Beruflich Dokumente
Kultur Dokumente
net/publication/51118458
CITATIONS READS
35 847
3 authors:
Mandakini Mohan
International Medical University (IMU)
14 PUBLICATIONS 350 CITATIONS
SEE PROFILE
Some of the authors of this publication are also working on these related projects:
All content following this page was uploaded by Kundabala Mala on 03 October 2016.
• Professional Liability
• Office Property
• Employment Practices Liability
• Workers’ Compensation
• Life/Health/Disability
• Long-Term Care
• Business Overhead Expense
• Home & Auto
d e pa rt m e n ts
129 The Editor/In the Blink of an Eye
137 Impressions
141 Periscope
185 Classifieds
137
f e at u r e s
152 E ndotox i n i n E ndodon t i c I nfe ct i o n s : A Rev i ew
The purpose of this paper is to review the role of gram-negative bacteria in endodontic infections,
structure and mechanisms of action of endotoxin, endotoxin in infected root canals, effects of
calcium hydroxide and polymixin B on endotoxin, and applications of endotoxin to measure leakage.
Zahed Mohammadi, DMD, MSD
163 P eri odon ta l P last i c I n terc ept i v e S u r gery for a Lab i a l ly I mpact ed
Ma x i l lary Can i ne: A Cas e R eport
The authors present a case that was managed by apically positioned flap surgery followed by
orthodontic treatment.
Neeraj Agrawal, BDS, MDS; Kavita Agrawal, BDS, MDS; K. Rosaiah, BDS, MDS;
and Ankur Chaukse, BDS, MDS
m a r c h 2 0 1 1 127
c da j o u r n a l , vo l 3 9 , n º 3
Editorial
Robert E. Horseman,
Reader Guide:
DDS Upcoming Topics
contribut ng editor april: Recession Erosion Letters to the Editor
may: Somnology Kerry K. Carney, DDS
Journal of the California Patty Reyes, CDE june: Aggressive Kerry.Carney@cda.org
Dental Association assistant editor Periodontitis
Subscriptions
published by the Jenaé Gruchow Manuscript Submissions The subscription rate is
California Dental communications Patty Reyes, CDE $18 for all active members
Association assistant assistant editor of the association. The
1201 K St., 14th Floor Patty.Reyes@cda.org subscription rate for
Sacramento, CA 95814 Advertising 916-554-5333 others is as follows:
800.232.7645 Corey Gerhard Author guidelines Non-CDA members and
cda.org advertising manager are available at institutional: $40
cda.org/publications/ Non-ADA member
Management Production journal_of_the_california_ dentists: $75
This
Kerry K. Carney, DDS Matt Mullin dental_association/ Foreign: $80
editor-in-chief cover design submit_a_manuscript Single copies: $10
Kerry.Carney@cda.org Subscriptions may
Randi Taylor Classified Advertising commence at any time.
is why
Ruchi K. Sahota, DDS, CDE graphic design Jenaé Gruchow Please contact:
associate editor communications Jenaé Gruchow
Kathie Nute, Western Type assistant communications
Brian K. Shue, DDS typesetting Jenae.Gruchow@cda.org assistant
we’re
associate editor 916-554-5332 Jenae.Gruchow@cda.org
California Dental 916-554-5332
Peter A. DuBois Association Display Advertising
executive director Andrew P. Soderstrom, Corey Gerhard Permission and Reprints
here.
DDS advertising manager Jeanne Marie Tokunaga
Jennifer George president Corey.Gerhard@cda.org publications manager
vice president, 916-554-5304 JeanneMarie.Tokunaga@
marketing and Daniel G. Davidson, DMD cda.org
communications president-elect 916-554-5330
128 m a r c h 2 0 1 1
Editor c da j o u r n a l , vo l 3 9 , n º 3
A
t 6:11 p.m. on a Thursday
evening, my dear aunt (who Though we in California see our
turned 80 last June) would
normally be watching Larry share of disasters, they are not uncommon
King Live in her living room.
She would be 3 feet from the glass in the other 49 states.
windows that face the street. She would
be overlooking the trees in the park on
the other side of Glenview Drive in San
Bruno, Calif. The backyard gate had been blown On Aug. 16, 2010, the Virginia Dental
On this particular Thursday, Sept. 9, open. This was lucky because by that time, Association headquarters was struck by
2010, she was downstairs in the most the extreme heat would have made the lightning and destroyed in the fire that fol-
protected part of the home she had lived metal handle too hot to touch. As she lowed. No one was hurt, but the VDA had
in for more than 40 years. She was busy exited, she could see the house across the to relocate and rebound from the setback.
working at her computer on one of her street already was melting. She said the Across the nation, dental association leaders
volunteer duties for Mission Hospice. stucco was slumping off like cake frosting. were asking, “What if that happened here?”
When the 30-inch gas pipe ruptured She turned to her left and walked up Earl For California, the answer is clear: CDA
and exploded at the corner of Glenview Avenue toward the fire station. The 800- would enact its comprehensive Business
Drive and Earl Avenue, it was 20 feet foot flame fed by the gas venting from the Continuity Plan (BCP). It would continue
from her sidewalk. When great chunks of ruptured pipe had created its own weather to serve its members and policyholders.
asphalt (which my aunt insists on calling and was sucking the air down to the com- In 2005, between the 9/11 terror-
“the macadam”) from the destroyed pave- bustion point creating a gale force wind ist attacks and Hurricane Katrina, CDA
ment on Glenview Drive came raining that she had to struggle against to walk. began to develop its BCP. It also began
down on her house, they had to pass A neighbor saw her, put her in his a companywide Disaster Recovery (DR)
through the roof, her bedroom, and the car, and drove her up to the fire station. planning process, which consists of defin-
ceiling of her basement/laundry room She got out of her home with her most ing the policies and procedures, related to
before falling fortuitously in locations precious possession: her life. Everything preparing for recovery or continuation of
other than where she was sitting. Looking else was gone. business after a technology infrastructure
up from her secretary’s chair in the base- In the months that have followed, she interruption following a disaster. Because
ment, she could see open sky. has spent every day trying to restore her of the complexity of the organization, a
She knew right away it was not an life to a normal, safe, and comfortable ex- comprehensive plan took years to develop.
earthquake and she didn’t think it was a istence. It is a full-time job, an emotional In March 2010, CDA’s BCP was introduced.
plane crash, though San Bruno is in the roller coaster, and a personal tragedy. A The planning process included an as-
flight path for San Francisco International disaster as unusual as a catastrophic gas sessment of risks and the establishment
Airport. She thought that terrorists had pipe failure is difficult to anticipate but of business requirements as a basis for a
blown up the airport. She walked up the disaster preparedness is something for technical solution. It was determined that
seven stairs to the kitchen and looked which we all must plan. CDA’s needs were best met by having a
around the corner into the living room. California has the distinction of small temporary off-site location to be used
Through the shattered glass windows, she having opportunities almost annually to in an emergency. A secure Business Re-
could see that the trees in the park across practice and refine our disaster prepared- sumption Center (BRC) has been outfitted
the street were ablaze. She had the pres- ness.1 This is, after all, earthquake country with servers, workstations, and phones.
ence of mind to get her phone, her purse (oh yes: mudslide and wildfire country If a disaster affects CDA’s physical or
and a bottle of water. She turned, walked as well). Though we in California see our computer infrastructure, the BRC will
back down the stairs, and out the back share of disasters, they are not uncom- be activated. E-mail will function almost
door of the basement. mon in the other 49 states. immediately and toll-free phone lines will
m a r c h 2 0 1 1 129
march 11 editor
c da j o u r n a l , vo l 3 9 , n º 3
be available at the BRC within 24 hours. they acquire that information? At what testing, and planning again that an orga-
Replicated and backed-up computer files point would the BRC need to be activated? nization develops the agility and resilience
will be used by IT to recreate a limited- The test enabled the team to become to meet and overcome unanticipated prob-
function working environment at the BRC familiar with the communication and lems. The BCP/DR must be continually
to allow continued business. Full function- decision-making challenges of a simulated updated and kept current as CDA evolves.
ality (within BRC limits) will be established disaster situation. However, disasters and CDA’s BCP/DR is not the part of CDA
sometime after 24 hours, depending on the catastrophic cascades do not follow an that we, as members, think about at all. It
scope and nature of the disaster. Manage- existing playbook. Events have a way of is more like disability insurance: You hope
ment laptops will be configured to interact exploiting gaps in our plans. The tests are you will never need to rely on it. However,
with the BRC environment. In a regional an opportunity to refine the planning for it is exactly this kind of planning that is
disaster similar in size and scope to Hur- disaster preparedness. the hallmark of what we have come to
ricane Katrina, the priority would be the Dwight D. Eisenhower is credited with expect of CDA: foresight, flexibility, and
safety and well-being of staff and members, having said, “It’s all in the planning. The preparedness. When in place and execut-
rather than resumption of CDA functions. plan is useless: It’s the planning that’s im- ed properly, one may never be aware of
Last year the BCP was tested. During portant.” Through battlefield experience, it. CDA will strive to deliver the services
the simulated emergency, management he knew that soldiers in the field meet and communication we expect even in the
staff had a chance to address the following unanticipated, complicating circumstanc- aftermath of catastrophic interruption.
questions: Who should be contacted, when, es. Through a planning process, a chain of Living life in terror of manmade or
and how? What resources would realistically command can be set and a list of resources natural disasters cripples one’s ability
be available? What information would they to help address unforeseen problems can to enjoy and participate in life. Being
need for their decision-making? How would be made available. It is through planning, prepared for catastrophic detours from
the quotidian path allows one to be fully
present in the here and now. It is impor-
tant to keep this in mind. If you ask my
aunt, she will tell you: everything can
change, in the blink of an eye.
reference
1. Shue B, Prepare your office for the big one. J Calif Dent
Assoc 38(11):781-2, November 2010.
additional resources
Tokunaga JM, California Dental Association’s Business
Continuity Plan, 2010
130 m a r c h 2 0 1 1
“I consider the decision to
attend this sedation course
among the most important
of my career. Here, at last, was
a system I could successfully
apply to my whole practice.”
– Larry Daugherty, DMD Sylvester, Georgia
Controversy Controversial
Journal
o f t h e 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 J A N UA RY 2 0 1 1
Dental Therapists
I
RDH in Alternative Practice
DHATs in Alaska
t is disturbing that the editor of the New Zealand, where dental therapists have
Journal of the California Dental Associa- existed for more than 50 years, oral health
tion proffers an obscure science-fiction has decreased after 40 years of improve-
BARRIERS
writer’s opinion as if it were a law of ment, according to one study in 2006 TO CARE :
nature like the Law of Gravity, then by the New Zealand Ministry of Health, a controversy
uses that law to discredit all with passion “Good Oral Health, for All, for Life — the
as ignorant. Sound silly? According to Strategic Vision for Oral Health in New
Benford’s Law of Controversy, “passion is Zealand. Clearly, additional provider types
inversely proportional to the amount of and expansion of duties do not provide the
part
1
true/real information available.” Diction- solution to caring for the underserved. For
ary.com defines ignorance as “lack of those who have caries and other oral health
knowledge, information, or education.” It problems, all the research leads to the
follows that those with the most passion conclusion that the single, largest barrier to
are the most ignorant. Benford’s Law of care is not the lack of a new provider.
