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May 2016 Lasers and Root Morphology Buccal Fat Pad Herniation

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Bioceramic Materials and the Changing Concepts in Vital Pulp Therapy

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May 2016

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

D E PA R T M E N T S

265 The Associate Editor/A Meaningful Glance at California’s Oral Health Care System

267 Letter to the Editor 269 Impressions 301 RM Matters/Mobile Device Dangers in Dental Practices 305 Regulatory Compliance/Who Can Inspect a Dental Practice? 309 Periscope 314 Tech Trends

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F E AT U R E S

278 Bioceramic Materials and the Changing Concepts in Vital Pulp Therapy With focused case selection, conservative vital pulp therapy can provide reliable treatment options for permanent teeth diagnosed with normal pulps or reversible pulpitis. Yangpei Cao, DDS, MS; George Bogen, DDS; Jung Lim, DDS; Won-Jun Shon, DDS, PhD; and Mo K. Kang, DDS, PhD

291 Effects of Er,Cr:YSGG Laser Treatment on Human Gingival Fibroblast Attachment, Viability and Morphology of Root Surface: An In Vitro Study This study was designed to evaluate human gingival fibroblast attachment viability to root surface after modification with therapeutic alternatives, including hand instrumentation with curettes, piezoelectric ultrasonic scalers and lasers, such as Er,Cr:YSGG. Reza Amid, DDS, MSc; Elahe Azizi, DDS; Maryam Torshabi, DDS, PhD; Mohammad Reza Talebi Ardakani, DDS, MSc; Sajjad Ashnagar, DDS; and Seyed Masoud Mojahedi, DDS, MSc

297 Traumatic Herniation of the Buccal Fat Pad Into the Oral Cavity of a 3.5-Year-Old Boy: A Case Report This paper presents a case of a traumatic herniation of the buccal fat pad in a 3.5-yearold boy caused by an injury from a wooden stick. Kalpna Chaudhry, MDS; Chanchal Singh, MDS; and Manisha Shishodia, BDS

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Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853. The California Dental Association holds the copyright for all articles and artwork published herein. The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal. Copyright 2016 by the California Dental Association. All rights reserved.

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Assoc. Editor

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

A Meaningful Glance at California’s Oral Health Care System Brian K. Shue, DDS, CDE

T

he Health Policy Institute (HPI) of the American Dental Association recently released a groundbreaking report called “The Oral Health Care System: A State-by-State Analysis.” Far from being a white paper, the December 2015 document is full of easy-to-understand multicolored graphics, comparing national data with individualized reports on each state and the District of Columbia. Abounding with festive smiley faces emojis, stacks of U.S. currency and rubenesque molars, it almost seems like the design was lifted directly from the pages of USA Today. In fact, that was the plan. But don’t take the eye-catching graphics too lightly. HPI labored diligently to get valid results behind the clipart, sometimes using innovative approaches. Marko Vujicic, PhD, HPI chief economist and vice president, said the report is directed at national and state policy makers and stakeholders to affect change. Along with basic facts and figures, HPI desired to focus on connections to oral health with categories like physical, social and emotional well-being. With a judicious touch of the human element, HPI’s format nudges us to step out of that clichéd box and continue this dialogue of putting people over science. The oral health care system of California is summarized on three pages with mostly expected results. The survey found 64 percent of Californians live in communities with fluoridated water. Nationally, the range of fluoridation goes from a high of 100 percent for Kentucky and Maryland and 99 percent for Illinois and Minnesota,

HPI’s format nudges us to step out of that clichéd box and continue this dialogue of putting people over science.

to a low of 23 percent for Oregon and 15 percent for New Jersey, with the lowest at 11 percent for Hawaii. The “number of dentists per 100,000 population” in California grew from 65.9 in 2001 to 76.6 per 100,000 population in 2013, while the number increased nationally at a slower pace from 57.3 to 60.5 per 100,000 population. The “percentage with a dental visit in the past 12 months” shows children with Medicaid (Medi-Cal in California) and children with private dental benefits coverage both had an increase of visits from 2005 to 2013, while adults with private benefits had a slight decrease in visits. This mirrors national trends. The “percentage of Medicaid children who received a sealant on a permanent molar in 2013” was 15 percent in California and 14 percent in the U.S. The report shows “Medicaid fee-forservice reimbursement as a percentage of private dental benefit plan charges for child dental services” is 29 percent for California, compared to the higher 49 percent in the U.S. The “percent of dentists participating in Medicaid for child dental services in 2014” is only 29 percent in California, which is quite a bit lower than the 42 percent in the U.S. In California from 2003 to 2013, there was a 31.6 percent decreased reimbursement rate for Medi-Cal child dental services.

