Shift Magazine - Spring 2018 by Sprig

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P E D I AT R I C D E N T I S T RY

SPRING 2018

YOU’RE HIRED!

Maximizing the value of residency in preparation for your transition into private practice

Asking

WHY

How I Rekindled My Passion for Pediactric Dentistry

This Might Come as a

SHOCK Should an automated external defibrillator be considered optional office equipment?

NOW WHAT? Dealing with $tudent Debt

SILVER DIAMINE FLUORIDE

With so much buzz, will it really become the next gold standard?

Evolution THE OF

Pediatric Dentistry « A look back at the innovative

developments in pediatric dentistry

TRANSITIONS from residency to reality

SPRIG UNIVERSITY DESTINATIONS FOR 2019

FEBRUARY - DALLAS, TX

AUGUST - BOSTON, MA

Simple Solutions to Real Challenges.

SEPTEMBER - NAPA, CA

DECEMBER - MIAMI, FL

CONTENTS

LETTER FROM THE EDITOR

CONTRIBUTORS

ng 2018

Leaving Residency Prepared

Without whom this issue would not have been possible.

18 CLINICAL PEARLS It’s worth reading, because you don’t know what you don't know.

22 ON THE SCENE

Spending good times with friends at all the Sprig-attended events throughout 2017 & 2018

DOCTOR TO DOCTOR

Hear from a colleague how attending Sprig University improved the way he practices.

26 THE EVOLUTION OF PEDIATRIC DENTISTRY

A look back at the innovative developments in pediatric dentistry.

NOW WHAT? DEALING WITH STUDENT DEBT Learn from the experiences of others and create a plan to build a strong financial future.

36 THIS MIGHT COME AS A SHOCK Should an automated external defibrillator be considered optional office equipment?

42 FROM RESIDENCY TO REALITY My journey to independent practice success.

CONTENTS Sp

ng 2018

46 YOU’RE HIRED!

Maximizing the value of residency in preparation for your transition into private practice.

54 SILVER DIAMINE FLUORIDE With so much buzz about SDF, will it really become the next gold standard?

60 ASKING WHY How I rekindled my passion for pediatric dentistry.

66 A GLOBAL JOURNEY

My ourney to 11 countries in 11 months . j

ON THE COVER COVER DESIGN BY MARK BOND PHOTOGRAPHY BY LEVI McPHERSON PRIMARY CHILDREN’S HOSPITAL RESIDENT— ANDY INGERSOLL, DDS This issue of Shift magazine features Andy Ingersoll, DDS, on the cover. On page 62, Dr. Brett Packham details the residency training program at Primary Children’s Hospital (Salt Lake City, Utah) and highlights some important features of residency training that help to prepare pediatric dental residents for the exciting world of private practice.

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SPRIG ORAL HEALTH TECHNOLOGIES, INC. FORMERLY EZPEDO, INC

LETTER

from

THE EDITOR

READY OR NOT… Leaving Residency Prepared

For those of us who have grown accustomed to the world of private dental practice for 15 or 20 years now (or even longer), it’s easy to forget the feelings many second-year residents will experience as they attend the AAPD annual meeting for the last time as resident dentists. In only a few short months, they will be entering the real world of daily practice. If you are a graduating resident, you face many choices and are being forced to make crucial decisions. Some of you may be troubled by thoughts of uncertainty and apprehension as to what the future may hold in store. You are excited, while at the same time, you are apprehensively wondering thoughts such as these. Where am I going to practice? Am I going to join a practice as an associate? Or do I want to try and find a partnership opportunity? Maybe it would just be better to strike out on my own! How am I going to afford all of this? All new graduates face real-life concerns, and the reality is, making the wrong decision can incur lasting consequences. Wise choices, on the other hand, can produce rewarding results. This issue of Shift magazine highlights real-life issues facing new graduates and residency programs today, while providing experienced dentists with fresh insights. “The Evolution of Pediatric Dentistry” discusses, from a program director’s point-of-view, the history of pediatric dentistry and why it is so important for pediatric residency programs (and established dentists) to keep pace with the rapid changes in today’s technology. “You’re Hired” shares what the ideal residency program can offer and how the post-graduate program you choose can give you a decided advantage when entering private practice. You’ll learn the latest available information on silver diamine fluoride (SDF) in “Will Silver Really Become the New Gold Standard?” Decide if a defibrillator might be a must-have device for your (new) practice after reading “This Might Come As a Shock.” “Asking Why?” will challenge you to seriously reconsider what really serves as your motivation to practice. “From Residency to Reality” shares how you can successfully build your practice and gives insightful tips on how to construct your own office building. “Dealing With Student Debt” provides some timely, practical counsel for new graduates (and for established dentists seeking grads as new associates.) Former Sprig employee, Kamiran, also shares her challenging but rewarding encounters as she participates in “World Race,” an 11-month international service journey. If you are a second-year resident preparing to graduate, we hope these topics provide some stimulating new insights as you prepare to launch your own career. If, on the other hand, you are an experienced dentist, why not share your expertise with a younger colleague by seeking an opportunity to be a mentor during the transition from residency to private practice? Each new chapter in our lives provides opportunities for us to accomplish grand things. My hope for everyone reading this issue—especially graduating residents—is that you’ll embrace this moment and strive to create a practice that will abundantly benefit your family, your patients, and your community. You have chosen a rewarding profession, and an incredibly bright future awaits you. Enjoy this issue, and happy reading.

Je rey P. Fisher, DDS Editor-in-Chief editor@sprigusa.com

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Shift Contributors Victoria Sullivan, DDS Dr. Victoria Sullivan is a 1995 graduate of the University of the Pacific School of Dentistry. In 1997, she received her pediatric certification at the University of Southern California. For more than 20 years, Dr. Sullivan was in private pediatric practice in Southern and Northern California. Recently, Dr. Sullivan moved to Texas where she is a full-time assistant professor of pediatric dentistry in the School of Dentistry at the University of Texas Health Sciences Center at Houston. Dr. Sullivan spends her free time jogging, traveling, or spending time with her two children. She is passionate about community service and education access.

Mandy Ashley, DMD, MSEd, MS Originally from upstate New York, Dr. Mandy Ashley followed an interesting pathway into pediatric dentistry. After graduating from the University of Pennsylvania in 1999 with a dental degree and master’s degree in education, Dr. Ashley embarked on an 11-year adventure as a general dentist in Barrow, Alaska. She brought dentistry to the villages along the Arctic Ocean and started a dental assisting program for local residents. In 2012, she finished her pediatric dental residency at The Ohio State University and moved to Bowling Green, Kentucky, to raise her family and start a private practice. In her spare time, Dr. Ashley plays hockey and travels the world with family, hoping to inspire her kids to enjoy big adventures of their own someday!

Steven Schwartz, DDS Dr. Steven Schwartz completed a postgraduate residency in pediatric dentistry at the Jewish Hospital and Medical Center of Brooklyn. He has served as clinical associate professor in the Department of Pediatric Dentistry, University of Medicine and Dentistry of New Jersey and as the director of the pediatric dentistry residency program at Staten Island University Hospital. Dr. Schwartz is a diplomate of the American Board of Pediatric Dentistry and writes and lectures on clinical and practice management topics.

Travis Nelson, DDS, MSD, MPH Dr. Travis Nelson is a clinical associate professor in the Department of Pediatric Dentistry at the University of Washington, and he maintains privileges at Seattle Children’s Hospital. Dr. Nelson received his DDS degree from Loma Linda University and subsequently completed a residency in pediatric dentistry and a MPH degree at the University of Washington. Dr. Nelson is a board-certified Diplomate of the American Board of Pediatric Dentistry. He has authored numerous published articles and has lectured both nationally and internationally. His clinical and research interests include providing dental care for children with autism, contemporary approaches to caries management, and procedural sedation. 14

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Susan Marder, MSN, ANP-C Susan Marder is a board-certified nurse practitioner, an assistant professor at Marshall B. Ketchum University’s School of Physician Assistant Studies (Fullerton, Calif.), and owner of Emergency Response Training—a medical education company that trains healthcare professionals in emergency resuscitations. She has been an American Heart Association BLS, ACLS, and PALS instructor for over 30 years. Susan was program director for Loma Linda University’s Life Support Education Department, serving as a lead instructor for 17 years. She has trained anesthesia providers, medical, dental, and nursing professionals nationwide. Susan earned a MS degree in nursing from the University of San Diego. Clinical experience includes critical care, ER, post-anesthesia care, cardiology, home health care and rural medicine. She currently practices internal medicine in Palm Desert, Calif.

Brett Packham, DDS Dr. Brett Packham graduated from the University of Iowa College of Dentistry in 2006 and completed his pediatric dental residency in 2008 at Primary Children’s Hospital, Salt Lake City. He is a diplomate of the American Board of Pediatric Dentistry, and currently is a part-time clinical attending dentist at Primary Children’s Hospital. In 2010, Dr. Packham established Kids Town Pediatric Dentistry in Ogden, Utah. He enjoys humanitarian work locally in Utah and has traveled abroad to Costa Rica and Guatemala trying to make a difference in the world.

Robert L. Delarosa, DDS Dr. Robert Delarosa is the founding partner of Associates in Pediatric Dentistry, Baton Rouge, Louisiana. He is a board-certified diplomate of the American Board of Pediatric Dentistry, and a Fellow of the American Academy of Pediatric Dentistry and the American College of Dentists. He obtained his DDS degree from the Louisiana State University School of Dentistry, where he received the ASDC outstanding undergraduate student award in pediatric dentistry. He completed his specialty training in pediatric dentistry at the University of Texas Health Science Center at San Antonio, serving as senior chief resident.

Kamiren Passavanti Kamiren Passavanti graduated in 2011 with a bachelor’s degree in marketing and a minor in Spanish from Georgia Southern University. After leaving the greater Atlanta area, she worked at Sprig Oral Health Technologies from 2013 to 2017, eventually holding the position of senior customer care specialist. Currently, Kami is working in South America with youth that have been affected by addiction. She is participating in World Race, an 11-month international service tour sponsored by Adventures in Mission.

Andrea Igowsky, DDS Dr. Andi Igowsky is a board-certified pediatric dentist and practices at Just Kids Dental in Sheboygan, Wisconsin. After graduating summa cum laude from the University of Minnesota Twin Cities with a BS degree in medical microbiology, she then attended Marquette University School of Dentistry and graduated at the top of her class with a DDS degree. Dr. Igowsky went on to specialize in pediatrics at the Children’s Hospital Colorado in Denver. She moved to Sheboygan in 2010 and joined her older sister, Dr. Jaime Marchi, as a partner and co-owner at Just Kids Dental. Dr. Igowsky has received several awards for her dedication to children in Wisconsin. In 2012, she was awarded Top Young Professional. In 2015, Just Kids Dental won Service Industry of the Year, the smallest business to ever win an award of this caliber. And most recently, in June 2017, she was awarded Emerging Leader of the Year. She is married to Ben Igowsky, a regional sales manager for an orthopedic medical supply company. They have two daughters, Harper, age 7, and Preslee, age 5. For fun, Dr. Igowsky loves to travel, do CrossFit, play soccer, sing, volunteer in the community, and spend time at their lake house in the northern woods of Wisconsin. She has been using Sprig EZCrowns since 2010 and became an instructor for Sprig University in 2015. She has attended and lectured at all four of the annual Sprig symposia.

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Issues in Pediatric Dentistry Previously published biannually as EZPEDO Magazine 2015—2016.

Vol. 4 No. 1 | Spring 2018

JEFFREY P. FISHER, DDS Editor-in-Chief TIMOTHY SHAMBRA

JAMES R. FISHER, MSPH, PhD

VLADIMIR SHCHERBAK

RICKY QUINTANA

MARK BOND Cover Designer

ANN FISHER, MAT, MMus

Graphic Designer

Issue Coordinator

Senior Consulting Editor

Design Consultant

Copy Editor/Proof Reader

Contributing authors Victoria Sullivan, DDS / Mandy Ashley, DMD, MSEd, MS / Steven Schwartz, DDS / Travis Nelson, DDS, MSD, MPH Brett Packham, DDS / Susan Marder, MSN, ANP-C / Robert L. Delarosa, DDS / Kami Passavanti / Andrea Igowsky, DDS

Contributing photographers Slava Daniliuk / Daniel Vakaruk / Timothy Shambra / Taylor Chobanian

Special thanks to Hans C. Reinemer, DMD, MS / Andy Ingersoll, DDS

SPRIG ORAL HEALTH TECHNOLOGIES, INC. Publisher RICKY QUINTANA Advertising Sales

LYUBA KOLOMIYETS Finance & Accounting

STEPHEN SMITH Advertising Contracts

For editorial inquiries, please email: editor@sprigusa.com For advertising inquiries, please email: ricky@sprigusa.com Subscriptions are available online by visiting: www.sprigusa.com/magazine For additional inquiries, please call: 888 539 7336 / Int. (1) 916 677 1447

SPRIG ORAL HEALTH TECHNOLOGIES, INC. 6140 HORSESHOE BAR ROAD, SUITE L LOOMIS, CALIFORINA 95650

Shift magazine, a contemporary dental publication highlighting relevant topics of interest for busy practitioners in private practice, publishes scientific articles, case reports, and human-interest stories focusing on current issues in pediatric dentistry. Pediatric and general dentists will learn about new concepts in restorative treatments and the latest innovations in techniques and products, all available in the one magazine that helps them keep pace with rapid changes in pediatric dentistry. © Copyright 2018 Shift magazine, a subsidiary of Sprig Oral Health Technologies, Inc. All Rights Reserved.