Controversy is no more a law than Mur- Despite the push toward expanding
phy’s Law of Rush-Hour Traffic, which the dental workforce model to include
states that during rush hour whatever midlevel-type providers, oral health group has made their report, yet CDA has
lane you are driving in will be the slowest. literacy and water fluoridation continue no such restrictions and continues to use
The board of directors of the San Fer- to be the most cost-effective methods to its full resources to sway opinion in favor
nando Valley Dental Society is passionate reduce caries. In New Zealand, as Dr. Jay of such alternative workforce models.
about the oral health of the people of the Friedman points out in his article in the Only with an impartial and balanced
state of California. The more the SFVDS Journal of the California Dental Association account can CDA membership make
Board learned about several concepts (39(1)22:9, January 2011), fluoridation was educated decisions in this complex arena.
offered to care for those patients not the cause for the great reduction in the To date, CDA members are not receiving
currently served, the more passionate the number of dental therapists from 1970 to such respectful balance of opinion. The
SFVDS board has become in protecting today. That reduction can only come as a SFVDS asks for inclusion of the many alter-
those most vulnerable patients. Currently, result in the reduction of need for the den- natives to the midlevel provider and access
California has more types of license levels tal therapists. The benefits of community to care issues rather than the one-sided
for dental providers than any other state. water fluoridation require no additional view we have been subjected to thus far.
Hygienists can practice in alternative effort by any patient and are available sincerely,
m e h r a n a b ba s s i a n , d d s, president
settings, assistants can place and finish across all racial, socioeconomic, cultural, Board of Directors of the
restorations, as well as cement permanent and geographic boundaries. Improving oral San Fernando Valley Dental Society
crowns. Studies are under way to deter- health literacy can be accomplished using
mine the safety and quality of diagnosis dental team members within the duties Reader Appreciates Debate Over
by off-site dentists to aid in urgent treat- currently allowed by law. Dental Workforce
ment decisions thus helping to overcome The effort CDA is making to educate I want to applaud you for the January
the geographical barrier to care. its members about access to care is almost issue of the Journal of the California Dental
Every time there is an expansion of exclusively about the MLP and the tone Association (39(1)1-60, 2011). I know it took
duties, addition of places of practice, or is so condescending that all this educa- no small amount of courage to confront
change in level of supervision proposed, tion seems more like indoctrination and the challenges we face as a profession by
one of the reasons put forth is that the groundwork for a predetermined out- publishing articles that represent view-
change will improve access to care and come from the Access-to-Care Workgroup. points that are anathema to many den-
reduce the disparity in oral health levels of We at the SFVDS have been repeatedly tists. I agree with the assertions in your
the underserved. Yet, year after year, the told by various members of the CDA Exec- editorial and commend its measured and
access-to-care problem worsens and the utive Committee to withhold making any professional tone. Only knowledge and
disparity in oral health continues. Even in judgments until the Access-to-Care Work- con t i n u e s o n 1 3 4
132 m a r c h 2 0 1 1
www.implantdirect.com
Implant Direct Sybron International
1-818-444-3333 • 1-888-NIZNICK a company
Nobel Replace®
One-Piece Implants
Ball RePlant®
Attachment Straumann®
† Tissue-Level Full
$85
SwishPlant™ Contour
$75
GPS™
Attachment
$100**
ScrewPlant® Gold/Plastic
ScrewPlus® Castable
Zimmer Screw-Vent® $100
15 & 30
0 0
GPS™ MIS
Attachment Legacy™
$120**
Titanium
Temporary
$35
Screw
Receiving Plastic
†
$85 Temporary
$35
150 & 300 Plastic
Screw Engaging $35
Receiving Non-Engaging $30
† Castable
$100
l e t t e r s , c o n t i n u e d f r o m 132
discussion will eliminate the controversy of AI/adolescents, age 15-19, have caries. Despite Dr. Nagel’s claim of “the imple-
The fallacy of the use of dental thera- Sixty-eight percent of AI/AN children mentation of significant public health pro-
pists to address the unmet dental needs of have untreated dental caries. One-third of grams of decay prevention by the Indian
native Alaskans is best illustrated by the schoolchildren report missing school be- Health Service (IHS) and tribe,” any dental
statistics cited by Dr. Nagel himself (page cause of dental pain and 25 percent report health professional understands these
31), “The American Indian/Alaska native avoiding laughing or smiling because of interventions, while well-intended, have
(AI/AN) population has the highest rate of the appearance of their teeth.” been inadequate for the circumstances.
dental caries of any population cohort in If the disease we were considering was We know no child is born with caries and
the United States, five times the U.S. aver- tuberculosis, no one would be suggesting we further know this epidemic is entirely
age for children 2 to 4 years of age. Seventy- we train an army of physician assistants preventable. While the damaged denti-
nine percent of AI/AN children, age 2-5, in Alaska (or New Zealand) to perform re- tions currently existing will all require a
have tooth decay, with 60 percent of these peated pulmonary surgeries. The surgical lifetime of professional care, the imple-
children having severe early childhood car- approach would be dismissed as insanity mentation of interceptive programs that
ies. Eighty-seven percent of these children, in favor of a medical approach that identi- either reduce the cariogenic pathogens or
age 6-14, have a history of decay, twice fied and then eliminated the underlying otherwise modify the dietary and learned
the rate of dental caries experience for the factors that allowed such an epidemic to behaviors that lead to the high incidence
general population. Ninety-one percent occur in the first place. of caries are the only hopes of significantly
reducing the suffering and would fur-
ther obviate the need for massive dental
manpower.
When do we, as a profession, stop
blaming the patients or citing their
geographical circumstances and start
implementing the practices we know will
solve the problem?
s t e p h e n o. glenn, dds
Tulsa, Okla.
Editor’s note: The January issue of the
Journal provided the history and context for
the RDH alternative practice in California,
the dental therapist internationally, and the
dental health aide therapists in Alaska. In
the February issue, the Journal brought you
a letter from an administrator of the dental
therapist program in New Zealand, a review
of effective ways of addressing barriers to care
across the nation, and an article by one author
on his belief that the therapist model is neither
appropriate nor effective for the United States.
February also included an overview of what
the CDA Foundation has done to address the
issue of barriers to care in California.
In order to make decisions, it is impor-
tant to determine the problem and thoroughly
understand the external landscape. The Jour-
nal will continue to present a spectrum of
information on issues of concern to dentistry.
134 m a r c h 2 0 1 1
Progress. It’s what happens
when 25,000 dentists work together.
cda.org/renew
Protecting dentists.
It’s all we do.
SM
800.733.0633
tdicsolutions.com
CA Lic. #0652783
Impressions c da j o u r n a l , vo l 3 9 , n º 3
m a r c h 2 0 1 1 137
march 11 impressions
c da j o u r n a l , vo l 3 9 , n º 3
D0274
CDT 2011-2012: The ADA Practical Guide to Procedure Codes
The American Dental Association is offering a resource, CDT 2011-2012: The ADA Practical
D9940
Guide to Dental Procedure Codes, to accurately and report dental services delivered to patients.
The book contains the updated edition of the “Code on Dental Procedures and Nomenclature,”
along with a number of expanded reference sections such as questions and answers concerning
Correction the selection of the appropriate procedure codes for patient records and for claim submissions.
D7295
Due to a technological error, several lines of New information and forms for caries risk assessment and documentation also are included.
one paragraph were missing from Page 99 of the
Additionally, the ADA also is offering a revised CDT companion: The ADA Practical Guide
February 2011 issue of the Journal. A corrected
version of the issue has been posted on CDA’s to Dental Coding that provides more information on areas ranging from dental/medical cross-
website at cda.org/publications. Following coding to how to submit dental claims to a patient’s medical insurance carrier. This version
D0470
are the restored sentences from the article
includes an expanded set of clinical coding scenarios that cover a wide variety of patient
“Improving Oral Health Care and Oral Health Care
Delivery for Children,” by James J. Crall, DDS, ScD:
services and can be a great resource for instructing dental staff on difficult coding scenarios.
In conclusion, national- and state-level The CDT 2011-2012: The ADA Practical Guide to Dental Procedure Codes that includes
evidence have clearly documented the a searchable CD-ROM, and the CDT Companion: The ADA Practical Guide to Dental Coding
D9940
existence and consequences of ongoing
are available as a set for $84.95 for ADA members and $127.45 for nonmembers. The CDT
disparities in children’s health and utilization
of oral health care services. Notable progress 2010-2012 and its CD-ROM are $49.95 for ADA members; $74.95 for nonmembers. The
in addressing these disparities has been CDT Companion is for $49.95 for ADA members and $74.95 for nonmembers. For more
made in states that have combined strong information, go to adacatalog.org or call 800-947-4746.
leadership in both public and private sectors,
broad-based support, and a strategic
framework geared toward two major goals:
reducing the burden of dental disease over
mona lisa , continued from 137
time and ensuring access to and utilization of
appropriate diagnostic, preventive, treatment dentist. “I brought her to work im- did. Amazing for a little Chihuahua.”
and disease management services (with mediately after adopting her from the Taddey said the staff enjoys taking
priority given to programs focusing on children shelter. The first time she provided her turns walking the dog and love being
and high-risk families). The complex nature of special “pet therapy” was when a nervous greeted by Mona Lisa every morning.
the determinants of oral health and utilization
patient, who immediately adored Mona, Reaction from staff and patients regard-
of oral health services underscore the need
asked if she could be on her lap during ing Mona Lisa has been very positive and
for collaborative multifaceted approaches
to achieve these goals, including involvement
her procedure. Mona is a very mellow and downright fun. “In general, the consensus
of “nontraditional oral health stakeholders.”
nurturing little animal; it is her nature to seems to be that most of the population
Prominent contextual and overarching be held and fall asleep in your arms. She does not like going to the dentist. Mona’s
considerations and an increasingly diverse is quiet, obedient, and adores everyone. presence in our office has changed that
population underscore the need for approaches Knowing this, I introduced her to sitting negative aura with anxious patients as
that are innovative, solidly evidence-based, on this patient’s lap while I performed my well as with patients who just love dogs
targeted, and coordinated in order to maximize dental work. Mona immediately curled up or who have pets. She seems to appeal to
effectiveness and efficiency. on the patients lap and took a nap, and everyone’s humanistic side, whether she is
the patient cuddled and petted Mona to present in the clinical setting or just says
ease her own nerves and distract her from hello as patients check in or out.”
the dental work I was busy doing. Mona’s Taddey added that she and her father,
mere presence changed the whole experi- a New York University Dental School
ence for the patient — from the injection graduate, “find it refreshing and so
to the drill. Mona does not even perk her rewarding that a little rescue dog can pro-
ears up when the high-pitched hand piece vide so much ease and a positive experi-
starts up; she seems to know that is the ence to going to the dentist.”
beginning of the procedure and the end It’s a good thing Mona Lisa has her
is when I take my gloves off, remove my own business card, which provides lots of
mask, and tell the patient how great they cont i n u e s o n 1 3 9
138 m a r c h 2 0 1 1
c da j o u r n a l , vo l 3 9 , n º 3
Lower Income, Minority, Special Needs Children More Likely to Suffer Toothaches
Toothaches, according to a recent study, are more likely to afflict poor, minority,
and special needs children.
“Toothache is a source of chronic and often severe pain that interferes with a child’s
ability to play, eat, and pay attention in school,” said authors in a report published in
an issue of Archives of Pediatrics and Adolescent Medicine. “The most common cause of
toothache is dental decay” and the “process of dental decay is one that optimally would
be prevented or, at the very least, identified early and then arrested through provision of
regular professional dental care. However, for some U.S. children, including those who
are Medicaid-insured, access to preventive and restorative dental care is more difficult.”