As part of this report, HPI commissioned a self-reported online oral health survey of adults nationwide in a six-week period in 2015 and received 14,962 responses. HPI then used Affordable Care Act parameters and the 2014 federal poverty index to divide the responders into a “highincome” category set at 400 percent above and a “low-income” category set at or below 138 percent of the index. One section of this survey asked eight true or false oral health questions set at a seemingly basic level of difficulty. For example, “Blood on your toothbrush is a sign of gum disease” is not meant to be a trick question. Some of the other true or false questions included, “Children do not need to see a dentist until they start school” and “Sugary foods and drinks cause tooth decay.” HPI tabulated the results to create the “Oral Health Knowledge Index Among Adults in 2015.” High-income Californians scored poorly, averaging only 44 percent correct responses, which was slightly worse than the national average. The highest score in the nation was 70 percent correct by high-income South Carolina adults. Lowincome Californians received a score of 45 percent, almost the same as the national average, but lower than Kentucky’s low-income cohort, which scored the highest nationally at 64 percent correct. M AY 2 0 1 6  265

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ASSOC . EDITOR C D A J O U R N A L , V O L 4 4 , Nº 5

Then it gets interesting. The next section of the survey asked the question, “How often have you experienced each of the following problems related to your mouth and teeth during the last 12 months: difficulty when biting or chewing foods, difficulty with speech or trouble pronouncing words, dry mouth, felt anxiety, felt embarrassment, avoided smiling, took days off work because of pain or discomfort, difficulty doing usual activities, reduced participation in social activities, problems sleeping and experienced pain.” The choices were, “never, rarely, occasionally, very often or don’t know.” HPI used this data to create the “Oral Health Status Index” and emphasize the effect of oral health on the human condition. The results were placed on a zero-to-10 scale, 10 meaning excellent oral health and zero meaning poor oral health. Respondents were divided into the same income categories. Nationally, high-income adults received a status index of 8.2 out of a perfect score of 10, and low-income adults scored 7.2. This is a measured difference of one point on the scale. The actual scores are not as important as comparing and contrasting results, which basically showed those with higher incomes have better oral health. That being said, high-income and lowincome adults in California had a measured difference of 0.9, which is about the same spread separating the two groups in the national data. However, the status index of high-income Californians was a low of 6.8, while the low-income Californians scored a high of 7.7. That means oral health symptoms in California were worse in the high-income adults compared to the low-income adults. Other than the District of Columbia, which had a similar reversal of expected outcomes (low-income adults scored 8.1 and high-income adults 7.9), no other state had the same result. 266 M AY   2 01 6

“That was not an error,” said Dr. Vujicic in a private email correspondence from December 2015, “but it certainly surprised us.” Examining this index a bit further, the states with the highest average of their low-income responders included the District of Columbia, Ohio, Rhode Island, New York and California. On the other hand, California’s high-income adults scored the lowest average of any state, just slightly worse than Montana. Does that mean the wealthy of California have more frequent oral health problems than the poor? The results seem to arrive at that conclusion. Or maybe it is that oral health has a significantly bigger impact on the health and well-being of California’s wealthy as contrasted with the poor. Again, this isn’t the norm — high-income adults in Connecticut and Illinois received almost a perfect score. The HPI report concludes with three key findings: “95 percent of adults say they value keeping their mouths healthy,” “more Medicaid children are accessing dental care” and “adult trends are different — the gap in dental care use between Medicaid and privately insured adults is much wider than it is for children.” Oral health can be examined purely on a superficial level, such arriving at a diagnosis based on clinical facts. A person’s front tooth can be missing, could be quite mobile due to severe periodontitis or may be severely decayed or fractured. That can be objective. On the human level, however, that missing or fractured tooth means more than just the absence of dentition. A person may avoid social interactions because of that missing anterior tooth, be prevented from gainful employment or even have despair and lack of self-worth. That nuance is not reflected by just examining raw data. But HPI hopes this innovative report can bring the person back to the

forefront, instead of narrowly focusing on just the tooth connected to the person. Such emphasis may influence stakeholders and legislative decision-makers in rethinking how dental care should be managed in federal and state policies. That can result in something meaningful. ■ REFERENCES

“The Oral Health Care System: A State-by-State Analysis.” Health Policy Institute. ADA. December 2015. Yarbrough C, Starkel R, Vujicic M. Methodology for developing the Health Policy Institute index measures of oral health status, oral health knowledge and attitude toward oral health. Health Policy Institute. ADA. November 2015.

Brian K. Shue, DDS, is the dental director of a federally qualified health center. He is a certified dental editor, the San Diego County Dental Society editor and is a fellow of the American College of Dentists and the Pierre Fauchard Academy.

