COMMENTARIES

issues remain to be solved. These are essential to eventually gaining complete foundational knowledge on which
we will build a platform for personalized dentistry and
medicine. We are now living in the dawn of a new era
in personalized health care.2,3,6-12 Are we prepared to
seize the opportunities? Are our educational institutions
as well as continuing education programs prepared to
provide the critical knowledge and clinical experiences
that will transform the practice of health care in the 21st
century? 6-9,11-20
doi:10.14219/jada.2014.11
Dr. Slavkin is a professor, Ostrow School of Dentistry, and the founding director, Center for Craniofacial Molecular Biology, University of
Southern California, 2250 Alcazar St., Los Angeles, Calif. 90033, e-mail
slavkin@usc.edu. Address correspondence to Dr. Slavkin.
The Santa Fe Group membership includes these currently active members (in alphabetical order): Stephen Abel, DDS, MSD; Michael Alfano,
DMD, PhD; John C. Baldwin, MD; Teresa A. Dolan, DDS, MPH; Peter
A. DuBois, JD; Earl Fox, MD, MPH; Ralph Fuccillo, MA; Raul Garcia,
DMD, M Med Sci; Jerold S. Goldberg, DDS; Ronald Inge, DDS; Steven W.
Kess, MBA; Dushanka Kleinman, DDS, MScD; Nicholas G. Mosca, DDS;
Wendy Mouradian, MD, MS; Linda Niessen, DMD, MPH; Fotinos S. Panagakos, DMD, PhD; Gary Price; and Harold C. Slavkin, DDS. Emeritus
members include Arthur Dugoni, DDS, MSD; Richard DEustachio, DDS;
and Terry Fulmer, PhD, RN. Deceased members include founding members Dominick P. DePaola, DMD, PhD; and Lawrence H. Meskin, DDS,
PhD. These men and women present a unique group of internationally
renowned scholars and leaders from business and the professions bound
by a common interest in improving oral health. For further information,
visit www.santafegroup.org.
1. Glick M. Expanding the dentists role in health care delivery: is it time
to discard the Procrustean bed? JADA 2009;140(11):1340-1342.
2. Collins FS. The Language of Life: DNA and the Revolution in Personalized Medicine. New York City: Harper; 2010.
3. Venter JC. A Life Decoded: My Genome, My Life. New York City:
Penguin Books; 2007.

4. Sachidanandam R, Weissman D, Schnidt SC, et al. A map of human

genome sequence variation containing 1.42 million single nucleotide
polymorphisms. Nature 2001;409(6822):928-933.
5. Davies K. The $1,000 Genome: The Revolution in DNA Sequencing
and the New Era of Personalized Medicine. New York City: Free Press;
2010.
6. Kornman KS, Duff GW. Personalized medicine: Will dentistry ride
the wave or watch from the beach? J Dent Res 2012;91(7)(suppl):8S-11S.
7. Glick M. Personalized oral health care: providing -omic answers to
oral health queries. JADA 2012;143(2):102-104.
8. Giannobile WV, Braun TM, Caplis AK, Doucette-Stamm L, Duff
GW, Kornman KS. Patient stratification for preventive care in dentistry.
J Dent Res 2013;92(8):694-701.
9. Giannobile WV, Kornman KS, Williams RC. Personalized medicine
enters dentistry: what might this mean for clinical practice? JADA 2013;
144(8):874-876.
10. Collins CS, Hamburg MA. First FDA authorization for nextgeneration sequencer. N Engl J Med 2013;369(25):2369-2371.
11. Slavkin HC. Recombinant DNA technology and oral medicine. Ann
NY Acad Sci 1995;758:314-328.
12. Slavkin HC, Navazesh M, Patel P. Basic principles of human genetics: a primer for oral medicine. In: Greenberg MS, Glick M, Ship JA,
eds. Burkets Oral Medicine. Hamilton, Ontario, Canada: BC Decker;
2008:549-568.
13. Slavkin HC. What the future holds for ectodermal dysplasias: future research and treatment directions. Am J Med Genet A 2009;149A(9):2071-2074.
14. Slavkin HC. Birth of a Discipline: Craniofacial Biology. Newtown,
Pa: Aegis Communications; 2012.
15. Kornman KS. Diagnostic and prognostic tests for oral diseases:
practical applications. J Dent Educ 2005;69(5):498-508.
16. Satcher D. Oral Health in America: A Report of the Surgeon General. Washington: U.S. Department of Health and Human Services; 2000.
17. Lammi L, Arte S, Somer M, et al. Mutations in AXIN2 cause familial
tooth agenesis and predispose to colorectal cancer. Am J Hum Genet
2004;74(5):1043-1050.
18. Collins F, Tabak L. A call for increased education in genetics for
dental health professionals. J Dent Educ 2004;68(8):807-808.
19. Genco RJ, Tabak LA, Tedesco LA, et al. Genetics and its implications
for clinical dental practice and education: report of panel 3 of the Macy
study. J Dent Educ 2008;72(2)(suppl):86-94.
20. Garcia I, Tabak LA. A view of the future: dentistry and oral health
in America. JADA 2009;140(1)(suppl):44S-48S.