Studying data from the 2007 National Survey of Children’s Health, Charlotte
Lewis, MD, MPH, and James Stout, MD, MPH, both of the University of Washington
School of Medicine, Seattle, tried to determine the risk factors and frequency for tooth-
ache in children. A population-based sample of parents/guardians of 86,730 children
between ages 1 and 17, from every state and the District of Columbia was the source of
the data. Authors found that an estimated 10.7 percent of U.S. children had a toothache
in the previous six months. A toothache was the most reported affliction for youngsters
between the ages of 6 and 12; one in seven reported toothaches in the past six months.
Additionally, findings revealed that 58 percent of children who had a toothache
also had cavities within the past six months.
The original article, “Toothache in U.S. Children,” by Lewis C, Stout J, appeared in Arch
Pediatr Adolesc Med, 164(11):1059-63, November 2010. Additional information provided by
ScienceDaily, sciencedaily.com/releases/2010/11/101101161831.htm. (Accessed Jan. 13, 2011.)
m o n a l i s a, c o n t i n u e d f rom 138
levity as patients register, leave the office, true blessing and is an amazing experience
or make their next appointment. Patients we are both grateful for every day,” said
can call and specifically ask if Mona will be Dr. Tracy Taddey. “My dad has always been
available for their appointment, Taddey my inspiration, my mentor, and my best “Not only do we
said. “One of our patients made (Mona friend. He has taught me more than I ever
Lisa) a handmade quilt, which accompa- could have learned in dental school, and provide excellent dental
nies us everywhere, and she sits on this as we combine our generations, we learn
on the patient’s lap when she is requested from each other all the time. My dad is very treatment to our patients,
for their procedure.” open-minded and progressive. He is very
but they are having a
Taddey practices with her father, John excited to have the addition of “pet therapy”
Taddey, DDS, just as he practiced with to his 37-year-old La Jolla practice. I am soothing and happy
his father, also named Dr. John Taddey, honored to follow in his path and provide
in the Bronx. Dr. Tracy Taddey’s father new dimensions to the strong foundation experience while we
also taught postgraduate dentistry at he has spent his life building.
Montefiore Hospital in the Bronx before “Having Mona on board only provides take care of their
putting down roots in La Jolla in 1974 at a another level of happiness, uniqueness, and
location where he still works today. Prior caring that we can offer to our patients. We long-term dental health.”
to joining her father’s practice, Dr. Tracy agree that it is very gratifying as doctors to
Tracy A. Taddey, DDS
Taddey, a 1998 graduate from what is now know that not only do we provide excellent
known as the Arthur A. Dugoni School of dental treatment to our patients, but they
Dentistry in San Francisco, opened her are having a soothing and happy experience
own in Clairemont Mesa in 2001, where while we take care of their long-term dental
she currently also works part time. health. Our relationships with our patients
“Practicing together as father-daugh- are our first priority and Mona only adds to
ter, and as a third-generation dentist, is a this bond and the evolution of the practice.”
m a r c h 2 0 1 1 139
march 11 impressions
c da j o u r n a l , vo l 3 9 , n º 3
Particular Diet May Be Beneficial the U.S. population,” said Asghar Z. Naq-
to Those With Periodontitis vi, MPH, MNS, Department of Medicine,
Periodontitis, if left unchecked, may Beth Israel Deaconess Medical Center.
lead to the accumulation of bacteria, and “To date, the treatment of periodontitis
potential bone and tooth loss. And while has primarily involved mechanical clean-
traditional treatments focus on bacterial ing and local antibiotic application. Thus,
infection, newer approaches target the a dietary therapy, if effective, might be a
inflammatory response. But there may be less expensive and safer method for the
another tack: diet. prevention and treatment of periodonti-
In a recent issue of the Journal of the tis. Given the evidence indicating a role
American Dietetic Association, Harvard for n-3 fatty acids in other chronic in-
Medical School and Harvard School of flammatory conditions, it is possible that
Public Health researchers found that di- treating periodontitis with n-3 fatty acids
etary intake of polyunsaturated fatty acids could have the added benefit of prevent-
“A dietary therapy, (PUFAs) such as fish oil, is known to have ing other chronic diseases associated with
anti-inflammatory properties and shows inflammation, including stroke as well.”
if effective, might be potential for treating and preventing Data from the National Health
periodontitis. Other foods that contain and Nutrition Examination Survey
a less expensive and
significant amounts of polyunsaturated (NHANES) was used. Investigators
safer method for the fats include fatty fish such as salmon; found that dietary intake of the PUFAs,
nuts, margarine, and peanut butter. DHA, and EPA were associated with a
prevention and treatment “We found that n-3 fatty acid intake, decreased prevalence of periodontitis,
particularly docosahexaenoic acid (DHA) although linolenic acid (LNA) did not
of periodontitis.” and eicosapentaenoic acid (EPA), are show this association, according to a
inversely associated with periodontitis in news release by ScienceDaily.
Asghar Z. Naqvi, MPH, MNS
upcoming meetings
2011
April 7–10 California Society of Pediatric Dentistry 36th annual Session/Western Society
of Pediatric Dentistry ninth annual session, San Francisco, 831-625-2773,
drrstewart@aol.com.
April 10–16 United States Dental Tennis Association, Tampa, Fla., dentaltennis.org.
May 12–14 CDA Presents the Art and Science of Dentistry, Anaheim, 800-CDA-SMILE
(232-7645), cdapresents.com.
June 16–18 ADA New Dentist Conference, Chicago, 800-621-8099, ext. 2779,
ada.org/goto/newdent.
Sept. 22–24 CDA Presents the Art and Science of Dentistry, San Francisco, 800-CDA-SMILE
(232-7645), cdapresents.com.
Nov. 6–12 United States Dental Tennis Association, Palm Desert, Calif., dentaltennis.org.
To have an event included on this list of nonprofit association continuing education meetings, please send the information
to Upcoming Meetings, CDA Journal, 1201 K St., 16th Floor, Sacramento, CA 95814 or fax the information to 916-554-5962.
140 m a r c h 2 0 1 1
Periscope c da j o u r n a l , vo l 3 9 , n º 3
technology implants
jin-ho phark, dds, dr.med.dent richard t. kao, dds, phd, and david w. richard, dds, phd
Resin Infiltration Helps Control Caries The Two-Implant Overdenture Can Function
Ekstrand KR, Bakhshandeh A, Martignon S, Treatment of proximal for a Long Period
superficial caries lesions on primary molar teeth with resin
Vercruyssen M, Marcelis K, et al, Long-term, retrospective
infiltration and fluoride varnish versus fluoride varnish only: efficacy
evaluation (implant and patient-centered outcomes) of the two-
after one year. Caries Res 44(1):41-6, 2010.
implant-supported overdenture in the mandible. Part I: survival rate.
aim: The purpose of this study was to assess the efficacy of resin Clin Oral Impl Res 21(4):357-65, April 1, 2010.
infiltration and fluoride varnish (FV) application combined versus FV
aim: This study reports the long-term survival rate of implants used in
treatment-only of interproximal carious lesions on deciduous molars.
paired situations to support mandibular overdentures at the Catholic
methods: Forty-eight children with one or more pairs of interproximal University, Leuven, Belgium.
caries lesions on deciduous molars with no or initial clinical signs of
methods: Retrospective analysis of 495 cases where two implants
caries and radiological extension of the lesion up to the outer third of the
were used to support mandibular overdentures was performed. This
dentin were selected. One lesion of each pair was randomly allocated to
represented cases treated over the past 25 years at this academic
the test treatment (resin infiltration) followed by 2.26 percent FV), the
center. Of the 495 cases, 75 percent were available for clinical
other lesion was allocated to the control treatment (2.26 percent FV
evaluation or chart review. The rest represented patients who could
only). ICDAS scores of the selected lesions were recorded before the
not be contacted or had died.
treatments. FV was applied to both, the test and the control lesions six
and 12 months after the first treatment. After one year, ICDAS scores results: Most implants were machined (95 percent) while the rest
were obtained for 42 children and radiographs for 39. One external were anodized (TiUnite) Branemark type implants. The paired implants
examiner scored the radiographs twice for progression of caries. were used either as a bar (86.3 percent), ball attachments (11.7
percent), or magnets (1.6 percent) anchorage. The survival rate after
results: Baseline mean age of the children was 7.17± 0.68 years 20 years of loading was 95.5 percent. Factors associated with implant
and mean def-s was 8.1±6.9. After one year, the ICDAS scores of
failure included smoking and one-stage-placed implants. Implant
31 percent of the test lesions and 67 percent of the control lesions
length and bone quality had no impact on implant survival.
had progressed (p <0.01). Radiographically, 23 percent of the test
lesions and 62 percent of the control lesions had progressed (p <0.01). conclusions: This study supports the two-implant overdenture
Thus, the clinical and radiographic therapeutic effect of both resin concept in the mandible as a treatment approach that can function for
infiltration/FV over FV alone was >35 percent and significant. a long period of time.
conclusions: Resin infiltration in conjunction with fluoride varnish clinical relevance: Given the difficulty in obtaining mandibular
seems promising for controlling proximal lesion progression on denture stability, the use of two implants to provide anchorage will
deciduous molar teeth. improve function and quality of life. This study provides clinicians
with evidence that implants used in this approach can function for a
clinical relevance: Resin infiltration is an innovative concept to long period of time. Furthermore, these results were obtained using
arrest progression of caries lesions noninvasively. Resin infiltration
predominantly the older-styled machine surface implants. The newer
of interproximal caries lesions on deciduous molars is efficacious.
implant surfaces may potentially provide better results.
Application of this treatment can prevent or delay invasive treatment
in deciduous teeth.
m a r c h 2 0 1 1 141
march 11 periscope
c da j o u r n a l , vo l 3 9 , n º 3
surgery periodontics
d.d.r. yamashita, dds gerald i. drury, dds
142 m a r c h 2 0 1 1
PRESENTS
The Art
and Science
of Dentistry
Anaheim,
California
May 12-14,
2011
New days:
Thursday-
Saturday
C.E. INFORMATION
• Write down course codes — During each course, the In an effort to do our part for the environment
host will give attendees a three-digit code that should be and save our members money, CDA Presents will
recorded and saved until you have your complete official no longer print course handouts for classes in
C.E. certificate after the convention. Anaheim and San Francisco. A small effort that will
save over 1.3 million pieces of paper each year.
• Go to the C.E. Pavilion or cdapresents.com after
Plus, by investing the savings, we can continue to
attending class — At the C.E. Pavilion, you will verify
your C.E. units as well as take a brief survey for each enhance the benefits of CDA Presents for members
course attended. For your convenience, you can wait until and their teams.
you have attended all of your courses to verify, or visit
cdapresents.com up to five days after the meeting. Please Attendees can access most course handouts at
keep in mind that all courses displayed in the C.E. Pavilion cdapresents.com and are welcome to print them
are those that have on-site scan activity and display does out if they wish. In addition, each show’s On-Site
not guarantee credit. Guide will now provide space for note taking. And
as always, audio recordings of most classes will be
• Print your certificate online — To make your C.E. available for purchase at the conclusion of each
certificates available in a timelier manner, certificates will show. By working together, we can do great things.
now be available online approximately three to four weeks
after the meeting. At that time, you will receive an e-mail
containing a link that will take you to your C.E. certificate.