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

Letter

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

The Pendulum Has Swung Too Far I have been enjoying reading your editorials in our Journal of the California Dental Association and I want to offer a suggestion to our current legislative debacle. While I understand that the opioidoverdose related deaths have skyrocketed and many steps are being taken to mitigate the overuse and over prescription of these drugs, it now seems that the legislation has gone too far with restrictions on phone-in prescriptions. For example, even though new tamper-resistant forms are now in place, if a postsurgical patient needs a narcotic to get them through the night and they don’t have a prescription already

in hand, they must meet the doctor at the office to write out a script. To avoid this possibility many surgeons are writing out a narcotic script “just in case.” This leads to more unnecessary narcotic prescriptions. It would have made more sense and been so much easier if our legislators could have allowed phone-in prescriptions for let’s say one to four tablets for short-term relief. If the patient still has ongoing needs he or she could get the tamper-proof prescription in the morning. I think the pendulum has swung too far in this regard. W. PETER NORDLAND, DMD, MS

La Jolla, Calif.

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Impressions

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

The Invasion of the Memes David W. Chambers, EdM, MBA, PhD

The nub: 1. We do not have habits; habits have us. 2. Memes do not serve out ends; they use us for their survival. 3. Dental ethics is a meme subject to possible mutation and extinction. David W. Chambers, EdM, MBA, PhD, is professor of dental education at the University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, and editor of the Journal of the American College of Dentists.

Your office is almost certainly infected with memes. They like to gather on the desk in the front office and many varieties are found chairside. They have even been found in the reception area, and parking lots, if you have one, are just one big meme. Infection control and OSHA standards offer no protection. In fact, they are memes themselves. All dentists work for memes. The CDA is a meme, and one of its most active branches is the publication you are holding in your hands at this moment or looking at on your screen. Genes have been with us for about 3.5 billion years as templates for controlling the transmission of physical characteristics. They explain the fact that humans continue to live even while no individual human makes it much beyond 100 years. Memes have been around about 50,000 years, and they work pretty much the same way. Like genes and viruses, they are packets of information that cannot sustain themselves or reproduce without a host. But neither can the host reproduce true or act consistently without the information in its genes and memes. Social media and selfies are memes. So are Labor Day barbecues and church attendance. When a colleague shows up at a professional meeting wearing the wrong clothes or without the report scheduled for discussion, we joke that he or she “must not have gotten the memo.” What we mean is that she or she did not get the meme. Evidence-based dentistry is a meme. It is a pattern of behavior, transmitted by contact with carriers such as colleagues, conferences and journals. It is a mutation that jumped species from epidemiological researchers in medicine. It briefly invaded management research and practices, but is now almost extinct there. Corporate dental practice is another meme. It is a variant of the “mall practice” meme that appeared in the early 1980s. It is more successful in its current form because of supportive host factors. Federal policy has multiplied onerous regulations on small businesses and subsidized oversized student loans. Mature as well as new practitioners are defining dentistry exclusively as technical work. Outside capital and control and mass marketing via social media recruit patient hosts. Organized dentistry is a meme. Although it is not fashionable to comment on this, membership numbers, participation rates, an increasing income gap within the profession and identification with nontraditional “nonprofessional” organizations are part of the new meme mix. Professional ethics is also a collection of memes. These are passed from generation to generation as patterns of behavior. Whether traditional professional ethics remains a viable meme, becomes one of several options or retires as a topic in lectures on the history of dentistry will be decided by whether the dentists who have that meme continue to flourish. ■ M AY 2 0 1 6  269

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IMPRESSIONS C D A J O U R N A L , V O L 4 4 , Nº 5

Researchers Reverse Signs of Periodontitis

Research Shows Promise of Fighting Cavities With a Pill A team of researchers from the University of Florida Health recently reported that they have identified a new strain of bacteria in the mouth that may keep bad bacteria at bay — and could produce a way to prevent cavities using probiotics. According to the researchers, the findings could lead to the development of a supplement taken orally to prevent cavities. Developing an effective oral probiotic will require more research, but authors report that a possible candidate organism has been identified: a previously unidentified strain of Streptococcus, currently called A12. A12 has a strong ability to fight Streptococcus mutans, and the researchers discovered that A12 not only helps neutralize acid by metabolizing arginine in the mouth, it also often kills Streptococcus mutans. “Also, if A12 doesn’t kill Streptococcus mutans, A12 interferes with Streptococcus mutans’ ability to carry out its normal processes that it needs to cause disease,” said Robert Burne, PhD, associate dean for research and chair of the UF College of Dentistry’s department of oral biology, in a news release. “If you grow them together, Streptococcus mutans does not grow very well or make biofilms, also known as dental plaque, properly.” For the study, plaque samples were collected and more than 2,000 bacteria were isolated and then screened. 270 M AY   2 01 6

