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Journa

March 2017
Antibiotic Prophylaxis
Mandibular Fractures
Photodynamic Therapy

C A L I F O R N I A D E N TA L A S S O C I AT I O N

The Management
of Infections and
the Use of Antibiotic
Prophylaxis by
Dentists:
A Review of the Evidence
Caution + control:
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March 2017 C D A J O U R N A L , V O L 4 5 , N 3

D E PA R T M E N T S
113 The Editor/Aliens Among Us
117 Impressions
147 RM Matters/Thorough Treatment Plans Build
Patient Trust

151 Regulatory Compliance/Guide to Dental Practice


Act Compliance

156 Tech Trends


157 Dr. Bob/Snakes: The Stu of Nightmaresssssss 117

F E AT U R E S
123 The Management of Infections and the Use of Antibiotic Prophylaxis by Dentists:
A Review of the Evidence
Clinical decisions on the use of antibiotics must be made on the basis of the scientific
evidence with knowledge of the most current guidelines and indications.
George Maranon, DDS

133 Management of Mandibular Fractures in Pediatric Patients With Conservative


Technique: A Case Series
This paper reports a variation in the technique of using circummandibular wiring with
acrylic splints in the conservative treatment of mandibular fractures in two pediatric patients.
Manisha Sahni Prabhakar, MDS; Khushboo Kansal, BDS; and Arjun Chawdhry

139 Ex Vivo Assessment of Photodynamic Therapy in Achieving Microbial Reduction


The study was to assess the effects of photodynamic therapy (PDT) on root canals
contaminated by Enterococcus faecalis (E. faecalis).
Rodrigo Rodrigues Amaral, DDS, MS; Eduardo Nunes, DDS, MS, PhD; Maria Eugnia Alvarez-Leite,
DDS, MS, PhD; Jos Cludio Faria Amorim, DDS, MS, PhD; Martinho Campolina Rebello Horta,
DDS, MS, PhD; Maria Ilma de Sousa Corts, DDS, MS, PhD; Frank Ferreira Silveira, DDS, MS, PhD;
and Stephen Cohen, MA, DDS

M A R C H 2 0 1 7 111
C D A J O U R N A L , V O L 4 5 , N 3

CDA Classieds.
JournaC A L I F O R N I A D E N TA L A S S O C I AT I O N
Volume 45, Number 3
March 2017

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112M A R C H 2 01 7
Editor C D A J O U R N A L , V O L 4 5 , N 3

Aliens Among Us
Kerry K. Carney, DDS, CDE

W
hen I was growing
up, there were two
popular science
When I see charts that tell me how profoundly
fiction series: The dierent millennials are and how the baby-boom
Twilight Zone and generation must learn a new language to speak
Outer Limits. They both aimed to scare to them, I become annoyed.
the beegeebies out of the viewer. Outer
Limits relied on the hideous monster-
of-the-week theme. The Twilight Zone
was more subtle and much scarier. It relied Most generational comparisons Our childhoods were very different,
on placing every story in an everyday seem fatally flawed. They compare but it might have been interesting if
setting with everyday characters who groups of people across age ranges. my uncle and I could have tampered
slowly were revealed to be somehow They are based on the assumption that with the time continuum and met as
alien. It was that aliens among us aspect we do not change in our behavior or young adults. We would not have been
that was so effective and unsettling. beliefs as we age. But we do change. contemporaries, but we would have
Now there are new aliens among us. When I reread a book or review a both been standing in the same section
They may look like us, but they are very film I first experienced as a young adult, of the river of our lives. We might
different. They are the millennials. I seldom have the same appreciation the have shared a common perspective.
It seems that every meeting I attend second time around. I perceive it later We might have found we had many of
has an authority that expounds on the through the lenses of my experience. the same motivators. We might have
unique characteristics of that generation of The first time I saw The Graduate I agreed on what makes a person good.
individuals born between 1980 and 2000. empathized with Benjamin Braddock. The baby boomers were subjected
It is not the amusing anecdotes about how Years later, on review, I empathized to the same kind of alienating
millennials incorporate new technology with Elaine Robinsons father. The criticisms when they were the new
into their lives; it is the undercurrent of movie did not change. I had changed. generation. The lyrics in a popular
strangeness, of foreignness attributed to Time even changes how we musical of the 1960s characterized
them that makes me uncomfortable. experience language. Now, as a boomers as disobedient, disrespectful,
When I see charts that tell me how homeowner, I can appreciate the phrase noisy, crazy, sloppy, lazy loafers. They
profoundly different millennials are and get off my property, in a much different went on to describe the cohorts
how the baby-boom generation must way than I did years ago as a child inability to live up to our parents
learn a new language to speak to them, I when a grouchy (my perception then) generational expectations, with the
become annoyed. It is not that I feel put neighbor used the phrase to advise my plaintive questions: Why cant they
upon or challenged to become fluent in playmates and me it was time to exit her be like we were, perfect in every way?
a foreign language. My disquiet comes yard. Our perceptions are fluid over time. Whats the matter with kids today?
from the implied insult to those folks born My uncle told me years ago that I agree with George Orwell when
between 1980 and 2000. We are told that he had feared my siblings and I would he noted that, Every generation
millennials need instant gratification. They never learn to read or appreciate the imagines itself to be more intelligent
need constant recognition. They have a written word. He was from a time before than the one that went before it, and
sense of entitlement. They boomerang and electricity in the home. As a child, wiser than the one that comes after it.
move back in with their parents rather he had read his books by the light of Wisdom can flow in both directions.
than independently striking out on their an oil lamp. He was sure that because The trick is to not overemphasize
own. They are not goal-oriented. They we spent so much time in front of the the differences and to continue to
choose fun over higher pay at work. They television set, my generation would learn from one another. The process
are selfish and shallow. The list goes on be intellectually stunted and never of maturation requires modifying
and on. They are so different; or are they? able to enjoy literature like he did. opinions and perceptions based
M A R C H 2 0 1 7 113
M A R C H 2 0 17 EDITOR
C D A J O U R N A L , V O L 4 5 , N 3

on experience and information.


Maybe our goal should be to try to
appreciate some of the wisdom that
millennials have distilled from their
unique experience and perspective.

Your library card Millennials are different. The


experiences of their childhood are as
distant and different from mine as those

will never expire. of my uncles oil-lamp-lit childhood.


But I think we have more in common
with millennials than many would lead
CDAs archive is online for your research. Access every issue us to believe. Yes, they grew up in a
of the Journal from the past 18 years at cda.org/journal. different world, but they are not aliens.
They are like us but younger.

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114M A R C H 2 01 7
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Impressions C D A J O U R N A L , V O L 4 5 , N 3

Brands and Independent


Contractors
David W. Chambers, EdM, MBA, PhD

Brands have value. That is certainly so for dentistry, where there


are 120 practices with fictitious business names in San Francisco.
That is part of the idea behind corporate dental practices.
The modern corporate business structure is a marvel because
it permits segmentation and separate ownership of various aspects
of the customer experience. The most successful limited liability
corporations own the controlling and most profitable aspects of
the enterprise and sell off the rest to independent contractors.
Ethics is one of those business assets or liabilities that
can be spun off to maximize profit. Responsibility for fixing
mistakes can be sold to others as easily as offering extended
warranties or subcontracting with other outfits that are willing
to buy ones boo-boos under their name. Companies can
The nub: actually sell their ethical liabilities. Read the fine print.
The current masters are in Big Pharma. Consider pay to delay
1. There is a secondary market for drug marketing settlements. A large firm faces revenue losses as its
professional ethics. patent is about to expire and a startup readies to introduce a generic
alternative. The business with a brand threatens a costly legal
2. Ethics, as a cost of doing action, which has little chance of prevailing in court but would
business, can be subcontracted. consume most of the small firms resources and some taxpayers
funding of our justice system. Constraint of trade is dodged by
3. Laws can be written to shift and reaching a court settlement where the generic manufacturer
disguise ethical risk. agrees to delay introduction of the competitive product for a
period, say seven years, in exchange for several millions in cash
payments from the larger firm each year. Both companies and
David W. Chambers, EdM, MBA, PhD, is professor
their lawyers come out ahead, but at the expense of the public.
of dental education at the University of the Pacic, Arthur Specific case: The pharmaceutical company Aventis was
A. Dugoni School of Dentistry, San Francisco, and editor making little from an anti-inflammatory orphan drug called Acthar,
of the American College of Dentists. charging only $50 per vile. Protecting its brand image, it was afraid
to raise prices out of fear of acquiring a reputation for price gouging.
Aventis slithered out from under this ethical limitation by selling
the patent to Questcor, evidently an outfit with no reputation to
protect, for a nominal $100,000 plus a percentage on all future
sales. A single dose of Acthar now costs $28,000. Aventis sold its
ethical responsibility and got another company to do its dirty work.
Here is another trick where a company with a brand uses
an entity with a weak reputation to extract money from the
public. Insurance companies derive income from copayments on
expensive brand-name drugs that they cannot get from the less
expensive generics. Some manufacturers now offer to reimburse
patients the copayment for continuing to buy their brand-
name pills. Customers come out ahead. Manufacturers have to
pay the insurance company a few bucks, but they are able to
retain the much larger profit margin while using the insurance
company to collect from employers and the government that
underwrite the insurance contracts. Could happen in dentistry.
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Abnormal Salivary Glands Linked to Cleft Lip,


Palate Dental Problems
A new study in the Journal of Dental Research suggests that dental problems
associated with cleft lip and palate may be caused by abnormalities in salivary
glands and an imbalance of immune compounds in the mouth.
Childrens Oral Health Timothy Cox, PhD, a craniofacial researcher at Seattle Childrens
Disparities Persist Despite Research Institute and lead author, found that mice with a gene mutation that
causes cleft lip and palate had problems in their salivary glands that
Equal Dental Care Access aected gum tissue and oral health.
Oral health of children who receive We found that the cleft lip and palate gene mutation also resulted in
dental care through Medicaid lags abnormal salivary glands, Cox said. The result was a mouth environment that
behind that of their privately insured was too acidic and contained excess bacteria, which led to problems in the
peers although the children receive the gums and more rapid tooth decay.
same amount of dental care, according In the study, the researchers oered mice with the cleft lip and palate
to a Columbia University College mutation and mice without the mutation a high-sugar diet. After just eight weeks
of Dental Medicine study published on this diet, the mice with the cleft lip and palate mutation had almost no molar
in Health Affairs in December. teeth left, while the mice without the mutation had only mild decay.
The study considered data from the The researchers focused on the gene IRF6, which is most commonly
20112012 National Survey of Childrens associated with cleft lip or palate. Many other genes have been linked to cleft
Health, which included parent reports lip or palate, and the researchers hope to understand if these additional genes
of oral health and use of dental care for are also associated with enhanced tooth decay.
79,815 children and adolescents (ages We hope that as the research progresses, doctors and dentists can apply the
1 to 17 years) of all social levels. No ndings in caring for cleft lip or palate patients
differences were found between Medicaid- and protect their teeth starting in early childhood
insured and commercially insured and into adulthood, Cox said.
children in the odds of their having a For more on the study, go to journals.sagepub.
dental visit, preventive or otherwise.
com/doi/full/10.1177/0022034516679376.
However, parents of children enrolled
in Medicaid were 25 percent more likely
to report that their children did not
have an excellent or very good dental
condition and 21 percent more likely
to report that their children had dental but do not have equal oral health, then We cant segregate oral health
problems within the last year than were the remedy should focus more tightly from overall health, he said.
parents of commercially insured children. on the day-to-day factors that put them Evolving health systems that
Burton L. Edelstein, DDS, MPH, at higher risk for dental problems, Dr. bring teams of providers together
chair of the section of population oral Edelstein said. Low-income families to promote healthy behaviors can
health, professor of dental medicine at the often face income, housing, employment address common risk factors that
College of Dental Medicine and professor and food insecurities that constrain benefit a childs overall and oral
of health policy and management at their ability to engage in healthy health. But if you segregate dentistry,
Columbias Mailman School of Public eating and oral hygiene practices. especially for Medicaid kids, then
Health, was the lead author of the study. Dr. Edelstein urged dentists to rethink you lose that opportunity.
If poor and low-income children the nature of oral health care by seeing To learn more about the study, go
now enjoy equal access to dental care it as part of a childs total health care. to healthaffairs.org.
118M A R C H 2 01 7
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Study Estimates Health Impact of UK Soft Drinks Levy


A soft drink levy set to be introduced low-sugar drinks, a low tax on mid-sugar
in the United Kingdom in April 2018 drinks and a high tax on high-sugar drinks.
could have a significant impact on the In the study, researchers modeled three
dental health of people of all ages, but ways that the soft drinks industry might
especially children, according to a study respond to the levy: reformulating drinks
published in The Lancet Public Health. The to reduce sugar content, passing some
study was the first to estimate the health of the levy to consumers by raising the
impact of the proposed soft drinks industry price of sugary drinks and using marketing
levy, which calls for no tax on diet and to encourage consumers to switch to

lower-sugar drinks. For each response


they identified a realistic best- and
worst-case scenario for health, by
Impact of NIH Research Funding to Dental Schools estimating the likely impact on rates
Articles published recently by the International and American Associations for of obesity, diabetes and tooth decay.
Dental Research (IADR/AADR) in the Journal of Dental Research shed light on The study finds that an industry
the trends and impact of National Institutes of Health research funding to dental response that focuses on reducing
schools and institutions. sugar content is likely to have the
A study titled The NIHs Funding to U.S. Dental Institutions from 2005 to greatest impact on health. Researchers
2014 by researchers at the National Institute of Dental and Craniofacial estimate that a reduction of 30 percent
Research (NIDCR) examined NIHs investment in both extramural research in the sugar content of all high-sugar
drinks and a 15 percent reduction
projects and training at dental institutions. Over the 10-year span, 56 U.S. dental
in mid-sugar drinks could result in
institutions received approximately $2.2 billion from more than 20 institutes,
144,000 fewer adults and children with
centers and oces at the NIH, according to the study. The NIDCR is the largest
obesity, 19,000 fewer cases of type 2
NIH supporter of dental institutions, having invested 70 percent of the NIH total,
diabetes per year and 269,000 fewer
about $1.5 billion. The NIDCR is also the primary supporter of research training
teeth suffering from decay annually.
and career development. Adam Briggs, MFPH, of the
Recent Trends in Oral Cavity Cancer Research Support in the United University of Oxford and lead author
States by researchers from Wayne State University, Michigan, University of of the study, said research suggests
Pittsburgh and Medical University of South Carolina found that overall that the most likely industry responses
funding for oral cavity cancer research decreased considerably after 2009. to the tax have the potential to
Funding administered through the NIDCR was 6.5 times greater than dollars improve overall health. The extent
awarded by the NIH National Cancer Institute (NCI) in 2000; over the time of the health benefits of the tax
period evaluated, NIDCR support decreased in most years while NCI will depend on industrys response,
support increased and approached NIDCR funding levels. Briggs said. We must therefore be
AADR will continue to communicate to vigilant to ensure the food industry
Congress the importance of biomedical acts to remove sugar from soft drinks,
research for the health of the population, and that where the tax is passed
said AADR President Jack Ferracane. on to consumers, it increases the
To read the full articles, visit price of targeted products only
sagepub.com/toc/jdrb/current. drinks with high levels of sugar.
To learn more about this
study, see The Lancet, vol. 2,
no. 1 e15-e22 January 2017.
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Scuba Divers Should Visit Dentist Before Diving


Recreational scuba divers who recently received dental care should
consider consulting with their dentists before taking their next plunge. A new
pilot study found that 41 percent of divers experienced dental symptoms in
the water, according to new research from the University at Bualo.
Debbie Guatelli-Steinberg. (Image courtesy of The study, Prevalence of dental problems in recreational scuba divers,
Ohio State University)
published last month in the British Dental Journal, was inspired by the lead
authors rst experience with scuba diving in 2013. Although she enjoyed
Fossilized Teeth Reveal Much being in the water, Vinisha Ranna, BDS, a student in the UB School of Dental
About Ancestors Medicine and certied stress and rescue scuba diver, couldnt help but notice
a squeezing sensation in her teeth, a condition known as barodontalgia.
A new book by anthropologist Published research on dental symptoms experienced while scuba diving is
Debbie Guatelli-Steinberg reveals what scarce or focuses largely on military divers, said Ranna, so she crafted her
scientists have learned about the life own study using an online survey that was distributed to 100 certied
history, growth and diet of primates recreational divers. Her goal was to identify the dental symptoms that divers
and our human ancestors by studying experience and to detect trends in how or when they occur.
fossilized teeth. The book, What Of the 41 participants who reported dental symptoms, 42 percent
Teeth Reveal About Human Evolution
experienced barodontalgia, 24 percent described pain from holding the air
(Cambridge University Press, 2016),
regulator in their mouths too tightly and 22 percent reported jaw pain.
also discusses what those findings say
Another 5 percent noted that their crowns were loosened during their dive,
about the teeth of humans living today.
and one person reported a broken dental lling.
Guatelli-Steinberg, a professor
of anthropology at The Ohio State The potential for damage is high during scuba diving, said Ranna, who
University, said modern humans have has completed 60 dives. The dry air and awkward position of the jaw while
teeth that were adapted for eating a very clenching down on the regulator is an
different diet than the one currently interesting mix. An unhealthy tooth
enjoyed by most Western societies. In underwater would be much more
the book, she notes that 99 percent obvious than on the surface.
of humans evolutionary history was For more information, read the
spent eating foods that were hunted study in the British Dental Journal
or gathered, much unlike current diets 221, 577581 (2016).
of soft, processed and sugary foods.
Problems like cavities and
plaque buildup have been magnified
tremendously in humans today, she said.
Natural selection has not prepared us remains found in fossils, making them species are related to one another.
well for the kinds of food we eat today. easily available for discovery and Guatelli-Steinberg said she expects
In addition to having much higher studying. Small and very mineralized, future anthropologists will likely have
rates of cavities and plaque, modern they are resistant to decomposition a field day studying modern human
humans are much more likely to have and able to maintain their original teeth. In various cultures today, we have
misaligned teeth that require orthodontic qualities, Guatelli-Steinberg said. people who notch teeth, inlay them with
treatment or surgery. Soft diets do Teeth also contain records of their jewels or gold, lengthen them, file them
not stimulate jaw growth, and teeth, development, including their chemistry down and remove them altogether,
especially our third molars, become and pathology. For example, researchers she said. One can only imagine what
impacted, Guatelli-Steinberg said. study the structure of teeth, such anthropologists will make of all the
Teeth are the most preserved skeletal as bumps and grooves, to see how things we do to our teeth today.
120M A R C H 2 01 7
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Dental Implant Coatings Help Prevent Infection