You may also access your C.E. certificate at cdapresents.com.
Should you need a copy of your certificate mailed to you,
please call 800.232.7645 approximately four weeks after the
meeting, and we will be happy to mail you a copy.
Visit cdapresents.com to
plan your meeting experience.
PRESENTS
REQUIRED COURSES
Infection Control
Time: 7–9 a.m.
Course #: 006
Tricia Fee: $20
Osuna,
RDH, BS,
FAADH
spot
the
learn, engage and recharge!
Featuring:
• Aneducational theater
providing C.E. credits
• Cool and new products
Experience it.
Anaheim Convention Center
Exhibit Hall, near Registration Area
WineFUNdamentals Seminar and Reception
Join us for interactive wine activities and trivia! You’ll learn to
distinguish the various scents and flavors in wine by tasting both
white and red varietals and about pairings with both cheese and
chocolate. Plus, you’ll have the opportunity to put your knowledge
to the test and win prizes!
Friday, May 13
Time: 4–5:30 p.m.
Fee: $25
Event #: 056
Location: The Spot, Exhibit Hall
CHILDREN’S PROGRAM
Ages 6 Months Through 6 Years For safety reasons, strollers are not
KiddieCorp professionals are bonded, qualified child care permitted on the exhibit floor.
specialists who are carefully selected and trained. Age-
appropriate activities are selected for the children who join
them during the meeting.
Parents with infants must provide diapers, changing supplies,
milk, formula, baby food, etc. Please label personal belongings
and lunches. Nutritious snacks and beverages will be provided
by KiddieCorp. Meals can be supplied by parents or purchased
at the children’s program registration area.
Cost: Full day: $40
Half day: $20 (7 a.m.–1 p.m. or 1–6 p.m.)
Event #: 055
one day/one park Admission to either Disneyland® Park or Disney’s California Adult: $68
Adventure® Park for one day. Child (3–9 years): $60
one-day park hopper® Admission and ability to visit both Disneyland® Park and Adult: $88
Disney’s California Adventure® Park on the same day for Child (3–9 years): $78
one day.
two-day park hopper® Admission and ability to visit both Disneyland® Park and Adult: $141
Disney’s California Adventure® Park on the same day for Child (3–9 years): $126
two days.
three-day park hopper® Admission and ability to visit both Disneyland® Park and Adult: $161
Disney’s California Adventure® Park on the same day for Child (3–9 years): $140
three days.
four-day park hopper® Admission and ability to visit both Disneyland® Park and Adult: $171
Disney’s California Adventure® Park on the same day for Child (3–9 years): $148
four days.
five-day park hopper® Admission and ability to visit both Disneyland® Park and Adult: $176
Disney’s California Adventure ® Park on the same day for Child (3–9 years): $151
five days. Enjoy two free days of magic when you visit both
Disney’s California Adventure ™ Park and Disneyland® Park
for five days for the price of three!
twilight convention An ideal admission option for after meetings or events! Ages 3 and up: $43
ticket Admission is valid for one visit to either Disneyland® Park
or Disney’s California Adventure® Park after 4 p.m., or four
hours before park closing, whichever is earlier, since park
hours are subject to change. “Back and forth” privileges
are not included.
Tickets are printed on demand from your home computer. Purchase is separate from meeting registration.
NOTE: The special pricing on this page is available only with your advance, pre-arrival purchase. Box office tickets will be available
at the Disneyland® Resort Main Gate Ticket Booths at regular prices. Prices subject to change.
endotoxin
c da j o u r n a l , vo l 3 9 , n º 3
O - A N T I GE N
C O RE
Endotoxin in
LIPID A
LIPOPOLYSAC C H A R I DE
(LPS)
Endodontic Infections:
A Review
zahed mohammadi, dmd, msd
W
author hen dental pulp is ex- more, some gram-negative anaerobic
Zahed Mohammadi,
posed to the oral cavity bacteria have been suggested to be
dmd, msd, is an due to caries or trauma, involved with symptomatic lesions.3
assistant professor and it is initially contami-
head, Department of nated by predominantly Lipopolysaccharide (Endotoxin)
Endodontics, Hamedan
aerobic and facultative microorganisms.
University of Medical
Sciences, Hamedan, Iran,
Due mainly to the existing nutritional Structure
and Iranian Center for relationships between microorganisms, The lipopolysaccharide (LPS) is located
Endodontic Research together with the slow decrease of oxygen in the outer membrane of the bacterial
(ICER), Tehran, Iran. tension in root canals, a microbial shift cell wall.4 It is composed of three dis-
takes place leading to a predominance tinct structural regions, the O-specific
of anaerobic microorganisms.1 Technical polysaccharide, the common core, and a
advances in microbiological culture and lipid component called lipid A. Lipid A is
identification have shown that anaerobic responsible for many, if not all, biological
microorganisms predominate in root activities exhibited by bacterial LPS.4 Lipid
canals of teeth with pulp necrosis and A is a gluco-configured hexosamine-based
radiographically visible chronic periapical phospholipid that serves as the hydro-
lesion, especially gram-negative bacteria.2 phobic anchor of LPS on the majority
The most frequently detected culturable of gram-negative outer membranes. The
species in primary infection belong to the majority of bacterial lipid A structure is
gram-negative genera Tannerella, Dialister, conserved and consists of a mono- or
Porphyromonas, Prevotella, Fusobacterium, bi-phosphorylated disaccharide backbone
Campylobacter, and Treponema. Further- that has been acylated with C12-C14-
m a r c h 2 0 1 1 153
endotoxin
c da j o u r n a l , vo l 3 9 , n º 3
length hydroxy and nonhydroxy fatty ac- how one motif can interact with all these (factor XII of coagulation), the first step of
ids at specific positions (C2, C3, C2’, C3’).5 molecules. The intracellular domain of the intrinsic clotting system that triggers
Furthermore, if present, the hydroxyl the TLRs, the TIR domain, is a conserved the coagulation cascade or the production
groups of these fatty acid chains can be protein-protein interaction module that of bradykinin.14-16 LPS also activates the
further esterified by additional fatty acids is also found in a number of transmem- complement system 6, induces the expres-
(second substitution). The classic struc- brane and cytoplasmic proteins in plants, sion of leukocyte adhesion molecules on
ture of lipid A is represented by Escherichia worms, arthropods, and even bacteria. endothelial cells, and stimulates osteo-
coli. This lipid A contains a one, 4-bi-phos- Interestingly, all these TIR-containing clast differentiation and bone resorption,
phorylated β(1-6)-linked D-glucosamine proteins seem to have a function in host particularly via interactions with TLR-4
disaccharide backbone (D-Glc N I, D-Glc defense, making the TIR domain one of on osteoblast-lineage cells.17-20 LPS may
N II) that is hexa-acylated via primary the earliest signaling motifs to evolve.10 be mitogenic to B-cells and epithelial
ester and amide linkages with secondary The region of homology is confined to cells. It also can stimulate B-cells in the
substitution on specific hydroxyl groups.5 absence of T-cells help.21 Wadachi and
Hargreaves proposed a mechanism of pain
Mechanisms of Action when free to act, associated with endodontic infections.22
When free to act, endotoxins do not They demonstrated that trigeminal af-
cause cell or tissue damage directly, but endotoxins do not cause ferent neurons express the TLR4 and
they stimulate competent cells to release cell or tissue damage CD14 receptor complex and that LPS
chemical mediators. It has been shown that activation of TLR-4/CD14 may trigger
macrophages are the main target of endo- directly, but they stimulate intracellular signaling cascades, leading to
toxins. After release from bacteria, LPS is competent cells to release peripheral release of neuropeptides and
initially bound to a plasma protein called central nociceptive neurotransmission.
LPS-binding protein (LBP) and is then chemical mediators.
delivered to CD14, a cell receptor for LPS LPS in Infected Root Canal
on the surface of macrophages. Subsequent Schein and Schilder showed that pulp-
activation of the macrophage is a result of three conserved boxes containing amino less teeth contained greater concentra-
a signal triggered by a signal-transducing acids crucial for signaling.11 An extending tions of endotoxin than those with vital
receptor called a toll-like receptor (TLR).6 loop in box 2, encompassing an RDxf1f2G pulps.23 Symptomatic teeth also contained
motif (where x represents any amino acid more endotoxin than asymptomatic teeth.
Toll-Like Receptors (TLRs) and f represents a hydrophobic residue) Dwyer and Torabinejad examined the
TLRs are evolutionarily conserved mediates interaction with the downstream periapical tissue reaction to three concen-
proteins characterized by an extracel- adaptor protein MyD88.12 The LPSd non- trations of E. coli endotoxin solutions, to
lular leucine-rich repeat domain and an responder phenotype of CH3/HeJ mice re- three detoxified E. coli endotoxin solu-
intracellular Toll/IL-1 receptor-like (TIR) sults from a Pro→His mutation at the f2 tions, and to a sterile saline as a control
domain.7 Leucine-rich repeats are found position in this loop in the TIR domain of solution in adult cats.24 The maxillary and
in both cytoplasmic and transmem- TLR4, which impairs interaction with the mandibular canines were isolated with a
brane proteins and are involved in ligand adaptor signaling protein MyD88, result- rubber dam, and the pulps were extir-
recognition and signal transduction.8 It ing in abrogation of the LPS response.12 pated. The solutions were deposited in
has been demonstrated that seven out The f2 proline residue is conserved in all the root canals of each cat, and the access
of 10 leucine-rich repeat motifs of the TLRs except TLR3, where it is replaced cavities were sealed. The periapical tissues
CD14 receptor, a transmembrane protein with another hydrophobic residue.13 were examined histologically and radio-
implicated in LPS recognition, could be graphically at two, four, and six weeks.
deleted without affecting LPS binding.9 Biological Activities of LPS The radiographic and histologic results
Furthermore, each TLR can recognize the Besides TLRs, there are some other indirectly demonstrated that endotoxins
most diverse ligands, lacking any struc- pathways regarding the biological effects had a part in initiating and perpetuating
tural similarity, making it hard to conceive of LPS. It activates the Hageman factor periapical inflammatory lesions. Pitts et
154 m a r c h 2 0 1 1
c da j o u r n a l , vo l 3 9 , n º 3
al. investigated the role of endotoxin in most extensive lesions in periapical bone minutes to 41/2 hours. In two specimens,
periapical inflammation.25 Dental pulps were observed in those canals treated the concentration of endotoxin in the
in two dogs were removed and the canals with E. corrodens endotoxin. No antibody effluent leveled off in 41/2 and 5 hours,
shaped in six matched pairs of roots. titers were detected in sera from any of respectively, whereas in another two
Canals on the experimental side were the dogs during the observation period. the concentration continued to increase
injected with Salmonella Minnesota R-595 Histological examination showed throughout the experiment. In one
endotoxin and canals on the contralateral significant bone destribution and heavy specimen, no endotoxin was detected.