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YOU DON’T KNOW WHAT YOU DON’T KNOW

CLINICAL

PEARL OF WISDOM

LOOKING FOR A PEARL OF WISDOM TO IMPROVE YOUR QUALITY OF DENTAL CARE? By Victoria Sullivan, DDS

Photo: www.youngdental.com

Ironically, many pediatric dentists who have accumulated years of valuable experience seldom enjoy opportunities to collaborate with one other. So, when we attend conventions or go to meetings, we often seek out those pearls of wisdom which will help improve our quality of care and enable us to treat our patients more proactively. Here’s one pearl I want to share with you. Among the dental materials which have profoundly affected the field of pediatric dentistry, fluoride varnish stands out as having played a key role. Fluoride varnish is a great tool in our dental armantarium. This product helps bring fluoride ions into contact with children’s teeth, and, with the help of the associated rosin, binds these ions to the outer matrix of teeth for up to 12 weeks. Unfortunately, the rosin, which performs such an important role, also generates a sticky sensation which many children find annoying. We pediatric dentists regularly hear complaints from children about the “icky taste” of fluoride. We have all watched our patients, crying, wincing, or otherwise rejecting this sensation, and trying to scrub off the stickiness. Currently, this unpleasant sensation is not one we can prevent or remove. However, once in a while we also will hear a child complain about a “burning feeling” when receiving fluoride varnish treatment. Can fluoride cause this burning sensation? The answer is “no,” but the ethanol

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contained within the product can. Ethanol acts as a skin irritant. Since the purpose of ethanol is significant in the chemical bonding process, ethanol will not be removed from fluoride varnish. However, there are steps we can take to minimize or eliminate the “burning” sensation. I have spoken with a number of varnish companies. Here is a simple step they recommend to eliminate the burning effect caused by ethanol. Mix the varnish together for a minimum of 10 seconds before applying. As you mix the varnish, it is exposed to air, and the ethanol evaporates. Allowing time for this evaporation to occur is the key to preventing a burning sensation. Although, at this time there does not yet appear to be an acceptable means of addressing the sticky sensory feeling associated with fluoride varnish treatment or a flavor we can use to adequately disguise it, we can easily solve the other problem of experiencing a “burning feeling.” Following the above advice, no practitioner needs to ever hear complaints about burning again. Remember, first mix the fluoride varnish for 10 seconds, then apply—a simple pearl with a very nice shine.

AN UNEXPECTED SUPRISE

R EC ONNECTING WITH

RILEY! SOMETIMES IT’S THE LITTLE MOMENTS IN LIFE THAT CAN REALLY BRIGHTEN MY DAY! By Jeffrey P. Fisher, DDS

he was my second patient of the day. I don’t know why, but something about her seemed strangely familiar. It was a Monday morning, and I was helping out a dentist friend by doing recall exams in her office for the day. As I started to speak with the girl’s mother, she reminded me, “This is Riley. She was your patient a few years ago.” Then it all clicked. I had provided anesthesia for Riley when she was only 4 years old. In fact, she had been one of the first little girls ever to have her smile restored using pediatric Zirconia crowns.

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Dr. Lindsey Robinson had placed crowns on both her laterals. I still remember how amazing they looked—so much so, that her pictures were featured at EZPEDO’s booth at the 2013 AAPD annual meeting in Orlando. It’s amazing how quickly the years have flown by. Being a provider of pediatric anesthesia, I rarely, if ever, have an opportunity to see my patients more than once. So, to be able to reconnect with Riley was a real treat, observing how she is becoming a beautiful young lady. Riley’s “big teeth” have now mostly replaced her baby teeth,

but I will always remember the little, 4year-old strawberry-blond girl wearing a shirt with watermelons on it who shared her beautiful smile with the world. As busy professionals, our lives too often tend to slip into a demanding, repetitive routine of humdrum activity. At times it may even seem overwhelming. It’s when we experience these unexpected special moments, such as my reconnection with Riley, that we truly realize some of life’s greatest joys. I feel a need to seek out such opportunities more often. How about you?

SOCIAL NETWORK

P E O P L E , P L AC E S, A N D PA RT I E S Dr. Sean Cooper, Cynthia Cacho, Vanessa Hurt, Ben Igowsky, Dr. LaJuan Hall The Sprig Symposium group of 2017

Chad Aeschlimann, Dr. Laura Aeschlimann, Dr. Tina Merhoff

Dr. Laura Aeschlimann, Vanessa Hurt, Dr. Nneka Davis, Dr. Greg Wilson, Cynthia Cacho, Michael Montes, Dr. Cheryl Cooper, Terry Acosta

THANK

YOU

Dr. Dusty Janssen

Dr. Andi Igowsky

KL Moore

Dr. Mark Casafrancisco, Dr. Eddie Correa, Dr. Sean Cooper

Your commitment to raising the bar in pediatric dentistry is inspiring. We had a great time sharing with you during our 4th Annual Sprig Symposium in Cabo San Lucas, Mexico.

Dr. John Hansen

Brenda Hansen, Dr. Tina Merhoff Dr. Eric Hodges

Dr. David Martinez , Dr. Jeff Fisher, Edie Martinez Dr. Sean Cooper, Dr. Trice Sumner, Dr. Courtney Alexander

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Dr. Shahnaz Ahmed

Absolute Joy Hands-on session with Dr. John Hansen

At Sprig University, San Francisco, we had such an amazing opportunity to spend quality time with leaders in pediatric dentistry and meet new friends. We invite each of you to join us at our 5th Annual Sprig Symposium this fall!

Dr. Bradley Thompson, Dr. Jeff Fisher, Dr. John Guijon, Dr. John Hansen

Sprig University - Graduation Reception

Sprig University - San Francisco

Welcome reception - Sprig University

Sprig University 2018

E V E N T S

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DOCTOR TO DOCTOR Through extensive training at Primary Childrenâ&#x20AC;&#x2122;s Hospital pediatric dental residency, I truly feel comfortable treating any dental situation that comes through our doors. Having four children of my own, I understand the importance of finding a provider that you trust to take exceptional care of your child regardless of the care they may need. Here at Kids Town, our mission statement is that we will always care for your child as we would our own.

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Testimonial

WHY I CHOSE SPRIG UNIVERSITY [Formerly EZPU]

myexperience. "Sprig University was one of the best CE courses I have ever taken. It was a perfect mix of lecture and hands-on training. This course isn't just for beginners with these crowns. I have done between 50â&#x20AC;&#x201D;100 and learned some great tips to improve my speed and quality. Thank you, Sprig, for your attention to detail and focus on outstanding customer service!"

BRETT PACKHAM, DDS

LAYTON, ROY, AND SYRACUSE, UTAH

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THE EVOLUTION OF

PEDIATRIC DENTISTRY By Steven Schwartz, DDS

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P e d i at r i c d e n t i s t r y, a s p r a c t i c e d t o d ay, h a s e v o lv e d o v e r a p e r i o d o f a l m o s t 1 0 0 y e a r s .

n the early 1900s, the treatment of childhood caries consisted of extraction or just leaving carious teeth, because many dentists felt, “They’re just going to fall out anyway.” Sometime later in the 1920s, groups of local study clubs, with an interest in treating children (and in some cases limiting their practices to pedodontics—the precursor of pediatric dentistry), banded together to form the American Society of Dentistry for Children (ASDC). These dentists dedicated themselves to researching definitive methods of treating and preventing childhood caries and to management of pediatric behavior in the dental environment. However, no established educational qualifications, standards of practice, or certifying board yet existed.

CERTIFYING PEDIATRIC DENTISTS To meet these needs, the ASDC established certification requirements that led to the formation of the American Board of Pedodontics in 1940. In the late 1930’s and early 1940s, dental schools instituted departments of pedodontics (the precursor to the term pediatric dentistry) followed by the establishment of postgraduate training programs. In 1942, the American Dental Association’s Council on Dental Education formally recognized pedodontics as a distinct specialty. In 1947, a group of ASDC members met to organize the American Academy of Pedodontics (AAP) with the objectives to research and critically evaluate procedures used in children’s dentistry. While ASDC membership was open to all dentists regardless of whether they went through a specialty training program, the AAP membership was open only to those dentists who limited their practices to children or who went through a formal specialty training program in pedodontics. It wasn’t until 1984 that the AAP changed its name to the American Academy of Pediatric Dentistry (AAPD). Eventually in 2002, the ASDC merged with the AAPD to form a single organization. After the establishment of certifying boards, the formal inclusion of pedodontics into dental school curricula, and the establishment of pediatric dentistry training programs, rapid strides were made in adopting better modes of behavior management. Caries prevention and clinical treatment for children also experienced significant advancement.

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ADVANCING DENTAL PROCEDURES During the 1930s and 1940s, the concept of restoring primary teeth as opposed to simply extracting them became the generally accepted practice. Restorations of small- to moderate-sized lesions in teeth were accomplished using amalgam. Treatment of more extensive caries (pulp exposure) was accomplished by introducing the practice of performing pulpotomies with formocresol, zinc oxide, and eugenol along with full-coverage gold crowns.

disposable plastic syringes in 1989.

IMPROVING DENTAL EQUIPMENT Preparation of tooth restorations advanced from using belt-driven handpieces in the 1930s to the development, in 1957, of air-driven handpieces by John Borden. The 1990s saw the rise in popularity of electric micromotor-driven handpieces offering high torque and low vibration. Advancement in soft tissue surgery and tooth preparation occurred with the introduction of lasers in 1960 for soft tissue management and the Preventing caries further advanced with the introduc- erbium YAG laser for use on dentin in 1997. tion of community water fluoridation programs in With the development of the first fully reclining, elec1945 and with the practice of adding sodium fluoride tric dental chair (DenTalEze), in 1958, sit-down, fourto toothpaste. handed dentistry was introduced, improving producDr. William Humphrey described the first use of stain- tivity and shortening treatment time. less steel crowns in 1950. During the 1960s, they were adopted more generally for use in the restoration of INTRODUCING INNOVATIVE MATERIALS grossly carious posterior and anterior teeth.

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es tre ate dp So rim c iet 1930s • Den ari y tal of ly b De sch ye nti oo xtr str l s act B yf 1930s • el ins ion o t-d t r i t C ute riv or hil en wit dd d ren h hi e a pa nd 1940s • Res ( nd AS rtm pie tor iffe D C) en ces ing ren ts o for com ce pri m f m pe ed mo 1940 • For ary d ma od nly tee on tio use th tic no be dw s f cam the ith 1942 • Ped et Am s od pe he on eri ed ge tic can s li n s re mi e Bo ral 1945 • Com ted cog ard ly a mu niz to c o c 3,0 fP ed nit ep ed 00 t yw as ed o a A rpm d a p 1947 • m d t o r e i a nti stin r fl eri cti c can uo c s ct e rid spe Ac ati a c i o d D alt 1947 • ire np em y ctrog yo fill f ram Pe ing do s in me do 1950s • Use tro t nti h du yl m of c s ced nit (A eth rou A P a so )o cry 1950s • Lid xid rga lat oca e e niz res for ine ed ins pa int i i r n n o tro 1950 • Sta con du inl du ced tro ess ced l a p s ste op a lo e u l cr lar cal 1955 • Mec ize ow an ha d( nr e nic s dis e t he sto al b cov t i r c o a A ere n tio ag 1957 • ir din n e di tur n s g t fi n1 bin of rst 84 res eh d 4) e ins an scr 1958 • Firs d d i b p e t fu ed iec mo llyes by nst int rec Dr. r a r t l o inin Wi ed du 1960s • Sta llia b g ced inle yD , el m e ss s in r Hu ctr . Mic the tee ic d mp h l U e a hre c nta el B Sw 1960 • Las row y ers l ch i u n t o h res air no de s p tor c vel in u ee ore ati ds op se on 1962 • Com ed up s -

Aesthetic dentistry took a big step forward in the late Although the use of nitrous oxide for pain control dates 1940s. In 1947, direct-filling methyl methacrylate resback to 1844 when first introduced by Horace Wells, its ins were introduced to dentists in the United States. use as an analgesic/anxiolytic agent was not commonly used until the 1950s. Lidocaine with a vasoconstrictor In the 1950s, bonding agents were introduced. In 1955, Dr. as a local anesthetic agent was introduced in the 1950s, Michael Buonocore found that by applying phosphoric but its routine use was advanced by the introduction of acid to enamel, significant mechanical bonding of resins

