The next dds magazine fall 2012 by The NEXTDDS

The Educational Resource Exclusively for Dental Students

THE

T H E N E X T D D S . c o m FALL 2012 / VOLUME 2 ISSUE 1

BUILDING A FOUNDATION for Adjunct Dental Education

THENEXTDDS.com: A GROWING EDUCATIONAL RESOURCE

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Avoid 8 Healthy Diet Mistakes

THE NEXT DDS Feature Interview

TUSDM School Spotlight

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anchored in better quality anterior bone and offer maximum support of the prosthesis by reducing cantilevers. They also help eliminate the need for bone grafting by increasing boneto-implant contact. All-on-4 can be planned and performed using the NobelGuide treatment concept, ensuring accurate diagnostics, planning and implant placement. Their smile, your skill, our solutions.

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Nobel Biocare USA, LLC. 22715 Savi Ranch Parkway, Yorba Linda, CA 92887; Phone 714 282 4800; Toll free 800 322 5001; Technical services 888 725 7100; Fax 714 282 9023 Nobel Biocare Canada, Inc. 9133 Leslie Street, Unit 100, Richmond Hill, ON L4B 4N1; Phone 905 762 3500; Toll free 800 939 9394; Fax 800 900 4243 * If one-stage surgery with immediate loading is not indicated, cover screws are used for submerged healing. © Nobel Biocare Services AG, 2012. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare. Straumann® is a trademark of Straumann Group. Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability.

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THE

Fa l l 2 0 1 2 C o n t e n t s

10 16 19 37 40 46 48 56

BALANCING YOUR MEDIA DIET by Colleen Greene, Harvard ‘13

5 THINGS ABOUT GROUPS ON THE NEXT DDS by John Papa

RESTORATIONS OF ENDODONTICALLY TREATED TEETH by Yoshihiro Goto, DDS, MSD, et al

TECHNOLOGY IN THE CURRICULUM by Richard Callan, DMD and Walter Renne, DMD

THE NEXT DDS FEATURE INTERVIEW — DR. ROBERT GEIMAN

BY THE NUMBERS

CLINICAL IMAGES: THE EYE OF THE BEHOLDER RESEARCH DAY AT TUFTS UNIVERSITY

SCHOOL OF DENTAL MEDICINE

© 2012 Next Media Group, Inc. All rights reserved. THE NEXT DDS is published and copyrighted by Next Media Group, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form—print, electronic, or otherwise— without the expressed written permission of the Publisher.

For reader inquiries: Tel: 201-490-8811 xmg@thenextdds.com

Opinions expressed in the articles and communications contained in this publication are those of the authors and not necessarily the editor(s) or the Publisher. The editor(s) and Publisher disclaim any responsibility or liability for such material and do not guarantee, warrant, or endorse any product presented in this publication, nor do they guarantee any claim made by the manufacturer of such product or service.

THE NEXT DDS

Fall 2012

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restorative orientation. Together with the strong sealed connection and built-in platform shifting, NobelActive 3.0 allows you to safely produce excellent esthetic results. After 45 years as a dental innovator we have the experience to bring you future-proof and reliable technologies for effective patient treatment. Their smile, your skill, our solutions.

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Nobel Biocare USA, LLC. 22715 Savi Ranch Parkway, Yorba Linda, CA 92887; Phone 714 282 4800; Toll free 800 993 8100; Technical services 888 725 7100; Fax 714 282 9023 Nobel Biocare Canada, Inc. 9133 Leslie Street, Unit 100, Richmond Hill, ON L4B 4N1; Phone 905 762 3500; Toll free 800 939 9394; Fax 800 900 4243 © Nobel Biocare Services AG, 2012. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare. Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability. 1 1 Dental Product Shopper voted NobelActive 3.0 Best Product 2012. www.dentalproductshopper.com/nobelactive-30

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e-commerce site that makes the buying experience more user-friendly. Robust search capabilities let you refine your search by connection type, drill protocol, compatible components, and more, making it easier to find exactly what you need. The Online Store also offers product descriptions, article numbers, and a virtual database of Nobel Biocare products – all at your fingertips.

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Nobel Biocare USA, LLC. 22715 Savi Ranch Parkway, Yorba Linda, CA 92887; Phone 714 282 4800; Toll free 800 993 8100; Technical services 888 725 7100; Fax 714 282 9023 Nobel Biocare Canada, Inc. 9133 Leslie Street, Unit 100, Richmond Hill, ON L4B 4N1; Phone 905 762 3500; Toll free 800 939 9394; Fax 800 900 4243 © Nobel Biocare USA, LLC, 2012. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare. Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability.

From Student. To Professional.

i n t r o d u c t i o n

Balancing Your Media Diet

t is an honor to present the appetizer for this issue of THE NEXT DDS Magazine. As a former editor, I know how much toil and collaboration a single edition represents. It’s a challenge to determine the perfect blend of enticing and educational topics, particularly given the amount of media to which consumers have access through the Internet. Sometimes our appetites for media “junk food” compete with the desire for nourishing information. Here are a few tips for developing healthy data consumption habits as a dental student: Portion Control The Internet is an all-you-can-eat buffet. Ever feel guilty for mindlessly gorging on bland status updates and artificial news stories? There are too many traps out there that repeatedly trick us into wasting time. If you lack an iron will, just set a timer before diving into the digital abyss. Don’t let hours pass by that could be spent in more satisfying or productive ways. If the volume of data available overwhelms you, seek print media sources (like this one!). In each there is a beginning, middle, and end without the social distractions that lurk online. In our increasingly electronic world, the printed word can ease the anxiety of having infinite choices and links to explore.

Enroll Now! TheNEXTDDS.com

Magazines perfectly balance brevity with variety. You can read every article in a magazine and let it soak in without drowning in information. On the other hand, a news website or even a scientific journal can feel endless.

THE ENROLLMENT IS

Know Your Source There is a movement today to know the source of your food and eat locally grown produce. This trend is based on a desire for purity and integrity in our diets. We also seek purity from our data sources, but it’s not easy to trust all choices. Be skeptical without becoming paranoid. When you find a reliable news outlet, stick to it. Consuming content that has undergone peer review is one simple way to be mindful of these recommendations. Articles in this issue explore several interesting students and schools. You can also be the source of media today. There are many opportunities for dental students to express ideas and calls to action. Be brave and share your insights with hungry audiences—THE NEXT DDS is one option to help each of us create a better dental school experience for those following in our footsteps.

FREE

THE KNOWLEDGE IS

PRICELESS

Embrace Variety Get adventurous with your next decision about a magazine subscription or online news portal. Seek clinical opinions from those who trained at institutions different from your own. Just like trying out a new cuisine or recipe, you may be surprised at how enjoyable the experience is. At the end of the day, you are your own information editor. Choose wisely and you will learn and be entertained daily. Enjoy the features contained here. Remember, you are what you read.

BECOME A FAN ON

Colleen Greene Harvard ‘13

THE NEXT DDS

Fall 2012

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TECHNOLOGY IN THE CLASSROOM By Kathleen A. Tracy

THE NEXT DDS

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FROM A SIMPLE CHALK

BLACKBOARD TO THE ONCE-

UBIQUITOUS

OVERHEAD

PROJECTOR

communication technology, however rudimentary, has always been part of the American classroom. That being said, the emergence of the Internet, cloud computing, laptops, and personal digital devices over the last decade has profoundly changed the dynamics of how students learn. While traditional in-class instruction is still employed, universities in general and dental schools in particular are increasingly integrating rich-media and e-learning into curriculums via web and computer-based learning, opensource software, virtual classrooms, and, most recently telepresence, all of which improve comprehension and enhance retention.

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THE NEXT DDS

TECHNOLOGY

Collaborative Learning

adding Apreso to our e-learning initiatives, our tutors can be liberated from One of the more significant trends prompted by the ease of communicabasic, repetitive presentations, enabling them to focus more on the practical tion offered by tablets and other wireless devices is the use of collaborative aspects of dental training.” learning in higher fields of education, where students work together in pairs Apreso captures a classroom’s audio, video, and synchronized visual or groups. Gone are the days of having to meet in the library to finish an aids, then presents it online as an interactive, indexed, full-motion version assignment. Students can use a cloud account, Google docs, or even “oldof the lecture. Dr. Reynolds adds: “We are developing more Apreso-enhanced fashioned” email to share material. classes in subjects such as Prosthodontics, and Therapeutics. We Rich media, which refers to digital interactive materials, have also used it to capture practical demonstrations such as has transformed the learning experience dramatidissections for anatomy courses. We are very pleased by cally for dental students. Modern educators have the ease of use look forward to extending our Apreso long known combining a visual aid with facts deployment in the future.” makes it easier to learn. In the early 1990s, PowerPoint started phasing out 35mm slide Student-Based Learning projectors because it was possible to post Apreso and the other technologies have prePowerPoint lectures via the Internet. Today, sented a paradigm shift in higher education, medical and dental programs across the resulting in a move away from instructorPERCENTAGE OF STUDENTS world are leveraging digital media. based curriculums to learner- or student-based WHO SAY THEY ARE For example, an Adobe White Paper approaches that focus on how students learn, MORE LIKELY TO BRING reported how “students in Carnegie Mellon’s what they experience, and how they engage Human Computer Interface program collabolearning. Students no longer sit for an hour listenA LAPTOP THAN A PRINT rated with the University of Pittsburgh’s School ing to a professor while taking notes. Through richTEXTBOOK of Dental Medicine to solve workflow and informamedia such as that afforded by THE NEXT DDS and TO CLASS tion sharing problems within dental practices.” The other modern technologies, learning is more hands-on, students created a 3D application that enabled dentists to making the student more responsible for what they get out communicate through a common visual display, improving the of the class. The teacher is less a captain and more of a collaborator. accuracy and alacrity of suggested treatments. For this approach to be successful, however, students The University of Maryland developed a virtual denneed to be wired in. As the technologies advance, there tal school to complement their brick and mortar is ever more dependence on digital devices, particuclasses. The digital school offers tools designed larly laptops and tablets. A recent study by Wakefield for role-playing scenarios—complete with Research found that a majority of students (51 customized character avatars—along with percent) say they are more likely to bring a lapresources such as a conference hall, a historitop than a print textbook to class. Nearly eight in cal dentistry museum, and simulations on cliniten admitted to doing a quick search on a mobile cal procedures. device or tablet to verify some piece of information PERCENTAGE OF In the fall of 2012, Southern Illinois Univerimmediately before a test or a quiz. More notably, STUDENTS WHO HAVE sity’s School of Dental Medicine will break ground 58 percent of students have taken an online course TAKEN AN ONLINE on a new simulation lab that will include flat-panel so they could take the class on their own time and COURSE monitors at each workstation so students can work learn at their own pace.* with simulated patients and patient records. And they’re That’s where THE NEXT DDS will continue to play a valunot the only school pursuing this objective. able role for dental students. There is no question that technology Britain’s King’s College London Dental Institute has implemented is and will continue to be an integral part of the higher education system in an automated lecture capture solution technology called Apreso. Apreso America. Dental schools are wedged into the unique position of having to stay will allow undergraduate and postgraduate dental students to access lecup-to-date on both educational technology, as well as emerging diagnostic and tures on demand, giving students more flexibility and enabling the Dental clinical technologies. How these technologies are implemented in the classInstitute to enhance the classroom experience by adding rich media to the room and clinics across the country remains to be seen. If new advances in lectures. All of these lectures can also be accessed through course maneducational technology are used to their maximum potential, the emerging agement systems such as Blackboard and WebCT. Similar technologies have generation of dentists in America are set to become the most informed and emerged in dental schools throughout the U.S. prepared individuals to ever emerge from a dental classroom. Dr. Patricia Reynolds, King’s Deputy Director of Education for Flexible Learning, explains, “The smaller, specialty disciplines in dentistry are chal*www.prnewswire.com/news-releases/college-students-boost-digital-adoptionlenged to teach the increasing numbers of much needed dental students. By according-to-coursesmart-survey-153042715.html Accessed August 2, 2012.

