CDA Journal - May/June 2020: Ahead of an Evolving Curve by California Dental Association

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Oral Health Disparities Unicystic Ameloblastoma Pediatric Behavior Guidance Centric Relation

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May/June 2020

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d e pa r t m e n t s

245 The Editor/Waiting for the Hurricane 249 Letter to the Editor/Thank You for Everything, Dennis 251 Impressions 285 RM Matters/Speak Up! Open Communication Strengthens Employer-Employee Bonds

291 Regulatory Compliance/Easy-To-Use Tool Helps Dental Practices Complete HIPAA-Required Analysis

295 Ethics/Money and Ethics: A Potential for Conflict 298 Tech Trends

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255 Oral Health Disparities: Proceedings of an Oral Health Innovation Forum This paper discusses the findings from an interprofessional forum to discuss and formulate policy solutions for addressing diversity issues in the dental workforce, access/barriers to care and the impact of emerging technology on patient care. Francisco Ramos-Gomez, DDS, MS, MPH; Hamida Askaryar, MPH, RDH; Janni Kinsler, PhD, MPH; Gayle Mathe, RDH; Steve Geiermann, DDS; and Mike Monopoli, DDS, MPH

263 Unicystic Ameloblastoma Presenting as Dentigerous Cyst: A Case Report This article presents a case of unicystic ameloblastoma in a 13-year-old patient that mimicked a dentigerous cyst on clinical, radiological and incisional-biopsy examination. Brinda Suhas Godhi, MDS; Raghavendra Shanbhog, MDS; Usha Hegde, MDS; and Suhas S. Godhi, MDS

271 Clinical Behavior Guidance for Children in Dentistry This manuscript discusses how effective behavior management is essential in achieving a desirable treatment outcome in pediatric dental practice. Brent P. Lin, DMD, and Michael I. Lin, MD

277 Reproducibility and Variability of Centric Relation Point in Completely Edentulous Patients This study evaluates the reproducibility and deviation from the centric relation point with time in completely edentulous patients. Sushil Kumar Kar, MDS; Arvind Tripathi, MDS; and Praveen Rai, BDS

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

CDA Officers Richard J. Nagy, DDS President president@cda.org

A S S O C I AT I O N

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

Editorial

Judee Tippett-Whyte, DDS President-Elect presidentelect@cda.org

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

Ariane R. Terlet, DDS Vice President vicepresident@cda.org

Ruchi K. Sahota, DDS, CDE Associate Editor

John L. Blake, DDS Secretary secretary@cda.org Steven J. Kend, DDS Treasurer treasurer@cda.org Debra S. Finney, MS, DDS Speaker of the House speaker@cda.org

Volume 48 Number 5/6 May/June 2020

Brian K. Shue, DDS, CDE Associate Editor Gayle Mathe, RDH Senior Editor Andrea LaMattina, CDE Publications Manager Kristi Parker Johnson Senior Communications Specialist

Blake Ellington Tech Trends Editor

Manuscript Submissions

Journal of the California Dental Association Editorial Board

Jack F. Conley, DDS Editor Emeritus

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

Robert E. Horseman, DDS Humorist Emeritus

Letters to the Editor

Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental Medicine, Pomona, Calif.

Production Randi Taylor Senior Visual Designer

Upcoming Topics July/Licensure August/Sugar and Health September/Ethics

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

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Subscriptions Annual subscriptions are available to association members at a rate of $36. To manage your printed Journal subscription online, log in to your cda.org account or email contactcda@cda.org for assistance. View the publication online at cda.org/journal.

Permission and Reprints Andrea LaMattina, CDE Publications Manager Andrea.LaMattina@cda.org 916.554.5950

R. Del Brunner, DDS Immediate Past President pastpresident@cda.org

The Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal of the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814. 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 2020 by the California Dental Association. All rights reserved. Visit cda.org/journal for the Journal of the California Dental Association’s policies and procedures, author instructions and aims and scope statement.

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Mina Habibian, DMD, MSc, PhD, associate professor of clinical dentistry, Herman Ostrow School of Dentistry of USC, Los Angeles Robert Handysides, DDS, dean and associate professor, department of endodontics, Loma Linda University School of Dentistry, Loma Linda, Calif. Bradley Henson, DDS, PhD , associate dean for research and biomedical sciences and associate professor, Western University of Health Sciences College of Dental Medicine, Pomona, Calif. Paul Krebsbach, DDS, PhD, dean and professor, section of periodontics, University of California, Los Angeles, School of Dentistry Jayanth Kumar, DDS, MPH, state dental director, Sacramento, Calif. Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral health education, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Nader A. Nadershahi, DDS, MBA, EdD, dean, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Francisco Ramos-Gomez, DDS, MS, MPH, professor, section of pediatric dentistry and director, UCLA Center for Children’s Oral Health, University of California, Los Angeles, School of Dentistry Michael Reddy, DMD, DMSc, dean, University of California, San Francisco, School of Dentistry Avishai Sadan, DMD, dean, Herman Ostrow School of Dentistry of USC, Los Angeles Harold Slavkin, dean and professor emeritus, division of biomedical sciences, Center for Craniofacial Molecular Biology, Herman Ostrow School of Dentistry of USC, Los Angeles Brian J. Swann, DDS, MPH, chief, oral health services, Cambridge Health Alliance; assistant professor, oral health policy and epidemiology, Harvard School of Dental Medicine, Boston Richard W. Valachovic, DMD, MPH, president emeritus, American Dental Education Association, Washington, D.C.

Editor

C D A J O U R N A L , V O L 4 8 , Nº 5/6

Waiting for the Hurricane Kerry K. Carney, DDS, CDE

f you have ever lived in a coastal area under a hurricane warning, you know what it means to prepare for a devastating event before there may be any direct evidence of the impending disaster. Blue skies can belie the hurricane to come. The first time one experiences the calm before the storm, there may be a fair amount of disbelief and denial: “It may not hit us.” “It may be much weaker than the forecast.” “Why put in a lot of fortification efforts when chances are that we won’t get the brunt of the storm?” Some folks board up their structures and move away from the coast. Some folks buy supplies and hunker down. Some folks disregard the warnings and hope to win the meteorological lottery. The strongest cyclonic event recorded was the Bay of Bengal cyclone of 1970. It resulted in over a half-million deaths in India and Bangladesh. The deadliest Atlantic hurricane, Mitch, occurred in 1998 and caused 11,000 to 19,000 deaths throughout Florida and Central America. In 2005, Hurricane Katrina claimed more than 1,800 lives and caused $125 billion in damage in the Gulf. The destructive power of nature is a sobering lesson to learn when you live in hurricane country. Now we prepare for another kind of hurricane. We face the public health cataclysm of COVID-19. Here at the Journal of the California Dental Association, we plot our issues a long way out. In 2020, we are already slotting topics for publication in 2022. I tell people that steering the CDA Journal is somewhat like piloting a supertanker. You have to navigate many miles ahead of where you are at the moment.

It is our hope that we can help all our readers appreciate and feel comfortable with the digital platform.

By careful planning, we stay relevant and even ahead of the curve with topical issues. However, the current public health turmoil has necessitated a pivot and a rapid course adjustment. We have decided that our primary mission under the present circumstances is to help our readers get the most up-todate and relevant information that can aid in the successful navigation of these choppy waters in this uncertain time. To that end, we have consolidated the May and June issues into one May/June issue. This allows the redirection of necessary staff to help with the dissemination of time-sensitive information to our members through other avenues. The combined issue not only provides an assortment of scientific articles on oral health, but it will act as a directional signpost pointing our readers to helpful and timely information on COVID-19. It is our hope that we can help all our readers appreciate and feel comfortable with the digital platform. At this time, we feel it is the most effective medium through which we can deliver the most current information available: ■ CDA COVID-19 Information Center: cda.org/COVID19. ■ Key CDA communications: cda.org/COVID19-leadership. ■ Economic relief FAQs: cda.org/COVID19-economic.

Educational webinar series: cda.org/COVID19-webinars. ■ Licensure and C.E. FAQs: cda.org/COVID19-licensure. ■ California Department of Public Health guidance documents: cdph.ca.gov/Programs/CID/ DCDC/Pages/Guidance.aspx. In times like these, when information is updated frequently and the environment is shifting rapidly, it is important to opt in and put your address on the list to receive emails and text alerts. To ensure you’re receiving the latest information from CDA, make sure your CDA profile is up to date. Log in at cda.org, click on My Account and update your email preferences. In a story I read long ago, two men prepared for a duel. They met on a hilltop and stood ready to engage. At the moment they were about to aim and shoot at one another, the wind changed. Both men were seafarers and both realized simultaneously that a storm was coming. Without hesitation, they both stood down because they recognized that the imminent danger of an approaching cyclone dwarfed their personal agenda of revenge or satisfaction. There is an approaching storm that may extract a devastating toll on human life. I am writing this message ■

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in the last days of March. I can only hope that by the time our May/June issue reaches our readers’ hands, we will have come through an economic and personal trial together, stronger and more convinced of the value of each other and more secure in our unity of purpose. n [Editor’s Note: As this last print version of the Journal goes to press, we have lived through eight weeks of shelter-at-home. Though oral health care providers are considered essential workers, in accordance with the advisory issued by the CDC,

we have closed our offices to all but emergency care in order to slow the COVID-19 infection rate and preserve personal protective equipment (PPE) for medical workers on the front line of the infection surge. As the momentum builds to return to practice, we are all evaluating our patient screening, engineering controls and administrative changes and counting PPE. Like mariners evaluating our ship after a storm, we hope for the best and prepare for more stormy seas ahead. It is yet to be seen if we are navigating into fairer winds or experiencing the calm of the hurricane’s eye.]

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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.

KEEPING AHEAD of the curve This issue of the CDA Journal offers the deeply researched clinical articles and ongoing access to dental education that you’ve come to expect from your peers each month. We also know the COVID-19 pandemic has brought many more challenges to the forefront for dentists and that those are changing rapidly. To best address members’ urgent concerns in today’s ever-evolving health care climate, cda.org is updated daily. Visit the COVID-19 information center and Back to Practice resource library for dentist-centric guidance, news from trusted sources and tools to navigate through change. If you’ve missed any updates along the way, we encourage you to opt in to receive emails at cda.org. Meanwhile, enjoy the research articles and case reports presented in this issue of the CDA Journal.

Journa C A L I F O R N I A

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A S S O C I A T I O N

Oral Health Disparities Unicystic Ameloblastoma Pediatric Behavior Guidance Centric Relation

AHEAD OF AN evolving curve Connect to expert guidance through cda.org

The next CDA Journal awaits you online. Our award-winning clinical publication, now in a new interactive digital format. In todayâ&#x20AC;&#x2122;s climate of rapidly evolving news, the clinical insights dentists need are evolving, too. To keep pace, the Journal of the California Dental Association will no longer be mailed to you. Weâ&#x20AC;&#x2122;re moving to an interactive digital format, which offers a responsive, high-quality reading experience across all devices.

Explore insightful articles online at cda.org/journal. Through the Issuu platform, you can now read the CDA Journal as a digital publication instead of in print, with the ability to flip pages and click on links in dynamic articles and advertisements. Ensure you can access future digital issues, along with updates on timely dentistry topics. Opt in to emails from CDA at cda.org.

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Letter

C D A J O U R N A L , V O L 4 8 , Nº 5/6

Thank You for Everything, Dennis

ennis Shinbori, DDS, passed away Feb. 18, 2020, after a protracted and valiant battle with cholangiocarcinoma. With his passing, our profession lost a true leader. Our association lost a true icon. And as human beings, we lost a true friend. Few have touched their world as profoundly as Dennis touched ours. So, as a tribute, I would like to say thank you, Dennis. Thank you for the 43 years of teaching fixed and removable prosthetics at the University of the Pacific, Arthur A. Dugoni School of Dentistry. That’s one heck of a lot of students. Very few people — if any — attended UOP over those years without learning something from you, Dennis. Furthermore, thank you for all of the programs you designed for the UOP Alumni Association’s annual meetings. Dennis, it’s predictable that you received the Medallion of Honor from UOP as well as now having the Dennis D. Shinbori Endowed Lectureship named in your honor. Dennis, thank you for everything you did for the California Dental Association. In addition to serving on some other councils, you served for more than 20 years on the CDA Presents Board of Managers. You were chair at one time and were instrumental in programming speakers, designing new programs and running the Table Clinics in Anaheim. None who have served or are currently serving on the board have designed a program without consulting you. You have made

this essential nondues revenueproducing event into a huge success — perhaps the best in the nation. You have also mentored each and every one of us during that process. Not surprising, we now know the table clinics as the CDA Presents Dennis D. Shinbori Table Clinics. Dennis, thank you for all the time you spent working with the ADA in a similar capacity. You spent four years on the council of the ADA annual session, including the chairmanship. Additionally, you were the committee on local arrangements chair on three different occasions when ADA came to San Francisco — another six years of commitment. At a 2019 meeting with the ADA, you were referred to as the “Yoda” of dental meeting planning. I couldn’t agree more. Again, it’s not surprising that the ADA now features the Dennis D. Shinbori Acclaimed Educator Series at its yearly meeting. Finally, Dennis, — swallowing with difficulty here — thank you for your friendship. I am truly honored to be included as a friend. You taught by example, and I have learned much about all of the above from you. Perhaps more important, I learned that calm interaction beats flamboyance every time and that compassion, perseverance and understanding are the most important attributes we can seek and deliver as humans. Thanks, again Dennis — we miss you already. j i m va n s i c k l e n , d d s

Stockton, Calif.

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A DEDICATED ADVOCACY TEAM. Weâ&#x20AC;&#x2122;re here to bring you support, protection and answers. CDA is working with local, state and national leaders to secure C.E. and licensure extensions, dental supplies and economic relief. See how we advocate for the change needed to resume patient care at cda.org.

HERE AT CDA, ADVOCACY MEANS ACTION.

Impressions

C D A J O U R N A L , V O L 4 8 , Nº 5/6

Lack of Dental Visits Linked to Oral Pathogen By taking a close look at invisible communities of microbes that live in every mouth, Colorado State University (CSU) microbiome researchers discovered fresh evidence to support that oral health habits affect those communities. The crowd-sourced, citizen science-driven study was conducted by a research lab at CSU and a research team at the Denver Museum of Nature & Science. Published in Scientific Reports, the study found, among other things, a correlation between people who did not visit the dentist regularly and the increased presence of a pathogen that causes periodontal disease. For the experiments, carried out by a community science team in the Genetics of Taste Lab at the museum, a wide cross-section of museum visitors submitted to a cheek swab and answered simple questions about their demographics, lifestyles and health habits. The study grouped people who flossed or didn’t floss. Participants who flossed were found to have lower microbial diversity in their mouths than nonflossers. This is most likely due to the physical removal of bacteria that could be causing inflammation or disease. Adults who had gone to a dentist in the last three months had lower overall microbial diversity in their mouths than those who hadn’t gone in 12 months or longer and had less of the periodontal disease-causing oral pathogen Treponema. This, again, was probably due to dental cleaning removing rarer bacterial taxa in the mouth. Youths tended to have had a dental visit more recently than adults. Youth microbiomes differed among males and females and by weight. Children considered obese according to their body mass indices had distinct microbiomes as compared to non-obese children. The obese children also tended to have higher levels of Treponema, the same pathogen found in adults who hadn’t been to the dentist in more than a year. In other words, the researchers saw a possible link between childhood obesity and periodontal disease. Other data found that microbiomes of younger participants, mostly in the 8- to 9-year-old range, had more diversity than those of adults. However, adult microbiomes varied more widely from person to person. The researchers think this is due to the environments and diets of adults being more wide-ranging than children. They also saw that people who lived in the same household shared similar oral microbiomes. “Our study also showed that crowdsourcing and using community scientists can be a really good way to get this type of data, without having to use large, case-controlled studies,” said Zach Burcham, PhD, the paper’s lead author. Learn more about this study in Scientific Reports (2020); doi.org/10.1038/s41598-020-59016-0. n M AY/JUNE 2 0 2 0 251

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Plaque-Identifying Toothpaste May Play Role in Heart Attack, Stroke Prevention Losing Tongue Fat Improves Sleep Apnea Using magnetic resonance imaging (MRI) to measure the effect of weight loss on the upper airway in obese patients, researchers found that reducing tongue fat is a primary factor in lessening the severity of obstructive sleep apnea (OSA). The findings were published recently in the American Journal of Respiratory and Critical Care Medicine. A 2014 study led by Richard Schwab, MD, chief of sleep medicine at the University of Pennsylvania, compared obese patients with and without sleep apnea and found that the participants with the condition had significantly larger tongues and a higher percentage of tongue fat when compared to those without sleep apnea. The researchers next step was to determine if reducing tongue fat would improve symptoms and to further examine cause and effect. The new study included just 67 participants with mild to severe obstructive sleep apnea who were obese — those with a body mass index greater than 30. Through diet or weight loss surgery, the patients lost nearly 10% of their body weight, on average, over six months. Overall, the participants’ sleep apnea scores improved by 31% after the weight loss intervention, as measured by a sleep study. Before and after the weight loss intervention, the study participants underwent MRI scans to both their pharynx as well as their abdomens. Then, using a statistical analysis, the research team quantified changes between overall weight loss and reductions to the volumes of the upper 252 M AY/JUNE

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A randomized trial that explored whether Plaque HD, a plaque-identifying toothpaste, reduces hs-CRP, a sensitive marker for future risks of heart attacks and strokes, found that the toothpaste is the first to identify plaque so it can be removed with directed brushing. Also, Plaque HD’s proprietary formulation contains unique combinations and concentrations of cleaning agents that weaken the core of the plaque structure to help the subject visualize and more effectively remove the plaque. The trial titled “Correlation Between Oral Health and Systemic Inflammation” (COHESION) was conducted by researchers at Florida Atlantic University’s Schmidt College of Medicine, Marshfield Clinic Research Institute and the University of Wisconsin School of Medicine and Public Health and published online ahead of print in the American Journal of Medicine. In the trial, all randomized subjects were given the same brushing protocol and received a 30-day supply of toothpaste containing either Plaque HD or an identical nonplaque-identifying placebo toothpaste. To assess hs-CRP, levels were measured by Quest Diagnostics using an enzyme-linked immunosorbent assay. Based on the findings, researchers are drafting an investigator-initiated research grant proposal to the National Institutes of Health (NIH). Their proposed randomized trial will test whether Plaque HD reduces progression of atherosclerosis in the coronary and carotid arteries, for which systemic inflammation is an important precursor. “Whether this plaque-identifying toothpaste decreases heart attacks or strokes requires a largescale randomized trial of sufficient size and duration,” said senior author Charles H. Hennekens, MD, DrPH. Learn more about this study in the American Journal of Medicine (2020); doi.org/10.1016/ j.amjmed.2020.01.023.

airway structures to determine which structures led to the improvement in sleep apnea. The team found that a reduction in tongue fat volume was the primary link between weight loss and sleep apnea improvement. The study also found that weight loss resulted in reduced pterygoid and pharyngeal lateral wall volumes. Both

these changes also improved sleep apnea, but not to the same extent as the reduction in tongue fat. Of note is the study’s small size, which could cause problems extrapolating findings. Learn more about this study in the American Journal of Respiratory and Critical Care Medicine (2020); doi.org/ 10.1164/rccm.201903-0692OC.

C D A J O U R N A L , V O L 4 8 , Nº 5/6

What and How You Eat May Affect Microbiome In a study published in Frontiers in Cellular and Infection Microbiology in December 2019, researchers from Tokyo Medical and Dental University (TMDU) show the importance of normal feeding for establishing and maintaining appropriate bacteria in the mouth and the gut. Our bodies are symbiotic units of human cells and microorganisms. Far from being deleterious, this microbiota is now recognized as a

vital modulator of functions such as digestion, mood, sleep and response to drugs as well as susceptibility to diabetes, autism, obesity and cancer. Patients convalescing from stroke often have dysphagia and need to be fed via a tube to bypass the mouth. The researchers hypothesized that resuming oral food intake could modify the composition of oral and gut microbial communities in tube-fed

Study Analyzes Antibiotic Resistance in Gut and Mouth Microbiome Although much work has been done analyzing the human gut microbiome and its associated genes, little is currently known about these genes in the mouth. In a paper published recently in Nature Communications, academics from King’s College London have taken the first step to examine the antimicrobial resistance potential of the mouth — the oral resistome. As the mouth is the first point of entry for food and many medications, it has the potential to influence the spread of antimicrobial resistance in the human microbiome. Antimicrobial resistance arises when the microbe acquires genes that attempt to avoid or destroy the drugs. Researchers accessed saliva, dental plaque and other oral data and analyzed them using the Comprehensive Antibiotic Resistance Database (CARD). They included data from several different regions within the study, including Asian, Pacific, European and American locations. The research found that there were unique resistome profiles in the mouth compared to the gut. While there was less diversity of antimicrobial resistance genes in the mouth, those genes present were more pervasive across the populations studied, according to the study. “Given what we are beginning to discover about the sheer variety of microbial species in the human microbiome, if we are to stand any hope of getting to grips with the spread and persistence of antimicrobial resistance, we need to expand human resistome studies to sample other body areas,” said David Moyes, PhD, lecturer in host-microbiome interactions at King’s College London. Read more about this study in Nature Communications (2020); doi.org/10.1038/ s41467-020-14422-w.

patients. To test this, they compared oral and gut microbiome profiles before and after the resumption of oral food intake in eight poststroke patients recovering from enteral nutrition. Oral and gut microbiota community profiles were evaluated by sequencing 16s rRNA in saliva and feces samples collected when the patients were being fed via tube and after they switched back to eating normally. Researchers then examined the co-occurrence and interaction patterns of the microbial communities and conducted computational prediction of their function. They were surprised to find that reinitiation of oral food intake dramatically altered and diversified both oral and gut microbiomes. Though very different in composition, both showed an increase of the family Carnobacteriaceae and genus Granulicatella suggesting that orally ingested bacteria may directly modulate the gut community thus affecting systemic health. Although oral microbiota alteration was more significant than that in the gut, metagenome prediction showed more differentially enriched pathways in the gut, especially those related to fatty acid metabolism. “Networks in both microbiomes were simpler and fewer, which may indicate healthier restructuring,” said lead author Sayaka Katagiri, DDS, PhD, assistant professor of periodontology at TMDU. “Additionally, altered interaction between core species suggests improved microbiome balance.” Learn more about this study in Frontiers in Cellular and Infection Microbiology (2019); doi.org/10.3389/ fcimb.2019.00434. M AY/JUNE 2 0 2 0 253

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proceedings C D A J O U R N A L , V O L 4 8 , Nº 5/6

Oral Health Disparities: Proceedings of an Oral Health Innovation Forum Francisco Ramos-Gomez, DDS, MS, MPH; Hamida Askaryar, MPH, RDH; Janni Kinsler, PhD, MPH; Gayle Mathe, RDH; Steve Geiermann, DDS; and Mike Monopoli, DDS, MPH

a b s t r a c t The UCLA Center for Children’s Oral Health (UCCOH) focuses

on translating evidence-based research into clinical care in order to improve children’s oral health. UCCOH held an interprofessional forum to discuss and formulate policy solutions for addressing diversity issues in the dental workforce, access/barriers to care and the impact of emerging technology on patient care. This paper discusses the findings from the forum.