control side were injected with saline inflammatory cell infiltrate. Yamasaki et Nakane et al. treated human dental pulp
solution at weekly intervals. Radiographic al. measured the amount of endotoxin as cells with 1, 10, and 100 µ/ml of LP).30
examinations were performed weekly, well as to identify gram-negative bacteria The effects of treatment were ex-
and histologic evaluations were made at in experimental periapical lesions in rats amined by measurement of the DNA
four to five weeks. Periapical radiographic and found that the amount of endo- content, protein content, and alkaline
changes occurred sooner and to a more phosphatase activity of the cells. LPS
severe degree with the roots containing samples were purified from P. gingivalis,
endotoxin than with the roots contain- periapical radiographic P. endodontalis, and F. nucleatum isolated
ing saline solution. Histologic evaluation from root canals, and E. coli 0111:B4 LPS
showed greater periapical bone destruc- changes occurred sooner and was used as a positive control. At a con-
tion and a more marked inflammatory to a more severe degree with centration of 1 µ/ml, none of the LPSs
response. Polymorphonuclear leukocytes caused any change in the production of
were the predominating cells. Pinero et the roots containing endotoxin DNA or protein, whereas the amount of
al. assessed the effect of endotoxin on than with the roots DNA was increased at 10 micrograms/
the synthesis of connective tissue matrix ml and inhibited at 100 micrograms/
components by pulp fibroblasts in vitro.26 containing saline solution. ml. Protein synthesis was decreased by
Human and bovine pulp fibroblasts LPSs at both 10 and 100 micrograms/
were treated with low levels of endotoxin ml. Alkaline phosphatase activity was
and assayed for the utilization of various toxin in the periapical tissues gradually not changed at any concentration of LPS
isotopes to measure synthesis of DNA, increased with increasing time and that tested. Nagaoka et al. found that pulpal
collagen, and sulfated and nonsulfated gram-negative bacteria were isolated from fibroblasts were immunoresponsive cells
glycosaminoglycans. Endotoxin at 5 to the same region but did not increase in and can elaborate IL-8 upon stimulation
125 μg/ml stimulated the uptake of 3H- number concurrently with the increase with P. intermedia LPS.31 Hosoys and Mat-
thymidine by both cell lines. Utilization in the amount of endotoxin.28 Nissan sushima demonstrated that Porphyromo-
of the other isotopes also increased but et al. developed an in vitro system to nas endodontalis LPS stimulated IL-1 beta
varied with the cell lines and endotoxin determine whether bacterial endotoxin release from human dental pulp cells in
concentrations. Mattison et al. examined was capable of diffusing through dentin a time- and dose-dependent manner.32
periapical bone reaction to Eikenella cor- without the use of filtration pressure.29 However, IL-1 beta converting enzyme
rodens endotoxin in adult mongrel dogs.27 Cavities were prepared in five third molar activity was not increased by P. endodon-
Mandibular third and fourth premolars teeth in order to produce a split chamber talis LPS. Furthermore, Northern blot
were biomechanically prepared and in- device consisting of occlusal and pulpal hybridization analysis revealed that the
jected with E. corrodens 23834 endotoxin, chambers with 0.5 mm of intervening IL-1 beta mRNA level in human dental
E. coli 055:B5 endotoxin, or pyrogen-free dentin. An endotoxin was introduced pulp cells was increased by P. endodontalis
water at weekly intervals for four weeks. into the occlusal chamber and the efflu- LPS. Ko and Lim demonstrated that P.
Radiographs and blood samples were ent in the pulpal chamber was sampled endodontalis LPS was capable of stimu-
obtained weekly for 12 weeks and one ani- every 30 minutes for five hours and at 24 lating PMNs to produce chemotactic
mal was killed for histological evaluation hours using the limulus lysate assay. In cytokines and suggested that PMNs
at the end of the test period. Radiographi- four specimens, the initial appearance of stimulated with P. endodontalis LPS might
cally, the most rapidly progressing and endotoxin in the effluent ranged from 15 co n t i n u e s o n 1 5 8
m a r c h 2 0 1 1 155
Sure, you could do dental charting blindfolded.
Whether they’re divorced, foster or nuclear, when caring for families, having
the right forms and asking the right questions are essential. Thankfully, there’s
cdacompass.com. From coordinated benefits between divorced parents to
authorization forms so a caretaker can accompany a minor to an appointment,
it’s one website that gives your front office the foresight it needs to make treating
families a snap.
play a crucial role in the inflammatory biomechanical preparation using different extensively used parenterally for approxi-
and immunopathological reactions irrigating solutions and a Ca(OH)2-based mately two decades, after which they
of pulpal and periapical diseases.33 root canal dressing in a dog experimental were gradually withdrawn from clinical
Tokuda et al. indicated that P. interme- tooth model containing endotoxin.40 Re- practice owing to reports of toxicity.44-48
dia LPS-induced IL-10R gene expression sults showed that biomechanical prepara- Polymyxins consist of a cyclic de-
in human dental pulp fibroblasts in vit- tion with only irrigating solutions did not capeptide molecule, which is positively
ro.34 Fouad and Acosta compared periapi- inactivate the endotoxin, however, the charged and linked to a fatty acid chain
cal lesion progression and the expression same treatment associated with the use that has been found to be either 6-m-
of the bone modulating cytokines (IL-1α, of the Ca(OH)2 root canal dressing was ethyl-octanic acid or 6-methyl-eptanoic
TNF-α, IL-4, IL-6 and IL-11) in periapi- effective in the inactivation of the toxic acid. The main difference between the
cal lesions of normal and C3H/HeJ (LPS effects of this endotoxin. Jiang et al. in molecules of polymyxin B and polymyxin
hyporesponsive) mice.35 Findings showed 2003 also evaluated the direct effects of E is in the amino acid components.43
that there were no statistically significant Polymyxin E consists of D-leucine, L-
differences in progression of periapical in patients threonine and L-αγ-diaminobutyric acid,
lesions for both mouse strains with time. while polymyxin B contains D-phenylala-
Furthermore, the immunohistochemical with sepsis, nine instead of D-leucine.43 The cationic
staining revealed no overall differences be- continuous hemodialysis molecules of polymyxin B and poly-
tween the two strains in levels of expres- myxin E compete and displace Ca2+ and
sion of the cytokines. IL-11 expression did therapy with polymyxin-B Mg2+ ions, which normally stabilize the
not change from control levels in BALB/c immobilized fiber have been lipopolysaccharide molecule of the outer
mice, but correlated with the expres- membrane of gram-negative bacteria.
sion of IL-6 and IL-4 in C3H/HeJ mice. correlated with improvement This displacement causes local distur-
of the survival rates. bance of the cell membrane, increased
Calcium Hydroxide and Endotoxin cell permeability, leakage of the cell con-
Safavi and Nichols evaluated the effect tent, cell lysis, and death.49,50 In addition,
of calcium hydroxide on the endotoxin LPS on osteoclastogenesis and the capac- a remarkable property of polymyxins is
of Salmonella typhimurium in vitro and ity of Ca(OH)2 to inhibit the formation of the ability to neutralize lipopolysaccha-
found that it hydrolyzed the highly toxic osteoclasts stimulated by endotoxin and ride molecules of gram-negative bacteria,
lipid A molecule.36 In another study on found that Ca(OH)2 significantly reduced thus inducing antiendotoxin activities.51
the P. intermedia endotoxin, researchers osteoclast differentiation.41 Buck et al. in In patients with sepsis, continuous
found that Ca(OH)2 transformed lipid A 2001 found that long-term Ca(OH)2 as hemodialysis therapy with polymyxin-B
into fatty acids and amino sugars which well as 30-minute exposure to an alkaline immobilized fiber have been correlated
were atoxic.4 Barthel et al. investigated the mixture of chlorhexidine, ethanol, and so- with improvement of the survival rates.52
effect of Ca(OH)2 on the toxic potential dium hypochlorite did detoxify LPS mol- Their spectrum of activity includes gram-
of an E. coli LPS.37 Findings indicated that ecules by hydrolysis of ester bonds in the negative aerobic bacilli only, including
Ca(OH)2 was able to eliminate the ability fatty acid chains of the lipid A moiety.42 Acinetobacter baumannii, Pseudomonas
of E. coli LPS to stimulate TNF-alpha pro- aeruginosa, Klebsiella species, Enterobacter
duction in peripheral blood monocytes. In Ploymyxin B and Endotoxin species, Salmonella species, Shigella
in vivo studies, Nelson-Filho et al., as well Polymyxins are a group of polypeptide species and E. coli. Stenotrophomonas
as Silva et al., evaluated the effect of endo- cationic antibiotics.43 Major components maltophilia strains are usually suscep-
toxin plus Ca(OH)2 on apical and periapi- of this class of antimicrobial agents tible to polymyxins.53,54 On the other
cal tissues of a dog’s teeth radiographically that have been used in clinical practice hand, Proteus species, Serattia species,
and found that the endotoxin caused the represent colistin (polymyxin E) and Burkholderia species, Providencia species
formation of periapical lesions and that polymyxin B. Colistin and polymyxin B and Edwardsiella spp. are resistant to
Ca(OH)2 inactivated bacterial LPS.38,39 were discovered from different species of polymyxins.53 Oliveira et al. showed that
Tanomaru et al. evaluated the effect of bacillus polymyxa in the 1940s and were polymyxin B as an intracanal medica-
158 m a r c h 2 0 1 1
ment for seven days detoxified endotoxin 0, 1, 7, 14, and 21 days. Results showed homologue of the Drosophila toll protein signals activation of
in root canals and altered the properties that thermoplasticized root canal filling/ adaptive immunity. Nature 388:394-7, 1997.
8. Kobe B, Deisenhofer J, Proteins with leucine-rich repeats.
of LPS to stimulate antibody produc- Roth’s 801 sealer permitting the least Curr Opin Struct Biol 5:409-16, 1995.
tion by B-lymphocytes.55 Hong et al. apical endotoxin penetration. Gulabivala 9. Juan TS, Kelley MJ, et al, Soluble CD14 truncated at amino
verified that systemic administration of et al. used radiolabelled LPS to assess acid 152 binds lipopolysaccharide (LPS) and enables cellular
response to LPS. J Biol Chem 270:1382-7, 1995.
polymyxin B in rats reduced the extent the coronal seal of retrograde amalgam 10. Aravind LV, Dixit M, Koonin EV, The domains of death:
of periapical lesion-associated bone fillings. Three different designs of retro- evolution of the apoptosis machinery. Trends Biochem Sci
resorption by 76 percent to 80 percent.56 grade cavities were evaluated: the con- 24:47-53, 1999.
11. Slack JL, Schooley K, et al, Identification of two major sites
ventional class 1 cavity, the slot cavity, in the type I interleukin-1 receptor cytoplasmic region respon-
Endotoxin to Assess Leakage and a previously unreported approach, sible for coupling to proinflammatory signaling pathways. J
There are several methods to assess the funnel cavity. Findings showed Biol Chem 275:4670-8, 2000.
12. Xu Y, Tao X, et al, Structural basis for signal transduction
leakage. One of these techniques is using that retrograde fillings in the funnel by the toll/interleukin-1 receptor domains. Nature 408:111-5,
endotoxin. Tang et al. used endotoxin cavity leaked significantly less than 2000.
to compare the sealing ability of Super- those in the other two cavity designs. 13. Kaisho T, Akira S, Dendritic-cell function in toll-like recep-
tor and MyD88-knockout mice. Trends Immunol 22:78-83,
EBA, IRM, amalgam, and MTA.57 Results 2001.
showed that MTA permitted less endo- Conclusions 14. Pettinger WA, Young R, Endotoxin-induced kinin (brady-
toxin leakage than IRM and amalgam at n Gram-negative bacteria play an kinin) formation: activation of Hageman factor and plasma
kallikrein in human plasma. Life Sci 9:313-22, 1970.
one, two, six and 12 weeks, and leaked essential role in primary endodontic 15. Morrison DC, Cochrane CG, Direct evidence for Hageman
less than Super-EBA at two weeks and 12 infections. factor (factor XII) activation by bacterial lipopolysaccharides
weeks. Carratu et al. evaluated the time n LPS is one of the major virulence (endotoxins). J Exp Med 140:797-811, 1974.
