factors and social determinants of health. d. Successful outcomes result from addressing a combination of the patient’s treatment delivery, genetics, social and physical environment and behavior/compliance. e. All of the above.

2. True/False: The authors posit that additional training will be required for precision dentistry to become a reality, as most dentists are currently not formally trained in “omics” analysis or the practice of caries management by risk assessment, both of which factor social health determinants into clinical care decisions.

3. Which of the following statements apply to the 2018 proposed framework for classifying periodontitis? (mark all that apply) a. It splits periodontitis classification into four stages, each of which corresponds to the disease severity and complexity of management. b. Each “stage” of periodontitis is further classified into “grades” that contain information about the inherent biological nature of the disease. c. It factors in the multidimensional complexity of short-term suppression of symptoms, long-term management and

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permanent impacts on functional and aesthetic aspects of the patient’s dentition. d. It includes the risk and prognosis of future complications. e. All of the above.

4. True/False: While advances in digital hardware and software and 3D imaging and printing show future promise for fabricating aligners, retainers and customized orthodontic brackets, these technologies are not yet developed enough for reliable use in orthodontics.

5. Which of the following statements is not accurate? a. Patients with clinically similar head and neck tumors have different responses to treatment and different clinical outcomes. b. Oral cancers possess complex growth, regulation and metastatic processes that are dependent on each individual’s unique environmental background and genetic predisposition. c. Surgical biopsy is the most common, reliable and minimally invasive diagnostic method for oral cancers. d. Biomarkers in oral cavity fluids, such as saliva, have been associated with a tumor’s unique characteristics.

6. Which of the following statements describe “radiomics?” (mark all that apply): a. This is a well-researched field of study with validated results. b. It utilizes advancement in computational power, machine learning and AI to capture various properties of head and neck squamous cell carcinomas. c. It can predict current and future morphologic, metabolic and

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C .E. CREDIT QUESTIONS

spatial aspects of a primary tumor and metastatic lymph nodes. d. The specificity of the information it provides may increase the chance for favorable treatment outcomes.

7. Which of the following statements was not part of the author’s discussion of head and neck squamous cell carcinoma? a. Head and neck squamous cell carcinoma cells often avoid immune recognition and antitumor immune response through manipulation of their immunogenicity and the production of immunosuppressive mediators. b. A new alternative treatment modality known as immunotherapies draws on the potential reactivation of the patient’s antitumor immune response. c. New immunotherapeutic agents, such as pembrolizumab and nivolumab, have demonstrated the capability of inhibiting tumor activity by reactivating the patient’s T-cell antitumor response. d. The success of using immunotherapeutic agents has shown significant promise, inhibiting tumor activity in more than 50% of head and neck cancer patients.

8. True/False: Comprehensive and continuous monitoring of patient health, involving different medical and dental disciplines, enhances clinical success, thereby making availability and access to patient records between all health care providers increasingly necessary for optimal treatment decisions.

9. Which of the following statements on HPV is accurate? (mark all that apply) a. Vaccinations are the primary prevention method to protect patients against HPV infection and HPV-induced oral cancers.

b. Vaccination against HPV is 83% effective among women with no prior HPV exposure and 58% among women with previous HPV exposure. c. The Centers for Disease Control and Prevention recommends two doses of vaccines between six to 12 months apart before age 15 for maximum preventive effectiveness. d. The overall vaccination rate in U.S. adolescents is impressively high, reaching more than 65% of the population. e. All of the above.

10. Which of the following are included in the authors’ discussion of artificial intelligence (AI) and machine learning (ML)? (mark all that apply) a. AI and ML offer dentistry an opportunity to optimize patient care, showing great potential in detecting caries and abnormal lesions and identifying abnormal anatomical structures from radiographs. b. AI and ML may assist orthodontic treatment planning to accurately determine the need for tooth extractions before orthodontic therapy. c. Intentional lack of transparency of AI algorithms from software providers and lack of clarity in the law about who will be held responsible for the consequences of decisions made by AI technology are current areas of concern for AI and ML use. d. To ensure patient safety, the Food and Drug Administration recently formulated a new drug category, Software as Medical Device, to regulate medical service companies that use AI and ML to make or suggest clinical decisions. e. Final clinical decisions must still be made by clinicians, not technology. f. All of the above.

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pain assessment C D A J O U R N A L , V O L 5 0 , Nº 8

How Do We Protect a Child’s Psychological Health During Procedures That Use Protective Stabilization?

Dennis Paul Nutter, DDS

abstract Background: If a child experiences pain during procedures while protective stabilization is in place, they will experience suffering, central sensitization and classical fear conditioning in direct proportion to the duration and intensity of their procedure pain. Rigorous and reliable procedure pain assessment during procedures is imperative if children’s psychological health is to be protected when protective stabilization is deployed.

Types of studies reviewed: A review of pain assessment guidelines and best practice recommendations, their supporting literature and the pain assessment practices of pediatric dentists was undertaken to determine if current pediatric dental pain assessment methodology conforms to best practice recommendations.

Results: Best practice recommendations for pain assessment in pediatrics allow the child to determine their own procedure pain intensity level, either by self-report or, for children younger than age 7, by observation of their distress behavior. Current practice in pediatric dentistry is to target behavior for assessment during invasive procedures and allow the dentist to decide the level of a child’s procedure pain that is associated with that behavior. Dentists, physicians and nurses all tend to underestimate their patients’ pain if they are allowed to make that determination.

Practical implications: Many pediatric dentists practice a method of procedure pain assessment that does not conform to best practice recommendations. Three practice recommendations are proposed to improve pain outcomes and protect the psychological health of children during potentially painful procedures, especially those involving the use of protective stabilization.

Keywords: Protective stabilization, papoose board, restraint, sensitization, fear, conditioning, pain, behavior management, pain justification, medical ethics

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AUTHOR Dennis Paul Nutter, DDS, is a diplomate of the American Board of Pediatric Dentistry and is immediate past president of the Western Society of Pediatric Dentistry.

He has authored articles and lectured nationally and internationally on pediatric procedure pain assessment.

He is a diplomate of the American Board of Pediatric Dentistry, a fellow of the American College of Dentists and a fellow of the Pierre Fauchard Academy. He is in private practice in Fairfield, California.

Conflict of Interest Disclosure: None reported.

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Editor’s Note: This issue of the Journal features two separate but companion manuscripts on pediatric dental care and the use of protective stabilization. The topic is controversial and instead of publishing one article and waiting for responses, we are publishing a second article to allow readers to immediately appreciate the range of opinions on the topic.

Dennis Nutter, DDS, authored this article and Paul S. Casamassimo, DDS, MS; Beau Meyer, DDS, MPH; and Janice A Townsend, DDS, MS, wrote the second piece.

They offer a thoughtful response in their article beginning on page 465. Both perspectives are informed by the experience and expertise of their pediatric dentist authors.

T

he American Academy of Pediatric Dentistry (AAPD) defines “protective stabilization” as the “physical limitation of a patient’s movement by a person or restrictive equipment or materials … to safely provide examination, diagnosis and/or treatment.”1 While protective stabilization refers to a constellation of immobilization equipment and methods, it most commonly refers to papoose-style restraining devices. During treatment, it is deployed predominately in children under age 5. In 2004, 36% of pediatric dentists who were members of the AAPD preferred to restrain a 3- or 4-year-old patient for limited treatment needs rather than use sedation.2 In 2006, a systematic review of pediatric dental sedation studies found that almost half of the clinicians used papoose board immobilization when sedating children for procedures.3 The average age of the child subjects was 4.5 years even though the inclusion criteria accepted subjects up to age 16.3 In some European countries, using a papoose board to restrain children during invasive procedures is legally restricted.4 Its use in the U.S. is not without controversy.5–9 The AAPD’s best practice recommendation for protective stabilization states that its goal is to “prevent or minimize psychological distress and decrease the risk of physical injury to the patient, parent and staff.”1 The policy’s authors warn that protective stabilization carries a risk of “psychological effects” and that the “psychological health

of the patient should override other factors.”1 The recommendation is also to terminate protective stabilization if a child is experiencing “severe emotional distress.” Protective stabilization was conceptualized with the intent that its use not result in harm to the “psychological health of the child.”

Clinicians have an ethical duty to “do no harm.” The concept of harm as it is applied to medical procedures is more broadly defined than is the concept of “hurt.” In the context of a medical procedure, a child is harmed when the patient experiences more negative procedural sequelae than necessary in order to obtain the intended benefit.10–12 Pain is a prime, negative procedural sequelae to be considered, but it is not the only one.

“Harm” is not equivalent to “hurt.”10 Procedures commonly cross a child’s pain threshold without harming them. A good injection technique can result in low levels of pain that are below the child’s pain tolerance level and are justified given the risk of alternatives. However, if a child experiences pain beyond their pain tolerance level by one procedure and if by an alternate procedure the child would not have experienced high intensity pain yet obtained the same benefit, then the child has been harmed.

Young children have only an emerging capacity to exercise autonomous decisions regarding their health. Their inability to effectively self-advocate warrants practice recommendations that protect their right

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to have their pain effectively managed.13,14 This paper proposes three practice recommendations to mitigate the ability of evaluator bias to enter the methodology of pediatric procedure pain assessment.

Two examples will illustrate how the proposed recommendations can affect clinical decisions to employ or not employ immobilizing restraint during procedures involving tissue trauma. The definitions of relevant terms are provided in the APPENDI X .

Practice Recommendation One

Until an accurate, reliable, clinically useful, objective measure of pediatric procedure pain is found, distress behavior that occurs coincident with procedural tissue trauma is pain behavior until the child says otherwise.

Rationale: Deeply imbedded in the clinical culture of pediatric dentistry is the suspicion that some children exhibit pain behaviors during procedures that are not authentic.2,15–20 Young children have difficulty with their self-report of pain.21,22 Children are known to exhibit pain behavior when there is no procedure pain stimulus. This pain magnification — an exaggerated response that is an attempt by the child to convince an observer that they really are experiencing some level of pain or expect to experience it23 — is the behavioral manifestation of anxiety or fear.

Behavior management authors and clinicians have cited intentional “misbehavior” as another confounding factor in assessment of a child’s procedural distress.15–17,24 Also, physiological distress related to hunger and the need for a nap in infants and toddlers can mimic pain behavior. To properly assess for the presence or intensity of pain, a dentist must be able to differentiate these confounding procedural behaviors from a pain behavior.

However, clinicians do not have this diagnostic capability.25–27 In a 2018

systematic review of 50 years of research that studied clinicians’ estimation of their adult patients’ pain, 91% of the high-quality studies found that dentists, physicians and nurses all tend to underestimate their patients’ pain.25 Adults are pragmatically used as subjects in these studies because consent is less complicated and they are regarded as reliable self-reporters. The review also found that the greater the pain intensity, as would occur when procedural distress behavior is restrained, then the greater was its underestimation.25

A majority of pediatric dentists target behavior (not pain) for assessment and intervention.

It has been hypothesized that clinicians have a psychological need to rationalize away pain they cannot alleviate.28,29 Deflecting blame for bad outcomes appears to be a tendency of human nature.30,31 Clinicians who cause pain and are unable to effectively eliminate or reduce it may feel pressure to assign blame to other distress etiologies for their ostensible pain management failure.11 The problem cannot be resolved by resorting to an independent, objective measure of pain. Objective, physiological measures exist, (e.g., heart rate, fMRI) but none are considered as accurate or reliable as the patient’s self-report.33–38 Without an objective instrument to measure pain, dentists have believed that it is their responsibility to determine what pain symptoms in children are

authentic and which are false.15–17,32 In 2012, 87% of pediatric dentists who were members of the AAPD believed they had the experience and training to determine what was pain and what behavior was not pain during procedures involving tissue trauma.32 A majority of pediatric dentists target behavior (not pain) for assessment and intervention.

Fifty-two percent of pediatric dentists use a formal behavior scale such as the Frankl scale to score the intensity of negative behavior during procedures involving tissue trauma.32 Another 32% of pediatric dentists use no formal measurement instrument to score the intensity of procedural distress behavior but likely target behavior by narratively describing a child’s behavior in the record.32 Only 10% of pediatric dentists use a formal pain scale to measure pain intensity.32 In 2021, 46% of pediatric dentists believe that the dentist should decide how much procedure pain a child is experiencing.32 This does not conform to best practice recommendations in general medicine, pediatrics and nursing, which direct that the child should determine the intensity of their procedure pain.25,39–43 When protective stabilization is used during invasive procedures, it is controlling distress movement that is identified as pain behavior by best practice recommendations, pain guidelines and established instruments of pain measurement.25,39–44 Accepting that only the child knows how much pain they are experiencing has long been regarded as the first principle of good, clinical pain practice.28,45,46 Most children ages 7 and older who are not cognitively impaired can selfreport their pain intensity using the faces pain scale.21,22,47,48 Children under age 7 increasingly lack the cognitive development needed to discriminate between the scale points of self-report AUGUST 2 0 2 2

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measures.49,50 With the faces pain scale, they tend to pick end points.21,22,49,50 For this reason, dentists, physicians and nurses must increasingly transition their method of pain assessment from a method that uses a child’s self-report of pain (e.g., revised faces pain scale51) to a method that relies on observation of a child’s distress behavior (e.g., face, legs, activity, cry and consolability (FLACC) scale44).