Mouth infections are currently regarded Beatriz Palla, a researcher in
as the main reason dental implants the biomaterials group of the UPV/
fail. A piece of research by the UPV/ EHUs department of polymer science
EHU-University of the Basque Country and technology, said the quest for
has succeeded in developing coatings surfaces capable of preventing bacterial
capable of preventing and eliminating colonization and adhesion in the area
potential bacterial infection, according surrounding the implant was borne out Moment during the experimental work when the
to a study published in the December of the huge number of publications that coating is added to the implant. (Image: Beatriz Palla)
issue of the Journal of Non-Crystalline have been developed in the field.
Solids. The coatings also provide implants We had already obtained coatings anchoring to the bone. In a bid to go a step
with osseointegrating properties that that facilitate the generating of bone further, we looked at how to turn these
facilitate anchoring to the bone. around the implant and thus facilitate coatings into bactericides, Palla said.
In the study, Palla developed three
types of coatings depending on the various
antibacterial agents chosen; each one had
a mechanism to tackle bacterial infections,
Alzheimers Drug Could Reshape Dental Treatments either prophylactically by preventing
the bacteria from becoming adhered
A new method of stimulating the renewal of living stem cells in tooth pulp
initially and the subsequent infection or
using an Alzheimers drug has been discovered by a team of researchers at by eliminating it once it developed.
Kings College London. In view of the results, Palla believes
Scientists from the Dental Institute at Kings College London have proven a that it is possible to confirm that coatings
way to stimulate the stem cells contained in the pulp of the tooth and generate with an antibacterial capability and which
new dentine in large cavities, potentially reducing the need for llings or cements, do not affect the proper integration of
according to a paper published in Scientic Reports. Signicantly, one of the the implant into the jawbone have been
small molecules used by the team to stimulate the renewal of the stem cells developed. She also admits, however, that
included Tideglusib, which has previously been used in clinical trials to treat there is still a long way to go until they can
neurological disorders including Alzheimers disease. This presents a real be applied and used at dentists surgeries.
opportunity to fast-track the treatment into practice, the scientists say. Apart from all the trials that remain
Using biodegradable collagen sponges to deliver the treatment, the team to be carried out, it would also be advisable
applied low doses of small molecule glycogen synthase kinase (GSK-3) to the to pursue the research a little further to
tooth. They found that the sponge degraded over time and that new dentine optimize the results more, she said.
replaced it, leading to complete, natural repair. Collagen sponges are For more information about the study,
commercially available and clinically approved, again adding to the potential of see the Journal of Non-Crystalline Solids
the treatments swift pick-up and use in dental clinics. vol. 453, 1 December 2016, pp. 6673.
Lead author of the study, Paul Sharpe, Dickinson professor of
craniofacial biology at Kings College, said the simplicity of our
CORRECTION
approach makes it ideal as a clinical dental product for the
It has come to the attention of the Journal of
natural treatment of large cavities by providing both pulp the California Dental Association that the
protection and restoring dentine. digital image that was originally published with
In addition, using a drug that has already been tested in the article Bite-Mark Pattern Injury Analysis: A
clinical trials for Alzheimers disease provides a real opportunity Brief Status Overview in the June 2015 issue
of the Journal was used in the Journals
to get this dental treatment quickly into clinics, he said.
February 2017 issue without permission of its
Learn more about this study at nature.com/articles/srep39654. copyright owner, Gregory S. Golden, DDS,
and has been removed at his request.

M A R C H 2 0 1 7 121
antibiotic prophylaxis
C D A J O U R N A L , V O L 4 5 , N 3

The Management of Infections


and the Use of Antibiotic
Prophylaxis by Dentists:
A Review of the Evidence
George Maranon, DDS

A B S T R A C T Dentistry plays an important role in managing the antibiotic resistance


problem. Guidelines for the use of antibiotics for prevention of endocarditis,
prosthetic joint infections and other medical conditions have changed frequently.
Unfortunately, the original guidelines and subsequent changes were often made
through consensus opinions and not evidence based. Clinical decisions on the use of
antibiotics must be made on the basis of the scientific evidence with knowledge of
the most current guidelines and indications.

AUTHOR

F
George Maranon, or the past 70 years, antibiotics postsurgical infections and to manage
DDS, is a diplomate of have proven to be a powerful infections. The inappropriate or misuse
the American Board of
adjunct in the management of of antibiotics has raised concerns about
Oral and Maxillofacial
Surgery. He received his infection. In spite of this, even antibiotic resistance. Although there
dental degree from the the appropriate use of antibiotics are often guidelines, it may be difficult
University of California, Los carries personal and community risk of for clinicians to decide in which
Angeles, and his medical bacterial resistance and adverse events. situations antibiotics are indicated. What
degree from New York
As health care professionals, dentists follows is a summary of the literature
Medical College and
completed his residency have a responsibility to help reduce the concerning clinical situations involving
in oral and maxillofacial risk of bacterial antibiotic resistance. the use of antibiotics by dentists.
surgery at the Westchester For patients at risk for infectious
County Medical Center. He endocarditis or prosthetic joint Infectious Endocarditis and Prosthetic
maintains a private practice
in oral and maxillofacial
infection after dental procedures, it Joint Guidelines for the Use of
surgery in Encino, Calif. is important that clinicians use the Prophylactic Antibiotics
Conict of Interest most current antibiotic prophylaxis The American Heart Association
Disclosure: None reported. guidelines. The cooperation of the (AHA) and the American Dental
dentist and physician in the management Association (ADA) have issued
of these patients is imperative. antibiotic prophylaxis guidelines to
Dentists prescribe antibiotics prior prevent infective endocarditis for high-
to prophylaxis to prevent infective risk patients undergoing certain dental
endocarditis and prosthetic joint procedures. It is important to note that
infections, to reduce or prevent the 2007 AHA guidelines stress the
M A R C H 2 0 1 7 123
antibiotic prophylaxis
C D A J O U R N A L , V O L 4 5 , N 3

TABLE 1 TABLE 2

Cardiac Conditions Associated With the Highest Risk of Adverse Outcomes From Dental Procedures for Which
Endocarditis for Which Prophylaxis With Dental Procedures is Reasonable Endocarditis Prophylaxis Is Reasonable
for Patients in Table 1
Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
All dental procedures that involve manipulation of
Previous IE
gingival tissue or the periapical region of teeth or
Congenital heart disease (CHD)* perforation of the oral mucosa*
Unrepaired cyanotic CHD, including palliative shunts and conduits
Completely repaired congenital heart defect with prosthetic material or device, whether placed by
* The following procedures and events do not need prophylaxis:
routine anesthetic injections through noninfected tissue, taking
surgery or by catheter intervention, during the rst six months after the procedure dental radiographs, placement of removable prosthodontic or
Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or orthodontic appliances, adjustment of orthodontic appliances,
placement of orthodontic brackets, shedding of deciduous
prosthetic device, which inhibit endothelialization teeth and bleeding from trauma to the lips or oral mucosa.
Cardiac transplantation recipients who develop cardiac valvulopathy Adapted from Prevention of Infective Endocarditis:
Guidelines From the American Heart Association A
* Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD. Guideline From the American Heart Association Rheumatic

Fever, Endocarditis, and Kawasaki Disease Committee,


Prophylaxis is reasonable because endothelialization of prosthetic material occurs within six months after the procedure. Council on Cardiovascular Disease in the Young, and the
Adapted from Prevention of Infective Endocarditis: Guidelines From the American Heart Association A Guideline From the Council on Clinical Cardiology, Council on Cardiovascular
American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease Surgery and Anesthesia, and the Quality of Care and
in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care Outcomes Research Interdisciplinary Working Group.
and Outcomes Research Interdisciplinary Working Group. Circulation 2007 Oct 9;116(15):173654. Epub 2007 Apr 19. Circulation 2007;116:17361754.

importance of optimum dental health and recommendations differ from those of Use of Antibiotics in Other Clinical
oral hygiene. For these patients at risk, it the patients physician. The dentist Situations
is important that the dentist inform the should also provide the patient with a For most clinical situations
patient about the need for maintaining thorough informed consent so that the encountered by dentists, antibiotics
his or her dental condition at the highest patient can make his or her own decision are rarely indicated. In patients with
state of health possible1 (TABLES 13 ). whether to use antibiotic prophylaxis. The intact defense mechanisms, most of the
There is increased legal risk of patient should be encouraged to discuss symptoms associated with these conditions
establishing guidelines. The ADA the treatment options with his or her are inflammatory or immunologic in
Division of Legal Affairs has offered a physician before making a decision.2,3,4 nature. In 2001, the American Academy
legal perspective on antibiotic prophylaxis The ADA Council on Scientific of Pediatric Dentistry (AAPD) published
in order to assist dentists with questions Affairs published the most recent guidelines to be used by clinicians when
regarding the indications and necessity of version of its clinical practice guidelines prescribing antibiotics to pediatric patients
premedication. The ADA recommends concerning prophylactic antibiotics based on their presenting condition.
that each dentist use his or her professional prior to dental procedures in patients These were revised in 2014. The AAPD
judgment in applying the ADA antibiotic with prosthetic joints. It concluded, In states that there are few indications
guidelines. It points out that occasionally general, for patients with prosthetic joint for the use of antibiotics in children.7
questions might arise when patients present implants, prophylactic antibiotics are not In the winter of 2012, the American
for treatment with a recommendation recommended prior to dental procedures Association of Endodontists (AAE)
from their physicians to use antibiotic to prevent prosthetic joint infection. For published Use and Abuse of Antibiotics to
prophylaxis that is outside the guidelines. patients with a history of complications educate the dental community on the
The physicians recommendation may be associated with their joint replacement appropriate use of antibiotics for dental
due to the patients medical condition or surgery, the council recommends that conditions associated with endodontics.
risk factors not known to the dentist or antibiotics should only be considered after The oral and maxillofacial surgery
because the physician is not familiar with consultation with the patient and the and periodontal surgery literature are
the most recent prophylaxis guidelines. orthopedic surgeon. If it is determined replete with articles on the appropriate
In an updated opinion, the ADA that antibiotics are indicated, the council management of infections and the
Division of Legal Affairs recommended suggests that the orthopedic surgeon use of antibiotics8 (TABLE 4 ).
that the dentist and physician recommend the appropriate antibiotic The dental pulp presents a unique host
communicate and try to reach agreement and when possible provide a prescription. environment. The circulation to the pulp
on the management of the patient. If In making that recommendation, the is limited and the bodys natural defense
consensus cannot be reached, the patient council cited the increased risk of mechanisms can be overwhelmed. In
should also be informed that the dentists antibiotic resistance and adverse effects.6 spite of this, in the majority of infections,
124M A R C H 2 01 7
C D A J O U R N A L , V O L 4 5 , N 3

TABLE 3

Regimens for a Dental Procedure


Regimen: Single dose 30 to 60 minutes before procedure
Situation Agent Adults Children
Oral Amoxicillin 2g 50 mg/kg
Unable to take medication Ampicillin 2 g IM or IV 50 mg/kg IM or IV
OR
Cefazolin or ceftriaxone 1 g IM or IV 50 mg/kg IM or IV

Allergic to penicillins or ampicillin Cephalexin* 2g 50 mg/kg
oral OR
Clindamycin 600 mg 20 mg/kg
OR
Azithromycin or clarithromycin 500 mg 15 mg/kg

Allergic to penicillins or ampicillin and Cefazolin or ceftriaxone 1 g IM or IV 50 mg/kg IM or IV
unable to take oral medication OR
Clindamycin 600 mg IM or IV 20 mg/kg IM or IV

IM indicates intramuscular; IV indicates intravenous


* Or other rst- or second-generation oral cephalosporin in equivalent to adult or pediatric dosage.

Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema or urticaria with penicillins or ampicillin.
Adapted from Prevention of Infective Endocarditis: Guidelines From the American Heart Association A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki
Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and
Outcomes Research Interdisciplinary Working Group. Circulation 2007;116:17361754.

patients with intact immune systems do found no statistically significant for surgical intervention (endodontic
not require antibiotic therapy. Even in difference in the rates of postoperative treatment, incision and drainage or
situations of moderately severe localized infections after endodontic surgery.10 extraction) to remove the source of
infections, these conditions can be In localized acute periradicular the infection. The AAE notes that
managed with incision and drainage and/ infections, bacteria gain access to the up to 60 percent of human infections
or removal of the source of the infection periapical tissues. These infections have a resolve by host defenses alone following
(endodontics or tooth extraction) without rapid progression and are associated with removal of the cause of the infection.8
antibiotic treatment. During infections, pain and swelling. There may be purulent According to Baumgartner,
the patients own systemic defenses are drainage through a sinus tract or a localized erythromycin is not a good choice for
attracted to the area of damaged tissue. abscess. If pus is present, this is an indication endodontics because it is not effective
In the normal process, an abscess forms that the infection is being controlled. against anaerobes. Clarithromycin
as a fibrocollagenous border around the These situations should be managed either and azithromycin have a spectrum of
responsible microorganisms and immune by incision, extraction of the tooth or activity that includes facultative bacteria
mediators isolating them. This border can endodontic treatment. Again, antibiotic and some anaerobes associated with
reduce circulation to the area and prevent treatment is generally not indicated.11,12 endodontic infections. Metronidazole is
antibiotics from reaching the source of the The AAPD recommends that for active against anaerobes but not against
infection. Chronic apical abscesses that are children with pulpitis, apical periodontitis, facultative bacteria and is typically
localized or have a draining sinus tract and draining sinus tract or localized intraoral used in combination with penicillin
develop gradually often have only mild or swelling, the most appropriate treatment when penicillin alone is not effective.
no symptoms. In these situations, the hosts is pulpotomy, polypectomy or extraction. Baumgartner states that cephalosporins,
immune system has already contained the Patients should be assessed for signs of ciprofloxacin, doxycycline and the
infection. Studies have shown that in the systemic infection including fever and other tetracyclines are not indicated in
case of asymptomatic necrotic teeth, the use facial swelling. If the patients condition these types of infections. If there is a
of prophylactic antibiotics was not found to is localized and there are no signs of cellulitis, this is an indication that the
be a benefit in reducing endodontic flare- systemic infection, it is the opinion of host response has not yet controlled the
ups or in significantly improved resolution the AAPD that antibiotic therapy is infection. In this situation, antibiotics
rates.9 A second similar study of the usually not necessary.7 The AAE agrees might be necessary though this hypothesis
prophylactic administration of clindamycin that antibiotics are not substitutes has been extensively studied.15
M A R C H 2 0 1 7 125
antibiotic prophylaxis
C D A J O U R N A L , V O L 4 5 , N 3

TABLE 4

Management of Patients With Prosthetic Joints Undergoing Dental Procedures


Clinical Recommendation
In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior
to dental procedures to prevent prosthetic joint infection.
For patients with a history or complication associated with their joint replacement surgery who are infections may be related to other
undergoing dental procedures that include gingival manipulation or mucosal incision, prophylactic conditions such as trauma, malignancies
antibiotics should only be considered after consultation with the patient and orthopedic surgeon.* To or infection from nonbacterial origin
assess a patients medical status, a complete health history is always recommended when making nal (fungal). If a patient presents with
decisions regarding the need for antibiotic prophylaxis. significant infection of odontogenic origin,
Clinical Reasoning for the Recommendation surgical intervention is again necessary to
There is evidence that dental procedures are not associated with prosthetic joint implant infections. address the source. Incision and drainage
There is evidence that antibiotics provided before oral care do not prevent prosthetic joint implant infections. should not be postponed to allow for
There are potential harms of antibiotics including risk for anaphylaxis, antibiotic resistance and abscess formation. In some of these cases,
opportunistic infections like Clostridium dicile. the patient may need to be hospitalized
The benets of antibiotic prophylaxis may not exceed the harms for most patients. and treated in the operating room under
The individual patients circumstances and preferences should be considered when deciding whether to general anesthesia. The adjunctive
prescribe prophylactic antibiotics prior to dental procedures. use of oral or intravenous antibiotics
* In cases where antibiotics are deemed necessary, it is most appropriate that the orthopedic surgeon may be indicated. The consultation of
recommend the appropriate antibiotic regimen and when reasonable write the prescription. infectious disease and other medical and
Copyright 2014 America Dental Association
surgical specialists may be necessary.