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STAy in touch WiTH your PrACTiCe. AnyTiMe, AnyWHere.

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Trust the dental malpractice experts.

CLINICAL STUDY

RESTORATIONS OF ENDODONTICALLY TREATED TEETH: CURRENT CONCEPTS AND MATERIALS

ABSTRACT: Left unrestored, endodontically treated teeth have complications that include coronal leakage and subsequent reinfection of the root canal system. These teeth are at risk for fracture, since they become predisposed to structural compromise when compared to their properly restored counterparts. Caries, previous restorations, fractures, wear, erosion, and endodontic procedures each require careful consideration and timely tooth reconstruction to ensure a favorable prognosis.

LEARNING OBJECTIVES: This article highlights recent advances in endodontic dowels and explains their use in aesthetic restorative dental procedures. Upon completing this article, the reader should: • Understand the types of endodontic dowels currently in clinical use. • Recognize the importance of the ferrule effect on the outcome of an endodontically treated tooth.

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by Yoshihiro Goto, DDS, MSD* Jeffrey Ceyhan, DDS, MSD† Stephen J. Chu, DMD, MSD, CDT‡

n extensive array of restorative systems, materials, techniques, and designs are now available to the clinician restoring the endodontically treated tooth. Even the basic scientific principles of dowel-and-core technologies are being altered by the constant introduction of more sophisticated dental materials. New patient concerns, including minimal invasiveness of the remaining dowel/endodontic dentin, biocompatibility of the restorative materials (eg, dowels, cores, cements), the expected longevity of the restoration, and the aesthetic compatibility of the dowel and core are affecting treatment decisions.1 When selecting an appropriate dowel system (Tables 1 and 2), several critical factors should

be considered. The treatment should attempt to satisfy these criteria:2 1. A stable dowel system that uniformly transfers the stress of mastication throughout the radicular root and into the periodontal attachment; 2. A dowel system that does not focus stress during function or create it during placement; 3. A stiff dowel system that resists deformation or permanent bending to protect the integrity of the crown margins and cement seal; 4. A cementation process that provides optimal luting of the dowel to the radicular dentin; and 5. Conservation of coronal tooth structure that allows adequate encasement of dentin by overcasting the “ferrule effect.”

TABLE 1. Metal or Alloy-Based Dowel Options

Indirect

Direct

• Cast precious metal • Cast base metal

• Prefabricated stainless steel • Prefabricated titanium TABLE 2. Aesthetic Dowel Options

Customized

Prefabricated

• Woven polyethylene fiber-reinforced

• Fiber-reinforced (eg, carbon fiber-reinfrced, epoxy resin, hybrid carbon and glass, white quartz fiber, translucent quartz fiber, resin fiber) • Ceramic post • Conventional feldspathic and glass • Aluminum oxide and ceramics (eg, glass-infiltrated, glass-sintered, zirconia-based)

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THE NEXT DDS

CLINICAL STUDY

Metal or Alloy-Based Dowels

FIGURES 1A AND 1B. Images of direct metal posts used for the restoration of endodontically treated teeth.

FIGURES 2A AND 2B. Images of indirect metal

posts utilized for endodontically treated teeth.

Alloy-based dowels can be of two types, custom-cast or prefabricated (Figures 1 and 2). The custom-cast post has a long history of clinical success.3 This approach uses a casting procedure to fabricate a one-piece dowel and core that has no interface between the two components. Ideal dowel materials should be inert and resistant to the effects of corrosion. Preformed systems generally use dowels made of stainless steel alloys containing nickel and chrome. Recently, concerns have been raised about the potential for sensitivity and allergy production from nickel alloys. Biocompatible titanium has less allergenic potential than do stainless steel alloys. Prefabricated dowels appear to be most useful in teeth that retain considerable coronal dentin; in these situations, the core can be made from materials that adhere to the dental tissues. The use of prefabricated dowels and custom-made buildups with amalgam or composite simplifies the restorative procedure because all steps can be completed chairside, and fair clinical success can be expected.4

Customized Woven Polyethylene Fiber-Reinforced Dowels

FIGURE 3. Facial view of incisor following apical seal and placement of fiber-reinforced post.

THE NEXT DDS

The use of fiber-reinforced composite resins to rehabilitate an endodontically treated tooth is new and provides reinforcement and aesthetics. The fiber-reinforcing material is made from high-strength polyethylene fiber, which is chemically inert, biocompatible, and can absorb and disperse shock energy. The leno weave of fiber is cross-linked and lock-stitched, which allows manageability and structural integrity when embedded in composite resins. The use of a fiber-reinforced resin-bonded dowel system eliminates the need for removal of intraradicular dentin. The bonded adaptation provides resistance form and antirotational features. Since the system does not require a straight path of insertion, there is close conformity to canal undercuts and morphologic irregularities. Research has also shown the ability of fabrics to limit the propagation of cracks within the composite resin. When a fiber-reinforced resin-bonded dowel system is selected, sufficient coronal structure must be available within the canal to support

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an adequate ferrule for the restoration and to resist shear forces during function. Although operator-placed fiber-reinforced resin-bonded systems are the least rigid of the various treatment options available for intraradicular rehabilitation, and are only faintly radiopaque, they can provide enhanced aesthetics when used in certain clinical situations.2

Prefabricated Fiber-Reinforced Dowels The physical properties (eg, strength, absence of corrosion, easy repair) of fiber-reinforced dowels have facilitated their application in various industries, and their importance in the dental field has grown. Depending on the type and direction of the fiber, the properties of the materials vary.5 The most pertinent feature of these dowels is their modulus of elasticity, which approximates that of dentin.6 This parameter results in dowel behavior that is similar to that of the dental structure and therefore reduces stress transmission to the root walls, decreasing the possibility of longitudinal root fracture.7 The dowels are made of a resin matrix in which various types of fibers are embedded. The microstructure of each fiber dowel is based on the diameter of the single fibers, their density, the quality of adhesion between the fibers and the resin matrix, and the quality of the outer surface of the post.6 In 1990, Duret et al introduced a nonmetallic material for fabrication of dowels, based on the carbon fiber-reinforcement principle.8 Carbon fiber dowels consist of equally stretched and longitudinally aligned carbon fibers, solidly attached to a special matrix of epoxy resin. With the carbon component constituting 64% of the final structure, the interface between the carbon filaments and the matrix is an organic composition. The carbon fibers, by exerting uniform tension on the filaments, impart high strength to the posts. The carbon dowels are passive and are designed to be used with a bonding technique. They exhibit high fatigue resistance and tensile strength and have a modulus of elasticity comparable to dentin. They effectively minimize the transmission of trauma to the dental structure. Reversible failures associated with these dowels may be attributed to such elasticity,9 and they are simple to remove via end-

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Fall 2012

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CLINICAL STUDY

FIGURE 4. Ceramic dowel and core ready for intracanal placement.

FIGURE 5. Ceramic dowel and core is placed in tooth #10.

FIGURE 6. The dentition are then prosthetically restored with all-ceramic crowns.

odontic treatment.10 The disadvantages of these dowels include a lack of radiopacity and poor adhesion to the composite resin cores. Despite the functional benefits offered by this option, the dowels possess a black (ie, carbon) color and do not provide any significant aesthetic advantage. In an attempt to combine the aesthetic requirements with the promising mechanical characteristics, dental manufacturers introduced an improved version of the carbon fiber post. The new dowels were made of a carbon fiber core covered with white quartz fibersâ&#x20AC;&#x201D; which are defined as hybrids. The white coating on the dowel effectively eliminates the shinethrough, but most of the light transmission through the root and gingival complex is still diminished. Laboratory and clinical studies have shown that the mechanical properties and clinical behavior of the dowels do not vary significantly with either carbon or with quartz fibers. This resulted in the introduction of dowels made from all-glass and all-quartz fibers embedded in a filled resin matrix. These dowels are completely white and, therefore, aesthetically superior.6 Subsequently, quartz fiber dowels with a translucent appearance have been introduced.6 This evolution has permitted the introduction of dual-cure resin cements, in which the translucency characteristics of the dowel are used as a light carrier.6 The composition of these glass fiber dowels by weight is 42% glass fiber and 58% resin. Recently, dowels based on the technology of fiber-reinforced resins have been fabricated and proposed in association with a new version of the self-activating bonding agent, in order to optimize bonding inside the root canal (Figures 3 and 4).11

Ceramic Posts In the 1990s, dowels of glass-infiltrated aluminum oxide ceramic,12 a â&#x20AC;&#x153;monoblocâ&#x20AC;? of glassceramic material,13 and zirconia ceramic were introduced as aesthetic post options. The major advantage of an all-ceramic dowel and core is its dentin-like shade. This positive contribution is related to the diffusion and absorption of the transmitted light in the ceramic core mass. An all-ceramic restoration transmits a certain per-

THE NEXT DDS

Fall 2012

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centage of incidental light to the ceramic core and dowel on which it is placed. Therefore, in all-ceramic dowels and cores, the color of the definitive restoration is derived from an internal shade similar to the optical behavior of natural teeth. In addition, ceramic dowels do not reflect intensively through thin gingival tissues and provide an essential depth of translucency in the cervical root areas. All-ceramic dowels and cores have excellent biocompatibility and do not exhibit galvanic corrosion.14 Low fracture strength and fracture toughness are the primary disadvantages of conventional ceramics as dowel-and-core materials. High-toughness ceramic (eg, glassinfiltrated alumina ceramic, and the densely sintered alumina ceramic) shows three to six times higher flexural strength and fracture toughness than conventional feldspathic and glass ceramics. Contemporary zirconia powder technology contributes to the fabrication of new biocompatible ceramic materials with improved mechanical properties (ie, increased flexural strength, fracture toughness). Therefore, zirconium oxide ceramic seems to be a very promising material for the fabrication of all-ceramic dowels and cores.14 Yttrium oxide partially stabilized zirconia dowels exhibit a better fracture toughness than do alumina ceramic posts. They are radiopaque, biocompatible, and mechanically rigid and can be bonded to a variety of ceramics and composites. The zirconia root canal dowels have been shown to be more rigid than stainless steel, and are, therefore, stiffer than dentin. Due to the high modulus of elasticity of zirconia, forces are transmitted directly to the post/tooth interface without stress absorption. This feature may account for the catastrophic fractures observed under compressive loading in teeth restored with zirconium posts.15 The retrievability of these dowels depends on the medium by which the dowel is cemented. With traditional cements, ultrasonic removal may be possible, although difficult. Adhesive resin cements, however, render these dowels virtually irremovable. A zirconia dowel can be used for direct and indirect fabrication techniques.2 The direct technique, which uses a zirconia dowel with a composite core, can be employed when a