When this occurs, the dentist is switching from a method of pain assessment in which the child determines the intensity of their procedure pain to a method in which the dentist decides the intensity of the child’s pain. This is how evaluator bias to underestimate pain finds its way into pain assessment methodology.

Urging dentists to use a validated pain scale is an important step in improving pain outcomes for children when they can reliably self-report their pain. But this step alone will not solve the problem of evaluator bias when dentists assess “behavior.” If a dentist who is performing an invasive procedure decides that a child’s distress behavior is not pain but some other construct such as anxiety, they will not feel the need to use a validated pain scale.

There is considerable supplementary evidence to support a best practice recommendation that instructs clinicians to treat a young child’s distress as pain when it is coincident to procedural tissue trauma until the child indicates otherwise: ■ The coincident presence of procedural tissue trauma implies that a distress behavior is a pain behavior.

■ A clinician cannot be sure that their local anesthetic has been effective.52,53 54–58 ■ Pain is subjective.

It is differentiated in each of us both genetically and environmentally by pain experience.59–63 There is no uniform pain response for a given 456

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■

■

level of tissue trauma.56,62,64,65 Pain is defined as having sensory and emotional dimensions that are inextricably intertwined.66 The emotional dimension of pain is not a false contribution to the pain experience.

The needle procedures required by medical prevention protocols (vaccinations, blood draws) ensure that, by age 3, most children will perceive the dental environment as a threat environment.65,67 Painful medical procedures (medical

■

■

Pain is defined as having sensory and emotional dimensions that are inextricably intertwined.

■

or dental) can classically fear/ threat condition children to any procedural environment.57,65–67 Multiple exposures to needle pain will also result in central sensitization, which amplifies the pain experience on subsequent exposures.68–72 The phenomenon of stimulus generalization will ensure that these phenomenon will occur in both medical and a dental environments.74,75 Piaget’s discovery of “conservation errors” in reasoning in children under age 7 demonstrates that young children cannot process problems like adults.76 Hence, they will not process threat like adults. Since the dental office is a threat environment

■

to most children, children should not be expected to respond to a dentist’s or parent’s instructions in a threat environment (dental operatory) with the same level of compliance as they would in their home.

Young children have had little exposure to cultural admonitions to not show pain. Hence, they are primed to exuberantly express their pain. Generally, older children and adults tend to hide pain that is over their pain threshold but under their pain tolerance threshold.77 Children can be classically fear/ threat conditioned by nonpain distress in the same manner that occurs with pain. People who get seasick (nonpain distress) are wary of boat trips. Avoiding or intervening procedural distress is a wise clinical strategy, regardless of its etiology.

The amygdala has the ability to associate neutral stimuli with threat (pain) on a single pairing, and there is general agreement that this learned fear can last a lifetime.73

Practice Recommendation Two

Intervene early in procedural pain behavior.

Rationale: “It is better to prevent pain than to treat it after it has occurred.”28 If the clinician elects to intervene late in procedure pain, when distress levels are beyond the pain tolerance level of the child, then the child will experience suffering, central sensitization and classical threat conditioning in direct proportion to the intensity of their procedure pain.56,72,78–92 The pain stimulus bell cannot be unrung.

Infantile amnesia is the general inability to recall events before age 3.5 and the decreased ability to qualitatively recall impactful events between the ages of 3.5 to age 7.93 It would seem that

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infantile amnesia would protect children from the psychological harm of recalling painful, protective stabilization events that occur before age 3.5. However, infantile amnesia only effects explicit, consciously accessed memory.94,95 If infantile amnesia affected implicit memory, children could not learn and retain the implicitly driven motor movements of walking at age 1. Because central sensitization and classical fear/threat conditioning are stored as implicit memories,70,74 infantile amnesia will not protect against amplified pain signaling after untreated procedure pain. When these conditioned stimuli are next experienced, they will trigger an automatic fight-or-flight physiology. This can debilitate a child’s capacity to tolerate future necessary medical procedures.67,70–72,79,95–99

Practice Recommendation Three

Choosing to not intervene in procedural pain behavior is only justified when the procedure represents the least-risk alternative.

Rationale: The assessments and judgements involved in the decision to not intervene in a child’s ostensible pain behavior is the essence of the ethical challenge inherent in the use of protective stabilization during procedures involving tissue trauma.

Procedures are justified by weighing their risks and benefits. When making this assessment, it is less complicated if the benefit is the same for all procedures.

Hence, the benefit of an invasive procedure in pediatric dentistry may be reduced to the remediation, stabilization or deferral of pathology. Stabilization and deferral are equivalent benefits to full remediation because as children get older they become more tolerant of procedures. Children under age 7 generally display five times more distress during the same medical procedure than

children over age 7.56 One only need examine and compare the risks of each procedure that achieves any of these three, equivalent benefits. The goal is to find the treatment plan that entails the least risk.

One confounding element in this method is that there are differences in treatment benefits that are not necessarily valued unless these benefits are translated into risks. Full remediation of caries pathology would seem to have a greater benefit than a temporary stabilization of caries rate or temporary deferral of invasive treatment. When distal caries

Children under age 7 generally display five times more distress during the same medical procedure than children over age 7.

on a posterior tooth are remediated with a distoocclusal restoration with substantial retention features (e.g., dovetail design) and prevention features (e.g., extending margins into sound enamel), this type of restoration has greater mechanical resistance to fracture and resistance to recurrent decay than a stabilizing, transitional atraumatic restorative technique.

These variations in benefit can be translated into differences in risk.

For example, the increased benefit in longevity of the more invasive restoration with retention dovetails can be translated into an increased risk of restoration failure for the less-invasive atraumatic restorative technique. However, the benefit of retention dovetails in very

young, highly anxious children will generate considerable risk of negative pain sequelae due to the potentially sensitizing needle procedure that would be needed to deliver an anesthetic to alleviate pain from the more invasive prep extensions. Needle pain can turn the child’s attention on the procedure and increase their pain perception for the procedure’s duration.72,101–103 Procedure pain that is over a child’s pain threshold but under their pain tolerance threshold does not need papoose-style restraints to control. Use of protective stabilization to control movement during procedures involving tissue trauma is likely restraining pain behavior that is well beyond clinical significance unless the child says otherwise. The resulting elevated levels of suffering, central sensitization and threat conditioning are difficult to ethically justify. If there is an alternate therapeutic pathway that would allow a child to be treated with reduced or no pain experience and still, in time, achieve the same benefit (remediation, stabilization or deferral), this pathway would represent the least risk alternative.

How Clinicians Decide

The examples that follow demonstrate how a clinician may decide to allow or not allow procedure pain experience to continue in children.

Note: Pain is multidimensional having both sensory and psychological dimensions.23 In the following examples, it is always assumed that age-appropriate psychological interventions in pain (e.g., distraction and desensitization) are planned to be performed sequentially or concurrently with sensory interventions.

Example One

A 9-month-old child presents with AUGUST 2 0 2 2

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vertical fracture of the maxillary central incisor that is through the pulp and down the root.

Treatment pathway A: Perform a less-invasive, less-pain-stimulating “transitional” procedure.

The level of procedure pain that is self-reported or observed in children decreases as they grow older.77,104–106 A transitional procedure is one that stabilizes pathology and defers more invasive treatment until the child is older and can better tolerate procedural stimulation. However, remediation of this fracture pathology will require a very invasive, nontransitional procedure — extraction. A less-invasive procedure is just not possible for remediation, and not treating it is therapeutically unsound. Half measures would likely expose the child to two traumatic procedures: one for the half measure and one for the eventual extraction.

Treatment pathway B: Defer treatment.

It may be possible to defer treatment for a short time to allow the child to unwind from their trauma, get needed sleep or eat to satisfy their hunger. Each of these physiological states in young children can cause distress during a procedure that is difficult to differentiate from a pain behavior. Pausing to eliminate them can be a useful strategy to lower variables of distress that can confound pain assessment. However, in this case, treatment cannot reasonably be deferred long enough for the child to grow, mature and develop significant pain modulating mechanisms. Therefore, this is not a viable long-term strategy.

Treatment pathway C: Perform treatment under sedation or general anesthesia. More pharmacology in the form of deep sedation or a general anesthetic is associated with a very high risk in this age group. For most clinicians, this would not be acceptable.107,108 458

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Treatment pathway D: Perform extraction using good, local anesthetic needle technique and protective stabilization. A child this age will likely exhibit high levels of distress during both the local anesthetic needle procedure and the subsequent extraction procedure.

Practice recommendation 1 compels the clinician to accept this distress as a pain behavior when tissue trauma is occurring.

Thus, we may expect that treatment pathway D will result in some level of suffering, central sensitization and classical fear/threat conditioning. The extent to

The need to monitor and maintain a less-invasive treatment pathway should be included in the consent process.

which this actually occurs will be evident when the child is released to the arms of their parent or caregiver. How long it takes for the child to be consoled will give some indication of the intensity of the pain they experienced during the procedure.109,110 Despite the anticipated development of central sensitization, classical fear/threat conditioning and suffering, the stabilizing use of protective stabilization is the least risk alternative. Exposing the child to the greater risk of general anesthesia or lessinvasive treatment would have harmed the child.

Example Two

A pediatric dental sedation fails to achieve its goal of attenuating the child’s sensory and psychological dimensions of distress/pain.

Treatment pathway A: Perform less-invasive, less-pain-stimulating “transitional” procedures. If the existing caries pathology does not require extractions or pulpotomies, it may be possible to perform lessinvasive, transitional procedures and thereby avoid the risk of suffering, central sensitization and classical fear/ threat conditioning. The possibility for transitioning to a less-invasive treatment plan should be discussed during the sedation consent process. The need to monitor and maintain a less-invasive treatment pathway should be included in the consent process. This treatment option requires a prudent frequency of observation and, when needed, repair of transitional restorations and reapplication of noninvasive measures.

Because clinicians cannot know the unique pain tolerance threshold of any child, the primary task of a pediatric dentist is to not perform any invasive procedure that can reasonably be deferred. Clinicians may choose to err on the side of caution and repeat less-invasive,111–113 stabilizing or noninvasive114–116 deferral procedures until the primary tooth exfoliates or until the child ages to procedural tolerance.

Treatment pathway B: Defer treatment.

This is usually performed on selected carious lesions in tandem with treatment pathway A. It always includes the use of mineralizing agents (e.g., fluoride varnish, silver diamine fluoride) to slow or reverse the rate of the decay.

Treatment pathway D: Abort the sedation and reschedule with general anesthesia at a later date.

This treatment pathway may be the least-risk alternative when there are extensive and deep caries that rule out less-invasive treatment alternatives.

Future novel interventions in caries or tooth fracture may change the risk

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that is associated with remediating, stabilizing or deferring these pathologies.

The value assigned to each component of risk will vary from clinician to clinician.

Each clinician has differences in skill, experience and education. Each clinician will have their favored procedures to achieve the same benefit. The previous examples have been designed to reduce ambiguity and variance in the clinician’s estimation of risk. As the child grows older and the clinical conditions become less sharply defined, clinician differences in the assessment of risk are more likely to come into play. When this happens, clinicians may take different clinical paths to achieve the same least-risk outcome for the pediatric patient. However, practice recommendation 1 will prohibit clinicians from downwardly revising the intensity of a child’s behavioral expression of pain in order to justify a procedure.

Conclusions ■

■

■

■

Many pediatric dentists practice a method of procedure pain assessment that does not conform to best practice recommendations.

Until an accurate, reliable, clinically useful and objective measure of pediatric procedure pain is found, distress behavior that occurs coincident with procedural tissue trauma is pain behavior until the child says otherwise.

Intervene early in procedural pain behavior.

Choosing to not intervene in procedural pain behavior is only justified when the procedure represents the least-risk alternative. n

AC KN OW LEDGM EN TS The author thanks the CDA peer reviewers and Dr. Adam Shaffer for their insightful comments on the manuscript.

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T HE AU T HOR , Dennis Paul Nutter, DDS, can be reached at dennispaulnutterdds@yahoo.com.

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APPENDIX

Important Concepts Anxiety is a vague awareness of danger. It is worrying that a threat is present.1 Since anxiety is a conscious feeling, it is an explicit memory phenomenon.1 It can be the “cognitive consequence” of implicit threat detection.2 Central sensitization is the neurobiological response to a noxious stimulus from tissue or nerve damage.3–5 Nociceptors transduce and encode tissue damage and transmit this information to the dorsal horn of the spinal cord. There it induces changes in synaptic plasticity to increase receptive fields and decrease depolarization thresholds.6–9 The more frequent or intense an exposure to procedure pain, the more amplified the child’s pain experience will be for future exposures.4,5,9,10 Things that did not hurt before now hurt. The molecules and mechanisms for learning in the spinal cord are similar to the mechanisms for memory in the brain.11 Since the memory for central sensitization is primarily located in the spinal cord, one can understand why this implicit memory is not accessible to conscious thought.

Classical fear/threat conditioning is the neurobiological response to two or more stimuli that develop a relationship because they “reliably appear together.”7 Pavlov’s dog was famously made to salivate to the sound of a tone because food had been reliably paired with that particular stimulus.12 It is termed “classical” conditioning to distinguish it from “operant” conditioning. Watson and Rayner showed how classical Pavlovian conditioning could be used to condition a child to experience fear.13 Children are classically conditioned to fear dental procedural environments from repeated vaccinations, blood draws and painful hospital visits.10,14–16 Otherwise neutral stimuli such as gloves, white coat or room geometry become paired with the pain experience of needle procedures. When these conditioned stimuli are reexperienced in the future, they cause an automatic elevation of fight-or-flight physiology and reflexive avoidance behavior.17–19 This can result in noncompliance with other necessary medical procedures.16,20 Through the phenomenon of “stimulus generalization,” neutral stimuli need only look similar to the original conditioning stimuli. In this way, dental procedure rooms can appear as a threat when the painful procedure occurred in medical procedure rooms.