Minor Oral/Facial Injury


In those situations where endodontic symptoms (fever, lymphadenopathy, Management
treatment is insufficient in controlling trismus, malaise). In vitro, newer and Because of excellent blood supply to
endodontic infections, Baumgartner broader spectrum antibiotics were the maxillofacial region, injuries to these
et al.13 and Skucaite et al.14 reported more effective against typical bacteria structures can often be managed without
that penicillin and amoxicillin or responsible for odontogenic infections. antibiotics given appropriate wound
clindamycin for penicillin-allergic In contrast, the use of amoxicillin, management. Patients with traumatic
patients should be considered. clindamycin and azithromycin have injury should be evaluated with respect
In the event a patient fails to been shown to result in equal or better to host risk (e.g., age, systemic illness,
improve, the initial diagnosis needs to clinical outcomes. For patients allergic malnutrition) and the nature of the
be reconsidered. The patient should to penicillin, clindamycin, azithromycin, wound when determining the need for
be re-evaluated to access the need for metronidazole or moxifloxacin can be antibiotics. Wounds should be classified
further surgical intervention. Culturing used as alternatives (TA BLE 5 ). As for the as either clean, potentially contaminated
to determine antibiotic sensitivities duration of antibiotic therapy, studies or contaminated/dirty. Clean wounds
for infections is important and may have shown that at seven days, there was are those that are uninfected and show
be necessary in instances of antibiotic no difference in clinical cure between no signs of inflammation. These wounds
failure. Empirically, clindamycin antibiotics given for short (one to three can be closed primarily. There is no need
may be considered. Clindamycin is days) or long (five to seven days) durations for antibiotic coverage in these patients.
given at a dose of 300 mg every six when combined with appropriate surgery.16 Wounds that are exposed to intrinsic
hours with a 600 mg loading dose. Patients with large facial swellings or bacteria are classified as potentially
infections need thorough assessment. A contaminated. Examples of this type
Large Odontogenic Infections With complete medical history and physical of wound might be a traumatic self-
Systemic Signs and Symptoms examination are necessary. These patients inflicted laceration from the patients
In situations where the infection may have compromised host defenses or own teeth. The initial use of antibiotics
has spread to adjacent areas, incision may have associated medical conditions in these cases is not indicated, but the
and drainage, endodontic treatment that may need to be addressed. There may wounds must be observed closely for
or extraction are considered primary be airway concerns as well as the risk of potential late infections. Wounds that
treatments. This may be sufficient, but rapid spread through neighboring fascial have obviously been contaminated
antibiotics may be necessary for patients spaces to the neck and mediastinum, by extrinsic bacteria would be
who present with systemic signs and orbits or brain. The cause of these classified as contaminated/dirty.17,18
126M A R C H 2 01 7
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TABLE 5

Empiric Antibiotics of Choice for Odontogenic Infections


Severity/Penicillin allergy Antibiotics of choice
Outpatient Amoxicillin, Clindamycin, Azithromycin
Penicillin allergy Clindamycin, Azithromycin, Metronidazole, Moxioxacin
Inpatient Ampicillin/sulbactam, Clindamycin, Penicillin + metronidazole, Ceftriaxone mediators (e.g., cytokines, interleukin-1 ,
tumor necrosis factor , prostaglandin E2,
Penicillin allergy Clindamycin, Moxioxacin, Vancomycin + metronidazole
IgG 2) that are involved in periodontal
Adapted from Flynn T R. What Are the Antibiotics of Choice for Odontogenic Infections and How Long Should the Treatment disease. It is these inflammatory
Course Last? Oral Maxillofacial Surg Clin N Am 23 (2011) 519536.
mediators that are responsible for most
of the periodontal tissue destruction.
Human or animal bites are considered have an autoimmune etiology or be Concomitant systemic diseases,
contaminated/dirty. Bite wounds are associated with a neoplasm. Patients along with the patients own dental
at increased risk of infection, but with dehydration or hyposalivation are and osseous deformities, also affect the
antibiotic prophylaxis continues to be at risk. This includes the elderly and progression of periodontal disease. In
controversial. Early management is patients on certain medications (e.g., addition, factors like smoking and stress
important to decrease risk of infection. antihistamines diuretics, anticholinergics, have an impact. Scaling and root planing
If indicated, amoxicillin clavulanate chemotherapeutics). Associated medical (SRP) have been shown to be the most
is considered the antibiotic of choice. conditions such as diabetes, Sjgrens effective way of managing periodontal
Tetanus and rabies prophylaxis should be syndrome, malnutrition, anorexia/ disease. The goal of SRP is to disrupt the
considered when appropriate and given bulimia, vomiting/diarrhea, HIV/AIDS, biofilm and eliminate the inflammation.
per accepted guidelines.17,19,20 These renal failure, liver failure or patients who However, SRP is not as effective deep
wounds must be monitored closely. The have received head and neck radiation in periodontal pockets where bacteria
duration of antibiotics should be based therapy increase the risk of sialadenitis. can invade the epithelium and where
on healing. The route of administration Clinically, patients will present with there are architectural barriers (e.g.,
(intravenous, intramuscular or oral) salivary gland enlargement that may furcations, grooves, dentinal tubules). For
and duration of treatment would be or may not be painful. Any purulence this reason, systemic combination drug
determined by the severity of the potential should be cultured and antibiotic therapy has been advocated for patients
contamination and patient host factors. sensitivities obtained. If the condition who have specific microbiological profiles
Traumatic injuries caused by linear worsens while eating, it is suggestive but in their subgingival biofilm. There is
shear forces tend to have less risk of not pathognomonic of sialolithiasis. support for the use of systemic antibiotic
contamination than deep or complex Acute salivary gland infections of in the treatment of periodontal disease
lacerations. Bite or crush injuries are bacterial origin respond to antibiotic that progresses in spite of conventional
more likely to involve tissue necrosis and therapy. Empirically, these conditions can mechanical treatment. These drugs enter
infection. In general, antibiotics can help be treated with broad-spectrum penicillins the periodontal tissues and the sulcus
reduce infection risk and promote healing (amoxicillin, amoxicillin clavulanate), via the bloodstream to areas that cannot
of these types of injuries, but they are not first-generation cephalosporins be reached by instrumentation.2327
a substitute for vigorous irrigation, surgical (cephalexin, cefadroxil), clindamycin or Unfortunately, the subgingival biofilm
debridement and appropriate wound care. a macrolide (erythromycin, azithromycin, may be protective as the matrix can act
Response to antibiotic therapy and wound clarithromycin). Depending on the as a barrier to antibiotics and facilitate
healing must be closely monitored. severity of the infection, hospitalization horizontal resistance gene transfer.28
with incision and drainage and The American Academy of
Salivary Gland Infections intravenous antibiotics may be indicated.21 Periodontology (AAP) addressed the
For suspected salivary gland issue of the use of systemic antibiotics in
infections, it must first be determined if Periodontal Disease the treatment of periodontal disease in a
the infection is of bacterial etiology. A Periodontal disease is a chronic position paper. In that report, the AAP
thorough history and examination must multifactorial condition. The bacteria stated that the use of systemic antibiotics
be performed. Swellings in the gland may associated with periodontal disease are in the treatment of periodontal disease
be secondary to sialoliths, nonbacterial usually divided microbial complexes is to reinforce mechanical treatment
organisms like viruses (mumps, HIV), that live in biofilms.22 Not only is there and to support host defenses. The AAP
mycobacteria (e.g., tuberculosis), fungus a bacterial component to periodontal recommended that consideration should
or, rarely, parasites. They may even disease, there are also inflammatory be given to single or combination drug
M A R C H 2 0 1 7 127
antibiotic prophylaxis
C D A J O U R N A L , V O L 4 5 , N 3

TABLE 6

Common Antibiotic Therapies in the


Treatment of Periodontitis*

Antibiotic Adult Dosage


Metronidazole 500 mg/t.i.d./8 days
therapy based on the individual clinical attachment). The panel felt that there were Clindamycin 300 mg/t.i.d./8 days
situation. If combination therapy is negligible adverse effects and that the risk
Doxycycline or 100200 mg/q.d./21 days
indicated, they cautioned that care of antimicrobial resistance was not a factor.
minocycline
must be taken to select combinations The use of systemic antimicrobials like
Ciprooxacin 500 mg/b.i.d./8 days
that are not antagonistic. For example, amoxicillin, metronidazole, azithromycin,
bacteriostatic tetracyclines halt bacterial clarithromycin, moxifloxacin and the Azithromycin 500 mg/q.d./47 days
reproduction hindering the bactericidal tetracyclines at higher doses was also Metronidazole + 250 mg/t.i.d./8 days of
actions of -lactam antibiotics. reviewed. Even though the net benefit amoxicillin each drug
In the position paper, the AAP was the same as the use of SDD (mean Metronidazole + 500 mg/b.i.d./8 days of
provided clinicians with a list of frequently 0.35 mm gain in clinical attachment), the ciprooxacin each drug
prescribed antibiotics for the treatment of panel felt that these higher doses were not
*The antibiotic regimens listed do not represent recommenda-
aggressive periodontal disease (TA BLE 6 ). justified because of the increased risk of tions of the American Academy of Periodontology. Adapted
The AAP report stated that the optimum adverse effects and antibiotic resistance. from Position Paper Systemic Antibiotics in Periodontics. J
Periodontol 2004:15531565.
dosage of the antibiotics remains unclear The panel recommended that these drugs
and that most antibiotic regimens for the at higher doses should be reserved for
management of aggressive periodontal short-term (less than 21 days) use only.34,35 disease, renal disease or patients who are
disease have been developed empirically.29 HIV positive with CD4 counts greater
Some studies have questioned whether Extraction of Teeth than 200 are at low risk for postsurgical
improvement in periodontal disease with There are many indications for infections for routine extractions.36
the adjunctive use of systemic antibiotics the extraction of teeth. Some of these With respect to the extraction of
was clinically meaningful.30,31 Because of extractions may or may not be associated teeth in the presence of infection, early
the wide variability of antibiotic-resistant with infection. Some examples are extraction is associated with faster clinical
pathogens in periodontal disease, it has the extraction of impacted teeth, and biologic resolution of infection.37
been suggested that microbiological supernumerary teeth or because of acute Delay in the extraction of necrotic
analysis and antibiotic susceptibility fractures of roots or coronal portions. teeth risks the spread of the infection.
testing to determine antibiotic sensitivities Teeth are also extracted for prosthodontic
and the minimal inhibitory concentration purposes, cosmetic concerns or as indicated Extraction of Impacted Third Molars
(MIC) be conducted when systemic by orthodontic treatment. These extraction Postsurgical surgical site infection (SSI)
antibiotics are being considered.32 There sites are considered contaminated by related to third molar surgery occurs at a
is no evidence that systemic antibiotics virtue of their exposure to the oral cavity. frequency of between 1.2 to 27 percent
are effective as monotherapy without Because the microorganisms involved are with the most reported frequency at 5
SRP in treating periodontal disease.33 part of the hosts normal oral flora, pre- or percent. In spite of 60 years of clinical
A panel of experts was assembled postsurgical antibiotics are not indicated. experience and numerous clinical studies,
by the Council on Scientific Affairs of The use of prophylactic antibiotics the indications for the use of prophylactic
the ADA to review the literature and prior to tooth extraction has been antibiotics for the extraction of third
develop clinical practice guidelines on suggested if the patients immune status molar teeth remains unclear. Most of the
nonsurgical treatments for patients with is compromised (e.g., poorly controlled studies were not performed in the typical
chronic periodontitis with and without diabetes, end-stage renal disease, outpatient oral surgery setting. There was
adjuncts. The panel found that for patients alcoholism, immune compromising variability in the type of anesthesia provided
with chronic periodontitis, SRP showed a diseases). The literature does not for these cases. Some of the procedures
moderate benefit as the initial nonsurgical necessarily support the need for antibiotic were performed under local anesthesia
treatment of this condition. They suggested prophylaxis in these situations. Studies while others were performed under
the use of systemic subantimicrobial-dose have shown that there are no differences in general anesthesia. An additional variable
doxycycline (SDD), 20 mg twice a day healing after routine extractions between was the use of nonstandard antibiotic
for six to nine months, as an adjunct to well-controlled and poorly controlled regimens, dosing strategies and intervals.
treatment with SRP resulted in a small diabetics. In addition, studies have shown There is some evidence that prophylactic
net benefit (0.35 mm net gaining clinical that patients with either alcoholic liver antibiotics reduced the risk of infection,
128M A R C H 2 01 7
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dry socket and pain following third molar rates for dental implants if patients Another study of 23 subjects failed to find
extraction. The estimated adverse effect were given presurgical antibiotics.43 a significant benefit.53 Because of the lack
(diarrhea, nausea, rashes, vomiting, There are also studies that do not of research, the benefit of antibiotics and
vaginitis) rate was 1 to 3 percent. The support presurgical antibiotics prior implant placement and intraoral bone
authors of this study suggest that because to implant placement. These clinical grafting is also unclear. Further research
of the risk of adverse effects and antibiotic trials found that there was no significant needs to be performed on the most effective
resistance it may not be appropriate to difference in postoperative infections, antibiotic dosing regimen and whether
treat 12 healthy people with antibiotics adverse events or implant failures in postsurgical antibiotics are beneficial.
in order to prevent one infection.38 patients given preoperative antibiotics.4446
The American Association of Oral The effectiveness of postsurgical antibiotics Medication-Related Osteonecrosis
and Maxillofacial Surgeons (AAOMS) on implant survival rates has also been of the Jaw
is currently conducting a prospective questioned when single-dose preoperative In 2014, the AAOMS published
study concerning the use of antibiotics antibiotics was compared with one a position paper, Medication-Related
for third molar extractions. The purpose week of postoperative antibiotics.4750 Osteonecrosis of the Jaw (MRONJ).
of the study is to determine the effect of This condition, originally named
the use of antibiotics on clinical outcomes bisphosphonate-related osteonecrosis of
associated with the extraction of soft tissue the jaw (BRONJ), involves osteonecrosis
or partial or full bony third molar teeth. In a study of 2,973 implants, related to the use of bisphosphonates.
the Dental Implant Clinical The name was changed to MRONJ
Implants Research Group found because a large number of osteonecrosis
The placement of dental implants cases began to be identified involving
has become a predictable method of
signicantly higher survival rates other antiresorptive (denosumab) and
replacing teeth. The question is whether for dental implants if patients antiangiogenic (bevacizumab, sorafenib,
antibiotic prophylaxis is indicated for were given presurgical antibiotics. sunitinib, pazopanib, everolimus)
implant placement to reduce the chance medications. Intravenous forms of these
of implant failure or postsurgical infection. medications (zoledronate, ibandronate) are
Esposito et al. performed systemic reviews used to treat hypercalcemia of malignancy,
and analysis of randomized control trials In practice, there is significant bone metastasis of breast, prostate and lung
of healthy participants given preoperative confusion concerning the effectiveness cancers and multiple myeloma. Intravenous
amoxicillin versus placebo prior to of antibiotic therapy in dental implant and oral bisphosphonates (alendronate,
implant placement. Their last report success. So much so that a study of 217 ibandronate, risedronate and zoledronic
was an analysis that included six trials oral and maxillofacial surgeons found acid) are approved for the treatment of
that showed that there was a statistically no consensus concerning the use of osteoporosis and osteopenia. Patients are
significant higher percentage of implant preoperative antibiotics. Though most considered to have MRONJ if they have
failures in the placebo group versus the studies only support the use of presurgical exposed bone in the maxillofacial region
antibiotic group. This finding translated to antibiotic prophylaxis prior to implant that can be probed either intraorally or
the number needed to treat (NNT) with placement to reduce failures, a significant extraorally and that has been present
prophylactic antibiotics for one additional number prescribed postsurgical antibiotics.51 for at least eight weeks, currently or
beneficial (prevention of one failure) With respect to intraoral bone grafting, previously treated with antiresorptive or
outcome was 25. They reported that there are few studies on this subject. A antiangiogenic medications and have
that there was no statistically significant prospective placebo-controlled, double- no history of radiation therapy to the
difference for postsurgical infections.39,40,41 blind pilot study of 20 patients reported that jaws or metastatic disease in the jaws.
Another independent systemic review there was a statistically significant decrease In its position paper, the AAOMS
and meta-analyses had similar findings.42 in infections after intraoral bone grafting made stage specific MRONJ treatment
Finally, in a study of 2,973 implants, if 2 g of pheneticillin (a semisynthetic recommendations. For patients in early
the Dental Implant Clinical Research acid-resistant analog of penicillin) was stages (Stage 0) of MRONJ, there may
Group found significantly higher survival administered one hour before surgery.52 be a role for systemic antibiotics. No
M A R C H 2 0 1 7 129
antibiotic prophylaxis
C D A J O U R N A L , V O L 4 5 , N 3

TABLE 7

Staging and Treatment Strategies


MRONJ Staging Treatment Strategies
At-risk category No apparent necrotic bone in patients who have been No treatment indicated
treated with either oral or IV bisphosphonates Patient education
Stage 0 No clinical evidence of necrotic bone, but nonspecic clinical Systemic management, including the use of pain medication and antibiotics
ndings, radiographic changes and symptoms
Stage 1 Exposed and necrotic bone, or stulae that probes to bone, in Antibacterial mouth rinse
patients who are asymptomatic and have no evidence of infection Clinical follow-up on a quarterly basis
Patient education and review of indications for continued bisphosphonate therapy
Stage 2 Exposed and necrotic bone or stulae that probes to bone, Symptomatic treatment with oral antibiotics
associated with infection as evidenced by pain and erythema in the region of Oral antibacterial mouth rinse
the exposed bone with or without purulent drainage Pain control
Debridement to relieve soft tissue irritation and infection control
Stage 3 Exposed and necrotic bone or stulae that probes to bone in patients Antibacterial mouth rinse
with pain, infection and one or more of the following: exposed and necrotic Antibiotic therapy and pain control
bone extending beyond the region of alveolar bone (i.e., inferior border and Surgical debridement/resection for longer-term palliation of infection and pain
ramus in the mandible, maxillary sinus and zygoma in the maxilla) resulting in
pathologic fracture, extraoral stula, oral antral/oral nasal communication or
osteolysis extending to the inferior border of the mandible of sinus oor

Exposed or probable bone in the maxillofacial region without resolution for greater than eight weeks in patients treated with antiresorptive and/or an antiangiogenic agent who have not received
therapy to the jaws.