HEPATITIS B

LETTERS

ADA welcomes letters from readers on articles that have appeared

in The Journal. The Journal reserves the right to edit all communications and requires that all letters be signed. Letters must be no
more than 550 words and must cite no more than five references. No
illustrations will be accepted. A letter concerning a recent JADA article
will have the best chance of acceptance if it is received within two
months of the articles publication. For instance, a letter about an article that appeared in April JADA usually will be considered for acceptance only until the end of June. You may submit your letter via e-mail
to jadaletters@ada.org; by fax to 1-312-440-3538; or by mail to 211 E.
Chicago Ave., Chicago, Ill. 60611-2678. By sending a letter to the editor, the author acknowledges and agrees that the letter and all rights of
the author in the letter sent become the property of The Journal. Letter
writers are asked to disclose any personal or professional affiliations or
conflicts of interest that readers may wish to take into consideration
in assessing their stated opinions. The views expressed are those of the
letter writer and do not necessarily reflect the opinion or official policy
of the Association. Brevity is appreciated.

230

JADA 145(3)

http://jada.ada.org

0228_0234_Slavkin_Editorial.indd 230

Dr. Rachel Radcliffe and colleagues

October JADA article, Hepatitis B Virus
Transmissions Associated With a Portable Dental Clinic, West Virginia, 2009
(Radcliffe RA, Bixler D, Moorman A, et
al. JADA 2013;144[10]:1110-1118), is a
detailed retrospective review of a free
dental clinic held in a school gymnasium
where hepatitis B was contracted by five
participants (three of the dental patients
and two nontreated volunteers). However,
have the facts presented by the authors
really identified the likely transmission
of HBV [hepatitis B virus]?
After all, the authors had no direct
observation of the infection control practices regarding these specific participants,
found no confirmed source for the HBV
among patients or volunteer staff and
wrote of their inability to link any specific

March 2014

2/18/14 9:17 AM

COMMENTARIES

practice to transmission of HBV.

Does just the presence of all five participants in the same location on the
same day mean that their infection
can be associated with dental treatment or dental equipment?
Another explanation for this
outbreak might be found in a report,
Healthcare-Associated Hepatitis B
and C Outbreaks Reported to the
Centers for Disease Control and
Prevention (CDC) in 2008-2012.1
This CDC report was not referenced
in this JADA article but is available
online. It summarizes not only this
West Virginia case but also the 34
other outbreaks that were reported
in seven other states during 2008
through 2012. Of these 35 outbreaks,
33 (94 percent) occurred in nonhospital settings.1
A comparison of several details
from the West Virginia outbreak
and from these other cases can show
one other possible explanation:
infection control breaches during
assisted monitoring of blood

glucose (AMBG).
1. The CDC report shows that
13 of the 15 HPV outbreaks (87
percent) that occurred in long-term
care facilities were associated with
infection control breaks during assisted monitoring of blood glucose
(AMBG).1 AMBG, a procedure not
usually offered in a dental setting,
was present at the West Virginia
outbreak. Unfortunately, the authors
write that they could not conduct
a full retrospective assessment of
infection control practices during
this procedure. Considering that
AMBG was used here and it is far
more commonly associated with
hepatitis outbreaks, I feel that it
still needs as much investigation as
dental care.
One of the three dental patients
in West Virginia did report a fingerstick to monitor blood glucose,
but it was not entered into his dental
chart. The other two patients were
lost to follow-up so they were not
questioned about this. Are we sure