According to a new study in the Journal of Clinical Periodontology, researchers have discovered that there may be hope for effectively reversing periodontitis. For their study, the authors employed an inhibitor protein called C3, the third component of the body’s complement system, which is involved in immunity and inflammatory responses. Delivering this inhibitor, Cp40, to the periodontal tissue just once a week reversed naturally occurring chronic periodontitis inflammation in a preclinical model. “Even after one treatment, you could see a big difference in inflammation,” said George Hajishengallis, DDS, PhD, a co-senior author of the study, in a news release. “After six weeks, we saw reversals in inflammation, both clinically and by looking at cellular and molecular measures of osteoclast formation and inflammatory cytokines.” C3 is a key part of signaling cascades that trigger inflammation and activate the innate immune system. Their previous research, which used an inducible model of periodontal disease, found that Cp40 could reduce signs of the disease. To get closer to a natural scenario, however, the current work was conducted on animals that naturally had developed chronic periodontitis. Initially the research team tried administering Cp40 three times a week, but after seeing significant reductions in inflammation, they tried giving it only once a week to a different group and saw the same good results. The authors delivered the drug via a local injection and reported no adverse effects. “Cp40 inhibits pre-existing chronic periodontal inflammation and osteoclastogenesis in NHPs, suggesting a novel adjunctive anti-inflammatory therapy for treating human periodontitis,” the authors concluded in their report. For more, see the study in the Journal of Clinical Periodontology, March 2016, vol. 43, issue 3, pp. 238-249. Detection of osteoclasts in nonhuman primate periodontitis. Photo courtesy of John D. Lambris, PhD, and George Hajishengallis, DDS, PhD.

“We then characterized 54 bacteria that metabolized arginine,” said Marcelle Nascimento, DDS, PhD, in a news release. “Out of these, A12 stood out for having all of the properties we were looking for in a bacteria strain that could prevent cavities in a probiotic application.” The researchers sequenced the entire genome of A12 and plan to turn this discovery into a tool to screen

for people who are at a higher risk for developing cavities, in combination with other factors. Next, the researchers hope to find more instances of A12 in a larger sample of people and to test how prevalent bacteria with similar properties are in the human mouth. For more, see the research published online Jan. 29, 2016, in the journal Applied and Environmental Microbiology.

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

Association Between Oral Bacteria, Esophageal Cancer In a recent study, researchers found that Porphyromonas gingivalis, (P. gingivalis) a bacterial species responsible for gum disease, is present in 61 percent of patients with esophageal squamous cell carcinoma (ESCC). P. gingivalis was only detected in 12 percent of tissues adjacent to the cancerous cells, while this organism was undetected in normal esophageal tissue.

“These findings provide the first direct evidence that P. gingivalis infection could be a novel risk factor for ESCC, and may also serve as a prognostic biomarker for this type of cancer,” said Huizhi Wang, MD, PhD, assistant professor of oral immunology and infectious diseases at the University of Louisville School of Dentistry, in a news release. “These data, if confirmed, indicate that eradication of

Gum Disease, Cognitive Decline in Alzheimer’s Researchers recently conducted an observational study to determine whether periodontitis or gum disease is associated with increased dementia severity and subsequent greater progression of cognitive decline in people with Alzheimer’s disease. The study found that “periodontitis is associated with an increase in cognitive decline in Alzheimer’s disease, independent to baseline cognitive state, which may be mediated through effects on systemic inflammation,” the authors wrote. The researchers cognitively assessed 59 participants with mild-to-moderate Alzheimer’s disease and took a blood sample to measure inflammatory markers. Dental health was assessed by a dental hygienist who was blind to cognitive outcomes. The presence of gum disease at baseline was associated with a sixfold increase in the rate of cognitive decline in participants over the six-month followup period of the study. Periodontitis at baseline was also associated with a relative increase in the pro-inflammatory state. The authors conclude that gum disease is associated with an increase in cognitive decline in Alzheimer’s disease, possibly via mechanisms linked to the body’s inflammatory response. Limitations of the study include the small number of participants and the authors advise that the study should be replicated ideally with a larger cohort. The precise mechanisms by which gum disease may be linked to cognitive decline are not fully clear and other factors might also play a part. “Previous studies have also shown that patients with Alzheimer’s disease have poorer dental health than others of similar age and that the more severe the dementia the worse the dental health, most likely reflecting greater difficulties with taking care of oneself as dementia becomes more severe,” said first author Mark Ide, BDS, in a news release. For more, see the study published online in the journal PLOS ONE, March 10, 2016.

Porphyromonas gingivalis

a common oral pathogen may contribute to a reduction in the significant number of people suffering with ESCC.” For their study, the research team tested tissue samples from 100 patients with ESCC and 30 normal controls, measuring the expression of lysinegingipain, an enzyme unique to P. gingivalis, as well as the presence of the bacterial cell DNA within the esophageal tissues. Both the bacteria-distinguishing enzyme and its DNA were significantly higher in the cancerous tissue of ESCC patients than in surrounding tissue or normal control sites. The researchers also found the presence of P. gingivalis correlated with other factors, including cancer cell differentiation, metastasis and overall survival rate. According to Wang, there are two likely explanations: either ESCC cells are a preferred niche for P. gingivalis to thrive or the infection of P. gingivalis facilitates the development of esophageal cancer. If the former is true, Wang says simple antibiotics may prove useful or researchers can develop other therapeutic approaches for esophageal cancer utilizing genetic technology to target the P. gingivalis and ultimately destroy the cancer cells. “Should P. gingivalis prove to cause ESCC, the implications are enormous,” Wang said. “It would suggest that improving oral hygiene may reduce ESCC risk, screening for P. gingivalis in dental plaque may identify susceptible subjects and using antibiotics or other antibacterial strategies may prevent ESCC progression.” For more, see the study in the journal Infectious Agents and Cancer, 2016, 11:3. M AY 2 0 1 6  271