Regardless of the disease stage, mobile segments of bony sequestrum should be removed without exposing uninvolved bone. The extraction of symptomatic teeth with exposed necrotic bone should
be considered because it is unlikely that the extraction will exacerbate the established necrotic process.
Adapted from: Ruggiero SL, Dodson TB, Fantasia J, Goodday R, Aghaloo T, Mehrotra B, ORyan F. American Association of Oral and Maxillofacial Surgeons Position Paper on Medication-Related
Osteonecrosis of the Jaw 2014 Update. J Oral Maxillofac Surg 72:19381956, 2014.

antibiotics are necessary for asymptomatic developing osteoradionecrosis of the care or may develop infections caused
patients with exposed bone without jaw (ORN). The use of hyperbaric by those pathogens when exposed to
signs of infection (Stage 1). In patients oxygen (HBO) therapy was proposed the conditions associated with delivery
in intermediate stages (Stage 2), oral for the prevention and management of health care. Dentists must recognize
antibiotics and oral antibacterial mouth of ORN by Marx based on his theory their role in transmission of disease.
rinses should be considered. Similarly, in the of hypoxichypocellularhypovascular Organisms (bacteria, fungi and
most advanced cases (Stage 3), adjuvant tissue after radiation therapy (> 6000 viruses) can be spread from patient to
antibiotic therapy and antibacterial cGy).55 Bacterial infections are not patient from contaminated health care
mouth rinses are considered along with the cause of ORN, but are considered workers. Close attention should be
surgical debridement or resection. The a contaminant or superinfection.56 At paid to asepsis and infection control.
position paper stresses the importance of best, the use of antibiotics should only be This includes standard precautions like
cultures in the selection of antibiotics. used to prevent or manage infection of hand hygiene, surface disinfection and
Bacteria cultured from exposed bone are impaired tissue. In infections associated sterilization procedures, the possibility
typically sensitive to the -lactamase with ORN, cultures and determination of cross-contamination and following
antibiotics. Quinolones, metronidazole, of antibiotic sensitivities are important. strict surgical protocols. Policies
clindamycin, doxycycline and erythromycin should be in place for handling and
have been successful for patients who Health Care-Associated Infections processing patient care equipment and
are allergic to penicillin54 (TABLE 7 ). Health care-associated infections refer devices contaminated with blood or
to infections associated with health care body fluids. Staff members must have
Osteoradionecrosis of the Jaw delivery in any setting (e.g., hospitals, the appropriate personal protective
Dentists may encounter patients long-term care facilities, ambulatory equipment (gloves, gowns, face and eye
who have received radiation therapy settings, home care). Health care workers protection) and protocols for prevention
for oral pharyngeal malignancies. and patients may be colonized with, or of sharps injury. Antibiotics should not
Some of these patients who received exposed to, potential pathogens outside be used as an excuse for inadequate
high doses of radiation are at risk for of the health care setting before receiving infection control procedures.57
130M A R C H 2 01 7
C D A J O U R N A L , V O L 4 5 , N 3

Conclusions should not be performed too quickly. At most appropriate antibiotic prophylaxis
In treating infections, an accurate least 48 to 72 hours may be necessary for each patient. Each patient has a role
diagnosis needs to be made to determine if for an antibiotic to have an effect. in making decisions concerning his or
there is a need for antibiotic therapy. The Prior to using antibiotics for infection her care. Prescribing stewardship is one
acute or chronic stage of the infection may management, patients must receive of the main ways dentists can reduce
dictate whether antibiotics are indicated. a thorough informed consent of the the risk of antibiotic resistance. With
Antibiotics cannot be a substitute for risks and benefits of using antibiotics. each antibiotic prescription, the patients
conventional therapy including indicated This must include possible antibiotic individual risk and the communitys risk of
surgical procedures. Patient host factors effects on medical and dental conditions antibiotic resistance must be weighed.
and immune status need to be determined. they may have, age-related effects, ACKNOWLEDGMENT
Antibiotics should only be used to support drug interactions, the risk of allergies, The author thanks Dr. Melanie Gullet, Dr. Jean Creasey, Dr.
the patients immune system in controlling other possible adverse effects, the Rick Nagy and Dr. Kevin Keating for their invaluable comments
and insight in writing this article.
infection. The use of antibiotics should likelihood of improvement and cost.
only be considered if there is an inadequate There may be some usefulness in REFERENCES

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George Maranon, DDS, can be reached at
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132M A R C H 2 01 7
pediatric fractures
C D A J O U R N A L , V O L 4 5 , N 3

Management of Mandibular
Fractures in Pediatric Patients
With Conservative Technique:
A Case Series
Manisha Sahni Prabhakar, MDS; Khushboo Kansal, BDS; and Arjun Chawdhry

A B S T R A C T The management of fractures in children is complex compared to that of


adults because of greater elasticity of bone, presence of tooth buds, faster healing rate,
potential for future growth and lesser co-operative ability. Fractures of the mandible
in children are conventionally treated by circummandibular wiring. This paper
reports a variation in the technique of using circummandibular wiring with acrylic
splints in the conservative treatment of mandibular fractures in two pediatric patients.

AUTHORS

A
Manisha Sahni Khushboo Kansal, BDS, fracture is a complete or whereas symphyseal and parasymphyseal
Prabhakar, MDS, is is an MDS student at Gian incomplete break in the fractures account for 15-20 percent
a professor, head and Sagar Dental College
continuity of bone or and body fractures occur very rarely.5
postgraduate teacher and Hospital Ludhiana in
and guide at Gian Punjab, India.
cartilage. Fractures in children Nondisplaced body or symphysis
Sagar Dental College Conict of Interest younger than 5 years of age are fractures in adult patients can be treated
and Hospital Ludhiana Disclosure: None reported. always challenging to the pediatric dentist. by close observation, avoidance of
in Punjab, India. She is a Most commonly, facial fractures occur due physical activity and a soft diet.6 If a
renowned pediatric dentist Arjun Chawdhry is
to falls (64 percent) followed by traffic- displaced fracture is present, reduction
with more than 20 years a BDS student at Gian
of teaching experience Sagar Dental College
(22 percent) and sports-related accidents by open method can be performed.7
in reputed professional and Hospital Ludhiana in (9 percent).1 Facial fractures account On the contrary, the management of
colleges and has served as Punjab, India. for less than 5 percent of all fractures in mandibular fractures in children is
principal, director, professor, Conict of Interest children, and this percentage drops down complex compared to that of adults due
head and dental practice Disclosure: None reported.
to 1 percent for ages less than 5.2 Among to greater elasticity of bone, the presence
manager.
Conict of Interest
all facial fractures, the most common of tooth buds, a faster healing rate, the
Disclosure: None reported. fracture is mandible (32.7 percent) potential for future growth and a lesser
followed by nasal (30.2 percent) and cooperative ability.8 All these issues
maxillary/zygoma (28.6 percent).3 Boys complicate the management of pediatric
are more commonly affected than girls mandibular fractures, so the treatment
and the ratio is 2:1.4 In children, condylar, of fractures in pediatric patients is to be
subcondylar and angle fractures account carefully planned and executed giving
for 80 percent of mandibular fractures, due consideration to the above factors.
M A R C H 2 0 1 7 133
pediatric fractures
C D A J O U R N A L , V O L 4 5 , N 3

In pediatric patients generally,


undisplaced body, symphysis and
condylar fractures can be treated with
close observation, blenderized diet and
FIGURE 1. A parasymphyseal fracture is present
avoidance of physical activities.9 But if
between teeth O and N.
fractures are displaced, close reduction
with or without immobilization should
be considered.10 The exact method of dental development, keeping in mind
immobilization depends on the childs the type of fracture. Fractures without
chronological age and stage of dental displacement can be managed by close
development.11 If the teeth are inadequate observation, soft diet, restriction of
to support wiring or splints, the fracture physical activities and analgesics.8 FIGURE 2 . A CT scan was taken to rule out any
head injury.
site should be immobilized and stabilized But in fractures with displacement
with acrylic or lingual splint for three and deranged malocclusion, management
to four weeks.12 Intermaxillary fixation with either closed or open reduction But this treatment modality remains
might be required if the fracture is not has to be done by splints and arch bars controversial in pediatric patients. The
adequately immobilized by splint. for two to three weeks. Rarely, where a mandibular cortex is thin and less dense
An understanding of all the fracture is limited to alveolar process, than in adults. This could lead to the
treatment options is essential for optimal long-term mono-maxillary immobilization plates being visible or palpable through
management of these injuries. This (via splinting) is indicated for up to two the childs skin or the screws and plates
paper reports two pediatric cases of months to prevent malocclusion.6 could migrate as the teeth are in an
mandibular fractures that were treated Intermaxillary fixation using arch eruptive stage. Also, the danger of damage
with acrylic splint using a modified bars and eyelets can also be used to the permanent tooth buds during
circummandibular wiring method. for the management of mandibular the placement of screws, restriction of
Conventionally, circummandibular fractures. It is a noninvasive, simple growth of the jaws because of periosteal
wiring is performed with a mandibular and low-cost technique, but the stripping, pain and secondary infection
awl, but a wound created by awl is quite arch bars and wires cause irritation preclude the use of ORIF as treatment of
conspicuous.13 In this article, we are using to the supporting tissues and lead to choice. ORIF in parasymphysis fractures
a variation of this technique by using a periodontal problems. The foundation can safely be done after 9 years of age
20-gauge spinal needle with 26-gauge for the arch bars is technically very when the permanent buds of the canines
orthodontic wire for stabilization of challenging due to the conical and have moved up from their inferior
the splint.14 This method is simple, tapered shape of crown and wide position at the mandibular border.6
conservative and easy to fabricate, cervical area. The primary teeth can The need for open reduction in
causes minimal trauma to surrounding be avulsed out during the procedure. pediatric fractures is minimal because
tissues, is cost effective and has good Also, the wires restrict the diet of malunion or nonunion in children is rare
stability during the healing period. the child, leading to weight loss.16 due to their greater osteogenic potential
Open reduction rigid internal fixation and faster healing rates.6 Keeping in mind
Discussion (ORIF) using plates and screws is also all the above factors, mandibular fractures
The management of jaw fractures one of the options in which fixation is in children are best treated by conservative
in cases of pediatric patients is very achieved under direct vision and with methods. We were able to successfully
challenging to dentists. Although the better approximation. Zimmerman et al. manage the cases by using acrylic cap
signs and symptoms in pediatric patients said in 2006 that in pediatric fractures splints with modified circummandibular
are the same as those in adults, the ORIF provides stable three-dimensional wiring. An acrylic cap splint is cost
treatment plan changes due to the growth reconstruction, promotes primary bone effective, easy to fabricate, requires less
of jaws and the developing dentition.2 healing, shortens treatment time and chair time, provides adequate stability to
Treatment of a pediatric patient eliminates the need for or permits early fragments and causes minimal trauma to
depends on the stage of skeletal and release of maxillomandibular fixation.6 supporting tissues. The modified technique
134M A R C H 2 01 7
C D A J O U R N A L , V O L 4 5 , N 3

FIGURE 4 . A mandibular cast was split into two


fragments at the fractured site.

FIGURE 3 . Preoperative orthopantomoradiogram showing the fracture line between the left lateral and
central incisors and fracturing of the left parasymphyseal region of mandible.

of circummandibular wiring using a A CT scan of the head was taken to


20-gauge spinal needle and orthodontic rule out any component of head injury
wire was atraumatic and led to a smaller (FIGURE 2 ). Panoramic radiograph
wound with a resultant smaller scar. confirmed the diagnosis of parasymphyseal
Reduction of fractured segments by splints fracture (fractures present lateral to mental
was achieved as close as possible to the prominences in mandible). A fracture line FIGURE 5 . The cast segments were joined with sticky
original positions and gave us satisfactory was seen commencing superiorly between wax in a reduced position.
results in both cases posttreatment. mandibular left central and lateral incisors
and extending up to the inferior border of
Case Reports the mandible on the same side (FIGURE 3 ).
Primary treatment was instituted
Case One and lacerated wounds were sutured.
A 5-year-old boy reported to Informed consent was obtained from
the department of pedodontics and the parents prior to treatment. Maxillary
preventive dentistry in Gian Sagar and mandibular impressions were made in
Dental College and Hospital in Rajpura, alginate and casts were poured in dental
Punjab, India, with the chief complaint stone. For the mock surgery, the fractured
of facial injury due to a fall from site was marked on the mandibular cast
height. There was no history of loss and then split into two segments with
of consciousness, vomiting or seizures, an electric saw (FIGURE 4 ). The cast
bleeding from the nose or ears or any segments were then joined with sticky FIGURE 6 . An interocclusal splint was fabricated
using clear self-cure acrylic.
other injuries, as elicited by the mother. wax in a reduced position simulating the
The patient was conscious, cooperative intact arch and after achieving proper
and well oriented in time and place. occlusion with maxillary cast (FIGURE 5 ). The splint was disinfected by overnight
On extraoral examination, there The casts were mounted on an articulator immersion in 2% gluteraldehyde.
was swelling on the left side of the face (three point or mean value articulator). The patient was recalled on the
and lacerations near the angle of the After the blockage of undercuts, an next day and premedicated with oral
mouth and left side of the forehead. interocclusal splint was fabricated using midazolam in a dosage of 0.5mg/Kg
Intraoral examination revealed clear self-cure acrylic on the mandibular body weight.15 The premedication was
bleeding within the mouth, limited cast (FIGURE 6 ). An arch wire was administered using clear apple juice as
mouth opening and deranged occlusion incorporated into the splint in order to the carrier vehicle 30 minutes before
with a displaced fracture between facilitate doing intermaxillary fixation surgery. Under local anesthesia, the
teeth O and N (FIGURE 1 ). on this patient if required at a later stage. mandibular arch was manually reduced
M A R C H 2 0 1 7 135
pediatric fractures
C D A J O U R N A L , V O L 4 5 , N 3

Soft tissue

Buccinator
muscle Buccinator Buccinator
muscle muscle
26-gauge Splint
wire 26-gauge
26-gauge wire
wire Spinal needle
Spinal needle Alveolar bone
Skin
Sublingual gland Skin

Sublingual gland Sublingual gland

FIGURE 7. In step one, a 20-gauge spinal needle FIGURE 8 . In step two, the spinal needle was FIGURE 9. In step three, the splint was stabilized by
was introduced through the skin and removed lingually passed on the buccal side through the same puncture twisting the wire in a clockwise direction.
close to the body of the mandible. hole in proximity to the bone.

FIGURE 10 . The stabilized splint in the oral cavity.

FIGURE 11. Postoperative radiograph shows the acrylic splint secured with circummandibular wiring.

FIGURE 12. Postoperative photograph after 21 days. into the lumen of the spinal needle (FIGURE 10 ). Finally, stability of the splint
and clamped intraorally. The spinal was verified (FIGURE 11 ). Postoperative
needle was then passed on the buccal instructions were given to the patient
and a splint was tried for stability taking side through the same puncture hole and medications were prescribed.
occlusion as a guidance. To stabilize in proximity to the bone (F I G U R E 8 ). After 21 days, the splint was
the fracture segments with the splint, Both buccal and lingual ends of wires removed as healing had occurred
circummandibular wiring was done were held together, freed from skin over satisfactorily and uneventfully without
(steps 13). The 20-gauge spinal needle the mandible by a sawing motion (pulling any complications. Masticatory functions
was introduced through the skin and the two free ends alternatively) and the were restored and the minimally
taken out lingually close to the body of splint was stabilized by twisting the wire invasive treatment proved quite effective
the mandible (F I G U R E 7 ). A 26-gauge in a clockwise direction (FIGURE 9 ). This (FIGURE 12 ). The patient was kept
orthodontic wire was then inserted procedure was repeated on the other side under supervision for three months.
136M A R C H 2 01 7
C D A J O U R N A L , V O L 4 5 , N 3

FIGURE 13 . CT scan shows the FIGURE 14 . Preoperative CT scan FIGURE 15 . Postoperative photograph with the
fracture in the symphyseal region. shows fracture in the symphyseal region splint in position.

Case Two Conclusion 11. Hooda A, Kumar A. Management of mandible fractures in


pediatric patients. Acta Biomedica Scientia 2015;2(4):173
A 2-year-old boy reported with the The management of mandibular
176.
chief complaint of trauma due to a fall fractures in children is complex and 12. Kruger GO. Fractures of the jaws. In: Kruger GO, ed.:
from height. The patient had no history conventionally done by circummandibular Textbook of Oral and Maxillofacial Surgery. 6th ed. St. Louis:
Mosby; 1989:364433.
of loss of consciousness and no bleeding wiring with a mandibular awl. The twisted
13. Thomas S, Yuvaraj V: Atraumatic placement of
from nose or ears. A CT scan was advised ends of the awl could cause trauma to circummandibular wires: A technical note. Int J Oral Maxillofac
for the patient. The CT revealed that the surrounding soft tissues because of its Surg 2010;39:8385.
14. Kapoor V. Injuries of the maxillofacial region. In: Kapoor V,
there was no head injury but a bony sharpness and thickness. In this case, a
ed.: Textbook of Oral and Maxillofacial Surgery 2nd ed. New
fracture was found in the symphyseal region modified atraumatic technique of placing Delhi: Arya; 228318.
of the mandible (FIGURES 13 and 14 ). circummandibular wiring was used, in 15. McMillan CO, Spahr-Schopfer IA, Sikich N.
Premedication of children with oral midazolam. Can J Anaesth
On extraoral examination, there was which a 20-gauge spinal needle along
1992;39(6):545550.
swelling of upper and lower lips. Intraoral with a 26-gauge orthodontic wire were 16. Singh J, Khadka R, Chaturvedi PC. Circummandibular
examination revealed deranged occlusion used to stabilize the splint. Not only is it wiring made easy: A case report. Rev Esp Cir Oral Maxilofac
2014;36(4):191195.
with step deformity and spacing between economical and disposable, this technique,
the maxillary central incisors. Informed being sharp in nature, also leaves a smaller THE CORRESPONDING AUTHOR, Manisha Sahni Prabhakar, MDS,
consent was obtained from the parents. wound leading to a smaller scar. can be reached at prof.manisha@gmail.com.
Oral premedication was given 30 minutes
REFERENCES
prior to taking impressions. Maxillary and 1. Kale TP, Urologin SB, Motwani NB. Management of
mandibular impressions were made and mandibular fracture in children with open cap splint: A
cast fabrication was done. Mock surgery treatment modality. Int J Contem Dent 2011;2(1):6972.
2. Aizenbud D. The management of mandibular body fractures
was done and casts were then mounted on in young children. Dental Traumatol 2009;25:565570.
an articulator. After the blockage of 3. Boyette JR. Facial Fractures in Children. Otolaryngol Clin N
undercuts, a cap splint was fabricated Am 2014;47:747761.
4. Maranoa R, Netoa PO, Sakugawab KO, et al. Mandibular
using clear self-cure acrylic. fractures in children under 3 years: A rare case report. Rev Port
Under premedication and local Estomatol Med Dent Cir Maxilofac 2013;54(3):166170.
anesthesia, the mandibular arch was 5. Adlakha VK, Bansal V, Chandna P, et al. Mandibular
fracture in an 18-month-old child. Ind J Dent Res
manually reduced and a splint was tried 2011;22(5):723725.
for stability. Modified circummandibular 6. Zimmermann CE, Troulis MJ, Kaban LB. Pediatric facial
wiring was done with the splint in position fractures: Recent advances in prevention, diagnosis and
management. Int J Oral Maxillofac Surg 2006;35:213.
(FIGURE 15 ) and stability of the splint was 7. Vasconcelos et al. Mandibular Fracture in a Premature Infant.
verified. Postoperative instructions and J Oral Maxillofac Surg 2009;67:218222.
medications were given to the patient. 8. Kaban LB. Facial trauma II: Dentoalveolar injuries and
mandibular fractures. In: Kaban LB, ed.: Pediatric Oral and
After 21 days, the splint was Maxillofacial Surgery. Philadelphia: WB Saunders 199:233260.
removed. In the postoperative 9. Stacey DH. Management of Mandible Fractures. Plast
orthopantomogram, fracture reduction Recons Surg 2006;117(3):4860.
10. Khatri A. A conservative approach to pediatric mandibular
occurred satisfactorily and masticatory fracture management: Outcome and advantages. Ind J Dent
functions were restored subsequently. Res 2011;22(6):873876.