AUTHORS Francisco Ramos-Gomez, DDS, MS, MPH, is a professor in the section of pediatric dentistry at the University of California, Los Angeles, School of Dentistry, and director for the UCLA Strategic Partnership for Interprofessional Collaborative Education in Pediatric Dentistry (SPICEPD) and the pediatric dentistry advanced clinical trainee program. Conflict of Interest Disclosure: None reported.

Hamida Askaryar, MPH, RDH, is a program manager for the UCLA School of Dentistry, section of pediatric dentistry. Conflict of Interest Disclosure: None reported.

Gayle Mathe, RDH, is the director of community health policy and programs at the California Dental Association. Conflict of Interest Disclosure: None reported.

Janni Kinsler, PhD, MPH, is a public health researcher and evaluation specialist in the section of pediatric dentistry at the UCLA School of Dentistry. Conflict of Interest Disclosure: None reported.

Steve Geiermann, DDS, is a retired captain in the U.S. Public Health Service and serves as the senior manager addressing access, community oral health infrastructure and capacity within the American Dental Association. Conflict of Interest Disclosure: None reported.

Mike Monopoli, DDS, MPH , is the director of policy and programs at the DentaQuest Foundation in Boston. Conflict of Interest Disclosure: None reported.

arly childhood caries (ECC) is the most common chronic childhood disease in the U.S. as well as globally.1–3 Untreated ECC in primary teeth affects more than 600 million children worldwide, and ECC shares common risk factors similar to other chronic diseases associated with excessive sugar consumption, such as cardiovascular disease, diabetes and obesity.3 As of 2016, approximately 22% of U.S. children aged 2 to 5 years and 51% aged 6 to 11 years have ECC.1,4 In California, 54% of kindergarteners and 70% of third graders have experienced dental caries, and nearly one-third of children have untreated dental caries.2,5 Hispanic children in California are more likely to experience ECC than non-Hispanic Whites and African Americans.1,5 Reversing the substantial and unfortunate impact of this preventable childhood disease has proven to be a considerable challenge. M AY/JUNE 2 0 2 0 255

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Understanding Oral Health Disparities in the Context of Macro- and Microsystem Levels

Viewing optimal oral health and access to effective and affordable oral health care as a right rather than a privilege results in systemic changes at both the macro and micro levels that lead to social justice and health equity. Macro-level systems involve interventions on a large scale that can affect entire communities, states and countries while microlevel systems involve intervention at the individual or family level. Macro-level systemic factors affecting oral health equity and social justice include global forces, government policies or social and structural influences on health that lead to the continuation of privilege for some and discrimination for others based on such characteristics as race/ethnicity, economic status, gender, age and special needs status. Such macro-level factors might include lack of access to affordable healthy food due to physical and environmental factors and lack of access to comprehensive, culturally and linguistically appropriate and affordable oral health care. Micro-level factors affecting oral health might include childhood difficulty with speech, attention problems in school and negative social interactions and lack of social relationships that result from poor oral health.6 Introducing comprehensive, culturally appropriate and affordable oral health care and addressing macro-level forces within a health equity and social justice framework can have a positive impact on micro-level systemic factors affecting an individual’s overall health in various ways such as the following: ■ Making it possible to access providers who are culturally responsive and patient centered. 256 M AY/JUNE

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Increasing trust in the providerpatient relationship. ■ Significantly decreasing socioeconomic-based disparities in oral health care. Applying a social justice and health equity lens to oral health care will require dental providers to build ongoing awareness and understanding of these issues within their practice. For example, dentists and other oral health care providers should receive training on the persistent patterns of (dis)empowerment and (dis)trust often ■

Applying a social justice and health equity lens to oral health care will require dental providers to build ongoing awareness and understanding of these issues. seen in patients, so they can learn how to recognize these patterns in their own patients. Additionally, they should learn to recognize the complexity of the human experience and pursue dignity for all patients seen in their practice.7 In October 2018, the UCLA Center for Children’s Oral Health (UCCOH) held a two-day interprofessional “Oral Health Innovation Forum.” This interactive event, the first of its kind, emphasized a cross-collaboration of five major UCLA schools to discuss and formulate policy solutions for addressing disparities in oral health with a focus on ECC through a lens of social justice and health equity. It was a pioneering event for advocating systems-change approaches in both the delivery of oral health care and primary care.

Methods

UCCOH is a multidisciplinary initiative that focuses on translating evidence-based research into clinical care in order to achieve policy developments and advocacy in the interest of improving children’s oral health locally, nationally and internationally.8 The center, established in 2015, builds, strengthens and coordinates activities in children’s oral health through developing and supporting interprofessional education in UCLA’s pediatric training program with the UCLA schools of dentistry, medicine, nursing and public health. The center’s two-day interprofessional oral health innovation forum attracted close to 200 interdisciplinary/interprofessional attendees from the UCLA schools of dentistry, medicine, nursing, public health and public affairs. Attendees also included representatives from the American Dental Association, political representatives from Los Angeles County and UCLA students, residents, fellows and many community partners. The keynote speaker was chief economist and vice president for the American Dental Association’s Health Policy Institute. Additional presenters were the California dental director, the Los Angeles County dental director, the executive director of the American Dental Association and Los Angelesbased political representatives. The morning session of the forum on Day One consisted of presentations on updates and innovations at the UCLA School of Dentistry and how these innovations could be adapted to other schools of dentistry in the U.S., the importance of building a multicultural movement for oral health equity, how to transform dentistry from a focus on volume to

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TABLE

Summary of Recommendations and Suggestions To Reduce Oral Health Disparities for Each of the Five Tracks Track

Recommendations/Suggestions

Track 1: Financial issues regarding early childhood caries

Institute value-based (patient outcomes-based) reimbursements systems. Utilize dental diagnosis codes and match billing codes. Merge medical and dental electronic records for patients. Provide microfinancial incentives to families/caregivers who promote early childhood toothbrushing and use fluoridated toothpaste.

Track 2: Policy developments with a focus on early childhood caries prevention

Implement a mandatory age-1 oral health visit. Require oral health screening/exams in day care centers and elementary schools and mandatory toothbrushing in schools. Mandatory inclusion of an oral health pamphlet in each child’s school admission packet to inform and educate families about the importance of early dental care and provide resources on where to access dental care. Strengthen kindergarten oral health assessments. Actively support allocating a percentage of soda and marijuana taxes to promote oral health. Consider potential opioid lawsuits as source of funds for use in oral health promotion.

Track 3: Diversity issues in the dental workforce

Increase minority admissions to schools of dentistry (via outreach to deans and admissions committees). Support pipeline programs for low-income and minority students to enter higher education professional programs and continue support and long-term mentorship for admitted students. Increase tracking of graduates, including where they practice. Utilize, support and better integrate foreign-trained dentists.

Track 4: Access to care and challenges to care

Establish best-practice model for the virtual dental home/teledentistry model and increase support for the use of the virtual dental home/teledentistry model. Increase support for community (oral) health care workers (COHWs). Implement widespread interprofessional education (IPE) curricula and support interprofessional practice (IPP). Increase access to care for special needs patients.

Track 5: Impact of emerging technology on future patient care

Support equitable access to and support fair and safe use of newest technology (such as lasers, omics, robotics and artificial intelligence) for the improvement of oral health for all.

a focus on value, the relevance of interprofessional education within oral health and primary health care and the role of community oral health workers. The afternoon was devoted to breakout sessions addressing five topics: financial issues regarding ECC, policy developments regarding ECC prevention, diversity issues in the dental workforce, access to care and barriers to care and emerging technologies for future patient care. Moderators for each breakout session are experts in their topic area and were chosen by the forum committee. In addition to the moderators, there were 12–15 other individuals in each of the five breakout sessions who were also experts in their topic area. The purpose of the breakout sessions was to establish a shared knowledge base, capture

collective insight and encourage innovative thought. The moderators for each session introduced the topic to the attendees and then gave them three to five questions to discuss. They were provided with an easel and markers to write down their thoughts and ideas. Dental students took notes. At the end of the day, the moderators presented each group’s main thoughts/ ideas to all participants of the forum. The second day of the forum was open to the public and attended by UCLA students, residents, fellows and many community partners. The day consisted of several presentations on topics pertaining to integrating oral health into overall health care, the importance of oral health equity and social justice, the state of dental insurance and children’s oral health

issues and the importance of policy, advocacy and interprofessional collaboration regarding children’s health. The afternoon session included a panel discussion that presented a summary from Day One’s breakout sessions. This summary discussion led to the creation of a strategic plan (including goals and next steps) for improving children’s oral health locally, nationally and internationally. Dental students and UCLA School of Dentistry staff took notes throughout the two-day forum. All notes were reviewed and edited by forum committee members and then combined into a complete forum report. The thoughts/ideas resulting from the breakout sessions for each of the five key forum topics are discussed in the next section. The TABLE provides a summary of the following discussions. M AY/JUNE 2 0 2 0 257

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Results Track 1: Financial Issues Regarding ECC

The Track 1 group discussed how to train and incentivize health care professionals (both dentists and medical care providers) to provide equitable and integrated oral health care and how to align and balance financing preventive efforts to support innovative and evidence-based care. To address these topics, the group recommended instituting a value-based reimbursement system that emphasizes quality of care over quantity of services provided, which would focus on incentivizing early oral health prevention and intervention strategies for children and reduce incentives that prioritize treatment over prevention. For example, instituting a bundled payment approach that would cover three to five preventive services to be provided at the same time was suggested (e.g., oral health exam, caries risk assessment, fluoride application, nutritional counseling). This might increase the probability that a child would receive their needed preventive care, as it is sometimes challenging for lower-income parents to bring their children to the dentist multiple times for various services. Providers would then be reimbursed only if all services were rendered and documented in the patient’s chart. Getting insurance companies/ payers and primary care providers (PCPs) to reimburse accordingly for oral health-related preventive behavior was also discussed by the group. Providing data-driven evidence to insurance companies demonstrating that paying for preventive behavior modification will lower overall costs by reducing the incidence of dental caries should be a priority. 258 M AY/JUNE

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The group also stressed the need to integrate electronic medical records (EMR) and electronic dental records (EDR) to improve interprofessional relationships and enhance interprofessional practice (IPP) as well as utilize diagnostic dental codes similar to medical diagnostic codes (International Classification of Diseases [ICD] 10), which would allow for a more consistent diagnosis identification and analysis of the oral health status of patients and would improve patient outcome tracking and elicit more individualized treatment plans.

The group recommended instituting a value-based reimbursement system that emphasizes quality of care over quantity of services provided.

Track 2: Policy Developments With a Focus on Early Childhood Caries Prevention

The Track 2 group focused their discussion on how to promote and increase the use of evidence-based policies pertaining to ECC prevention, concentrating on ensuring oral health visits for all infants. The group suggested a life course continuum of risk assessment and early intervention with a policy system change approach of a mandatory age-1 dental visit for all infants in addition to mandatory oral health assessments as children enter school (as required by AB 1433). Data gathered through these assessments is crucial for monitoring oral health status, developing strategies to address needs, establishing priorities for the

use of resources and evaluating the outcomes of implemented actions.9 Mandatory age-1 dental visits should also apply to infants and preschoolers in day care centers, Women, Infants and Children (WIC) centers and Early Head Start (EHS). Additionally, Track 2 suggested expanding mandatory oral hygiene/health services education into elementary schools (requiring brushing and flossing at least once during the school day and providing dental referrals and follow-ups), similar to the mandate in day care centers and full-day Head Start programs. Track 2 also suggested mandatory inclusion of an oral health pamphlet, written in English, Spanish and other languages based on the community’s demographics, in each child’s school admission packet to inform and educate families about the importance of early dental care. This pamphlet should include resources on where to access dental care and information (including websites) about obtaining affordable dental insurance. Funding Oral Health Track 2 recognized the need for consistent funding for oral health initiatives and suggested advocating for using a percentage of soda and marijuana taxes to promote oral health as well as trying to pursue funds from opioid lawsuits to promote oral health care in day care centers, WIC, EHS and primary care sites.10,11 Other policy developments and recommendations included improving access to fresh and healthy foods, incentivizing retail outlets to sell healthy foods in low-income neighborhoods through tax credits and rebates, implementing healthy vending machine policies and enacting laws that would restrict advertising for unhealthy and highly processed foods.

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Track 3: Diversity Issues in the Dental Workforce

Participants in Track 3 agreed the makeup of the current provider pool did not match the racial/ ethnic composition of the patient pool, and therefore focused on how to diversify the dental workforce and how to eliminate barriers for international dentists to obtain licenses to practice in the U.S.2,12 To increase the number of educated, well-trained health care providers of all racial/ethnic backgrounds, Track 3 suggested expanding pipeline programs in mostly minority and low-income middle and high schools and support efforts to address disparities that exist in dental education. The group also suggested supporting minority students during their professional training with focused and deliberate mentorship programs and grants as well as supporting them during their education period to become licensed health care providers with increased scholarships and loan repayment programs. Track 3 recognized there is a pool of well-trained, ethnically and culturally diverse foreign-trained dentists in California and recommended establishing a California foreign-trained dentists association that could provide strategies and grant opportunities for supporting foreign-trained dentists’ transition to licensed status in California.

Track 4: Access to Care and Barriers to Care The group’s key recommendations for increasing access to care and decreasing barriers to care include expansion of the virtual dental home, support of community oral health workers (COHW) and promoting interprofessional education (IPE) and interprofessional practice (IPP).

Virtual Dental Home/Teledentistry Virtual dental homes and teledentistry are increasingly being used to increase access to care, as it is a challenge for many people to visit a dental office due to factors such as distance, lack of transportation and inflexible work schedules. Track 4 recommended schools be responsible for helping children who do not have a dental home find one. The group discussed how to incentivize school principals to ensure all children have a dental home. One suggestion was that kids with dental caries sequelae should

The Track 4 group suggested training and supporting nurses and medical assistants to provide proper patient oral health education.

not be allowed to attend school until they receive care. Because schools are paid per daily student attendance, this would provide a strong financial incentive to comply with this requirement. Community (Oral) Health Workers (COHWs) Community health workers (CHWs) are valuable resources, particularly for high-risk and vulnerable communities, and are an important link between the community and utilization of health care services. They can provide counseling, referrals and follow-up appointments. The group suggested having CHWs with oral health training (COHWs) educate and train other oral health stakeholder organizations on oral health care, as AARP, PTAs, nurse-family partnerships

and EHS do. All COHWs should be trained to have a general knowledge of oral health and should have access to a limited number of dentists with whom they can consult to ask specific questions. COHWs should connect with the entire health care network (both medical and dental) and should be part of an integrated team (versus a silo) that will follow up with patients to maintain continuity of care. There should be a formalized system of getting COHWs into the community that is both systematic and efficient. They can then connect families with the right type of care. Providing referrals to patients in person and offering to assist them in setting up appointments may help ensure children actually see a provider and obtain any needed follow-up care, as opposed to just receiving a piece of paper with a referral written on it. Interprofessional Education (IPE) — Interprofessional Practice (IPP) Interprofessional education is being discussed all over the nation but has not yet been universally implemented. Systems are needed to establish formal communication, collaboration and referral networks across professions at all levels.13,14 The Track 4 group suggested training and supporting nurses and medical assistants to provide proper patient oral health education (e.g., conduct oral health screenings and apply fluoride varnish) and increasing collaboration among dental and medical professionals, beginning when they are in training. The committee discussed how dentists and PCPs could better work together to improve their patients’ oral health and overall health by viewing IPE as part of the core curricula rather than as supplemental. Working closely with dental hygiene schools was also suggested. M AY/JUNE 2 0 2 0 259

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Track 4 also recognized that increasing access to care for special needs patients should be a priority and recommended incentivizing dentists to provide care to these patients because the work is time and labor intensive. Additionally, it was recommended to improve system structures and protocols to ensure effective referrals and aligned responses across clinical care, social services and family support for patients with special needs.

Track 5: The Impact of Emerging Technology on Future Patient Care

Track 5 participants discussed the role of emerging technologies in the field of dentistry, such as lasers, robotics and omics (the use of biological molecules/ biomarkers as diagnostic tools). Technology can connect, empower and support health professionals wherever they practice. Harnessing the power of technology allows providers to impact communities by creating a culture of health, supporting health care education and providing preventive care practices. Group members also discussed the importance of ensuring underrepresented populations have access to technologies intended to be used by patients, such as smartphone apps and e-health communication.

Discussion The Path Forward

While achievements in expanding health care to all have been made in recent years, improving the quality of oral health care and funding innovative local oral health pilots that reach underserved populations are desperately needed. ECC is still the most common chronic disease of children, and communities of color still experience the burden of disease and persistent health disparities. 260 M AY/JUNE

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The group members for each of the five tracks proposed many insightful policy and advocacy recommendations and suggestions for how to promote social justice and health equity in oral health and ECC prevention for California’s children and underserved populations. Key recommendations included the following: ■ Instituting a value-based/patient outcome-based reimbursement system that removes current incentives that prioritize treatment over prevention. For example, the Centers for Medicare & Medicaid (CMS) funded a Californiabased pilot program known as the Dental Transformation Initiative (DTI). This five-year program, implemented in California’s MediCal Dental Program, utilizes four “domains” to emphasize investment in preventive strategies, payment incentives for dentists who deliver appropriate care, continuity of care and risk assessment.15 In particular, Domain 2 provides an additional monetary incentive for dental providers to perform a preventive caries risk assessment and provide nutritional counseling and selfmanagement goals to patients.16 ■ Implementing a mandatory age-1 visit for all children and mandatory oral health assessment at all elementary schools as required by AB 1433. Mandatory age-1 visits should also apply to infants and preschoolers in day care centers, WIC centers and EHS. Currently, Head Start encourages parents to take their children to a dentist before age 3, but parents are not required to provide a written form documenting a dental visit until their child is 3 years old. Fully implementing and enforcing

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AB 1433 is crucial, as it would hold schools accountable for collecting, tracking and following up on oral health assessment forms for kindergarteners entering schools.17 Using portions of soda and marijuana taxes and, potentially, funds from opioid lawsuit judgments for oral health promotion. Increasing the number of educated, well-trained health care providers of various racial/ ethnic backgrounds by expanding pipeline programs in mostly minority and low-income middle and high schools and supporting efforts to address racial/ethnic disparities in dental education. Tapping into the underutilized pool of well-trained, ethnically and culturally diverse foreigntrained dentists and establishing a California foreign-trained dentists association that could provide strategies and grant opportunities for supporting foreign-trained dentists’ transition to licensed status in California. Maximizing the use of successful CHW models to improve access to care for underserved and minority populations. For example, a pilot study conducted by Salcedo et al. used a promotoras de salud (promoters of health) model to examine changes in caregivers’ knowledge, attitudes and practices regarding their children’s oral health after the implementation of a targeted and culturally appropriate educational intervention.18 Caregivers trained by dental students and pediatric dental residents were assessed prior to the start of the training/ intervention and six weeks after its completion. The results showed