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IMPRESSIONS C D A J O U R N A L , V O L 4 4 , Nº 5

Ad Council: More Children Brushing 2min2x

Antifungal Therapy Shows Promise for Asthma Patients Researchers have found that patients with asthma or chronic sinusitis may benefit from antifungal therapies — even those patients who weren’t particularly sensitive or allergic to fungi, according to a news release from the American Academy of Allergy, Asthma and Immunology. Sensitization to fungi is an important risk factor in patients with allergic respiratory tract diseases, like asthma, because it plays a major role in the development, persistence and severity of lower airway disease. “Current data on the effectiveness of antifungal therapy in asthma and chronic sinusitis is limited but there is indication that antifungals are effective in treating severe asthmatics — specifically for patients with allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitization (SAFS),” said first author Evan Li, MD. The authors collected data from patients who visited the Michael E. Debakey VA Allergy Clinic between 2012 and 2015 and provided sputum samples for fungal cultures. Of the 134 patients included in the study, 112 (83.5 percent) had positive fungal cultures. “When performing the cultures in our labs, we defined a positive fungal culture as one where we saw at least six colony forming units growing within two weeks on culture plates,” Li explained. Seventy-five (62 after 13 were lost to follow-up) of these patients with either asthma, chronic sinusitis or 274 M AY   2 01 6

The number of English- and Spanish-speaking parents who say their children brush for two minutes, twice a day has increased since the launch of the Kids’ Healthy Mouths campaign in 2012. According to a recent report from the Ad Council and the Partnership for Healthy Mouths, Healthy Lives, there has been a 13 percent increase — from 48 percent in 2012 to 61 percent in 2015 — in English-speaking parents who report their child brushes twice a day, and a 4 percent increase in those who report their child brushes two minutes each time. This has been an upward trend since the public service campaign began, but now, 15 percent more Spanish-speaking parents are reporting that their child brushes two times a day, from 63 percent in 2012 to 78 percent in 2015. The Partnership for Healthy Mouths, Healthy Lives, a coalition of 36 dental organizations, including CDA, and the Ad Council launched the Kids’ Healthy Mouths campaign designed to teach parents, caregivers and children about the importance of oral health, and it has been effective. According to the report, compared to other social causes, children’s oral health remains one of the top social issues that parents consider “very important” — ranking higher than autism but just below drinking and driving and texting and driving. With more than $119 million in donated and earned media across the country, the campaign has received tremendous exposure through widespread TV, radio, print, outdoor and digital public service announcements (PSAs) in both English and Spanish, including The New York Times, Good Morning America, Yahoo! News and CBS Sports, resulting in 9.4 billion impressions. For more information on the Kids’ Healthy Mouths campaign, visit 2min2x.org.

both were treated with voriconazole, terbinafine, fluconazole or some combination of these antifungals. Of the antifungal-treated patients who had follow-up data available, the majority saw improvements. Overall, 54 out of 62 (87.1 percent) reported benefits. Fifty percent of patients reported less sputum production, 38.7 percent reported improved breathing, 32.2 percent reported less cough and 14.5 percent reported less

frequent rescue inhaler use. Only 9 percent demonstrated true fungal sensitization or allergy via scratch test or radioallergosorbent testing. These findings support the need for additional randomized clinical trials to clarify the utility of antifungal agents in asthma, the authors concluded. For more, see the research published in a supplement to The Journal of Allergy and Clinical Immunology, February 2016, vol. 137, issue 2, supplement, p. AB214.

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

Antidepressants Linked to Implant Failure A new pilot study by researchers from the University at Buffalo has discovered that antidepressants may play a role in dental implant failure — with use of antidepressants increasing the odds of implant failure fourfold, according to a news release from the university. The

research team found that each year of antidepressant use doubled the odds of failure. “Antidepressant medication may relieve depression symptoms and help millions of patients worldwide; however, their benefits must be weighed with the side effects. Patients should