16. Bjornson HS, Activation of Hageman factor by lipopolysac-
required for endotoxins and bacteria to factors of gram-negative bacteria, which charides of Bacteroides fragilis, Bacteroides vulgatus, and
penetrate through root-canal obtura- play a fundamental role in the initiation Fusobacterium mortiferum. Rev Infect Dis 6(suppl 1):S30-33,
tions performed with vertical and lateral and maintenance of periapical 1984.
17. Grandel U, Grimminger F, Endothelial responses to bacte-
gutta-percha condensation techniques.58 inflammation. rial toxins in sepsis. Crit Rev Immunol 23:267-99, 2003.
Specimens prepared by the two alter- n TLR-4 is involved in cellular 18. Jersmann HP, Hii CS, et al, Bacterial lipopolysaccharide
native methods were exposed to con- activation by LPS from most bacteria. and tumor necrosis factor alpha synergistically increase
expression of human endothelial adhesion molecules through
taminated saliva, and leakage into the n LPS is present in infected root
activation of NF-kappaB and p38 mitogen-activated protein
root was evaluated over time. Findings canals and its concentration proportional kinase signaling pathways. Infect Immun 69:1273-79, 2001.
demonstrated that none of the obturated to the number of cells of gram-negative 19. Huang K, Fishwild DM, et al, Lipopolysaccharide-induced E-
selectin expression requires continuous presence of LPS and
roots was infiltrated by endotoxins after bacteria. is inhibited by bactericidal/permeability-increasing protein.
31 days. On the contrary, between Day n Calcium hydroxide and polymixin B Inflammation 19:389-404, 1995.
13 and Day 37, bacteria had infiltrated all are potent inhibitors of endotoxin. 20. Zou W, Bar-Shavit Z, Dual modulation of osteoclast dif-
ferentiation by lipopolysaccharide. J Bone Miner Res 17:1211-8,
specimens. Williamson et al. assessed 2002.
the magnitude of endotoxin penetration references 21. Janeway CA, Travers P, Immunobiology. The immune system
through root canal treated teeth using a 1. Sundqvist G, Figdor D, Life as an endodontic pathogen. in health and disease, third ed., London, Current Biology Ltd,
Endod Top 6:3-28, 20032. 1997.
dual chamber model system.59 Forty-four 2. Fouad AF, Endodontic Microbiology. Wiley-Blackwell, pages 22. Wadachi R, Hargreaves KM, Trigeminal nociceptors ex-
maxillary anterior teeth were prepared 40-67, 2009. press TLR-4 and CD14: a mechanism for pain due to infection.
endodontically and canals filled either by 3. Siqueira JF, Update on endodontic microbiology: candidate J Dent Res 85:49-53, 2006.
pathogens and patterns of colonization. Endod Pract Today 23. Schein B, Schilder H, Endotoxin content in endodontically
lateral condensation or a warm thermo- 2:7-20, 2009. involved teeth. J Endod 1:19-21, 1975.
plasticized technique in combination 4. Safavi KE, Nichols FC., Alteration of biological properties of 24. Dwyer TG, Torabinejad M, Radiographic and histologic
with either Roth’s 801 or AH 26 sealer. bacterial lipopolysaccharide by calcium hydroxide treatment. evaluation of the effect of endotoxin on the periapical tissues
J Endod 20:127-9, 1994. of the cat. J Endod 7:31-5, 1980.
Teeth were suspended in the model sys- 5. Dixon DR, Darveau RP, Lipopolysaccharide heterogeneity: 25. Pitts DL, Williams BL, Morton TH Jr., Investigation of the
tem with a mixed anaerobic bacterial sus- innate host responses to bacterial modification of lipid A role of endotoxin in periapical inflammation. J Endod 8:10-8,
pension in the upper chamber and HBSS structure. J Dent Res 84:584-95, 2005. 1982.
6. Leonardo MR, da Silva RA, et al, Importance of bacterial 26. Pinero GJ, Kiatpongsah S, et al, The effect of endotoxin on
in the lower chamber. The QCL-1000 LAL endotoxin (LPS) in endodontics. J Appl Oral Sci 12:93-8, 2004. the synthesis of connective tissue matrix components by pulp
assay was used to measure endotoxin at 7. Medzhitov R, Preston-Hurlburt P, Janeway CA, A human fibroblasts in vitro. J Endod 9:2-7, 1983.
m a r c h 2 0 1 1 159
endotoxin
c da j o u r n a l , vo l 3 9 , n º 3
27. Mattison GD, Haddix JE, et al, The effect of Eikenella cor-
rodens endotoxin on periapical bone. J Endod 13:559-65, 1987.
28. Yamasaki M, Nakane A, et al, Endotoxin and gram-negative
bacteria in the rat periapical lesions. J Endod 18:501-4, 1992.
29. Nissan R, Segal H, et al, Ability of bacterial endotoxin to
diffuse through human dentin. J Endod 21:62-4, 1995.
30. Nakane A, Yoshida T, et al, Effects of lipopolysaccharides on
human dental pulp cells. J Endod 21:128-30, 1995.
31. Nagaoka S, Tokuda M, et al, Interleukin-8 gene expression by
human dental pulp fibroblast in cultures stimulated with Pre-
votella intermedia lipopolysaccharide. J Endod 22:9-12, 1996.
32. Hosoys S, Matsushima K, Stimulation of interleukin-1 beta
production of human dental pulp cells by Porphyromonas
endodontalis lipopolysaccharide. J Endod 23:39-42, 1997.
33. Ko HJ, Lim SS, Production of macrophage inflammatory
protein (MIP)-1alpha and MIP-1beta by human polymorphonu-
clear neutrophils stimulated with Porphyromonas endodonta-
lis lipopolysaccharide. J Endod 28:754-7, 2002.
34. Tokuda M, Miyamoto R, et al, Substance P enhances expres-
sion of lipopolysaccharide-induced inflammatory factors in
dental pulp cells. J Endod 30:770-4, 2004.
35. Fouad AF, Acosta AW, Periapical lesion progression and
cytokine expression in an LPS hyporesponsive model. Int
Endod J 34:506-13, 2001.
C
36. Safavi KE, Nichols FC, Effect of calcium hydroxide on bacte-
M
facebook.com/cdafan rial lipopolysaccharide. J Endod 19:76-8, 1993.
37. Barthel CR, Levin LG, et al, TNF-alpha release in monocytes
Y after exposure to calcium hydroxide treated Escherichia coli
LPS. Int Endod J 30:155-9, 1997.
CM
38. Nelson-Filho P, Leonardo MR, et al, Radiographic evaluation
of the effect of endotoxin (LPS) plus calcium hydroxide on api-
MY
cal and periapical tissues of dogs. J Endod 28:694-6, 2002.
CY 39. Silva LA, Nelson-Filho P, et al, Effect of calcium hydroxide
on bacterial endotoxin in vivo. J Endod 28:94-8, 2002.
CMY
40. Tanomaru JM, Leonardo MR, et al, Effect of different
irrigation solutions and calcium hydroxide on bacterial LPS. Int
K
Endod J 36:733-9, 2003.
41. Jiang J, Li H, et al, Quantitative analysis of osteoclast-spe-
cific gene markers stimulated by lipopolysaccharide. J Endod
32:742-6, 2006.
42. Buck RA, Cai J, et al, Detoxification of endotoxin by endo-
dontic irrigants and calcium hydroxide. J Endod 27:325-7, 2001.
43. Michalopoulos AS, Tsiodras S, et al, Colistin treatment in
patients with ICU-acquired infections caused by multiresistant
gram-negative bacteria: the renaissance of an old antibiotic.
Clin Microbiol Infect 11:115-21, 2005.
44. Fekety FR Jr, Norman PS, Cluff LE, The treatment of
twitter.com/cda_dentists gram-negative bacillary infections with colistin. The toxicity
and efficacy of large doses in four patients. Ann Intern Med
57:214-29, 1962.
45. Koyama Y, Kurosasa A, et al, A new antibiotic “colistin” pro-
duced by spore-forming soil bacteria. J Antibiot 3:457-8, 1950.
46. Nord NM, Hoeprich PD, Polymyxin B and colistin. A critical
comparison. N Engl J Med 270:1030-5, 1964.
47. Yow EM, Tan E, et al, Colistin (coly-mycin) in resistant bacte-
rial infections. A clinical appraisal. Arch Intern Med 108:664-70,
Join the conversation. 1961.
48. Flanagan AD, Adverse effects of sodium colistimethate.
Ann Intern Med 74:143-4, 1971.
49. Davis SD, Iannetta A, Wedgwood RJ, Activity of colistin
160 m a r c h 2 0 1 1
c da j o u r n a l , vo l 3 9 , n º 3
ZSV#VXFFHHGQHW
DGVWUDQVLWLRQVFRP
(G&DKLOO-' ZHVWHUQSUDFWLFHVDOHVFRP
m a r c h 2 0 1 1 161
Protecting
dentists.
It’s all
we do.
We produced two of the nation’s We protected nearly 18,000
premier dental conventions. dentists nationwide. Thirty years
CDA Presents The Art and Science ago, in a climate of skyrocketing
of Dentistry is where more than premiums, a brave group of CDA
32,000 dental professionals learn dentists decided it was time to
about the industry’s latest clinical and intercede and created The Dentists
technological advancements, hear Insurance Company. Today, three
from top-tier speakers, connect with out of four CDA members choose
like minds, and have an opportunity TDIC for their Professional Liability
to gain 50 C.E. credits a year. insurance.
Education Protection
Progress.
It’s what
happens
when 25,000
dentists work
We added more than 100 new together.
resources to help you run your
practice like a pro. In fact, from
the Sample Employee Manual to the
Dental Benefit Plan Handbook to
blogs that feature feedback from your
peers, cdacompass.com has helped
nearly 9,000 members better manage
the business side of their practices.
cda.org/renew
Support
interceptive surgery
c da j o u r n a l , vo l 3 9 , n º 3
Periodontal Plastic
Interceptive Surgery
for a Labially Impacted
Maxillary Canine:
A Case Report
neeraj agrawal, bds, mds; kavita agrawal, bds, mds; k. rosaiah, bds, mds;
and ankur chaukse, bds, mds
authors
A
Neeraj Agrawal, bds, mds, K. Rosaiah, bds, mds fter the third molars, the crown tipping of the lateral incisor.2
is a senior lecturer, is a professor, Department
maxillary canines are the About one-third of impacted maxillary
Department of of Periodontics, People’s
Periodontics, People’s Dental Academy,
second-most commonly canines are positioned labially or within
Dental Academy, Bhopal, India. impacted permanent teeth the alveolus, and two-thirds are located
Bhopal, India. with the incidence of 1 to 2.5 palatally.3 There are three techniques for
Ankur Chaukse, bds, mds, percent.1 Management of impacted maxil- uncovering a labially impacted maxillary
Kavita Agrawal, bds, mds, is a senior lecturer,
lary canines can be very complex and canine: gingivectomy, apically positioned
is a senior lecturer, Department of
Department of Oral Orthodontics, People’s
requires a carefully planned interdisciplin- flap surgery, and closed eruption tech-
Medicine, Diagnosis and Dental Academy, ary approach. On the other hand, with nique.4 When there is an inadequate
Radiology, People’s Bhopal, India. the appropriately planned treatment, the width of the attached gingiva (WAG),
College of Dental eruption process can be simplified, result- the gingivectomy procedures may cause
Sciences, Bhopal, India.
ing in a predictably stable and esthetic post-treatment soft-tissue recession. To
result. Various clinical signs of canine preserve the WAG, an apically positioned
impaction are documented in the dental flap technique should be used. This article
literature. They include delayed eruption describes the management of a labi-
of the permanent canine, over-retention ally impacted maxillary canine uncov-
of primary canine, absence of labial bulge, ered by apically positioned flap surgery
presence of a palatal bulge, and distal followed by orthodontic treatment.
m a r c h 2 0 1 1 163
interceptive surgery
c da j o u r n a l , vo l 3 9 , n º 3
Case Report
A 16-year-old female was referred
from the department of orthodontics for
surgical exposure of the impacted right
maxillary canine after the extraction of f i g u r e 2 . Intraoral periapical X-ray showing f i g u r e 3 . Occlusal X-ray showing position of
the retained deciduous right upper canine. mesioangular impacted canine and retained impacted canine.