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minimum of one third of the clinical crown is present. During this process, the surface of the zirconium oxide dowel is abraded, a chemical silanization treatment is applied, and the dowel is cemented with an adhesive procedure. A hybrid composite is then built up to serve as a core.16 One recent study,17 however, demonstrated that a less-than-ideal bond strength appears to exist between the zirconia and the composite materials. Zirconia dowels can also be used for the indirect restoration of compromised teeth. In this technique, a leucite-reinforced ceramic material is used for the fabrication of the core buildup over the dowel (Figures 5 and 6). This forms a single unit that can be etched and silanated in order to allow a more predictable bond strength between the final dowel and core and the resin cement.16 The zirconia dowel can also be used with an all-ceramic core made of alumina-magnesia ceramics fabricated by the slip-casting or copy milling techniques.14 In addition to dowel selection, several primary factors influence the outcome of restored endodontically treated teeth. One is the presence of a coronal seal with 4.5 mm of suprabony solid tooth structure (ie, the biologic width plus ferrule length) and a minimum dentin thickness of 1 mm after tooth preparation. For teeth requiring a dowel, sufficient root length is necessary to allow a 4-mm apical seal.18 Additionally, the dowel length (apical to the crown margin) should be equal to the length of the crown, and an adequate ferrule effect is required.19

The “Ferrule Effect” For a cast restoration, it is accepted that encirclement of the root with a ferrule will protect the endodontically treated tooth against fracture.20 A ferrule is an encircling band of cast metal that acts as a reinforcing sleeve around the coronal portion of the tooth (Figure 7). Tjan and Whang found that using a short 60-degree collar did not increase resistance to root fracture.20 Other studies have shown that ferrules impart a significant increase in fracture resistance.19,21 The differences stem from a range of interpretations about what constitutes a ferrule. Sorensen and Engelman define the “ferrule effect” as a 360-degree metal collar of the

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crown,22 surrounding the parallel walls of the dentin and extending coronal to the shoulder of the preparation. The result is an elevation in resistance from the extension of dentinal tooth structure. Eissman and Radke recommended a cast restoration that extended at least 2 mm apically to the junction of the core and the remaining tooth structure.23 They also suggested that encirclement of the root with the ferrule effect would protect the pulpless tooth against fracture by counteracting spreading forces generated by the dowel. Libman and Nicholls compared the effects of different ferrule heights (eg, 0.5 mm, 1 mm, 1.5 mm, 2 mm) of a maxillary central incisor in a clinically relevant manner, using a dynamic repetitive load.24 They found that the preliminary failure was the breakage of the cement seal (ie, a clinically “invisible” failure that leads to the “visible” failures of cement leakage, secondary caries, subsequent crown dislodgement, and dowel and tooth fracture.) A minimum of 1.5 mm of ferrule height significantly improved crown resistance (Figure 8). When the ferrule is absent, occlusal forces must be resisted exclusively by the dowel, which may fracture eventually.25 Accepting that the ferrule is effective only when the walls are nearly parallel, and allowing a somewhat rounded transition from ferrule wall to the preparation margins, it seems prudent to accept 2 mm of ferrule length as a clinical minimum to help ensure long-term dowel-and-core survival beneath a crown restoration. In order to obtain 2 mm of tooth structure for the ferrule effect, clinical crown-lengthening and/or orthodontic forced eruption may be required. When deciding which of these procedures to utilize, several factors must be considered, such as crown-to-root ratio, probing depths, aesthetics, and treatment time.

FIGURE 7. Tapered collar of ferrule and parallel-

sided collar of ferrule. The parallel-sided ferrule significantly improves crown resistance.

FIGURE 8. Test results indicate that more than

1.5 mm of ferrule height significantly improved crown retention.

FIGURE 9. Conventional cast post and core used in support of a metal-ceramic crown restoration placed in tooth #9.

Conclusions When selecting the appropriate system to address morphologic or aesthetic considerations, various risk factors that can contribute to material or dentin failure must be considered. The dowel-and-core technique selected must be conservative, morphologically retentive, aesthetic, and resist radicular fracture (Figures 9

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CLINICAL STUDY

FIGURE 10. Conventional cast post and core used in support of a metal-ceramic crown restoration placed in tooth #9.

through 12). Although metal dowels were used extensively for many years, their popularity has been declining steadily. With over 10 years of proven clinical success, there is now widespread interest in the use of nonmetallic dowel materials and techniques. These contemporary dowel designs and endodontic procedures have been shown to alter and reinforce radicular structure, and the technology of adhesive science has yielded new and creative solutions to a host of complex challenges. As stated herein, the restoration of endodontically treated teeth will almost certainly fall into two distinct categories: those with 2 mm or more of ferrule length, and those with a core of less than 2 mm of remaining suprabony tooth structure. Historically, restorations with a 2 mm or greater ferrule demonstrate significantly greater long-term survival rates than their monocore concept counterparts. Acknowledgment Adapted with permission from Goto Y, Ceyhan J, Chu SJ. Restorations of Endodontically Treated Teeth. In: Tarnow DP, Chu SJ, Kim J, eds. Aesthetic Restorative Dentistry: Principles & Practice. Mahwah, NJ: Montage Media, 2008:161-193. The authors mention their gratitude to Dr. K.M. Wong, Dr. Kakehashi and Dr. Shimada for their clinical images. References 1. Freedman GA. Esthetic post-and-core treatment. Dent Clin North Am 2001;45(1):103-116.

FIGURE 11. An aesthetic dowel and composite

core are placed in tooth #9 prior to seating and cementation of an all-ceramic restoration.

2. Gluskin AH, Ahmad I, Herrero DB. The aesthetic post and core: Unifying radicular form and structure. Pract Proced Aesthet Dent 2002;14(4):313-321. 3. Morgano SM, Milot P.Clinical success of cast metal posts and cores. J Prosthet Dent 1993;70:11-16. 4.

Heydecke G, Butz F, Hussein A, Strub JR. Fracture strength after dynamic loading of endodontically treated teeth restored with different post-and -core systems. J Prosthet Dent 2002;87(4):438-445.

5. Quintas AF, Dinato JC, Bottino MA. Aesthetic post and cores for metal free restoration of endodontically treated teeth. Pract Periodont Aesthet Dent 2000;12(9):875-884. 6. Ferrari M, Scotti R. Fiber posts: Characteristics and clinical applications. Milano, Italy: Masson SpA;. 2002. 7.

FIGURE 12. An aesthetic dowel and composite

core are placed in tooth #9 prior to seating and cementation of an all-ceramic restoration.

Asmussen E, Peutzfeldt A, Heitmann T. Stiffness, elastic limit, and strength of newer types of endodontic posts J Dent 1999;27(4):275-278.

8. Duret B, Reynaud M, Duret F. Long life physical property preservation and post endodontic rehabilitation with the Composipost. Compend Cont Educ Dent 1996;20(Suppl): S50-S56. 9.

Sidoli GE, King PA, Setchell DJ. An in vitro evaluation of a carbon fiber-based post and core system. J Prosthet Dent 1997;78(1):5-9.

10. Fredriksson M, Astback J, Pamenius M, Arvidson K.. A retrospective study of 236 patients with teeth restored by carbon fiber-reinforced epoxy resin posts. J Prosthet Dent 1998;80(2):151-157. 11. Martelli R. Fourth-generation intraradicular posts for the aesthetic restoration of anterior teeth. Pract Periodont Aesthet Dent 2000;12(6):579-584. 12. Kern M, Knode H. Posts and cores fabricated out of In-Ceram--Direct and indirect methods. Quintessenz Zahntech. 1991;17(8):917-925. 13. Pissis P. Fabrication of a metal-free ceramic restoration utilizing the monobloc technique. Pract Periodont Aesthet Dent 1995;7(5):83-94. 14. Koutayas SO, Kern M. All-ceramic posts and cores: The state of the art. Quint Int 1999; 30(6):383-392. 15. Akkayan B, Gulmez T. Resistance to fracture of endodontically treated teeth restored with different post systems. J Prosthet Dent 2002;87(4):431-437. 24

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16. Fradeani M, Aquilano A, Barducci G. Aesthetic restoration of endodontically treated teeth. Pract Periodont Aesthet Dent 1999;11(7):761-768. 17. Dietschi D, Romelli M, Goretti A. Adaptation of adhesive post and cores to dentin after fatigue testing. Int J Prosthodont 1997;10(6):498-507. 18. Goodacre CJ, Spolnik KJ. The prosthodontic management of endodontically treated teeth: A literature review. Part II. Maintaining the apical seal. J Prosthodont 1995;4:(1)51-53. 19. McLean A. Criteria for the predictably restorable endodontically treated tooth. J Canad Dent Assoc 1998;64(9):652-656. 20. Tjan AH, Whang SB. Resistance to root fracture of dowel channels with various thicknesses of buccal dentin walls. J Prosthet Dent 1985;53(4):496-500. 21. Assif D, Bitenski A, Pilo E, Oren E. Effect of post design on resistance to fracture of endodontically treated teeth with complete crowns. J Prosthet Dent 1993;69(1):36-40. 22. Sorensen JA, Engleman MJ. Ferrule design and fracture resistance of endodontically treated teeth. J Prosthet Dent 1990;63(5):529-536. 23. Eissman HF, Radke RA. Postendodontic restoration. In: Cohen and Burns, eds.Pathways of the Pulp. 4th Ed. St Louis, MO: CV Mosby;1987:640-643. 24. Libman WJ, Nicholls JI. Local fatigue of teeth restored with cast posts and cores and complete crowns. Int J Prosthodont 1995;8:155-161. 25. Torbjorner A, Karlsson S, Odman PA. Survival rate and failure characteristics for two post designs. J Prosthet Dent 1995;73(5):439-444.