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a significant improvement in caregivers’ knowledge and practices about their children’s oral health. Using virtual dental homes and teledentistry to increase access and reduce barriers to care. Dental homes promote patient-provider relationships that build trust, cultural competency and continuity of care across the patient’s lifetime. Teledentistry allows for the exchange of clinical information and images between dentists and dental team members over remote distances for consultation, diagnosis, treatment planning, selective dental care, education and public awareness. Teledentistry has the ability to improve access to and delivery of oral health care while lowering costs. It also has the potential to reduce the disparities in oral health care between rural and urban communities.19 Enhancing IPE and cross-training between primary care providers and dental professionals so that dentists and other health care providers work together to meet the growing oral health needs of children from underserved and special needs populations. Medical/ dental collaboration and integration is the main goal of the Strategic Partnership for Interprofessional Collaborative Education in the Pediatric Dentistry’s (SPICE PD) supplemental residency curriculum at the UCLA School of Dentistry.20–22 IPE training in which SPICE PD faculty cross-trains pediatric dental and medical residents, pediatric nurse practitioner (PNP) students and advanced education general dentistry residents (AEGDs/GPRs) in basic principles of oral health

is a core component of the SPICE PD program. Practicing preventive, culturally competent and minimally invasive dentistry, conducting oral health risk assessments and applying fluoride varnish to address oral health disease at an early stage is the focus of IPE training. Increased implementation of mandatory IPE will be critical to achieving IPP. The recommendations and policy suggestions in this proceeding will provide a platform for further discussion and meaningful implementation actions to overcome oral health inequalities in California as well as nationally. System reform that positions dentistry in an era of social justice, equity, more wholistic, humanistic, patient-centric approach, where patients are treated with empathy, cultural competencies, respect in a family-centric focus with a medical/dental integrated health care reform is needed. n ACKNOWLEDGMENTS We express our sincere gratitude to our excellent forum speakers: Dean Paul Krebsbach, Dr. Jay Kumar, Marko Vujicic PhD, Dr. James Crall, Eileen Espejo, Dr. Maritza Cabezas, Dr. Nini Tran, Dr. Daniela Silva and Alani Jackson. We thank you for your time, dedication and support for this forum. REFERENCES 1. Fleming E, Afful J. Prevalence of Total and Untreated Dental Caries Among Youth: United States, 2015–2016. NCHS Data Brief 2018 Apr;(307)1–8. PMID: 29717975. 2. California Department of Public Health. Status of Oral Health in California: Oral Disease Burden and Prevention, 2017. www.cdph.ca.gov/Programs/CCDPHP/DCDIC/ CDCB/CDPH%20Document%20Library/Oral%20Health%20 Program/Status%20of%20Oral%20Health%20in%20 California_FINAL_04.20.2017_ADA.pdf. 3. Pitts NB, Baez RJ, Diaz-Guillory C, et al. Early Childhood Caries: IAPD Bangkok Declaration. J Dent Child (Chic) 2019 May 15;86(2):72. PMID: 31395110. 4. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and sealant prevalence in children and adolescents in the United States, 2011–2012. NCHS Data Brief 2015 Mar;(191):1–8. PMID: 25932891. 5. Dental Health Foundation. “Mommy, It Hurts to Chew” The California Smile Survey: An oral health assessment of California’s kindergarten and third grade children, 2006. www. astdd.org/docs/ca-third-grade-bss-2006.pdf. 6. Jackson SL, Vann WF Jr., Kotch JB, Pahel BT, Lee JY. Impact of poor oral health on children’s school attendance and

performance. Am J Public Health 2011 Oct;101(10):1900–6. doi: 10.2105/AJPH.2010.200915. Epub 2011 Feb 17. 7. DentaQuest Foundation. How to apply a health equity and social justice lens: Accountability guidance for the oral health 2020 network, 2015. www.heartlandalliance. org/oralhealth/wp-content/uploads/sites/19/2016/07/ HealthEquityGuidance_rev2.original.1477530689.pdf. 8. Ramos-Gomez F. UCLA Center for Children’s Oral Health, 2018. www.uccoh.org. Accessed March 18, 2019. 9. Department of Health Care Services. California Proposition 56, 2017. www.dhcs.ca.gov/provgovpart/Pages/ Proposition-56.aspx. Accessed Aug. 20, 2019. 10. Harris A, Hopkins J, Recht H. Justice for opioid communities means massive payday for their lawyers. July 25, 2018. www. bloomberg.com/graphics/2018-opioid-lawsuits. 11. Japson B. Opioid lawsuits look more like a tobacco settlement every day. Forbes Aug. 25, 2018. 12. Manchir M. Virtual dental homes offer way to get care to the underserved. ADA News Sept. 6, 2016. www.ada.org/ en/publications/ada-news/2016-archive/september/virtualdental-homes-offer. Accessed Aug. 20, 2019. 13. Section on Oral Health. Maintaining and improving the oral health of young children. Pediatrics 2014 Dec;134(6):1224–9. doi: 10.1542/peds.2014-2984. 14. Atchison KA, Weintraub JA. Integrating Oral Health and Primary Care in the Changing Health Care Landscape. N C Med J 2017 Nov–Dec;78(6):406–409. doi: 10.18043/ ncm.78.6.406. 15. Department of Health Care Services. Dental Transformation Initiative, 2019. www.dhcs.ca.gov/provgovpart/Pages/DTI.aspx. 16. Centers for Medicare & Medicaid Services. May 2019 Medicaid and CHIP Enrollment Data Highlights. www. medicaid.gov/medicaid/national-medicaid-chip-programinformation/medicaid-chip-enrollment-data/monthly-medicaidchip-application-eligibility-determination-and-enrollment-reportsdata/index.html. 17. Kindergarten Oral Health Requirement, 2005. www.cda. org/public-resources/kindergarten-oral-health-requirement. Accessed Aug. 20, 2019. 18. Salcedo G, Ramos-Gomez F, Askaryar H, Tseng C, Kritz-Silverstein D. Effects of an Educational and Outreach Intervention on Community Oral Health Workers. J Calif Dent Assoc 2018 Jul;46(7):415–421. 19. Jampani ND, Nutalapati R, Dontula BS, Boyapati R. Applications of teledentistry: A literature review and update. J Int Soc Prev Community Dent 2011 Jul;1(2):37–44. doi: 10.4103/2231-0762.97695. 20. Ramos-Gomez F. Strategic Partnership for Interprofessional Collaborative Education in Pediatric Dentistry (SPICE-PD) 2019. www.uclachatpd.org. 21. Ramos-Gomez F, Askaryar H, Garell C, Ogren J. Pioneering and interprofessional pediatric dentistry programs aimed at reducing oral health disparities. Front Public Health 2017 Aug 14;5:207. doi: 10.3389/fpubh.2017.00207. eCollection 2017. 22. Ramos-Gomez FJ, Silva DR, Law CS, Pizzitola RL, John B, Crall JJ. Creating a new generation of pediatric dentists: A paradigm shift in training. J Dent Educ Dec 2014;78(12):1593–1603. PMID: 25480274. THE CORRESPONDING AUTHOR, Janni Kinsler, PhD, MPH, can be reached at jannikinsler@hotmail.com. M AY/JUNE 2 0 2 0 261

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unicystic ameloblastoma C D A J O U R N A L , V O L 4 8 , NÂş 5/6

Unicystic Ameloblastoma Presenting as Dentigerous Cyst: A Case Report Brinda Suhas Godhi, MDS; Raghavendra Shanbhog, MDS; Usha Hegde, MDS; and Suhas S. Godhi, MDS

a b s t r a c t Unicystic ameloblastoma (UA) is a subtype of the common

odontogenic tumor ameloblastoma. The clinical and radiological presentation of UA can present a confusing picture of an odontogenic cyst. Several reports in the literature claim that a UA arises from a dentigerous cyst (DC), but there is no conclusive evidence to support such a contention. With these conflicts, we report a case of UA in a 13-year-old patient that mimicked a DC on clinical, radiological and incisional-biopsy examination.

AUTHORS Brinda Suhas Godhi, MDS, is a reader in the department of pedodontics and preventive dentistry at the JSS Dental College and Hospital, JSS Academy of Higher Education and Research in Mysuru, India. Conflict of Interest Disclosure: None reported.

Usha Hegde, MDS, is a professor and head of the department of oral pathology at the JSS Dental College and Hospital, JSS Academy of Higher Education and Research in Mysuru, India. Conflict of Interest Disclosure: None reported.

Raghavendra Shanbhog, MDS, is a reader in the department of pedodontics and preventive dentistry at the JSS Dental College and Hospital, JSS Academy of Higher Education and Research in Mysuru, India. Conflict of Interest Disclosure: None reported.

Suhas S. Godhi, MDS, was a professor and head of the department of oral and maxillofacial surgery at the I.T.S Centre for Dental Studies and Research in Ghaziabad, India. He died in 2011. Conflict of Interest Disclosure: None reported.

dontogenic cysts and tumors constitute a considerable percentage of pathologies involving jaws.1 Unicystic ameloblastomas (UA) are variants of ameloblastomas, which refer to those cystic lesions that show clinical and radiological characteristics of odontogenic cysts, but on histological examination show typical ameloblastomatous epithelium that lines part of the cyst cavity with or without luminal or mural tumor proliferation.2 Dentigerous cysts (DC) are common developmental odontogenic cysts of the jaws and account for approximately 20% to 24% of all epithelium-lined jaw cysts.1 In the literature, a number of authors have claimed that ameloblastoma arises in a dentigerous cyst. But according to Shear, there is no evidence to support such a contention.3 Much of the confusion has

probably arisen for three reasons. Firstly, ameloblastoma, which is similar to an odontogenic keratocyst, may involve an unerupted tooth and may incorrectly be interpreted as a DC on radiographs. The second reason is that the biopsy in an ameloblastoma may be taken from an expanded locule lined by a thin layer of epithelium and thus mimicking a dentigerous cyst. Third, as Lucas pointed out, apparently isolated islets or follicles of epithelium are sometimes found in the cyst wall some distance from the epithelial lining.3 These have been interpreted as ameloblastoma, although they bear only a superficial resemblance to the tumor. With these conflicts, herewith we report a case of a 13-year-old female patient with a unicystic ameloblastoma that mimicked a dentigerous cyst on clinical, radiological and incisional biopsy examination. M AY/JUNE 2 0 2 0 â&#x20AC;&#x192;263

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The importance of examining the complete excised biopsy specimen before arriving at a conclusive diagnosis in such cases has been highlighted.

Case Report

A 13-year-old female reported with the chief complaint of swelling on the lower left side of the face for a year. There was no history of pain or discharge associated with the swelling. The swelling gradually increased to the present size. On extraoral examination, diffuse swelling was seen on the lower border of the mandible extending from the angle of the mouth to 1 cm anterior to the angle of the mandible. The overlying skin was normal; no visible pulsations or discharge were seen. On palpation, the swelling was afebrile, nontender and firm in consistency. No appreciable paresthesia of the lower lip and chin regions were found. On intraoral examination, all permanent teeth were present except the left second premolar with a retained deciduous mandibular second molar. Nontender diffuse swelling was seen in the mandibular left buccal vestibular region extending from the lower left canine to first permanent molar. (FIGURES 1 ) The swelling was firm in consistency with classic eggshell crackling concerning the deciduous mandibular second molar region. Past dental history and medical history were unremarkable. Her physical examination revealed no abnormality other than those related to the chief complaint. The panoramic radiograph revealed a well-defined homogeneous unilocular radiolucency measuring 3 cm by 3 cm with a sclerotic border associated with the crown of the impacted left second premolar arising from the cementoenamel junction. The left first premolar and first permanent molar were partially displaced with resorption of the roots 264 M AY/JUNE

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FIGURE 1A . Preoperative clinical

FIGURE 1B . Intraoral swelling in the mandibular left buccal vestibular region.

picture at the first visit. Extraoral swelling on the lower left side of the face. FIGURE 2 . Panoramic

radiograph showing welldefined homogeneous unilocular radiolucency with sclerotic border associated with the crown of the impacted left second premolar.

of the deciduous second molar. The left second premolar was displaced to the inferior border of the mandible. The distal aspect of the lesion showed a scalloped outline suggestive of two-wall resorption (FIGURE 2 ). The mandibular cross-sectional occlusal radiograph showed expansion of the buccal cortical plate. Two milliliters of yellow, straw-colored fluid with cholesterol crystals was obtained on aspiration. Biochemical analysis of the fluid showed 8 gm/dl of protein. Based on these findings, a provisional diagnosis was made of a dentigerous cyst (central type) associated with an impacted left second premolar. Differential diagnoses of odontogenic keratocyst, unicystic ameloblastoma and odontogenic myxoma were considered. An incisional biopsy was planned and the parents were informed to report back for the hematological investigations; however, the patient did not report back. After 18 months, the patient

once again reported with the history of mild pain and increase in size of the extraoral swelling on the left side of the face. Worm’s-eye view showed an increase in the expansion of the left buccal cortex. Intraoral examination showed expansion of the left buccal cortical plate with complete obliteration of the left buccal vestibule. (FI G URES 3 ) All signs and symptoms were aggressive when compared with the initial visit. The second panoramic radiograph showed unilocular radiolucency with the migration of the lower left permanent canine and first premolar and resorption of the first permanent molar (FIGURE 4 ). The impacted left second premolar was displaced further, thinning the inferior border of the mandible and indicating the aggressiveness of the lesion. Considering the aggressive nature of the lesion, a keratocystic odontogenic tumor and ameloblastoma were considered as differential diagnoses.

C D A J O U R N A L , V O L 4 8 , Nº 5/6

FIGURE 3A . Preoperative clinical picture

FIGURE 3B . Worm’s-eye view showing

at the second visit. Extraoral swelling on left side of the face.

expansion of the left buccal cortex.

FIGURE 4 . Panoramic radiograph showing unilocular radiolucency with migration of teeth Nos. 21 and 22 and resorption of No. 19. Impacted tooth No. 20 perforating the inferior border of the mandible is also seen.

FIGURE 5A . CT scan (axial view) shows a welldefined buccal cortical expansion with intact lingual cortical plate showing little expansion.

FIGURE 5B . Sagittal and coronal section 3D reconstruction image shows expansion and involvement of

the lower left permanent canine, first premolar and first permanent molar.

FIGURE 3C . Intraoral photograph showing

expansion of the left buccal cortical plate with complete obliteration of the buccal vestibule.

A CT scan was advised to assess the nature and extent of the lesion and to plan appropriate surgical treatment. The axial view of the CT showed a welldefined buccal cortical expansion with an intact lingual cortical plate showing little expansion. A 3D reconstruction image also showed expansion and involvement of the lower left permanent canine, first premolar and first permanent molar (FIGURES 5 ). Based on the clinical and radiographic examinations, an incision biopsy was planned. The deciduous second molar was extracted and an incision biopsy from deeper tissue was obtained by raising an envelope flap under local anesthesia. Histopathology of the incisional biopsy specimen showed a cystic lumen lined by three to four layers of flat to cuboidal cells with chronic inflammatory cell infiltration in the connective tissue capsule suggestive of a dentigerous cyst (FIGURE 6 ). Surgical enucleation of the cyst was planned under general anesthesia with the extraction of the permanent canine, the first premolar, the first permanent molar and the impacted second premolar on the left side of the mandible, followed by prosthetic rehabilitation.

Surgical Phase

The surgical area was exposed by placing a crevicular incision buccally extending from the mandibular left central incisor to the distal of the mandibular left second molar with a releasing incision to raise a mucoperiosteal flap M AY/JUNE 2 0 2 0 265

unicystic ameloblastoma C D A J O U R N A L , V O L 4 8 , Nº 5/6

b c

FIGURE 6 . Hematoxylin- and

eosin-stained sections reveal reduced enamel epithelium transforming into a multilayered stratified epithelium from left to right (40 times magnification): a. cystic lumen, b. reduced enamellike epithelium, c. focal thickening of the lining epithelium and d. chronic inflammatory cell infiltrate underneath the epithelial lining.

FIGURE 7A . Surgical exposure of the lesion.

FIGURE 7B . After surgical excision, peripheral

FIGURE 7C . Excised specimen.

FIGURE 7D. Wound closure using 3-0 Vicryl suture.

appearance with a well-polarized nuclei, subnuclear vacuolization and subepithelial hyalinization, suggestive of unicystic ameloblastoma. Apart from areas showing luminal and intraluminal proliferation, there was no evidence of any solid tumor islands or mural proliferations. Hence, a conclusive diagnosis of unicystic ameloblastoma type 1.2 was given (FIGURES 8 ). Oneyear postoperative radiographic findings showed satisfactory healing with normal bone formation (FIGURES 9 ).

in second or third decade of life are usually diagnosed as DCs. Sometimes they may become extremely large and cause cortical expansion and erosion.3 In this case, based on clinical demographics and radiographic findings, a diagnosis of DC was made when the patient presented the first time. When the patient presented for the second time, based on the clinical findings and the aggressive nature of the lesion on a panoramic radiograph and CT scan, an incision biopsy was planned to rule out the possibility of an aggressive lesion. The results of the incision biopsy revealed a DC. DCs with an extensive nature have the potential for a more aggressive transformation to an ameloblastoma; hence, complete removal of the lining

corticotomy.

and to expose the surgical field. The lesion was excised and the decision to apply Carnoy’s solution over the defect was made on the surgical table due to the extensive aggressive nature of the lesion. The flap was approximated and wound closure was done using 3-0 Vicryl (Ethicon, Somerville, N.J.) after placing platelet-rich plasma (PRP) in the surgical wound. (FIGURES 7 ) The entire excised specimen was sent for histopathological examination. The hematoxylin and eosin (H&E) stained sections of the excised specimen revealed features suggestive of a unicystic ameloblastoma type 1.2 in areas, along with the incisional biopsy findings of a dentigerous cyst in other areas. In a few areas, the epithelium lining of the cyst showed basal cells with a palisaded 266 M AY/JUNE

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Discussion

Cystic lesions of the jaws presenting as small, asymptomatic unilocular radiolucencies enclosing the crown of an unerupted or an impacted tooth with predilection for males and occurrence

C D A J O U R N A L , V O L 4 8 , Nº 5/6

a b

FIGURE 8A . Hematoxylin- and eosin-stained sections with epithelial lining showing Vickers and Gorlin criteria (40 times magnification).

FIGURE 8B . Hematoxylin- and eosin-stained sections of epithelial lining showing: a. luminal proliferation, b. intraluminal proliferation and c. subepithelial hyalinization.

FIGURE 9A . Follow-up findings after 12 months. Orthopantomogram at 12 months revealed no evidence of recurrence and favorable bone remodeling.

by enucleation rather than conservative procedures like decompression and marsupialization is suggested.4 Studies have shown that the use of Carnoy’s solution reduces chances of reoccurrence by its penetration into the depth of cancellous bone by 1.5 mm.5,6 Due to the extensive nature of the lesion in the present case, and awaiting conclusive diagnosis following excisional biopsy, the present case was treated by surgical enucleation followed by use of Carnoy’s solution to decrease the chances of recurrence. To call a cystic lesion a UA, it should satisfy the Vickers and Gorlin criteria.7 In the present case, the complete examination of the excised specimen clearly revealed the presence of lining epithelium

satisfying the Vickers and Gorlin’s criteria with luminal and intraluminal proliferations, suggestive of UA. The present case also established an increasing growth rate potential of UAs, as there was a definite increase in the size of the lesion from the initial presenting time to that after 18 months later. To aid in treatment planning, the present case was classified as a UA according to the World Health Organization system of 20038,9 and as subgroup 1.2 as per the recently modified classification of Ackermann et al. by Philipsen and Reichart.8 It is indicated that a tumor in subgroup 1.2 needs not be treated by segmental resection, but treated conservatively. Hence, in the present case, the treatment carried out was appropriate

FIGURE 9B . Followup findings after 12 months. A satisfactory clinical picture is seen at 12-month follow-up.

and did not need further intervention. The present case reemphasizes the importance of observation of a complete specimen rather than small incision bits in arriving at a final diagnosis and to intervene with further treatment process if necessary, after the final excisional biopsy report. According to various theories, UAs may arise from reduced enamel epithelium associated with the developing tooth, or it may develop in a preexisting dentigerous cyst or other types of odontogenic cysts. Also, areas of solid ameloblastoma may undergo cystic degeneration leading to a UA-like appearance. However, satisfactory evidence to prove these theories is difficult and UAs are said to be de novo cystic neoplasms.9 M AY/JUNE 2 0 2 0 267

unicystic ameloblastoma C D A J O U R N A L , V O L 4 8 , Nº 5/6

Macroscopically, UAs reveal several intraluminal and/or intramural focal thickening nodules, but the absence of these does not contradict the diagnosis of UA. Microscopy of UAs shows the cystic lining with the basal ameloblast-like cells and suprabasal stellate reticulum-like cells. Ameloblastomatous proliferation in the lumen of the cystic cavity is termed as luminal and the same proliferation in the connective tissue as intramural and is considered to be aggressive compared to other variants.10 Due to its aggressiveness, the treatment of UA continues to be controversial. Determinant factors for treatment planning are age, clinicalradiographic variant, anatomic locations, clinical behavior of the lesion, size, extent of the lesion and the histopathological variant.5 In the present case, both luminal and intraluminal proliferation was seen. Considering these factors, the treatment of enucleation followed by the use of Carnoy’s solution was justifiable in this case. The use of Carnoy’s solution decreases the chances of recurrence after conservative surgical treatment of UA.6 After surgical treatment, 93% of UAs with mural invasion have shown a recurrence rate of 10%. This further reinforces the use of Carnoy’s solution after surgical treatment in combating the recurrence of these lesions.11 PRP is known to aid in fast healing by various mechanisms,12,13 hence it was placed in our case before wound closure. Interestingly, in the present case the placement of PRP resulted in considerable filling of the defect with bone within a short period. After enucleation, the wound site showed good bone remodeling after six months of treatment without any evidence of recurrence. A long-term follow-up is mandatory, as recurrence of UA may be long delayed.14 Our case was lost for follow-up after one year. 268 M AY/JUNE

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Lessons learned from this case that could drive a strong message to practitioners encountering such cases are: ■ When a cyst of the jaw is associated with an impacted tooth, the most common provisional diagnosis is a dentigerous cyst. The importance of the radiologist in carefully examining the radiograph to assess the true dentigerous cyst/ impacted tooth relationship needs no emphasis. Yet, unicystic ameloblastoma (dentigerous variant) needs to be considered as one of the differential diagnoses along with other cysts of the jaws until the histopathological examination of the complete excised specimen warrants otherwise. ■ An incisional biopsy cannot be the representation of the total lesion. A conclusive diagnosis can be arrived at only after examining the complete excisional specimen. ■ A thorough macroscopic examination of the excised specimen gives clues to the diagnosis as any nodular growths on the walls of the specimen imply more toward UA with intraluminal/mural growths. ■ Because the incisional biopsy will not give a complete picture and hence the definitive diagnosis, the treatment of an odontogenic lesion with aggressive cystic radiographic picture and not-soagreeable histopathologic findings on incisional biopsy should be treated by enucleation followed by Carnoy’s solution application rather than by the conservative approach. ■ If the final diagnosis favors UA, revision of the treatment based on the type and nature of UA as proposed in the literature with a long-term follow-up of the patient should be mandatory. n

REFERENCES 1. Ikeshima A, Tamura Y. Differential diagnosis between dentigerous cyst and benign tumor with an embedded tooth. J Oral Sci 2002 44(1):13–7. doi: 10.2334/josnusd.44.13. 2. Reddy SK, Rao GS. Unicystic ameloblastoma in 6-year-old child and its significance. World J Dent 2011 2(4):363–366. doi:10.5005/jp-journals-10015-1116. 3. Shear M, Speight P. Cysts of the Oral and Maxillofacial Regions. 4th ed. Oxford: Wiley-Blackwell; 2009:74. 4. Bhushan NS, Rao NM, Navatha M, Kumar BK. Ameloblastoma arising from a dentigerous cyst – a case report. J Clin Diagn Res 2014;8(5):ZD23–25. doi: 10.7860/JCDR/2014/5944.4387. 5. Marx RE, Smith BH, Smith BR. Swelling of the retromolar region and cheek associated with limited opening. J Oral Maxillofac Surg 1993 51(3):304–309. doi: 10.1016/ s0278-2391(10)80180-6. 6. Stoelinga PJ, Bronkhorst FB. The incidence, multiple presentations and recurrence of aggressive cysts of the jaws. J Craniomaxillofac Surg 1988 16(4):184–95. doi: 10.1016/s1010-5182(88)80044-1. 7. Vickers RA, Gorlin RJ. Ameloblastoma: Delineation of early histopathologic features of neoplasia. Cancer 1970 Sep 26(3):699–710. doi: doi.org/ 10.1002/1097-0142(197009)26:3<699::aidcncr2820260331>3.0.co;2-k. 8. Philipsen HP, Reichart PA. Unicystic ameloblastoma. A review of 193 cases from the literature. Oral Oncol 1998 Sep 34(5):317–25. doi: 10.1016/s13688375(98)00012-8. 9. Reichart PA, Philipsen HP. Odontogenic Tumors and Allied Lesions. Batavia, Ill.: Quintessence Publishing; 2004:77–86. 10. Gabane M, Kulkarni M, Mahajan A. Unicystic ameloblastoma of mandible: A case report. Indian J Stomatol 2011;2:273–6. 11. Lee PK, Samman N, Ng IO. Unicystic ameloblastoma — use of Carnoy’s solution after enucleation. Int J Oral Maxillofac Surg 2004 Apr;33(3):263–267. doi: 10.1006/ ijom.2003.0496. 12. Forni F, Marzagalli M, Tesei P, Grassi A. Platelet gel: Applications in dental regenerative surgery. Blood Transfus 2013 Jan 11(1):102–7. doi: 10.2450/2012.0007-12. 13. Nevins M, Giannobile WV, McGuire MK, Kao RT, Mellonig JT, Hinrichs JE, et al. Platelet-derived growth factor stimulates bone fill and rate of attachment level gain: Results of a large multicenter randomized controlled trial. J Periodontol 2005 Dec;76(12):2205–15. doi: 10.1902/ jop.2005.76.12.2205. 14. Ackermann GL, Altini M, Shear M. The unicystic ameloblastoma: A clinicopathological study of 57 cases. J Oral Pathol 1988 Nov;17(9–10):541–6. doi: 10.1111/ j.1600-0714.1988.tb01331.x. THE CORRESPONDING AUTHOR, Brinda Suhas Godhi, MDS, can be reached at drbrinda7@yahoo.co.in.