Historically, the term “fear conditioning” has been used.3,21 However, LeDoux has pointed out that these two terms are incongruous. A person is consciously aware of their fear. It is therefore the result of explicit mechanisms. (People who do not have an amygdala can still experience fear.22) Conditioning refers to an implicit memory that is recalled automatically without a person’s awareness. LeDoux has suggested that it is more appropriate to remove the word fear from references to conditioning. He suggests that the term “threat conditioning” is more apropos.1,19,23 Since both “explicit” fear and implicit “threat” memory can contribute to avoidance behavior in the clinical setting, the hybrid term “classical fear/threat conditioning” is used in this paper. Because infantile amnesia affects explicit memory and not implicit memory, younger children will be dominated by implicit contributions in a threat setting.

Distress refers to an unpleasant emotional experience that may have a sensory dimension. All pain is distress, but not all distress is pain.

Explicit memory is consciously recalled memory of facts and events such as what you had for dinner last Thursday.3,24,25 The hippocampus and the medial temporal lobe of the brain are required to move working memory into long-term explicit memory.26–28 It is stored in areas of the cerebral cortex that process the information.26 For example, visual information that is processed in the visual cortex is also stored there. Because it is memory that, once recalled, you can tell someone, it has been termed “declarative.”3 Fear is an unpleasant emotion associated with a conscious awareness that a specific threat (e.g., needle) is present.2 An awareness of fear is the result of explicit mechanisms but can be the “cognitive consequence” of “implicit threat processing.”2 Implicit memory is stored in a collection of subcortical, unconscious memory systems of the brain. The physiological state of fight-or-flight and the reflexive motor movements of threat avoidance result from the automatic recall of an implicit threat memory stored in the amygdala.27,29 The balance that you use to ride a bicycle is the automatic recall of implicit, procedural memory stored in the cerebellum.3,30 The implicit memory for habits is stored in the striatum.31,32 Implicit memory recall automatically initiates changes in behavior that run to completion without monitoring or awareness.3,32–36 Central sensitization and Pavlovian fear conditioning are both stored as implicit memories.33 Because implicit memory is not a memory that a person can tell someone about, it has been termed “nondeclarative.”3 Infantile amnesia is the inability to consciously (explicitly) remember events before the age of 3 and only a gradually increased memory retention until efficiency achieves relative stability at age 7.37,38 Evidence suggests that rapid, hippocampal neurogenesis is rewriting young children’s memories before the age of 7.39,40 Supporting this theory is the observation that as neurogenesis in the hippocampus goes down, memory retention goes up.39 The subcortical structures that retain implicit memory (e.g., amygdala and cerebellum) do not appear to be measurably affected by infantile amnesia.3,41 Thus, children who learn to walk at age 12 months retain the implicit memory they need to continue building on that motor skill.

Intervene: See pain intervention.

Pain is an unpleasant sensory and emotional experience that is associated with, or resembling that associated with, actual or potential tissue damage.44 The presence of tissue trauma does not guarantee the presence of pain (e.g., itch) and the absence of tissue trauma does not guarantee the absence of pain (e.g., phantom limb pain). “Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.”42 Pain intervention is used in this paper to indicate a sensory technique (e.g., local anesthesia or less stimulation in the form of a silver modified atraumatic restorative technique) and/or psychological technique (e.g., distraction or desensitization) that eliminates or reduces pain experience.

Stimulus generalization is a phenomenon whereby a conditioned stimulus only needs to look similar to the original conditioned stimulus to evoke fear or anxiety. In a medical office, room geometry, white coats, gloves or masks can become paired with the needle pain of vaccinations, blood draws or other medical procedures.3,43,44 Reexperiencing the room geometry of a dental office or other similar stimuli will trigger a conditioned distress response with commensurate fightor-flight physiology and behavior.3,13,14,19 This is how children who have never been to a dentist can have an emotional, panic-driven meltdown at their first visit.

Threat: A stimulus or stimuli that are associated with harm or danger.27,45 Threat is recorded in the amygdala as implicit memory.27,45,46

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11. Ji RR, Kohno T, Moore KA, Woolf CJ. Central sensitization and LTP: Do pain and memory share similar mechanisms?

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12. Pavlov IP. Conditioned Reflexes. New York: Dover; 1927.

13. Watson JB, Rayner R. Conditioned emotional reactions. J Exp Psychol 1920; 3(1):1–14. doi.org/10.1037/h0069608.

14. Cemeroglu AP, Can A, Davis AT, et al. Fear of needles in children with Type 1 diabetes mellitus on multiple daily injections (MDI) and continuous subcutaneous insulin infusion (CSII). Endocr Pract 2015 Jan;21(1):46–53. doi: 10.4158/ EP14252.OR. 15. McMurtry MC, Riddell RP, Taddio A, Racine N, Asmundson GJG, Noel M, Chambers CT, Shah V, HELPinKids&Adults Team. Far From “Just a Poke:” Common Painful Needle Procedures and the Development of Needle Fear. Clin J Pain 2015 Oct;31(10 Suppl):S3–11. doi: 10.1097/ AJP.0000000000000272. PMCID: PMC4900413.

16. Taddio A, Ipp M, Thivakaran S, et. al. Survey of the prevalence of immunization non-compliance due to needle fears in children and adults. Vaccine 2012 Jul 6;30(32):4807–12. doi: 10.1016/j.vaccine.2012.05.011.

Epub 2012 May 19.

17. Shechner T, Hong M, Britton JC, Pine DS, Fox NA. Fear

conditioning and extinction across development: Evidence from human studies and animal models. Biol Psychol 2014 Jul;100:1–12. doi: 10.1016/j.biopsycho.2014.04.001. Epub 2014 Apr 16. PMCID: PMC4629237.

18. LeDoux J. Life is dangerous. In: Anxious: Using the brain to understand and treat fear and anxiety. New York: Viking, Penguin Random House LLC; 2015:52–81.

19. LeDoux J, Moscarello J, Sears R, Campese V. The birth, death and resurrection of avoidance: a reconceptualization of a troubled paradigm. Mol Psychiatry 2017 Jan;22(1):24-36. doi: 10.1038/mp.2016.166. Epub 2016 Oct 18. PMCID: PMC5173426.

20. Thyer BA, Himle J, Curtis GC. Blood-injury-illness phobia: A review. J Clin Psychol 1985 Jul;41(4):451–9. doi: 10.1002/1097-4679(198507)41:4<451::aidjclp2270410402>3.0.co;2-o.

21. Kim JJ, Wang MW. Neural circuits and mechanisms involved in Pavlovian fear conditioning: A critical review.

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22. Feinstein JS, et al. Fear and panic in humans with bilateral amygdala damage. Nat Neurosci 2013 Mar;16(3):270–2. doi: 10.1038/nn.3323. Epub 2013 Feb 3. PMCID: PMC3739474.

23. LeDoux JE. Coming to terms with fear. Proc Natl Acad Sci U S A 2014 Feb 25;111(8):2871–8. doi: 10.1073/pnas.1400335111. Epub 2014 Feb 5. PMCID: PMC3939902.

24. LeDoux JE. It’s personal: How memory affects consciousness. In: Anxious: Using the brain to understand and treat fear and anxiety. New York: Viking; an imprint of Penguin Random House LLC; 2015:181–202.

25. Buckner RL, Koutstaal W. Functional neuroimaging studies of encoding, priming and explicit memory retrieval. Proc Natl Acad Sci U S A 1998 Feb 3;95(3):891–8. doi: 10.1073/ pnas.95.3.891. PMCID: PMC33813.

26. Kandel ER. Different memories, different brain regions. In: In search of memory: The emergence of a new science of mind.

New York: W.W. Norton & Company; 2006:116–134.

27. Knight DC, Waters NS, Bandettini PA. Neural substrates of explicit and implicit fear memory. Neuroimage 2009 Mar 1;45(1):208–14. doi: 10.1016/j.neuroimage.2008.11.015.

Epub 2008 Nov 28. PMCID: PMC2789597.

28. Horner AJ, Doeller CF. Plasticity of hippocampal memories in humans. Curr Opin Neurobiol 2017 Apr;43:102–109. doi: 10.1016/j.conb.2017.02.004. Epub 2017 Mar 4. PMCID: PMC5678278.

29. Davis M. Neurobiology of fear responses: The role of the amygdala. J Neuropsychiatry Clin Neurosci Summer 1997;9(3):382–402. doi: 10.1176/jnp.9.3.382.

30. Squire LR. Memory systems of the brain: A brief history and current perspective. Neurobiol Learn Mem 2004 Nov;82(3):171–7. doi: 10.1016/j.nlm.2004.06.005.

31. Kandel E, Siegelbaum S. Cellular mechanisms of implicit memory storage and the biological basis of individuality. In: Kandel ER, Schwartz JH, Jessell TM, Siegelbaum SA, Hudspeth AJ, eds. 5th ed. Principles of Neural Science. New York: McGraw Hill Medical; 2013:1461–1486.

32. Kandel ER. The age of insight: The quest to understand the unconscious in art, mind and brain from Vienna 1900 to the present. New York: Random House; 2012:304–321.

33. Tamietto M, de Gelder B. Neural bases of the non-

conscious perception of emotional signals. Nat Rev Neurosci 2010 Oct;11(10):697–709. doi: 10.1038/nrn2889. Epub 2010 Sep 2.

34. Manassero E, Mana L, Concina G, Renna A, Sacchetti B. Implicit and explicit systems differently predict possible dangers.

Sci Rep 2019 Sep 16 9;13367. doi.org/10.1038/s41598019-49751-4.

35. Squire LR. The Legacy of Patient H.M. for Neuroscience. Neuron 2009:61; 6-9. doi.org/10.1016/j. neubiorev.2005.06.005 36. Corkin S. Acquisition of motor skill after bilateral medial temporal-lobe excision. Neuropsychologia 1968:6;255–265. doi.org/10.1016/0028-3932(68)90024-9.

37. Rubin DC, Schulkind MD. The distribution of important and word-cued autobiographical memories in 20-, 35- and 70-year old adults. Psychol Aging 1997 Sep;12(3):524–35. doi: 10.1037//0882-7974.12.3.524.

38. Peterson C. Children’s long-term memory for autobiographical events. Developmental Review 2002;22:370402. doi.org/10.1016/S0273-2297(02)00007-2.

39. Akers KG, Martinez-Canabal A, Restivo L, et al. Hippocampal neurogenesis regulates forgetting during adulthood and infancy. Science 2014 May 9;344(6184):598–602. doi: 10.1126/science.1248903.

40. Josselyn SA, Frankland PW. Infantile amnesia: A neurogenic hypothesis. Learn Mem 2012 Aug 16;19(9):423– 33. doi: 10.1101/lm.021311.110.

41. Davidson A. Depth of anesthesia monitoring and awareness. In: Bissonnette B, ed. Pediatric Anesthesia: Basic principles, State of the Art, Future. Shelton, Conn.: People’s Medical Publishing House; 2011:1285–1303.

42. International Association for the Study of Pain. Terminology: Pain. Accessed Dec. 27, 2020.

43. Dunsmoor JE, Paz R. Fear generalization and anxiety: Behavioral and neural mechanisms. Biol Psychiatry 2015 Sep 1;78(5):336–43. doi: 10.1016/j.biopsych.2015.04.010.

Epub 2015 Apr 20.

44. Pearce JM. A model for stimulus generalization in Pavlovian conditioning. Psychol Rev 1987 Jan;94(1):61–73.

45. LeDoux J. Rethinking the emotional brain. Neuron 2012 Feb 23;73(4):653–76. doi: 10.1016/j.neuron.2012.02.004.

46. Siegelbaum SA, Kandel ER. Prefrontal cortex, hippocampus, and the biology of explicit memory storage. In: Kandel ER, Schwartz JH, Jessell TM, Siegelbaum SA, Hudspeth AJ, eds. Principles of Neural Science. 5th ed. New York: McGraw Hill Medical; 2013:1487–1521.

T HE AU T HOR , Dennis Paul Nutter, DDS, can be reached at dennispaulnutterdds@yahoo.com.

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protective stabilization C D A J O U R N A L , V O L 5 0 , Nº 8

Pain, Psyche and Protective Stabilization Paul S. Casamassimo, DDS, MS; Beau Meyer, DDS, MPH; and Janice A. Townsend, DDS, MS

abstract Background: Protective stabilization (PS) and its subset of medical immobilization (MI) with a passive device have been part of advanced behavior guidance in pediatric dentistry for decades, yet they remain controversial. Inadequate evidence on risks and benefits, ambiguous indications and newer societal and professional skepticism make application of these techniques the subject of continuing debate. PS and MI are often the treatments of last resort and can be effective and safe.

Conclusions: Clinical, psychological and logistic considerations should guide clinicians when these techniques are among behavior guidance choices. Like other forms of advanced behavior guidance, PS and MI affect children and family, and their application is also shaped by the community and care system.