*Clinical Assistant Professor, Graduate Prosthodontic Program, University of Southern California, School of Dentistry, Los Angeles, CA; private practice, Los Angeles, CA. †Affiliated Assistant Professor, University of Washington School of Dentistry, Seattle, WA; private practice, Calgary, Alberta, Canada. ‡Associate Clinical Professor, Department of Prosthodontics and Director of Aesthetic Dentistry, Columbia University College of Dental Medicine, New York, NY; private practice, New York, NY. Yoshihiro Goto, DDS, MSD, 11645 Wilshire Blvd, Ste. 704, Los Angeles, CA 90025Tel: 310-820-6696 • ygoto@usc.edu w w w. T H E N E X T D D S . c o m

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The First Step Towards Your Future Career

DENTAL

MATCH DAY

Q&A

— with — Matthew Ronconi, DDS*

atthew Ronconi is a 2012 graduate of the UCLA School of Dentistry in Los Angeles, California. Last year Dr. Ronconi successfully completed his preparations for the Postdoctoral Dental Matching Program, which matches dental students pursuing specialty training with corresponding residency programs. THE NEXT DDS asked Matthew a series of questions to explain how “Match Day” is structured, to highlight the associated timelines, and share ‘best practices’ that may help future applicants prepare their candidacies. The following is an excerpt from our interview. LISTENT TO THE FULL INTERVIEW AT WWW.THENEXTDDS.COM/ PODCASTS/MATCH-DAY-RECOMMENDATIONS-FOR-SUCCESS OR SCAN WITH YOUR SMART PHONE HERE

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Thanks for joining us Dr. Ronconi. “Match” Day is an important milestone in the lives of many future dental professionals. For dental students who haven’t yet been through the process, can you summarize the Postdoctoral Dental Matching Program in a few sentences? The Postdoctoral Dental Matching Program, also known as the “Match,” places dental students into residency programs. Each applicant is required to submit a Rank Order List. The list comprises all of the programs that the dental student interviewed at and would like to attend. All of the participating schools also submit a Rank Order List, which is a list of applicants who they interviewed and who they feel would be a good fit for their program. From these two lists, the Match Program determines the most favorable matches for the dental student and the program. Do all dental students participate in the Match? Is it mandatory? Which specialty programs do and which don’t? The postdoctoral dental education programs that participate in the match are Advanced Education in General Dentistry (AEGD), General Practice Residency (GPR), Oral and Maxillofacial Surgery (OMS), Orthodontics, Pediatric

Orthodontics and Anesthesiology positions. The second phase of the Match is for applicants pursuing a position in AEGD, GPR, OMS. How does Pre-Match work? Do you have to drop out? I ended up applying to two Pre-Match orthodontic programs and was fortunate enough to get offers from both of them. The way Pre-Match works is that you will get an interview from the Pre-Match school just as you would for a Match school. You will then go on the interview and about a week later you will receive formal notice if you are indeed accepted. The school will then give you a deadline to accept or decline their offer. In my experience, I had approximately four or five days to make a decision. If I had accepted, I would have had to put a down payment to reserve my spot and withdrawal from the Match. My best advice for those of you applying to Pre-Match programs is to go to the interview with the mentality that you are going to get offered a spot. The reason I recommend this is that everything happens very fast for Pre-Match and you are forced to make a decision very quickly—which is stressful. During your interview, look for red flags or potential concerns that you have with attending that program. If you

Trust the Match. Wherever you match is the best school for you. Don’t be bummed if you don’t match at your #1. Dentistry, and Dental Anesthesiology. There are some specific schools within the programs listed above that do not participate in the Match. These programs are called “Non-match” programs and they are able to offer positions directly to their desired applicants. The ADA recognizes 9 different specialties. Of the nine, the specialties that do not participate in the match are Endodontics, Oral and Maxillofacial Pathology, Oral and Maxillofacial Radiology, and Prosthodontics. Do you have to sign up to take part in the Match? If so, how does one go about doing that? Yes, you have to sign up to take part in the Match system. Once you have completed your ADEA Postdoctoral Application Support Service (PASS) application you will be eligible to sign up for Match. I was able to sign up for Match through the PASS website. Is there only one Match for all students entering postdoctoral programs, or is it broken out by the type of program in which you’re interested? The Match is broken down in to two different phases. The first match is for

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don’t see any red flags or have any concerns and you get offered a spot, take it, and you’re gold. It’s an extremely difficult decision to turn down a guaranteed Pre-Match spot to stay in the Match and have that possibility of not matching at all. I was sweating bullets when I turned down the two programs to stay in the Match. What are some important dates associated with the process? How do you prepare for the application process? The deadline dates change each year, so be sure to check the Match website and the PASS website for current deadline information. The best way to prepare for the application process is to start early. Each school program has a set application deadline. I recommend going to each program’s website in order to find out its specific deadlines. The programs also have different requirements that you need to fulfill in order to apply. For example, I applied to orthodontic programs, and most of the schools required a GRE (Graduate Record Exam) score as part of the application process. Therefore, if you are applying to an orthodontics residency you need to take the GRE well before the different program application deadlines so that you will be able to receive and submit a score. I recommend making a spreadsheet of

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all the programs to which you intend to apply. On the spreadsheet, have a column for application deadline and a column for required materials. I cannot stress enough the importance of starting the application process early. I missed multiple deadlines because I was waiting on my GRE scores. Schools will not wait for you and they will not make exceptions. What advice would you give to someone preparing to apply for Match for the first time? Keep detailed notes about all of the programs at which you interview. This will be instrumental when you come up with your Rank Order List. One thing I did that was very useful to me was make a “pro and con” list for each program; I taped the lists up on my wall so I could see them all at once. I recommend giving yourself plenty of time to come up with your Rank Order List, as it can be very time consuming. When you are coming up with your Rank Order List, be sure to rank programs based entirely on what program you would want to be at most. There is no strategy to it. It does not help you in any way to put a school you think you have a better chance at matching ahead of a school you would rather go to. For example, the program where I ended up ranking number one was Montefiore. Based off of my interview, I did not think I had a snowball’s chance in you know where of matching there—but it was the school that I wanted to go to most so I ranked it number one. Although I felt like I had a better chance at matching at other schools, I still kept Montefiore number one.

post graduate program. As for getting an interview at a post graduate program, each school has its own requirements. In order to get an interview schools look at GPA, National Board Scores, Class Rank, leadership experience, research and other factors. Most schools do not publish a cutoff for GPA, class rank or board score but due to the competitive nature of all the residency programs, I would recommend being in the 90th percentile for each category. How many positions are generally filled on Match Day? According to the National Matching Website for the 2012 Match, there were 2,562 applicants that participated in the Match and 1907 were offered positions. The Match website breaks down these numbers by postgraduate program on their website: http://www.natmatch.com/dentres/

Applying to specialty programs is a full-time job, and it’s not something you can swing together last minute

Is there anything that younger dental students (D1-D3) can do to make the application process easier on them? Start early and be organized. Applying to specialty programs is a fulltime job, and it’s not something you can swing together last minute. It’s important that you are aware of what each school requires as part of their application. Starting early gives you ample time to satisfy the requirements and submit your application on time. One thing you need to keep in mind is that some programs require three letters of recommendation and five PPIs (Personal Potential Index). That means you need eight faculty members to know you well enough to satisfy this requirement. Also, many faculty members like to have plenty of notice if you ask them to write a letter or fill out a PPI. You don’t want to be waiting on busy professors when you are trying to submit your applications. Also, take your auxiliary tests early. You don’t want test scores to be holding you up from submitting your application, either. Are there certain requirements a dental student must have fulfilled (passed regional exam, overall GPA, interviews, etc) in order to be eligible to be matched? Do different post-doctoral specialties have different requirements? The only requirement to participate in Match is to have interviewed at a

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For those that were unlucky and did not match, how does the Post-Match process work? My best advice for this question is to read “Navigating the dental postMatch” in the March 2012 issue of ASDA News. Kallie Law does a wonderful job outlining all the options available to those who do not match. What one piece advice would you leave for next-year’s applicants? What one thing do you know now that you wished you knew then? I would advise them to apply to lots of programs. It’s just so competitive and it’s better to apply to lots of schools once than having to go through the application process twice. Of all the schools I applied to, I would never have been able to guess which programs that ended up selecting me for an interview. I feel like nothing is a lock so it’s best to cover your bases and apply across the board. Any final words or thoughts about Match Day before we let you go? Trust the Match. Wherever you match is the best school for you. Don’t be bummed if you don’t match at your #1. For those of you who don’t match at all, don’t let the Match stop you from doing what you want to do. Work hard, make yourself more competitive, and reapply next year.

*Orthodontic resident, Montefiore Medical Center, Bronx, NY.

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LEARN MORE ABOUT THIS TOPIC WWW.THENEXTDDS.COM / PODCASTS/ADAPTIVE-LEARNING-TECHNOLOGY-IN-THE-CLASSROOM

TECHNOLOGY IN THE DENTAL CURRICULUM

HE GOAL OF ALL DENTAL EDUCATIONAL INSTITUTIONS IS TO PREPARE THEIR STUDENTS WITH THE FUNDAMENTALS AND SKILLS NECESSARY TO ENSURE FUTURE COMPETENCY AND PROPER PATIENT CARE. This includes all aspects of diagnosis and treatment as well as awareness of the current (or future) standard of care in technology, materials, and techniques. Today’s dental students, more than ever before, have lived and been educated in an interactive world, using technology to enhance the learning process and expecting an immediate response, feedback, and results. Current and future technological advances in dentistry (e.g., CAD/CAM, digital radiography and digital record keeping) must be incorporated in existing dental curricula in order to prepare tomorrow’s dentists properly. At the same time, many dental schools across North America are experiencing a shortage of funds and faculty, along with an ever-increasing curriculum crunch. There is a nationwide emphasis to address a purported “access to care” issue through increased class size in existing dental schools and the building of numerous new ones. Under these circumstances, in order for any new technology to have a viable chance of being incorporated into an existing dental curriculum, it must save time and money and be a better solution than the current modality. In private practice, chairside CAD/CAM systems offer the advantage of in-office scan-

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by Richard Callan, DMD* Walter Renne, DMD** ning, designing, milling, and delivery, providing clinicians with complete control of their schedule, their quality, and consistency. They provide a tremendous convenience factor for patients and practices as well as maximizing profitability. While these same Innovation provide benefits to the university/teaching environment, there are many more advantages of chairside CAD/CAM systems that can enhance the learning experience and provide unparalleled opportunities for faculty and students. In the simplest terms, current chairside CAD/CAM systems can be used as learning tools and methodologies to enhance educational objectives in the following categories: • Tooth anatomy and morphology • Preparation design (Figure 1) • Restoration design • Material understanding and selection • Occlusion/articulation One major advantage of CAD/CAM from an educational standpoint is the students’ ability to magnify preparations on the computer screen and mark their own finish lines. It is remarkable how they grow as student clinicians when they can see at 50x magnification the errors in their finish line designs. The most common errors are lipped margins, bevels, rough spots, and feathered areas. Before CAD/CAM, a student would not have the opportunity to evaluate his or her preparations at this level of detail and magnification (Figure 2). As a result, the quality of prepara

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FIGURE 1 Three-dimensional visualization of a virtual molar tooth preparation provides clear understanding of clinical requisites.

FIGURE 2 Viewing of the tooth preparation via E4D Compare enhances the user’s ability to selfassess areas requiring refinement or correction.

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FIGURE 3 Objective comparisons between proposed (student) and preferred (master) preparations.

FIGURE 4 Color coding: red (over-reduction) and blue (under-reduction) provide immediate feedback and assessment of quality based on the school’s chosen tolerances.

THE NEXT DDS

tions starting in the pre-clinics and carried over to the clinics has been remarkable and considerably better since the introduction of CAD/CAM. The addition of CAD/CAM in the pre-clinical curriculum mandates increased knowledge and more curriculum time devoted to the study of ceramic materials. Students are very familiar with all types of ceramics and have hands-on time manipulating, custom characterizing, and bonding a variety of materials before they reach the clinics. They also have a profound understanding of advanced ceramics and adhesives that are essential to successful treatment in a modern dental office. There are some who feared having students utilize digital dentistry would compromise or cause them to lose the fundamentals and conventional techniques that are essential to successful comprehensive care. Ironically, CAD/CAM technology has resurrected some principles that were no longer taught. For example, gold inlays and onlays were removed from the curriculum as gold prices increased, patient demand decreased, and curriculum load increased. Now, however, using the E4D System, students learn about conservative all-ceramic onlay and inlay preparation principles and design elements. Before the end of the pre-clinic semester, students will prepare, scan, mill, and bond an onlay on the dental simulator in addition to various other anterior and posterior crowns. Furthermore, this treatment option is carried over when they get to the clinics, and more conservative partial coverage restorations, such as onlays, are being treatment planned over more aggressive full-coverage options. Today, instructors can use E4D Compare software in order to improve their evaluation of students’ preclinical work. The software objectively compares two similar environments: prep to prep, prep to preop, pre-op to restoration—essentially any combination of comparisons. It then automatically and objectively evaluates a student’s preparation based on an ideal preparation of the same tooth that a faculty member scanned into the system (Figure 3), effectively removing

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all subjectivity from grading. Performance evaluations can be more objective and less likely to be called into question. This software will scan a student’s work, create a 3D model and superimpose this model onto the ideal, allowing instant feedback and visualization of errors (Figure 4). The digital model can be rotated and magnified on the screen and viewed from all angles. Students can instantly obtain objective feedback. Not only will this assist the objective evaluation, but it will also improve the learning process as students progress along their “confidence curves.” They can selfevaluate their preparations or restorations and gain reinforcement toward continual improvement on their own, not just when faculty members are present. Each institution must decide the degree to which this technology will become part of its curriculum. Timing of the various aspects to be incorporated is equally critical. Any change to the curriculum will undoubtedly create a certain degree of angst among the majority of the faculty. It is therefore imperative to present to the entire faculty the advantages of CAD/CAM technology and how it can enhance our students’ dental education throughout the curriculum. It is clear that CAD/CAM technology is the future of dentistry, and the earlier we can teach students the indications and contraindications the better. With quality CAD/CAM systems available from various manufacturers, it is only a matter of time before more institutions adopt this technology as a way to teach students and provide more conservative and economical care to patients.