CDC Provides Guideline for Prescribing Opioids As part of the U.S. government’s urgent response to the epidemic of overdose deaths, the Centers for Disease Control and Prevention (CDC) has issued new recommendations for prescribing opioid medications for chronic pain, excluding cancer, palliative and end-of-life care. The new guideline aims to improve the safety of prescribing and curtail the harms associated with opioid use, including opioid use disorder and overdose. The guideline also focuses on increasing the use of other effective treatments for chronic pain, such as non-opioid medications or nonpharmacologic therapies, and provides recommendations on the use of opioids for chronic pain — pain lasting longer than three months or past the time of normal tissue healing. Among the 12 recommendations in the guideline, three principles are key to improving patient care: ■ Non-opioid therapy is preferred for chronic pain outside of active cancer, palliative and end-of-life care. ■ When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose. ■ Providers should always exercise caution when prescribing opioids and monitor all patients closely. In developing the guideline, the CDC followed a rigorous scientific process using the best available scientific evidence, consulting with experts and listening to comments from the public and partner organizations. The CDC is dedicated to working with partners to improve the evidence base and said it will refine the recommendations as new research becomes available. The CDC has provided a checklist for prescribing opioids for chronic pain as well as a website with additional tools to guide clinicians in implementing the recommendations, which can be found at cdc.gov/ drugoverdose/prescribing/resources.html. For more, see the article published in the CDC’s Morbidity and Mortality Weekly Report, Recommendations and Reports, March 18, 2016, 65(1);1-49.

cooperate with their physicians to reach the right balance,” said Latifa Bairam, DDS, MS, an investigator on the study and clinical assistant professor in the department of restorative dentistry in the UB School of Dental Medicine. “Four of the many known side effects that are reported in the literature are a big concern to us as dentists in regard to oral and bone health.” Additional side effects of the drug include osteoporosis, a condition in which bones become weak and brittle; akathisia, a disorder characterized by the need to be in constant motion, including the head and jaw; bruxism or teeth grinding; and dryness of the mouth, all of which affect the implant healing process, Bairam said. After analyzing data from the medical charts of UB Dental Clinic patients in 2014, the researchers found that of the few patients who experienced implant failures, 33 percent used antidepressants. For patients who did not experience failures, only 11 percent used the drug. “The difference between 33 percent and 11 percent is quite remarkable and needs further in-depth analysis,” said Sebastiano Andreana, DDS, MS, associate professor and director of implant dentistry. The researchers plan to build on the study by retesting their results on a larger scale. For now, they advise those using antidepressants to consult with their physicians about the drug’s side effects and alternative methods of managing depression, anxiety or pain. For more, see the news release at buffalo. edu/news/releases/2016/03/020.html. M AY 2 0 1 6  275

Parenteral Moderate Sedation for Dentists Lectures and Workshops Wednesday - Sunday, July 13 - 17, 2016 8:00 am - 5:00 pm (at USC)

Limited Attendance

Clinical Sessions Thursday, July 28, 2016 7:00 am - 9:00 pm (at Solis Surgical Arts Center) 10:00 am -5:00 pm (at USC) Friday - Sunday, July 29 - 31, 2016 Friday - Sunday, August 5 - 7, 2016 8:00 am - 5:00 pm (at USC) Course Directors: Dr. James Tom, Dr. Kenneth K. Lee This comprehensive course expands its curriculum to include new drug regimens, advances in patient monitoring, and ACLS Certification. The course consists of 12 days for a total of 96 hours; 8 days of lectures and workshops and 4 days of clinical patient interaction. The course meets (and exceeds) the educational requirements established by the ADA Guidelines and fulfills most state regulations for administration of IV moderate sedation to dental patients. Each didactic day begins with a pre-session knowledge assessment and concludes with a case-based group learning exercise. Participants will perform physical evaluation, take medical history, outline an anesthetic plan, initiate and confirm intravenous access, administer and become competent in the titration of sedative medications, and perform dental procedures under close supervision of faculty who have had post-graduate training in dental anesthesiology.

Registration: Office of Continuing Professional Education Phone: 213-821-2127 Email: [email protected] Online: www.uscdentalce.org

Locations: Herman Ostrow Solis Surgical School of Dentistry of USC Arts Center 925 W. 34th Street, Room 201J 4940 Van Nuys Blvd # 103 Los Angeles, CA 90089-0641 Sherman Oaks, CA 91403

To register, please call 213.821.2127 or visit www.uscdentalce.org

June

August

03

Minimally Invasive and Esthetic Dentistry: A Review of Available Treatment Options & Materials

10 - 12

Advanced Soft Tissue and Bone Grafting with Cadaver Workshop

10 - 12

Endodontics from A to Z: Hands-On Workshop for the General Practitioner (Part I)

17 - 18

Temporomandibular Disorders, Arthrocentesis, and Botox/Trigger Point Injections (Webinar Available)

24 - 26

Endodontics from A to Z: Hands-On Workshop for the General Practitioner (Part II)

25

Suturing Techniques: A Practical Hands-On Course on Soft Tissue Suturing

July

01 - 04

The 42nd Annual Review of Continuing Education in Dentistry (Maui, Hawaii)