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behavior management C D A J O U R N A L , V O L 4 8 , Nº 5/6

Clinical Behavior Guidance for Children in Dentistry Brent P. Lin, DMD, and Michael I. Lin, MD

a b s t r a c t Behavior management is an integral component of pediatric care.

It is the ability to guide children through their dental experience to meet their immediate dental needs, to plant seeds for future dental needs and to promote positive dental attitudes. A positive first dental experience paves the way for good oral health practice and success in future dental visits. It is therefore critical to understand children’s behavior and fundamentals for success in clinical pediatric dental care by all providers, including general and family dentists.

AUTHORS Brent P. Lin, DMD, is a clinical professor in the division of pediatric dentistry at the University of California, San Francisco. He obtained his dental degree from Temple University in 1992 and completed his pediatric dentistry residency program at St. Barnabas Hospital. In addition, he did a general practice residency program at Yale-New Haven Hospital and a geriatric fellowship program at the University of Michigan. Conflict of Interest Disclosure: None reported.

Michael I. Lin, MD, is the assistant chief of psychiatry at the Veterans Affairs North Texas Health Care System. He obtained his medical degree from the University of Texas Health Science Center at San Antonio in 1995 and completed his psychiatry residency program at the Texas Tech University Health Sciences Center El Paso, where he served as the chief resident in the department of psychiatry and vice president of the House Staff Association. Conflict of Interest Disclosure: None reported.

ehavior guidance is an integral component of pediatric dental care. It is the ability to guide children through their dental experience to meet their immediate dental needs, to plant seeds for future dental needs and to promote positive dental attitudes. Children of different age groups exhibit general behavior and reaction toward dental procedures corresponding to their developmental stages. In the maturational theory of child development, Gesell described personality characteristics and behavior norms related to specific ages that unfold in a predictable and sequential pattern during growth and development.1,2 A 3-year-old child typically has a more developed imagination than a 2-year-old toddler. All children undergo the same stages and sequences of development, but each child accomplishes these developmental milestones at their own pace.1–3 Hence, a child’s developmental age might not coincide with chronological age. Assessing a child’s development is critical in predicting the ability of a child to cope with dental procedures,

and it is imperative to understand that human development is not unitary. The relationship between a provider and a child patient is not linear, and parental factors play a critical role in the care of a child (FI G URE 1 ). Wright and Alpern cited variables and environmental factors that could affect children’s behavior in the dental setting, such as the impact of parental or community influence.4 Previous health care visits could also potentially instill or alleviate fear and anxiety in a dental visit. A child’s visit to the dental office may be the first exposure to oral health, and dental care providers have the opportunity to influence and shape the child’s oral health well-being and dental experience for a lifetime. A positive first dental experience paves the way for good oral health practice and success in future dental visits. It is therefore critical to understand children’s behavior and fundamentals in management for success in clinical pediatric dental care by all providers, including general and family dentists. M AY/JUNE 2 0 2 0 271

behavior management C D A J O U R N A L , V O L 4 8 , Nº 5/6

Child

Children’s Behavior in Dental Setting

Evaluation of a child’s behavior starts as soon as the child steps into the dental office. Some children are cheerful, giving high-fives to everyone in the office and can’t wait to get their teeth cleaned. Others may hold onto their parents or start crying even before they enter the office. Parents play a key role in determining a child’s dental experience. High parental anxiety can negatively affect a child’s behavior. Effective communication, cooperation and concurrence with parents on all procedures to be performed are essential. The quality of a child’s previous health care experience is more emotive than the number of visits. Similarly, a child known to have a dental problem tends to display negative behavior in a dental appointment. Hence, a planned wellchild dental visit is invaluable in setting the tone for future dental experiences. General behavior patterns are observed throughout the age spectrum in healthy children. Prior to age 3, infants and toddlers display undiscerned emotions and, in the absence of developed verbal and communication skills, discomforts or fears are expressed through crying. The world of very young children is more binary than multifaceted. For example, difficulty may present in processing the thought of “pressure” during extraction. It either “hurts” or “not hurts.” Toddlers expand their language skill, and curiosity and the ability to reject a proposed action emerge by age 3, leading to frequent “why” and “no.” Separation anxiety is observed among this age group, and parental presence may be helpful to ease a child’s fear and anxiety. Toddlers may not want to sit in a dental chair; therefore, dental care providers should be flexible and perform dental examinations in 272 M AY/JUNE

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Society Dentist

Parent

FIGURE 1. Dynamic relationship between provider, child patient and parent in pediatric dental setting.

FIGURE 2 . Lap-to-lap examination for toddlers and

young children.

a nontraditional position, such as a lap-to-lap examination (FI G URE 2 ). In this position, the child’s head rests on the care provider’s lap and the legs straddle the parent’s waist. While the care provider stabilizes the head of the child, the parent holds the child’s hands and controls body movements. Although precooperative behavior is often associated with toddlers prior to age 3, one should never generalize behavior based on chronological age. Each child should be assessed and evaluated and a management strategy should be customized for each child. Due to differential maturation, a 2-year-old toddler may display a more cooperative behavior than an 8-year-old child. At the preschool age, children develop the processes of self-control and reasoning but continue to have short attention spans. They want to help during dental procedures but may easily become distracted and frustrated. A 4-year-old child, for example, may only have an eight- to 12-minute attention span, thus it is critical to work efficiently as the working time starts to dwindle as soon as the child sits in the dental chair. According to the Diagnostic and Statistical Manual of Mental Disorders, anxiety is the anticipation of future threat and fear is the emotional response to real or perceived imminent threat.5 They are often multifactorial, with significant influence from peers and parental figures. At age 5 or 6, a child goes to school and establishes peer relations,

self-identity and body image. With increased socialization and exposure to societal norms for rules-based behavior, children this age are more likely to follow instructions and obey orders. They may learn simplified concepts behind medical and dental procedures. With limited understanding and prior adverse experience, a child at this age may exhibit fear toward certain dental procedures. As children grow, they gain social independence and improve their ability to care for themselves. With maturity and cognitive development, the ability to cope with dental procedures gradually enhances over the years. In uncooperative patients with nonurgent and asymptomatic conditions, definitive treatment could be deferred to a later date when the child is able to better cope with procedures. Treatment options that halt the progression of carious lesions, such as interim therapeutic restoration or silver diamine fluoride, may be considered. Documentation and classification of behavior are not only helpful in evaluating a child’s cognitive development over the years but also essential in planning appropriate management strategies for future dental visits. One of the most common behavior classification is the Frankl Behavior Rating Scale.6 It is based on assigned numerical value on behavior, ranging from 1 being definitely negative to 4 being definitely positive (TA BLE 1 ). A descriptive evaluation, including tactic or strategy that is helpful in managing the

C D A J O U R N A L , V O L 4 8 , Nº 5/6

TABLE 1

TABLE 3

Behavior Classification

Behavior Management Techniques

Frankl Behavioral Rating Scale 1. Definitely negative (– –) 2. Negative (–) 3. Positive (+) 4. Definitely positive (+ +)

Clinical Management Techniques n State the goal or task n Tell-show-do (TSD) n Distraction n Modeling n Positive reinforcement n Behavior shaping n Disregard of minor inappropriate behavior n Nonverbal communication

Wright’s Behavioral Clinical Classification n Cooperative n Potentially cooperative n Lacking in cooperative ability TABLE 2

Fundamental Principles for Successful Behavior Management Positive approach Team attitude n Organization n Tolerance n Flexibility n Truthfulness n n

child, should also be noted. For example, if a child loves soccer, it should be documented, and the subjects of interest for the child could enhance rapport during subsequent visits. Symbols such as + and − have also been utilized in behavior classification, with + indicating good behavior and − signifying poor behavior. Wright and colleagues distinguished a child’s behavior in three categories based on the ability to cooperate: cooperative, potentially cooperative or lacking in cooperative ability.7 Children who were potentially cooperative hadn’t yet developed the ability but would likely become cooperative later as they matured. A subset of children who may not fully develop that coping skill, such as special needs children, would be classified as lacking in cooperative ability under the Wright’s behavior assessment.

Fundamentals of Behavior Management

Effective behavior management in children is based on several fundamental principles (TA B L E 2 ). A functional inquiry should be obtained through a brief parental interview. Information on the child’s

Advanced Management Techniques n Parental presence/absence n Voice control n Protective stabilization or medical immobilization Pharmacological Anxiety Management n Nitrous oxide and oxygen n Oral conscious sedation n Deep sedation/general anesthesia

reaction during past medical and dental procedures, the parents' own anxiety, the child's perception of their dental health and parental opinion regarding their child’s behavior and reaction in the dental chair could provide critical background in developing a management approach. A negative response to any question may increase the chance of encountering behavior issues. When working with a child, it is fundamental to have a positive approach. The dental team should be affirmative, validating and supportive. A friendly and encouraging team attitude eases a child’s anxiety, and a great way to build rapport is listening and learning about their interests. Children are observant; any sign of indecisiveness, delays or poor organization could result in apprehension. Tolerance and gentle redirection of misbehaviors of a child are essential while maintaining composure, adaptability and flexibility according to situational demands. Under all circumstance, a dentist should be truthful to the child and their parents to foster a trusting relationship.

Clinical Guidance Techniques

Behavior management should start with the least invasive and simplest techniques that could accomplish the intended tasks (TABLE 3 ). Often a combination of two or more techniques is utilized. The goals or tasks for the visit should be stated simply and to their level of understanding. Tell-show-do (TSD) is a technique that is routinely used and is helpful in introducing a new setting, material or procedure to children. The intended procedures would first be explained in age- or developmentally appropriate phrases (tell), followed by a demonstration of the procedure in a carefully defined, nonthreatening setting (show). The procedure should then be accomplished without much deviation from what is demonstrated (do). Another strategy to promote good behavior is to show a child the cooperative behavior of another child who is undergoing similar procedures. The intent is to have children model after each other in a positive manner. Positive reinforcements of desired behavior in the form of praise or prize further buttress the behavior via operant conditioning. Positive reinforcements should be specific to the particular behavior or action that is to be promoted. Prize should be used to reward appropriate behavior and positive outcome for the dental visit and should not be given indiscriminately. However, minor inappropriate behavior by the child should be disregarded. Anxious and fearful children often focus on every task and movement made around them. They may suddenly grab the dentist’s hand or turn their head during the local anesthetic administration process. Coaching M AY/JUNE 2 0 2 0 273

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in soothing, child-friendly language or terms, coupled with positive reinforcement, may be helpful in easing anxiety and improve coping ability. Distraction could be an effective method in shifting the child’s focus away from perceived fear and anxiety. Gently tapping on the child’s forehead, telling a story, singing a song or mildly shaking the cheek or lip during administration of local anesthesia are examples of tactics to distract a child from an intended procedure. Watching a movie or listening to a song not only provides comfort and entertainment but also serves as effective visual and auditory distractors. If the root of the problem stems from past dental experiences, progressive exposure and desensitization may be required. For example, treatment could be started with something simple and easy before proceeding to more difficult or extensive procedures. Utilizing nonthreatening or familiar objects, such as a toothbrush, may encourage the child to open their mouth. The ultimate goal is alleviating the anxiety and fear response to optimize treatment outcome. Children are influenced by their environment and interactions with others. The design of a pediatric dental office should be kid-friendly and a fun place children would enjoy. Asking silly yet appropriate questions and telling age-appropriate jokes could at times be helpful in building rapport. Children have incredible imaginations; hence, storytelling or singing during the dental procedure could keep their minds spellbound and engaged. For very young children, the story can be a fictional customization with characters that capture their imagination, keeping their mind distracted from the procedure. Holding a comforting security object such as a teddy bear or a parent’s hand could keep the child’s hands preoccupied 274 M AY/JUNE

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and relaxed. If a child has questions and can’t verbalize due to the ongoing procedure, the practitioner could instruct the child to gently raise their hand on the side that is away from the procedure. Due to the short attention span among young children, a practitioner should work efficiently and may perform a procedure in short intervals with breaks. Counting backward could be helpful in keeping children occupied and giving them a goal to accomplish. Not all techniques require spoken words to be effective. Nonverbal communication is the reinforcement and guidance of behavior through appropriate contact, body language, facial expression and posture. One example is to give a thumbs-up gesture for approval, encouragement and acknowledgement for good behavior and a job well done. The purpose is to gain the patient’s attention and to maintain compliance. It should be used in conjunction with other management techniques.

Advanced Management Techniques

With changes in society and a new generation of parenting, the use of some behavior management techniques has become questionable or controversial, especially with the influence of social media. For example, the hand-over-themouth method that was practiced for decades is currently not a standard of care in the profession and is not used in modern pediatric dental practice. The traditional school of thought was that children behaved the same with or without parental presence.8–10 However, dentists these days are facing an increasing demand from parents to be in the room with their child. Practitioners have either adapted to parental requests or set up official policy to address this issue. A toddler may exhibit separation anxiety before age 3;

FIGURE 3 . Facilitation of pediatric dental

treatment utilizing passive medical immobilization.

therefore, parental presence may comfort the child and ease their fear and anxiety. After the third year of developmental age, parental presence can potentially serve as a reward for good behavior. For example, if the child is cooperative and behaves appropriately, the parents can stay in the operatory at the request of the child. By age 9, parental presence may not matter to most children. Voice control is another effective technique with the intent to gain immediate attention of a child by sudden and firm commands and can potentially halt an adverse behavior. It should not be presented in an angry voice or give the perception of being mad. For example, a child may place their hands over the mouth to prevent procedural progress despite repeated and gentle requests. The practitioner may consider changing the tone to a firm and commanding voice for a more favorable outcome. Protective stabilization has generated mostly negative attention from parents and the press.11 A child may require medical immobilization for immediate medical attention in an urgent situation, such as the extraction of an infected tooth. For children with special needs, a dental

C D A J O U R N A L , V O L 4 8 , Nº 5/6

TABLE 4

Examples of Child-Friendly Terms for Dental Instruments and Materials Professional terms

Child-friendly terms

Mouth prop

Tooth pillow

Dental explorer

Tooth counter

Local anesthesia

Sleepy juice

Topical anesthesia

Sleepy jelly

Dri-Angle cotton roll substitute

Sticker

Gauze

Tooth towel

Suction

Mister thirsty

Slow-speed handpiece

Mister bumpy

High-speed handpiece

Mister whistle

Rubber-dam clamp

Tooth ring

Rubber dam

Raincoat

examination may not be possible without brief immobilization. There are two general categories of medical immobilization. Active medical immobilization is the personal hold of the child by parents or others, while a stabilization device is considered as passive medical immobilization. Passive medical immobilization could provide stability and protect the child from harmful sudden movement in the setting of a procedure or examination (FI G URE 3 ). Erythema, abrasion and petechiae may be observed in children resisting medical immobilization; therefore, it is essential to obtain informed parental consent covering the rationale, expected outcome, potential complications and risks and benefits of proposed techniques. Mandatory written documentation prior to protective stabilization deployment should include signed informed consents (risks and benefits, potential complications and alternative treatment options), indication and type of restraint, duration and behavior evaluation/rating prior to and during stabilization. This will optimize effective communication and avoid potentially costly and detrimental misunderstandings.

Pharmacological Anxiety Management

Clinical management techniques may not be effective in the management of all behavior issues. Pharmacological agents may be needed to supplement the clinical management techniques. The most commonly used pharmacological agent in a dental office is the nitrous oxide and oxygen mixture, which is easily administered with a relatively high margin of safety. When used appropriately, a state of relaxation and enhanced cooperation should be achieved. The patient monitoring requirement for nitrous oxide/ oxygen varies among states, ranging from visual monitoring to pulse oximetry. Oral anxiolytic agents for oral conscious sedation or intravenous agents for deep sedation are alternative treatment options.12 These specialty services are usually available in a pediatric dental office. A more controlled setting is provided by general anesthesia with the airway secured via intubation; however, this is only available at selected hospitals or surgery centers with dental service. When encountering difficulty in achieving cooperative behavior for safe dental care delivery, appropriate timely referral for pediatric dental specialty care should be made. Due to the extensive available literature and page limitation, pharmacological anxiety management is beyond the scope of this article.

Communicating With Children and Use of Child-Friendly Terms

To communicate effectively with children, language and terms should be appropriate for their developmental level. The vocabulary and sentence form, for instance, are different for a 3-year-old compared to a 14-year-old. Children are more receptive to procedures or materials utilizing words or terms that they recognize, understand and can relate

to (TA BLE 4 ). For example, a gauze could be referred to as a “tooth towel” and a Dri-Angle cotton roll substitute could be termed as a “sticker” for your cheek. Children like to engage in activities around them. It is appropriate to let children feel empowered. For instance, one should not ask the child, “Do you want to finish?” Instead, the practitioner should rephrase such question to, “Do you want to finish in two minutes or 15 minutes?” Another useful strategy is “don’t ask but give choices.” For example, don’t seek permission for using an explorer by asking, “Let’s use the tooth counter, okay?” A child would be more likely to accept it with simple instruction and choices, such as “Let’s use the tooth counter. Do you want to start on the bottom or the top?” Another common pitfall in communication is that dentists often try to keep the conversation going by asking patients questions during procedures. Between the mouth prop, rubber dam, sharp instruments and handpiece in the mouth, it may be difficult for a child to verbally respond. Hence, it is preferable to make comments, instead of asking questions, during dental procedures.

Summary

A common myth among practitioners is that children under a certain age, those with extensive dental treatment needs and special needs children, require treatment under general anesthesia. Practitioners tend to deploy pharmacological intervention when faced with behavioral challenges. The reality is that a majority of children are cooperative and are able to cope with dental procedures. All practitioners have their own favorite tools or strategies for managing children. Any behavior management technique utilized should be acceptable and meet the standard of care of the profession. Any advanced or controversial method requires parental informed consent before utilization. If a wellM AY/JUNE 2 0 2 0 275

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behaved child becomes combative or anxious during a procedure, a brief time-out period may alleviate behavioral issues and facilitate a discussion of management strategies with parents. Detailed documentation of behavior is an integral part of the pediatric dental record at each visit. It provides an overview of a child’s cognitive development, maturation, temperament and ability for cooperation and facilitates behavior management in the subsequent visits. Effective behavior management is essential in achieving a desirable treatment outcome in children. n

REFERENCES 1. Gesell A. Infancy and Human Growth. New York: Macmillan; 1929. 2. Gesell A, Ilg FL. Child development, an introduction to the study of human growth. New York: Harper; 1949. 3. Thelen E, Adolph KE. Arnold L. Gesell: The paradox of nature and nurture. In Parke RD, Ornstein PA, Rieser JJ, et al., eds: A Century of Developmental Psychology. Washington, D.C.: American Psychological Association; 1994:357–388. 4. Wright GZ, Alpern GD. Variables influencing children’s cooperative behavior at the first dental visit. ASDC J Dent Child 1971 Mar–Apr;38(2):124–128. 5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, D.C.: American Psychiatric Publishing; 2013. 6. Frankl S, Shiere F, Fogels H. Should the parent remain with the child in the dental operatory? J Dent Child 1962 29:150–163. 7. Wright GZ. Behavior management in dentistry for children. Philadelphia: W.B. Saunders Co.; 1975.