A T I M E L I N E O F P E D I AT R I C D E N T I S T R Y ’ S E V O L U T I O N 28

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could be achieved. Rafael Bowen introduced composite ADOPTING IMPROVED TECHNIQUES resins in 1962. Their use was enhanced with the intro- Currently, there is movement toward more aggressive duction of ultraviolet curing in 1973, and, in 1978, the preventive treatments with the introduction of miniintroduction of visible light-curing resins. Microfilled mally invasive techniques such as using an application resins came into use in 1977, providing practitioners with of fluoride varnish, silver diamine fluoride (SDF—aphighly-polishable and stain-resistant restorations. proved as an anti-cavity agent by the FDA in 2015), and remineralization materials. The 1970s also brought about the use of sealants as a preventive measure. Acceptance of the concept of pre- Recently, I conducted an informal poll targeting members ventive restoration involving removal of only carious of a Collaborative Pediatric Dentist group on Facebook. I tooth structure had been secured by the practice of do- questioned the members regarding what techniques, teching restorations using composite resins. Furthermore, nologies, and products they started using in the past five the application of sealant to the remaining pits and fis- years that have: 1) made a significant improvement in the sures served to introduce dentists to the importance of way they deliver care, 2) improved treatment outcomes, minimally invasive dentistry. Glass ionomer cements and 3) enhanced patient satisfaction. (GIC) were also introduced in the early 1970s. Taking advantage of GIC’s fluoride-releasing properties, GICcomposite restorations soon replaced amalgam as a preferred restorative technique. The 1980s saw stainless steel crowns being replaced by more esthetic full-coverage techniques such as preveneered stainless steel crowns and composite strip crowns. More recently, Zirconia crowns (originally used only for adults) were introduced for pediatric use

ced ssu pre et ven rea e tiv rc tm 1973 • Ult em em rav en en e t iol asu ts ( etr GIC eb cur eg ) in ing 1977 • Mic an rotro o f du fill com ed c ed po com site 1978 • Vis po ibl s in site e li tro gh r du e sin t-c ced sc uri 1980s • Pre r n ea -ve gu ted ne nit ere s in ds tro 1984 • AA tai du Pc nle ced ha ss ng to s tee ed rep l cr its lac 1989 • Dis o na po eU wn me sab s, c Vc le p to uri o m A ng las po me 1997 • Erb t s ic s ite ric ium an yri str YA ng Ac ip Gl ad es cro ase em ma wn 1997 • Ele yo r in rke ctr s in fP ic m tro ted tro e d du dia icr uce ced o t ric mo df 2002 • ASD o D t ru or e Cm nti se ha str erg nd on y( pie ed d AA e P ces nti wit 2010 • re PD n fab hA int ) ric r A o PD du ate c int dZ ed 2015 • Silv oa irco off er s eri n ing dia ia c ng l eo mi r hig o w n r ga e fl ht ns 2017 • Intr n orq u p iza od ori ion ue t uct de i e o /lo e n ion red (SD wv of F) f o ibr rp Bis ap ati ed pro mu on i a v th t e r ic u db Ox yt ide se he fre F eS DA ma as rtM an TA an . ti-c avi ty ag en t

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in 2010 followed by fiberglass crowns in 2017.

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fordable. The higher fees charged for full-coverage aesthetic restorations and laser treatment, however, may make these options unaffordable for parents without insurance reimbursement. In addition, respondents mentioned longer prep time for Zirconia crowns compared to SSCs. ! Lack of or minimal instruction in pediatric dentistry training programs in utilizing new technologies (lasers, single-tooth anesthesia, Zirconia crowns.)

A relatively small number of the collaborative members posted responses, yielding the following results: Technique, Technology, or Product Mentioned Silver diamine fluoride (SDF)

Times Mentioned 109

Isolite

Glass ionomer cement (GIC)

Regarding the issue of prep time, it should be pointed out that hands-on training programs sponsored by Zirconia crown manufacturers help practitioners improve their technique and reduce their prep time. The second point cited above in the poll results (lack of or minimal instruction) especially warrants being addressed more fully, and ought to be resolved by ensuring adequate instruction during dental residency training. See discussion below.

ENHANCING RESIDENCY INSTRUCTION During a period of approximately 100 years, chilMineral trioxide aggregate (MTA) 26 drenâ&#x20AC;&#x2122;s dentistry treatment options have evolved, MI paste 18 following these sequential, progressive steps: 1) no Hall crown 8 treatment (or tooth removal), 2) treatment of caries Tooth snack guide 3 using unaesthetic materials, 3) use of aesthetic materials, 4) minimally invasive restorative treatments, Single-tooth anesthesia 2 5) more proactive preventive treatments. Likewise, I was surprised no one mentioned lasers, prefabricated behavior management has similarly evolved from Zirconia crowns, or social media services, considering relying on physical restraint as previously practiced these technologies, products, and services are so highly to the non-traumatizing dental experiences of toadvertised in print and at dental meetings. day. Parents, with increased awareness of the newer techniques providing more aesthetic treatment outHow do we explain why respondents failed to mencomes and overall pleasant dental experiences for tion these widely advertised items as contributing any their children, are demanding that dental providers significant improvement in the way they deliver care? use these newer treatment options and techniques. Why did only three additional responses even attest to their use? Forum members mentioned two reasons To meet parental expectations and patient needs, denwhy they did not include such items as laser treatment tal provider training opportunities in these newer techor Zirconia crowns in their responses. The reasons they niques and technologies must be available to those in offered were: dental undergraduate and post-graduate training proIcon resin infiltration

grams as well as those in practice. ! Issues relating to the business/practical application of the procedure. They mentioned coding and re- Dental schools and hospital residency programs must imbursement issues. While getting reimbursed for provide adequate training that will enable graduates to SDF or remineralization may be a problem, the implement the newest and most advanced techniques fees charged for these procedures are generally af- and technologies. Only in this way will their graduates

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be able to meet patient needs and satisfy parental expectations. School, hospital, and program administrators often claim funds are not available to provide such training, but it is their obligation as advocates at teaching institutions responsible for training the next generation of pediatric dentists to find the means to do so. Funding one or two faculty members to attend educational forums or manufacturer-sponsored programs will enable them to return to their programs with the knowledge and ability to train students. Requesting manufacturers and suppliers to provide a limited amount of free product, or in the case of technology companies (lasers, isolation products, computerized delivery systems), requesting use of their products for a limited time period, will expose trainees to the proper techniques required in the use of these products. CONTINUING DENTAL EDUCATION If you are a provider already in practice and no longer able to benefit from training offered in a residency program, you must take advantage of continuing education opportunities to keep abreast of recent advances in pediatric dentistry. You may do so by attending formal training programs and meeting with exhibitors at dental meetings. Or make the effort to attend specialized training programs sponsored by product manufacturers. Sales representatives should be welcome to visit your office rather than brushed off. As providers, we must become involved in organized dentistry to educate and encourage third-party payers to reimburse patients, at a reasonable level, for newer and more effective procedures. Advances and innovations in pediatric dentistry are coming down the pike at quantum speed. As dental health professionals, it is our obligation to keep up with them and make them available to our patients. References:

Bogert J, Richman G, Teuscher G. In the Beginningâ&#x20AC;&#x201D;A History of the American Academy of Pedodontics. American Academy of Pediatric Dentistry; 1997. Schulein T. The history of operative dentistry. J Hist Dent. 2005;53(2):63-72. Swift EJ, Perdigao J, Heyman HO. Bonding to enamel and dentin: A brief history and state of the art, 1995. Quintessence Int 1995;26:95-110.

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Now what?

Dealing With Student Debt. By Robert L. Delarosa, D.D.S.

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“

I have never been more excited about our pediatric dentistry specialty, the opportunities for private practice, or the future potential of our millennial generation.

hould

student debt—incurred by borrowing large sums to finance an expensive professional education—be viewed as a wise investment? Many of us have enjoyed great educational opportunities which we wouldn’t otherwise have experienced had they not been financed based on the promise of a successful future dental career. That fact cannot be denied. However, we must also consider other aspects related to the issue of educational debt that student borrowers sometimes overlook when confronted with access to “cheap” money. Let me share three facets of student debt I have observed in my experience and three take-away lessons.

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amily Debt—Counting the Cost

My family—having a set of twins who attended an out of state university and a son in training to be a hand/wrist orthopedic surgery fellow—is keenly aware of the rising costs of higher education. We certainly considered the substantial expense of professional education a worthwhile investment. But we also firmly believed that our children needed to learn important lessons regarding the value of money.

We had more than a few conversations with our children about loan fees, debt service, amortization, and the true costs of this money relative to their future earning potential. Had they chosen different professions, we would have had more reservations about the return on our investment.1 Lesson one: Count the realistic cost of incurring debt.

Partner Debt—Structuring the Payback The next lesson I personally learned about student debt came when we began bringing on associates and partners in our dental practice. Each of these fine young individuals brought with them six-figure debt, easily in the range that is recognized as the national average of dental graduates today.2 We had absolutely no concerns that they could service the debt with the potential income they would earn in the practice. But here was the sticky part. Because they didn’t have the necessary financial background (How many dental/medical students really do?), we felt this required a structured plan that would allow them to pay back their loans, begin to slowly enjoy the fruits of their labor, and prepare for future expenses— specifically buying into the practice, purchasing a home, etc. As with my children, we wanted our associates to understand their finances and have a plan to reach their fiscal potential while enjoying life professionally and personally. We made the decision to initially invest in our associates by providing them with the services of our financial team, which consisted of a financial planner/advisor, tax attorney, banker, and CPA. This gave them the organization and structure to begin their careers with a financial program they could follow. This plan also required them, early in their career, to be accountable to objective professionals. It didn’t matter if they retained these particular individuals moving forward, but it was important to me that they adopt a strategic plan from the outset, enabling them to make prudent fiscal decisions. From my perspective, having viewed their success over the last 12 years, I believe this early investment significantly paid off, both for them and for our practice. Lesson two: Adopt a plan to structure debt repayment and require accountability.

Millennial Debt—Mentoring the Millennials From my experiences described above and my opportunity to serve on the board of the American Academy of Pediatric Dentistry, I have become particularly interested, not only in student debt but the individuals accruing this debt—our millennials. Recently, having heard a presentation by two residents from California that focused on the attributes of their generation, I subsequently recommended that the AAPD create a task force on millennials. The task force produced an excellent document on millennials and early career professionals, including recommendations for

how the academy could assist these future leaders in their professional development. With debt and finances being a major issue young dental professionals face, the academy partnered with Social Finance, Inc. (SoFi) to specifically restructure student loan debt. Since the program was initiated at the end of 2015, approximately $37 million dollars has been refinanced, with an average amount per loan of approximately $215,000.3 In addition, the AAPD is developing a Finance 101 program for young members and residents that could help provide them with a sound fiscal basis as they begin their careers. If we can do a small part in producing a generation of financially savvy individuals, then that act alone may make them better dentists, freeing them to focus more clearly on caring for their patients and their families. Lesson three: Mentoring millennials and helping them establish a secure financial basis for success is important.

Manageable Debt—Facing the Future I have never been more excited about our pediatric dentistry specialty, the opportunities for private practice, or the future potential of our millennial generation. I believe this because even though their debt burden is high, I have seen how, with a structured fiscal plan in place, this debt can be managed and paid off while still allowing for a balanced lifestyle. Also, I have observed how many of our more mature pediatric dentists are willing to be mentors and advisors for the next generation. They do this through personal contact, involvement in various groups and study clubs, and participation in national professional organizations. Finally, I have witnessed how the AAPD has responded by developing programs and activities to assist our younger members as they begin their careers. For those of you who are just getting started or who are early in your career, my simple call to action is this, “Don’t go it alone!” Resources are available. Take advantage of them, and they will make your transition into practice easier and help you become more organized. And remember, as one of my mentors, Dr. Heber Simmons, told me, “It’s all about the kids.” Adopt this motto, implement it daily, and you’ll enjoy your career fiscally, professionally and personally.

References: 1.

Asch DA, Nicholson S, Vujicic M. Are we in a medical education bubble market? N Engl J Med. 2013 Nov 21;369 (21:1973-5).

American Dental Education Association. “Average Debt Among Graduating Students with Debt by Type of School. 1996-2016 (Current Dollars).” http://www.adea.org/data/seniors [Select “Debt and Tuition” and click on Table/Graph title.]

Personal Email communications with the AAPD and Social Finance, Inc., February 22, 2018.

YOUR FINANCIAL FREEDOM Loading…

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Did you know, for every minute after an arrest, your chances of survival decrease by 10 percent? Did you know, the average response time of paramedics across the USA is seven minutes? Did you know, early CPR and deďŹ brillation gives you the best chance for survival?