50% OF SALIVA

MAY BE LOST

BEFORE
PATIENTS COMPLAIN

Waiting for complaints isnt enough. Patients

may lose up to half of their protective saliva before they
become aware of their discomfort.1 Many patients dont
even realize they are coping with reduced saliva,1 and
frequently carry candies or sip water throughout the day.

this isnt a 14th AMBG-associated

outbreak that happened during a
temporary free dental clinic instead
of at a long-term care facility?
2. The CDC report mentions
one outbreak in which two staff
members also contracted HBV. They
may have exposed themselves while
changing lancets that were used
while performing AMBG. In another
case, the CDC reports the crosscontamination of clean supplies
with contaminated blood glucose
monitoring equipment.1 One of the
two case volunteers in West Virginia
was involved in the maintenance of
clean and dirty medical equipment.
Could these errors have happened in
West Virginia?
3. One West Virginia volunteer
escorted patients from the dental
triage section to the waiting area of
the treatment section. Could this
person have been exposed to HBV in
other areas where AMBG was being
performed, such as the medical triage area, but not reported it months

Asking the right questions is the rst step. In fact,

the ability to identify Dry Mouth can increase from
54% to 75% when patients are asked three questions
besides oral dryness.5 Do they regularly do things to
keep their mouth moist? Are they getting out of bed
at night to drink uids? Does their mouth become dry
when they speak? Knowing these answers can help
you identify Dry Mouth patients before its too late.
A daily Biotne routine can help protect your
patients from the consequences of Dry Mouth. Biotne
is a specically designed system of products for dry
mouth. So help patients manage Dry Mouth properly by
recommending the Biotne family of products.

If Dry Mouth goes unmanaged, it can lead to

bad breath, mouth infections, and a 3x greater risk of
cavities. 2-4 Thats why its important to be proactive,
and talk to patients about doing more than coping.
Moisturizing Relief

2014 GlaxoSmithKline
Consumer Healthcare

Everyday Protection

1) Guggenheimer J, Moore PA. Etiology, recognition and treatment. JADA. 2003;134:61-69. 2) Papas AS, et al. Caries prevalence in
xerostomic individuals. J Can Dent Assoc. Feb. 1993;59(2):171-9. 3) Wind DA. Management of Xerostomia: An overview. Jnl Prac
Hygiene Sept/Oct 1996:23-27. 4) Cassolato SF, Turnbull RS. Xerostomia: clinical aspects and treatment. Gerodontology.2003;20:6477.
5) Dry Mouth The Malevolent Symptom: A clinical Guide. Ed. Sreebny LM, Vissink. Blackwell Publications 2010:pg 55

JADA 145(3)

0228_0234_Slavkin_Editorial.indd 231

Saliva Stimulation

#1 BRAND FOR DRY MOUTH

http://jada.ada.org

March 2014

231

2/18/14 9:16 AM

COMMENTARIES

later to the investigators because he

was not familiar at the time with
AMBGs causing HPV? Later investigations were focused primarily on
the dental issue instead, and memories fade with the passage of time.
4. The CDC report mentions one
case of a family member of an infected assisted-living facility resident
who contracted HBV when the family member experienced a needlestick injury while assisting with the
residents blood glucose monitoring.1 Could something similar have
happened in West Virginia?
The CDC report classifies only
one of the 35 known hepatitis
outbreaks as oral healthrelated: the
West Virginia outbreak. Their summary of the known or suspected
mode of transmission in this case
concludes sparse documentation
did not provide evidence to link specific breaches with infection.1 They
did not identify a likely transmission of HBV, as stated in the JADA
article.
The authors have identified areas
of poor infection control (such as
not heat-sterilizing handpieces) in
West Virginia. However, can they
really be more certain of a cause
than the CDC, especially when
another explanation, unsafe AMBG
practices, is just as likely?
I greatly appreciate the authors
diligent efforts in their retrospective
review of this event, but neither the
public nor the profession benefits if
the blame for this event is misplaced.
The real truth is that there is no
smoking gun. We will never know
what was the likely cause of this
hepatitis outbreak.
Thomas R. Osborn, DDS

Torrance, Calif.