On intraoral examination, it was found deciduous tooth.
164 m a r c h 2 0 1 1
c da j o u r n a l , vo l 3 9 , n º 3
figure 4. Reflection of flap with one crestal and two f i g u r e 5 . Exposure of the crown up to the f i g u r e 6 . Apical positioning and suturing of the flap
vertical incisions. Only the tip of the crown is visible, the cementoenamel junction by careful removal of the thin to the periosteum with closure of the distal wound with
rest of the crown is covered by bone. shell of the bone. free gingival graft.
table 1
m a r c h 2 0 1 1 165
interceptive surgery
c da j o u r n a l , vo l 3 9 , n º 3
Summary and Conclusion Therefore, clinicians should intercede 5. Elefteriadis JN, Athanasiou AE, Evaluation of impacted
canines by means of computerized tomography. Int J Adult
Although interceptive periodontal and extract the primary canine in a timely Orthodon Orthognath Surg 11(3):418-23, 1996.
plastic surgery is a successful procedure manner to prevent impaction of perma- 6. Friedland B, Medicolegal issues related to cone beam CT.
for providing long-term results, it is nent canines. But once it is impacted, Semin Orthod 15: 77-84, 2009.
7. Kokich VG, Surgical and orthodontic management of im-
influenced by the degree of impaction and a careful multidisciplinary treatment pacted maxillary canines. Am J Orth Dent Orthop 126(3):278-83,
the patient’s age during diagnosis. Early plan is required as discussed above. 2004.
diagnosis of impaction and intervention 8. Vermette ME, Kokich VG, Kennedy DB, Uncovering labially
impacted teeth: apically positioned flap and closed eruption
is the best strategy. Williams suggested references techniques. Angle Orthodont 65(1):23-32, 1995.
that extraction of the maxillary deciduous 1. Bass TB, Observations on the misplaced upper canine tooth. 9. Williams B, Diagnosis and prevention of maxillary cuspid
canine as early as 8 or 9 years of age will Dent Pract Dent Rec 18:25-33, 1967. impaction. Angle Orthod 51:30-40, 1981.
2. Bishara SE, Impacted maxillary canines: a review. Am J
enhance the eruption and self-correction Orthod Dentofacial Orthop 101:159-71, 1992.
of a labial or intra-alveolar maxillary ca- 3. Johnston WD, Treatment of palatally impacted canine teeth. to request a printed copy of this article, please contact
Am J Orthod 56:589-96, 1969. Neeraj Agrawal, BDS, MDS, at dna7kgmc@gmail.com.
nine impaction.9 However, the probability
4. Bedoya MM, Park JH, A review of the diagnosis and
for eruption and self-correction decreases management of impacted maxillary canines. J Am Dent Assoc
as the horizontal angulation increases. 140(12):1485-93, 2009.
166 m a r c h 2 0 1 1
dentinal hypersensitivity
c da j o u r n a l , vo l 3 9 , n º 3
Management of
Dentinal Hypersensitivity:
A Review
abhishek parolia, mds; m. kundabala, mds; and mandakini mohan, mds
abstract Dentinal hypersensitivity is a very common clinical finding that can cause
considerable concern for the patient. Clinicians must understand the various etiological
factors, their complexities, and numerous treatment options available. This article
reviews the etiology, management, and prevention of dentinal hypersensitivity.
D
authors
Abhishek Parolia, M. Kundabala, mds, entin hypersensitivity has frequency of dentinal hypersensitivity
mds, is an assistant is a professor and been referred in the past by 38 percent in premolars, 26 percent in
professor, Department of head, Department of
various terminologies such incisors, 24 percent in canines and 12
Conservative Dentistry Conservative Dentistry
and Endodontics, Manipal and Endodontics, Manipal
as dentin sensitivity, cervical percent in molars.5 Dentinal hypersensi-
College of Dental College of Dental Sciences, dentin sensitivity and dentinal tivity may present on any surface, which
Sciences, Mangalore, Mangalore, Manipal hypersensitivity. Dentin hypersensitiv- includes cuspal or incisal edges, and on
Manipal University, India. University, India. ity (DH) is characterized by short, sharp lingual or palatal surfaces, but often it
pain arising from exposed dentin, in occurs on the buccal cervical margins (82
Mandakini Mohan,
MDS, is an assistant
response to stimuli typically thermal, percent), proximal surface (10 percent)
professor, Department of evaporative, chemical, tactile, or osmotic and lingual surfaces (8 percent).
Prosthodontics, Manipal that cannot be ascribed to any other
College of Dental Sciences, form of dental defect or disease.1 The Neuroanatomy of Pulp Dentin Complex
Mangalore, Manipal
prevalence appears to be fairly similar The sensory system of the pulp
University, India.
in different parts of the world, although appears to be well-suited for signal-
there are some regional differences. The ing potential damage to the tooth. The
reported prevalence of dentine hyper- pulp is richly innervated and contains
sensitivity varies from 4 to 57 percent.2-3 both A (myelinated) and C (unmyeli-
Dentin hypersensitivity often occurs nated) nerve fibers. Most of the nerve
in patients who are between 30 and 40 fibers enter the tooth through the apical
years old but it may affect the patients foramen or foramina, although a small
of any age.4 It affects women more often number may enter through accessory
than men, though the gender differ- canals. The nerves of the pulp include
ence rarely is statistically significant. primary afferent fibers that are involved
This condition may affect any tooth, in pain transmission as well as sym-
but it most often affects canines and pathetic efferent fibers that modulate
first premolars because they are promi- the microcirculation of the pulp.
nent in the arch.4 Orchadson found the These latter fibers originate in the su-
m a r c h 2 0 1 1 167
dentinal hypersensitivity
c da j o u r n a l , vo l 3 9 , n º 3
table 1
168 m a r c h 2 0 1 1
c da j o u r n a l , vo l 3 9 , n º 3
Attrition
Abrasion
Erosion
Abfraction
Loss of enamel
Gingival recession
Prominent roots
Faulty toothbrushing
After periodontal therapy
Traumatic oral habits (excessive toothpicking)
Excessive tooth cleaning
Excessive flossing
ANUG, herpetic gingivostomatitis
Periodontal diseases
Trauma during tooth preparation
Anatomy of cementoenamel junction
(No union in between enamel and cementum)
Bleaching
Theories of Dentine Sensitivity direct communication with pulpal nerve that this fluid movement through dentin
fibers. While this theory has been support- excited mechanoreceptors nerves near the
Odontoblastic Transduction Theory ed by the observation of the presence of pulp. A corollary to this theory is that any-
According to this theory, odontoblastic unmyelinated nerve fibers in the outer lay- thing that interferes with fluid movement
processes are exposed on dentinal surface er of root dentin and the presence of neu- through dentinal tubules, or which lowers
and can be excited by a variety of chemi- rogenic peptides, it is still considered theo- nerve excitability, would decrease dentin
cal and mechanical stimuli. As a result of retical with little evidence to support it.7 sensitivity. In general, the excitement of
such stimulation, neurotransmitters are nerve fibers by different stimuli can be
released and impulses are transmitted Hydrodynamic Theory explained by the hydrodynamic theory.
toward the nerve endings. To date, no neu- The most accepted theory put forth by
rotransmitters have been found to be pro- Brannstrom and Astrom proposes that the Alternative Mechanism (Modified
duced or released by odontoblastic process. stimuli (temperature, physical, or osmotic Hydrodynamic Theory)
changes) cause a displacement of the fluid Several investigators have used a neuro-
Neural Theory that exists within the dentinal tubules physiological model to evaluate dentin hy-
This concept advocates that thermal (either in the inward or the outward direc- persensitivity. The results from these stud-
or mechanical stimuli directly affect nerve tion) and this mechanical disturbance ac- ies suggest that the application of various
endings within the dentinal tubule through tivates the nerve endings.8 They reasoned chemical solutions in particular potassium-
m a r c h 2 0 1 1 169
dentinal hypersensitivity
c da j o u r n a l , vo l 3 9 , n º 3
Subjective assessment
Verbal rating scale
Visual analog scale
McGill pain questionnaire
Verbal descriptive checklist which is sealed peripherally by enamel
Tactile method or cementum, is not sensitive to osmotic
Thermal test
or tactile stimuli. However, the degree of
thermal sensitivity increases when dentin
Electric stimuli
becomes exposed. Exposure of dentine may
Osmotic stimuli
occur by loss of either enamel or peri-
Chemical stimuli odontal tissues, the latter of which is often
termed gingival recession11-13 (figure 1).