* Associate Professor and Chair, Department of General Dentistry, Georgia Health Sciences University School of Dental Medicine. ** Assistant Professor, Department of Oral Rehabilitation, Medical University of South Carolina. Acknowledgment: E4D Compare is developed by D4D Technologies, Richardson, TX.

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The

Next DDS DR. ROBERT GEIMAN

FORMER INTERNATIONAL STUDENT REPRESENTATIVE ALPHA OMEGA DENTAL FRATERNITY ETA CHAPTER PRESIDENT COLUMBIA UNIVERSITY interviewed by Rich Groves

THE NEXT DDS

obby Geiman graduated May 2012 from Columbia University School of Dental Medicine with his DDS degree as well as an MA in Science and Dental Education. While at Columbia, Bobby helped to revive the University’s Alpha Omega Dental Fraternity chapter and has served as its president from February of 2009 until graduation. In this interview, Bobby discusses his thoughts on dental education, THE NEXT DDS, and the important role of new technology in the future of dental education. IS THERE SOMEONE ASSIGNED TO TAKE LECTURE NOTES ON BEHALF OF ALL THE STUDENTS IN THE CLASSROOM? My classroom experience at Columbia was great. There wasn’t a “stenographer” per se for each class, but a growing number of our classes were videotaped so that the students can have access in preparation for exams and clinical work. In some classes we did have class representatives; they didn’t necessarily transcribe everything that was said, but they volunteered to take notes and share them with the class. Those notes are posted on the website for our class—anyone at Columbia with a student username and password can access through that environment.

HOW ARE THE VIDEOS SHARED FOR DENTAL STUDENTS AT COLUMBIA UNIVERSITY COLLEGE OF DENTAL MEDICINE (CUCDM)? It’s all done through iTunes University, so it’s really convenient. You can download these instructional videos right onto your iPod, iPad, etc., and students can listen to lectures on the subway or on their computer.

Fall 2012

Volume:2

Issue:1

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There is so much dental information out there, and having a central location like THE NEXT DDS where you can access dental topics is vital for students — it’s vital for the profession

About Robert: EDUCATION University of Maryland Baltimore, MD Ortho degree program pursuing Master of Science in Oral Biology — Started July 2012 Columbia University College of Dental Medicine New York, NY DDS — May 2012 Columbia University Teacher’s College New York, NY Master of Arts in Science and Dental Education — May 2012 Brandeis University Waltham, MA Bachelor of Arts in Mathematics — May 2008

AWARDS AND FELLOWSHIPS 1st place, Student Poster Competition Alpha Omega (International) Convention — 2011 Third-Year Student Research Fellowship Columbia University — 2010 New York Academy of Dentistry Student Research Fellowship – 2009 Dr. Ralph Berenberg Memorial Award: Recognition of Pre-Dental Achievement — 2008

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Fall 2012

Volume:2

Issue:1

THE NEXT DDS

PROFILE: DR. ROBERT GEIMAN

WHAT OTHER TECHNOLOGIES ARE INVOLVED IN YOUR CLASSROOM OR CLINICAL EXPERIENCE? In the classroom, we used everything we could get our hands on. We first started with Courseworks, which evolved into Classweb; both of which are online course directories. Additionally, almost all the students have laptops out during lectures, so they can take notes and search the Internet for credible information as our professors are presenting—you know, working to piece things together and better understand a given topic. Many professors make their own multimedia, and those are nice adjuncts to class. We used electronic oral health records in the clinic, Axium, which is a technological aspect of the experience. In a few years, the Axium model, will create an excellent database for data mining. We had access to CAD/CAM in clinic too. At Columbia we were exposed to many innovations in lectures and benefitted from additional clinical instruction on how to apply this technology for optimal patient care. Many of us worked with digital orthodontics, made CAD/CAM crowns chairside, and used lasers for certain clinical procedures.

TELL US MORE ABOUT THE ELECTRONIC HEALTH RECORDS. At CUCDM, electronic oral health records were actually implemented in July of 2011. My class was the first to use them, and it was an interesting experience. Some of my research was on users’ expectations versus perceptions, and a lot of students had false perceptions about how electronic records would impact the clinic experience. From a layman’s point of view, when people think of electronic records, they think technology—which usually makes a process faster, more efficient, and that’s why people buy into it. To date, electronic records have not made things more efficient. Charting electronically often takes significantly more time, and there’s a larger learning curve because the faculty and the students are not used to it yet. And of course there were different levels of computer skills throughout the class and the faculty. Despite all this, we were all obviously expected to perform at a high speed. However, with time, the use of EoHRs will enhance our education and increase research possibilities.

THEY’RE A GROWING PART OF DAILY DENTAL PRACTICE. WHAT BENEFITS DO YOU FORESEE FROM ELECTRONIC HEALTH RECORDS ONCE YOU OVERCOME THE INITIAL LEARNING CURVE? From an educational standpoint, it is necessary to first identify the patient’s problem, then to create a diagnosis, and finally, to create a treatment plan in a logical order. In the EOHR system, you are actually blocked from proceeding to the second or third step, without first getting approval for the initial step from the faculty. That’s a good aspect to it, especially for people who are just starting clinic. I think the other very powerful thing about electronic health records is data mining. So much data are generated and collected that you can crossreference every patient with any given disease or disorder and see all the similarities between them. Any single systemic disease, disorder, or diagnosis can be looked at very, very quickly, so from that perspective it’s very good. And I think with time there’ll be a lot of improvement and the experience will be more rewarding and simplified for everyone. The ramp up is just a little difficult. Additionally, faculty and students can view all of our patients, chart notes and more information from their personal computer, using a secure VPN connection. This makes life easier for students preparing for procedures, and faculty approving procedures.

SPEAKING OF EDUCATIONAL RESOURCES AND TECHNOLOGIES, WHAT TYPE OF SMARTPHONE USER ARE YOU? I have an android phone. Additionally, I think that more and more students are using tablets in the clinic rather than smartphones because of the advantages a bigger screen presents. My classmates often used their tablets to access electronic dental records so that they don’t have to bring professors over to their chairs all the time. Instead, they bring their tablet directly to the professor, and they can look at it together. The portability of a tablet is important in clinic. Additionally, they can use tablets to bring up radiographs and demonstrate them to the patient and the faculty from various aspects. There are also a lot of oral hygiene instruction videos, and other educational videos

•

2007

Dec 2007

May 2008

Feb 2009

Oct 2009

Jun 2009

Aug 2010

Accepted into Columbia University DDS program

Awarded the Dr. Ralph Berenberg Memorial Award in Recognition of Pre-dental Achievement – Brandeis University

Participated in research project headed by Dr. John Zimmerman, DDS [The Expectations and Perceptions of an EoHR System in an Academic Institution]

Served as Orientation Chair for new students at Columbia University

Accepted into Masters in Science and Dental Education Degree program (Columbia)

Receives Jerome Heffer Award for Excellence in Chapter Leadership – Zeta Beta Tau National

THE NEXT DDS

Fall 2012

Named Chapter President of the Eta Chapter of Alpha Omega Dental Fraternity

Volume:2

Issue:1

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available online—for example, how to clean a denture, explaining how a bridge compares to an implant, etc. All of those different instructional videos greatly help to educate a patient in making decisions regarding his or her case. I think technology has been really effective in this way. As for actual educational tools for students, I can’t say that I’ve seen much of that in clinic, but THE NEXT DDS seems to be gearing up as the big one.

THANKS, THE NEXT DDS MOBILE HAS BEEN REALLY WELL RECEIVED BY THE DENTAL STUDENT COMMUNITY, AND WE’RE VERY EXCITED ABOUT ITS POTENTIAL. DO YOU USE YOUR SMARTPHONE TO CHECK DRUG INTERACTIONS AND SUCH THINGS? Definitely. When a patient comes in and starts listing all the medications that he or she takes, there’s no way to remember all the specific interactions—that’s where it valuable to have access to the information online. I’m on my phone right away to find sound information on my patient’s medications. Before we prescribe anything, we have to understand potential drug interactions. That’s a big one. Back “in the day” you would ask a knowledgeable professor, hoping that he or she did in fact know it all. Dental students are supposed to know our pharmacology, of course, but it’s almost impossible to remember all the drug interactions. Using today’s resources, we’re in a much better position to respond to our patient’s needs. If you use credible technologies to verify potential drug interactions, you can obtain a [fool-proof] answer—that’s extremely beneficial. In Axium, if the patient is allergic to penicillin and you try to write a prescription for penicillin, the program will actually show an alert and won’t let you.

LET’S SWITCH GEARS FOR A MOMENT. WHAT DO YOU THINK ABOUT THE ABILITY OF THE NEXT DDS TO SUPPORT YOUR PROFESSORS? I think that instructors can use THE NEXT DDS in many ways. First, they can have their students read specific articles or watch certain videos before or after class as a homework assignment. For example, maybe if you are in pre-

clinic one day and it’s the day you’re learning how to use composite, you can watch a direct resin bonding video in the general dentistry or the operative dentistry section of THE NEXT DDS, which will explain all of the steps necessary to be successful in the aforementioned procedure. As faculty, I think having that multimedia aspect to your instructional methods shows students that you’re open to new means of education, and I think the younger people like that; it gets them a little more interested than just a standard PowerPoint lecture. It also shows that you’re demonstrating current techniques—a concern many students share. I think that professors who don’t use THE NEXT DDS or any new technology are potentially hurting their class, because I think the move toward technology and new methods is inevitable, and it only enhances the educational experience in terms of comprehension and retention.

A DENTAL STUDENT IN OUR BREAKOUT SESSION AT THE 2012 ASDA ANNUAL SESSION WAS COMPLIMENTARY ABOUT MULTIPLE MEDIA IN THE NEXT DDS. Yes—bear in mind that we spend hours in lectures, so when someone comes out and does something different it really gets our minds working. It happens all the time; a lecturer presents with a whole different style and everyone’s paying attention--that’s great. When students are invested in the material it can have a domino effect: One person will ask a question, then another person, and you’re learning together.