1. Centers for Disease Control and Prevention. Healthcare-associated hepatitis B and C

outbreaks reported to the Centers for Disease
Control and Prevention (CDC) in 2008-2012.
www.cdc.gov/hepatitis/outbreaks/
healthcarehepoutbreaktable.htm. Accessed Jan.
19, 2014.

Authors response: We would

like to thank Dr. Osborn for his
comments on our article and for
highlighting how infection control
232

JADA 145(3)

http://jada.ada.org

0228_0234_Slavkin_Editorial.indd 232

lapses during assisted monitoring of

blood glucose (AMBG) have served
as an important mode of transmission of hepatitis B virus (HBV)
infection.1
As discussed in our article, exposure to AMBG was assessed and the
information obtained did not suggest that this was a common factor
among the five cases. Neither of the
two infected dental clinic volunteers
reported exposure to blood glucose
monitoring equipment, and neither
reported any sharps injuries. The
volunteer who worked in maintenance and logistics did not handle
sharps but primarily worked on the
dental chair units and associated
equipment, some of which may have
been contaminated with blood and
other body fluids.
The other volunteer escorted
dental clinic patients but reported
no contact with medical equipment.
Only one of the three infected
dental clinic patients had a history
of diabetes documented in medical
records obtained from the clinic, and
this patient later reported having
had a fingerstick for blood glucose
monitoring at the clinic. The other
two dental clinic patients could not
be interviewed about this procedure.
On the other hand, we did
identify multiple opportunities for
potential exposure to HBV related to
provision of dental care at the clinic.
Although rare, there is ample precedent for this type of transmission.
Both HBV and hepatitis C virus
infections have been reported during
the provision of dental care, including a recent event at a dental surgery
practice in Oklahoma.2,3
As described in our article, there
were several limitations to our
investigation, and a single definitive
source for the HBV infections within
the clinic could not be identified.
However, infection control oversight
for the clinic was lacking; written
infection control guidelines were not
available, and there was no formal
policy requiring volunteers to be
vaccinated against HBV.
Health care should provide no

mechanism for the transmission of

bloodborne pathogens, regardless of
the setting or level of care provided.
Therefore, the key lesson from our
article is to incorporate infection
control into every stage of planning,
implementation and evaluation of
mobile clinics. A checklist for planningthe Infection Control Checklist for Dental Settings Using Mobile
Vans or Portable Dental Equipmentis available online (www.
osap.org/?page=PortableMobile).
Those who plan mobile clinics now
can use the checklist as a tool to
ensure patient and volunteer safety
while offering dental services to
those most in need. Infection control
for ancillary procedures, such as
AMBG, also should be considered
when planning dental clinics.4,5
Rachel Radcliffe, DVM, MPH

Program Manager
Division of Acute Disease Epidemiology
South Carolina Department
of Health and Environmental Control
Columbia

Danae Bixler, MD, MPH

Director
Division of Infectious Disease
Epidemiology
Office of Epidemiology and
Prevention Services
Bureau for Public Health
West Virginia
Department of Health and Human
Services
Charleston
1. Thompson ND, Perz JF. Eliminating the
blood: ongoing outbreaks of hepatitis B virus
infection and the need for innovative glucose
monitoring technologies. J Diabetes Sci Technol
2009;3(2):283-288.
2. Redd JT, Baumbach J, Kohn W, Nainan O,
Khristova M, Williams I. Patient-to-patient
transmission of hepatitis B virus associated
with oral surgery. J Infect Dis 2007;195(9):
1311-1314.
3. Oklahoma State Department of Health.
Public health investigation of Tulsa dental practice: health officials announce new results of
Harrington investigation. www.ok.gov/health/
Organization/Office_of_Communications/
News_Releases/2013_News_Releases/Public_
Health_Investigation_of_Tulsa_Dental_
Practice.html. Accessed Jan. 29, 2014.
4. Centers for Disease Control and Prevention. Infection prevention during blood glucose
monitoring and insulin administration. www.
cdc.gov/injectionsafety/blood-glucosemonitoring.html. Accessed Jan. 29, 2014.
5. Centers for Disease Control and Prevention. Infection prevention checklist for outpatient settings: minimum expectations for safe

March 2014

2/13/14 12:01 PM

COMMENTARIES

care. www.cdc.gov/HAI/settings/outpatient/
checklist/outpatient-care-checklist.html.
Accessed Jan. 29, 2014.