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This might come as a

k c o h

Should an Automated External Defibrillator Be Considered Optional Office Equipment? By Susan Marder RN, MSN, ANP-C

Statistics tell us that, in the United States, someone has a heart attack every 40 seconds.1 There are more than 350,000 out-of-hospital cardiac arrests (OHCA) among adults annually, and approximately 90 percent of those cases result in death. The incidence in children is approximately 7,000 cases annually. According to CDC mortality figures for 2017, one in every seven people died from sudden cardiac death (SCD).2 However, statistics are numbers—just hard, calculated figures. When we view the people represented by these numbers from a personal perspective, a story might be told of a dad or mom, son or daughter, husband or wife whose life was tragically lost due to SCD. Based on this perspective, the American Heart Association (AHA) introduced its newest slogan, “Life Is Why,” with the 2015 Guidelines Update for CPR and ECC, in order to draw attention to the human and humane side of SCD and the impetus to implement “The Chain of Survival” when such an event occurs.3

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It has been evident within the last few AHA guidelines updates that there has been a shift in the focus of resuscitation medicine, away from the perfect execution of appropriate interventions within the code event, to the best practices that will deliver the most timely and effective care to ensure survival. Indeed, the meaning of “survival” itself has been redefined—from being solely “the return of spontaneous circulation” to “discharge from the hospital neurologically intact.”3 Once again, referencing statistics, the current survival rate for adults with OHCA nationwide is 9 percent and for children is 8.2 percent, despite the availability of emergency medical services (EMS) systems, CPR training, and public-access defibrillation (although with limited accessibility).2 According to the AHA, a sudden cardiac arrest (SCA) event will most likely display ventricular fibrillation (VF) and/or ventricular tachycardia (VT) as the underlying rhythm. The definitive treatment for an SCA is early defibrillation. Thus, the major determinants of meaningful survival from SCA are the time from collapse to the start of CPR and the time of collapse to the first defibrillation.3 Figure 1 demonstrates that the earlier CPR and defibrillation are implemented the better the prognosis. CPR sustains a limited perfusion state that will keep core tissue oxygenated for

fail to receive delivery of oxygen and metabolic substances (caused by circulation deprivation) will begin to sustain damage after four minutes. The most common underlying rhythm state in SCA, ventricular fibrillation, causes cardiac cells to become depleted of adenosine triphosphate (ATP) in approximately 10 minutes. ATP is a nucleotide that is responsible for the storage and transport of chemical energy and allows for cellular metabolic activities. With ATP depleted and cellular function disrupted, attempts to convert the chaotic VF rhythm to an organized perfusion state with defibrillation will more likely result in asystole of a permanent nature.4

improved nearly 10-fold in Pittsburgh, Pennsylvania suburbs when police officers utilized AEDs as the first responders to an OHCA scene. AED usage by security personnel in casinos has documented a recent survival rate of 74 percent. Statistics recorded from Chicago-area airports show a 61 percent survival rate. A report generated from the Resuscitation Outcomes Consortium and funded by the National Institutes of Health stated that AED use doubled the likelihood of survival. Victims of OHCA who had early CPR and defibrillation delivered by willing bystanders had a survival-to-hospital-discharge rate of 36 percent as compared to the current standard of only 7 percent.4

It is important to understand that defibrillation does not restart the heart’s regular rhythm pattern; it essentially stuns and briefly terminates all electrical activity. If cardiac cells are viable, normal pacemaker and conduction activity may likely resume, leading to the return of spontaneous circulation (ROSC). However, for every minute that passes from the moment of SCA to defibrillation, the potential for a positive response to the shock declines by 10 percent. Research has shown that OHCA events that had a time-to-first-shock interval of < 3 minutes saw successful conversion to an organized rhythm and ROSC 95 percent of the time with that

An Unlikely Event— Perhaps The AHA’s Pediatric Advanced Life Support training course identifies two pathways to cardiac arrest in children: hypoxia/asphyxia and SCA. The hypoxic/ asphyxia-driven arrest states are typically characterized by asystole or pulseless electrical activity, which are not treated with defibrillation. Interestingly, even during those resuscitation events, VF/VT are likely to occur 27 percent of the time during the course of the resuscitation.13 Being that the typical instigating event

Initiating both CPR and defibrillation early in the arrest event has demonstrated a crucial positive impact on survival. a short period, but it does not convert the ventricular dysrhythmia to normal sinus rhythm. Defibrillation is required to restore an organized, perfusing rhythm. A delay in delivery, however, will lead to the deterioration of viable cardiac cells, ultimately resulting in the lack of successful conversion when the shock is delivered. Thus, initiating both CPR and defibrillation early in the arrest event has demonstrated a crucial positive impact on survival.

Facts and Physiology Research has clearly pointed out that the amount of time that passes from arrest to initiation of intervention greatly influences the ultimate chance for survival from the event. Neurons which 38

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first delivered shock.5 It is obvious, then, that there is a “narrow therapeutic window of opportunity” and one that, logistically, emergency medical services (EMS) personnel cannot work within, as that is an unrealistic response time in most circumstances. However, since the inception of automated external defibrillators (AEDs), the reported time-to-first-shock and resultant survival rates have been dramatically improved, due to defibrillation being immediately available and easily administered, ahead of arrival of EMS providers. For example, an initial study from the 1990s demonstrated that survival

for SCA is the sudden development of VF/VT, it is an uncommon scenario in pediatric settings.13 VF/VT are the presenting rhythm disturbances identified in only 7–10 percent of pediatric resuscitations as opposed to 75–80 percent of adult cases.6,7 Asystole and pulseless electrical activity are the most common arrest rhythms for children, especially in those under 12 years of age. Older children and children with underlying cardiac conditions are more likely to experience the ventricular arrhythmias.13 The most common causes of VF/VT in children are cardiomyopathies, channelopathies, and cardiac anomalies, as opposed to coronary artery disease and myocardial ischemia in adult cases.8

Figure 1

Exertional activity is the usual stimulus for VF/VT with cardiomyopathies and cardiac anomalies. With channelopathies the ventricular arrhythmia can be triggered by exercise, loud noise, stress, anxiety, pain, or the relatively bradycardic heart rate produced when the child is at rest or asleep. Maneuvers like the Valsalva may lengthen the QT interval, while intubation and extubation are concerning because they create a stimulus for ectopic beats that, in turn, may initiate a sudden ventricular arrhythmia.8,9 Ventricular tachycardia (VT) may also present as a tachyarrhythmia that still produces a pulse, but will ultimately threaten hemodynamic stability over time. Its occurrence may be related to hypoxia, hypovolemia, electrolyte abnormalities, and drug toxicities. If left untreated, VT with a pulse readily deteriorates into pulselessness and VF.5 A number of commonly used drugs have been identified as increasing the risk for VT, particularly if a channelopathy exists. Certain antibiotics, antihistamines, and

20 %

6min

Minutes to Defibrillation / A channelopathy is a disorder caused by a genetic mutation of a cardiac ion channel that increases the potential for arrhythmias. These mutations are present in 14–20 percent of pediatric SCA victims and are frequently inherited. A particular channelopathy, known as “Long QT Syndrome,” occurs in one in 2500–3500 people and is characterized by an abnormally prolonged QT interval.8 Prolongation of the QT interval on the ECG means the relative refractory period (also known as the vulnerable period) is extended, making the repolarization phase a somewhat precarious period. Any ectopic ventricular impulses, such as premature ventricular contractions (PVCs), occurring in the presence of a prolonged QT interval, can trigger a particularly lethal form of VT known as Torsades de Pointes.3

30 %

5min

40 %

4min

50 %

3min

60 %

2min

70 %

80 %

90 % 1min

Chance of Survival From Cardiac Arrest

7min

8min

10 %

9min

Potential for successful defibrillation in relation to collapse-to-defibrillation time intervals.

the anti-nausea drug, ondansetron, may exacerbate Long QT Syndrome. Various bronchodilators and sympathomimetics may be the instigator of a sudden ventricular arrhythmic event when there is an underlying prolonged QT interval.3 Several agents used for anesthesia and sedation, such as droperidol, Sevoflurane, Halothane, Ketamine have been shown to lengthen the QT interval as have preprocedure medications like atropine and succinylcholine.9

Making This Make Sense for Your Practice It is evident from the above discussion that a ventricular arrhythmia, as well as SCA, should be considered as a possible scenario in any pediatric dental practice, albeit a rare one. We are all acutely aware, in recent years, of the increased number of pediatric incidents in practice settings that have led to emergency interventions and/or resuscitations.10,14,15 The causes underlying these cases are diverse, but if VF/VT presented during any of these events, the only definitive intervention for the situation would be defibrillation. Experts assert that an AED should be readily available in any setting where the potential for ventricular arrhythmia exists, and that prevention of morbidity and mortality from a sudden medical emergency requires immediate and effective intervention, including timely defibrillation when needed.3,5,8,9,13 Recall that AHA’s basic life support courses, healthcare provider and lay level alike, train the responder in the proper use of an AED along with CPR technique. Both interventions are viewed as critical initial elements of a high-quality resuscitation effort.11,12 It is recognized as grossly unacceptable, if not negligent, to delay the initiation of CPR when circumstances arise in a professional healthcare setting. Would the same not hold true for a delay in delivering an

immediate shock from a defibrillator when warranted? In comparison, certification in Pediatric Advanced Life Support (PALS) represents possessing the knowledge and ability to recognize and manage both shockable and nonshockable cardiac arrest scenarios. 13 Possessing the ability to manage the scenario would imply having the appropriate medications and equipment to intervene as the training guidelines recommend. Would it be acceptable for a provider to declare they are PALS certified yet do not possess the necessary tools to manage all types of emergency situations that may occur? Could the same argument hold for Healthcare Provider CPR certification and the supplies recommended for those first few minutes of an arrest?

Playing the Odds It is clear that VF/VT and SCA are uncommon events in the pediatric population as a whole. However, unidentified underlying conditions, peculiar circumstances, and/or untoward drug interactions are factors that have been identified as contributing to an increased risk of their occurrence, even during routine dental office procedures. As a result, one of the more debatable issues among many providers is whether an AED is a necessary piece of equipment in an otherwise prudent office setting that cares for an average-risk pediatric dental patient. A myriad of facts and opinions have contributed to the ongoing debate. Financial, legal, professional, and ethical viewpoints are all equally compelling stances brought to the discussion. The following are some points for further consideration: • It is estimated that 25 percent of any and all pediatric sudden deaths could be prevented with early CPR and AED availability.8 www. sp r ig u sa.co m / Spr ing 2 018

of people congregate. Should not healthcare facilities follow suit?3,8,11,12

• Most young children do not have an ECG on file nor have they been previously exposed to sedation/ anesthetic agents, so the effects on them and their response to these drugs are essentially unknown. • Stimuli like sleep, loud noise, startling, and anoxia may lead to VT in patients with underlying (and possibly unidentified) Long QT Syndrome. • Immediate use of an AED may improve initiation of resuscitation in some cases, as the device is more sensitive to the signs of an arrest state than the initial assessment provided by some first responders.3

• Many states have enacted laws stipulating availability of AEDs in specific locations, including dental offices and facilities that administer sedation and/or anesthesia.16

• AEDs on the market today are easy to use and are available with a wide variety of functions and price tags; many designed for small offices and personal use are priced under $1,000.16

• Almost every state has laws in place that protect the owner of the AED and the individual who provides treatment with the device from liability.16

• Having an AED in the office may offer far-reaching, unexpected benefits, as it may save the life of a colleague, coworker, building mate, or community member.

• If there is an arrest event, use of an AED may protect the practice from a wrongful death lawsuit, regardless of the outcome. This protection may extend even to circumstances in which a victim is just on the premises and not the patient in the chair.17

• The determining factor for AED placement in public places, like malls and office buildings, is the calculated risk of one cardiac arrest per year happening or one AED use in a five-year period, for that location. Alternatively, the determining factor may be when a call-to-shock interval of < 5 minutes cannot be achieved by EMS for > 50 percent of SCA calls in that locale.3,4

• “Community expectations” and “reasonableness” may be more important than laws. Having an AED may be the expected standard of care due to known existing ADA recommendations, statutes in other states, and widely available CPR/AED/ emergency response training.17

• Realistically, EMS will not arrive at the scene and be poised to deliver a shock until 5–10 minutes (and sometimes longer) after the 911 call has been placed.

• The Journal of the American Dental Association (JADA) published an article in 2010 titled Preparing for Medical Emergencies, The Essential Drugs and Equipment for the Dental Office, that outlined critical drugs and necessary emergency equipment; the immediate

• It is widely advocated that AEDs be readily available wherever large groups

availability of an AED was discussed as an “evolving standard of care.”18

Concluding Thoughts From the public’s “reasonable expectation” point of view, a dental practice should have the ability to respond to medical emergencies and sudden cardiac arrest, especially when a patient is under sedation or anesthesia.17 From the professional’s point of view, what value would one place on an office practice, a provider’s career and reputation—or a life? Whether a dental practitioner is mandated by law, driven by an ethical imperative, reacting from personal experience, or just unwilling to gamble, an AED is destined to become a standard fixture in most all office settings.

REFERENCES 1.

American Heart Association. heart.org. Published January 11, 2018. http:www. heart.org/HEARTORG/Conditions/ HeartAttack/AboutHeartAttacks/AboutHeartAttacks_UCM_002038_Article.jsp#. WnZjRXxG2M8. Accessed February 3, 2018. 2. Newman MM. SafeBeat. Published February 1, 2018. http:safebeat.org/ newsroom/headlinesaha_releases_latest_ statistics_on_sudden_cardiac_arrest. Accessed February 3, 2018. 3. Cummins RO, Field JM, and Hazinski M. ACLS: Principles and Practice. Dallas, TX: American Heart Association; 2003. 4. Field JM, Kudenchuk PJ, O'Connor R, VandenHoek T. The Textbook of Emergency Cardiovascular Care and CPR. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. 5. Sinz E, Navarro K, Soderberg ES. Advanced Cardiovascular Life Support Provider Manual. Dallas, TX: American Heart Association; 2011. 6. Israel CW. Mechanisms of sudden cardiac death. Indian Heart J. 2014;66(Suppl 1):S10S17. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC4237287. doi: 10.1016/j.ihj. 2014.01.005. Accessed March 3, 2018. 7. Tress EE, Kochanek PM, Saladino RA, Manole MD. Cardiac arrest in children. J Emerg Trauma Shock. 2010;3(3):267-72. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2938492. doi: 10.4103/ 0974-2700.66528. Accessed March 3, 2018.