M A R C H 2 0 1 7 137
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photodynamic therapy
C D A J O U R N A L , V O L 4 5 , N 3

Ex Vivo Assessment of
Photodynamic Therapy in
Achieving Microbial Reduction
Rodrigo Rodrigues Amaral, DDS, MS; Eduardo Nunes, DDS, MS, PhD; Maria
Eugnia Alvarez-Leite, DDS, MS, PhD; Jos Cludio Faria Amorim, DDS, MS, PhD;
Martinho Campolina Rebello Horta, DDS, MS, PhD; Maria Ilma de Sousa Corts,
DDS, MS, PhD; Frank Ferreira Silveira, DDS, MS, PhD; and Stephen Cohen, MA, DDS

A B S T R A C T The study was to assess the effects of photodynamic therapy (PDT)


on root canals contaminated by Enterococcus faecalis (E. faecalis). PDT was
performed with 0.005% methylene blue dye and with a low-intensity red emission
laser. Microbiological samples were collected before, immediately and 72 hours
after instrumentation. Although PDT performed with the chosen light parameters
promoted additional microbial reduction, this therapy did not achieve a statistically
significant reduction of E. faecalis.

AUTHORS

I
Rodrigo Rodrigues Maria Eugnia Alvarez- Martinho Campolina Frank Ferreira Silveira, n the last several decades, endodontics
Amaral, DDS, MS, is in Leite, DDS, MS, PhD, is in Rebello Horta, DDS, MS, DDS, MS, PhD, is has evolved substantially along with
the department of dentistry the department of dentistry PhD, is in the department an adjunct professor
the development and adoption of
at Pontifcia Universidade at Pontifcia Universidade of dentistry at Pontifcia of endodontics at the
Catlica de Minas Gerais Catlica de Minas Gerais Universidade Catlica University of the Pacic,
new technologies and materials. The
in Belo Horizonte, Brazil. in Belo Horizonte, Brazil. de Minas Gerais in Belo Arthur A. Dugoni School of quality of endodontic treatment has
Conict of Interest Conict of Interest Horizonte, Brazil. Dentistry in San Francisco. been maximized, and the time required
Disclosure: None reported. Disclosure: None reported. Conict of Interest Conict of Interest to accomplish it has been substantially
Disclosure: None reported. Disclosure: None reported.
reduced. Most therapeutic failures
Eduardo Nunes, DDS, Jos Cludio Faria
MS, PhD, is in the Amorim, DDS, MS, PhD, Maria Ilma de Sousa Stephen Cohen, MA,
are associated with the persistent
department of dentistry is in the department of Corts, DDS, MS, PhD DDS, is an adjunct presence of microorganisms, which
at Pontifcia Universidade dentistry at Itana University is in the department of professor of endodontics at are able to survive chemomechanical
Catlica de Minas Gerais in Itana, Brazil. dentistry at Pontifcia the University of the Pacic, preparation or intracanal medication.1
in Belo Horizonte, Brazil. Conict of Interest Universidade Catlica Arthur A. Dugoni School of
Protected by the favorable anatomy
Conict of Interest Disclosure: None reported. de Minas Gerais in Belo Dentistry in San Francisco.
Disclosure: None reported. Horizonte, Brazil. Conict of Interest
of the root canal system (RCS),
Conict of Interest Disclosure: None reported. microorganisms cannot be reached by the
Disclosure: None reported. hosts defenses or systemic antibiotics.
Microorganisms are eliminated by the
mechanical action of instruments, the
irrigation process and the action of
antimicrobial irrigants and intracanal
medication. Several studies have shown
M A R C H 2 0 1 7 139
photodynamic therapy
C D A J O U R N A L , V O L 4 5 , N 3

that chemomechanical preparation in at Pontifical Catholic University of


combination with sodium hypochlorite Minas Gerais approved the study.
solution at different concentrations does The teeth were stored in 0.5%
not completely eliminate microorganisms sodium hypochlorite solution for two to
from the RCS, which can still be four weeks. The crowns were removed
found in 40-60 percent of teeth and at the cementoenamel junction using
FIGURE 1. Photodynamic therapy as a supplement
thus represent a negative factor for the a diamond disk. The canals were
to instrumentation.
success of endodontic treatment.25 instrumented sequentially using #15 to
The microorganism Enterococcus #20 K-type files (Dentsply Maillefer,
faecalis (E. faecalis) has been reported Ballaigues, Switzerland) at the level water and were adjusted to McFarland
as the most prevalent species associated of the apical foramen, as established turbidity standards (3 x 108 cells/mL).
with endodontic treatment failure by direct visualization. Preliminary One milliliter was removed from the
and was isolated in 70 percent of such instrumentation was facilitated by initial suspension to prepare another
cases.1,4,6 E. faecalis is resistant to most irrigation with 1 mL of 5.25% sodium suspension in 10 mL of BHI broth. After
intracanal medications, including calcium hypochlorite (NaOCl) solution. To five hours of incubation at 37 degrees
hydroxide, tolerates pH levels up to 11.57 remove the smear layer, the root Celsius in aerobiosis, approximately
and can lead to mono-infection, which canal was flooded with 1 mL of 17% 20 mL of the bacterial suspension was
is extremely difficult to eradicate by ethylenediaminetetraacetic acid applied to each experimental unit by
conventional methods. The presence of E. (EDTA) solution, pH 7.4, for three being smoothly injected into each root
faecalis at the time of root canal obturation minutes followed by final irrigation canal using a plastic syringe. Subsequently,
can be a continuing source of infection.8,9 with 5.25% NaOCl solution. After the a #15 K-type file was used to drive
Photodynamic therapy (PDT) has canals were dried with size 20 Endo the bacterial suspension to WL. Each
emerged as a promising antimicrobial Points absorbent paper points, (Endo experimental unit was placed in a sterile
treatment. PDT involves the use of a Points Industrial da Amaznia Ltda., plastic flask with a screw cap and was
photosensitizer (dye) that is activated Manacapuru, Brazil) a #20 K-type file incubated for 24 hours at 37 degrees
by light at a specific wavelength in the was stabilized at working length (WL) Celsius in aerobiosis. The root canals
presence of oxygen. Energy transference that was established 1 mm short of the were reinoculated over 21 days at 48-hour
from the activated photosensitizer to apical foramen. Subsequently, the apical intervals with fresh E. faecalis suspensions
available oxygen results in the formation foramen and the final 3 mm of the root that were prepared as described above.
of toxic oxygen species, such as singlet were sealed with two cyanoacrylate The teeth were divided randomly
oxygen and free radicals. These oxygen layers (Super Bonder, Henkel Loctite in two experimental groups and two
species are highly reactive and harm Adhesives Ltd., Itapevi, Brazil). Each (one positive and one negative)
proteins, lipids, nucleic acids and other root was coupled to the central section control groups. In group one (n = 10),
microbial cellular components.10 of the rubber lid of a glass container, and chemomechanical preparation was
To assess the effectiveness of these experimental units were sterilized performed using 5.25% NaOCl solution
photodynamic therapy in achieving with ethylene oxide gas (Curar Centro as an irrigant. In group two (n = 10),
microbial reduction in root canals de Esterilizao Ltda., Belo Horizonte, chemomechanical preparation was
contaminated by E. faecalis, our study Brazil) and appropriately packaged. performed by irrigation of the canals with
employed an ex vivo comparative design. The root canals were contaminated 5.25% NaOCl solution followed by PDT.
with a suspension of E. faecalis (ATCC The positive control group consisted of
Materials and Methods 4083, American Type Culture Collection, four teeth instrumented and irrigated
The sample consisted of 28 Manassas, Va. ). Microorganisms were with 0.85% saline solution and the other
human single-root teeth extracted seeded in Brain Heart Infusion Agar four teeth were allocated to the negative
for several reasons and freely and (BHI) solid medium (Difco Laboratories, control group, which was not inoculated
spontaneously donated by patients Detroit). To prepare the suspension, with the indicator microorganism.
who signed an informed consent three to five colonies from a 24-hour All root canals were instrumented
form. The research ethics committee culture were added to 5 mL of distilled sequentially up to WL by means of
140M A R C H 2 01 7
C D A J O U R N A L , V O L 4 5 , N 3

TABLE 1

Mean and Standard Deviation of the Values of CFU Assessment (Log 10)

Pre-instrumentation Post-instrumentation 72 hours


A,a B,a
Saline solution (positive control group) 6.40 0.22 1.76 0.19 1.95 0.24 B,a
NaOCl (group one) 5.78 0.47 A,a 0.19 0.61 B,b 0 0 B,b
NaOCl + PDT (group two) 5.77 0.62 A,a 0 0 B,b 0 0 B,b
A,B Within rows, means followed by the same uppercase letter are not signicantly dierent from each other (p > 0.05). P values were obtained by using repeated measurements one-way ANOVA
followed by Tukeys post-hoc test.
a,bWithin columns, means followed by the same lowercase letter are not signicantly dierent from each other (p > 0.05). P values were obtained by using one-way ANOVA followed by Tukeys
post-hoc test.

TABLE 2

Qualitative Data Evaluation (Medium Turbidity)

Pre-instrumentation Post-instrumentation 72 hours


Saline solution (positive control group/n = 4) 4(+) and 0(--)A,a 4(+) and 0(--)A,a 4(+) and 0(--)A,a
NaOCl (group one/n = 10) 10(+) and 0(--)A,a 3(+) and 7(--)B,a,b 0(+) and 10(--)B,b
NaOCl + PDT (group two/n = 10) 10(+) and 0(--)A,a 2(+) and 8(--)B,b 0(+) and 10(--)B,b
Positive (+)/Negative (--)
A,B Within rows, values followed by the same uppercase letter are not signicantly dierent from each other (p > 0.05). P values were obtained by using the Fischer exact test.
a,b Within columns, values followed by the same lowercase letter are not signicantly dierent from each other (p > 0.05). P values were obtained by using the Fischer exact test.

a rotary instrumentation technique 0.85% saline solution and dried with pure samples and the dilutions of 101
using ProTaper S1, S2, F1, F2 and F3 Endo Points size FM absorbent paper to 104 were sown in BHI medium and
files (Dentsply Maillefer, Ballaigues, points. The photosensitizer was placed incubated at 37 degrees Celsius for 48
Switzerland); ProTaper F4 (#0.40 mm) inside the canals using a sterile disposable hours in aerobiosis. Subsequently, the
was used to finish the preparation. syringe and a 23-gauge needle and culture growths were counted and the
Irrigation with 1 mL of 5.25% NaOCl left for five minutes of pre-irradiation typical morphological characteristics
solution was performed after each time. Next, irradiation was performed of E. faecalis colonies were sought.
change of instrument all throughout the with optic fiber for 180 seconds. For qualitative assessment, the
preparation using a sterile, disposable Microbiological samples procedures microbiological samples were collected
plastic syringe. At the end of preparation, were blinded and collected before, using a similar procedure as the pure
root canals were irrigated with 1 mL of immediately after and 72 hours after samples using three absorbent paper
17% EDTA solution, pH 7.4, for three instrumentation. The canals were filled points before, immediately after and 72
minutes followed by a final irrigation with 0.85% saline solution by means of hours after instrumentation, seeded in
with 1 mL of 5.25% NaOCl solution. a sterile, disposable plastic syringe and a triplicate in BHI broth, incubated as
For the PDT group, a 0.005% 23-gauge needle. Each microbiological described above and assessed regarding the
methylene blue solution (Chimiolux, sample was collected using FM absorbent presence or absence of medium turbidity.
Hypofarma, Belo Horizonte, Brazil) paper points previously sterilized with To identify the morphological
was used as a photosensitizer for 5 ethylene oxide, left in the canals for and tinctorial characteristics of the
minutes11 and Twin Flex laser equipment one minute. The canals were filled recovered microorganisms, the samples
(MMOptics, So Carlos, Brazil) at a again with 0.85% saline solution and were stained using Grams method.
660-nm wavelength and 40 mW of were kept sufficiently hydrated to allow The quantitative data (colony-
power to a total energy density of 1.8 J/ for the collection of samples. The forming unit counting) were statistically
cm.2 A 300-m optic fiber (MMOptics) absorbent paper points were transferred analyzed by one-way ANOVA followed
was coupled to the diode laser and was to test tubes containing 2 mL of 0.85% by Tukeys post-hoc test. The qualitative
inserted into the root canal 2 mm short saline solution, which were agitated data (medium turbidity) were evaluated
of WL, where it was set to allow for for one minute in a Vortex (Eletrolab, by Fishers exact test. Tests were
better diffusion of light (FIGURE 1 ). So Paulo, Brazil). For quantitative performed by using GraphPad software
Before placing the photosensitizer, assessment, the dilutions were performed (GraphPad Software, San Diego) at
the canals were irrigated with 1 mL of in triplicate, and 1-mL aliquots of the significance level of 5 percent.
M A R C H 2 0 1 7 141
p h o t o d ye n
y eabmrioc wt h e r a p y
C D A J O U R N A L , V O L 4 5 , N 3

Results the positive control group with no Microorganisms located in


Effective colonization was confirmed difference among the other groups (TABLE ramifications, isthmus and dentinal
by colony-forming unit (CFU) count 2 ). Finally, 72 hours after instrumentation, tubules can escape the effects of the
and medium turbidity assessment medium turbidity was lower in groups one instruments and irrigants used during
of the samples collected before and two when compared to the positive chemomechanical cleansing of RCS20
instrumentation (TABLES 1 and 2 ). control group with no difference between and can eventually lead to late failure of
In quantitative analysis, the first (TABLE 2 ). endodontic treatment.21 The use of EDTA
microorganisms were recovered from all during cleaning of the root canal seems to
samples of the positive control group, from Discussion improve the microorganisms reduction.2
one single sample from group one and no The aim of this study was to assess E. faecalis was selected due to its
micro-organisms measured as CFUs were the effectiveness of photodynamic ability to survive without synergism
recovered from samples from group two. In therapy in achieving microbial with other microorganisms, and it
all groups, the CFU count was lower reduction in root canals contaminated seems to tolerate ecological changes in
immediately after and 72 hours after by E. faecalis with conventional the root canal and to exhibit greater
instrumentation when compared to the persistence than other species.22 E.
CFU count before instrumentation with faecalis was observed in a remarkable
no difference between the first (TABLE 1 ). proportion of teeth exhibiting persistent
When the groups were compared, no E. faecalis was observed periapical lesions, despite well-performed
difference was observed in the CFU count in a remarkable proportion endodontic treatments,23 as well as in
before instrumentation (TA BLE 1 ). treatments with inappropriate obturation
of teeth exhibiting persistent
Moreover, the CFU count was lower in of the root canal.6 Similar to other
groups one and two when compared to the periapical lesions, facultative anaerobic microorganisms,
positive control group, immediately after despite well-performed E. faecalis can exhibit resistance to
and also 72 hours after instrumentation endodontic treatments. antimicrobial agents, endodontic
(TA BLE 1 ). In both collection times, no procedures and intracanal medication.24
differences were observed between groups The antimicrobial property of sodium
one and two (TA BLE 1 ). hypochlorite solutions are proportional to
In qualitative analysis, medium endodontic treatment. Thus to its concentration. E. faecalis are resistant
turbidity was positive in three samples from evaluate the effect of PDT alone was to NaOCl in low concentrations.2527
group one and in two samples from group not the purpose of the study because The ideal concentration of sodium
two after instrumentation (TABLE 2 ). PDT is not a substitute for NaOCl. hypochlorite to achieve antimicrobial
Microorganisms were not observed in these PDT seems to be a promising activity against E. faecalis was 5.25
two groups 72 hours after instrumentation adjuvant therapy to endodontic percent when the time needed for
(TABLE 2 ). In the positive control group, treatment to eliminate the microbial elimination was considered.28
no differences were observed in medium microorganisms that remain after In this study, the previous enlargement
turbidity between the collection times chemomechanical preparation. PDT of the root canal was limited to the action
(TABLE 2 ). In groups one and two, medium is easy to apply in clinical practice, of #15 and #20 K-type instruments, as
turbidity was lower immediately after and and it might be indicated in single or in a previous study,29 aiming to maintain
also 72 hours after instrumentation when multiple-session endodontic treatments. the experiment as close as possible to
compared to medium turbidity before Several studies using PDT1219 have actual clinical conditions. Other studies,
instrumentation with no difference suggested that it might be employed as however, have performed full preparation
between the first (TABLE 2 ). When the an adjuvant to endodontic treatment of the root canal before the inoculation of
groups were compared, no difference was to achieve significant reduction of microorganisms and have applied average
observed in the medium turbidity before microorganisms. PDT can destroy inoculation and incubation times of 48
instrumentation (TABLE 2 ). Immediately the remaining microorganisms or 72 hours.12,13,15,16,30 The microbial load
after instrumentation, medium turbidity inside the RCS after conventional inoculated in most studies, including this
was lower in group two when compared to chemomechanical preparation. one, corresponds to McFarland standard 1.
142M A R C H 2 01 7
C D A J O U R N A L , V O L 4 5 , N 3