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8. Lewis TM, Law DB. An investigation of certain anatomic responses of children to a specific dental stress. J Am Dent Assoc 1958 57:769–777. 9. Venham L, Bengston D, Cipes M. Parent’s presence and the child’s response to dental stress. ASDC J Dent Child 1978 May–Jun;45:37–41. 10. Pfefferle JC, Machen JB, Fields HW, Posnick WR. Child behavior in the dental setting relative to parental presence. Pediatr Dent 1982 4(4):311–316. 11. Fields HW, Machen JB, Murphy MG. Acceptability of various behavior management techniques relative to types of dental treatment. Pediatr Dent 1984 Dec;6(4):199–203. PMID: 6596566. 12. American Academy of Pediatric Dentistry. Guideline on use of anesthesia personnel in the administration of office-based deep sedation/general anesthesia to the pediatric dental patient. Pediatr Dent 2015 37(special issue):211–227. THE CORRESPONDING AUTHOR, Brent P. Lin, DMD, can be reached at linb@dentistry.ucsf.edu.

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centric relation C D A J O U R N A L , V O L 4 8 , Nº 5/6

Reproducibility and Variability of Centric Relation Point in Completely Edentulous Patients Sushil Kumar Kar, MDS; Arvind Tripathi, MDS; and Praveen Rai, BDS

a b s t r a c t The purpose of the study was to evaluate the reproducibility and

deviation from the centric relation point with time in completely edentulous patients.

AUTHORS Sushil Kumar Kar, MDS, is a professor in the department of prosthodontics at Saraswati Dental College and Hospital in Lucknow, India. Conflict of Interest Disclosure: None reported. Arvind Tripathi, MDS, is a professor and head of the department of prosthodontics at Saraswati Dental College and Hospital in Lucknow, India. Conflict of Interest Disclosure: None reported. Praveen Rai, BDS, is a junior resident in the department of prosthodontics at Saraswati Dental College and Hospital in Lucknow, India. Conflict of Interest Disclosure: None reported.

roviding harmony between the occlusion and the condylar paths has a significant role for edentulous patients to restore oral function, preserve the stomatognathic system and prevent oral diseases and has a great influence on mandibular movements.1–3 Factors that govern the condylar paths are mainly bony fossae, muscle tone, attached ligaments, shape and movements of the menisci and anterior guidance.4–11 Among the methods that have been performed to establish a stable maxillomandibular relationship, gothic arch tracing has been broadly accepted clinically for determining the horizontal mandibular position of an edentulous jaw. The gothic arch (needle point) tracing is not only effective to record maxillomandibular relationships in completely edentulous patients but is helpful during the diagnosis and treatment of restorative problems. The main aim of the tracing needle is to record the 3D movement of the temporomandibular joint (TMJ) onto a 2D flat plate on a certain level.12 Most of the patients could not reproduce the centric point due to long-term edentulism, uncontrolled muscle movement and some symptoms of temporomandibular

disorder.13 The purpose of this study is to evaluate the reproducibility of centric point and changes in vertical dimension of occlusion (VDO) by cone beam computed tomography (CBCT) at different intervals in completely edentulous patients.

Material and Methods

The study was conducted on 60 completely edentulous subjects (male and female) aged 45 to 70 from our outpatient department. All subjects were informed in detail about the nature of the study and a written consent was obtained. Ethical clearance was obtained from the ethical committee of our institution before starting the study. For better standardization of all the study subjects and to avoid bias in the study, the inclusion criteria applied were edentulous subjects with healthy residual ridges showing Angle’s class I ridge relations, a period of edentulism of more than one year and no preprosthetic surgery. The exclusion criteria were history of any craniofacial surgery or trauma, signs and symptoms of TMJ disorders, facial asymmetries, history of uncontrolled systemic disorders, poor neuromuscular control, highly resorbed ridges, previous denture wearers and poor mental attitude. M AY/JUNE 2 0 2 0 277

centric relation C D A J O U R N A L , V O L 4 8 , Nº 5/6

FIGURE 1. Deviation from centric relation position calibrated with Vernier caliper.

FIGURE 2 . Complete dentures with the metallic balls.

64.50mm

Preparation of Work Field

Occlusal rims were fabricated following all impressions-making protocols and lab procedures and were adjusted in the patient’s mouth to register the maxillomandibular relations. Using a facebow transfer (Spring-Bow, Water Pik Technologies, Fort Collins, Colo.), the maxillary cast was mounted on the articulator (Hanau Wide-Vue, Whip Mix, Louisville, Ky.). Tentative centric relation was then registered at the conventionally established vertical dimension and the mandibular cast was mounted. Four millimeters of freeway space was adopted as a standard in subsequent appointments. As the objective of the present study was to evaluate the reproducibility of centric relation point over a period of two years, four sets of occlusal rims were fabricated from four definitive impressions at an interval of six, 12, 18 and 24 months respectively. In order to use a standard occlusion rim for the tracers at subsequent appointments, the following procedure 278 M AY/JUNE

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was adopted. A line was drawn on the mounting plaster parallel to the occlusal plane at a known distance. The line was used to verify the height of the occlusion rim on future replication. The base with the occlusion rim was then embedded in putty silicone to form an index that enabled the replication of occlusion rims with an assumption that no changes had occurred in the stomatognathic systems in subsequent appointments. The tracer assemblies (Hight extraoral tracers, Teledyne Technologies, Thousand Oaks, Calif.) were secured to the respective maxillary and mandibular occlusal rims following all standardize protocols to assure that they maintained the absolute parallelism. The tracing table was covered with permanent marker and the subjects were asked to perform centric, protrusive and lateral movements repeatedly until satisfactory tracings were obtained. The whole procedure was repeated after six, 12, 18 and 24 months respectively following the denture insertion. Deviation from

FIGURE 3 . CBCT of a subject with the dentures.

the centric point, protrusive, left and right lateral track was recorded and measured for any changes from the earlier tracings. The errors in the measurements were minimized by maintaining the same dimensions of the occlusal rims and attachment of tracer assemblies at the fixed reference positions. The mean of five readings was calculated by a digital Vernier caliper with an error of 0.01 mm (FI G URE 1 ).

Preparation of Subjects

Two metallic balls (0.2 mm diameter) were embedded on the labial and buccal notch of the maxillary and mandibular denture respectively (FI G URE 2 ). CBCT (KaVo Dental, Biberach, Germany) of subjects

C D A J O U R N A L , V O L 4 8 , Nº 5/6

TABLE 1

Group Comparison of Age and Gender Age and gender

Total

Group A (n = 18)

Group B (n = 42)

No.

Up to 50

27.77

28.57

51–60

33.33

47.61

61–70

38.88

23.80

c” = 15.085(df = 2); p > 0.005 Min–Max (Mean ± SD)

47–65 (55.98 ± 5.71) 47–65 (56.56 ± 7.21)

48–65 (55.74 ± 5.02)

Female

Male

38.89

21.43

61.11

78.57

c” = 1.964(df = 1); p = 0.161

were taken and the images were then reconstructed and converted into the DICOM format (Cybermed Inc., Daejeon, Korea) (FI G URE 3 ). The vertical dimension of occlusion (VDO) was recorded at the time of insertion and changes in VDO were measured at intervals of six, 12, 18 and 24 months respectively.

Statistical Tools Employed

The statistical analysis was done using SPSS Version 15.0 statistical analysis software (IBM, Armonk, N.Y.). The values were represented in number (%) and mean ± SD. Student’s t-test was used to test the significance of two means and a paired t-test was used to compare the change in a parameter at two different time intervals. The level of significance was designated by p.

Results

A total of 60 edentulous subjects aged 45 to 70 were included in the study based on the inclusion and exclusion criteria from a patient pool of 200. Reproducibility of centric relation was evaluated at six, 12, 18 and 24 months, and it was found that 18 subjects (30.0%) gave nonreproducible records (designated as A), while in 42 subjects (70.0%), the centric point was reproducible (designated as B). The proportion of B subjects was higher until the

age group 60 years (47.61% versus 33.33%), while in the age group 60 to 70 years, the proportion of A subjects was more (38.8% versus 23.8%). The difference in the age of group B and group A subjects was not found to be statistically significant (p > 0.005). Further, in females (n = 16), the percentage of reproducible subjects was slightly greater than nonreproducible subjects and this difference was not significant statistically (TA B L E 1 ). The VDO for the reproducible group was relatively unchanged during the study period, but the VDO was reduced from 66.69 ± 1.02 mm to 65.39 ± 1.01 mm at the end of 24 months for the nonreproducible subjects. The difference in VDO among subjects in groups B and A was found to be statistically significant during the study period (p < 0.001) (TABLE 2 ). In both the groups, loss in VDO from baseline (at insertion) was observed with time. In group A subjects, the VDO was reduced by 1.30 ± 0.09 mm at the end of 24 months with a percentage change of 1.95%, while in group B, subjects’ decline in VDO was only 0.71 ± 0.17 mm at the end of 24 months (TA B L E 2 ). For group A subjects, no diversion from the centric was found in the majority of the subjects (55.56%) at the end of six months. Subsequently, the deviation during the excursive movements was 38.89% on the left

side and 33.33% on the right side, while during protrusion the deviation was 27.78% of the subjects (TA B L E 3 ). At six months, diversion from the centric point was observed in only eight subjects with a mean value of 0.46 ± 0.12 mm, but progressively the numbers of subjects were increased with mean diversion of 1.13 ± 0.20 mm at the end of 24 months. Diversion from the centric point was found to be statistically significant (p < 0.001) in all the succeeding months (TA B L E 3 ).

Discussion

In the fabrication of a complete denture, the most important step is the establishment of a stable maxillomandibular relationship at the centric relation position. Numerous methods have been advocated to determine the centric relation position, and gothic arch tracing is one such method. In this method, the stylus traces the path of the excursive movements of the mandible and converts 3D movement of the bilateral TMJ onto the 2D flat plate in the shape of a gothic arch or an arrowhead. But most of the patients face difficulty in reproducing the centric relation point because of long-term edentulism, uncontrolled muscle movements or temporomandibular disorder symptoms, the state of underlying supporting tissue, the accuracy of the final impression, the size of the residual ridges, movement of the tongue, cooperation by the patient, stability of the trial bases, errors in mounting and processing of the final denture. Hence, the present study was conducted in order to compare the reproducibility of the centric point by gothic arch tracing and its possible correlation with changes in the VDO by CBCT at intervals of six, 12, 18 and M AY/JUNE 2 0 2 0 279

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TABLE 2

Intergroup Comparison of Vertical Dimension of Occlusion (mm) in Groups A and B at Different Intervals Intergroup Period of observation Group A (n = 18) (months) Mean

Group B (n = 42) Mean

Statistical significance t p

At insertion

1.02

67.11

0.68

– 1.842

66.69

0.071

6 months

66.33

1.01

66.90

0.68

– 2.543

0.014

12 months

66.01

0.99

66.73

0.67

– 3.323

0.002

18 months

65.74

0.99

66.59

0.65

– 3.954

< 0.001

24 months

65.39

1.01

66.40

0.65

– 4.597

< 0.001

TABLE 2A

Intragroup Comparison of Vertical Dimension of Occlusion (mm) within Groups A and B at Different Intervals Intragroup Period of Group A (n = 18) observation Mean diff. SE

% change

Group B (n = 42) Mean diff.

% change

6 months

– 0.36

0.12

– 0.54

– 13.277

< 0.001

– 0.21

0.06

– 0.31

– 21.285

< 0.001

12 months

– 0.69

0.12

– 1.03

– 22.624

< 0.001

– 0.37

0.09

– 0.56

– 26.690

< 0.001

18 months

– 0.96

0.13

– 1.43

– 31.254

< 0.001

– 0.51

0.12

– 0.76

– 28.734

< 0.001

24 months

– 1.30

0.09

– 1.95

– 58.384

< 0.001

– 0.71

0.17

– 1.06

– 27.137

< 0.001

24 months respectively. CBCT was preferred over orthopantomograph and lateral cephalometry in the present study, because it is a diagnostic tool that has revolutionized diagnosis and treatment planning in the dental field. It is an image scanning and volumetric reconstruction technique that allows us to obtain linear measurements in 3D using computer software. The advantages of CBCT are reduced size of irradiation, minimized scattered radiation that would degrade image quality, provided isotropic voxels, i.e., equal in all three proportions and rapid scanning time. Ever since Gysi proposed this method in 1910, needle point tracing has been accepted as the most accurate method for location of the centric maxillomandibular relation at a given degree of jaw separation.14 El-Aramany et al. showed that determination of the centric point by the gothic arch tracing method could be accurately reproduced in the same appointment.15 Grasso and Sharry found a variability in the apex positions of the needle point tracings, 280 M AY/JUNE

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which were recorded over a period of time, and consequently recommended that a 1 mm area of freedom be given in the centric occlusion in order to accommodate this variability.16 Pyott et al. proved that the measurements at vertical dimensions may be checked before, during and after completion of the restorations in order to verify the vertical dimension.17–19 In his experiment, Myers found that the forefinger- and thumb-pressure method of recording the occlusal reference position did not consistently give a more posterior position than the needle point tracing method.20 Atashrazm said that there was no influence of the fast-processing technique on the number of the occlusal contacts and occlusal vertical dimension of complete dentures.21 Several authors have investigated the use of radiographic images for gnathological studies, but very few studies have incorporated CBCT to assess the vertical relation of occlusion. Panoramic images are often not accurate for measuring the vertical dimension due to several structures

being superimposed. The use of CBCT has recently become a versatile tool because more reliable results can be expected. Although the CBCT are subdivided into two types, the authors have used the cross-section CBCT to measure and compare the VDO. Results of the present study showed that in 70% of the patients, centric relations were reproducible and the probability of reproducibility of centric relation was relatively higher up to the age group 51 to 60 in comparison to the age group 61 to 70. Further, the proportion of group A subjects was higher among females as compared to group B subjects and the difference was found to be statistically significant. Douglas reported 20 years’ of findings after he researched the changes on the craniofacial complex in complete denture wearers.22 He concluded that there was a loss in the vertical dimensions and the mandible was shifted in a counterclockwise manner and slightly forward. These changes were completely unaffected by the gender of the patient or the

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TABLE 3

Direction of Diversion at Different Intervals in Group A (n =18) During the excursive movements No diversion

Left side

Right side

Protrusion

No.

At 6 months

55.56

16.67

11.11

16.67

At 12 months

0.00

38.89

33.33

27.78

At 18 months

0.00

38.89

33.33

27.78

At 24 months

0.00

38.89

33.33

27.78

TABLE 3A

Details of Group A at Different Intervals At the centric Duration of study

Number of subjects

Mean change from centric point

At 6 months

0.46

0.12

11.014

< 0.001

At 12 months

0.62

0.13

20.206

< 0.001

At 18 months

0.83

0.13

27.549

< 0.001

At 24 months

1.13

0.20

23.696

< 0.001

dental technique employed. In the present study, the differences in VDO among subjects with reproducible and nonreproducible centric relation subjects at six, 12, 18 and 24 months after insertion was found to be statistically significant (p = 0.071). However, a loss in the VDO was observed from the baseline in both nonreproducible and reproducible centric relation subjects with time. Hadjieva investigated the changes in the measurement of the VDO with different durations of full denture treatments and found that the difference between the VDO in the old and the new dentures was from 2 mm to 3.99 mm in subjects who had the old denture treatment for a period of three to six years.23 All patients undergoing the new treatments had their vertical dimension of occlusion increased by 2 mm to 6 mm. This demonstrated how there were significant changes in the dimensions of VDO even after only three years of wearing dentures. He concluded that the changes that occurred in patients with complete

denture treatment were due to a variety of reasons, such as resorption of the residual alveolar ridges and wear of the occlusal surfaces of the artificial teeth leading to shortening of the length of the lower third of the face, making the patient appear older than their actual age. Serrano et al. studied centric relation change during therapy with corrective occlusion prostheses and found that corrective occlusion prosthesis therapy for 24 hours a day did not improve the reproducibility of the centric relation of asymptomatic patients within three months.24 At the end of six months, 55.56% of group A subjects showed no diversions from the gothic arch tracing, but the remaining subjects produced a diversion of 16.67% on the left lateral path, 16.67% toward protrusion and 11.11% on the right lateral path. Subsequently, the diversion was increased to 38.89% on the left lateral path and 33.33% on the right lateral path while toward protrusion it was increased to 27.78% at the end of 24 months. At six months, the diversion from the centric point

was seen in only eight cases. The mean diversion was found to be 0.46 mm ± 0.12 mm and was statistically significant (p < 0.001). At 12, 18 and 24 months, the diversions from centric were progressively increased with a value of 0.62 mm ± 0.13 mm, 0.83 mm ± 0.13 mm and 1.13 mm ± 0.20 mm respectively and were found to be significant statistically (p < 0.001). Breitner put forward a report on the transformation of the TMJ in rhesus monkeys when the mandible displaced anteriorly.25 In the report, he concluded that by raising the bite, excessive stress was transmitted to the extra-alveolar bone when forces were applied parallel to the long axis of the tooth. In the present study, diversions from the centric point were more common in nonreproducible subjects as compared to reproducible subjects with the duration of time. Hence, it can be assumed that the longer the duration of wearing a complete denture, the more difficult reproducing the centric relation point and the diversion from the mandibular paths will be. M AY/JUNE 2 0 2 0 281

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Conclusion

Within the limitation of this study, it can be concluded that the centric relation point can be reproducible with age and duration of wearing a complete denture irrespective of gender. Changes in the vertical dimension of a complete denture patient is due mainly to the resorption of the residual alveolar ridges and wear of the occlusal surfaces of the artificial teeth, which result in shortening of the lower onethird of the face, making the patient look older, which leads afterward to hypertonus of the muscles and changes in the TMJ. The loss of the VDO was found to be comparatively higher among nonreproducible subjects. n

ACKNOWLEDGMENT The authors acknowledge the technical support provided by all faculty members and postgraduate students of the department. The authors also acknowledge the management of the institution for its valuable support. REFERENCES 1. Winkler S. Complete denture prosthodontics. 2nd ed. Ishiyaku Euroamerica Inc.: St. Louis; 2000:151–53. 2. Bolender Z. Prosthodontic treatment for edentulous patients. 12th ed. St Louis: Mosby; 2004:199–201. 3. Heartwell CM, Rahn AO. Syllabus of complete dentures. 4th ed. India: Varghese; 1992:294–96. 4. Shillinburg HT, Brackett SE, Whitsett L, Hobo S. Fundamentals of fixed prosthodontics. 3rd ed. Carol Stream, Ill.: Quintessence; 1997:22–25. 5. Granger RE. Centric relation. J Prosthet Dent 1952 2:160–71. 6. Villa AH. Condyle path tracer for diagnosis. J Prosthet Dent 1959 Sep–Oct;9(5):800–02. doi.org/10.1016/00223913(59)90042-3. 7. Kingery RH. The maxillomandibular relationships of centric relation. J Prosthet Dent 1959 Nov–Dec;9(6):922–26. doi. org/10.1016/0022-3913(59)90150-7. 8. Isaacson D. A study of the condyle path. J Prosthet Dent

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1959 Nov–Dec;9(6):927–35. doi.org/10.1016/00223913(59)90151-9. 9. Granger ER. The temporomandibular joint in prosthodontics. J Prosthet Dent 1960 Mar–Apr;10(2):239–42. doi. org/10.1016/0022-3913(60)90046-9. 10. Posselt U, Skytting B. Registration of the condyle path inclination: Variations using the Gysi technique. J Prosthet Dent 1960 Mar– Apr;10(2):243–47. doi.org/10.1016/0022-3913(60)90047-0. 11. Posselt U, Franzén G. Registration of the condyle path inclination by intraoral wax records: Variations in three instruments. J Prosthet Dent 1960 May–Jun;10(3):441–54. doi.org/10.1016/00223913(60)90007-X. 12. Michman J, Langer A. Comparison of three methods of registering centric relation for edentulous patients. J Prosthet Dent 1963 Mar–Apr;13(2):248–54. doi.org/10.1016/00223913(63)90169-0. 13. Hughes GA. Discussion of “factors influencing centric relation records in edentulous mouths.” J Prosthet Dent 1964 Nov–Dec;14(6):1066–68. doi.org/10.1016/00223913(64)90174-X. 14. Dubois BL. Condylar guidance inclination changes. J Prosthet Dent 1966 Jan–Feb;16(1):44–55. doi.org/10.1016/00223913(66)90111-9. 15. El-Armany MA, George WA, Scott RH. Evaluation of the needle point tracing as a method for determining centric relation. J Prosthet Dent 1965 Nov–Dec;15(6):1043–54. doi: 10.1016/00223913(65)90181-2. 16. Grasso JE, Sharry J. The duplicability of arrow-point tracings in dentulous subjects. J Prosthet Dent 1968 Aug; 20(2):106–15. doi: 10.1016/0022-3913(68)90133-9. 17. Pyott J, Schaeffer A. Centric relation and vertical dimension by cephalometric roentgenograms. J Prosthet Dent 1954 Jan;4(1):35– 41. doi.org/10.1016/0022-3913(54)90063-3. 18. Langer A, Michman J. Evaluation of lateral tracing of edentulous subjects. J Prosthet Dent 1970 Apr;23(4):381–86. doi: 10.1016/0022-3913(70)90004-1. 19. Ramjford SP, Blankenship JR. Interarticular disc in wide mandibular opening in rhesus monkeys. J Prosthet Dent 1971 Aug;26(2):189–99. doi: 10.1016/0022-3913(71)90052-7. 20. Myers M, Dziejma R, Goldberg J, Ross R, Sharry J. Relation of gothic arch apex to dentist-assisted centric relation. J Prosthet Dent 1980 Jul;44(1):78–81. doi: 10.1016/0022-3913(80)90052-9. 21. Atashrazm P, Alavijeh LZ, Afshar MS. Influence of the fastprocessing technique on the number of the occlusal contacts and occlusal vertical dimension of complete dentures. J Contemp Dent Pract 2011 Mar 1;12(2):84–90. doi: 10.5005/jpjournals-10024-1014. 22. Douglas JB, Meader L, Kaplan A, Ellinger CW. Cephalometric evaluation of the changes in patients wearing complete dentures: A 20-year study. J Prosthet Dent 1993 Mar;69(3):270–75. doi. org/10.1016/0022-3913(93)90105-W. 23. Hadjieva H, Dimova M, Hadjieva E, Todorov S. Changes in the vertical dimension of occlusion during different periods of complete denture wear — a comparative study. J of IMAB 2014 Jul– Sep;20(3):546–49. doi: 10.5272/jimab.2014203.546.a. 24. Serrano PT, Nicholas JI, Yuodelis RA. Centric relation changes during therapy with corrective occlusion prostheses. J Prosthet Dent 1984 Jan;51:97–104. doi: 10.1016/s0022-3913(84)80114-6. 25. Breitner C. Experimentelle Veranderungen der mesiodistalen Beziehungen der oberen undunteren Zahnreihen I and II. Ztschr Stomatol 1930;134:620. THE CORRESPONDING AUTHOR, Sushil Kumar Kar, MDS, can be reached at drsushil_kar@yahoo.co.in.