Practical implications: Professional guidelines provide general directions for use of PS and MI, and these should be refined by the clinician’s recognition of the limitations and possible effects of use. Finally, in the absence of a clear evidence-based pathway, application of a logic algorithm can both maximize the benefit of PS and MI and minimize negative outcomes.

Keywords: Behavior, pediatric dentistry, safety, medical immobilization, protective stabilization

AUTHORS Paul S. Casamassimo, DDS, MS, is a professor emeritus at The Ohio State University College of Dentistry and an attending dentist at Nationwide Children’s Hospital in Columbus, Ohio.

Conflict of Interest Disclosure: None reported.

Janice A. Townsend, DDS, MS, is the chief of pediatric dentistry at Nationwide Children’s Hospital and the chair of the division of pediatric dentistry at The Ohio State University College of Dentistry.

Conflict of Interest Disclosure: None reported.

Beau Meyer, DDS, MPH, is an assistant professor at The Ohio State University College of Dentistry, division of pediatric dentistry and is on the medical staff at Nationwide Children’s Hospital in Columbus, Ohio.

Conflict of Interest Disclosure: None reported.

Editor’s Note: This article is a companion to “How Do We Protect a Child’s Psychological Health During Procedures That Use Protective Stabilization?” on page 453.

T

he use of protective stabilization (PS) must consider the overall health and safety of the pediatric patient as the highest priority. Consideration of important ethical and pragmatic consequences is integral to proper application of PS. Paying attention to pain management, maintaining patient safety, providing quality dental care and protecting the developing psyche are assumed in every application of PS and essential to the decision-making process when choosing to use PS. The umbrella of PS includes active stabilization by the parent or dental team as well as passive stabilization with an

immobilization device that we will refer to as medical immobilization (MI). While most PS in pediatric dentistry is limited to hand guarding and head stability, the term immediately conjures up the image of a papoose board. It should escape no one that MI remains controversial.

Unlike the hand-over-mouth technique (HOM), MI remains in our guidelines and in the acceptable practice of pediatric dentistry, as it does in medical care. MI has been reshaped by societal, safety and ethical shifts as well as advances in other pharmacologic forms of behavior guidance. Its place in our therapeutic toolkit has admittedly narrowed, yet MI remains an indicated behavior guidance AUGUST 2 0 2 2

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tool in some clinical situations. The growing difficulty in obtaining operating room access for dental care1 and changing state laws potentially restricting in-office moderate sedation2 in the U.S. suggest that MI will remain in pediatric dental health care for the foreseeable future.

This paper briefly reviews the role of MI and PS, offers qualifiers before their use, builds on some of the concepts in Dr. Dennis Paul Nutter’s article in this issue, suggests an algorithm for application of PS in today’s pediatric dentistry environment and offers illustrations of PS and MI use or better-advised alternatives.

general restraint, MI is typically a single episode limited to the time needed for a procedure, and the short-term and long-term effects of MI in dentistry are simply unknown and can only be surmised. Guidelines and decision tools do exist2,3 and are improved regularly but still lack high-quality evidence and would be best described as expert opinion.

Strong evidence remains elusive.

A Realistic View of MI

The context of MI use has changed from a generation ago. The Fisher-Owens

Evolution of PS Using MI

The terms protective stabilization (PS) and medical immobilization (MI) are often used interchangeably, but MI is the use of a temporary protective stabilization device indicated when alternatives may not be available, not timely or not the best choice. Before sedation and general anesthesia became more common, MI filled a void as dentists attempted to improve safety and technical quality and increase the chances of treatment completion. As with many forms of behavior guidance in dentistry, MI has been, until recently, provider- rather than patient-centered. Dr. Nutter’s article offers a useful 180-degree perspective long overdue. Interestingly, unlike pediatric sedation, MI lacks rigorous evaluation using today’s tri-factorial definition of behavior guidance success: safety, efficacy and long-term impact. The accumulated references and literature basis for MI are outdated, testimonial in nature and largely lacking clinical data.1 In medicine, use of restraint for general behavior management of patients with intellectual disability or behavior disorders has been shaped by a decades-long recognition of institutional abuses, mental health inequities and wider availability of alternatives. In contrast to 466

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Stoicism, dental fatalism, religious aspects of physical contact and other issues all can impact the acceptability of MI.

et al.4 conceptual model of caries initiation is surprisingly useful in delineating the contextual environment in which a provider today decides to use MI: ■ The child. Dr. Nutter’s paper lays out a variety of little understood potential effects of PS on a child, ranging from fear to residual impact on the developing psyche to central pain sensitization. In a patientcentered model, these risks, even without supporting data, take center stage as the dentist weighs risks and benefits along with medical necessity when deciding to use MI. ■ The family. Often only involved in consent issues by the dentist, little is known about the psychological effects of MI use on parents. Parents must juggle a complicated set of

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factors: The medical necessity of the procedure, their innate desire to protect their child, the child’s previous or potential response to MI, their own dental anxiety and history, their feelings and emotions related to their role in the presenting problem and, in some cases, spousal disagreement and limited resources for other choices. In short, consent for MI is not simple. On the other hand, the dentist should consider the implications of withholding this modality, especially from a family facing barriers to care when the dental procedure completed using MI may eliminate unnecessary pain or suffering. If providers exclude patients in poverty from their practice, they may have the luxury of easy access to general anesthesia.

However, these providers must acknowledge the barriers that patients who are uninsured or have public insurance face and recognize that MI may be the compassionate choice for these children.

The community. In our more diverse world, dentists are challenged to understand still another potential conflict within today’s health care where professional and patient perspectives can collide. Townsend et al.5 recently documented the mosaic of opinion about PS/ MI across the world. Stoicism, dental fatalism, religious aspects of physical contact and other issues all can impact the acceptability of MI. The reputational risk of accusations of misuse of MI might further limit use of this technique.

The system. Our health care system impacts use of MI in various ways. Regulatory bodies may inadvertently increase its use by limiting availability or practicality

C D A J O U R N A L , V O L 5 0 , Nº 8

of certain pharmacological behavior guidance options.6 Conversely, they may discourage its use through heightened oversight resulting from parental complaints to licensure bodies. Alternatives to MI are often more expensive and sometimes inaccessible, particularly in the case of long waitlists for general anesthesia. Understandably, MI persists in situations where it may not be the ideal choice due to regulatory, financial and access barriers.

The above builds on Dr. Nutter’s article’s admonition that application of MI isn’t simply a checklist based on professional guidelines, but a far more complex decision, using professional guidelines more as guardrails than guidance. It is not, nor should it be, a simple decision to use MI. The best preparation for safe, compassionate and effective application of MI would be to internalize the previous four concepts influencing the decision to use MI and any advanced behavior guidance tool.

Having a flexible clinical pathway to a sound, sensitive and effective decision should be the ideal, with potential pitfalls identified early and discussed during the consent process if possible.

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The American Academy of Pediatric Dentistry (AAPD) defines PS as an advanced behavior guidance technique.

Aiming for Superlatives

The following terms describe when, where and how to use PS, and these terms should shape clinicians’ decisions to use it and what form it should take. These include: ■ Gentlest. Protective stabilization prompts images of a pedi-wrap or papoose board, but the literature provides numerous examples ranging from sheets and blankets to staff and parental engagement with their relief and satisfaction.7,8 Children with autism spectrum disorder may benefit from MI8 and report comfort

from weighted coverage like a lead apron used for radiographs.9 The least invasive and least traumatizing technique should be employed.

Gentleness conceptually may mean adjunctive emotional support rather than just physical contact.

Shortest. It should be assumed that PS is a later choice on the behavior guidance continuum and that attention to principles proposed in this and Dr. Nutter’s article would limit the length of time PS is used.

Medical application of PS is often

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monitored in increments of 15 to 20 minutes and limited to one hour without review,10 which presumes reevaluation of all aspects of its choice before continuation. For many children, MI can be removed after the procedural step with the highest risk for harm, such as the local anesthesia injection or the final delivery of an extracted tooth, is completed.

Safest. Media reports of broken bones, dislocated joints and bruising have highlighted supposed extremes of PS.11,12 Potential psychological and emotional concerns described in Dr. Nutter’s article are likely tied to potential physical side effects.

The examples at the end of this article speak to choices around PS that consider the range of safety.

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Rarest. The American Academy of Pediatric Dentistry (AAPD) defines PS as an advanced behavior guidance technique.2,3 Inherent in the continuum of intensity of behavior guidance techniques is that basic tools like communication, distraction and tell-show-do are applied in nearly every patient encounter, whereas advanced tools like sedation or general anesthesia are used in special circumstances. PS may be erroneously assumed to be on a continuum, suggesting its frequency is more than pharmacologic. In truth, PS is really meant to be a deadend tangent relegated, as suggested in this article, to situations when either simple or more advanced techniques are not options.

An Algorithm for Safe and Necessary Use of PS

The proposed algorithm (FIGURE ) builds on those of Meyer et al.13,14 for treatment decisions and adds elements both pre- and post-PS application.

Readers are encouraged to look at other algorithms that help guide clinicians through treatment decisions that require balancing medical necessity for a given clinical presentation with behavior guidance guidelines in a potentially emotional real-time crucible.

To build on principles in Dr. Nutter’s article, we posit the following additional principles that are meant to be useful clinically.

■ Establish medical necessity. A valuable insight from Dr. Nutter’s article is that PS is an advanced technique and one that should not be used routinely. Media accounts and dental board complaints about MI being abused for financial purposes15 should be enough to convince anyone that PS is not intended for routine AUGUST 2 0 2 2

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Dental Condition

Basic Behavioral Guidance Techniques

Cooperative

Uncooperative Advanced Behavioral Guidance Techniques

Not Possible Sedation General Anesthesia Not Possible Apply Protective Stabilization Checklist Is procedure medically necessary?

PS/MI

Is alternative behavior guidance available?

Can the condition be resolved?

Conduct Procedure Under Protective Stabilization, Assessing Frequently

Post-Treatment Instructions for Dental Procedure and Post-Protective Stabilization FIGURE . Algorithm for use of protective stabilization/medical immobilization (PS/MI) for dental care.

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Negative Outcome (Uncooperative)

Positive Outcome (Cooperative)

Prepare for Unexpected Outcomes

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care. Defining medical necessity in nonlife-threatening scenarios balances potential risk with common sense. For example, the case of a child or adolescent with autism whose status can only be assessed with PS likely benefits from PS. By using PS for the examination, the dentist can determine whether alternative advanced behavior guidance is needed.

That scenario is commonplace in pediatric dental practice.

Assess the likelihood of treatment completion or achievement of stability.

PS can be an appropriate option in cases where treatment needs to be completed for the child to reach a point of stability. The concept of treatment completion includes managing untoward events during or following a procedure as well as minimizing need for subsequent treatment. A few examples of the previous criteria in pediatric dentistry would be the ability to manage postoperative bleeding complications after a PS-supported tooth extraction (achievement of stability) or choosing to defer completing tooth restoration following a pulp procedure on a primary tooth (treatment completion) requiring an additional treatment session perhaps unnecessarily.

Determine timely alternatives. PS should be the last resort for treatment that cannot wait and for which no alternative advanced behavior guidance technique is available within a reasonable time frame.

Some dentoalveolar trauma can wait and delay may not affect outcomes, such as in a complicated crown fracture of a permanent tooth. In some clinical situations, an antibiotic course may allow better access, more effective local anesthesia and

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a less painful procedure later.

Prepare for possible outcomes, expected or otherwise. Treatment may become more complicated, parental consent may change after viewing the reality of care unfolding, an untoward event may occur, a parent may faint or a child may experience a medical issue. While it isn’t always possible to prepare for every contingency or complication, a pathway for dealing with unexpected outcomes during and/or as the result of PS should be established before using

Postoperative instructions should include debriefing about the child’s reaction to PS as well as the parents’ feelings about what transpired.

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it. Importantly, if parental consent changes, the provider and parent should have a clear understanding before beginning the procedure of what constitutes “the point of no return” – the stage at which treatment must be completed for that patient.

Assess child and parent status frequently. The concept of continuous monitoring during PS has not become as widespread in dentistry as in medicine. As with all other advanced behavior guidance techniques, like sedation or general anesthesia, good practice of PS dictates frequent evaluation of child fear, pain, physiologic status and parental response. In medical application of PS, usually at 15- to 20-minute intervals, the process is

assessed for safety and efficacy and often needs to be reassessed by a physician after these status checks.

It is unlikely that regular recording of status at short intervals will soon become standard or practical. These progress checks likely occur as an internal informal process with dental staff, which is then described in the patient record treatment note postoperatively. Quality and safety steps, such as procedural timeouts and procedure completion status, should also be a part of a PS episode, due to its intensity, and recorded.

■ Account for after-visit care prior to initiation of PS. If circumstances around dental treatment mandate PS, it is prudent to consider aftercare and the difficulties caretakers might encounter in managing healing and homecare procedures. Standard postoperative instructions may fall short. The failure to account for postoperative pain, cooperation and other aspects of aftercare can cause problems that range from irritating to catastrophic.

Postoperative instructions should include debriefing about the child’s reaction to PS as well as the parents’ feelings about what transpired. A discussion would also entail next steps and how to approach future dental visits.

As indicated in the algorithm, future visits might entail some alternate form of advanced or basic behavior guidance.