05 - 07

Parenteral Moderate Sedation for Dentists: Clinical Session II

12

New Approaches for Antimicrobial Treatment of Periodontal Disease

13 - 14

Safe, Precise and Predictable Implant Placement

19 - 20

The Artistic Dentist: Excellence in Direct Anterior and Posterior Composites

26 - 28

Fundamentals of Implant Surgery and Restoration (Part I)

September

08 - 10

Advanced Clinical Dental Hygiene Techniques: Lectures and Hands-On Workshops

17 - 18

Horizontal and Vertical Augmentation - Myths Versus Reality

09 - 10

Complications of Implant Therapy

23 - 24

13 - 17

Parenteral Moderate Sedation for Dentists: Lectures & Workshops

Minimally Invasive Adhesive and Esthetic Indirect Anterior Bonded Restorations: Lecture & Hands-On

30 - 01

The USC Geriatric Dentistry Annual Symposium (Webinar Available)

15 - 16

Advanced Restorative Options with Dental Implants for Fully Edentulous Arches

22 - 24

Esthetic Full-Mouth Implant Reconstruction: Advanced Prosthodontic Techniques for Challenging Patients

28 - 31

Parenteral Moderate Sedation for Dentists: Clinical Session I

30 - 31

Immediate Implant - Atraumatic Extraction, Immediate Implant Placement, Chairside Provisional Restoration - A Lecture and Hands-On Workshop (Las Vegas, Nevada)

Herman Ostrow School of Dentistry of USC Continuing Professional Education 925 W. 34th Street, Room 201J, Los Angeles, CA 90089 Phone: 213.821.2127 Fax: 213.740.3973 E-mail: [email protected] Website: www.uscdentalce.org Facebook: www.facebook.com/USCdentalCE

vital pulp therapy C D A J O U R N A L , V O L 4 4 , Nº 5

Bioceramic Materials and the Changing Concepts in Vital Pulp Therapy Yangpei Cao, DDS, MS; George Bogen, DDS; Jung Lim, DDS; Won-Jun Shon, DDS, PhD; and Mo K. Kang, DDS, PhD

A B S T R A C T Vital pulp therapy (VPT) is devised to preserve and maintain vitality of

pulpally involved teeth challenged by a variety of intraoral conditions. Notable progress has been made in this field due to a better understanding of pulp physiology, improved clinical protocols and advanced bioceramic materials paired with adhesive technology. With focused case selection, conservative VPT can provide reliable treatment options for permanent teeth diagnosed with normal pulps or reversible pulpitis.

AUTHORS Yangpei Cao, DDS, MS, is an assistant clinical professor in the endodontics section at the University of California, Los Angeles, School of Dentistry. Dr. Cao and Dr. Bogen contributed equally to this manuscript. Conflict of Interest Disclosure: None reported.

George Bogen, DDS, is a board-certified endodontist in private practice in Los Angeles. He received his dental degree and certificate in endodontics from the Herman Ostrow School of Dentistry of USC, where he served as an assistant clinical professor. He is a lecturer at the University of California, Los Angeles, School of Dentistry, VA Long Beach, Loma Linda University School of Dentistry and Nova Southeastern University in Fort Lauderdale, Fla. Conflict of Interest Disclosure: None reported.

Jung Lim, DDS, is a lecturer in the section of endodontics at the University of California, Los Angeles, School of Dentistry and maintains a private practice limited to endodontics in Arcadia, Calif. Conflict of Interest Disclosure: None reported. Won-Jun Shon, DDS, PhD, is an associate professor at the Seoul National University School of Dentistry in Seoul, Korea. He is a visiting scholar at the University of California, Los Angeles, School of Dentistry, in the section of endodontics. Conflict of Interest Disclosure: None reported.

Mo K. Kang, DDS, PhD, is professor and chair in the section of endodontics, division of constitutive and regenerative sciences at University of California, Los Angeles, School of Dentistry. He is the first to hold the Jack A. Weichman Endowed Chair. Conflict of Interest Disclosure: None reported.

T

reatment of permanent teeth with pulpal involvement presents significant challenges for clinicians. Traumatic injury, anatomical anomalies and extensive caries can advance pulpal inflammation and cause arrested root development in immature permanent teeth. Direct or indirect pulp capping and pulpotomy procedures are clinical strategies used in vital pulp therapy (VPT) that can potentially resolve these complications. Advanced treatment options using mineral trioxide aggregate (MTA) and other bioceramic or calcium silicate-based cements (CSCs), have improved clinical outcomes by encouraging hard tissue barrier formation and promotion of root-end closure (apexogenesis) in immature teeth with open apices. Definitive treatment intervention during the early stages of pulpal inflammation and before bacterial M AY 2 0 1 6  279