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10.

11.

12.

13.

14.

Gajewski KK, Saul JP. Sudden cardiac death in children and adolescents. Ann Pediatric Cardiol. 2010;3(2): 107-12. https:/ www.ncbi.nlm.nih.gov/pmc/articles/ PMC3017912. doi: 10.4103/0974-2069.74035. Accessed March 3, 2018. Fazio G, Vernuccio F, Grutta G, Lo Re G. Drugs to be avoided in patients with long QT syndrome: Focus on the anaesthesiological management. World J Cardiol. 2013;5(4): 87-93. https://www.wjgnet.com/1949-8462/ full/v5/i4/87.htm. doi: 10.4330/wjc.v5.i4.87. Accessed March 10, 2018. Bradford H. Dental Sedation Responsible for at Least 31 Child Deaths Over 15 Years. Huffington Post. July 13, 2012. http://www. huffingtonpost.com/2012/07/13/dentalsedation-child-deaths_n_1671604.html. Accessed March 11, 2018. Hazinski MF. Highlights of the 2010 American Heart Association Guidelines for CPR and ECC. Dallas, TX: American Heart Association; 2010. Hazinski MF, et al. Highlights of the 2015 American Heart Association Guidelines Update for CPR and ECC. Dallas, TX: American Heart Association; 2015. Chameides L, Samson RA, Schexnayder SM, Hazinski M, Ashcraft J. Pediatric Advanced Life Support Provider Manual. Dallas, TX: American Heart Association; 2011. Stiegler M. Why Are Kids Dying at the Dentist? Marjorie Stiegler, M.D.

Published July 2016. http://www. marjoriestieglermd.com/why-are-kids-dying -at-the-dentist. Accessed March 17, 2018. 15. Lee H, Milgrom P, Huebner CE, Weinstein P, Burke W, Blacksher E, Lantos JD. Ethics Rounds: Death After Pediatric Dental Anesthesia: An Avoidable Tragedy? Pediatrics. Published November 2017. http:// pediatrics.aappublications.org/content/ early/2017/11/03/peds.2017-2370. Accessed March 17, 2018. 16. National Conference of State Legislatures. State Laws on Cardiac Arrest and Defibrillators. Published January 3, 2017. http://www.ncsl.org/research/health/lawson-cardiac-arrest-and-defibrillators-aeds. aspx. Accessed March 17, 2018. 17. Ford D. Does a Dental Practice Have a Common Law Duty to Have an AED Available? Dentistry iQ. Published December 17, 2013. http://www.dentistryiq. com/articles/2013/12/does-a-dentalpractice-have-a-common-law-duty-to-havean-aed-available.html. Accessed March 18, 2018. 18. Rosenberg M. Preparing for medical emergencies: The essential drugs and equipment for the dental office. J Am Dent Assoc. 2010;141(5suppl):14S-19S. http:// jada.ada.org/article/S0002-8177(14)63474-7/ pdf. Accessed March 24, 2018.

DR. MANDYâ&#x20AC;&#x2122;S DREAM: It all starts with a dream. The only question is, are you going to think about your dream or are you going to live it? BELIEVE IN YOURSELF

With a vision and hard work, the sky is the limit to the heights your practice can reach.

FROM RESIDENCY TO REALITY My Journey to Independent Practice Success

by MANDY ASHLEY, DMD, MSEd, MS Shortly before finishing your pediatric residency, several doors of opportunity may open for you. You might be tempted to accept an associate position and receive a guaranteed salary with a generous benefits package. Or you may opt to take the initiative, build your own office, and create the practice you know you will love. I chose the second option.

CALCULATING THE START-UP COSTS. I know that crushing student loan debt can limit your potential to qualify for a large start-up business loan. When I finished my pediatric dental residency in 2012, I had already worked as a general dentist for 11 years and had no student loan debt. With the modest collateral provided by my house, I qualified for a $618,000 start-up loan from Bank of America. In Kentucky, that provided me with 3,000 square feet of leased space and a five-operatory office. In my experience, due to the initial expense of

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purchasing quality dental equipment such as a digital x-ray machine and the Nomad handheld x-ray, it would be difficult to start even a small two-operatory pediatric dental practice for less than $400,000. But creative options are available. One option is to lease space on Fridays in an existing dental practice while working in an ambulatory surgery center another one or two days a week. This choice may result in start-up costs of $100,000 or less.

FINANCIAL LENDING IS CRUCIAL IN BUILDING YOUR OWN OFFICE. I think anyone interested in starting their own practice and building their own office should start by visiting local banks and also talking with national lenders familiar with start-up dental lending. You need to have a realistic idea of what you can borrow before spending time and money for design fees and construction plans.

Keep in mind, after you have secured your start-up loan, you have three main choices for the design and construction phase of the process. One option is to use a dental company like Patterson or Schein to create your design. Just be aware that these companies are in the business of selling dental equipment. Alternatively, you could also use a builder with an in-house design department. However, remember that they need to understand in detail the unique needs of a dental office, specifically the regulations relating to nitrous and oxygen (med gas) lines applicable in your state. I chose a third option and hired a dental architect who drew a great set of detailed MEP (mechanical, electrical and plumbing) plans, including interior design for a 3,000-square-foot starter office. I bid these plans out to four contractors in my town and got a variance of $100,000 between bids. I went with a smaller, newer firm that had just finished their first dental office. I most definitely made the right choice. I used the same firm for my second office and now am designing my third office with them as well. Here are some tips I learned along the way that may make your journey easier.

BUILD YOUR VIRTUAL OFFICE BEFORE YOUR PHYSICAL ONE. Prospective parents learn about you through your online presence. Your website should be well designed and easy to use on a mobile phone. Offer a secure patient-registration portal that ideally feeds directly into your electronic patient record system. Build a Facebook community by using FB business tools such as promoted targeted posts and contests. I had my website and FB business page up and running a few months before our office doors opened. I was able to create online interest in the practice and register patients in advance, so that when we opened, we were booked solid for the first couple weeks. I would suggest opting out of allowing parents to select their own appointment times. Many nuances in pediatric dentistry must be factored in when choosing the best time to schedule each patient. I would suggest you retain

control over the appointment times offered and have your staff help coach parents, explaining why certain select times are offered. Who really wants to end their happy work day doing two pulps and SSCs on a 3-year old child?

BUILD LOW-COST, HIGH-RETURN “BABY SMILES” ROOMS. These non-traditional spaces are geared towards treating kids up to 4 years old who may not be ready for a traditional dental chair. You can turn a 16-squarefoot space into a great area to do a D0145 CAMBRA oral evaluation for a patient under 3 years of age while counseling with the primary caregiver. In my offices, I have five rooms each with a unique design feature—a starry sky, a playhouse with a window, a jeep, a John Deer tractor, and a climbing caterpillar. Each room provides a comfortable area for parents to sit. We use a lighted mirror, a cordless prophy angle, and lots of tell-show-do activities to introduce kids and their families to caries risk factors on their first dental visit. Since these rooms do not have traditional dental chairs or handpieces, they cost on average about $1,000, rather than the cost of over $10,000 per room required to furnish traditional treatment areas.

BE PREPARED FOR PEOPLE NOT TAKING YOU SERIOUSLY. Depending on where you locate your practice, this tip may be especially true if you are a woman, and even more so if you are a mom. I am an outspoken, board-certified, self-made entrepreneur with four children age 10 and under. I was grossly underestimated by my peers in terms of how fast my practice would grow and how determined I was to succeed. This underestimation even carried over into the construction process. Some days, I resorted to bringing my husband, a biology professor and a wonderful man (but not a “handyman” by any stretch of the imagination), down to the

job site to raise a ruckus and make the “final decisions” regarding some construction issues. I did this because some guys on the job just were not used to building for a woman. I might have felt a little underappreciated after all of the education I have obtained and all the blood, sweat and tears that went into the design and building process. But in the end, there comes a time when you just need to get the job done so you can open the doors to your practice and get on with life. My advice to residents or others considering whether to construct a new office building is this. Use whatever resources you have available to help get the job done. Bring your loud dad, your linebacker cousin, or whoever you have that is big and intimidating to your job site, and have them help you accomplish your dream and get your office built.

BE PREPARED FOR EMOTIONAL FREAK-OUTS TO HAPPEN. Make sure the people who love you, like your spouse or your parents, are also ready to support you when you freak out. It is really scary to open the doors to your new office and wait for the insurance and Medicaid gears to creak into action as you try to make your first payroll with $3.22 to spare. About two months into my new practice, the cash balance was so tight that I was balancing my practice account nightly, holding vendor checks until the day before they were due to make sure they didn’t bounce. I remember asking my husband, “When do you think Rumpelstiltskin will stop by to pick up our firstborn child?” Getting your practice off the ground is financially frightening, but if you have a little cushion built into your practice loan—an amount called “working capital” that can get you through the first few payroll periods (not paying yourself!)—you will be better able to sleep at night.

Facebook made the IBuild mostadeﬁnitely community byIusing right choice. usedFB the same ﬁrmtools for such my second business as ce and targeted now amposts opromoted designing my third o ce and contests. with them as well. www. sp r ig u sa.co m / Spr ing 2 018

GETTING DOWN ‘N DIRTY

Dr. Mandy isn’t afraid of getting involved onsite. She recommends at least weekly visits to the construction site for the best outcome.

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VIRTUAL REALITY

Sky Pediatric Dentistry is excited to open their third location in 2019.

FROM THE AIR

A bird’s-eye rendering of the facility and parking lot.

appointment. Such parents may not schedule a specific time for their next appointment. They must call after 9:00 am any day they have transportation available, and, if we have an opening from a cancellation, we will fit them in. This practice resets their no-show status, and if they arrived on time, they can schedule a date and time for their child’s next appointment.

YOU SHOULD SET POLICIES TO MAKE MEDICAID WORK. Please consider adopting policies right from the beginning to help parents place a high value on their children’s dental appointments at your office. This will dramatically limit their noshows. Because of my experience as a public health dentist in Alaska, I remain personally committed to serving the underserved. At least here in Kentucky, a large percentage of the traditionally underserved community qualifies for Medicaid benefits. I have developed a three-pronged approach to limiting Medicaid noshows to fewer than 15 percent. Our first approach is to inform parents about our “No-show Policy” and make sure they have an appointment date and time that works for them. If they cannot make an appointment, we don’t ask for anything more than just calling us prior to 9:00 am that same day. The second tactic we employ is offering only “same day scheduling” to parents with Medicaid who have either been more than 15 minutes late or who have been a no-show at a previous

The third step is using dismissals. If a child has no-showed and the parent did not call within 24 hours of the no-show, we send a letter informing the parent that they have 30 days to call, text, email, or just come by the office and let us know they would still like their child to be our patient. After the 30-day window closes, we are no longer the child’s dentist until custody changes (foster care or grandparents given legal rights, etc.). By using these simple tactics, we are able to limit Medicaid no-shows. At the same time, I believe we are teaching parents how to better value their child’s dental appointment. If you are on the fence facing a choice between accepting a terminal associate position or starting your own practice, I hope this article nudges you toward making a decision to start your own practice. There is a reason why so many practice owners, myself included, are gratified we made the right decision. We set our own schedule, we know who we work for, and we can set our own goals to practice at the highest level possible. And hey, if I can jump in and do it, with my four young kids, you’ve got this!

PLANNED TO PERFECTION

Sky Pediatric Dentistry’s new facility is 8,000 sq. ft. and designed to treat patients in an environment that is friendly and comfortable for both children and their parents.

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Youâ&#x20AC;&#x2122;re Hired! Maximizing the value of residency in preparation for your transition into private practice.

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Primary Childrenâ&#x20AC;&#x2122;s Hospital Salt Lake City, Utah

by Brett Packham, DDS

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ow I Transitioned From Pediatric Resident to Attending I still remember the emotions of excitement and nervousness as a dental student, exploring a number of pediatric dental programs and struggling over a decision of which ones would be best to apply to. I vividly remember the morning when the “match” was announced. What a feeling of relief when I discovered I had been accepted to the program of my choice at Primary Children’s Hospital in Salt Lake City—my hometown. Since the program was hospital-based with only three residents, we enjoyed the opportunity of frequent hands-on training. This was a huge benefit and enabled me to treat over 200 children in an operating-room setting, improving my skills and speed. This also helped me to make the transition to private practice more smoothly. One of my favorite things about my residency training was working with multiple private-practice attendings who shared their experiences “in the trenches.” Interacting with them, I found that there are many ways to be a successful pediatric dentist, including both the behavior management options we adopt and the treatment techniques we utilize. It was awesome to learn from each attending and then create my own style and employ my own methods that have allowed me to experience excellent outcomes with my little patients. Shortly after finishing my training, I recall my decision to apply to be an attending dentist in the very program I had recently completed. My goal was to provide just as amazing an experience for the current residents as my attendings had given to me. And now, on the other side of this full circle—having become a private-practice attending dentist myself—I not only enjoy teaching and learning alongside our residents, but I also view them as potential associates in my own practice and future colleagues in this amazing specialty.