Use of the memory restructuring behavior guidance technique to help the child cope with a difficult appointment can promote coping and minimize dental fear.16

Some Experiences From the Field

Many pediatric dentists will have both poignant and humorous recollections of PS, and we felt it might be instructive to give case examples from our own experiences, some as recent as the writing AUGUST 2 0 2 2

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protective stabilization C D A J O U R N A L , V O L 5 0 , Nº 8

of this article and some from the past, and our reflections on what transpired.

was a win-win for all.

Case One

The mother of an 8-year-old girl with multiple developmental delays requested MI for a periodic exam and cleaning. The child screamed throughout the procedure.

The dental resident periodically checked in with the mother during the procedure and constantly consoled the child. The young mother was adamant that her daughter “get used to” her frequent health care experiences, including dental care, and said PS is a regular part of many

A 17-month-old child with a vertical complicated crown root fracture on tooth E would not nurse or eat due to pain. She had the tooth extracted with local anesthesia while restrained in a papoose board with mother holding her hand and in sight. Mother declined knee-to-knee treatment due to her own anxiety. The child was engaged and happy at her one-week follow-up.

A host of factors played into use of MI, not the least of which was a worried young mother unsure of her ability to help and a very young child who would not eat. Her age and weight made general anesthesia the only other advanced behavior guidance option, but her age was also a factor in deciding that this event would be lost in the comfort of her mother’s arms and soothing voice immediately after treatment.

Case Three

Case Five

The wisdom of “good cop/ bad cop” is one played out often in pediatric dentistry.

Case Two

A 10-year-old boy with an abscessed maxillary second primary molar and week-long pain refused treatment in spite of parental firmness to do so. The father exited the operatory in frustration. The pediatric dentist offered basic behavior guidance if the child would be cooperative, but said he would “bring in the muscle” to hold him if needed, pointing to an athletically built resident and staff member.

The boy uttered, “No muscle, no muscle,” cooperated for care, which was uneventful, and was praised by staff and his parent as he left smiling, proud of his courage, with his tooth to brag on with his friends.

The wisdom of “good cop/bad cop” is one played out often in pediatric dentistry.

For this boy on the cusp of puberty, this decision was probably a hard one, but one that demonstrated a small step toward maturity. In this case, PS was not used and the outcome 470

AUGUST 2 0 2 2

refused to leave the car. The dentist asked her family to help restrain and comfort her while removing the offending tooth in the car under local anesthesia. Ten minutes postoperatively, the teen was laughing and walking hand-in-hand with her mother in the parking lot.

This may be as unorthodox a case of PS as exists, but 40 years ago, there weren’t many good alternatives. The dentist clearly read the family’s despair, the child’s fear and the child’s inability to cooperate before engaging the family in the best way possible.

The power of love and caring by family and provider may be the best psychological salve we can call on when PS is needed.

health care visits. Mom rewarded her daughter with praise and reassurance and the dental staff did as well.

Unless you live every day with a child with special health care needs, as this single mother does, it is hard to argue that her operant conditioning leading to an acceptance of life’s realities was a bad thing.

In this case, MI was employed effectively for routine preventive care. At some point, hopefully, this child will say she does not need PS and will enjoy the satisfaction of accomplishment on her own terms.

Case Four

A 17-year-old with significant intellectual disability sat in the backseat of a car after she and her family traveled several hundred miles through the night to find a dentist to treat her pain. She

A 10-year-old boy with autism had done well with tell-show-do and other basic behavior guidance in previous visits, but today was pacing and clearly agitated. Using a camping and sleeping bag metaphor to explain the papoose board, the dentist completed restorative treatment under local anesthesia and the boy was perfectly still throughout the appointment and left smiling.

This successful use of MI brought together advanced and basic behavior guidance to achieve positive emotional and dental outcomes. It was both ethical, clever and consistent with behavioral guidelines to relate MI to familiar positive experiences and administer it with the overlay of ongoing communicative behavior guidance. Imagery like seat belts, burritos, snuggling, car seats and other positive associations have all been used to desensitize children for MI.

Case Six

An obese 16-year-old teenager with significant intellectual disability was seen on emergency for dental pain and cellulitis and placed, with assistance from the parents and several staff, into a large papoose board on a reclined dental chair.

C D A J O U R N A L , V O L 5 0 , Nº 8

Her negative and violent reaction early in the experience caused her to struggle to escape and ended with her, still wrapped, falling off the chair, being bruised and then traveling to an emergency department for physical examination for injury and treatment of the offending tooth.

The lesson here may be no good deed goes unpunished, think twice before you act or both. The better approach might have been to use the child’s trust of her parents to gain a view of the dental situation and then consider available options. Physical injury with ill-advised MI or PS is always a risk to be considered a priori at any age.

Summary

The decision to complete dental treatment with protective stabilization is often a marriage of psychology and surgery, where decision-making balances both seen and unseen psychological trauma with medically necessary treatment. Use of PS and MI in dentistry has undoubtedly at times been inappropriate, resulting in harm to children and the profession’s image, but also been successful in reducing pain and suffering, with no untoward short- or long-term effects. Every tool in the pediatric dentist’s toolbox has potential for abuse, whether it be unsafe in-office sedation, inappropriate use of stainless-steel crowns or overuse of general anesthesia. The profession should not discard a modality based on risk of abuse alone and should test its safety and utility through the use of guidelines based on evidence and clinical research and practice. It is doubtful that PS will leave our armamentarium soon nor would that be desirable as it allows us another care option, after weighing its risks and benefits.

Greater awareness of its possible effects and potential risks serves both patients and providers well. This article and Dr. Nutter’s should help set a practitioner’s compass in caring for those challenging patients

for whom PS and MI may be the best or worst choice of behavior guidance. n RE FE RE N CE S 1. Vo A, Casamassimo PS, Peng J, Litch CS, Hammersmith K., Amini H. Denial of operating room access for pediatric dental treatment: A national survey. Pediatr Dent 2021; 43(1):33–41.

2. Coté CJ, Raeford EB, Kaplan A. The single-clinicianoperator/anesthetist model for dental deep sedation/ anesthesia: A major safety issue for children. JAMA Pediatr 2019 Dec 1;173(12):1127–1128. doi: 10.1001/ jamapediatrics.2019.3823.

3. American Academy of Pediatric Dentistry. Behavior guidance for the pediatric dental patient. The Reference Manual of Pediatric Dentistry. Chicago: American Academy of Pediatric Dentistry; 2021:306-24.

4. Fisher-Owens SA, Gansky SA, Platt LJ, Weintraub JA, et al. Influences on children’s oral health: A conceptual model.

Pediatrics 2007 Sep;120(3):e510–20. doi: 10.1542/ peds.2006-3084.

5. Townsend JA, Peng J, McDaniel JC, Casamassimo PS. Acceptability of medical immobilization: results from a pilot international survey. Int J Paediatr Dent 2021 Dec 19. doi: 10.1111/ipd.12948. Online ahead of print.

6. Lee H. California doesn’t ensure the safe use of sedation on kids at the dentist. As an anesthesiologist, I’m worried. San Francisco Chronicle, Jan. 3, 2022.

7. Malik P, Ferraz Dos Santos B, Gerard F, Hovey R, Bedos C. Physical restraint in pediatric dentistry: The lived experiences of parents. JDR Clin Trans Res 2021 Oct 10;23800844211041952. doi: 10.1177/23800844211041952. Online ahead of print.

8. National Council on Severe Autism. In dental care for severe autism, a papoose board comes to the rescue. Nov. 8, 2019.

Accessed March 27, 2022.

9. Nelson, Travis M., et al. Educational and therapeutic behavioral approaches to providing dental care for patients with autism spectrum disorder. Spec Care Dentist May–Jun 2015;35(3):105–13. doi: 10.1111/scd.12101. Epub 2014 Dec 3.

10. Recupero PR, et al. Restraint and seclusion in psychiatric treatment settings: Regulation, case law and risk management.

J Am Acad Psychiatry Law 2011;39(4):465–76.

11. Associated Press. Dentist accused of breaking boy’s leg gives up his license. New York Times, Nov. 2, 2000. Accessed March 27, 2022.

12. Adams C. Pediatric dentist, 78, accused of torture, choking kids and performing painful procedures without anesthetic for decades. Daily Mail, May 8, 2015. Accessed March 28, 2022.

13. Meyer BD, Lee JY, Thikkurissy S, Casamassimo PS, Vann WF. An algorithm-based approach for managing dental caries and behavior in young uncooperative children. Pediatr Dent 2018 Mar 15;40(2):89–92.

14. Meyer B, Casamassimo PS, Vann WF. An algorithm for managing emergent dental conditions for children. J Clin Pediatr Dent 2019;43(3):201–206. doi: 10.17796/10534625-43.3.10. Epub 2019 Apr 9.

15. Domino D. Small Smiles agrees to $39 M settlement in mistreatment lawsuit. DrBicuspid.com, May 12, 2015.

Accessed March 28, 2022.

16. Pickrell JE, Heima M, Weinstein P, Coolidge T, Coldwell SE, Skaret E, Castillo J, Milgrom P. Using memory restructuring strategy to enhance dental behaviour. Int J Paediatr Dent 2007 Nov;17(6):439–48. doi: 10.1111/j.1365263X.2007.00873.x.

T HE CORRE S P ON DIN G AU T HOR , Paul S. Casamassimo, DDS, MS, can be reached at Paul.Casamassimo@nationwidechildrens.org.

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PRACTICE SALES • VALUATIONS/APPRAISALS • TRANSITION PLANNING • PARTNERSHIPS • MERGERS • ASSOCIATESHIPS SONOMA COUNTY: Price Adjustment! Large GP, 2019 GR $2.3M BRENTWOOD: New Listing! 4 Ops, +. Stand-alone 3,000 sf prime Real Estate, 72 NP/mo. & 10 Hyg Days. 6 professionally designed, Dentrix, Ops, Pano, Dexis, Cameras, Laser, Paperless, Laser, great location. 2019 GR $520K on 2.5 day week. #CA3008 Dentrix. Both Business & RE for sale or Lease. Doctor Retiring. #CA544 FAIRFIELD/VALLEJO AREA: 7 Ops, Paperless practice in a high-traffic SONOMA COUNTY: 4 Ops in spacious layout in heart of the area off area. Digital, CEREC with 43 yrs. main highway. Est 22 yrs with 5-star Goodwill. 2021 GR $1.5M. #3117 FAIRFIELD AREA: High traffic area, Google reviews, Paperless with CEREC, Scope, Laser, Strong hyg. Retiring 7 Ops Digital, Pano/CB, 23+ NP/mo. with 8+ Hyg. days/wk. Room to grow seller. 2019 GR $782K with good postCOVID recovery. #CA2594 with specialties. 2019 GR $1.7M and SONOMA COUNTY: Price Reduced!

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Laser, and Digital Pano. #CA2850 Goodwill. 2021 GR $1.4M. #3118 S. SACRAMENTO/POCKET ROAD/ PLEASANTON: New Listing! Great ELK GROVE AREA: 5 Ops, neighborhood practice, paperless, digital, 6 Ops, 5 equipped. Don’t miss Paperless, Digital X-ray, Soft Tissue Lase, Pano X-ray, CEREC. 73 yrs. opportunity in this great community.

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missed appointments C D A J O U R N A L , V O L 5 0 , Nº 8

Missed Dental Care Appointments in an Urban Safety Net Hospital Katheryn Goldman, DMD, MPH, ABD; Muath A. Aldosari, BDS, MPH, DMSc; and Keri Discepolo DDS, MPH

abstract Background: A paucity of literature has focused specifically on the sociodemographic and concrete resources available to patients who have missed pediatric dental care appointments in the United States.

This pilot study aims to assess the factors associated with missing dental care appointments among pediatric patients visiting a hospital-based dental clinic. Specifically evaluated is the association between both the guardian’s adverse childhood experience (ACE) and access to concrete supports to determine how they relate to missed dental appointments.

Methods: This study is a cross-sectional analysis of 150 randomly sampled pediatric patients who visited the dental clinic at a large urban children’s hospital in July 2019. Of those identified, 30 random guardians were interviewed via simple random sampling using the modified ACE questionnaire and surveyed for access to concrete supports.

Results: The average number of missed dental care appointments was 10.6%. The majority of children who missed >10% of dental care appointments were Hispanic (54.6%), non-Hispanic Black (44.4%) utilizing public insurance (41.6%) and living in low-income neighborhoods (46.8%) and within 10 miles from the hospital (43.8%). Of those interviewed, 20% of families were found to have high-risk ACE scores.

Conclusions: This study illustrates a targeted demographic and identifies adverse experiences and access to concrete supports.

Practical implications: The research reinforces the value of identifying vulnerable populations through trends in care utilization and also is suggestive of the benefit of social resource involvement in the dental setting.

Keywords: Health care disparities, oral health, child health services, behavioral risk factor, surveillance system, health knowledge, attitudes, practice, vulnerable populations

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AUTHORS Katheryn Goldman, DMD, MPH, ABD, attended dental school at the University of Pennsylvania. She earned a Master of Public Health degree from SUNY-Albany where she was inducted into the Delta Omega National Public Health Honor Society. She completed her pediatric dental residency at Boston Children’s HospitalHarvard University and is a diplomate of the American Board of Pediatric Dentistry.

Dr. Goldman is currently completing a PhD program in social welfare at the Wurzweiler School of Social Work.

Muath A. Aldosari, BDS, MPH, DMSc, received his Master of Public Health in epidemiological methods and biostatistical analysis from the Johns Hopkins University Bloomberg School of Public Health.