Business loan options Patient screening Practice interruptions Local ordinances & regulations Leaves of absence Infection control Dental billing &time telehealth Paid & unpaid off Patient communication Employeevs. communication Mandates recommendations Termination & unemployment Rescheduling appointments License Sick leaverenewal policies & C.E. HIPAA considerations Informed consent forms

NEW & COMPLEX QUESTIONS? Today, the countless sources and rapid pace of news make it more challenging than ever to navigate the business side of dentistry. Thatâ&#x20AC;&#x2122;s why CDAâ&#x20AC;&#x2122;s Practice Support analysts have developed new tools to guide members through the COVID-19 crisis and toward practice recovery. Access 24/7 online resources and tap into specialized expertise on practice management, compliance, employment and dental benefits.

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TOGETHER WE ARE LIMITLESS

Specializing in selling and appraising dental practices for over 46 years! LOS ANGELES & VENTURA COUNTY

VENTURA - GP w/ 4 eq ops . PPO & Cash only. 40 years goodwill. Projection approx. $470K in 2019. Property ID #5288.

BEVERLY HILLS - Established in 1981. Grossed approx. $1M in 2019. Net of $244K. Has 5 eq ops and 1 plmbd not eq op room for expansion. Property ID #5307.

VENTURA (LH) - GP located in a 2 story med prof. bldg with 2 eq ops. Prop. #5304.

ORANGE COUNTY

CERRITOS— GP with 40 yrs of goodwill in shopping plaza. Grossed approx. $1.4M in 2019. NET $261K. Property ID #5295.

ANAHEIM— GP located in a small shopping center. Has 4 eq ops w/ digital x-ray. Approx. 40-45 new patients/mo. Grossed approx. $1.35M in 2019. Net $876K. Property ID #5296.

DUARTE— GP established in 1964 located in a 2 story mixed bldg. Grossed approx. $350K in 2019. Property ID #5183.

CORONA DEL MAR—Well established GP

GLENDALE—GP w/ 3 eq ops and 1 plmbd not eq op in a 3 story medical professional bldg. Grossed approx. $544K in 2019. Property ID #5305.

with walking distance to the ocean. Consists of 3 eq ops. Grossed approx. $788K in 2019. Property ID #5285.

FOUNTAIN VALLEY— GP in strip shopping center w/ great street visibility. Grossed $238K in 2018. Has 4 eq ops and 1 plmbd not eq. Great staff. Property ID #5293.

GRANDA HILLS— With 50 yrs of goodwill this general practice grossed approx. $392K in 2019. NET $149K. Property #5276.

IRVINE—Turn-Key GP in 3 story medical dental professional building. Has 3 eq ops and 2 plmbd not eq in an approx. 1,562 sq ft suite. Grossed approx. $265K in 2019. Property ID #5311.

LONG BEACH—GP with approx. 60 yrs of goodwill. Projecting approx. $373K in 2019. Property #5303. LONG BEACH—Established in 1985. GP in a 2 story prof. bldg. w/ 4 eq ops and 2 plmbd not eq on a 1,800 sq ft suite. Grossed approx. $718K in 2019. Property ID #5302.

NEWPORT BEACH—Beautiful fee for service GP, located in a corner 2 story med bldg. Well established practice with 4 eq op with windows views. Grossed approx. $616K in 2019. Property ID #5310.

SOLD

ROWLAND HEIGHTS— Estab. in 2009, this GP is located in a 1 story free standing bldg. Grossed approx. $806K in 2019. NET $314K. Property ID 5278. SAN GABRIEL— GP located n a 2 story building with 42 yrs of goodwill. Has 11 eq ops. Grossed approx. $1.2M in 2019. NET $243K. Property ID#5309.

SOLD

SIMI VALLEY— GP w/ 54 years of goodwill in free standing building. Grossed approx. $575K for 2019. NET $185K. ID #5294.

WESTMINSTER/FOUNTAIN VALLEY— Established in 1978 GP in 2 story free standing bldg. Grossed approx. $763K in 2019. Has reasonable rent. Property ID #5291.

SOLD

SAN DIEGO COUNTY CARLSBAD— This beautiful practice has over 22 yrs of goodwill. Has 4 eq ops in a 1,800 sq ft suite. Fee for service office. Grossed approx. $440K for 2018. Property ID # 5256.

SOLD

EL CAJON (GP) - Price Reduced! Consists of 5 eq ops and equipped with 3D Sirona CBCT Digital X-ray. Grossed over $1M in the past 10 years. Property ID # 5265. LEMON GROVE— Fee for service general practice with over 48 years of goodwill located in 2 story corner building. Has 4 eq ops. Grossed approx. $398K for 2019. Property ID #5308.

RIVERSIDE COUNTY LA QUINTA— Price Reduced! Well established GP with over 8 years of goodwill. This modern designed practice has 8 eq ops. On a the busiest major intersection. Grossed approx. $1.5M for 2019. NET $344K. Property ID #5130. SAN BERNARDINO - GP established circa 1950 located in 2 story bldg. Has 4 eq ops in approx. 1,500 sq ft suite. Grossed approx. $322K in 2019. Seller is retiring . Property ID #5292. UPLAND—Beautiful general practice located in 2 story building with 4 equipped operatories. Grossed approx. $920K in 2019. Property ID #5237.

YORBA LINDA—GP in strip shopping center with 33 years of goodwill. Has 3 eq operatories. Grossed approx. $285K in 2019. Buyer’s net $80K. Property ID #5299.

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RM Matters

C D A J O U R N A L , V O L 4 8 , Nº 5/6

Speak Up! Open Communication Strengthens Employer-Employee Bonds TDIC Risk Management Staff

t’s been said that the art of communication is the language of leadership. In the dental office, open communication between practice owners and staff ensures an efficient workplace, reduces employee turnover and helps mitigate potential employment-related claims. Communication is at the heart of maintaining a cohesive team, thus improving job satisfaction and reducing employee turnover. There are many factors that go into job satisfaction. Some are obvious, such as pay and benefits, while others less so, such as opportunities for advancement, feeling of belonging and being professionally challenged. One of the most important aspects to job satisfaction is a positive working environment. Positive working environments are those that embody fair policies and practices, good leadership and strong relationships among colleagues and supervisors. In one case reported to The Dentists Insurance Company’s Risk Management Advice Line, an employee was hired as a full-time registered dental assistant. She was instructed to write down eight hours on her timecard, regardless of the actual hours worked. She was also asked to report 15 minutes prior to the start of her shift for a mandatory daily huddle. Although the employee was not happy about these requests, she complied because she needed the job. Ultimately, the employee became fed up with not being paid for the actual hours worked. After a few months, she began to record her accurate hours on the timecard. Payroll denied the overtime. The employee questioned the dentist about the missing overtime on her paycheck and was told that his office policy is not to pay overtime unless prior approval is obtained. However,

Positive working environments are those that embody fair policies and practices, good leadership and strong relationships among colleagues and supervisors.

he had not previously informed her of his office policy regarding overtime. To make matters worse, the office manager changed the employee’s schedule, resulting in a reduction of hours. The manager also changed her position from RDA to DA without prior notice. The employee contacted the office the following week and informed them that she would not be returning to work. Two months later, the office received a letter from an attorney representing the former employee, who alleged a hostile work

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environment and failure to pay overtime. Eventually, the case was settled through mediation for a high five-figure amount. When communicating with employees, TDIC recommends that practice owners be clear, direct and decisive. This should begin with employee onboarding and continue through the duration of employment. A good starting point is a comprehensive and up-to-date employee manual. In addition, new employees must clearly understand the practice's vision, goals, policies and procedures. It’s also a leadership best practice to clearly outline each employee’s role and responsibilities. Each position should

have a written job description and written expectations, and these expectations should be discussed with the employee in person to ensure understanding. This establishes accountability and increases motivation and performance for each member of the team. How you communicate is often as important as what you communicate. The following tips can help: Be authentic. Being honest and approachable helps build relationships. Sharing personal stories, finding common ground and asking open-ended questions creates a connection with the team, thus establishing trust.

Be positive. Approaching challenges with a can-do attitude works wonders on employee morale. Letting staff know you’re in it together creates a camaraderie that leads to buyin from the entire team. Focus on successes and learn from failures. Be consistent. Nothing kills employee morale faster than employees who feel they are treated differently or unfairly. Maintaining consistent policies in all aspects of practice management, from dress codes to time off, ensures each staff member feels respected. Be concise. A lack of clear instructions is one of the greatest causes of lackluster performance in the dental office. Giving directives and using straightforward language illustrated with cause-and-effect examples can help in understanding. Practice owners are advised to conduct regular performance evaluations and morning huddles. Employees should also be asked whether they have follow-up questions.

Listening

It’s not enough to simply talk to your employees. Listening is arguably the most important skill in effective communication, and too often people listen only with the intent to reply. Instead, effective communication means listening with the intent to understand. To ensure goals and policies are clearly understood, practice owners are advised to encourage employees to provide feedback and comments, which can identify weak spots and provide valuable information for improvement. Simply asking the team “how can we improve communication in the office?” or “what would be one thing that you would like CONTINUES ON 288

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Making your transition a reality.

Dr. Thomas Wagner

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(916) 812-0500 (949) 300-0312 (707) 391-7048 (949) 675-5578 (951) 314-5542 (408) 687-5001 (949) 675-5578 36 Years in Business 35 Years in Business 30 Years in Business 30 Years in Business 26 Years in Business 16 Years in Business 11 Years in Business

PRACTICE SALES • VALUATIONS/APPRAISALS • TRANSITION PLANNING • PARTNERSHIPS • MERGERS • ASSOCIATESHIPS SACRAMENTO AREA: Price reduced by $100K! GP & Specialty HMO/some PPO Practice. AUBURN & FOOTHILLS AREA: Fast 9 Ops, I/O Cam, Digital Pano. 2017 GR $1.1M+, growing practice in 2,500 sf w/ 6 equip. Ops, 2018 Quickbooks (to be verified) GR $680K. 5,000 1 add’l plumbed. 2019 GR on track to exceed sf bldg. avail. #CA567 $1.2M on 3 avg. Dr. days/wk. #CA632 SACRAMENTO AREA: SELLER MUST SELL! CONCORD: East Bay, Contra Costa Seller considering all offers. 4 Equip Ops w/1 Community: Digital Practice with 3 Ops, additional available, 45+ yrs Goodwill in wellmodern/attractive bldg., PPO, 1,200 sf, and established location. 1,403 sf office condo Dentrix. 2018 GR $1M+ on 34 avg. Dr. hrs/wk. available for purchase. 2018 GR $574K. #CA603 #CA595 SAN FRANCISCO: Low Rent! 30+ yrs Goodwill. CONTRA COSTA COUNTY: Records for Beautiful 4 Op office w/ strong hyg program. 2019 only the Pedo and/or Ortho portion of Practice. GR $740K+. #CA657 11+ yrs Goodwill. Buyer must be within 15 SAN JOSE: Great cash flow in beautiful retail miles of Contra Costa County. Asking Price is space with high traffic and visibility. Spacious below appraised value. #CA576 3,150 sf with 10 Ops, 6 Equip. 2018 GR $998K. EAST BAY: New Listing! Central beautiful #CA600 location with 4 Ops in 1,350 sf. 2019 GR $659K SAN JOSE: Beautiful practice, very busy retail on only 4 doctor days/week. #CA644 plaza, luxuriously designed 2,700 sf w/8 Ops. 2019 FAIRFIELD AREA: 4 Ops in 1,500 sf, 30+ yrs GR $483K on 34 hrs./wk. Priced to sell! #CA627 Goodwill. Dentrix PMS, I/O Cam, Digital X-ray, SONOMA COUNTY: 2018 GR $906K. 1,000 sf, paperless practice. 2018 GR $840K on 4 day/ 3 Ops w/ opportunity to expand. Paperless, wk. #CA655 Dentrix, Digital, I/O Cam. Selling both Practice FOLSOM/RESCUE/EDH AREA: 5 Op digital and portion of dental building ownership. #CA594 practice, modern space w/ low overhead. 2019 SONOMA COUNTY: Price Reduced! Modern GR $802K. Office condo also for sale. #CA581 GP offering a broad range of service. 6 Ops in FREMONT: 4 Equip Ops in 1,800 sf. Dentrix 2,200 sf, seller-owned facility. 2018 GR $802K w/ PMS, Digital X-ray, Diode Laser, I/O Cam. 4 hyg days. Digital, Dentrix, I/O Cam, Laser. #CA547 MOVE-IN READY, this will not last! #CA564 FREMONT: Priced to sell! 40+ yrs Goodwill. SONOMA COUNTY: Large GP, 2018 GR above Spacious 2,900 sf suite with 9 Equip Ops in $2.8M. Stand-alone 3,000 sf prime Real Estate, 72 stand-alone bldg. 2019 GR $578K. #CA607 NP/mo.10 hyg days. 6 Ops, Pano X-ray, Dexis, Cameras, Laser, Dentrix. Both Business & Real GREATER EL DORADO HILLS: MultiEstate for sale or Lease. Doctor Retiring. #CA544 doctor practice, 3,000 sf office, 8 Ops, 7 Equip, I/O Cam, Digital X-rays & Pano. 2019 GR SONOMA COUNTY: 2018 GR $2M+. 8 Ops in $2.2M. Sellers will consider working back P/T. 4,600 sf, 13 hyg days on 4½ day/wk. 42 yrs #CA578 Goodwill. Doctor retiring and will work back. Paperless, Digital, hi-tech, modern. #CA601 GREATER SACRAMENTO: Price Reduced by $50K! PPO Practice with 4 Ops, digital VACAVILLE AREA: Centrally-located & hisensors, imaging system, I/O Cam. Practice open traffic location with 25+ yrs Goodwill. 5 Ops in 33 yrs. 2017 GR $652K; Office Condo 1,700 sf. 2019 GR $556K on 32 hrs/wk. #CA645 available for purchase. #CA561 VALLEJO: 4 Ops, 1,650 sf w/ below-market rent. GREATER SACRAMENTO: Great area w/ 38 2019 GR $791K, 4 hyg days/wk, low OH. #CA469 yrs Goodwill. 4 Ops in 1,100 sf. 2018 GR of WOODLAND/DAVIS AREA: 6 Ops, 40+ yrs $1M+ on 32 hrs/wk. #CA656 Goodwill. Real Estate available. 2018 GR $1.1M+ HAYWARD: Dr. retiring from cozy, 900 sf, 3 on 32 Dr. hrs/wk. #CA629 Op practice with opportunity to purchase part of YUBA CITY AREA: 46 yrs Goodwill, GP the bldg. Desirable area. #CA649 Practice with 3 Ops w/ 4th Open in 1,400 sf. Priced LAKE TAHOE AREA ENDO PRACTICE: below professional Valuation. 2018 GR $271K. 3 Ops, 3 digital sensors, Cone Beam in 1,100 sf. #CA580 Consistent GR $525K for the last three years on CENTRAL CALIFORNIA 32 avg. Dr. hrs/wk. #CA602 LAKE TAHOE AREA: GP practice with 5 CENTRAL VALLEY PEDO PRACTICE: Ops w/ 6th Open, Operatory views of Lake Tahoe, only 34 Delta Premier patients, 2,100 sf. Shared space w/Ortho, 7 Op, 3,800 sf. 2019 GR of $610K as part-time practice. Great starter practice 2019 GR $579K on 22 avg. Dr. hrs/wk. #CA608 or satellite office. #CA660 MONTEREY: 4 Op, 1,600 sf in highly FRESNO AREA: GP and Prosthodontic Practice desirable area with plenty of free parking. 2018 prime for a GP to purchase. 4 Ops, 1,500 sf, Digital GR $1M+ on 32 hrs/wk. #CA650 Sensors, film Pano, DentalMate Software, MONTEREY PENINSULA: Practice attractive office bldg. 2018 GR $386K. #CA588 established for 70+ years, 32 w/ present owner. Beautiful 1,130 sf office w/ 3 Ops. Dentrix PMS, GREATER FRESNO AREA: Great location for well-established practice with 40+ yrs Goodwill. 6 Dexis Digital X-ray, I/O Cam, Diode Laser. Ops, Digital X-ray, Diamond Dental PMS. 2018 2019 GR $520Kon 4 day/wk. #CA625 GR $638K. #CA621 NORTHERN CA PEDO PRACTICE: Large GREATER MODESTO AREA PEDO practice in downtown location, 5,000 sf with 7 PRACTICE: Digital, 7 Op practice in 2,812 sf. equip Ops, 2 add'l plumbed. 2018 GR $3M+. Practice has small growing patient base, priced as #CA658 start-up/acquisition opp. #CA646 REDDING AREA: Modern practice in 1,600 sf MERCED AREA: 30+ yrs Goodwill in great with 4 equipped Ops, 1 additional plumbed. location. 4 Ops, Dentrix, Digital, I/O Cam, Laser, 2019 GR $558K on 32 hrs/wk. #CA648 Pan/Ceph. 2018 GR $691K. #CA642 ROCKLIN/LINCOLN AREA: 10 Ops, 6 equip, 4 plumbed,. 2,619 sf. Growth potential in MODESTO AREA PERIO PRACTICE: 4 Ops, 5th Available. 1,600 sf. LANAP Laser and Digital all Specialties, 2018 GR $747K on 4 days/wk. Sensor. 2019 GR $455K on 4 day/wk. Bldg. also #CA641 available. #CA598 SACRAMENTO: Downtown/Midtown: Hitraffic, 4 Ops, under 5% Delta Premier patients. 2018 GR $607K on 30 Dr. hrs/wk. #CA590

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MODESTO AREA: Established neighborhood with 60+ yrs Goodwill. 5 Ops, 1,450 sf. 2018 GR $1.1M+ on 3 day/wk. Dental Condo also available for purchase or lease. #CA635 STOCKTON AREA: Great opp to purchase practice and bldg, 3,000+ sf with 6 Ops, good hyg recall. 2018 GR $1M+ on avg 37 hrs/wk. #CA616 VISALIA: Practice+Bldg, 5 Ops, 2,000 sf, street frontage, 2019 GR of $353K. Great deal for quick sale, Most Specialty referred out. #CA628

SOUTHERN CALIFORNIA BAKERSFIELD: New Listing! Well-established, 5 Ops, 4 Equip. In-house dental lab. Condo also for sale. 2019 GR $363K on 3 days/wk. #CA674 BAKERSFIELD AREA: 6 Ops, 39 yrs. Goodwill, Dentrix, and I/O Cam. 2019 GR of $454K. Unique opportunity to merge two practices to one large one. #CA622 BAKERSFIELD AREA: Practice +RE (Merger w/ #CA622) 5 Ops, 4 hyg days. Most specialty referred, room to grow! 2019 GR $376K #CA623 BAKERSFIELD PEDO: Rare opportunity to purchase successful 30+ yr old practice w/ Ortho/ Oral Surgery services. Over 4k active patients, avg. 40 NP/mo. $2.5M+ GR for past 3 yrs. #CA599 COASTAL ORANGE COUNTY: New Listing! 5 Ops, Nicely appointed, long-term staff, specialty work referred. 2019 GR of $456K. #CA679 DIAMOND BAR: New Listings! Beautiful, 5 Ops in Prof. Bldg., Digital, Dentrix, Must-see, call for an appointment. #CA672 HUNTINGTON BEACH: New Listing! 4 Ops, located in a busy retail center with great visibility. Practice utilizes Digital X-rays and Easy Dental PMS. 2019 GR $466K. #CA673 EL CENTRO: New Listing! Great location with low rent. 4 Ops, 3 Equipped, Digital, 25 Yrs Goodwill.2019 GR $850K. #CA680 INLAND EMPIRE: New Listing! 2 Dental Offices next to each other, One GP, One Ortho/ Pedo. Digital, 13 Ops total. GR $850K. #CA681 INLAND EMPIRE: New Listing! 4 Ops, Across from busy hospital. Digital, Real Estate also for sale. 2019 GR $432K. #CA682 LOS ALAMITOS: Beautiful state-of-the-art practice with 4 Ops, and mostly associate-run. Digital, cash and PPO in a great location. GR $900K w/ $390K Adj. Net. #CA662 LOS ANGELES: Price Reduced! West Side, 5 Ops, 4 Equip, EagleSoft, Digital, 40 yrs Goodwill, Up-and-coming area. 2019 GR $610K. #CA640 LOS ANGELES: Near Glendale, 4 Ops in standalone bldg w/ great visibility. Low rent and $6K/ mo. CAP check. Room to grow! GR $200K+ with low OH. #CA665 LOS ANGELES: 7 Ops. Prof. bldg. in great location of LA. Strong hyg. program w/ 5+ hyg. days/wk and 37 yrs. Goodwill. 2018 GR $983K w/ $277K Adj. Net. #CA606 NORTH ORANGE COUNTY: 5 Ops, has been open since 1965. Dentrix, digital Pano. Retiring seller will assist w/ smooth transition. One-story prof. bldg. 2018 GR $231K. Room to grow. Most specialty procedures are referred out. #CA558 ORANGE COUNTY: 5 Ops, Beautiful office, Digital, Paperless, Hi-traffic area with great signage and low-rent. #CA670 ORANGE COUNTY ENDO PRACTICE: New build-out in 2018, 6 Ops, 5 Equip, 3 Scopes, Cone Beam CT, fully digitized and paperless. Consistent GR for the past 3 yrs. at $1.2M+ with very low overhead. 19 yrs Goodwill. Seller retiring. #CA593

www.henryscheinppt.com

PALM SPRINGS AREA MULTISPECIALTY: Priced to sell @ $775K - 5 Ops, lecture room, 28 yrs Goodwill. Hi-end, mostly cash patient base. Dentrix, Digital, CT Scan & Gemini Dual Wave Laser. History of collecting $1.2M+/yr on 4 days/wk. #CA604 POMONA: Great potential! Low rent. 4 Op practice. Only open 2 days/wk. Seller is retiring. 2018 GR $279K. Priced to sell. #CA610 SAN FERNANDO VALLEY: 10 Ops, 8 Equip, hi-tech, fantastic location. Digital, Pano, CT Scan. GR $1.1M+. #CA664 SAN GABRIEL VALLEY: 4 Ops, Digital X-rays, 65 yrs Goodwill. Most specialty work referred out, most PPO plans are accepted. Busy road with great visibility, open 4 days/wk. Nicely appointed; excellent opportunity. #CA596 SIMI VALLEY: Price Reduced! 3 Ops, 30 yrs Goodwill, Strip Mall Location. 2018 GR $263K with $77K Adj. Net. #CA626 SIMI VALLEY: 6 Ops, 5 Equip. Great location, low rent, 45 yrs Goodwill. 2018 GR $297K w/ $89K Adj. Net. #CA637 SIMI VALLEY: 6 Ops, 39 yrs Goodwill. Strong hyg prog. Prof. bldg. in a great location. EagleSoft, Digital, Pano. 2019 GR $604K. #CA617 SOUTH ORANGE COUNTY PERIO: 4 Ops, 3 Equip, Coastal Community, Modern, Busy strip center location near hi-end residential. 2019 GR $845K. #CA643 SOUTH BAY/LOS ANGELES AREA: New Listing! Family practice est. in 1950. 3 Ops, Digital, Strong hyg. prog. Great area. 2019 GR $651K. #CA671 SOUTH BAY/TORRANCE AREA: 6 Ops in prof. bldg. 44 yrs. Goodwill. SoftDent, Digital Xrays, I/O Cam, and Laser. Visiting Specialists keeps procedures in-house. Strong hyg. prog. 2019 GR of $972K. #CA624 WEST COVINA: State-of-the-art practice with 3 Ops and is all digital and modern with 1 day of Hygiene/wk. 2019 GR $1.2M+ with Adj. Net of $420K in a great location with low rent. #CA661 WESTERN SAN FERNANDO VALLEY: 5 Ops, 4 Equip, EagleSoft, Digital, Laser, I/O Cam. 12+ yrs Goodwill, Prof. bldg. near hospital. Accepts PPO/3 HMO plans. 2019 GR $405K. #CA614