HOW COULD THE NEXT DDS BE ENHANCED FOR THE STUDENTS THAT FOLLOW BEHIND YOU? I think THE NEXT DDS is a great idea all around. When I first heard about it, I imagined a dental Wikipedia meets Facebook. I think it has the informational part down really well, and I think by enhancing user’s profile a little bit more it might be more engaging from a social media standpoint. In this day and age, privacy is important to everyone—users and patients alike. THE NEXT DDS keeps personally identifiable patient information (e.g., photos, radiographs) private on the site, and as a user I can always control how much of my profile that I share with the community, right?

•

Aug 2010

Jan 2011

Mar 2011

Dec 2011

Feb 2012

May 2012

Participated in research project headed by Dr. John Zimmerman, DDS [Human Anatomy: Is dissection an outdated means of education?]

Named International Student Representative of Alpha Omega Dental Fraternity

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As ISR for the fraternity, brings THE NEXT DDS to AO

Fall 2012

Matched at UMaryland for Orthodontics

Volume:2

Won first place in the Student Poster Competition at Alpha Omega 2011 International Convention

Issue:1

Participate in Global Health Externship in the Philippines

THE NEXT DDS

Graduation from Columbia University School of Dental Medicine Graduation from Columbia University Teacher’s College

PROFILE: DR. ROBERT GEIMAN

EXACTLY. YOU HAVE THE ABILITY TO DISPLAY OR CONCEAL ALL THE RELEVANT PARTS OF YOUR PROFILE—ALL CONTROLLED AT YOUR OWN DISCRETION. Right, and then other users can still contact you through THE NEXT DDS messaging. It’s good, you really have control over your own level of privacy.

WHAT IS YOUR OVERALL IMPRESSION OF THE NEXT DDS? I think it’s great. I think it’s a resource that’s really necessary. There is so much dental information out there in general, and having a central location like THE NEXT DDS where you can access dental topics is vital for students— it’s vital for the profession. It’s good to have one place that confirms proper techniques and considerations via peer-reviewed content. Searching on THE NEXT DDS is also very quick and efficient, which is something I like about it. As a busy student, the worst thing is when you’re trying to find an answer to a question and you spend so much time looking for an answer and you forget what the question was. It happens so many times when we’re studying. We go on Google to find information on acid etching or some small detail, and then 20 minutes later you question why you started the search in the first place.

HOW DO YOU SEE THE NEXT DDS FIVE YEARS IN THE FUTURE? Presumably, if everyone joins the community by then, I see THE NEXT DDS as a very robust networking site, search engine, and overall great tool for students. Let’s put it this way—if I could invest in THE NEXT DDS, I would. I really think it has a very bright future, and a lot of possibilities. And when it’s been adopted by students globally, you’re going to get different experiences from all over the world, and it’s going to be interesting to see how dentistry is different all over the world. We’ll sit here in the United States and debate which crown preparation is right for a given condition, but what about in some countries where they’re just trying to learn how to fill a cavity, or about water fluoridation? The sort of information provided on THE NEXT DDS can be so powerful.

When I first heard about THE NEXT DDS, I imagined a dental Wikipedia meets Facebook.

LET’S TALK ABOUT THE ALPHA OMEGA DENTAL FRATERNITY. HOW DID YOU GET INVOLVED IN THIS GREAT ORGANIZATION? When I started dental school, I saw Alpha Omega on the clubs list and started to ask around about it. At that time, it was relatively non-existent at Columbia. I think a lot of the principles of AO were the same that I hold, so I contacted [national] leadership and asked what I could do to regain momentum with the Eta Chapter at Columbia—they essentially gave me full reign to rebuild.

THE NEXT DDS

So I started from scratch. Eta had been a large chapter in the 60s and 70s, so there were many professors at Columbia who were AO Alumni. I learned more about the organization from a local and national perspective while helping to restart the chapter and, after completing my term as president, thought I should get more involved on the international level. I decided to run for the highest student position, which is called International Student Representative or “ISR”. Basically, that person is a student liaison to the national board. Overall I’m very pleased with the roles I’ve held within the organization, and with the AO as a whole, and I hope to continue that next year in residency and beyond. Something I like about AO is that you join as a student—as you do with a lot of other organizations—but your membership doesn’t end when you graduate. You’re a member for life. A lot of AO alumni are as active or more active than students are, which is nice.

Fall 2012

WE SET UP A GROUP WITHIN THE NEXT DDS JUST FOR ALPHA OMEGA TO CONTINUE FOSTERING THESE RELATIONSHIPS. TOMORROW IF YOU SAW A D1 WALKING THROUGH CUCDM, WHAT POINTS OF ADVICE WOULD YOU GIVE THEM TO HELP THEM GET THROUGH SCHOOL IN AN EASIER WAY?

I would stress the importance of effective time management and self-discipline. There are so many classes we take, and there are tests throughout the process. You need strong organizational skills to manage that type of schedule. To help stay organized, it’s important to set daily goals and to actually write down a daily schedule—how long you’re going to spend studying for this class, how long you’re going to spend on research, and even for social events. You’re going to go out this night and you’re going to wake up at this hour and get to work at this time the next day. All of us have a mental to-do list, but when we actually write things down it helps us get things done a lot quicker and more efficiently. I think it’s important for D1s to know that dental school is going to be hard, but it’s not only about studying. They should definitely get involved in organizations that interest them. Most dental schools have so many organizations that students can get involved easily. Lastly, I think I would remind a First Year to consider the dual degree opportunities that many schools offer. I completed a DDS / MA at Columbia, but there are a lot of others (e.g., DDS MPH, DDS MBA) that many students don’t know about. The opportunities are there—you just need to take them.

VALUABLE ADVICE, DR. GEIMAN, AND THANKS FOR SPENDING TIME WITH THE NEXT DDS TODAY. WE WISH YOU MUCH SUCCESS WITH YOUR ORTHODONTICS RESIDENCY AND THE NEXT PHASE OF YOUR BRIGHT CAREER!

Volume:2

Issue:1

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THE

BY THE NUMBERS Curious about how dental students at other schools are digging into THENEXTDDS? Wondered about how they use the site, its educational resources, how they log on? Here are some statistics that weâ&#x20AC;&#x2122;re proud to share about how you and your classmates have engaged with this excited new educational resource! (Time period measured: June 1, 2011 to May 31, 2012)

What is the most commonly used browser for exploration of THE NEXT DDS? 6% Other (1,896)

19% Internet Explorer (5,703)

32% Safari (9,828)

21% Firefox (6,372)

22% Chrome (6,608)

Your Top Five Blog posts on THE NEXT DDS

Exploring Associateship: Due Diligence Questions (126)

Improving Clinical Effectiveness of Dentin Enamel Bonding Agents (71)

Preventing Aspiration or Accidental Ingestion (70)

Social Networking â&#x20AC;&#x201C; A Good Thing from a Malpractice Perspective? (68)

Holistic Treatment Gone Awry (58)

TOTAL Visits: 30,407

DENTAL STUDENTS WERE ASKED: When we add a Licensure feature to THE NEXT DDS, what is the most valuable information it could share?

What topic would you like to see more of on THE NEXT DDS in the future? (Check all that apply) Practice Administration

83%

Dental Technology

72%

Oral Hygiene

65%

Infection Control

54%

Orthodontics

48%

Periodontology

34%

Restorative Dentistry

28%

Tips and Hyperlinks to recommendations Ethics/ related content from previous (e.g., articles, standardization participants videos, etc.)

Operative Dentistry

26%

Endodontics

22%

Implantology

20%

General Dentistry

14%

Issue:1

BEST PRACTICES

Important dates/times/ locations

THE NEXT DDS

Frequently asked questions

Fall 2012

Volume:2

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Focusing on Innovation, Crosstex Protects. You may not always consider how important a role everyday products such as face masks, sterilization pouches and environmental barriers play in protecting healthcare

Among our best-selling patented, patent pending or innovative products are: • Face Masks with SecureFit® Technology • Sure-Check® Sterilization Pouches

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ASSOCIATESHIP

FOR ADDITIONAL INFORMATION ON THIS RELEVANT TOPIC, BE SURE TO VISIT WWW.THENEXTDDS.COM/PODCASTS/DEBT1 OR WWW.THENEXTDDS.COM/PODCASTS/DEBT2 OR SCAN WITH YOUR SMART PHONE HERE

MANAGING DEBT AFTER GRADUATION

UNDERSTANDING COMPOUNDING AND DEBT The beginning of your new professional career will bring a new set of challenges. If you are like most new dentists, you will graduate with considerable school-related debt. Dealing with the repayment of that debt will be, for most new dentists, not only their first career challenge, but also an ongoing challenge.

any new dentists are first employed as associates after graduation. While providing an immediate and sizeable income for the recent graduate, most associateships have limited earning capac-

ity. Dental practice owners generally earn three to four times the average income of an associate. Consequently, every new graduate needs to set his or her sights on ownership as soon as possible. How all debt is handled, including school debt, between the time of graduation and practice ownership, is critical if ownership is to become a reality.

by Dr. Gene Heller*

Understanding Debt

Adapted with permission from New Dentist â&#x20AC;&#x201C;The Resource For Career Success.

THE NEXT DDS

Most new dentists are familiar with the concept of compounding. After the first compounding period, a savings account or similar investment is compounding interest on interest in addition to the interest on principle. As interest continues to compound, eventually the compounding on the interest will exceed the compounding of the original principal. For example, $1,000 at 10% interest will double in value after 7.2 years, or earn $1,000 of interest in 7.2 years. It will take a little over four years to earn the second $1,000--and in less than three more years, the third $1,000. Unfortunately, unpaid debt also compounds.

Fall 2012

Volume:2

Issue:1

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One Adhesive: Two Powerful Monomers

GET A FREE SAMPLE

Visit www.shofu.com Enter code: NDDSBB11 while supplies last

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ASSOCIATESHIP

At the same 10% interest rate, a $100 debt grows to $400 in 15 years, $672 in 20 years, $1,083 in 25 years and $1,700 in 30 years. The average new dentist carries, at the minimum, school debt amortized over a 15-year period and carries home mortgages with 30-year amortizations. Therefore, each $100 they spend on non-essentials in lieu of pre-paying their school debt actually costs them $400 to $1,700.

THOSE WHO ELIMINATE ALL DEBT WITHIN SEVEN TO TEN YEARS OF GRADUATION, WILL ACCUMULATE SUFFICIENT WEALTH TO ALLOW FOR RETIREMENT Putting an unnecessary or luxury purchase (usually via credit at an APR of 18+%) in this perspective makes it much easier to decline making the $100 purchase. Each $100 meal actually costs $400 as long as long-term debt exists. Conversely, an additional $300 per month payment added to the monthly payment of $1,100 on a $150,000, 30-year mortgage will decrease the number of years for pay-off of the mortgage from 30 to 15 years, or a savings in excess of $144,000. Measured in today’s money, those dentists, typically aged 25 to 30 at graduation, who eliminate all debt within seven to ten years of graduation, will accumulate sufficient wealth to allow for retirement, if they so choose, by the age of 45.