vital pulp therapy C D A J O U R N A L , V O L 4 4 , Nº 5

colonization of the dental pulp can prevent or postpone the need for more aggressive endodontic procedures. Moreover, pulp preservation in immature teeth advances tooth strengthening by root growth and wall thickening during maturation. One of the main challenges in VPT is to predictably diagnose the degree of pulpal inflammation and clinically manage the repair of the remaining exposed pulpal tissue.1 According to a classic study in 1965, dental pulp shows exceptional healing potential in a microbial-free environment.2 However, continued bacterial invasion can lead to pulp necrosis when pulpal protection by innate and adaptive immune responses are unsuccessful during microbial invasion. Thus, the principle goal of VPT is to preserve healthy pulp tissue or remove contaminated and bacterially colonized tissue to encourage pulpal repair by hard tissue bridge formation.3 In the absence of bacterial challenges, the introduction of bioceramic materials paired with adhesive restorations can produce a hermetic environment so that pulpal repair and healing can proceed normally. There are long-held perceptions that direct pulp capping performed in a carious field on permanent teeth is unpredictable and, therefore, clinicians have been encouraged to provide more invasive endodontic treatment alternatives.4 This view is not entirely unfounded, as several former and current clinical investigations using calcium hydroxide (CH) support the contention. A retrospective study evaluating pulp-capping outcomes of carious exposure cases employing CH showed a 44.5 percent failure rate in a five-year group and 79.7 percent in a 10-year group.5 The study attributed the high failure rates to uncontrolled pulp hemorrhaging during the procedure, the use of hard setting CH and time spans longer than two days before restoration placement. Also contributing to these 280 M AY   2 01 6

FIGURE 1A.

FIGURE 1B.

FIGURE 1C .

FIGURE 1D.

FIGURES 1. Mineral trioxide aggregate (MTA) direct pulp capping in an 18-year-old patient with a 14-year recall. The patient presented with a carious mandibular right first molar (No. 30) sensitive to chewing. Cold testing of No. 30 elicited a short, nonlingering but painful response. FIGURE 1A. Preoperative radiograph showing deep caries near the pulpal roof. FIGURE 1B. Photograph after caries excavation using caries detector dye and five-minute sodium hypochlorite hemostasis. Note distobuccal pulp horn exposure and reactionary (reparative) dentin over distolingual pulp horn (arrow). FIGURE 1C. Postoperative radiograph of bonded composite placement at second visit after confirmation of MTA curing and continued pulp vitality. FIGURE 1D. Fourteen-year radiographic review. Patient was asymptomatic and No. 30 responded normally to vitality testing. The bonded composite restoration was intact with no marginal degradation.

outcomes, more than 10 percent of patients in both the five-year and 10-year groups presented with temporary restorations at recall. This observation underscores the importance of a sealed permanent restoration to guard against microleakage and ensure favorable outcomes in VPT. Another long-term retrospective study evaluating hard setting CH-based direct pulp capping reported an overall survival rate of 76.3 percent for 248 teeth after 13.3 years.6 The overall clinical outcomes of CH in VPT reported by other investigations has revealed a 61-82 percent success rate over a period of four to seven years.7-9 However, these treatment outcomes were based on traditional clinical regimens and the use of CH as the direct capping

material. More important, these studies were completed without the benefit of technical endodontic advances that include magnification with illumination, guided caries removal, hemostasis management, recently introduced bioceramic cements and bonded restorations.

Compatible Biomaterials in Vital Pulp Therapy With the introduction of modified treatment protocols and innovative bioactive materials, VPT has become a more predictable and beneficial option for all patients. The following is a brief synopsis of currently available conventional and advanced dental products with broad applications in VPT.

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

TABLE

Commercially Available Calcium Silicate-Based Cements Commercial brand

Company

Working time

Setting time

BIOAGGREGATE

Innovative BioCeramix Inc., Vancouver, B.C.

5 min

2.5-6 h

BIODENTINE

Septodont, Saint-Maur-des-Fossés, France

6 min

12 min

Calcium Enriched Mixture

Bionique Dent, Tehran, Iran

5 min

5 min

4h

ENDOCEM MTA

Maruchi, Wonju, Korea

2 min

4 min

EndoSequence

Brasseler USA, Savannah, Ga.

4h

4-10 h

Generex-A

DENTSPLY, Tulsa, Okla.

N/A

75 min

Grey MTA Plus

Avalon Biomed Inc., Bradenton, Fl.

12-20 min

1.25 h

Harvard MTA

Harvard Dental International GmbH, Hoppegarten, Germany

>2 min

5 min

iRoot BP Plus

Innovative Bioceramix, Vancouver, B.C.

Premixed

5-7 d

MM-MTA

MICRO-MEGA, Besançon, France

2 min

20 min

MTA Angelus, MTA Bio

MTA-Angelus, Londrina PR, Brazil

10 min

10-15 min

MTA Plus

Prevest-DenPro, Jammu, India

12 min

< 1h

MTA-Caps

ACTEON, Merignac, France

N/A

20 min

MTA-CPM

EGEO SRL, Buenos Aires, Argentina

N/A

15 min

NeoMTA Plus

Avalon Biomed Inc., Bradenton, Fl.

20 min

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