SAN DIEGO NORTH COUNTY COASTAL ORTHO: 4 Chairs + Consult Room, Desirable area, Digital Pano/Ceph, Excellent location. 2018 GR $273K. #CA653 NORTH COUNTY PERIO: 4 Ops, 3 Equip. Newer equip. including CT Scanner, Digital, Dentrix. Well-maintained complex. Priced to sell quickly. 2018 GR $269K. #CA605 POWAY: 3 Ops, located in a busy strip center w/ room to grow! Digital X-rays, I/O Cam, Pano, and Laser. 2018 GR $226K. #CA659 SAN DIEGO COUNTY ORTHO: Rare Opportunity in the San Diego County area, Established office with updated computer hardware. Paperless with many years of goodwill. Excellent location. This will sell quickly. #CA615

OUT OF CALIFORNIA CENTRAL COAST, OREGON: Minutes to the ocean. 3 Dr. days/wk, 2 hyg days/wk. 2019 GR $404K, positioned for growth, Doctor is retiring. #OR112 SOUTHWEST PORTLAND: 7 Ops, 6 Equip, Dentrix, Digital, Pano. Well-maintained leased space. 2019 GR $598K. #OR115 BURIEN AREA, WA: New Listing! 3 Ops, Busy Area. Very low overhead and good cash flow. Could relocate in Bldg to bigger suite. #WA102

Southern California Office

1.888.685.8100

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to change in the office?” can provide valuable insight and solutions that may not have previously been considered. Open-door policies encourage employees to speak their minds and further promote the team mindset.

Communication Channels

Using the right communication channel for the message is also important. While email and texting have become commonplace in our society, they are not appropriate for sharing information in the workplace. Having face-to-face conversations with employees, whether individually or during morning huddles or meetings, builds relationships and

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trust in a way that sending a group email can’t. It also provides the opportunity for employees to ask clarifying questions, thus ensuring everyone is on the same page. Texting is especially detrimental to workplace communication as it decreases professionalism and makes it difficult, if not impossible, to deliver clear, concise information. Similarly, it’s a communications best practice to require employees to call in sick, rather than emailing or texting. Naturally, the focus of most practice owners is on clinical care. But brushing up on basic leadership skills, such as communication, can do wonders for improving the workplace. Open

dialogue between practice owners and staff establishes clear responsibilities and expectations, builds relationships and improves employee morale. Not only does an efficient workplace improve employee morale, it can help mitigate potential claims in the long run. n TDIC’s Risk Management Advice Line is a benefit of CDA membership. If you need to schedule a no-cost consultation with an experienced Risk Management analyst, visit tdicinsurance.com/RMconsult or call 800.733.0633.

Specialists in the Sale and Appraisal of Dental Practices

Serving California Dentists since 1966 How much is your practice worth??

Practices Wanted

The Sun will Shine again but Brighter! NORTHERN CALIFORNIA (415) 899-8580 – (800) 422-2818 Raymond and Edna Irving Ray@PPSsellsDDS.com www.PPSsellsDDS.com

SOUTHERN CALIFORNIA

(714) 832-0230 – (800) 695-2732 Thomas Fitterer and Dean George PPSincnet@aol.com www.PPSDental.com

California DRE License 1422122

California DRE License 324962

6177 SALINAS During the Great Recession, Salinas dentists did well as Salinas Valley is one of California’s most productive agricultural regions and is the engine driving this area’s economy. And Salinas shall bounce back quickly once Shutdown is lifted. Practice has been $900,000 per year performer. Housed in well maintained suite. Condo optional purchase. 6176 SANTA CRUZ Delta PPO practice seeks Successor skilled in placing implants. Last 2-years averaged $1.18 Million in collections and $735,000 in Available Profits. $400,000+ invested in technology to make this possible. 4-days of Hygiene. 6175 OAKLAND’S DESIRABLE COMMUNITY Collections last 2-years averaged $1.425 Million with Available Profits averaging $560,000. Has been consistent performer. 11-days of Hygiene per week booked 6+ months in advance. Great location. Housed in stand-alone building dedicated to practice. 6174 HUMBOLDT COUNTY’S UNIVERSITY COMMUNITY – ARCATA Special area to raise one’s family and enjoy quality of life benefits. Best location, great foundation, dedicated Team. Seller works 3-day week by choice. 2019 collected $360,000. Before reducing schedule, collected $420,000 in 2018. Beautiful Victorian building is optional purchase. Practice wants to be full-time. 6173 SAN FRANCISCO – OUT-OF-NETWORK 2019 collected $1,315,000. 6-ops. 8-days of Hygiene. 1,500+ active patients. Contract with specialists to perform referred work in-house and take to next level. 6172 SAN FRANCISCO’S EAST BAY – OUT-OF-NETWORK 2019 collected $850,000 with Profits of $430,000. 4-days of Hygiene. Requires skilled, easy temperament and great communicator as Successor. Seller shall work-back to assist in transition. 6171 SANTA ROSA Great DNA in long-established practice. Strong patient foundation per 6+ day Hygiene Schedule. 2019 collected $990,000 with Available Profits of $338,000. Great Team. Full price $285,000. 6170 MANTECA / RIPON AREA 2019’s revenues totaled $860,000 with Available Profits of $352,000. 5-days of Hygiene. Refers endo, most OS and implant placements. Extensive patient base. Successor should contract with specialists to perform referred work. Facility perfect for making this a full-service practice. Full price $450,000. 6169 VACAVILLE Long established Delta PPO practice. 5-days of hygiene. 2019 trending $700,000+ with Available Profits of $285,000. Great north side location. Great area to raise one’s family. 6167 DOWNTOWN PALO ALTO – OUT-OF-NETWORK Perfect for skilled Dentist seeking strong patient relationships and insurance independency! 2019 topped $800,000 on Owner’s 3-day week with 5-days of Hygiene. Office has been completely upgraded and charting is paperless. 6165 ROSEVILLE ORTHO – OUT-OF-NETWORK Stanford Ranch. $455,000 invested in build-out, furnishings, computers and equipment. 3-chair Bay. Digital Pan with Ceph. Averages 3 New Patients per month. Full Price $125,000. 6164 SAN FRANCISCO’S UNION STREET – OUT-OF-NETWORK Highly regarded as evidenced by 9-days of Hygiene per week. Collections topped $2 Million each last 3-years with Profits averaging $1 Million. Paperless. 3D Cone Beam. 6163 LAKEPORT Attractive option to practicing in competitive areas in expensive housing markets. 6-op facility completely networked. Great main street location. 2019 collected $969,000. Building optional purchase. 6158 FORTUNA Relaxed lifestyle in Humboldt’s Banana Belt, adjacent to Ferndale. Perfect for Dentist seeking small town living. 2019 collected $379,000. 6-weeks off. Building optional purchase.

4003 PEDO CHINESE /HISPANIC 3,000+ Charts. Move to your office. Full Price $150,000. 4006 ALTA LOMA High identity Center. Absentee. Grossing $700,000. 4011 DIAMOND BAR Dream Million Dollar location. 5-ops. Restaurants bring in lots of people. Full Price $150,000. 4018 TWO SOUTH ORANGE COUNTY PRACTICES Each does $800,000. 4019 $1 MILLION NET PROFIT Opportunity of a lifetime. BAKERSFIELD Small City. Grossing $40,000/month on 2-days. 5-ops. BURBANK - NORTH HOLLYWOOD HMO Grossing $2.2 Million. High Tech. 5 ops. CAPISTRANO BEACH Grossing $200,000 “fee for service” in 16 hours per-week. HEMET Seller works one day and produces $240,000. Practice asking $110,000. Bargain on RE IRVINE Lady DDS grossing $1 Million. Will share office. LA HABRA Huge Shopping Center. Well maintained. PT Seller will stay. LADERA RANCH 4-ops. Grossing $500,000. High Growth area. LAGUNA WOODS Grossed $800,000 during Renovation. Renovation done. Should gross $1 Million. MIRACLE MILE NEAR FAIRFAX Beautiful corner suite with Wilshire view. 3-ops recently remodeled. ORANGE Grossing $1.2 Million. State-of-art beautiful! ORANGE COUNTY High profile shopping center. Grossing $1.5 Million. ORANGE COUNTY Near Chapman / Tustin Streets. Gross $400,000. Merge or grow. ORANGE COUNTY BEACH 5-ops. Gross $1.2 Million first year. Area growing. ORANGE COUNTY BEACH CITY Absentee. Grossing $900,000+. 4-ops, room for 5th. ORANGE COUNTY BEACH CITY Grossing $800,000 part-time. Valuable Real Estate may be available. PALM SPRINGS AREA Grossing $1.5 Million. 8-ops. REDLANDS 5-ops. Grossing $500,000. Part Time. Full Price $450,000. RIVERSIDE Lady DDS Grossing $300,000. 3-ops. Full Price $250,000. SAN JUAN CAPISTRANO BEACH Grossing $200,000 on 16 hour week. SANTA CLARITA 70,000 Autos pass daily. Tremendous upside. Full Price $250,000. SAN DIEGO GROUP DSO 4 offices Grossing $3.7 Million. SOUTH BAY AREA TOTAL ABSENTEE Nets $750,000 on Gross of $2.3 Million. Can grow to $3.5 Million. SOUTH ORANGE COUNTY Crown Valley Shopping Center. Grossing near $800,000. SOUTH ORANGE COUNTY 2-offices, each doing near $800,000. Available by one Seller UNION PRACTICE - INLAND EMPIRE Grossing $650,000 on 2.5 day week. Nets close to $400,000. UPLAND 3-ops, low overhead. Seller will transition. Full Price $360,000. WANTED: IRVINE - NEWPORT BEACH - COSTA MESA – TUSTIN Dentist lost lease. Owner will merge his $800,000 practice into yours. WEST LOS ANGELES Prestigious Medical Building. Unique.

. . . . to the right buyer! Knowing how, means doing all of the following - with precision:

Valid practice appraisal.

Contract preparation and negotiations, including critical tax allocation consideration.

Bank financing or Seller financing, with proper agreements to adequately protect the Seller and make the deal close - realistically and expeditiously.

Performance of “due diligence” requirements, to prevent later problems.

Preparation of all documentation for stock sale, when applicable.

Lease negotiations.

All six of these services costs no more. Maybe even less!

Lee Skarin & Associates

has scores of Buyers in their database. The Buyers’ profiles personal desires and financial ability have been categorized to expertly select the right Buyer for your practice. Expert Buyer selection solidifies a deal. Lee Skarin & Associates services all of Southern California.

LEE SKARIN & ASSOCIATES INC.

SELL YOUR PRACTICE . . . . .

Lee Skarin & Associates is California’s leading Dental Practice Broker. Their in-house attorney, Kurt Skarin, PhD., J.D., specializes in these matters. He does all of the above, and more. He is the catalytic agent that makes the sale happen - quickly and smoothly.

Dental Practice Brokers CA DRE #00863149

Your calls are invited. Put our thirty years of experience to work for you! Visit our website for current listings: www.LeeSkarinandAssociates.com

Offices:

805.777.7707 818.991.6552 800.752.7461

Regulatory Compliance

C D A J O U R N A L , V O L 4 8 , Nº 5/6

Easy-To-Use Tool Helps Dental Practices Complete HIPAA-Required Analysis CDA Practice Support

ne of the essential elements to HIPAA compliance is the completion of an enterprisewide risk analysis. A risk analysis generally is comprised of three parts: ■ A compliance assessment — Is a covered entity in compliance with every element of the HIPAA privacy and security rules? ■ A technical assessment — Does a covered entity have the technology necessary to comply with the technical implementation specifications, or safeguards, of the HIPAA security rule?

A risk assessment — How well is a covered entity prepared to manage the threats and vulnerabilities to the systems that store and communicate protected health information? The risks of not conducting a risk analysis can be severe for small-sized health care providers. On March 3, 2020, the Office for Civil Rights (OCR) announced it had reached a settlement with a medical practice that provides services to over 3,000 patients. OCR found that the practice never conducted a risk analysis and failed to implement security measures sufficient to reduce risks and vulnerabilities to a ■

reasonable and appropriate level. The practice agreed to pay $100,000 and to implement a corrective action plan that includes two years of monitoring.1 Conducting a thorough risk analysis, especially the risk assessment, is a timeconsuming task for a small health care provider. Fortunately, the Office of the National Coordinator for Health Information Technology (ONC) provides a free security risk assessment tool created specifically to assist small businesses.2 ONC recognizes that smaller health care entities face greater challenges in meeting information security standards because of limited resources. The Security Risk Assessment Tool organizes information entered into it and produces reports. The tool can be as useful as the work put into it, much like the usefulness of a business plan to the development of a dental practice. The process forces the user to consider questions it may not have considered before. However, the tool may not account for newer or previously unrecognized risks and vulnerabilities, for example, social media use, and the user should be careful to include these newer risks while entering information into the tool. The information a user enters into the tool is saved on the device of the user’s choosing and is not transferred to or collected by ONC or the Department of Health and Human Services. The user can stop entering information at any point, save the information and continue the process another day. The tool allows an individual to include an inventory of assets that hold PHI and a list of vendors that use PHI. With asset tracking, the tool allows an individual to note each asset’s encryption level, type of information held or used, location, assignment (individual or purpose), internal identifier and disposal status. Vendor tracking includes vendor contact information, M AY/JUNE 2 0 2 0 291

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purpose for the vendor’s use of PHI and whether vendor has provided assurances of performing its own risk analysis. An individual also may upload to the tool other documents that are relevant to the risk assessment, for example, a plan prepared by an IT consultant to address vulnerabilities in the covered entity’s information systems or a document describing an implemented alternative to an addressable security rule safeguard. The risk assessment tool has seven sections of multiple-choice questions (FIGURE 1 ). It uses branching logic, which means the questions posed depend on responses to previously asked questions. Vulnerability selection and threat rating is presented after each section (FIGURE 2 ). A risk report is generated after all sections are completed (FIGURE 3 ). The report provides a risk score, details the areas that need review and identifies vulnerabilities along with associated threats. A detailed report, which includes all the information entered into the tool except for uploaded files, can be viewed as well as saved as a PDF or Excel document. The current version of the tool is only available for Windows operating systems. However, any dental practice using iPads may still download the previous version from the Apple App Store or the HealthIT.gov website. A PDF copy of the paper version of the older tool and a video recording of a training session can be found on the HealthIT.gov website. n

Assessment Content Content within the assessment is broken down into these main categories: Section 1: Security Risk Assessment (SRA) Basics (security management process) Section 2: Security Policies, Procedures and Documentation (defining policies and procedures) Section 3: Security and Your Workforce (defining/managing access to systems and workforce training) Section 4: Security and Your Data (technical security procedures) Section 5: Security and Your Practice (physical security procedures) Section 6: Security and Your Vendors (business associate agreements and vendor access to PHI) Section 7: Contingency Planning (backups and data recovery plans) FIGURE 1. Content within each assessment section.

FIGURE 2 . One of the assessment screens on the ONC Security Risk Assessment Tool.

REFERENCES 1. U.S. Department of Health and Human Services. Health care provider pays $100,000 settlement to OCR for failing to implement HIPAA security rule requirements. www.hhs.gov/ hipaa/for-professionals/compliance-enforcement/agreements/ porter/index.html. 2. HealthIT.gov. Security Risk Assessment Tool. www.healthit.gov/ topic/privacy-security-and-hipaa/security-risk-assessment-tool.

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. 292 M AY/JUNE

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FIGURE 3 . Part of a summary risk report produced by the ONC Security Risk Assessment Tool.

CARROLL &COMPANY 4408 SONOMA COUNTY Beautiful 2,100 sq. ft., 6 op practice, 4 doctor-days & 3 hygiene days per week. Average gross receipts $1M+. Asking $590K. 23-year perio practice, also ideal for GP; loyal, seasoned staff and great location. 4407 SAN MATEO GP Exceptional 5-operatory San Mateo practice in popular health provider neighborhood generating significant daily business draw. Beautiful 2,200 sq. ft. seller-owned facility, handsomely equipped to highest standards. Average GR $1.4M, average overhead 61%. Seasoned and loyal staff. Seller willing to help for a smooth transition. 4381 SOUTH SF GP 23 year practice close to Kaiser Hospital; phenomenal shopping and residential mix area. 4 op facility with new/ recently upgraded equipment. Great location in desirable neighborhood. Owner willing to help for smooth transition of the practice. Average gross receipts approximately $250K with average 60% overhead. Asking $170K. Retiring seller very motivated. Contact us for more detail. 4359 SANTA CRUZ GP 30+ years of goodwill within walking distance of the beach! Located in a well-known, attractive, single story professional building with ample parking, good visibility and easy ING2 hygiene days/week, 380 active patients access. 2 doctor days/week, ND E with approx. 10 new patients/mo. 3 fully equipped ops in 850 sq. ft. P Average GR $250K with adj. net of $135K. Asking price $150K. 4394 SANTA CRUZ GP Retiring seller offering 33+ years of goodwill in stunning 1,534 sq. ft. facility with 4 fully-equipped ops. Pristine leasehold improvements/gorgeous cabinetry make this a mustsee! Prime corner location with dedicated parking lot, situated in one of the most desirable areas of Santa Cruz, close to shoreline and tourist attractions. 2019 GR $887K with adj. net of $353K. 1,500+ active patients with average of 19 new patients/month. Seller works 3+ days/ week with 5+ days of hygiene. Asking $729K. 4376 SANTA CRUZ GP High revenue opportunity in 31-year practice. Average GR $1.6M with average adj. net of $756,029.00. Owner/ Doctor works 4 days/week. Hygiene 6 days/week. 1,200+ active patients. Easy freeway access and parking; close to all amenities. Nicely appointed 1,200 sq. ft office with 4 ops. Owner/Doctor will help for smooth transition. Asking $1,206,000.00 4382 MONTEREY COUNTY GP Established practice in Monterey County, California Coast. Multiple ops can expand, approx. 900 active patients, 4 days of hygiene per week. Ideal for a mature, experienced dentist for this adult-focused practice in an Extraordinary location. Periodontal emphasis with communicative technology in each operatory for multiple crown and implant restorative procedures. Loyal, committed staff will remain through transition. Future opportunity to purchase office building. 4351 SEBASTOPOL AREA GP & BLDG. Beautiful, modern practice in seller-owned building (available for purchase); 3 fully-equipped ops, room for a 4th. Pristine equipment including digital X-ray, most purchased 2016-2018. 2019 GR annualized at $679K+ with adj. net of $210K. Average 3.5 doctor days/week and 4 hygiene days/week. 800 active patients, all fee-for-service. 70+ years of goodwill = longstanding, loyal patient base in scenic vineyard country. Asking $305K for practice, $425K for building. Owner/doctor willing to help for smooth transition.

carroll.company

dental@carrollandco.info

“Matching the Right Dentist to the Right Practice” 4399 SAN JOSE GP Well established, East San Jose neighborhood practice. Smooth running practice with seasoned and loyal employees. Approx. 2,000 active patients and 12-13 new patients per month. 1,860 sq. ft. office with 6 fully equipped ops. Over $1,300,000 avg. gross receipts. Asking $977K. 4366 SONOMA COUNTY GP Fabulous practice and location in a stellar North Bay town. Beautiful, well-appointed office with 4 ops in 1,425 sq. ft. Excellent storefront location G on a well traveled road, walking distance IN center. 900+ active patients, all fee-forto pedestrian-friendly downtown D N service. 4 doctor days/week PE and 4 hygiene days/week. Last two years’ average GR $786K with average adj. net of $341K. Asking price $450K. Seller will help for smooth transition. 4392 SAN JOSE GP Offering 40+ years of goodwill. Excellent location in beautiful bldg on well-traveled thoroughfare. 6+ ops in 1,882 sq. ft. Lots of natural light with views of the eastern foothills. 1,800 active patients. 8 hygiene days/wk. Average GR $900K with adj. net of $295K. Terrific upside potential. Asking $621K. Owners will help for smooth transition. 4387 SF GP 50 year Nob HIll neighborhood practice with approximately 1,000 active patients. Almost no Delta Premier patients. Average GR $600K. Seller transitioning into retirement. Asking $315K. 4362 MARIN COUNTY GP 36 years of goodwill, Seller-owned 1,550 square foot facility with 5 fully-equipped ops. Prime position in charming town; desirable area known for temperate weather, easy, outdoor living and natural beauty. No Delta Premier patients. Excellent reputation and word-of-mouth referrals. Retiring seller will help for smooth transition. Average Gross Receipts last 2 yrs is $450K. Asking $248K for the practice. Bldg condo is available for purchase. 4360 SALINAS GP Seller transitioning into retirement and offering wellestablished practice located near downtown Salinas and Salinas Valley Memorial Hospital. Average Gross Receipts $250K. Asking $133K. 4389 SALINAS GP Stable, 2400+ patient base. Seasoned and dedicated staff. Practice with an emphasis on Restorative treatment. 4 doctor days & 5 hygiene days per week. Average GR $910K. Asking $670k. Retiring owner. 4375 LOS GATOS DENTAL FACILITY Unique opportunity in highly desirable area! Seller offering two full suites of state-of-the-art equipment and modern, 2-operatory facility including furniture, fixtures and leasehold assets in medical office building adjacent to Los Gatos Community Hospital. Asking $250K. UPCOMING: Redwood Shores GP $1.2M+ avg. GR, Los Gatos GP $1.2M+ avg. GR & Redwood City GP $1M+ avg. GR.