Dr. Muath then joined the Harvard School of Dental Medicine for his doctoral degree, where he focused his research on the evaluation of school-based delivery of dental services.

He is an assistant professor at King Saud University in Riyadh, Saudi Arabia.

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Keri Discepolo, DDS, MPH, is a board-certified diplomate of the American Board of Pediatric Dentistry and a fellow of the American Academy of Pediatric Dentistry. She was awarded her DDS from the New York University School of Dentistry. Dr. Discepolo received her training in pediatric dentistry at the Yale New Haven Hospital/ Yale School of Medicine and was awarded a Master of Public Health from the Mailman School of Public Health, Columbia University.

She is a clinical associate professor of pediatric dentistry and acting chair for the department of pediatric dentistry at the Boston University Henry M. Goldman School of Dental Medicine.

Conflict of Interest Disclosure: None reported for any of the authors.

A

n estimated 23% to 34% of outpatient medical care appointments in the United States are missed annually.1 Missed health care appointments can be a prediction of poorer health outcomes.1 Investigations have shown risk factors for missed dental care appointments to include forgetfulness, confusion surrounding appointment schedule and utilization of public insurance.2–4 Health-seeking behaviors can also be subjectively related to perceived need and the patient’s value of care.5–7 Those of racial minority background are particularly vulnerable to the obstacles of accessing preventive health care and are susceptible to poor oral health outcomes.8 One study of appointments in the dental setting found patients who were Black and those categorized racially as “other” missed significantly higher numbers of appointments than all other groups of patients, and research that emphasizes health communication with a specific focus on racial minority patients, particularly in the dental setting, is needed.9,10 In a pediatric dental context, children with a “high” caries-risk assignment during their first dental visit have 1.7 times the odds of missing more than 20% of all scheduled appointments compared to children with “low” caries risk.2 The causes of missed dental appointments are multifaceted and warrant further investigation.

Existing literature has demonstrated that individuals with high adverse childhood experience (ACEs) scores had more late-canceled and no-show medical appointments than those with no ACE scores.11 Other research has demonstrated that ACE exposure of mothers is negatively associated with follow-through with preventive health care visits among their children in early

life.12 Because caregivers’ responsibilities are planning and transporting children to dental appointments, it is possible to hypothesize that parental ACEs scores may correlate with missed pediatric dental appointments.

Existing literature focuses on missed medical care appointments and outcomes of those missed appointments.13 Sociodemographic and concrete resources have not been studied as extensively with respect to missed pediatric dental care appointments in the United States.

Studies outside of the United States have shown that low socioeconomic status, young age of the patient, large unstable family structure and previously broken appointments are all significantly correlated with a missed appointment.11,12 Access to concrete supports can be a useful indicator of some of the socioenvironmental factors that may impact care decisions. Access to concrete supports may also prevent unintentional neglect, such as failure to follow through with dental appointments, when families are unable to adequately provide for their children.14 While existing studies offer important insight into global trends in care utilization, it is important to evaluate sociodemographic barriers that are specific to the social structures of families living in the United States.

Therefore, this study aims to evaluate characteristics of those patients who miss dental care appointments

Methods

This pilot study is a cross-sectional quantitative analysis of patients who visited the dental clinic at a large urban children’s hospital in the Northeast.

Institutional review board approval was obtained through the hospital. The sample population consisted of primary caregivers of children of English-speaking

C D A J O U R N A L , V O L 5 0 , Nº 8

TABLE 1

Descriptive Characteristics of the Sampled Patients From the Dental Department Characteristics

N

Proportion (%)

Total

150

100

Age 0—5 6—12 13—17

18 65 67

12.0 43.3 44.7

46 36 15 22 10 21

30.7 24.0 10.0 14.7 6.7 14.0

101 40 3 6

67.3 26.7 2.0 4.0

Race White Black Asian Hispanic/Latino Other Did not report Dental insurance Public Private None Both

Presence of untreated dental caries Yes No

26 124

17.3 82.7

ZIP code median annual income < 65,000 65,000—89,000 ≥ 90,000

62 39 49

41.3 26.0 32.7

Distance from the hospital 48.7 73 Less than 10 miles 20.7 31 10—30 miles 30.7 46 More than 30 miles Proportion of missed medical care opportunities 10% or less More than 10%

102 48

68.0 32.0

families, with children aged 0 to less than 18 years who had a dental appointment scheduled in the month of July 2019 and who had at least one continuity of care visit scheduled in the department in the past two years. The month of July was selected for the temporal frame, as school is not in session during this time. Families may have less conflict in attending dental appointments and trends in missed dental care appointments could be more closely reviewed excluding scheduling conflicts due to school hours. All patients who were

scheduled during this time frame were contacted and given the opportunity to decline from participation in the study and chart review via email notification.

Out of 1,140 patients, a random number generator was utilized to contact caregivers to participate in a phone interview until 30 caregivers agreed to participate in order to pilot the desired questionnaires. The caregivers’ children’s charts were also evaluated for review. These participants were utilized to pilot the use of a modified version of the validated Behavioral Risk Factor Surveillance System (BRFSS) survey and the Protective Factors second-edition survey (PFS-2). The sample size was selected to enable us to detect a difference in proportion of missed dental appointments by one standard deviation between groups, with 0.8 power and alpha set at 0.05.

An additional 120 charts of patients whose caregivers were not contacted to be surveyed were selected for a clinical chart review by a simple random sample utilizing a random number generator. This chart review was completed in order to understand general trends in care utilization and characteristics of individuals who missed dental appointments and to provide a comparative reference to the specific trends seen in care utilization and characteristics of individuals in the interview group. Interviews were conducted by a single provider in order to maintain consistency and reliability.

Verbal consent was obtained by interviewees and a copy of the consent was emailed to the family after participation.

A gift card raffle was used as an incentive to complete the surveys. As previously noted, the study piloted the use of a modified version of the validated BRFSS, consolidating questions specific to in-

depth discussions of sexual abuse, which we did not believe were pertinent to this study and the PFS-2. The study was chosen to be a pilot to evaluate the applicability of these surveys in terms of the feasibility of use in a dental setting as well as the ability to acquire participation by parents and caregivers given the sensitive nature of the questionnaire and the lack of surface-level connection to dentistry. The modified BRFSS questionnaire, which asks questions in regard to an individual’s exposure to childhood abuse and neglect, measured caregivers’ ACEs. A higher score represents higher risk for ACEs. Based on their score, we categorized caregivers into low (0-1), medium (2-3) and high (4+) risk for ACEs. The PFS-2 is utilized with caregivers participating in family support and child maltreatment services and evaluates familial protective factors to prevent child abuse. We specifically focused on concrete supports and questions relating to the subject’s ability to pay rent, utilities, child care services, etc. Our modified version of this questionnaire grouped individuals into low (0-3), medium (4-6) and high (7+) accessibility to concrete support.

Patients’ attendance and missed dental care appointments (outcomes) were collected from their clinical charts. Based on the proportion of missed dental care appointments, we dichotomized our outcome of interest to children with 10% or less missed dental care appointments and children with more than 10% missed dental care appointments. In addition, we collected information about their nondental care appointments in the hospital for comparison. To quantify oral health, we recorded the presence of untreated dental caries. Demographic and insurance information was collected, and ZIP codes were used to approximate the distance traveled to their appointment AUGUST 2 0 2 2

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missed appointments C D A J O U R N A L , V O L 5 0 , Nº 8

TABLE 2

Average Scores Among Surveyed Guardians of Children Visiting the Dental Department Caregivers’ adverse childhood experience (ACE) Average score ± SD*

2.0 ± 2.0 N

Proportion (%)

30

100

Low risk (Score 0—1)

16

53.5

Medium risk (Score 2—3)

8

26.7

High risk (Score 4—5+)

6

20.0

Total Groups

Results

Guardians’ reported level of concrete supports Average score ± SD*

2.2 ± 2.6 N

Proportion (%)

30

100

High support (Score 7+)

22

73.3

Medium support (Score 4—6)

4

13.3

Low support (Score 0—3)

4

13.3

Total Groups

*Higher score represents higher risk for ACE or better access concrete support.

and the family median income. Income categories were calculated utilizing data published by the Pew Research Center data for 2018 utilizing the income tiers.15 Descriptive analysis was done first to report the characteristics of our sample.

Then, Fisher’s Exact Test was used to assess if there were differences in these characteristics between the outcome groups: patients who missed 10% or less of their dental care appointments compared to children with more than 10% missed dental care appointments.

The Mann–Whitney two-sample nonparametric test was employed to compare the ACE and PFS scores between 476

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the outcome groups. The differences deemed statistically significant at p value of 0.05. All statistical analyses were performed using Stata/SE Version 15.1 (StataCorp, College Station, Texas).

For the study, 120 patient charts were reviewed without interviews, and 30 patients consented out of 109 to complete the survey (27.5% response rate) and have their child’s chart reviewed. The average proportion of missed appointments was 10.6% for dental care appointments and 10.5% for medical care appointments.

The majority of our sample (44.7%) were adolescents between ages 13-17 with permanent dentition (TA BLE 1 ). Nearly 1 in 5 (17.3%) children had untreated caries and more than half (67%) were covered only by public dental insurance. A third of our sample (30.7%) lived in a neighborhood more than 30 miles away from the hospital, and 41.3% resided in low-income neighborhoods.

One in 5 (20.0%, P = 0.06) of the caregivers were categorized as high-risk for ACE, and 46.7% of caregivers reported at least two or more adverse childhood experiences. On the other hand, 73.3% (P = 0.04) of caregivers had high access to concrete supports. The differences between ACE and concrete support scores were not statistically significant between guardians who missed 10% or less dental care appointments compared to those who missed more than 10% in ACE score (p-value = 0.60) or concrete support score (p value = 0.41). TA BLE 2 demonstrates the average ACE and concrete support scores of guardians surveyed.

TA BLE 3 compares the proportion of missed dental care appointments with the children’s sociodemographic characteristics. Children who were less likely to miss their dental appointments

were of Asian descent (6.7%), while 54.6% of Hispanic/Latino children missed more than 10% of dental care appointments (p-value < 0.01). Of the patients who missed > 10% of dental care appointments, the majority of them (41.3%) had public dental insurance, followed by the noninsured (33.3%) (p-value < 0.01). In addition, 77.1% of patients with ≤ 10% of missed hospital care appointments had also missed ≤ 10% of all dental care appointments (p-value < 0.01). Two in 5 patients (43.8%) who lived within 10 miles of the hospital missed > 10 of their dental care appointments (p-value = 0.03), and a similar proportion of children living in low-income neighborhoods (46.8%) missed >10 of their dental care appointments (p-value 0.03).

Discussion

The data from this study indicate that Black and Latino, low socioeconomic status families and families living in an urban environment (less than 10 miles from the hospital), represent the largest proportions of patients with > 10% of missed dental care appointments.

Utilizing public insurance was also associated with higher missed dental care appointments. In congruence with the public discussion that is currently occurring across the United States, the data is suggestive of structural inequalities in place that inhibit the aforementioned demographic groups from utilizing pediatric dental care to the same capacity as their white, high socioeconomic status, suburban counterparts. It has been noted that the intersectionality of race and socioeconomic status produces complex patterns of inequality in community life and neighborhood norms, and that adverse conditions and stressors at the neighborhood level were found to be

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TABLE 3

Missed Dental Appointments by Children’s Sociodemographic Characteristics Among Patients Visiting the Dental Department Variables

Total

Children missed ≤ 10% of dental care opportunities

Children missed >10% of dental care opportunities

N

%*

N

%

100

66.7

50

33.3

13 38 49

72.2 58.5 73.1

5 27 18

27.8 41.5 26.9

0.19

37 20 14 10 2 17

80.4 55.6 93.3 45.5 20.0 81.0

9 16 1 12 8 4

19.6 44.4 6.7 54.6 80.0 19.1

< 0.01

59 43 2 5

58.4 85.0 66.7 83.3

42 6 1 1

41.6 15.0 33.3 16.7

< 0.01

70.2 50.0

37 13

29.8 50.0

0.07

53.2 69.2 81.6

29 12 9

46.8 30.8 18.4

< 0.01

56.2 77.4 76.1

32 7 11

43.8 22.6 23.9

0.03

13 37

12.8 77.1

< 0.01

p-value†

Age 0—5 6—12 13—17 Race White Black Asian Hispanic/Latino Other Did not report Dental insurance Public Private None Both

Presence of untreated dental caries Yes No

87 13

ZIP code median annual income < 65,000 65,000—89,999 ≥ 90,000

33 27 40

Distance from the hospital Less than 10 miles 10—30 miles More than 30 miles

41 24 35

Proportion of medical care opportunities missed 10% or less More than 10%

89 11

87.6 22.9

*Row percentage represents †based on two-sided Fisher’s exact test.

more pronounced among low-income Black parents; such stressors may have had a subsequent impact that led to inequities of care utilization.14 Larger demographic data trends found in the U.S. population support the trends found in our study. As of 2016, 19% of all children in the U.S. live in poverty.16 By race and ethnicity, this amounts to 34% of Black

children and 28% of Hispanic children, compared with 12% of white children.16 Out of the children who missed >10% of dental care appointments, 74% of them had untreated caries. This could be related to missing dental appointments and therefore not receiving care, which demonstrates the consequences that barriers to care utilization can have on

a child’s oral health. As found in the literature, having a history of broken dental appointments has a significant association with caries outcomes.2 The relationship between untreated caries and missed dental appointments could also be due to the fact that the populations at risk for missing dental appointments are also at high risk for having untreated caries. Research has shown in one study that non-Hispanic and Black youth had the highest prevalence of untreated caries and that the prevalence of untreated caries increased as the family income level decreased.17 Missed appointments have been associated with medical complexity and mental illness; emergency room utilization has shown to have a negative correlation to attending appointments.18 Importantly, access to specialized care or continuity care can be disproportionate for Black or Hispanic patients when compared to their white peers.3,18 Significant differences in psychosocial stress exposure by race/ethnicity have been demonstrated to also be a predictor in oral health care usage.12 As these individuals age, it is predicted they will have more instances of undiagnosed conditions with respect to oral health, which can lead to lifelong consequences.19,20 Furthermore, the demonstration of these trends in a smaller data set such as this one, while limited in generalizability due to its size, follow trends that are reflective of greater national trends demonstrating racial and socioeconomic inequality, indicating how deeply inequity is ingrained into the health care system in the United States.