Why Choosing a Hospital-based or School-based Residency Matters Choosing what residencies to apply to can be a daunting task. You face so many important decisions. Will it be a hospital-based program or a school-based program? Will it emphasize strong clinical training or give preference to strong research and educational components? Some of us are “hands on” learners and thrive in a clinical setting, while others learn best through a deeper understanding of the principles and concepts taught in a classroom or research environment. Sometimes you may not realize what your learning

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style is or which type of program will benefit you the most until you interview and see if a specific program appears to be a good fit for you. Hospital-based programs typically have a very strong clinical component due to higher patient counts and less time spent in educational settings such as classrooms or research labs. All residency programs will be required to provide a certain amount of education and research in order to prepare residents for their pediatric dental boards. A school-based program very often has a strong academic and research component but may dedicate less time to the clinical side of training. Once again, all training programs meet minimal requirements for providing clinical experience. Thus, all residents will receive the training needed to pass their boards regardless of the type of program they choose. In fact, many programs provide a combined emphasis on both clinical experience and education, providing access to hospital dentistry as well as the school-based classroom setting. For many residents, this combination provides the best of both worlds.

Other Criteria for Choosing a Residency Program Finding a program that is never complacent and always looking to improve their residents’ clinical abilities is one of the key factors to consider when choosing where to apply. Look for a program that emphasizes new technology and high exposure to many dental materials and current, cutting-edge techniques. Currently at Primary Children’s Hospital, each resident treats over 200 patients in the operating room during their two-year residency. Many of these cases have severe early childhood caries which involve all four maxillary incisors. Nearly every one of those cases is treated with Zirconia crowns, and our residents finish their training very proficient in placing these crowns. This competency will be a huge asset as they transition to private practice. Residents also receive extensive training in four different areas of sedation: nitrous oxide, oral sedation, IV sedation, and general anesthesia. This training is invaluable as it enables a resident to better understand patient management in each area. Residents are also trained to develop treatment plans for patients that will ensure the safest and most successful approach to treatment.

One of my favorite things about my residency training was working with multiple privatepractice attendings who shared their experiences “in the trenches.”

Intermountain Primary Children’s Hospital on the University of Utah Campus

Hans C. Reinemer, DMD, MS DIRECTOR OF THE PEDIATRIC DENTAL RESIDENCY PROGRAM AT PRIMARY CHILDREN'S HOSPITAL SALT LAKE CITY, UTAH

A MESSAGE FROM THE PROGRAM DIRECTOR As director of the pediatric dental residency program at Primary Children’s Hospital in Salt Lake City, my goal is to provide our residents with an exceptional clinical experience in all aspects of the specialty. We introduce residents to the practice of restorative dentistry, utilizing the latest techniques and materials for the treatment of early childhood caries. Although we continue to teach and practice evidence-based dentistry, we also recognize that new materials and methods are changing the face of pediatric dentistry. This training intentionally includes experience in the use of a variety of composites, RMGI’s, bioactive restorative materials and cements, MTA for pulpal therapy, and the placement of Zirconia crowns. In our program, we treat large numbers of children presenting with a great variety of conditions and we have the option of treating them in different ways. Exposure to the future-altering advances in pediatric restorative dentistry is vitally important for the modern training of all residents. In harmony with this belief, we encourage all of our residents to gain experience in using the most up-to-date treatment methods and materials in order to better prepare them for their transition into private practice.

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THESE PAGES: Dr. Andy Ingersoll, a second-year resident at Primary Childrenâ&#x20AC;&#x2122;s Hospital, joins his attending, Dr. Brett Packham, at his o ce to discuss what opportunities might be available in the transition from residency to pediatric private practice.

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â&#x20AC;&#x153;

I not only enjoy teaching and learning alongside our residents, but I also view them as potential associates in my own practice and future colleagues in this amazing specialty. Brett Packham, DDS

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RESIDENT ON THE COVER

“

Before attending my pediatric dental residency, I had been practicing as a general dentist for several years. In addition to the enjoyment I experienced while working with kids, I decided to take additional residency training for two basic reasons. My first reason was I wanted to become familiar with the most current research data so that I could make evidence-based recommendations for the patients I treated. The second reason was that I wanted to offer the most up-to-date treatment alternatives which I would learn about through extensive clinical experience at an institution that was providing cutting-edge treatment options. The Primary Children's Hospital pediatric dental residency program in Salt Lake City provided me the opportunity to reach both of these objectives. The residents in this hospital-based program gain extensive clinical experience in all sedation methods and a variety of restorative options. Our experience in restorations included training in the use of a variety of composite and RMGI restorative materials, bioactive restorative materials and cements, MTA for pulpal therapy as well as the restoration of primary teeth with pre-veneered stainless steel crowns and Zirconia crowns. As a former practice owner, I cannot overstate the value of a dentist being prepared for private practice, trained in all facets of modern dentistry. Being ready to "hit the ground running" gives me a definite edge over other graduating residents who may not have experienced the same level of practical training. Andy Ingersoll, DDS

Resident, Primary Children’s Hospital

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Another strength of our residency program is that it provides an opportunity for our residents to come to private dental offices and observe how their attending dentists actually run their own practices. During these “shadowing” days, residents learn practical tips about marketing, practice flow, management style, behavioral management, and many other things that make each practice unique and successful. When I was a resident in this program, my “shadowing” experience provided some of the most memorable and enjoyable times of my training. Other important items to consider when choosing a residency program include the following. Where is the program located? What is the call schedule like? Is a stipend provided? But have you ever considered what it will be like at the end of your training and what your future employer may be looking for?

What Offices Look for When Hiring a New Associate Typically, private practice pediatric dental offices are fast-paced, seeing a high volume of patients. When a new associate arrives, a transition period is always necessary. During this time, a newcomer adjusts to the flow of the practice and works on getting up to speed. If the new associate received a lot of experience working with a variety of patients during residency, then that transition is usually much smoother for both the practice and the new dentist. It is also a huge positive if a new associate has been trained using multiple sedation options and is proficient in using a variety of materials. When this is the case, a new associate’s experience adapting to a new practice environment is much easier. One of the more important things I have found over the years when hiring new associates is the ability of the new dentist to integrate quickly into my practice. This requires high-level clinical skills and familiarity with or expertise in both the latest dental materials and the newest technology. For example, in my practice the ability to place Zirconia crowns is paramount. I have had associates who only learned strip crowns in their residency programs. As a result, we had to train them how to use a new technique when seating Zirconia crowns. Due to this deficiency in their residency training, the transition was slow. It required increased treatment times for the patients which, in many ways, increased their cost, particularly if treatment was provided under sedation. As a result, the practice was less productive during such a transition time. On the other hand, we have had associates hit the ground running because their residency training included experience using these crowns. The practice never skipped a beat. If a new associate has trained with Zirconia crowns in residency, that is a huge benefit to both them and to my practice. At times, we have had such well-trained associates that they are qualified to teach both doctors and assistants the latest techniques they learned in residency. We have benefited from their instruction in the use of such items as Isodry, SDF, and the Hall technique with stainless steel crowns.

Coming Full Circle Just 10 years ago, I finished my pediatric dental residency. The time has passed quickly, and a lot has happened. Following graduation, I went on to establish my own private practice. I have definitely come full circle, now that I find myself hiring new associates that are in the same boat I was in just 10 short years ago. My perspective on the whole process involved in training new graduates to become successful private-practice pediatric dentists is now much better informed. My advice to dental graduates applying to a residency program? Remember, this is a time to grow and improve the skills required in your dental specialty. Apply to a residency program that will both fit your personal needs and help you get a jumpstart on establishing a successful career. A wise residency choice can make you a very desirable candidate when applying for elite associate positions around the country. I also have a challenge for all residency programs. Take a moment and evaluate the level of training we are providing to residents. Are we providing just enough to meet the minimum standards required to train our future colleagues and leaders? Or are we giving them everything our programs can possibly offer and preparing them fully for the adventure of private practice and the opportunity to serve their communities? The future of pediatric dentistry is bright; let’s be intentional about making it as bright as it possibly can be!

At this stage of my career, I find special meaning in the phrase “coming full circle.” A decade ago, I was a resident. Today, I hire residents. Brett Packham, DDS

Attending at Primary Children’s Hospital & owner of Kids Town Pediatric Dentistry

Many times, recent graduates have had experience with different oral sedation regimens that they have shared with us, helping us improve or modify our current practice. When well-prepared new associates join our practice, their arrival provides us with great learning opportunities. They have just been exposed to much of the latest research and the most recent information dental education has to offer and are able to share this knowledge with our office staff.

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SDF ILVER

IAMINE

LUORIDE

With so much buzz about SDF, will it really become the next gold standard? By Travis Nelson, DDS, MSD, MPH

What

Silver diamine fluoride—Ag(NH3)2 F / SDF—and its predecessor silver nitrate have been used by dentists around the world for decades to arrest dental caries.1 In the US, 38% SDF first became available in the spring is SDF and of 2015. Since then it has been widely adopted and become the topic of extensive discussion in the dental community and popular press. While other fluoride products are indicated for caries prevention, the FDA has awarded SDF breakthrough therapy status as the first drug to treat severe early childhood caries.2

How Does it

Work?

SDF has antimicrobial and remineralization properties. The exact mechanism of action is not fully understood. However, researchers theorize that carious lesions are arrested because cariogenic bacteria are killed by the silver compounds, and fluoride ions strengthen the tooth. When SDF is applied to caries lesions, a precipitate of Ag3PO4 forms on the softened dentin. This black insoluble “crust” reduces the impact of acid challenges and increases dentin hardness.3, 4 SDF is indicated for treatment of caries in teeth that do not have symptoms of irreversible pulpitis or infection. The literature suggests SDF can arrest up to 80 percent of lesions in primary teeth. Another very exciting finding is that patients who have received this treatment show an over 50 percent decrease in new lesions.2

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Silver Diamine Fluoride in Pediatric Practice

Limitations of

Effectiveness. When used properly, SDF can be very effective for managing dentin lesions. Arrest is relatively predictable in primary anterior teeth, but caries in posterior teeth are less accessible and more difficult to isolate. Achieving arrest in these areas is significantly more challenging.6 SDF is also not appropriate for treating pulpally involved teeth and odontogenic infection. Similarly, it does not restore form and function to the oral complex. At present, by the time many patients reach the dentist, they already have severe tooth breakdown and pulp involvement that may be best managed with traditional operative care. What’s more, SDF isn’t completely effective. Even the most promising studies suggest that SDF is ineffective for at least 20 percent of teeth. Practitioners with real-world experience recognize that some teeth never fully arrest and may eventually fracture or develop abscesses.

SILVER

Used?

DIAMINE

SDF can be used to arrest caries in young children who are unable to cooperate for conventional restorative care, children with special needs, and those who are medically fragile. It is also increasingly seen as a minimally invasive option for avoiding or postponing conventional restorative care. Treatment protocols are evolving, but today’s best evidence suggests that SDF should be applied at least twice annually to maintain arrest. Currently, many practitioners suggest an initial application, a three-month follow-up, and a semiannual reapplication thereafter.5 Anecdotally, others suggest a more intensive 2—4 applications within weeks. Considering the frequency of follow-up that is needed, SDF is most effective when implemented as part of an ongoing caries management plan within the context of regular dental visits. This therapy is generally not well suited for children who only access care periodically, though international aid groups and others have used it in this way.

How Is SDF

FLUORIDE

Ag(NH3)2F

Members of the dental community are highly polarized on the issue of SDF use. Some practitioners have gone so far as to suggest that performing traditional restorative dentistry with sedation/general anesthesia (GA) is no longer the current standard of care,7 having been replaced by SDF treatment. On the other hand, traditionalists resist its use, suggesting that: 1) parents do not accept the cosmetic discoloration from SDF, 2) a decision to leave decay in the mouth is irresponsible practice, and 3) chronic disease management protocols are not likely to be accepted by parents. These all-or-nothing approaches are confusing for parents and practitioners alike, and they lead to further problems for children who are under or over treated. It is possible to embrace SDF as one of the cornerstones of practice while continuing to leverage restorative skills that we have honed over decades to alleviate pain and restore smiles in our patients.

Weighing Treatment Options:

Ethical and Practical Considerations The principle of autonomy in biomedical ethics states that healthcare providers have an obligation to create conditions that allow patients to make their own informed choices. Clinicians must thoroughly explain the risks, benefits, and limitations of a procedure. Unfortunately, no perfect treatment for early childhood caries (ECC) exists, so compromise is inherent in this discussion. To arrive at the best

possible treatment for each individual patient, we must assess the needs of the children and their parents within the context of our own clinical skill set. (Figure 1) The child’s age and health status are the first things to consider. Very young children and those with medically complex conditions are often unlikely to cooperate for restorative care. They may, therefore, require pharmacologic behavior guidance in order to effectively restore their caries. Unfortunately, these children are at greater risk for adverse outcomes under sedation and GA. There is also concern that early and repeated exposure to sedation and GA may negatively impact neurologic development. Consequently, in 2017, the US FDA issued a statement warning that sedation and GA should be avoided in children under age 3, unless the procedure is medically necessary.8 SDF offers an effective method of delaying or avoiding pharmacologic treatment in this at-risk population.