Different from other studies, in this study, study by Silva Garcez et al.12 In addition, preparation, the microbial load
inoculation and incubation were performed no difference was shown in the use of PDT measured by CFU count decreased by
over 21 days at 48-hour intervals and in periods one, two and four minutes.36 100 percent, thus suggesting the absence
with 24-hour reinoculation seeking to Quantitative analysis of the of cultivable microorganisms. These
accomplish complete contamination of the positive control group made evident two experimental groups exhibited
RCS, which was confirmed by the average the importance of using an irrigant different results in the assessment
values in the samples collected before exhibiting antimicrobial action, such of medium turbidity, although not
instrumentation (TABLE 1 ). Therefore, this as NaOCl. Reduction of the microbial statistically significant. In the group
study found an initial microbial load in the load was observed with 0.85% saline receiving 5.25% NaOCl only, three
samples collected before the endodontic solution, which was probably due to the specimens remained contaminated after
procedures, which was different from physical effects of irrigation. This finding instrumentation, thereby attaining
other similar studies.12,13,15,16,30 is in agreement with Bystrms and a 70 percent reduction. In the group
Photosensitizers derived from Sundqvists observations.37 Nevertheless, treated with 5.25% NaOCl followed
phenothiazines, tricyclic heteroaromatic bacterial growth was observed 72 by PDT, microorganisms were found in
compounds and blue dyes, such two specimens after instrumentation,
as toluidine blue O (TBO) and thereby attaining an 80 percent
methylene blue (MB), have been widely reduction. Microorganisms were not
used in endodontic research using This study found an initial found in both groups when assessed
PDT.13,15,16,19,30,31 MB has been used as microbial load in the 72 hours after instrumentation.
a target for endodontic microbiotic Although qualitative and
samples collected before
microorganisms13,15,19,30 and compared quantitative analyses exhibited
to a novel photosensitizer (Rose Bengal the endodontic procedures, diverging results, this finding can be
functionalized chitosan nanoparticles).32 which was dierent from explained. E. faecalis might be present
MB at a concentration of 0.005% other similar studies. in numbers below the number detected
was used in this study, because of its by CFU counting when assessing
hydrophilic nature and low molecular the culture method. The relatively
weight.33 The reduced amount of MB frequent occurrence of E. faecalis was
was shown to be effective against the E. hours after instrumentation, which investigated38 in primary infections
faecalis.34 The dye exhibits an absorption indicates the presence and viability when polymerase chain reaction was
band resonant with the wavelength of the remaining microorganisms. used as an identification method, and
of the employed light source. The In qualitative assessment, the these researchers compared it to the
present study applied the same pre- presence of microorganisms was conventional culture method; E. faecalis
irradiation times as similar studies.13,19,30 confirmed in all of the samples by was found in 82 percent versus 4 percent
The study by Souza et al. did not find means of medium turbidity. of cases, respectively. Assessment by
a significant effect on the reduction of Microorganisms were not found medium turbidity might reveal the
E. faecalis with either MB or TBO.35 in the negative control group upon presence of possibly viable E. faecalis
The optic fiber used in this study was assessing medium turbidity, which after chemomechanical preparation and
55 mm in length; its initial diameter was confirms the sterilization of the specimens PDT, albeit in numbers that cannot be
1 mm and it decreased gradually to reach accomplished by ethylene oxide. detected in solid medium (Agar BHI).
0.3 mm at the opposite end. According to The experimental group treated with Under the investigated conditions, the
the manufacturer, the optic fiber output 5.25% NaOCl exhibited a dramatic light parameters, photosensitizer, power,
power was 10 mW. Because the equipment reduction of microorganisms after energy and pre-irradiation time outlined
power was adjusted to 40 mW, there was a instrumentation. Quantitative analysis in this study were able to promote
30-mW power loss. Therefore, by applying revealed that microorganisms were additional reduction of the microbial load
a 180-second exposure time, energy recovered from one single sample in after chemomechanical preparation; the
density of 1.8 J was attained at the spot in terms of CFU count. When PDT was application time was shorter compared
keeping with the results obtained in the used as an adjuvant to chemomechanical to other suggested protocols.13,15,16,30
M A R C H 2 0 1 7 143
photodynamic therapy
C D A J O U R N A L , V O L 4 5 , N 3

Conclusion of NaOCl and laser-assisted photosensitization on the


reduction of Enterococcus faecalis in vitro. Oral Surg Oral
vitro. Lasers Surg Med 2007;39(10):782787.
31. Seal G, Ng YL, Spratt D, et al. An in vitro comparison of
This study confirmed that the Med Oral Pathol Oral Radiol Endod 2006;102(4):9398. the bactericidal ecacy of lethal photosensitization or sodium
procedures of instrumentation and 13. Soukos N, Chen P, Morris J, et al. Photodynamic therapy hypochlorite irrigation on Streptococcus intermedius biolms in
irrigation using NaOCl were efficient in for endodontic disinfection. J Endod 2006;32(10):979984. root canals. Int Endod J 2002;35(3):268274.
14. Garcez A, Ribeiro M, Tegos G, et al. Antimicrobial 32. Shrestha A, Kishen A. Antibacterial ecacy of
accomplishing microbial reduction of E. photodynamic therapy combined with conventional endodontic photosensitizer functionalized biopolymeric nanoparticles
faecalis biofilm; however, they were not treatment to eliminate root canal biolm infection. Lasers Surg in the presence of tissue inhibitors in root canal. J Endod
able to promote its full eradication from Med 2007;39(1):5966. 2014;40(4):566570.
15. Fimple J, Fontana C, Foschi F, et al. Photodynamic 33. Wainwright M. Photodynamic antimicrobial chemotherapy
the RCS. Despite the use of PDT with treatment of endodontic polymicrobial infection in vitro. J (PACT). J Antimicrob Chemother 1998;42(1):1328.
the described light parameters promoting Endod 2008;34(6):728734. 34. Komine C, Tsujimoto Y. A small amount of singlet oxygen
additional microbial reduction, the 16. Fonseca M, Jnior P, Pallota R, et al. Photodynamic therapy generated via excited methylene blue by photodynamic
for root canals infected with Enterococcus faecalis. Photomed therapy induces the sterilization of Enterococcus faecalis. J
overall effect did not exhibit statistically Laser Surg 2008;26(3):209213. Endod 2013;39(3):411414.
significant reduction. Further studies are 17. Garcez A, Nuez S, Hamblin M, et al. Antimicrobial eects 35. Souza LC, Brito PRR, Oliveira JCM, et al. Photodynamic
needed to establish the best protocol for of photodynamic therapy on patients with necrotic pulps and therapy with two dierent photosensitizers as a supplement to
periapical lesion. J Endod 2008;34(2):138142. instrumentation/irrigation procedures in promoting intracanal
PDT regarding light parameters, type 18. Garcez A, Nuez S, Hamblin M, et al. Photodynamic reduction of Enterococcus faecalis. J Endod 2010;36(2):292
and concentration of photosensitizer, therapy associated with conventional endodontic treatment in 296.
pre-irradiation time and energy to patients with antibiotic-resistant microora: A preliminary report. 36. Yildirim C, Karaarslan ES, Ozsevik S, et al. Antimicrobial
J Endod 2010;36(9):14631466. eciency of photodynamic therapy with dierent irradiation
maximize reduction or even achieve 19. Ng R, Singh F, Papamanou DA, et al. Endodontic durations. Eur J Dent 2013;7(4):469473.
full elimination of microorganisms. photodynamic therapy ex vivo. J Endod 2011;37(2): 37. Bystrm A, Sundqvist G. Bacteriologic evaluation of the
217222. eect of 0.5 percent sodium hypochlorite in endodontic
REFERENCES 20. Nair P, Henry S, Cano V, et al. Microbial status of apical therapy. Oral Surg Oral Med Oral Pathol 1983;55(3):307
1. Siqueira JF Jr, Ras I. Clinical implications and microbiology root canal system of human mandibular rst molars with 312.
of bacterial persistence after treatment procedures. J Endod primary apical periodontitis after one-visit endodontic 38. Gomes B, Pinheiro E, Sousa E, et al. Enterococcus faecalis
2008;34(1):12911301. treatment. Oral Surg Oral Med Oral Pathol Oral Radiol in dental root canals detected by culture and by polymerase
2. Bystrm A, Sundqvist, G. The antibacterial action of sodium Endod 2005;99(2):231252. chain reaction analysis. Oral Surg Oral Med Oral Pathol Oral
hypochlorite and EDTA in 60 cases of endodontic therapy. Int 21. Vieira AR, Siqueira JF Jr., Ricucci D, et al. Dentinal tubule Radiol Endod 2006;102(2):247253.
Endod J 1985;18(1):3540. infection as the cause of recurrent disease and late endodontic
3. Sjgren U, Figdor D, Persson S, et al. Inuence of infection treatment failure: A case report. J Endod 2012;38(2): THE CORRESPONDING AUTHOR, Frank Ferreira Silveira, DDS, MS,
at the time of root lling on the outcome of endodontic 250254. PhD, can be reached at frankfoui@uol.com.br.
treatment of teeth with apical periodontitis. Int Endod J 22. Fabricius L, Dahln G, Holm S, et al. Inuence of
1997;30(5):297306. combinations of oral bacteria on periapical tissues of monkeys.
4. Siqueira JF Jr, Magalhes K, Ras I. Bacterial reduction in Scand J Dent Res 1982;90(3):200206.
infected root canals treated with 2.5% NaOCl as an irrigant 23. Sundqvist G, Figdor D, Persson S, et al. Microbiologic
and calcium hydroxide/camphorated paramonochlorophenol analysis of teeth with failed endodontic treatment and the
paste as an intracanal dressing. J Endod 2007; 33(6):667 outcome of conservative retreatment. Oral Surg Oral Med
672. Oral Pathol Oral Radiol Endod 1998;85(1):8693.
5. Waltimo T, Trope M, Haapasalo M, et al. Clinical ecacy 24. Evans M, Davies J, Sundqvist G, et al. Mechanisms
of treatment procedures in endodontic infection control involved in the resistance of Enterococcus faecalis to calcium
and one year follow-up of periapical healing. J Endod hydroxide. Int Endod J 2002;35(3):221228.
2005;31(12):863866. 25. Baumgartner J, Cuenin P. Ecacy of several concentrations
6. Peciuliene V, Balciuniene I, Eriksen H, et al. Isolation of of sodium hypochlorite for root canal irrigation. J Endod
Enterococcus faecalis in previously root-lled canals in a 1992;18(12):605612.
Lithuanian population. J Endod 2000;26(10):593595. 26. Heling I, Chandler N. Antimicrobial eect of irrigant
7. Siqueira JF Jr., Lopes H. Mechanisms of antimicrobial combinations within dentinal tubules. Int Endod J
activity of calcium hydroxide: A critical review. Int Endod J 1998;31(1):814.
1999;32(5):361369. 27. Ayhan H, Sultan N, Cirak M, et al. Antimicrobial eects of
8. Figdor D, Davies J, Sundqvist G. Starvation survival, growth various endodontic irrigants on selected microorganisms. Int
and recovery of Enterococcus faecalis in human serum. Oral Endod J 1999;32(2):99102.
Microbiol Immunol 2003;18(4):234239. 28. Gomes B, Ferraz C, Vianna M, et al. In vitro antimicrobial
9. Sedgley C, Lennan S, Appelbe O. Survival of Enterococcus activity of several concentrations of sodium hypochlorite and
faecalis in root canals ex vivo. Int Endod J 2005;38(10):735 chlorhexidine gluconate in the elimination of Enterococcus
742. faecalis. Int Endod J 2001;34(6):424428.
10. Konopka K, Goslinski, T. Photodynamic therapy in dentistry. 29. Siqueira JF Jr., Ras I, Favieri A, et al. Chemomechanical
J Dent Res 2007;86(11):694707. reduction of the bacterial population in the root canal after
11. Pagonis TC, Chen J, Fontana CR et al. Nanoparticle-Based instrumentation and irrigation with 1%, 2.5% and 5.25%
Endodontic Antimicrobial Photodynamic Therapy. J Endod sodium hypochlorite. J Endod 2000;26(6):331334.
2010;36(2):322328. 30. Foschi F, Fontana C, Ruggiero K, et al. Photodynamic
12. Silva Garcez A, Nez S, Lage-Marques J, et al. Eciency inactivation of Enterococcus faecalis in dental root canals in

144M A R C H 2 01 7
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(5<;2  )
C CARROLL Matching the Right Dentist to
the Right Practice
&COMPANY
Complete Evaluation of Dental Practices & All Aspects of Buying and Selling Transactions

4103 SAN FRANCISCO GP 4160 SONOMA COUNTY GP


Vibrant downtown location in historic high-rise bldg. Retiring Prime well-travelled downtown location, close to highly-rated
doctor offering 30+ years of goodwill. 4.5 days of hygiene, wineries in seller owned re-designed building. 35 year-old
1,500+ active patients, 20-25 new patients/mo. Gorgeous, practice, averaging $569K w/4 doctor-days. Asking $393K.
spacious facility in approx. 2,500 sq. ft. 2015 GR $796K.
2014 GR $768K. Average adjusted net income $274K+ 4129 PETALUMA GP
Asking $599K. GP located in stunning 1,856 sq. ft. seller owned facility.
State-of-the-art office includes 6 ops, staff lounge, reception
4133 NAPA GP area, private office, business office, lab area, sterilization
Napa County GP in newly furnished, fully equipped 2 op area, consult room, separate storage area, bathroom plus
facility with digital x-ray. 4 doctor day/week with 3 hygiene private bathroom. Asking $525K.
days. Monthly average revenue of $36K. Seller willing to
help for a smooth transition. Asking $331K. 4134 MENLO PARK GP
Open bay style practice on second floor of professional
4139 MILPITAS GP
office building in the heart of downtown Menlo Park.
4 fully equipped ops in 1,300 sq. ft. Attractive office with
G
newer equipment, new flooring, etc. Great location with L D
Established in 1982, well-trained, seasoned and loyal staff.
N SO
DI
easy freeway access off 680. Average gross receipts
N
Average Gross Receipts $726K. Asking $338K.

PE
$616K. Asking $450K. 4138 SOUTH SAN FRANCISCO GP
1,100 sq. ft. beautifully appointed, state-of-art 4 op office
4135 CAMPBELL OPPORTUNITY
located near Tanforan in modern professional building.
Join a well-run solo group practice in a highly desirable
NG
2016 annualized gross receipts $415K with adj net income
I
ND
location near Westfield Valley Fair Mall. Each doctor has a of $166K. Doctor works 4 day work week. 3 hygiene days.
N G
separate practice in a spacious and modern facility with 14
DI
ops. and 6 additional hygiene ops. plus in house dental lab. PE
Approx 1,000 active patients. Asking $327K.

P EN
Seller offering interest plus one fifth group assets. Asking 4091 SOUTH VALLEY - HOLLISTER GP & PEDIATRIC
$154K. Country living at its best ~ small town community feel with
affordable housing. Fully-equipped 1,600 sq. ft. office with
4131 PETALUMA FAMILY PRACTICE
2 enclosed adult ops and 3 open pedo ops. Great
Well established family practice located in charming
opportunity with trained staff and approximately 550 active
downtown Petaluma. More than 1,300 sq. ft main floor
patients. 2014 GR $228K. Seller is willing to help for a
facility with 4 spacious fully equipped operatories in
smooth transition. Asking price only $125K.
professional building, reserved staff parking, friendly team,
many years of patient goodwill, low overhead. Asking 4093 SAN JOAQUIN ORTHO
$375K. Established over 35 years with a solid reputation, near
several referral sources in seller owned building. 2,500 sq.
4108 HUMBOLDT COUNTY GP ft. office with 7 chair open bay in professional center on a
Well-established, high performing general practice boasts 6 well-travelled street with many retailers. Avg. Gross Receipts
fully equipped ops. in 2,900 sq. ft. free standing office w/ $763K. Seller retiring and willing to help for smooth
Digital X- ray, 2 platinum Dexis sensors, & Cerec Omnicam transition. Asking $561K. The building is available to
& MCXL units. Loyal & stable pt. base in charming purchase as well for $608K.
community, w/ a small town feel. Perfect for a dentist who
wants to escape the grind and live along the coastline. Avg. UPCOMING: San Mateo GP, Santa Rosa GP
GR $1.4M+, 2016 on schedule for $1.5M+. Seller willing to Petaluma GP & Santa Cruz County GP
help for smooth transition. Asking $1,041,000. Carroll & Company
4140 SAN FRANCISCO GP P (650) 362-7004
Seller offering 37 year family practice. Prime location in the F (650) 362-7007
heart of San Francisco's financial district. Modern 1,537 dental@carrollandco.info
square foot office built out in 2005. 3 year average gross www.carrollandco.info
receipts $735K with 4 doctor days and 4 hygiene days per BRE #00777682
week. Lease expires 2025 with option to extend. Asking
$601K. Contact Carroll & Company at (650) 362-7004 for
Mike Carroll Pamela Carroll-Gardiner
details.

www.carrollandco.info dental@carrollandco.info P (650) 362-7004 F (650) 362-7007


RM Matters C D A J O U R N A L , V O L 4 5 , N 3

Thorough Treatment Plans Build Patient Trust


TDIC Risk Management Sta

I
magine taking your car to the shop card company asked for documentation
for a minor repair say, to replace to support the charges. The office could
the spark plugs or patch a tire. Now, only provide documentation of the
imagine picking your car up at the Far too often, dentists patients acceptance of the fee for the
end of the day to discover that your either fail to provide a three-surface filling, as a new treatment
engine has been completely rebuilt plan was never presented or signed by the
thorough treatment plan
and youre responsible for the bill. patient when the treatment changed.
This scenario would be unlikely to or fail to update the plan Trina Cervantes, Risk Management
occur in the auto repair industry, but once the recommended analyst with TDIC, said the issue
it happens all too often in the dental treatment changes. stemmed from the dentists failure to
industry, leaving broken trust, unhappy disclose the cost involved with the
patients and disputed bills in its wake. crown prior to preparing it. While he
In one case reported to The Dentists went over the cost of the filling and
Insurance Company, a patient was
diagnosed with needing a three-surface
filling. Although the patient was not
experiencing any pain, decay was
visible on the radiograph. The dentist
explained to the patient that there
was a possibility a three-surface filling
would not suffice and instead a crown
may be needed, which would be a You are not a sales goal.
more involved procedure. The patient
scheduled an appointment for the filling.
During treatment, the dentist
discovered that the tooth required more
support and a crown would be a better
option. The dentist told the patient that
the treatment would take a bit longer
and proceeded with preparing the tooth
for a crown and provisionalizing it. He
advised the patient to return in a few You are a dentist deserving of an insurance company relentless
weeks for the permanent crown. Upon in its pursuit to keep you protected. At least thats how we see
scheduling his next appointment, the it at The Dentists Insurance Company, TDIC. Take our Risk
patient was presented with a bill that
Management program. Be it seminars, online resources or our
was three times the original estimate.
Advice Line, were in your corner every day. With TDIC,
Staff explained the reason for the price
difference and although the patient was you are not a sales goal or a statistic. You are a dentist.
upset about the increased treatment cost,
he reluctantly paid with a credit card.
The patient failed the appointment

to seat the permanent crown. Instead, he


Protecting dentists. Its all we do.
800.733.0633 | tdicinsurance.com | CA Insurance Lic. #0652783
disputed the charge with his credit card
company, which initiated a chargeback to
the dentists merchant account. The credit
M A R C H 2 0 1 7 147
M A R C H 2 0 17 RM MAT TERS
C D A J O U R N A L , V O L 4 5 , N 3

mentioned the possibility the tooth may are so focused on clinical care that they do the moment when the patient is in the
need a crown, he did not inform the not consider the financial impact for the chair. But even when the treatment plan
patient that should he need a crown, it patient. Others assume that patients are changes course midtreatment, a revised
would be significantly more expensive. as versed in the cost of dental treatment treatment plan should be printed and
The patient felt ambushed, as they are; to a dentist, it makes sense signed by the patient before proceeding.
Cervantes said. Had he known earlier, that a crown would cost more, but the Clear communication is critical to
he could have saved up the money, difference is not so obvious to a layperson. transparent practices, especially when
waited until he was in a better financial What is clear to a dentist is not money is involved, Cervantes said. It
situation or set up a payment plan. Rather, necessarily clear to a patient, Cervantes is important that dentists and staff get in
he felt he was taken advantage of and said. If it is not outlined in a treatment the habit of confirming that the treatment
questioned the need for the crown at plan, patients may not understand plan is reviewed and accepted by the
all since it was not causing him pain. what their financial obligations are. patient prior to performing the work.
Unfortunately, this is a common Cervantes says communication is key TDIC recommends keeping a signed
scenario. Far too often, dentists either to avoiding misunderstanding. Providing copy of the treatment plan on file. In
fail to provide a thorough treatment detailed treatment plans outlining all fact, Cervantes says having a signed
plan or fail to update the plan once the options and the costs associated with treatment plan and consent form is the
recommended treatment changes. The them can help mitigate any potential first line of defense should a lawsuit arise.
reasons for this are varied. Some dentists risk. Dentists can easily get caught up in It is up to the dentist to outline the
risks associated with not following through
with proposed treatment, she said. You
cant make the patient get the work done,
but you can show evidence of reviewing
these risks and trying to get the patient
back in the office to complete treatment.
Another consequence of poor doctor-
patient communication is a breakdown
of trust. Patients can begin to question
whether the treatment was needed or
whether the dentist was simply trying
to make a quick and easy buck. In
some cases, unhappy patients have
filed complaints with the dental board,
placing a practice under unwanted
scrutiny and causing avoidable headaches.
In other cases, patients turn to social
media to voice their dissatisfaction
through negative comments.
Providing patients with detailed
treatment plans with cost breakdowns
is essential for any practice owner.
Communication and transparency allow
patients to make informed decisions about
their oral health, meet patient expectations
and minimize patient complaints.