THE NEXT DDS

Fall 2012

Volume:2

Issue:1

Those who eliminate their debt within 15 years of graduation find themselves able to retire by age 50. Those who fail to eliminate their debt within 20 years of graduation will typically find themselves working past the age of 62 and have a net worth of less than $100,000 by retirement. A common misconception about debt relates to taxes. Many have heard that some debt is in fact good, as long as it provides a tax write-off. A simple example will point to the fallacy of this approach. Suppose a dentist has $100 in taxable income. Let’s further suppose that he has debt resulting in an interest charge of $100. If he in a 33% combined state and federal tax bracket, the dentist will save $33 in taxes, but will have spent the $100 for interest. Net in their pocket after taxes? Zero. If the dentist did not have a $100 interest expense, he would owe $33 in taxes from the $100 profit. Net in their pocket? $67. You are always better off paying your taxes than paying interest on a loan. A second fallacy is “buy now, pay back later” with cheaper money because of inflation. Unless the inflation rate exceeds the interest rate, this does not work. Furthermore, history has shown that for the few brief periods when this was in fact true, loan re-payment terms always exceeded the term of this brief excess inflation rate, meaning the purchaser had to repay debt with the compounding interest-bearing loan long after the inflation had subsided. The only time it is permissible to “buy now, pay later” is to acquire productive assets that generate income that exceeds the compounding rate of interest.

Conclusion The above is but part of a series that focuses on the principle of compounding and the easiest way to manage one’s debt after dental school. By understanding the impediments to wealth—the most significant being debt—the more prepared each new graduate will be to deal with his or her own situation and enjoy the fruits of the dental profession.

Nationally recognized expert in practice transitions and Vice President of Practice Transitions, Henry Schein Dental.

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school spotlight

RESEARCH DAY

at Tufts University School of Dental Medicine

ithin each edition of the Magazine, THE NEXT DDS endeavors to highlight various research activities conducted at dental schools around the U.S. We are privileged to feature herein several of the Bates-Andrews Research Day winners from the 2012 competition at Tufts University School of Dental Medicine. Each year, the university conducts this activity to commemorate George A. Bates, an alumnus who taught Tufts medical and dental students. We are proud to share some of their accomplishments with THE NEXT DDS community within these pages and look forward to spotlighting student research from around the country in subsequent editions.

Special thanks to Drs. Gerard Kugel and Eileen Doherty for their assistance, and to all the TUSDM participants who continue to advance the profession through their research.

THE NEXT DDS

Fall 2012

Volume:2

Issue:1

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Shear and Tensile Strength of Silk Coatings on Titanium Surfaces Courtney Michelson Tufts University School of Dental Medicine, Boston, MA Masty Harsono Tufts University School of Dental Medicine, Boston, MA Roberto Elia Tufts University, Department of Biomedical Engineering, Medford, MA Gary Leisk Tufts University, Department of Biomedical Engineering, Medford, MA Racquel Legeros New York University College of Dentistry, Department of Biomaterials and Biomimetics, New York, NY. David Kaplan Tufts University, Department of Biomedical Engineering, Medford, MA Gerard Kugel Tufts University School of Dental Medicine, Boston, MA

Introduction: Insertion of dental implants has become a standard procedure; however, the osseointegration process at the implant-bone interface remains a challenge. Coatings have been introduced to accelerate the rate of osseointegration. An optimal adhesion is required for coating materials to adhere on titanium surfaces. Objective: To develop a silk-based material that would provide an adhesive coating on dental implants and to assess the effectiveness of two silk coatings (silk and combination of silk and carbonate apatite) on three different surface treatments by comparing their shear and tensile strengths. Methods: Sixty commercially pure titanium discs (7mm-diameter) were randomly divided into three groups: Group 1: Control (no surface treatment); Group 2: Sintered with apatite grit (MCD sand blasted); Group 3: Acid etched (3.5% HCl/H2SO4, 24hr). Using a patented process, silk fibroin was extracted and melted into e-gels. In each group, half of the samples were coated with silk only e-gel and the other half were coated with a combination of carbonate-apatite and silk in 1/5 ratio by volume. Two titanium studs were adhered using melted e-gel and allowed to dry overnight at room temperature. Tensile and shear tests were carried out with Universal testing machine (Instron) with a crosshead speed of 0.5mm/min. Statistical analysis was accomplished with one-way ANOVA. Significance was at p<0.05.

Group 1 Group 2 Group 3

Coating

Tensile

Shear

Silk

0.34±0.11*

0.61±0.14*

Silk+Ca-apatite

0.54±0.04*

0.75±0.18*

Silk

0.82±0.12*

1.37±0.32

Silk+Ca-apatite

0.64±0.04*

1.07±0.34

Silk

0.43±0.18*

0.76±0.52*

Silk+Ca-apatite

0.88±0.05*

0.97±0.52*

1.80

1.60

1.40

1.20

1.00

Tensile

MPa

0.80

Shear 0.60

0.40

0.20

0.0

Only Silk

Silk/Hydroxy -apatite

No Treatment

Only Silk

Silk/Hydroxy -apatite

MCD Blast

Only Silk

Silk/Hydroxy -apatite

HCI/H2S04

— continued on next page

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Fall 2012

Volume:2

Issue:1

THE NEXT DDS

s c h o o l

s p o t l i g h t

â&#x20AC;&#x201D; continued from previous page The silk coatings produced significantly different tensile strengths for all surface treatment groups. For shear strength, significant differences were seen between surface treatments Groups 1 and 3. MCD-blasted surface treatment on titanium with silk coating exhibited the highest shear strength. Acid etched surface treatment coated with combination of silk and Ca-apatite exhibited the highest tensile strength.

Tensile Set-up

No Treatment

MCD Sand Blasted

HCI/H2SO4 Treated

Conclusions: Melted e-gel silk coatings were successfully fabricated and adhered to titanium with various surface modifications. The mechanical properties of these coatings were comparable to current literature for coatings on titanium surfaces. This process shows promise for use as functional coatings on dental titanium implants.

Shear Set-up

Peptides Derived from Leptin Inhibit Prostate Cancer Signaling Arpan Desai Tufts University School of Dental Medicine, Boston, MA Victor Mai Tufts University School of Dental Medicine, Boston, MA Maria Townes Tufts University School of Medicine, Boston, MA Paul Leavis, PhD Boston Biomedical Research Institute, Boston, MA

Introduction: Leptin is a protein hormone secreted by adipose tissue. It plays critical roles in both normal physiological processes (eg, energy balance, reproductive function) and in pathological conditions such as breast and endometrial cancer, in which overproduction of leptin is linked to progression of the disease. Leptin acts by binding to a receptor called Ob-R on the surface of its target cells which, in turn, initiates the phosphorylation of the Jak/Stat3 (Janus kinase/signal transducer and activator of transcription) pathway within the target cells that regulates their growth, invasiveness and their generation of other signaling molecules that regulate the cell cycle and angiogenesis. As tools for the study of leptin receptor function several polypeptides were synthesized based upon computer-generated structural models of leptin complexed to its receptor.1 Two of these peptides, called LPA-1 and LPA-2, correspond to two short regions of leptin that bind specifically and strongly to OB-R and block leptin signaling. These peptides have been shown to retard the growth of human breast cancer cells both in vitro and in vivo in mice, and to inhibit the secretion of downstream cytokines such as Il-1, VEGF, MMP-9, and LIF. Recent studies2,3 have shown that in several prostate cancer cell cultures, addition of leptin stimulates cell growth as indicated by an increase in Jak/Stat3 phosphorylation. In this study, we examined whether LPA peptides could inhibit the leptin effect. Methods: The investigators cultured two prostate cancer cell lines, PC-3 and DU-145. Cultures were grown in normal growth medium containing fetal bovine serum, then

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serum starved for 18 hours followed by addition of leptin alone or leptin plus LPA-1 or LPA-2, or leptin plus pegylated LPA-1 or pegylated LPA-2. The effects of these treatments on signaling and growth were determined using an ELISA assay for Stat3 phosphorylation and MTS assay (see sidebar). Peptide design and synthesis: Although the crystal structure of leptin is known, that of its receptor, Ob-R, is not. However, Ob-R belongs to the same receptor family and is highly homologous to the receptor for granulocyte colony stimulating factor (G-CFS-R), the structure of which is known. Therefore we employed a computer model to approximate the likely conformation of the leptin-receptor complex. This model suggested that helices H1and H3 of leptin bind to Ob-R. Peptides corresponding to H1 and H3 were synthesized by solid phase peptide synthesis using Fmoc (fluorenyl-methoxycarbonyl) as the amino protecting group. Peptides were purified by HPLC and characterized by

Cell Line

Cell Type

Growth Medium

MCF-7

human breast cancer (+ estrogen)

DMEM

PC-3

human prostate cancer

F12K

DU-145

human prostate cancer

RPMI-1640

mass spectrometry. Results for the tested cell lines are displayed on the following page. Conclusions 1. Serum starvation of cells removes hormones and cytokines necessary for normal growth and, therefore, inhibits cell proliferation. Addition of leptin to serum starved MCF-7, PC-3 and DU-145 cells partially restores their growth as indicated by both the MTS proliferation assay and by the ELISA, which reveals an increase in phosphorylation of STAT3. 2. The leptin-induced enhancement of growth is reduced when LPA peptides are added to the system. This suggests that the LPAs competitively inhibit leptin binding to OB-R, thus decreasing signaling. 3. Pegylated peptides are as effective as LPA peptides in retarding the leptin signaling in these assays. Their large PEG moiety does not seem to sterically hinder binding of peptide to Ob-R. Studies are currently underway to design modifications of LPA-1 and LPA-2 that will exhibit greater competition with leptin. Additionally, studies are underway to determine effects of leptin and leptin peptides in other prostate cancer cell lines, and in other cancer cell lines. References 1 Gonzalez RR, Leavis PC. Leptin up-regulates b3-integrin expression and IL-1b up-regulates leptin and leptin receptor expression in human endometrial epithelial cell cultures. Endocrine 2001;16:21-28. 2 Gonzalez RR, Leary K, Petrozza JC, Leavis PC. Leptin regulation of the interleukin-1 system in human endometrial cells. Mol Hum Reprod 2003;9:151-158. 3 Gonzalez RR, Leavis PC. A peptide derived from the human leptin molecule is a potent inhibitor of the leptin receptor function in rabbit endometrial cells. Endocrine 2003;21:185-195. 4 “Highlights from Epidermal Growth Factor Signaling Pathway”. Biowire: A Biofiles Special Edition (2011): 22. Print. 5 Garofalo C, Surmacz E. Leptin and Cancer. J Cell Physio 2006;207:12-22. 6 Somasundar P, et al. Prostate cancer cell proliferation is influenced by leptin. J Surg Res 2004;118:71-82. Acknowledgments The authors acknowledge the contributions of Elizabeth Gowell and note the above was supported in part by research fellowships and MBS thesis funding,and in part by Discovery Grant, Cancer-UK.