Child

Needs:

Disease severity and time to tooth exfoliation must also be taken into account. Teeth with extensive lesions that compromise tooth function and those with deep lesions approximating the pulp should be considered for restoration. While we as clinicians do not always prioritize a child’s selfimage, we should consider this matter more thoughtfully. Reasonable evidence suggests that preschool-aged children with discolored, fractured, and missing teeth experience significantly more sadness and negative feelings about themselves than children with healthy dentitions.9 We also know that quality of life for children and their caregivers improves after oral rehabilitation.10

Figure 1:

PARENT DESIRES

Factors to consider when determining treatment options for early childhood caries.

Pain free Zero risk Low cost Esthetic Fewer Tx visits Minimal maintenance

DENTIST SKILL SET Restorative experience Sedation General anesthesia

*No Treatment Option

Satisfies All

Criteria. 56

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Treatment Options* • • • • •

Zirconia Composite Hall SSC ITR SDF

CHILD NEEDS No pain/infection Positive experience No fear

Silver Diamine Fluoride in Pediatric Practice

“Today’s practitioner has more good options available to address children’s dental needs than ever before.”

SILVER DIAMINE FLUORIDE

38% For most parents, the ideal treatment would be low cost, pose zero risk, cause no discomfort, be esthetic, and not require a large time commitment on the part of the family. In reality, no treatment plan offers all these things. Practitioner surveys indicate that today’s parents often have unrealistic expectations for their child’s dental treatment and that social media in our culture has created significant societal pressure for families.11 Millennial parents report significant anxiety over how others judge their children and their parenting decisons.12

Parent

Desires:

Perhaps these factors are part of the reason that in one study only 30 percent of US parents found photographs of discoloration from SDF in primary anterior teeth to be acceptable or somewhat acceptable. Interestingly, approximately two thirds of respondents in this same study found staining acceptable if that treatment was necessary to avoid GA. One third reported that the discoloration was unacceptable under any circumstance. Parental perception is mediated by education, income, and ethnicity, so it is important to consider cultural and individual factors in decision making.13

Our own experience and familiarity with materials and techniques affects which treatment options we will feel comfortable offering to our patients. A wise observer has noted, “If all you have is a hammer, everything looks like a nail.” In this scenario, both restorative treatment with sedation/GA and caries management with SDF are powerful and effective tools. Our obligation as experts is to incorporate these methods and others as part of a comprehensive toolkit. We then use our skills judiciously, as indicated by the extent of the disease, the child’s needs, parental preferences, and individual community standards to decide which tool is best to use in a given situation.

dentistry and photos by

Levi Palmer, DDS Chico, California

While some evidence seems to suggest that parents are opposed to pharmacologic behavior guidance, longitudinal surveys indicate that today’s parents are even less tolerant of strong-handed behavior management than past generations. As a result, they are more likely to accept procedural sedation and GA for treatment.14, 15 Accordingly, in North America we have seen an increase in pharmacological management technique use.16, 17 While relatively well accepted by many parents, we are now seeing increased scrutiny of procedural sedation and GA by the media and the medical community.18 It is, therefore, incumbent upon practitioners to reserve pharmacologic behavior guidance for children with dental needs that cannot be treated effectively using other methods. Today’s practitioner has more good options available to address children’s dental needs than ever before. SDF and other minimally invasive methods allow us to prevent decay and treat early carious lesions. Through pharmacology, we have the ability to safely and atraumatically offer beautiful restorations, extractions, and space-maintenance procedures for children who need them. This leaves patients free from dental fear and sets them on course to enjoy a healthy dental future.

Dentist

Skill Set:

TOP PHOTO: ECC ﬁrst treated with SDF. BOTTOM PHOTO: Complete arch later restored with Zirconia EZCrowns. Early treatment with SDF is highly effective in arresting damaging decay while allowing time for the child to grow and further mature, before ﬁnal restorations are placed.

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Best Used With a

Where Itʼs Found

Balanced Approach

References

Indiscriminate use of SDF will result in unequal distribution of societal resources and health outcomes that ignore patient autonomy. On the other hand, our ability to successfully treat caries with restorative methods has significant limitations, and sedation/ GA come with real risks. In this context, we must redouble our efforts to ensure that all children have access to: 1) dental care from their first birthday, 2) effective emergency services when needed, and 3) high-quality dental restorations when indicated. This goal can only be achieved by focusing on prevention and caries arrest protocols from a very early age. The result will be fewer children who have cosmetically objectionable SDF staining and less need for complex surgical care.

We live in an exciting time to be practicing dentistry. We now have at our disposal an effective, low-cost treatment for early lesions, and we can deliver highly esthetic and predictable restorations when indicated. SDF is already changing the dental landscape and the way we approach the practice of our profession. Our challenge is to use it in ways that improve safety, parent and patient satisfaction, and overall health outcomes.

2. 3.

Disclosure: Dr. Nelson is a consultant with DMG, a dental materials manufacturer.

Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: A caries “silver-fluoride bullet.” J Dent Res. 2009;88(2):116-25. Horst JA. Silver fluoride as a treatment for dental caries. Adv Dent Res. 2018;29(1):135-40. Mei ML, Chu CH, Lo EC, Samaranayake LP. Fluoride and silver concentrations of silver diamine fluoride solutions for dental use. Int J Paediatr Dent. 2013;23(4):279-85. Mei ML, Ito L, Cao Y, et al. Inhibitory e ect of silver diamine fluoride on dentine demineralization and collagen degradation. J Dent. 2013;41(9):809-17. Crystal YO, Marghalani AA, Ureles SD, et al. Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs. Pediatr Dent 2017;39(5):135-45. Llodra JC, Rodriguez A, Ferrer B, et al. E cacy of silver diamine fluoride for caries reduction in primary teeth and first permanent molars of school children: 36-month clinical trial. J Dent Res. 2005;84(8):721-24.

dentistry and photos by

Travis Nelson, DDS, MSD, MPH Seattle, Washington

TOP LEFT PHOTO: ECC prior to treatment. TOP RIGHT PHOTO: EEC after treatment with SDF. BOTTOM LEFT PHOTO: ECC after treatment under general anesthesia using Zirconia EZCrowns. BOTTOM RIGHT PHOTO: ECC after treatment using SDF and Hall crowns.

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Silver Diamine Fluoride in Pediatric Practice

10.

11.

12. 13.

14.

Lee H, Milgrom P, Huebner CE, et al. Ethics Rounds: Death After Pediatric Dental Anesthesia: An Avoidable Tragedy? Pediatrics 2017;140(6). pii: e20172370. doi: 10.1542/peds. 2017-2370. Andropoulos DB, Greene MF. Anesthesia and developing brains —Implications of the FDA warning. N Engl J Med. 2017;376(10): 905-07. Soares FC, Cardoso M, Bolan M. Altered esthetics in primary central incisors: The child's perception. Pediatr Dent 2015;37(5):29-34. Jankauskiene B, Narbutaite J. Changes in oral health-related quality of life among children following dental treatment under general anaesthesia. A systematic review. Stomatologija. 2010;12(2):60-64. Adair S, Waller J, Schafer T, Rockman R. A survey of members of the American Academy of Pediatric Dentistry on their use of behavior management techniques. Pediatr Dent. 2004;26(2): 159-66. Kathy S. Help! My Parents are Millennials. Time. October 26, 2015. Crystal YO, Janal MN, Hamilton DS, Niederman R. Parental perceptions and acceptance of silver diamine ﬂuoride staining. J Am Dent Assoc. 2017;148(7):510-18.e4. Patel M, McTigue DJ, Thikkurissy S, Fields HW. Parental attitudes toward advanced behavior guidance techniques used in pediatric dentistry. Pediatr Dent. 2016;38(1):30-36.

15.

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Eaton JJ, McTigue DJ, Fields HW, Jr., Beck M. Attitudes of contemporary parents toward behavior management techniques used in pediatric dentistry. Pediatr Dent. 2005;27(2):107-13. Schroth RJ, Pang JL, Levi JA, Martens PJ, Brownell MD. Trends in pediatric dental surgery for severe early childhood caries in Manitoba, Canada. J Can Dent Assoc. 2014;80:e65. Meyer BD, Lee JY, Casey MW. Dental treatment and expenditures under general anesthesia among medicaidenrolled children in North Carolina. Pediatr Dent. 2017;39(7):439-44. Chicka MC, Dembo JB, Mathu-Muju KR, Nash DA, Bush HM. Adverse events during pediatric dental anesthesia and sedation: A review of closed malpractice insurance claims. Pediatr Dent. 2012;34(3):231-38.

Six Helpful Tips: How to Best Use SDF in Your Practice.

Purchase SDF through Elevate Oral Care—currently the only source of SDF in the US.

Obtain written informed consent before SDF application.

Use color photos to demonstrate post-SDF appearance to parents.

Bill using CDT code D1354.

SDF stains tissue, clothing, and equipment. Be careful not to spill!

Plan for regular follow-up and repeat SDF applications.

TOP PHOTO: Severe ECC, upper incisors and 1st primary molars requiring extractions. BOTTOM PHOTO: Cuspids restored with Zirconia EZCrowns, posteriors restored with crown/loop SSCs.

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Asking Why

By Andrea Igowsky, DDS

How I rekindled my passion for pediatric dentistry.

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After being in private practice seven years, I found myself often in a reflective mood asking the question, “Why?” Why pediatric dentistry? Why Zirconia crowns? I also started posing this question to attendees at Sprig University courses where I lecture. I think this question is an important one each of us should ask ourselves if we expect to continue to grow and become successful in our careers. Following four long years in dental school and two even longer years in residency training, we are all eager to start working. By the time we have invested that much time and expended that much effort, earning money and making our mark professionally are the activities that initially grab our attention. However, once in daily practice, we then quickly begin to realize that pediatric dentistry is indeed hard work, confronting us with challenging situations. We face exhausting behavior management issues, the unrealistic expectations of demanding parents, and the stresses of building a practice, and the need to foster office morale, hoping employees will love our practice just as much as we do. We also provide the same routine five procedures (sealants, fillings, crowns, pulp therapy, extractions) day in and day out. I’ve heard way too many colleagues after only a few short years of practice share their frustration, saying, “I’m burned out.” Well, I became determined not to let that happen to me. So, I started taking a serious internal inventory and asking myself the central important question, “What will my response be to the ‘why' question?” Eventually, I arrived at the following conclusions.

Why pediatric dentistry? I discovered my answer—because I want to connect with people. I want to get to know them and understand why they chose me to care for their children’s teeth and overall oral health. When we make meaningful connections with people, we become a part of their medical team. They trust us to educate them about the best available treatment options and then provide the best care possible. We develop a team approach which carefully coordinates the parents’ wishes and needs, the child’s best interest, and our skills and expertise. Our emphasis is no longer focused simply on fixing a cavity, but on providing patient-centered care. I find that parents are much more willing to trust me and accept my treatment recommendations when they feel that they are respected, listened to, and play a valued role in developing an overall philosophy of care. If you don’t make these personal connections with the parents of your patients, then your practice easily lapses into a daily routine of just “drilling and filling.” And when that happens, we may be tempted to dwell on discouraging doubts and mull over feelings of burnout.

Why Zirconia crowns? For me it’s about how our products and services will improve the lives of the children we treat. As professionals, we instinctively understand why a baby tooth needs a crown. But this need isn’t always easily understood by parents. Once we convince them a tooth needs a crown, we then traditionally had to tell them it would be silver and might not look quite like a natural tooth. We are all fully aware that a silver tooth 62

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isn’t any worse esthetically than the decayed tooth they had been looking at for months. But we could never say that. Parents today want the best of the best for their children. They want them to have beautiful white teeth so no one will judge them as parents for allowing their child to develop cavities or make fun of their child for having silver teeth. They want for their child what every human being wants deep in their core—to be accepted. I learned this very quickly when I started offering Zirconia crowns. The most common comments I would hear from parents during follow-up visits were these: “Thank you for making my child’s teeth look so natural,” or “Thank you for making the tooth look the same as before.” It comes as no surprise when parents’ initial questions about the crowns are always, “Will the teeth look like chiclets?” or “Will the crowns look too white and not match natural teeth?” Parents ask these questions because that is what the crowns we used to use looked like! Since switching exclusively to Zirconia crowns in 2010, I can confidently tell them, “No! These crowns will look exactly like a natural tooth!” Every parent wants this result for their child. They will seek out a dentist that is willing and able to provide that kind of service, and we are the lucky ones who get to provide care that will change their lives for the better.