TDICs Risk Management Advice Line at


800.733.0633 is staffed with trained analysts
who can answer treatment planning and
other questions related to a dental practice.

148M A R C H 2 01 7
QUESTIONS MOST OFTEN ASKED BY SELLERS:

& ASSOCIATES INC.


1. Can I get all cash for the sale of my practice?

2. If I decide to assist the Buyer with financing, how can I be


guaranteed payment of the balance of the sales price?

3. Can I sell my practice and continue to work on a part time basis?

4. How can I most successfully transfer my patients to


the new dentist?

LEE SKARIN
5. What if I have some reservation about a prospective
Buyer of my practice?

6. How can I be certain my Broker will demonstrate


absolute discretion in handling the transaction in all
aspects, including dealing with personnel and patients?

7. What are the tax and legal ramifications when a


dental practice is sold?

QUESTIONS MOST OFTEN ASKED BY BUYERS:


1. Can I afford to buy a dental practice?

2. Can I afford not to buy a dental practice?

3. What are ALL of the benefits of owning a practice?

4. What kinds of assets will help me qualify


for financing the purchase of a practice?

5. Is it possible to purchase a practice


without a personal cash investment?

6. What kinds of things should a Buyer consider when evaluating a practice?

7. What are the tax consequences for the Buyer when purchasing a practice?
2IFHV
Lee Skarin & Associates have been successfully assisting Sellers and Buyers 805.777.7707
of Dental Practices for nearly 30 years in providing the answers to these and other
questions that have been of concern to Dentists. 818.991.6552
Call at anytime for a no obligation response to any or all of your questions
Visit our website for current listings: www.LeeSkarinandAssociates.com 800.752.7461
CA DRE #00863149
DENTAL PRACTICE BROKERAGE
Making your transition a reality.

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PRACTICE SALES PARTNERSHIPS MERGERS VALUATIONS/APPRAISALS ASSOCIATESHIPS CONTINUING EDUCATION


NORTHERN CALIFORNIA
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1.800.519.3458 www.henryscheinppt.com 1.888.685.8100

 37B2FWREHU
Regulatory Compliance C D A J O U R N A L , V O L 4 5 , N 3

Guide to Dental Practice Act Compliance


CDA Practice Support Sta

A
n updated Guide to Dental Clinical staff wear name tags or Advertising Discounts
Practice Act Compliance is have licenses or certificates posted. The advertisement of a discount must:
now available on cda.org/ Prominently post the name, List the dollar amount
practicesupport. Following license type and highest of the nondiscounted
are excerpts from the guide. level of academic degree of fee for the service.
each licensed individual or List either the dollar amount
Licenses, Academic Degrees and provide the information in of the discount fee or the
Name Tags writing in 24-point type to the percentage of the discount
Every dental licensee must patient at the initial visit. for the specific service.
communicate to a patient his or Prominently display the name, Inform the public of the
her name, license type and highest license type and highest level of length of time the discount
level of academic degree by one or academic degree of each licensed will be honored.
both of the following methods: individual on the practice website. List verifiable fees.
In writing at the patients
initial office visit.
In a prominent display in an
area visible to patients in his
or her place of practice.
If method one is chosen, the
required information must be presented
in 24-point type in the following format:
Health Care Practitioner
Information
Name and license type.
Highest level of academic degree.
Board certification, You have goals.
where applicable.
This same information must also be
PARAGON can help you reach them.
prominently displayed on a website that
is directly controlled or administered Are you thinking of buying a dental practice, merging, or selling
by the licensee or his or her staff. your practice? The future you want is closer than you think.
This law does not apply to a person Our guidance makes all the difference.
working in a facility licensed under
Section 1250 of the Health and Safety 7DNH\RXUQH[WVWHSZLWKFRQGHQFH
Code, which includes hospitals and &DOO3$5$*21WRGD\
skilled nursing facilities (B&P 680.5).
The names of every person Your local PARAGON
dental transition consultant
employed in the practice of dentistry Trish Farrell
must be posted in a conspicuous place
in the facility (B&P 1700 (c)).
Comply with the requirement 866.898.1867 Approved PACE Program Provider
FAGD/MAGD Credit
to notify patients of clinical staff info@paragon.us.com Approval does not imply acceptance
by a state or provincial board of
dentistry or AGD endorsement
names, licenses and academic degrees paragon.us.com 4/1/2016 to 3/31/2020
Provider ID# 302387.

by following these three actions:


M A R C H 2 0 1 7 151
M A RC H 2 017 R E G U L ATO RY C O M P L I A N C E
C D A J O U R N A L , V O L 4 5 , N 3

Identify specific groups who ensured. If electronic record-keeping has proprietary interest or right to
qualify for the discount or systems only are utilized in the management or control in the practice.
any other terms, conditions dental office, the office must use an This requirement does not apply to
or restrictions for qualifying offsite backup storage system, an licensees who practice dentistry outside
for the discount. image mechanism that is able to copy of his or her registered place of practice
(CCR 16 Section 1051) signature documents and a mechanism in specified settings, such as licensed
to ensure that record is unalterable health facilities, schools and the homes
Corporation Name once it is input. The electronic health of nonambulatory patients (B&P 1658,
Business and Profession record system also must automatically CCR 16 Sections 1045 and 1057).
Code Section 1804 states that: record and preserve any change or A licensee who transfers an
Notwithstanding subdivision (i) of deletion of electronically stored additional office to another licensee
Section 1680 and subdivision (g) of health information and requires must notify the Dental Board
Section 1701, the name of a dental the record to include, among other within 30 days of the transfer
corporation and any name or names things, the identity of the person who (CCR 16 Section 1048).
under which it may be rendering accessed and changed the information A dentist maintaining more than
professional services shall contain and the change that was made to one office in this state must assume
and be restricted (emphasis added) the information. The dentist must legal responsibility and liability for the
to the name or the last name of one develop and implement policies and dental services rendered in each office
or more of the present, prospective or procedures to include safeguards for and ensure each office complies with
former shareholders and shall include confidentiality and unauthorized supervisory requirements and posts in
the words dental corporation or access to electronically stored records, an area likely to be seen by all patients
wording or abbreviations denoting authentication by electronic signature a sign with the dentists name, mailing
corporate existence, unless otherwise keys and systems maintenance. Original address, telephone number and dental
authorized by a valid permit issued hard copies of patient records may be license number (B&P 1658.1).
pursuant to Section 1701.5. destroyed once the record has been
electronically stored. The printout Regulatory Compliance appears
Dental Materials Fact Sheet of the computerized version shall monthly and features resources about laws
A dentist is required to provide be considered the original (H&S that impact dental practices. Visit cda.org/
a Dental Board-approved dental 123149 and Civil Code 56.101). practicesupport for more than 600 practice
materials fact sheet to new patients support resources, including practice
and at least once to a patient before Place of Practice management, employment practices, dental
performing a restorative procedure. A licensed dentist is required to benefits plans and regulatory compliance.
The dentist should obtain patients register his or her place or places of
acknowledgement of receipt of the fact practice or if he or she has no place
sheet and place the acknowledgement of practice. Such registration must be
in the patient record. done within 30 days of obtaining his or
The current fact sheet is dated her license (B&P 1650 and 1655). A
2004. The fact sheet may not be dentist must register any new place of
altered but dentists may provide practice within 30 days (B&P 1651).
patients with supplemental information Prior to opening an additional
(B&P 1648.10-1648.20). place of practice, a licensee or
dental corporation must apply and
Electronic Records receive permission from the Dental
The safety and integrity of all Board for the additional place of
patient records, including both hard practice. This additional office permit
copies and electronic files, must be requirement applies to a licensee who

152M A R C H 2 01 7
Specialists in the Sale and Appraisal of Dental Practices
Serving California Dentists since 1966 Practices
How much is your practice worth?? Wanted
Selling or Buying, Call PPS today!

NORTHERN CALIFORNIA SOUTHERN CALIFORNIA


(415) 899-8580 (800) 422-2818 (714) 832-0230 (888) 440-5957
Raymond and Edna Irving Thomas Fitterer and Dean George
Ray@PPSsellsDDS.com PPSincnet@aol.com
www.PPSsellsDDS.com www.PPSDental.com
California DRE License 1422122 California DRE License 346937

6118 SAN FRANCISCOS EAST BAY Unique opportunit opportunity. Large ANTELOPE VALLEY Has grossed $1.8 Million. Fantastic location.
equity stake and 4-day work week being offered in an extremely well 60,000 autos pass by per day. 8 ops. Partnership for $250,000 or buy all.
positioned and branded practice. 2016 produced $2.64 Million and ARCADIA Facility only. 3-ops equipped. $65,000 or $95,000 with Ortho.
collected $2.53 Million, reflecting a 10% improvement over 2015. BAKERSFIELD AREA 5-ops, next to McDonalds. 1,800 sq.ft. includes
Full complement of specialties offered. 300+ new patients in 2016. building. Grosses $40,000/month. Full Price with building $350,000.
Delta Premier status shall continue. BAKERSFIELD Established 55 years. 5-ops in 3,000 sq. ft. Will do
$1 Million. Full Price $300,000. Building available for $350,000.
6117 PATTERSON AREA 2016 collected $657,000 with $365,000
BELLFLOWER Established 60-years. Grossing $350,000. Full Price
in Profits. PPO practice. Full Price $275,000. $240,000.
6115 SAN FRANCISCOS RUSSIAN HILL CHINESE EAST LOS ANGELES One million Latinos in service area. PPS sold
PRACTICE 2016 shall collect $300,000 with Profits of $145,000. to Seller in 1985. Will do $1 Million in 18 months. Full Price $300,000.
Has been a $400,000 year performer. Full Price $0,000. EAST SAN FERNANDO VALLEY Absentee Owner. $8,000/month
Cap Check. 4-ops. Do a Million within a year.
6114 AUBURN ROSEVILLE AREA 2016 realized another
OLD $425,000+. Beautiful and
INDIO 4,000 sq.ft. dental building. Full Price $650,000.
$1.1+ Million year. Profits tracking
extensive facility leases forS$1.60 sq.ft. Not a Premier Practice.
LADERA RANCH Grossing $650,000. Shopping center location.
LAGUNA NIGUEL Location, location, location! 4-ops with Panorex.
6113 FRESNO Consistently collecting $600,000+ per year. Full Price $185,000.
Shopping center location with fixed rent. Profits topped $3,000 in LA JOLLA Established 20-years. 3-ops. Grossed $150,000. Super
201)XOO3ULFH. opportunity with immediate growth. Full Price $150,000.
6112 HEALDSBURG Ideal as part-time practice in desirable locale LAWNDALE Hi identity. 2 ops . Full price $125,000.
or foundation to grow. 100% out-of-network. 2016 topped $210,000 LOS ANGELES HMO Grossing $1.2 Million. 5-ops. Full Price $1.2 Million.
LOS ANGELES HMO Does $4 Million. OLD
in collections. Full Price $30,000.
S
NORCO CORONA Will do $1.5 Million. 8-ops. Exquisite. Full
6111 SANTA ROSA Perfectly positioned for next Owner. Best
Price $1.2 Million.

SOLD
equipment, networked and digital including Pano. 3-days of Hygiene.
NORWALK Fantastic high identity location. 5 ops. Full Price
2016 trending $520,000+ with profits exceeding $250,000. $250,000.
Conservative Owner. *UHDWOocation.
ORAL SURGERY PRACTICE LOS ANGELES Established 40 years.
6110 CONCORD Well cared for practice. 2016 collected $260,000. ORANGE Beautiful 10 operatory office ready for merger.
3-ops. 580 patients. Great curb appeal. Little done in marketing. PASADENA Established 60 years. 7-ops. Always $1+ Million. Full
Great merger opportunity for nearby practice. Full 3rice $135,000. Price $600,000.
6107 EUREKA 100% out-of-network with insurance industry. 2016 REDLANDS Shopping center. Grosses $350,000. Full Price $250,000.
produced and collected $1 Million on Doctors 20-hour week. RIVERSIDE Facility only. 4 ops. Full Price $50,000.
Doctor's schedule booked 3-months out. 7+ days of Hygiene. Highly SOUTH ORANGE COUNTY BEACH CITY Grosses $650,000.
respected. Full Price $250,000. 4 ops. Beautiful!
PERIO PRACTICE - PRESTIGIOUS BEACH CITY Established
D
6106 SACRAMENTO'S EL DORADO HILLS 2015 collected
SOLoffice. Very solid opportunity.
40 years.
$640,000. UCR Fees. Beautiful TORRANCE Established 12 years. 5 star building. 3-ops. Grossing

SOLDSuccessor should open 4th day.


6105 MODESTO Collected $430,000+ on 3-day week. 3-days of $250,000. Full Price $195,000.
Hygiene. 5-ops. Central location. TUSTIN Dental building. Full Price $1.5 Million.
6103 SAN FRANCISCOS UNION SQUARE Opportunity to VENTURA - OXNARD 5-ops. Grossing $850,000. High identity. Full
Price $685,000.
S O L D
acquire highly regarded practice with condo. Beautiful 5-ops, digital
YUCCA VALLEY 8/10th of an acre. Great highway visibility. Full
and paperless. 6th op available. 2015 collected $658,000.
Price $250,000.
6098 WEST PETALUMA THE business center of the North Bay!
Business parks are growing and young families are drawn to this Seeking Senior Dentists wishing to have more time to enjoy life, be free
great family community per the unique amenities of this historic river of management & overhead to join a Dental Cooperative. Call Tom
Fitterer at 714-832-0230 or cell 714-345-9659.
city. Collected $468,000 with Profits of $212,500. 4-days of Hygiene.
6089 MOUNT SHASTA Small town living renowned for outdoor **FOUNDERS OF PRACTICE SALES**
lifestyle. 3-day week collected $950,000. Very strong bottom line. 120+ years of combined expertise and experience!
3,000+ Sales - - 10,000+ Appraisals
Digital including Pano. Full Price $350,000.
**CONFIDENTIAL**
PPS Representatives do not give our business name when returning your calls.
BAY AREA BAY AREA CONTINUED

Largest AC-566 SAN FRANCISCO: Spectacular views of


Washington Square. 3ops +2 addl, 1400 sf $225k
CC-632 SAN RAFAEL: Small town life, vibrant-growing
city, 6-8 pts/day, 3ops in 800sf office in beautiful

Broker in AC-578 SAN FRANCISCO Patient Charts: near Un-


ion Sq., 7 Doctor pts/day and 8 Hygiene pts/day
$190k
bldg $165k
CC-661 SAN RAFAEL: Starter Practice in beautiful
location w/ like-new Equipment hardly used, 3 ops,