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Assay Protocol

Cells cultured in growth medium + 10% FBS

Cells are plated in a 96-well microplate and grown for 24hr

Serum-starve cells for 18hr

Add leptin ± LPAs to wells for 1-24hrs

For MTS assay

For ELISA assay

Add mts reagent and read absorbance at 490nms

Lyse cells and apply lysates to ELISA and plate-incubate overnight

Apply primary and secondary antibodies, and colorimetric agent to ELISA plate. Read absorbance at 450nm

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— continued from previous page Results Results indicate that in all cell lines, addition of leptin to the medium enhanced cell signaling, and the LPA peptides inhibited the leptin effect. These data suggest that targeting Ob-R might represent a novel therapeutic approach to the treatment of prostate cancer. Effect of Leptin and Pegylated Leptin Peptide on DU-145 Cells – Normalized

Effect of Leptin and Leptin Peptides on MCF-7 and PC3 Cell Lines MCF-7

1.00

0.95

Serum-free Well Leptin 100ng

0.9 Leptin 100ng+ MPEG-LPA2 100ng

0.85

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PC3

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1 Time Point (hr)

Effect of Leptin and Pegylated Leptin Peptide on PC-3 Cell Line – Normalized

0.80

0.60

0.40

0.20

0.0

Complete Medium

Addition of pegylated leptin peptides with leptin partially inhibits leptin effect in DU-145 Cells. ELISA experiment conducted to test leptin and pagylated leptin peptides individually and in combination. MPEGLPA-2 knocks down leptin signaling by approximately 12.3%. The absorbance is close to the absorbance in the serum-free well.

MCF-7

1.00

PC3

Percent Growth of Cells in 24 Hours

1.0

Normalized Absorbance Value at 450nm

Normalized OD450 Absorbance Value

1.05

Proliferation of MCF-7 and PC-3 Cells Determined by MTS Assay

Starvation

Leptin (100nM)

Leptin + LPA

Effect of Leptin and Leptin Peptides on DU-145 Cell Line – Normalized

Complete Medium

Starvation

Leptin (100nM)

Leptin + LPA

Addition of leptin peptides with leptin inhibits leptin effect in MCF-7 and PC3 cell lines. MTS assay conducted to determine the effect of leptin and leptin peptides on proliferation of MCF-7 and PC3 cell line. Leptin leads to growth that was lost because of starvation by 22% and 19% for MCF-7 and PC3 respectively. LPA decrease growth regained by leptin by 15% and 11% for MCF-7 and PC3 respectively. Effect of Leptin and Leptin Peptides on PC-3 Cell Line – Normalized

1.2

Serum-free Well

0.6

Leptin 100ng

0.4 Leptin 100ng+ MPEG-LPA2 100ng

0.2

Time Point (hr)

Addition of pegylated leptin peptides with leptin partially inhibits leptin effect in DU145 Cells. ELISA experiment conducted to test leptin and pegylated leptin peptides individually and in combination. MPEGLPA-2 knocks down leptin signaling by approximately 10%.

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1.0 Serum-free Well

0.95

Leptin 100ng

0.9

Leptin 100ng+ LPA1 1ug

0.85

Leptin 100ng+ LPA2 10ng

0.8

1.0

Time Point (hr)

Leptin 100ng

0.9

Leptin 100ng+ LPA1 1ug

0.85

Leptin 100ng+ LPA2 10ng

Time Point (hr)

Addition of leptin peptides with leptin partially inhibits leptin effect in DU-145 Cells. ELISA experiment conducted to test leptin and leptin peptides individually and in combination. LPA-1 and LPA-2 knockdown leptin signaling by 9% and 5.3%, respectively.

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Addition of leptin peptides with leptin partially inhibits leptin effect in PC-3 cells. ELISA experiment conducted to test leptin and leptin peptides individually and in combination. LPA-1 and LPA-2 knockdown leptin signaling by 12.9% and 13%, respectively.

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Retrospective Evaluation of Implant Failure Predictors at TUSDM Diego A. Camacho Tufts University School of Dental Medicine, Boston, MA James Koehler Tufts University School of Dental Medicine, Boston, MA Jessica Silva Tufts University School of Dental Medicine, Boston, MA

Introduction: The aim of the study is to retrospectively analyze a cohort of patients who had implants placed at Tufts University School of Dental Medicine (TUSDM) during the academic years from 2004-2010 and who sustained implant failure(s). This study investigates the possible causes of implant failure. The pre-implant findings will be reviewed. They include: radiographs, medical history and habits, past and present dental information (e.g., the history of why the natural tooth was lost), bone graft materials (bone type), previous bone distribution, bone quality, the size, design and manufacturer of the implant(s), and other parameters that will be discovered in conducting the research. Ultimately, through investigation and discovery of implant failure predictors, present therapies can be improved for future procedures. The aims of this study are to: 1) Calculate the failure rate of implants placed at TUSDM 2) Determine factors that affect implant failure at TUSDM One problem, however, is a lack of consistent protocols to ensure proper implant diagnosis, treatment planning, and vital record keeping across all specialties. Based on current literature and the University’s exceptional reputation, the authors hypothesize that the overall implant failure rate from 2004-2010 at TUSDM will be equivalent to that found in previously published non-university studies. Materials & Methods Experimental Design • Utilizing the electronic dental management software Axium, patient records demonstrating dental implant placement from 2004-2010 were accessed. • Records involving failed implants were examined. • Implant “failure” is defined as an implant that had to be removed or implants that exfoliated. Inclusion Criteria • ADA Code D6010 (i.e. Surgical placement of implant body: endosteal implant – includes second stage surgery and placement of healing cap) • Evidence of Failure o Diagnostic Radiographs o Keywords in Case Notes (including but not limited to) - “Implant failure” - “Implant removed and/or re-do” - “No osseointegration” - “Mobility of implant” - “Explantation” - Patient’s chief complaint o Procedure Codes - D6100 Implant removal - D7952A Implant salvage - D6199 Unspecified implant procedure - D4999 Unspecified periodontal procedure

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Radiographic Failures - Twice-Failed Implant

Figure R1

Figure R2

Figure R3

Figure R4

Figure R5

Figure R6

Twice-Failed Implant. Review of radiographs for a patient treated with multiple implants in the maxillary posterior quadrant. Note the bone levels (R1 through R3) and eventual failure of the implant (R4). Following additional site grafting to improve bone quality and facilitate re-implantation (R5), the implant failed as well (R6).

Clinical Failures

Figure C1

Figure C2

Figure C3

Figure C4

Figure C5

Figure C6

Failure in Diabetic Patient. Implant placed to restore a missing posterior molar tooth (C1). Exposure of the healing implant (C2). View of the treatment site following removal of the failing implant (C3). Esthetic Implant Failure. Facial view following implant surgery (C4). Flap elevation reveals failing implant (C5) and its subsequent removal (C6). â&#x20AC;&#x201D; continued on next page

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Exclusion Criteria • Patients where the information regarding the implant placement and the follow-up is incomplete enough to not allow a thorough analysis were excluded.

Results 8

Yearly Implant Failure Rates

Total Implant Failure Rate 2004-2010

7 6.2% 6

4.3%

5.5%

Conclusions: We found an overall failure rate of 4.3% at Tufts University School of Dental Medicine. We calculated a failure rate range from 2.4% in 2010 to 6.2% in 2004. Future Research Specific Aim 1 – Discover trends among possible contributing factors to implant failure. Parameters that will be used in analysis can include: • Age of patient at time of implant placement • Gender • Presence of systemic disease(s) • List of medications being taken • Smoking history • Previous periodontal treatment • History of implant failure • Presence of caries • Plaque & calculus levels • Presence of pocket and attachment loss • Parafunctional habits (clenching/bruxism) • Implant brand, size and type • Occlusal trauma incidence • Presence of infection (# of days postop) • Type of prosthesis • Loading time • Abutment connection • Bone graft material (bone type) • Bone-density (radiolucent/radiopaque/ Hounsfield units) • Clinician’s level of experience Specific Aim 2 - Determine interventions to improve failure rates • Specific protocols for each aspect of implant placement and follow up Specific Aim 3 – Improve efficiency in case noting and documentation • Implement universal implant failure code • Proper use of diagnostic radiographs when failure occurs

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4 3 2

3.8%

2.6% 2004

2005 2006

2007 2008

Total Successful Implants

95.7%

Total Failed Implants

2.4%

2009 2010

Implants Evaluated vs. Implant Failures Per Year 1500

1200 Implants Evaluated Implant Failures

900

600

300

2004 2005 2006 2007 2008 2009 2010

References • Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: A review and proposed criteria for success. Int J Oral Maxillofac Impl 1986;1:11-25. • Hui D, Hodges J, Sandler N. Predicting cumulative risk in endosseous dental implant failure. J Oral Maxillofac Surg 2004;62(Suppl.1):40-41. • Misch CE, Dietsch F. Bone-grafting materials in implant dentistry. Implant Dentistry 1993 Fall; 2(3):158-67. • Misch CE, Perel ML, Wang HL. Implant success, survival, and failure: The International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Impl Dent 2008;17(1):5-15. • Paquette DW, Brodala N, Williams RC. Risk factors for endosseous dental implant failure. Dent Clin North Am 2006;50:361-374. • Seckinger RJ, Barber HD, Phillips K, et al. A clinical study of titanium plasma sprayed (TPS)-coated threatened and TPS-coated cylindrical endosseous dental implants. Guide Implant Restoration 1996;1:5-8. • Smith DE, Zarb GA. Critera for success of osseointegrated endosseous implants. J Prosthet Dent 1989;62:567-572. • Strietzel FP, Reichard PA, Kale A, et al. Smoking interferes with the prognosis of dental implant treatment: A systemic review and metanalysis. J Clin Periodontol 2007;34:523-524. • Tomasi C, Wennstrom JL, Berlundh T. Longevity of teeth and implants - A systematic review. J Oral Rehabilitation 2008; 35(Suppl.3): 22-32. Acknowledgments The authors mention their gratitude to mentors Paul A. Levi, Jr., DMD, and Eduardo Marcuschamber, DDS, MSc, TUSDM Department of Periodontology, as well as to Maud Lassonde, DMD, William Trahan, DMD, and the TUSDM Information Technology Department.

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THE NEXT DDS | Magazine is currently welcoming submissions for the forthcoming Spring 2013 edition. Do you have an experience to share from your classroom, clinic, or even a dental mission abroad? We are interested in providing your classmates with a glimpse of your daily life in dental school. With a variety of formats that include podcasts, forums, blogs, and the like, THE NEXT DDS has the perfect venue for your idea and an experienced Editorial Staff that can assist you with your submissionâ&#x20AC;&#x201D;all while allowing you to focus on your classroom and clinic requirements! THE NEXT DDS is accepting submissions from dental students and dental professionalsâ&#x20AC;&#x201D;feel free to mention to your favorite professor!

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Revisit Toronto 30 years later. 1982 Toronto Conference Dr. George Zarb (front row, far right) seated next to P-I Brånemark at the landmark conference.

October 19–20, 2012

Nobel Biocare Symposium Sheraton Centre Toronto Hotel, Toronto / Canada Join us as we celebrate three decades of patientm e d i a t e d o u tc o m e s a n d c o n c e r n s w i t h osseointegration. “ Per-Ingvar Brånemark’s seminal osseointegration research led to its global launch in May 1982 at the Toronto Conference on Tissue Integrated Prostheses. The resultant worldwide trajector y of its clinical application ensured exciting and continuing synergies between clinical disciplines and the world of biomaterials; and the ensuing years have also seen numerous clinical scientists coloring in novel additional details to the technique with a resultant and exciting expansion of its

versatility and application. Ongoing research continues to nur ture and expand clinic al applic ations of osseointegration and this 30th Anniversary Symposium offers presentations from some of the best minds in clinical dentistr y. Our invited lecturers from the international community of dental scholars will synthesize current information on what is best and safest in providing treatment with dental implants; and in the necessary context of patient-mediated concerns regarding optimal outcomes.” Dr. George Zarb, C.M., D.D.S., F.R.C.D.C., M.D.(h.c.) Scientific Committee Chair

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