The survey data offered valuable information regarding family resources that could be collected in a dental setting to gain a more comprehensive understanding of a family’s social background. For example, 46.7% of parents reported at least two or more AUGUST 2 0 2 2

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adverse childhood experiences, indicating the importance of trauma-informed care, not only with children but with their caregivers as well. The survey data also indicated that 73.3% of caregivers reported high access to concrete supports.

This could demonstrate that the patient families surveyed feel secure in their ability to access basic needs including food, shelter and clothing. However, we must also acknowledge that the families may have overreported access to concrete supports as response bias. For example, families may feel embarrassed to report difficulty paying for groceries or meeting other basic needs and will overreport their ability to meet those needs. Disseminating data in a written format, as opposed to a verbal questionnaire, may change the way families respond to sensitive questions relating to security surrounding concrete supports. It is also important to note that phone survey response rates are declining.

In 2018, the Pew Research Center reported 6% as the average response rate for phone surveys.21 While our survey data had a much higher response rate, 27.5%, we believe this may be due to the fact a dental provider conducted the survey and allowed herself to be identified with her full name and title. Due to the hesitancy of the subjects noted during the collection of these surveys, written questionnaires may be more appropriate in future research, given the national decline in participation in phone surveys. Even though the data set was small, the information gathered about patient families demonstrated that certain questions from modified versions of validated BRFSS and PFS-2 surveys may be useful in family questionnaires to establish a more nuanced understanding of a history of family trauma and resources available to the family that may influence a family’s oral health practices or care utilization.

Our dental setting afforded the 478

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opportunity to review medical records due to our integrated system. Many institutions throughout the United States are moving toward this type of integration. The nuanced information provides specific information around medical missed appointments and social information that may not be part of the routine discussion in the dental setting.

Utilizing more of this information to inform approaches to care or identifying possible barriers to obtaining care should be our goal as a health care system.

In addition to piloting ways of gaining

This study supports the existing literature that missed dental care appointments are associated with overall incomplete use of health services. a more nuanced understanding of a family’s social history, the study evaluated a multitude of characteristics that could impact a family’s dental care utilization.

The variables that demonstrated a significant relationship with pediatric dental care utilization were (i) race of the child, (ii) median household income by ZIP code, (iii) distance from the hospital, (iv) missed medical care appointments and (v) insurance.

It is important to note that the study did not collect specific socioeconomic variables such as the family’s individual household income. However, the results of the study demonstrate the power of the living environment on health outcomes and further support existing research that has linked community social characteristics with

variations in individual-level health.17 Missed dental appointments should be evaluated in the context of oral health care and oral health needs. Recently, recommendations have emerged that focus on enhancing health care provider education about the causes of racial and ethnic disparities that affect health care access and delivery. An important goal for providers should be improved understanding of the existence and magnitude of disparities and health care obstacles that patients face.22,23 Our data suggests that barriers extend beyond just oral health care utilization; furthermore, this study supports the existing literature that missed dental care appointments are associated with overall incomplete use of health services.4 Therefore, issues of care utilization can impact both a child’s systemic and oral health and subsequently emphasize the importance of an intersectional approach to helping families with care utilization in order to support vulnerable populations and achieve optimal health care use and patient outcomes. The research reinforces the value of identifying vulnerable populations through trends in care utilization and is suggestive of the benefit of social resource involvement in the dental setting. Follow-up research will be required to identify what specific factors prevent dental care utilization in order to target resources to the specific needs of the patient population to increase ease of service utilization.

Limitations

It is important to acknowledge that a small number of patients and families surveyed for this study were sampled from a single hospital in an urban setting in the Northeast, therefore the results cannot infer generalizability. Future research should replicate this study in a larger patient

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pool within various practice settings to see how, and if, trends change across geographic and care environments. n RE FEREN CE S 1.Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998 May;14(4):245–58. doi: 10.1016/s0749-3797(98)00017-8.

2. American Academy of Pediatric Dentistry. Predictive model for caries risk based on determinants of health available to primary care providers. Accessed July 24, 2020.

3. Baskaradoss JK. The association between oral health literacy and missed dental appointments. J Am Dent Assoc 11 2016;147(11):867–874. doi:10.1016/j.adaj.2016.05.011.

Epub 2016 Aug 3.

4. Iben P, Kanellis MJ, Warren J. Appointment-keeping behavior of Medicaid-enrolled pediatric dental patients in eastern Iowa. Pediatr Dent Jul–Aug 2000;22(4):325–9.

5. Lacy NL, Paulman A, Reuter MD, Lovejoy B. Why we don’t come: Patient perceptions on no-shows. Ann Fam Med 2004 Nov–Dec 2004;2(6):541–5. doi:10.1370/afm.123. PMCID: PMC1466756.

6. Hwang AS, Atlas SJ, Cronin P, et al. Appointment “noshows” are an independent predictor of subsequent quality of care and resource utilization outcomes. J Gen Intern Med 2015 Oct;30(10):1426–33. doi:10.1007/s11606-0153252-3. PMCID: PMC4579240.

7. Nelson TM, Berg JH, Bell JF, Leggott PJ, Seminario AL. Assessing the effectiveness of text messages as appointment reminders in a pediatric dental setting. J Am Dent Assoc 2011 Apr;142(4):397–405. doi:10.14219/jada.

archive.2011.0194.

8. Como DH, Stein Duker LI, Polido JC, Cermak SA. The persistence of oral health disparities for African American children: A scoping review. Int J Environ Res Public Health 2019 Feb;16(5):710. doi:10.3390/ijerph16050710.

PMCID: PMC6427601.

9. Lynn JV, Ranganathan K, Bageris MH, Hart-Johnson T, Buchman SR, Blackwood RA. Sociodemographic predictors of missed appointments among patients with cleft lip and palate.

Cleft Palate Craniofac J 2018 Nov;55(10):1440–1446. doi:10.1177/1055665618764739. Epub 2018 Mar 23.

10. Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. In: Stith A, ed. Washington, D.C.: National Academies Press (U.S); 2003.

11. Simons D, Pearson N, Dittu A. Why are vulnerable children not brought to their dental appointments? Br Dent J 2015 Jul;219(2):61–5. doi:10.1038/sj.bdj.2015.556.

12. Bhatia R, C Vora E, Panda A. Pediatric dental appointments no-show: Rates and reasons. Int J Clin Pediatr Dent May–Jun 2018;11(3):171–176. doi:10.5005/jp-journals 100051506. Epub 2018 Jun 1. PMCID: PMC6102432.

13. Menasce Horowitz, J, Igielnik R, Kochhar R. Trends in U.S. income and wealth inequality. Pew Charitable Trusts. Accessed July 1, 2014.

14. Henry DA, Miller P, Votruba-Drzal E, Parr AK. Safe and sound? Exploring parents’ perceptions of neighborhood safety at the nexus of race and socioeconomic status. Adv Child Dev Behav 2019;57:281–313. doi:10.1016/ bs.acdb.2019.05.001. Epub 2019 Jun 20.

15. Pew Charitable Trusts. Falling Short on Dental Sealants: Connecticut.

16. The Anne E. Casey Foundation. Children in poverty by race and ethnicity. Aug. 3, 2020.

17. Sampson RJ. The neighborhood context of well-being.

Perspect Biol Med Summer 2003;46(3 Suppl):S53–64.

18. Shimotsu S, Roehrl A, McCarty M, et al. Increased Likelihood of Missed Appointments (“No Shows”) for Racial/Ethnic Minorities in a Safety Net Health System.

J Prim Care Community Health 2016 Jan;7(1):38–40. doi:10.1177/2150131915599980. Epub 2015 Aug 18.

19. Kim EJ, Kim T, Conigliaro J, Liebschutz JM, Paasche-Orlow MK, Hanchate AD. Racial and Ethnic Disparities in Diagnosis of Chronic Medical Conditions in the USA. J Gen Intern Med 2018 Jul;33(7):1116–1123. doi:10.1007/s11606-0184471-1.

20. Torres O, Rothberg MB, Garb J, Ogunneye O, Onyema J, Higgins T. Risk factor model to predict a missed clinic appointment in an urban, academic and underserved setting.

Popul Health Manag 2015 Apr;18(2):131–6. doi:10.1089/ pop.2014.0047.

21. Kennedy C, Hartig H. Response rates in telephone surveys have resumed their decline. Accessed May 30, 2021.

22. Smith WR, Betancourt JR, Wynia MK, et al.

Recommendations for teaching about racial and ethnic disparities in health and health care. Ann Intern Med 2007 Nov 6;147(9):654–65. doi:10.7326/0003-4819-147-9200711060-00010.

23. Brottman MR, Char DM, Hattori RA, Heeb R, Taff SD. Toward Cultural Competency in Health Care: A Scoping Review of the Diversity and Inclusion Education Literature.

Acad Med 2020 May;95(5):803–813. doi:10.1097/ ACM.0000000000002995.

T HE CORRE S P ON DIN G AU T HOR , Katheryn Goldman, DMD, MPH, can be reached at katheryngoldman1992@gmail.com.

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C D A J O U R N A L , V O L 5 0 , Nº 8

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Enter to win a vacation ($5,000 value) to your choice of three destinations.* Visit The Dentists Insurance Company in booth 712 at CDA’s convention in San Francisco, September 8–10.

• Talk to experts about the right type of protection for you and your practice.

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RM Matters

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When Patients Are Angry: De-escalation and Risk Mitigation Are Vital Tools TDIC Risk Management Staff

I

n some situations, anger can be a good thing. It can provide an outlet to express negative feelings or motivate the search for solutions to problems.

But when an angry patient manifests their feelings into threatening behavior such as yelling, cursing, stalking or even violence, practice owners must intervene.

As employers, they are obligated to provide a safe working environment for their staff, one in which employees are not fearful for their own safety. Caution should be taken to address threats to the well-being of staff just as seriously as threats to the practice owner.

The Dentists Insurance Company’s Risk Management Advice Line, which provides guidance to TDIC policyholders and dental association members, has received an increasing number of calls recently regarding patients who are overly aggressive or display unreasonable anger toward dental providers and staff.

Risk Management Analyst Shelli Macaluso reports, “We get calls where the patients are refusing to leave the office and are acting aggressively, using profanity and making threatening statements while other patients are present. Staff members are usually fearful.” Unfortunately, these matters can escalate to the point where staff and practice owners feel threatened.

The following case studies illustrate how TDIC’s Risk Management analysts have advised practice owners to respond when patient behavior crosses the line from anger to aggression and even outward displays of physical threats or action.

accompanied by both of her parents — as they had on previous visits — was seen for pain in tooth No. 9. The dentist recommended a crown due to a fracture at the gingival crest and placed a temporary crown. The patient was cautioned that the temporary crown had little retention due to the lack of remaining tooth structure and could become loose or fall off.

Therefore, the dentist encouraged her to see the endodontist as soon as possible, as

the existing root canal would need to be retreated.

A few days after the initial treatment, the patient’s mother called the general dentist demanding an immediate appointment, stating the crown had indeed come off. The office scheduled her for an afternoon appointment that same day. The patient arrived an hour early, accompanied by her mother, and began loudly demanding that the dentist fix the

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Case Study One

In one recent call, an adult patient AUGUST 2 0 2 2

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tooth immediately. Both the patient and her mother stated that they were not willing to comply with the endodontic referral and insisted that the dentist “fix” the tooth instead.

Despite the dentist’s assurance that she would see the patient at her scheduled time, the mother became increasingly hostile. There was a waiting room full of patients and every operatory was full.

The mother became more aggressive as she waited with her daughter, causing disruption and concern for other patients and staff. The dentist recognized that the matter was escalating and asked a staff member to call the police. When the police arrived, the patient’s mother continued her tirade and refused to leave.

The officer explained to the parent that her refusal to leave would be treated as unlawful trespassing on private property and instructed her to immediately leave the premises. She again refused, so the officer informed the mother that his next course of action would be to place her in handcuffs and remove her from the premises.

At this point, the patient and parent agreed to leave. Regrettably, before exiting, the parent witnessed a staff member relaying events to the police and reached out and struck the staff member, which resulted in the parent’s arrest by the attending police officer.

When the dentist contacted TDIC’s Advice Line, the Risk Management analyst who took the call assured her that contacting law enforcement had been the best choice and recommended that the next steps should be an immediate patient dismissal and refund for the crown. The dentist did not have reservations about contacting the police but was concerned that the patient was mid-treatment.