Kenzie personalizes the “Why?” question. One patient and her mom have helped me realize the answer to my “Why?” question. Kenzie and her mom, Amy, came to my office for a new patient consult in 2015. Kenzie is an adopted child from China who has been diagnosed with Sjorgren Larsson Syndrome, an unknown brain injury, epilepsy, poor muscle tone requiring a wheelchair, and other special healthcare needs. Amy knew that Kenzie had decay on her front teeth, but treatment had been put on the back burner, given all her other medical conditions. At first, Amy was hesitant to approve extensive treatment or general anesthesia, so I attempted slow-speed excavation and glass-ionomer restorations to buy us some time. Those restorations lasted about a year. About that same time, Amy noticed spontaneous gingival bleeding occurring and worried that Kenzie still was not eating much textured food by mouth. She came to me seeking advice and was now ready for more definitive treatment to be done, if needed. Kenzi received several medical consults, and most of her doctors recommended extractions of her teeth to eliminate the decay. She was referred to a children’s hospital where they recommended either full-mouth stainless steel crowns or extractions. Amy was not happy with these options. Kenzie may not be able to talk, but her mom knew that her daughter—always happy and smiling—definitely communicates with her beautiful smile. What would pulling her teeth or replacing them with silver crowns do to that special smile?

“I find that parents are much more willing to trust me when they feel that they are respected and listened to …”

Rekindling Your Passion THIS PAGE: Five-year-old Kenzie was adopted from China as an infant with several unknown special healthcare needs. She has been diagnosed with Sjogren-Larsson Syndrome, brain injury, and development delays. She is non-verbal but speaks volumes with her smile.Â

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Rekindling Your Passion

With Kenzie

not able to speak for herself, we are so grateful to have Dr. Andi using her expertise to be our daughter’s voice, advocating on her behalf regarding her dental healthcare needs. Although I’m not great with words, whenever I share with others regarding Kenzie, my adopted daughter from China, I speak from the heart. We were over-the-moon happy with Dr. Andi’s suggestion of using Zirconia crowns for Kenzie’s dental work. My daughter has such a magnetic smile that it can light up a room, and Dr. Andi was determined to preserve Kenzie’s trademark smile. Because of Kenzie’s syndrome, we see many medical specialists. As our dentist, Dr. Andi also plays an important role on the healthcare team that treats our girl. Dr. Andi keeps up-to-date on all Kenzie’s ongoing treatments and required procedures. I think special-needs kiddo’s mouths often get overlooked with all the other therapies they receive and specialty appointments they must keep, but Dr. Andi doesn’t allow that to happen. These special-needs kids deserve all the dignity that every other child deserves, and Dr. Andi sees to it that they receive the same kind of respect. She treated Kenzie just like she would any other child and didn’t treat her differently just because of her special healthcare needs. Since Kenzie is not able to speak for herself, we are so grateful to have Dr. Andi using her expertise to be our daughter’s voice, advocating on her behalf regarding her dental health needs. Thank you, Dr. Andi, for preserving Kenzie’s beautiful, magnetic smile. After all, we know that it’s her smile that makes our Kenzie, Kenzie.

Kenzie’s Mom

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My concern, as Kenzie’s dentist, was how the spontaneous gingival bleeding would respond to stainless steel. In my experience, the gingival response to Zirconia crowns is superior to any other restoration we place in a child’s mouth. I offered to place Zirconia crowns for Kenzie, if we could get her medical team to approve the treatment. After having several conversations, they did approve for Kenzie to receive general anesthesia at our local hospital so we could seat Zirconia crowns, canine to canine, and place stainless steel crowns in the posterior. Kenzie did great during the surgery and shortly thereafter began to eat by mouth again. Every time I see her, she is smiling ear to ear. Although she still has occasional bleeding in the posterior where the stainless-steel crowns were placed, I find it no surprise that the gingiva in the anterior looks fantastic with no inflammation or spontaneous bleeding.

The bottom line is that we can’t forget there is a “human” side to every dental procedure we do.

Her medical team has commented several times on how amazing Kenzie’s Zirconia crowns look and that they wish we would have used Zirconia in the posterior after seeing how well the gingiva responded. They now readily recommend Zirconia crowns for their patients with special healthcare needs who require dental work. When I ask Amy about her own feelings throughout this experience, she always responds with gratitude, saying, “You treated Kenzie like any other child and didn’t treat her differently just because of her special healthcare needs.” And during each visit since the surgery, Amy doesn’t miss an opportunity to say, “Thank you for preserving Kenzie’s smile, because her smile is what makes Kenzie, Kenzie.” PICTURE ABOVE: Dr. Andi and Kenzie both light up with smiles as they share a hug before Kenzie's Christmas program at school.

“Why?” has a human component. The bottom line requires that we must never forget the reality that every dental procedure we do has a “human side” to it, involving a little boy or girl who talks, eats, and smiles everyday. And each patient has parents who don’t want their child to be viewed as different. They want us as pediatric dentists to join with them as a member of their child’s healthcare team. These parents want to connect with us and know that we care about them and their children just as if they were our own. It’s amazing how rewarding providing patient-centered care can be when you stop worrying about whether insurance will cover the cost of treatment you know is best and which uses options such as silver diamine fluoride, space maintainers, interceptive orthodontics, oral sedation, or Zirconia crowns. It makes a difference if you truly believe that the treatment you are providing meets the gold standard of care and is the best option for your patient. And if you speak from your heart and establish a connection with the child’s parents, then you will have no problem convincing them of the value of such treatment. So, why do I do what I do day in and day out? What makes me truly happy and satisfied in my job and throughout every aspect of my life? It’s this, knowing that I put a little love into every patient I see and every last crown I place. I challenge each of you, new graduates and experienced pediatric dentists alike, to do the same. Ask yourself “Why?” And then search for the answers—the things that make you wake up in the morning and want to come to work, the things that make you love your job, the things that make your patients and parents love you, and the things that make you truly happy. I challenge you to do this without considering money as your motivator. Go each day and discover anew what motivates you in response to the “Why?” questions. If we all do this, I have no doubt we will advance the pediatric dentistry profession, live a satisfied life, and better the world we live in.

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A GLOBAL JOURNEY My Journey to 11 Countries in 11 Months . By Kamiren Passavanti

Cherishing a memory

Wondering if I could do it

Garbage lines the streets in every direction. Seven of us American girls have just squeezed onto a bus with our 50-pound packs. The windows hardly roll up or down. It is more like they just barely hang from their metal frames. We can smell the trash through the thick smog as we honk our way through traffic over dusty roads to get to our first ministry site. I have never seen so much poverty, so many dirt-caked sandals of pedestrians as they roam along the sides of our bus asking for money.

The truth is, I didn’t know if I could do it. I sold everything I owned to be on the garbage-covered streets of India. I quit my sweet job at Sprig to play with orphan girls in Thailand. I said goodbye to my friends for a year to renovate a moldy, roach-infested home in Nepal. I spent a year fundraising so I could sweep and mop a cold kitchen in Ethiopia. I left my precious dog with my dad in Georgia to teach the alphabet in a Rwandan cement-block classroom. I never thought I would actually get on the plane or be seven months into this thing called World Race, but here we are now in month eight.

We have only been in Hyderabad, India for a few hours, and I can’t yet process how different everything is compared to my cozy American lifestyle. How, if I were home, I would be sitting on the couch with my two roommates, probably watching Friends or The OC and eating freshly-mixed eggless cookie dough. Yet, somehow, I know my decision is right; this is one of the places where I am supposed to be for the next year.

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In August 2017, I left America to spend eleven months travelling to eleven countries. We would be traveling from one country to another—a new country each month—spending our time volunteering to help meet the basic needs of local people. I didn’t know what I would be doing or where I would be living, but I decided this was something that had been pulling on my heart strings for over a year. Since being on the race we have done several amazing things.

Nepal When we arrived in Nepal, we were asked to paint a few rooms in one of our local pastor’s home. Seemed simple enough. So, three other girls and I went to buy the paint and get started. When we arrived at the house, we could not have been more surprised by the living conditions in the home. Five people were living in a space about the size of my American kitchen. The walls were shedding sheets of old paint. Roaches were crawling through the furniture. Piles of ants covered trash on the floor. The carpets had never been cleaned and were caked with dirt. The mattresses were soiled and looked like they were on their last leg. This situation was going to require a lot more than paint to improve living conditions for the family.

Thailand While in Thailand, we ran a kid’s camp for 40 girls who were living apart from their families. This ministry was started by an American from Ohio who had the vision to bring the goodness of community to girls in need. Here in Thailand, children may be seen as a curse if they come from a broken marriage. They are essentially “on-purpose orphans.” It came as no surprise how welcoming these girls were when our team first showed up on the property. They are so hungry for love and affection. During the month of October, we were able to teach them Bible stories, aid in teaching English lessons, and play sports. They taught us how to be joyful in pain, and that family doesn’t always need to look just like your own relatives. Through this month we formed incredible relationships with these girls.

I know how having a nice place to come home to at the end of the day is what makes a house a home. More than anything, I wanted to provide this couple a safe and inviting environment to raise their kids. We couldn’t just slap on paint; we had to deep clean, fix, and then paint. It took four pails of paint, a few garbage bags, a tub of spackle paste, four bars of carpet soap, a spatula, endless cups of Nepali tea, and a week of hard work. I wish we could have done more, but I know our pastor friend was over-the-moon happy with the small progress we made before leaving Nepal for our next country. The look on his face made every roach I had to kill and every piece of mold I had to scrape worth it.

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Ethiopia In Ethiopia, we partnered with local churches to share our experiences. We lived in a little compound without running water or electricity which quickly become our home. Itâ&#x20AC;&#x2122;s amazing how much more you get to know people when electricity is out of the picture. Here we were able to deepen team friendships that would take years to form in America. Together, we visited villages and entered homes where we prayed for those who had been injured. I will never forget the living conditions of one home. From now on, every time I use a dishwasher in America, I will think about how I accidentally dropped a bucket in a well, and my friend, Daniel, had to fish it out just to get dish water. Whenever I take a hot shower in my apartment, I will remember how we had to set buckets of water in the sun to warm them so we could take a bucket shower. The next time Iâ&#x20AC;&#x2122;m in a place with easy access to electricity and feel like I have nothing to do, I will remember learning how to play a guitar using the light of my headlamp. The next time I feel like eating chicken in America, I will remember how we had to slaughter our own chickens to get adequate protein. Lastly, I will always rejoice over the healthy options available to shoppers in an American food store.

Rwanda After arriving in Rwanda, we assisted by teaching English and sharing in local churches. Our translator was an 18-year-old boy, who, to our surprise, could not get into school. We learned that Emmy had been kicked out of his high school because he was unable to pay his tuition. Yet, our new friend, who had learned English by befriending American missionaries, had his sights on being a software engineer. We desperately wanted to help Emmy in some tangible way. The poverty level was high, but his desire to achieve his goal was even higher. Eventually, after meeting with the school board of Kigali, we got a phone call during our last week, letting us know that Emmy got into school. We used the rest of our team budget to pay his tuition, and now he is on his way out of the poverty cycle. His whole life trajectory will be changed because we were there at the right time. 68

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Bolivia

World Race is an international journey sponsored by Adventures in Missions which challenges young adults to serve selflessly in 11 countries over an 11-month time frame. Participants partner with churches and organizations in countries throughout the world to help meet the basic needs of local people. Kamiren’s itinerary on the current season of World Race takes her to India, Nepal, Thailand, Cambodia, Vietnam, Ethiopia, Rwanda, Bolivia, Peru, Ecuador, and Colombia. To learn more, visit worldrace.org.

Recently, we have traveled to Bolivia. Here we are connected with a program to work with children and teenagers that have been affected by addiction. We are able to serve these young people with urgent needs and provide welcome relief to other long-term volunteers. Then we will be off to Peru!

How it’s impacting me When I think about everything we have done and everything we are about to do, it can be overwhelming. Some days I think, “I can’t believe I left California and five-star hotels for this.” Then I think that I am so thankful to have these opportunities to feel grateful. All the people that I have encountered have so much joy, even though they don’t know about all the stuff they are missing. It makes me wonder if Western culture might have it worse because we are so involved with our stuff that we can’t see what is really important in life. I love my MacBook, my Frye boots, and my Longchamp bag, but I don’t want to be owned by these things. I have been living out of a 65-liter bag for five months now, and there’s nothing really from home I wish I had with me, except my goldendoodle Sophie. I decided this year I was going to work on my soul above all else and learn to choose joy even in the hard things. Everything is better when you can be joyfully authentic about a gross situation like a squatty potty or eating plain rice for the 14th meal in a row.

rejoice each day even though I may never know who has been impacted by my choice to serve alongside the other ministries in this World Race. Yes, I put my life in America on hold for a year of international service, and to some that may appear as a year lost. However, when I think of all that I have gained—the stories I can tell and the people I now count as friends—I realize these cherished memories and adventures have their own eternal value. The best part for me is now realizing that we can positively impact others around us without travelling to faraway places. We never know what encouraging word or act of kindness will brighten someone else’s day. So, I challenge you, “What will you bring to your community?” Whether it’s sweeping the floor or sharing in a vulnerable conversation—remember it could change someone’s life. If you want to learn more about my journey or keep up with what we are doing on World Race, you can visit my blog at kamirenpassavanti.theworldrace.org.

All things aside, I am so grateful for this experience and all the hilarious stories that come along with it. I can

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