Mike Carroll

Pamela Carroll-Gardiner

Mary McEvoy Carroll

CalRE# - 00777682

(650) 362-7004

(650) 362-7007

Call us today at (855) 337-4337

or visit www.integritypracticesales.com

A Professional Team Dedicated to Your Successful Practice Sale

Bill Kimball, DDS Broker / Partner (619) 933-6225 DRE# 01921421

Darren Hulstine Broker / Partner (805) 878-0633 DRE# 01899816

Trevor Kimball, PhD President (805) 748-7439 DRE# 02078646

Brian Flanagan Northern California (707) 898-0842 DRE# 01947466

Ken Skeate Southern California (805) 338-5850 DRE# 00885612

Tim Miller Southern California (714) 272-8408 DRE# 02107070

From our families to yours, we wish all of you good health and a safe, speedy return to practice.

Together, we will get through this.

“Integrity Practice Sale’s customer care, reliability, and knowledge about the rapidly changing dental practice sales market is the highest anyone could expect to ﬁnd.” - R. Adames, DDS

COVID-19 Resources from IPS: Market Updates & Post-Covid Practice Success Blueprint at www.integritypraticesales.com/covid DRE #01911548

Broker-Partners: Darren Hulstine and Bill Kimball, DDS

Ethics

C D A J O U R N A L , V O L 4 8 , Nº 5/6

Money and Ethics: A Potential for Conflict Gary Herman, DDS

have an old-school family practice. A colleague nearby has recently opened a very different style of office. He is aggressively marketing, offering discounts, doing free exams and “upselling.” To me, he is violating his ethical duties, but I do not know that for sure. What should I do? Dentistry is not a charity. Dentists are allowed, even encouraged, to be successful. Making money is necessary, especially as the costs of education and establishing and running a practice grow and payments are being restrained by outside forces, such as third-party payers and nontraditional practice models. However, dentistry is both a business and a profession. Conflicts can occur when trying to function in both of these arenas. In the scenario described above, marketing, discounting and discussing the results of an examination and proposal of treatment could all be appropriately ethical. Even providing free care can be done within dentistry’s ethical framework. However, each of the situations described, depending on exactly how these subjects are addressed by the dentist, could be flagrantly unethical. Section 6 of the CDA Code of Ethics concerns false claims and representations in advertising and is based on the Ethical Principle of Veracity. Intentionally misleading the public with false statements and/or partial disclosure of facts could lead to a false or unjustified expectation of

results and would be unethical. If the advertising is factual and intended to educate potential patients of services provided, it is very likely acceptable. Similarly, promoting discounts to specific groups of patients is acceptable as long as the discount is applied appropriately. Providing free care as a charitable gesture is completely professional; however, luring patients to the practice by offering free exams only to propose an expensive list of treatments (that may be only elective or even unwarranted without discussing lower cost options) or not presenting the patient with information as to what could result from no treatment would be ethically wrong under Section 1D of the CDA Code of Ethics and is based on the Ethical Principle of Patient Autonomy. Yes, money is important, and you should be able to provide dentistry at a fee level that is fair to the patient as well as to your practice. We should all strive to make patients understand all that we are providing within the scope of the treatment they have received; hopefully, you have helped your patients realize they have received a good value for the money they have spent. The conflict between money and ethics occurs primarily when money is valued by the practice more than ethics are valued. Wouldn’t it be nice to see your practice grow not from spending a lot of that

money on advertising, but rather by spending time establishing trust and respect from your patients and letting them be your investment in word-of-mouth advertising? n Gary Herman, DDS, teaches at the University of California, Los Angeles, School of Dentistry and lectures on ethics, dental law and patient management. He is past chair of the ADA Council on Ethics, Bylaws and Judicial Affairs and is a member of the CDA Judicial Council. Have an ethical question you’d like to have addressed by the Judicial Council? Email lori.alvi@cda.org.

M AY/JUNE 2 0 2 0 295

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BAY AREA

BAY AREA CONTINUED

AC-989 SAN FRANCISCO (Facility): Busy Retail Shopping Plaza w/ major anchor tenants! 3 ops Price Reduced $99k AC-1059 DALY CITY: Amazing practice w/ seasoned staff in highly desirable neighborhood. 1500 sf w/ 4 ops $345k AC-1072 DALY CITY: Seller to work back until May 2022! 1045 sf w/ 3 ops. Plumbed for 1 add’l $450k AC-1075 DALY CITY: Rare 2 DR Practice in Daly City. One seller would like to work-back. Offered at $795k AG-944 SAN FRANCISCO: An opportunity like this does not come along very often! ~998 sf w/ 3 ops Reduced $495k AG-993 WEST PORTAL AREA: Desirable area w/ easy commute to downtown San Francisco. ~1000sf w/ 3 ops Reduced Price: $395k AG-1079 SAN FRANCISCO: Quality Practice in Heart of City! 1931 sf w/ 5 ops offering in-house specialists $685k BC-949 ALBANY: Desirable commercial/residential area. Medical Prof Bldg w/ good frontage. 3200sf w/ 4 ops $695k Real Estate: $1.8 BC-1010 ANTIOCH: Amazing Opportunity in Health Prof. Complex 2118 sf w/ 2 equipped ops + 3 add’l $225k BC-1022 OAKLAND: “Pill Hill” Area adjacent to hospital! 1064 sf & 2 ops. Plumbed for 1 add’l $150k BC-1056 SAN RAMON (Facility): Move-in ready facility in well maintained professional complex. 1698 sf w/ 4 ops $60k BG-1085 BERKELEY: Stay young and on the cutting edge as you practice in this UC collegiate town! ~ 1,600 sf w/ 4 ops $975k BN-1023 RICHMOND: This is a rich opportunity for the astute dentist! 1450sf w/2 ops + 2 add’l. $50k/ Real Estate $750k BN-1060 LAYAFETTE: Imagine practicing & raising your family here in this community! 1400sf w/ tivvated! Now $198k 3op. Seller Moti BN-1067 SAN LEANDRO: Imagine owning this family-oriented practice with a large patient base. 1495sf w/ 3 ops 2 + 1 add’l. $325k BN-1109 SAN LORENZO: Seller is retiring and passing along almost 60 years of goodwill! 2700 sf w/ 6 ops + 2 add’l. $175k CC-846 SAN RAFAEL: Prof/Retail Building Complex. 3 ops 640 sf Collections $433k in 2017 $275k

CC-963 SANTA ROSA: Practice & Real Estate Available! 1765 sf w/ 5 ops Practice $395k & Real Estate $735k CC-979 NOVATO: Seller Retiring. 803 sf w/ 3 ops near downtown and Old Town Novato. $195K (Real Estate $215k) CC-1030 SANTA ROSA: Extraordinary practice in prime location. 30k+cars drive by per day! 1683sf w/5ops. Great opportunity! Only $325k CC-1049 SANTA ROSA: Fully Remodeled, Amazing Location. 2000 sf w/ 5 ops $500k Real Estate Also Available CC-1096 VACAVILLE: Little Gem located in Retail Shopping Center. 1500 sf w/ 4 ops ONLY $89k CC-1115 WESTERN MARIN COUNTY: One of a Kind Seaside Community! Seller Retiring. Established for 30 yrs 510 sf w/ 2 ops ONLY $75k CC-1119 SANTA ROSA Facility: You will not find another facility in this area with these build-outs at this price!! 1200 sf 3 ops $140k CG-1048 SONOMA: This highly successful familyoriented practice has it ALL! ~1500 sf w/ 4 ops $630k CG-1110 PETALUMA: Established 30+ years, with a large, stable and loyal patient base! ~ 2300 sf w/ 6 Ops $180K CN-911 SANTA ROSA: This fabulous practice is the heart of the Wine Country! 2250 sf w/4 ops + 1add’l.. Seller Motivated $465k CN-1090 VACAVILLE: This amazing, state-of-the-art practice is an outstanding opportunity! 2400 sf w/ 7 ops + 1 add’l. $695k / Real Estate $780k DC-1080 ALAMEDA: Established for 25 years. Seller retiring from this amazing practice. 1200 sf w/ 3 ops $575k DC-1094 LOS GATOS Facility: Unbeatable location! 2 story Med/Prof Bldg near Netflix Headquarters! 1059 sf w/ 2 ops $200k DC-1111 SAN JOSE: Established for 40 yrs. Dental Prof Bldg on major thoroughfare! 1200 sf w/ 4 1/2 fully equipped ops $1.05M DG-986 CAMPBELL: The ideal opportunity to practice in this community! ~988 sf w/ 3 ops Seller Motivated $288k DG-1014 MONTEREY: Don’t miss your opportunity to live and practice in beautiful Monterey! ~1125 sf w/ 4 Ops. $650k DG-1081 SAN JOSE: Located in popular retail shopping center. Spacious 2800 sf office w/ 8 fully equipped ops $295k

800.641.4179

WPS@SUCCEED.NET

Timothy Giroux, DDS

Jon B. Noble, MBA

Mona Chang, DDS

Edmond P. Cahill, JD

John M. Cahill, MBA

BAY AREA CONTINUED

NORTHERN CALIFORNIA CONTINUED

DG-1099 SANTA CRUZ: Consistently voted as the BEST DENTIST in Santa Cruz! ~ 1,547 sf w / 4 Ops. Reduced Price: $495k DG-1112 LOS GATOS: Hesitate and you might just miss out on the opportunity of a lifetime! ~ 850 sf w/ 3 ops. $375k DN-1031 CUPERTINO: This remarkable practice awaits only your talent and skill! 1500sf w 3 ops + 1 add’l. $1.25M DN-1041 SAN JOSE: This stunning practice is an excellent opportunity for new grads! 1207sf w 2ops + 1 add’l.. Reduced! $175k DN-1046 SANTA CRUZ AREA: Opportunities like this does not come along, except once in a lifetime! Office 2050 sf w/ 5 ops. Total sq ft 3880. $595k /Real Estate: $1.1mil DN-1084 SAN JOSE: Built-out in 2015, this beautiful, spacious, modern office is conveniently located! 2204sf w/ 4 ops + 2 add’l Now Only $495k DN-1107 SAN JOSE: Quality, family-oriented practice. Hesitate & you

GN-1071 REDDING: Streamlined policies & loyal patient base, this quality practice is your springboard to success! 2264sf w/ 4 ops. $525k GN-1073 PARADISE: Quality, fee-for-service practice with a stellar reputation! 1800sf w/ ops. Reduced! $325k / Real Estate Available HG-1068 LAKE TAHOE AREA: Imagine living and practicing in the majestic Sierra Nevadas and lake community! ~2500 sf w/ 3 Ops. $315k/Real Estate Available HG-1089 CALAVERAS COUNTY: Est. 25 yrs w/ Stellar Reputation! 3000+ sf w/ 6 ops $465k/Real Estate Also Available HG-1116 AUBURN VICINITY: Family-oriented practice, loaded with warmth, charm and personalized service! ~ 1430 sf w/ 4 ops $525k HG-815 TRUCKEE AREA: Amazingly priced at 50% of Collections! ~1000 sf w/ 3 ops $150k/ Real Estate Available HG-983 GRASS VALLEY: Newly remodeled office in highly desirable neighborhood! ~1250 sf w/ 3 ops. Reduced Price $185k/Real Estate Available HG-987 LAKE TAHOE AREA: LIVE THE DREAM! The mountains are calling you to this Alpine Paradise! ~ 3,400 sf w/ 6 Ops $785K/Real Estate Available HN-879 SONORA: Great Cash-Flow for Only 3 Days a Week! 2950 sf w/ 3 ops Reduced Price: $265k HN-991 PLACERVILLE: Quality, conservative and compassionate practice! Will consider work back. 1,654 + 473 sf w 5 ops. $675k

may miss out on the best decision of your life! 1200sf w/ 3op.. $535k NORTHERN CALIFORNIA EG-1012 EAST SACRAMENTO: A practice like this one does not come available very often! ~ 2900 sf w/ 8 Ops $2.5M EG-1016 LINCOLN: Look no further than this growing community to springboard into your success! ~1800 sf w/ 4 Ops Reduced $560k EG-1039 SIERRA FOOTHILLS: The ideal opportunity to practice in this community! ~1100 sf w/ 4 Ops Reduced Price $310k EG-1061 SOUTH AUBURN VICINITY: Come live, play and practice in the heart of this pristine town! ~1100 sf w/ 4 Ops Reduced Price $310k EG-1092 GRASS VALLEY/AUBURN: If you’ve always wanted to live in Gold Country, look no further! ~ 1500 sf w/ 4 Ops $295k EG-1093 AUBURN: Enviable location, stable patient base and located in the heart of town! ~ 1000 sf w/ 3 Ops $120k EG-1100 CARMICHAEL: Be rewarded for your talent and skill at this proven location. ~ 2,271 sf w/ 5 Ops $535k Real Estate Available EG-1104 ROSEVILLE: Spacious, modern office is equipped with mostly new, state-of-the-art equipment. ~ 1500 sf w/ 4 Ops $295k EN-1055 ROCKLIN Facility: Build your own success here in this familyoriented community! 1650 sf w/ 4 ops +1 add’l. $95k EN-1077 DAVIS: Imagine living and practicing here! Hesitate and you may miss out on your dream! 1100sf. w/ 5 ops. Reduced $495k EN-1095 SACRAMENTO: Outstanding Growth Potential! Seller retiring and refers out most Specialties. 1000 sf w/ 3 Ops. $75k EN-1108 GRANITE BAY Facility: Perfect for a satellite office or start-up practice! Updated & equipped with high-tech equipment! 1,500 sf w/ 5 ops. $195k FC-650 FORT BRAGG: Family-oriented practice. 5 ops in 2000 sf $3 350k for the Practice & $400k for the Real Estate FG-1086 UKIAH: This excellent opportunity awaits your talent and skill! ~1200sf w/ 4 ops $550k FN-855 NO. HUMBOLDT: Seller relocating! Long-established, 100% FFS practice! 1600 sf w/ 3ops + 1 add’l. $190k/ Real Estate Available

CENTRAL VALLEY & SOUTHERN CALIFORNIA IG-1007 GREATER MODESTO AREA: Combines a quality learning environment with relaxed rural living. ~3000sf w/ 6 ops. $645k IN-1091 TRACY: Spacious, beautiful, modernly equipped, well-designed and is a fully digital office! 2,200sf w/ 6 ops. $490k IN-1113 LODI: Small town charm, stable patient base and low overhead! 1,100sf w/ 3ops. $225k JC-811 FRESNO COUNTY: Seller willing to consider Associateship for qualified DDS w. intention to Buy In! Considerable Goodwill in Community! 3,000 sf w/ 6 ops $350k JC-823 LOS BANOS: Heavy emphasis on hygiene. 1000 sf w/ 3 ops $80k JC-1054 VISALIA: Practice AND REAL ESTATE! Prof Bldg on major thoroughfare. 2,260 sf w/ 6 ops $275k/ Real Estate $517k SPECIALTY PRACTICES BG-843 WALNUT CREEK Perio: Priced at 50% of collections! ~1085 sf w/ 4 ops $390k IC-1102 MERCED Endo: Strong Referral Base, Professional Corridor, Highly Desirable Neighborhood. 2500 sf w/ 5 ops. Plumbed for 2 add’l $210k We are a proud member of:

* Western Practice Sales is a member of American Dental Sales (ADS Transitions), a nationally recognized organization of dental practice brokers throughout the United States. ADS members have a strategic alliance & combined marketing efforts with other practice brokerage firms, financial companies & lending organizations. All ADS companies are independently owned and operated.

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Tech Trends

C D A J O U R N A L , V O L 4 8 , Nº 5/6

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

Microsoft Teams (Free, Microsoft)

Discord (Free or $9.99 per month, per user for premium)

With the outbreak of the COVID-19 respiratory disease this year, federal, state and local governments mandated shelter-in-place orders, which have caused many organizations to enact work-fromhome policies. Physical meetings have been replaced by online meetings, resulting in a large-scale dependence on reliable virtual conference technologies. Microsoft Teams is a technology platform that combines many Office 365 services to provide an ultimate hub for meetings, collaboration and communication for small and large businesses, organizations and institutions.

Suddenly, online communication tools have become the primary means of keeping people together. The events of previous months have seen applications like Zoom, Teams and Hangouts normalize as the world implements social distancing and isolation. In this moment of crisis, every means of staying in touch is valid and worthy of being explored. In the sea of communication tools lies Discord, a free-to-use, platform-agnostic, gamer-focused voice chat application with a host of useful tools for small groups like dental practices, families and study clubs.

Getting started with Teams requires a free Microsoft account to take advantage of its features. Users begin by creating a few teams, which are groups of people or members within and/or outside the organization. Dedicated sections within teams called channels are then created. Team members can take advantage of core features within a channel, such as chat messaging, file attachments and sharing and Office document collaboration. Additionally, integrations with 250-plus apps and services can be added to any channel, providing additional tools for teams to complete tasks. Audio/video calls and screen sharing can be initiated with any individual or group that has Teams installed and logged in with a Microsoft account. With eligible Office 365 account subscriptions, users can schedule online Teams meetings ahead of time and send Outlook calendar invitations. Subscribers can also record meetings to be viewed/downloaded later from Microsoft Stream, which is a video-sharing platform similar to YouTube. Channels can be made private, limiting activity to a select number of team members. Guests without a Microsoft account can participate in chats and channel conversations by getting an invitation link from an owner of a team. This platform has taken the best features of popular services such as Slack, Zoom and Skype and integrated them into a unified product that is robust and responsive without being too complicated.

Discord originally started as an add-on to a game to help facilitate player voice and text communication. It was meant to be more secure, less resource intensive and easier to use than its competitors of the time like Skype and TeamSpeak. Discord boasts features like push-to-talk, granular user-level management and video screen sharing for up to 10 members. Accounts are free to create, the webpage does a great job setting up user devices for immediate use and the user community has active troubleshooting forums that address Discord’s most common issues. The application interface is on the juvenile side, and diving into any of the open, unsecured Discord servers can be confusing and often offensive with some of its unregulated content. While Discord was never meant to store or discuss protected health information (PHI), its user-centric approach coupled with excellent mobile integration, push-to-talk functionality and a free price tag make it a viable option for those practitioners looking to keep communication channels open with a small group of individuals in this tumultuous time.

Working from home and social distancing have become the new normal as the entire world responds to mitigate the COVID-19 outbreak. Microsoft Teams is a scalable platform that can meet the demand for a group of any size to connect, collaborate and communicate in an online world. — Hubert Chan, DDS

298 M AY/JUNE

2020

— Alexander Lee, DMD

Would you like to write about technology?

Dentists interested in contributing to this section should contact Andrea LaMattina, CDE, at andrea.lamattina@cda.org.

MARK YOUR CALENDAR Be a part of CDA’s next convention. Save the date for CDA Presents The Art and Science of Dentistry. More details are coming soon about our hands-on workshops, lectures from leading speakers and exhibit hall this fall.

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CDA has made online and audio learning options available at no cost through June 16, 2020. Learn more and register to earn convenient C.E. at cda.org/cdapresents.

San Francisco, California Sept. 10–12, 2020 Sept. 9–11, 2021 #cdaSF

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CDA Journal - May/June 2020: Ahead of an Evolving Curve

Articles inside

Letter to the Editor — Thank You for Everything, Dennis

Tech Trends

Money and Ethics: A Potential for Conflict

Easy-To-Use Tool Helps Dental Practices Complete HIPAA-Required Analysis

Speak Up! Open Communication Strengthens Employer-Employee Bonds

Reproducibility and Variability of Centric Relation Point in Completely Edentulous Patients

Clinical Behavior Guidance for Children in Dentistry

Unicystic Ameloblastoma Presenting as Dentigerous Cyst: A Case Report

Waiting for the Hurricane

Oral Health Disparities: Proceedings of an Oral Health Innovation Forum