Considering the mother’s irrational and violent behaviour, the dentist asked if the mother would now allege that the patient had been abandoned. The analyst advised the 482

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dentist that in this case, the dismissal was justified despite the patient being in the middle of treatment. While the aggressive mother was not a patient, she consistently accompanied her daughter to appointments and clearly posed a threat to the safety of staff.

The analyst reminded the dentist that, as an employer, she has a responsibility to keep her staff safe and prevent exposure to this kind of hostility. The parent was angry enough to physically assault a staff member, therefore injury to patients or staff could possibly occur again in the future.

The analyst reminded the dentist that, as an employer, she has a responsibility to keep her staff safe.

Case Study Two

In another instance, the Advice Line received a call from a dentist right in the midst of an escalating situation.

In this scenario, a large, muscular male patient who was known to be very fearful of dental treatment had presented for his appointment. The dentist and her assistant always spent time trying to comfort the patient and minimize his anxiety. During the call to the Advice Line, the dentist explained to the analyst that despite red flags and signs that the patient could get hostile when upset, she really had a desire to help him. Before treatment, the assistant expressed her concerns to the dentist and was nervous about being near the patient given his intimidating size and what seemed to be a propensity to escalate his behavior toward

physical interaction. The dentist assured the assistant that they were not in danger.

The dentist proceeded with treatment, communicating to the anxious patient that she would be as gentle as possible with him. She cautioned him that he might feel slight discomfort while the anesthetic injection was administered.

During the injection, the patient violently grabbed the dentist’s hand and squeezed it hard enough to cause pain. She withdrew the needle and tried to calm him down without success.

At this point, the patient jumped up, moved aggressively toward the dentist and began to angrily accuse her of intentionally causing him pain. The dentist assured the patient that she did not intentionally hurt him, but the more she talked the angrier he became. The dentist suggested that the patient leave until he was able to discuss his treatment calmly.

The patient left the treatment area, but then entered the front office area where he continued to behave in a way that upset and frightened the office staff. He eventually left the building but lingered outside the office for an extended time pacing back and forth while angrily staring in the windows, which prompted the dentist’s call to the Advice Line.

The Risk Management analyst recommended that the dentist contact law enforcement immediately given the patient’s outward expression of anger, physical interaction with the dentist and menacing behavior outside the office.

Again, this was a situation that warranted immediate dismissal of the patient, so the analyst guided the dentist in the proper documentation and communication.

As a result of her experience with this patient, the dental assistant felt traumatized and later requested to open a workers’ compensation claim as she continued to experience anxiety during patient care following the incident. In

C D A J O U R N A L , V O L 5 0 , Nº 8

hindsight, the dentist realized that downplaying the concerns of her assistant regarding this patient led to unnecessary risk for the entire office.

De-escalation and Mitigation

Patients and their accompanying family members or friends can pose a threat to dentists, staff and other patients when their emotions lead to aggressive behavior. Heightened emotions should never be taken lightly. Physical and verbal threats should be responded to with equal caution, as there is no way to anticipate how far (or fast) a situation will escalate.

Some key communication strategies are important when dealing with angry or aggressive patients.

■ Set boundaries. Have clear expectations of behavior for both patients and staff, along with planned responses for when anyone crosses those boundaries.

■ Remain calm. Always respond with a professional demeanor.

■ Be understanding and empathetic.

Listening is an essential element of communication. Let upset patients know you are willing to hear them out. “Sometimes patients just want to be heard,” Senior Risk Management Analyst Taiba Solaiman explains.

“Sit down with them privately and let them know you understand they are upset and that you are willing to listen to their concerns.

A compassionate ear can go a long way in diffusing a tense situation.”

■ Remember documentation.

Just as you make careful notes regarding treatment in a patient’s chart, you should document any conflicts that arise with a patient.

■ Know when to contact law enforcement. It may not be necessary to contact police every time a patient is upset or confrontational. However,

when a patient refuses to leave the office when asked to do so or engages in behavior including — but not limited to — harassing staff by calling repeatedly, making threats to show up at the office and do harm or physically interacting with anyone in the office, it is appropriate to call the police to intervene. (If you are not in immediate danger, it is advisable to seek guidance from the Risk Management Advice Line when these situations arise).

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 877.269.8844.

Be mindful of the anxiety you and your employees may experience after a traumatic event and provide supportive resources.

Handling unhappy patients can be an unfortunate reality of practice ownership and as these incidents demonstrate, have been on the rise in recent years. On the rare occasion anger escalates to aggression, be mindful of your obligation to provide a safe working environment for your employees. Be mindful of the anxiety you and your employees may experience after a traumatic event and provide supportive resources. Request the aid of law enforcement to assist with de-escalating the situation when needed and seek expert support from TDIC risk management analysts to assist with properly dismissing a patient from care. n

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Regulatory Compliance

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Avoid Problematic Social Media, Marketing Activities CDA Practice Support Last March, the U.S. Department of Health and Human Services Office for Civil Rights (OCR) announced the resolution of three investigations, one of which involved a North Carolina dental practice that impermissibly disclosed a patient’s protected health information on its Google page.1 This was not the first time a dental practice was investigated for impermissibly disclosing a patient’s protected health information on a social media page. In October 2019, the OCR announced it had investigated a complaint by an individual who said their last name, treatment details and more were disclosed on a Texas dental practice’s Yelp review page. The OCR reached a settlement agreement with the dental practice, which also agreed to adopt a corrective action plan.2 “The HIPAA Privacy Rule gives individuals important controls over whether and how their protected health information is used and disclosed for marketing purposes. With limited exceptions, the rule requires an individual’s written authorization before a use or disclosure of their protected health information can be made for marketing,” said OCR Director Jocelyn Samuels in 2016 when commenting on a settlement agreement reached with a physical therapy provider. “All covered entities, including physical therapy providers, must ensure that they have adequate policies and procedures to obtain an individual’s authorization for such purposes, including for posting on a website and/or social media pages, and a valid authorization form.”3

An authorization form must meet both HIPAA and state requirements.

California requires the form be in type no smaller than 14 points. A valid HIPAA authorization form must contain these core elements: ■ A specific and meaningful description of the information to be used or disclosed.

■ The name or other specific

■

■

■

identification of the person or entity authorized to request the use or disclosure.

The name to whom the covered entity may make the requested use or disclosure.

A description of the purpose of the requested use or disclosure.

An expiration date or event for the authorization.

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Signature of the individual and date signed. If the authorization is signed by a personal representative of the individual, a description of such representative’s authority to act for the individual must also be provided.

In addition, certain statements must be included in the form. More information is available on cda.org with the following resources: Consent Form for Use or Disclosure of Patient Health Information, Sample Patient Testimonial Authorization Form and Sample Patient Photograph Authorization Form.

The best practice for responding to online reviews is to keep it simple and positive. Encourage the reviewer to ■

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communicate directly with your practice to address their concerns. Do not mention an individual’s name or confirm that the individual was in the practice.

Incentives for Positive Reviews

Positive online reviews are effective marketing. Given a choice of businesses to patronize, individuals will prioritize customer ratings over location, price or other factors. For this reason, business owners actively solicit customer reviews.

A business, however, should be careful in how it seeks endorsements and positive reviews. The U.S. Federal Trade Commission, which enforces truth-inadvertising laws, earlier this year

promoted guidance for businesses and online platforms to help ensure customers are being provided with honest opinions from actual customers.4 The FTC urges transparency. For example, incentives for favorable reviews should be disclosed. If a dental practice uses a raffle to encourage “likes” on a Facebook page or online reviews, that incentive must be disclosed on the platform. Online platforms are required to treat positive and negative reviews equally.

Incentives for Patient Referrals

Providing incentives for patient referrals is prohibited by the state dental

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practice act.5 For example, you may not provide someone with a gift certificate as thanks for referring a new patient or have prize drawings or other reward systems for those who refer patients to your practice. A licensed individual is prohibited from offering, delivering, accepting any rebate, refund, commission, preference, discount or other consideration as compensation or inducement for referring patients to any person, irrespective of any membership, proprietary interest or co-ownership in or with any person to whom these patients or customers are referred. (“Fee-splitting” is a term commonly used to describe some of these practices.) Be careful to avoid these arrangements, which are sometimes recommended by consultants.

Social Couponing

When using a social couponing company for marketing, a dental practice should be aware of the conditions for appropriate advertising. If a dentist offers or sells services through a third-party website, the third party does not itself recommend, endorse or otherwise select the dentist and the fee paid by the dentist to the third party is

commensurate with the service provided, this type of marketing may not be considered “referral of patients,” which is prohibited in Business & Professions Code Section 650. Other conditions that apply are: ■ The dentist must disclose in the advertisement that a consultation is required and that the purchaser will receive a refund if they are not eligible to receive the advertised service.

■ Any discount-price advertising must include the regular, nondiscounted price for that service.

■ The law does apply to the provision of “basic health care services” or “essential health benefits,” which include medically necessary dental anesthesia and pediatric oral care.

■ The purchaser is entitled to a refund of the full purchase price (as determined in the agreement between the dentist and the third party) if the purchaser elects not to receive the service for any reason and requests a refund or if the dentist determines, after consultation with the purchaser, that the service is not appropriate for the purchaser.

■ The third party must be

■

able to demonstrate that the dentist consented in writing to the above requirements.

The third party must make available to prospective dentist-advertisers all advertisements on its website by other dentists located in the same geographic region. n

RE F E RE N C E S 1. U.S. Department of Health & Human Services. Four HIPAA enforcement actions hold healthcare providers accountable with compliance.

2. U.S. Department of Health & Human Services. Dental practice pays $10,000 to settle social medial disclosures of patients’ protected health information.

3. U.S. Department of Health & Human Services. Physical therapy provider settles violations that it impermissibly disclosed patient information.

4. Atelson M. I’ll pay you to give this blog post five stars. Jan. 25, 2022.

5. California Business and Professions Code Section 650.

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

Durgod Taurus K320 TKL Cherry MX Blue Keyboard ($99, Durgodkeyboard) Despite many users opting to spend top dollar on memory, storage and processing power, there is a thriving high-end keyboard market that focuses on every minutia of the typing experience. Do highend keyboards have a place in a dental practitioner’s office? This review looks at the Durgod Taurus K320 Tenkeyless (TKL) keyboard with Cherry MX Blue keys. On first look, the K320 appears to be a shortened, but standard plastic keyboard without the number pad (hence the term “tenkeyless”). It connects to computers via the included 3-foot USB-C-to-USB-A or USB-C-to-USB-C cables.

Channels under the K320 direct the cable exit in three directions to maintain a neater work surface; adjustable stands underneath allow the keyboard to tilt at steeper angles. The keys themselves are from the famed German company, CHERRY, long regarded as one of the top makers of keyboard keys. Its “Blue” line of keys is one of their heavier models geared toward typists, requiring more force to push, traveling longer, providing an extremely audible “click” on pressing and boasting impressive durability (50 million keystroke durability). All this conveys a high-end keyboard experience, complete with more accurate typing, better tactile feel and possibly improved ergonomics. However, the K320 is not rated for disinfectant use, and its manual clearly states that the keyboard should not be exposed to moisture. For dental offices, the K320 is an excellent choice for computers not exposed to direct patient care, as it provides an improved typing experience. For direct patient care computers, practitioners should look to devices that can be used with disinfectants or even sterilized.

— Alexander Lee, DMD

iSmile Teledentistry (Free, BlueSkyBio) Technological advances in mobile device hardware and software have given providers more options for diagnostic tools to monitor their patients from far away, thereby reducing the frequency of in-person contact necessary for care. One of these tools is iSmile Teledentistry, a mobile app for patients to record video scans or images of their teeth and send them to their provider to track treatment progress. iSmile Teledentistry has two modes for patients to choose from: monitoring and simulation. Simulation mode is simple and does not require a login to use. Patients simply follow the prompts given by the app to take an optimal selfie picture of their smiling face. The app processes the image and provides the patient with a before and after simulation of how a perfect smile would appear on themselves. Simulation mode is only used to generate a discussion with a patient about their smile and does not take into consideration any other conditions. Monitoring mode requires the provider to have a BlueSkyBio digital product account, which includes LabPronto and BioBigBox, a HIPAA-compliant file storage platform. Providers can sign up for a free account on the web and have the option to upgrade to paid subscription plans based on their practice needs. Through this account, providers can add patients to their BioBigBox with a name, mobile number and email address. From the BioBigBox patient list, providers can then request video scans or images of a patient to monitor treatment progress.

Patients receive text and email notifications indicating their provider has requested progress video scans or images with a link that takes them directly into the monitoring mode of the iSmile Teledentistry app where they can login using their mobile number or email address. Patients follow a tutorial to acquire and send the video scans and images ordered by the provider. Scanning requires a special scope that attaches to the mobile device allowing its camera to have optimal focal length and lighting conditions. Providers can purchase these scopes for their patients from Blue Sky Bio or 3D print their own with free downloadable STL images. Providers can view the progress scans through their BioBigBox account. The scans are currently limited to facial surfaces and appear to be most useful in remotely tracking orthodontic clear-aligner therapy but may have potential for other uses as technology continues to advance.

— Hubert Chan, DDS

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DR. SHIV SHARMA CDA member since 2014

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Join us for, inspiring speakers, hands-on learning and new ways to learn and connect with your dental community.

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