Northern AC-624 SAN FRANCISCO: Wonderful Patients,


solid income in great stand-alone bldg. $475k
AC-640 SAN FRANCISCO: On 23rd Floor of Prestig-
900sf $250k
CG-616 NAPA: State of the Art Practice - Seller mov-
ing out of state! Call for Details!
ious SF Bldg, 2ops in 700sf. Seasoned Staff, Seller DC-480 SILICON VALLEY: Multi-Specialty Practice,
California Retiring $175k
AC-649 SAN FRANCISCO Facility Only: Richmond
14+ops in 7500 sf, Owner Financing avail-Terms
$1.075M
District, 3 ops+1 addl, Equipment less than 5yrs DC-604 LIVERMORE Facility: Turn Key Facility, fast
old $155k growing city, 3ops +3 addl plumbed in 2380 sf mod-
AG-564 SAN FRANCISCO: 25 + yrs goodwill. Large ern office $110k
Extensive Buyer 5600+ sf w/ 9 ops near Lands End $2.225M
AG-645 SAN FRANCISCO: Low Overhead, compact
DC-623 MENLO PARK: LOTS of room for GROWTH w/
close proximity to Facebook, Stanford, Google &
practice ready for expansion or relocation. Retail/ Telsa $380k
Database & Commercial area. 2nd Floor $125k DN-497 PLEASANTON Facility: Great Location! 870 sf
AG-648 SAN FRANCISCO: Newly Built Dental Space w/ 3 ops + 1 addl. Owner Financing w/10% Down!
Unsurpassed now Available for Rent! Call for Details!
AN-514 SAN FRANCISCO Facility: Located in the bus-
$95k
DN-631 CAMPBELL: Rare Opportunity! 1100 sf w/
tling financial district! 1007 sf w/4 ops Only $75k 3 ops, busy retail shopping center $249k
Exposure allows AN-565 SAN FRANCISCO: Remarkable opportunity DG-519 SANTA CLARA Facility: Move In Ready! 2240
2067 sf w/ 6 ops $1.05M sf w 6 fully equipped ops $225k
us to offer you AN-592 SAN FRANCISCO: Easy accessibility, visibility
& free parking! 1000sf w/ 2 ops + 1 addl $100k
DG-530 SAN JOSE: Dentrix JUST Installed! Highly
respected prac ce! 2015 collec ons $1M+ $795k
AN-513 REDWOOD CITY: The prac ce of your DG-635 CASTRO VALLEY: Excellent Loca on & Stellar
dreams! 900 sf w/ 4 ops + 2 addl $375k Reputa on! Solo Group Prac ce $690k
AN-642 SAN BRUNO: Dont miss this one! FFS, 5 ops DG-643 SAN JOSE: Seller Mo vated! 3,300 sf w/ 4
1950 sf $740k (Real Estate $1.2M) ops + 2 addl available! Call for Details! Only $65k
BC-432 PITTSBURG: Family-oriented Practice! 1640 DG-581 SAN JOSE: Must See to Appreciate! Gor-
sf w/ 6 ops. Seller retiring. $350k geous Prac ce, stable pa ent base & loyal sta
BC-520 HAYWARD Facility: Located in Downtown, $496k
1500 sf, 4 equipped ops, X-Rays in 3 ops. $65k DG-619 SAN JOSE: One of the most unique prac c-
BC-646 ORINDA: Well-established, family-oriented es you will ever see! 1450 sf w/ 5 ops $1.1M
Prac ce, Word-of-Mouth Refs, 4ops in 1080sf. DG-620 SAN JOSE: Loca on, Stable Educated Pa-
$825k ent Base, Spacious 2100 sf 3 op oce! $290k
BN-504 RICHMOND: Established Practice & Real DG-657 SARATOGA: Once in a Life me Opportuni-
Estate! 1450 sf w/ 2 ops + 2 addl $100k /RE ty! 1750sf 6 ops. Steadily increasing annual collec-
$700k ons! $1.05M
CC-567 ST. HELENA: Live & Practice in beautiful Wine DN-647 SANTA CRUZ: Family-Oriented with low
Country, 5 ops 1842 sf single-story bldg $790k overhead! 850 sf w/3 ops $210k
CC-599 SANTA ROSA: Stable pts base, Well-
respected Practice, 3 ops in 1040 sf $250k NORTHERN CALIFORNIA
CC-611 S. MARIN CO: Desirable, well-established
neighborhood, 20npts/mo 3ops, 1100 sf $650k EC-525 SACRAMENTO: Great Location! Excellent
Visibility! 1500 sf w/ 3ops, 10-15 new pts/mo. Mo -
vated Seller $195k

800.641.4179 WPS@SUCCEED.NET
Timothy Giroux, DDS Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA Edmond P. Cahill, JD

NORTHERN CALIFORNIA CONTINUED NORTHERN CALIFORNIA CONTINUED

EC-531 GREATER SACRAMENTO: Prac ce & Real Estate 1750 sf w/ 4ops + HN-213 ALTURAS: Well managed, consistent revenues! Collected ~$760 in
1 addl, 8npts/mo $800k 2016! 2200 sf w/ 3 ops + 1 addl. $195k
EN-464 ROCKLIN Facility: Dont miss out on this remarkable opportunity! HN-280 NO EAST CA: Only Practice in Town 900 sf w/ 2 ops REDUCED! ONLY
2150 sf w/ 4 ops $100k $60k
EG-638 CITRUS HEIGHTS: Focus on Crown & Bridge. 1,680 sf w/ 2 ops. HN-618 SIERRA FOOTHILLS: Seller Retiring! Much room for growth by in-
Plumbed for 1 addl & Room to expand. (Real Estate also Available) CALL creasing office hours! 750 sf w/ 2 ops $95k
for DETAILS! HN-633 AUBURN VICINTY: Loaded w/ warmth, charm & goodwill galore!
EG-639 CITRUS HEIGHTS: Real Estate for Sale Call for Details! 1,430 sf w/ 4 ops $525k
EN-625 SACRAMENTO: Looking for a HMO prac ce in a great Loca on?
2,500 sf w/5 ops $450k CENTRAL VALLEY
EN-626 CARMICHAEL: Lifestyle you just cant be beat! HMO 1,250 sf w/ 3
ops $350k IC-468 SAN JOAQUIN VALLEY: High-End Restore Prac ce! 6 ops in 2500+ sf
EN-628 ORANGEVALE: Great place to work, play & live. HMO 1,310 sf w/ 4 oce. Call for Details! $425k
ops + 1 addl $3375k IN-569 MADERA: Stellar reputa on and load with goodwill! 2,900 sf w/ 7
EN-627 CARMICHAEL: Remarkable HMO opp. awaits your talent & skill! ops $634k
1,200 sf w/3 ops + 1 addl $268k JC-541 FRESNO Facility: 1210 sf & consists of 2 fully equipped ops &
EN-634 ROSEVILLE: Beau fully designed, well-appointed and fully digital! plumbed for addl op Call for Details!
2352 sf w/4 ops + 2 addl $235k JN-551 COALINGA AREA: Serving community of working families! Paper-
EN-660 ROSEVILLE: Highly-esteemed, well-respected, fee-for-service prac- less Prac ce. 1200 sf w/ 3 ops $395k
ce w/ loyal pa ent base. 2,950 sf w/ 5 ops $995k
EN-654 CITRUS HEIGHTS: Well-Established, & loaded with 30+ years of SPECIALTY PRACTICES
goodwill! 1300 sf, 3 ops + 2 addl. $150k
EN-651 SACRAMENTO: Well-known for delivery excellent & compassionate BC-600 CONCORD Ortho/Pedo Charts Only: Continue treatment to these
care. 1750 sf, w/ 4 ops. $150k Ortho/Pedo patients Call for Details! $400k
FC-489 CLEARLAKE: Great lifestyle. 2015 Gross $915k on 3 day week, BC-612 CONTRA COSTA COUNTY Ortho: Just of the I-80 commuter corri-
4ops. Real Estate 3600 sf shared, interest Pride Instute designed dor! Call for Details! Only $40k
oce $470k CG-424 NAPA Prostho: Digital X-ray & NEW 3D Imaging Unit! On track to
FN-527 TRINITY COUNTY: Be the only dentist in town! Pride Ins tute de- collect just under $1m $690k
signed! 2350sf w/ 5 ops +1 addl. $250k EG-637 CITRUS HEIGHTS (Prostho): 1,680 sf w/ 2 ops. Plumbed for 1 addl
GC-472 ORLAND: Live & Practice in charming small town community. 1000 sf & Room to expand. $390k (Real Estate Also Available)
w/ 2ops, Seller Retiring. $160k FN-536 LAKE COUNTY Pedo: Focusing on Prevent dental problems before
GG-453 CHICO: 5000 sf w/ 7 ops Perfect for 1 or more dentists! $325k they begin! 1750 sf w/ 3ops $225k
GG-454 PARADISE: 2550 sf w/ 9 ops, 40 yrs goodwill! Amazing Opportunity! HG-644 NORTH AUBURN (Ortho): 1750 sf w 5 chairs in open bay! Call for
$525k Details!
GG-617 YUBA CITY: Rare Opportunity to purchase Dental Facility with IC-543 CENTRAL VALLEY Ortho: 1650 sf w/ 5 chair bays & plumbed for 2
REAL ESTATE! $275k addl, Strong Refs & Satisfied Pts Base $125k
GN-244 OROVILLE: Must See! Gorgeous, Spacious 2500 sf w/5 ops! JC-540 FRESNO Sleep Apnea: Mo vated Seller re ring! Step right in &
$315k make it yours! Call for Details!
GN-399 REDDING: Loyal patient base & relaxed workweek schedule, 1440 sf
w/3 ops $150k
GN-546 CHICO AREA: Catering to fearful pa ents, oering quality seda on
den stry, 2600 sf w/ 4 ops $350K
GN-606 BUTTE COUNTY: Hesitate & youll miss out on this one-of-a-kind
opportunity! 1700 sf w/ 4 ops Reduced $125k
GN-641 YUBA CITY: Fantas c signage & visibility. Building available for pur-
chase! 2,400 sf w/ 5 ops $475k
GN-656 NO. TEHAMA CO: Great Loca on! Ideal place to work, live and raise
a family! 2,468 sf w/ 5 ops $275k

ASK THE BROKER CAN NOW BE FOUND AT WWW.WESTERNPRACTICESALES.COM


Tech Trends C D A J O U R N A L , V O L 4 5 , N 3

A look into the latest dental and


general technology on the market

CDC DentalCheck (Centers for Disease Control and Epson Home Cinema 3100 Projector
Prevention, Free) (Epson, $1,299)
Dental health care facilities must perform routine audits of The Home Cinema 3100 Full HD 1080p 3LCD projector is a new
infection prevention compliance and keep detailed records of addition to Epsons line-up of projectors geared toward the home
these reviews on site. This responsibility typically is assigned to theater enthusiast. Boasting optimized brightness and contrast,
a qualied team member who coordinates policies, procedures, this projector features 2,600 lumens of both color brightness
education and training for continuous improvement to maintain and white brightness, as well as up to a 60,000:1 dynamic
compliance with Centers for Disease Control and Prevention (CDC) contrast ratio providing rich detail during dark scenes. What that
recommendations and ensure quality control. This task may be translates to is an incredibly bright, crisp and detailed image,
dicult to organize, as there are many elements to assess, both eliminating the need for blackout viewing conditions.
administratively and in the clinical practice setting. DentalCheck
The 3LCD, 3-chip technology provides 3-D in full 1080p high
from the CDC is a tool that dental practices can use to automate
denition and the projector is capable of projecting a 110
this monitoring process and keep records to assure compliance with
image from only 10.5 away. The ability to position both the
CDC recommendations as contained in the Guidelines for Infection
mounting of the projector as well as the projected image on the
Control in Dental Health Care Settings.
screen is made much easier given both vertical and horizontal
To begin a routine audit from the home screen, users simply start lens shift, plus a 1.6x zoom lens. The 3100 provides dual HDMI
a new checklist, which contains a series of elemental questions inputs, with one oering MHL to allow for the direct-streaming of
categorized by Policies and Practices, followed by Direct movies, games and more from MHL-enabled devices (such as a
Observation of Personnel and Patient-Care Practices. For each Roku Streaming Stick.) As for lamp life, Epson touts up to 3,500
subcategory, users assess elements, or statements in the CDC hours in normal mode and up to 5,000 hours in ECO mode.
recommendations in their dental health care facility, and answer
The unit itself is solidly built (weighing in at nearly 15 pounds),
Yes, No or N/A. An area to input notes or areas of improvement is
and the default image was impressive right out of the box.
provided for each element. Once users complete the entire checklist
While calibration is always recommended, and it takes quite a
series of assessment questions, the audit is complete and recorded
bit of ne-tuning to dial in the projected image to just the right
in the app. The entire history of assessments can be accessed from
proportions (given the many adjustable settings that are included
the home screen, where users can edit, preview, email or delete
with this projector), the end result is an image that looks fantastic.
individual checklists. Additional resources from the CDC regarding
However, the projector does not have a 12v screen trigger port
infection control can be directly opened from the home screen.
(for the automatic triggering of the screen rolling up or down
Having a safe health care and working environment is vital to any based on projector turning on or o ), but thats easily remedied
dental care setting. Members of the dental team responsible for by an add-on wireless unit for your screen.
compliance in their own facilities need every tool at their ngertips
Blaine Wasylkiw, CDA director of online services
to organize and keep track of these reviews. DentalCheck enables
these team members to easily monitor and maintain records to
ensure that their facilities are doing their best to maintain safety for
Would you like to write about technology?
patients and sta.
Dentists interested in contributing to this section should contact
Hubert Chan, DDS Andrea LaMattina, CDE, at andrea.lamattina@cda.org.

156M A R C H 2 01 7
Dr. Bob C D A J O U R N A L , V O L 4 5 , N 3

Snakes: The Stu of


Nightmaresssssss

As every Boy Scout worthy of The following Dr. Bob column was with its leather punch for punching
originally printed in the April 2006 issue of leather and its main blade, so dull from
his Tenderfoot badge soon
the Journal. playing mumbly peg and carving trees
learns, snakes present such that it couldnt slice margarine. Armed

C
a life-threatening hazard all me prejudiced. Call with this snakebite armamentarium, our
me paranoid, biased instructions were clear: The moment
that an entire section in the and ignorant if you like, one of the 42 million species of snakes
BSA Handbook is devoted especially if you are larger bites you or a friend, apply the tourniquet
than I am, but the fact between the bite and the victims heart.
to coping with anticipated of the matter is, I dont like snakes. This The handbook assumes the snake has had
encounters with them. reptilian anathema goes back to the early the decency to not go for a midsection
days of my Boy Scout career. Prior to my or butt bite. Tighten until the extremity
induction into the BSA, I considered turns indigo, then grasping the Scout
snakes to be just overachieving worms, knife firmly, slice an X over each fang
Robert E. just as a rat was a buff mouse. But as every puncture until the area hemorrhages freely.
Boy Scout worthy of his Tenderfoot badge Sometimes a sock stuffed into the
Horseman, soon learns, snakes present such a life- victims mouth helps reduce distractions.
DDS threatening hazard that an entire section The rescuer, assuming there is one and
ILLUSTRATION
in the BSA Handbook is devoted to coping the bitten person is experiencing syncope
BY VAL B . MINA with anticipated encounters with them. by this time, places his mouth over
Our motto Be Prepared was not a the puncture/slice wounds and sucks
hollow challenge. We had our tourniquet out the snakes venom, being careful
(neckerchief) and our Boy Scout knife not to swallow it. It is then discreetly
(precursor of the Swiss Army knife) expectorated in a downwind fashion as
M A R C H 2 0 1 7 157
M A R C H 2 0 17 DR. BOB
C D A J O U R N A L , V O L 4 5 , N 3

approved by the EPA. By this time, the Forever vivid in my memory They do not bark, moo, meow, chirp
snake, not being of a poisonous variety or quack. Compared to a snake, a
in the first place, has laughed itself is the vision of the unhinged mime is a regular chatterbox. You cant
to death and is no longer a threat. jaw, the slow, peristaltic call, Here, boy! Cmon lets go for
I understand this technique is a slither. No. They hiss. They stare
no longer in common use. Even
bulge moving tailward, the at you with those slit eyes, flick that
12-year-old boys not subject to the mouses tail still signaling forked tongue and they hiss. I cannot
civilizing influences of society found fruitlessly as it disappears. be simpatico with anything that hisses
this procedure disquieting, so it has and slithers. Or scuttles. A forthright
been supplanted with a more modern animal worthy of trust does not scuttle.
treatment wherein the offending Assuming that the snake, in order
snake is counseled and given a severe the ponytailed, eyebrow-pierced youth to survive even one semester of biology,
reprimand. The victim may or may serving us. The snake is about 18 inches must eat something, I questioned the Snake
not be covered by his HMO at the long, banded orange and white. I Man about the dietary requirements of our
discretion of his primary care provider. conceded that it might be considered as purchase. I figure a corn snake eats corn,
Too late for me, however. My antipathy attractive as a four-alarm fire silhouetted right? Wrong. Mice. He eats mice, he said.
toward snakes is too deeply rooted to be against an evening sky enthralling an Well, thats unfortunate, we
influenced by herpetologists unconvincing arsonist. Another snake of the opposite dont have any mice. Lets go, I
explanations of their gentleness and gender might even offer a judgment whispered to my granddaughter.
general benefit to the ecology. of Hubba, Hubba! The snake and I Not a problem, interrupted
In my view, every snake is a flexible, maintained our distance and regarded the Snake Man. We have plenty of
protein-based tube of neurotoxins. Its each other with mutual loathing. mice right here. He indicated a cage
one purpose in life is to propel itself My dislike for snakes is scientifically where dozens of tiny mice, hairless,
straight for my jugular where the based on the following factors: No. 1: sightless and unsuspecting, stumbled
tourniquet/Scout knife technique is Locomotion. The verb slither had around in sweet rodent innocence.
not applicable. The fact that I have to be coined for snakes. Should it ever Out of respect for your sensibilities,
not seen a snake for upward of 30 years become necessary for you to inspect I will spare you the gruesome details,
is no excuse to relax my vigilance. the underside of a snake, even though but take my word, there is no sight
All of which explains why I was common sense dictates otherwise, more hurtful to the human psyche
visibly shaken when my granddaughter youll notice it has no legs or feet. If it than witnessing a snake devouring
announced that if we expected her to were human, it would be a quadriplegic a live mouse. Forever vivid in my
emerge from her high school biology class and could park in restricted zones. memory is the vision of the unhinged
with anything more than a C, it would In spite of this handicap, a really fast jaw, the slow, peristaltic bulge
be expedient to purchase a snake for her snake on Full Red Alert has been moving tailward, the mouses tail still
and a receptacle to contain it. What role clocked at 8 mph. I realize this doesnt signaling fruitlessly as it disappears.
the snake would play in the furtherance seem too impressive compared to Its the stuff of nightmares and the orgy
of her education was not clear, but its the human he was chasing who was repeats every week as long as the snake
procurement was not to be denied. hitting 52 mph on the straightaways. is our responsibility. We are petitioning
There are actually reptile stores, up- The slithering is accomplished by one the guidance counselor for a transfer
scale boutiques where exotic vertebrates of four methods: The Undulating Crawl or to Early American Folk Dancing.
are offered to reptilian aficionados at Serpentine, the Caterpillar or Rectilinear, FREE TO GOOD HOME: Corn
equally exotic prices. My granddaughter the Sidewinder and the Concertina. snake, like new. Lo miles; ideal pet; loves
and I peered gingerly at a colorful All four methods of locomotion are children and mice. Easily trained to slither
variety of snakes, lizards, chameleons unnatural, if not actually obscene, and I and hiss on command. Complete with
and turtles. The captive denizens stared dont want to talk about them anymore. cage and subscription to Rodent Raising
back, transfixed as if fashioned of stone. Reason No. 2 why snakes and I are for Fun and Profit. Call anytime, day
Heres a nice corn snake, said not pals is that they are inarticulate. or night will deliver; 5551212.
158M A R C H 2 01 7
Discover your talent. Get your skills polished. Earn C.E.
credits learning cutting-edge techniques
in hands-on workshops. See your talent,
tools, inspiration and community in a
new light at CDA Presents.

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