UNNECESSARY TREATMENT

These comments are in regard to

Dr. Kevin Henner and Dr. Jeffrey
Esterburgs January Ethical Moment,
Dealing With a Dentist Who Has
Recommended Unnecessary Treatment (JADA 2014;145[1]:88-90).
I was very disappointed in the
lawyerly wording of the column.
In a time where ethical lines are
becoming more and more blurred, I
was hoping that the American Dental Association (ADA) would take a
stance and give a direct answer.
This column quoted multiple sections of the American Dental Association Principles of Ethics and Code
of Professional Conduct1 yet gave no
recommendations on what course of
action would be appropriate in this
situation. If you are going to publish
an article regarding an ethical concern, then give concrete suggestions
based on the facts presented and

dont just quote legal jargon from

our bylaws [sic]. Help our profession
do the right thing and quit worrying
about what the lawyers say.
I would bet that multiple lawyers
representing the ADA read and
edited the content of this column.
What a sad world we live in where
doing what is right becomes a difficult thing to do.
I understand the fact that you
must gain adequate information
first, and that it is wrong to judge till
you walk in their shoes, yet we are
starting to see more and more cases
of unethical treatment and need
more concrete guidance to deal with
these situations.
If you truly believe in our mission
statement, The ADA is the professional association of dentists that
fosters the success of a diverse membership and advances the oral health
of the public,2 then give us honest
answers and concrete advice on how
to handle our ethical concerns. At
least give contact information so we
can discuss our concerns with a pro-

fessional and get guidance on what

our options are.
Thaddeus Chamberlain, DDS

Langley Air Force Base, Va.

1. American Dental Association. American

Dental Association Principles of Ethics and
Code of Professional Conduct, With Official
Advisory Opinions Revised to April 2012. www.
ada.org/sections/about/pdfs/code_of_ethics_
2012.pdf. Accessed Jan. 19, 2014.
2. American Dental Association. Mission and
history. ADA mission statement. www.ada.org/
missionandhistory.aspx. Accessed Jan. 29, 2014.

SUSPICIOUS TREATMENT PLAN

In reference to Dr. Kevin Henner

and Dr. Jeffrey Esterburgs January
Ethical Moment, Dealing With a
Dentist Who Has Recommended
Unnecessary Treatment (JADA
2014;145[1]:88-90), two things come
to mind. First, the word pathology
is used erroneously for pathosis.
Pathology is the study of pathosis.
Pathosis is disease.
Second, Drs. Henner and Esterburg never answered the question of
what a dentist should do when she
or he sees a documented treatment

HELPING YOU SEARCH

FOR TOOTH WEAR
In a recent European study, up to 1 in 3 young adults*
exhibited signs of tooth wear, with acid erosion being the
leading cause.1 As identication of early clinical signs is the
rst step in helping to protect patients from further acid
erosion, the BEWE (Basic Erosive Wear Examination) expert
tool can simplify your search. It can help you assess patients
level of risk of acid erosion and ultimately inform your
treatment decision. 2

Tooth wear

Protect your patients teeth from the

effects of acid erosion and recommend
the ProNamel range
Visit www.dental-professional.com/EPADA
to nd out more.
*18-35 year olds1
References: 1. Bartlett DW et al. J Dent 2013; doi.org/10.1016/j.
dent.2013.08.018. [Epub ahead of print]. 2. Bartlett DW et al.
Clin Oral Invest 2008; 12(Suppl 1): S65-S68.

JADA 145(3)

0228_0234_Slavkin_Editorial.indd 233

http://jada.ada.org

March 2014

233

2/13/14 12:00 PM

Copyright of Journal of the American Dental Association (JADA) is the property of American
Dental Association and its content may not be copied or emailed to multiple sites or posted to
a listserv without the copyright holder's express written permission. However, users may
print, download, or email articles for individual use.