Bleaching as a Cause14
Increase rate of Dental bleaching has been reported to
dentinal fluid cause a number of side effects, including
tooth sensitivity, gingival irritation, tooth
movement
pain, tingling of the tissues, and a sore
throat. Tooth sensitivity and gingival irrita-
tion are the most frequently reported com-
plaints. The hypersensitivity that occurs in
association with bleaching has been attrib-
uted to patient factors, length of exposure
Stimulation of to the bleaching agent, the concentration
Pulp nerve endings of the bleaching agent, pH of the whitening
solution, and tray factors. Patients, especial-
ly those who already have exposed dentin
figure 2. Etiology and predisposing factors for dentinal hypersensitivity.
or already have some type of hypersensitiv-
ity or those with larger pulps, should be
containing compounds to dentin resulted in of stimulus transmission across dentin warned that they may have a greater risk of
raising the intratubular potassium content appears to be an attractive alternative hypersensitivity secondary to bleaching.
that in turn rendered the interdental nerves to the hydrodynamic theory, this hy-
less excitable to further stimuli by depolar- pothesis requires further investigation. Measurement of Dentinal Pain
izing the nerves fibers of the membrane. Most methods for studying dentinal
Based on these studies, Kim pro- Etiology and Predisposing Factors of sensitivity use thermal, mechanical, os-
posed an alternative mechanism namely Dentinal Hypersensitivity motic, evaporative or electrical stimuli, all
depolarization of the dentin by blocking By virtue of its relation with the pulp, of which can elicit dental pain. However,
nerve activity (direct ionic diffusion).9 This dentine is naturally sensitive, but for this not all of these are equally suitable or
hypothesis was, however, criticized by sensitivity to manifest clinically, the den- sufficiently quantifiable for use in clinical
Sena who showed that Kim’s experiment tine must be exposed which can influence assessments. Ideally, the stimuli chosen
was based on deep-cut cavity prepara- its sensitivity. Dentine freshly exposed by for evaluation ought to be measurable and
tions with only a very thin slice of dentin cutting or root planing may not be particu- reproducible, but should also be clinically
between the exposed dentin surface and larly sensitive because of the presence of relevant and take account of the pain
the pulp.10 In consequence, potassium a smear layer.11 In hypersensitive dentine, experience of the individual (figure 2 ).
ions would have to overcome the opposing the smear layer is generally absent and the The requirements of methods
pulpal pressure that produces an outward tubules are patent. Two processes need used to evaluate sensitivity are:
flow of dentinal fluid. Such an outward to occur for dentine hypersensitivity to n It should be quantifiable and
flow can prevent the inward diffusion of arise: the dentine has to become exposed reproducible;
substances from the oral cavity. While and the dentine tubule system has to be n It should elicit dentinal pain rather
the alternative or modified hypothesis opened and be patent to the pulp. Dentin, than pulpal pain; and
170 m a r c h 2 0 1 1
c da j o u r n a l , vo l 3 9 , n º 3
n When more than one stimulus is Drawbacks of Tactile Method temperature would be easily measured.16
used there should not be any interference n Testing and measuring tactile The apparatus consists of a miniature
with each other. sensitivity levels are dependent on the thermistor connected to a medical multi-
In practice, dentine sensitivity can patience and expertise of the investiga- channel recorder with a hand-held device to
be measured either as pain thresholds tor. The person should develop a feel register pain. When agents affecting tooth
to graded stimuli or by using one of the for applying tactile pressure to exposed sensitivity are assessed by this method, im-
various forms of subjective rating scales. dentin areas regardless of the device. provements are measured in centigrade and
Traditionally, dentin hypersensitivity n Care must be exercised that the are expressed as percentage improvements.
has been evaluated mainly subjectively force is applied gradually and the force The tactile stimuli are usually applied
on the basis of the individual patient’s should not go beyond the point at which before the thermal stimuli if the two are
subjective response, for example, in the the subject actually perceives sensitivity. used in the same subject, since some time
form of verbal rating and visual ana- n The total area of exposed dentin site is required for the test tooth to return to
logue scales. Furthermore, the subjective may not be sensitive. Only specific spots baseline and some adaptation to incremen-
nature of the response and variability tal temperature changes may take place.
in patient ability to express a given Thermal stimuli are effective hy-
response may also complicate the as- the tactile stimuli drodynamic stimuli because of the
sessment. Currently, no single method are usually applied differences in the thermal conductivity
of eliciting and assessing dentin hyper- and coefficients of expansion or con-
sensitivity may be considered ideal. before the thermal traction of pulpal/dentinal fluids and
stimuli if the two are used their containers: enamel and dentin.
Tactile Method Application of cold causes a more rapid
Different methods of applying tactile in the same subject. volumetric contraction of dentinal fluid
stimuli include scratching the dentin than occurs in dentin. This mismatch
surface with a sharp probe, scaling proce- of volumetric changes produces nega-
dures, mechanical pressure stimulators, may have to be swept in the suspected tive intrapulpal pressure that displaces
and, more recently, the Yeaple probe has area until the sensitive spot is found. mechano-reception and causes pain.
been used. The simplest tactile method
used to test for hypersensitivity is to Thermal Test Electrical Stimuli
lightly pass a sharp explorer over the A simple thermal method for testing The use of electrical stimuli to
sensitive area of a tooth cementoenamel is directing a burst of air at room temper- quantitate the degree of dentin hyper-
junction and to grade the response of the ature from a dental syringe onto the test sensitivity has been criticized on several
patient on a severity scale of 0-3. tooth. Generally, room air is cooler than grounds as being nonphysiologic. It
0: No pain felt teeth, and cooling by this means is easily only evaluates the presence or absence
1: Slight pain or discomfort detected as pain if the tooth is sensitive. of nerve vitality rather than degree of
2: Severe pain Air stimulation has been standardized sensitivity. Electrical stimuli differ from
3: Severe pain that lasts in a number of studies as a one-second most other dentinal stimuli in that they
Another tactile method is a hand-held blast from the air syringe of a dental unit, bypass the normal receptor mechanisms
scratch device developed by Kleinberg where its temperature is set generally be- and excite nerves directly in the pulp.
that consists of torsion gauge and a sharp tween 65- and 70-degrees Fahrenheit and
explorer-like probe that can be passed a pressure of 60 psi. The air is directed at Osmotic Stimuli
easily across a sensitive tooth.15 It has an right angles to test surface with adja- Osmotic stimuli is done by preparing
indicator that is displaced by the arm of cent teeth usually isolated by operator’s fresh, saturated solution of sucrose and
an explorer tine that records the force of fingers. Response is assessed from 0-3. allowing it to reach room temperature.
displacement in centi-Newton. A tooth Thrash, Deumen, and Smith used a The solution is applied to root surfaces
that fails to respond to a force of 80 centi- miniature thermistor that is connected to after isolation and retained in place for
Newtons is classified as nonsensitive. a multichannel recorder and found that the 10 seconds or until discomfort is per-
m a r c h 2 0 1 1 171
dentinal hypersensitivity
c da j o u r n a l , vo l 3 9 , n º 3
Bleaching Baradontalgia
step v
Remove or modify identified
etiological or predisposing factors
Recommend or provide treatments
appropriate to the individual needs
172 m a r c h 2 0 1 1
c da j o u r n a l , vo l 3 9 , n º 3
ceived. The sensation is rated as pain n The mathematical interpretation of Management of Dentinal Hypersensitivity
or no pain, which then is correlated to the scoring system is also challenging, in There are various treatment op-
reading 1 or 0. The osmotic challenge is that the scores are then analyzed as these tions available to manage dentinal
stopped by rinsing with warm water.17 numbers reflected true quantitative differ- hypersensitivity. Thorough diagno-
ences in pain, rather than simple qualita- sis and proper treatment planning
Chemical Stimuli tive differences. are the essential keys to treat den-
Chemical stimuli, for example, sodium tinal hypersensitivity (figure 3 ).
chloride, glucose, sucrose, and calcium Visual Analogue Scale (VAS) Requirements for an ideal therapy:
chloride have been used to elicit dentin A visual analogue scale is a line usu- n Relatively painless on application
hypersensitivity. The stimulus is not ally 10 cm in length, the extremes of the n Easily applied
conducive to threshold measurement line representing the limits of pain a n Rapid in its action
because repeated application of chemical subject might experience during a dentin n Permanently effective
stimulus reduces sensitivity of exposed hypersensitivity episode. One end could n Not discolor tooth structure
dentin. Problems such as inconvenience be labeled “no discomfort” or “no pain” n Be cost effective
or difficulty in administering and control- whereas the other end could be labeled
ling the stimulus and possible injury to “severe discomfort” or “severe pain.” Prevention of Dentine Hypersensitivity
the adjacent soft tissues are the draw- Patients are asked to place a mark on a
backs of the chemical stimulus to be used 10 cm line that indicates the intensity of Suggestions for Patients
as a practical method of assessment of their current level of sensitivity or dis- n Maintain good oral hygiene.
hypersensitivity in chemical studies.15 comfort following application of the test n Avoid using large amounts of
stimuli. When VAS is properly explained dentifrice.
Subjective Assessment to subjects, they can easily understand n Avoid hard-bristled toothbrushes
The subject’s quantitative assessment its use and successfully use it to indicate without end-rounded bristles.
of their own overall perception of hyper- their level of pain response to hypersen- n Avoid brushing teeth immediately
sensitivity pain has been used in clinical sitive stimuli. The VAS is a more appro- following ingestion of acidic food or
studies. Patients were asked to rate their priate device than VRS for measuring beverages.
own perception of overall sensitivity to levels of sensitivity pain during subject n Avoid overbrushing with excessive
hot/cold food and drink, air, toothbrush- assessment and for measuring tactile pressure for prolonged periods of time.
ing and sweet and sour food as expe- and thermal stimuli of hypersensitivity. n Avoid excessive flossing or
rienced during everyday routine. They incorrect use of other interproximal
reported using either verbal rating scale McGill Pain Questionnaire cleaning devices.
or visual analogue scale. It is used to evaluate a variety of pain- n Avoid “pecking” at the gums or
ful dental conditions including dentine using toothpicks inappropriately.
Verbal Rating Scale (VRS) sensitivity. The patient is shown 20 sets
The typical VRS to assess pain may of words and then asked to select a word Suggestions for Professionals
look like the following: from each set which best describes present n Avoid overinstrumentation of root
0: No pain felt pain experience. Each set contains up to surfaces during calculus removal and
1: Slight pain or discomfort six words in descending order of severity. scaling and root planing.
2: Severe pain n Avoid overpolishing the exposed
3: Severe pain that lasts Verbal Descriptor Checklist roots during stain removal.
A verbal descriptor checklist al- n Avoid violating the biologic width
Drawbacks lows quantitative assessment of both when placing crown margins causing
n The VRS offers a restrictive choice the sensory and affective dimensions subsequent recession.
of words that may not represent the pain of pain using a continuum across dif- n Avoid “burning” the gingival tissue
experience with significant precision in all ferent pain condition instead of words during in-office tooth whitening or
the patients. intended to distinguish conditions. bleaching procedures.
m a r c h 2 0 1 1 173
dentinal hypersensitivity
c da j o u r n a l , vo l 3 9 , n º 3
table 2
174 m a r c h 2 0 1 1
c da j o u r n a l , vo l 3 9 , n º 3
table 3
m a r c h 2 0 1 1 175
dentinal hypersensitivity
c da j o u r n a l , vo l 3 9 , n º 3
G
Fluoride is negatively charged and applied on negatively charged electrode disadvantages
G n Expensive
Current is adjusted until the patient feels some sensation n Difficult
to use
G n Time consuming
Procedure is repeated at 7 days n Operator sensitive
Cavity Varnish
or promote peritubular dentin formation. Sodium fluoride blocks dentinal Dentin becomes insensitive when
Calcium hydroxide might be capable of tubules by fluoride precipitation.36 open tubules are covered with a thin film
suppressing nerve activity because of an Stannous fluoride causes calcific of varnish. The use of 5 percent sodium
increase in the concentration of calcium barrier on dentinal tubules. fluoride (NaF) in a thick varnish as a
ions around nerve fibers, which can Sodium monofluorophosphate dentine desensitizer has been reported
result in decreased nerve excitability.33 interacts with hydroxyapatite crystals and to be an effective means of provid-
forms a barrier on dentinal tubules. ing temporary relief. The varnish does
Disadvantages temporarily occlude dentinal tubules but
n One of the disadvantages is the action Fluoride Iontophoresis the material is readily lost over time.38,39
is not very prolonged and excess calcium Iontophoresis is the use of an elec-
hydroxide may irritate gingival tissue. trical potential to transfer ions into Adhesive Resin Primers
the body for therapeutic purposes. The use of adhesive resin primer
Oxalates The main objective of fluoride ionto- products has been shown to decrease
Oxalate-containing products are a phoresis is to drive fluoride ions deep dentine permeability for many years.40,41
popular agent for treating dentinal hyper- into dentinal tubules37 (figure 4). The treated surface becomes covered
sensitivity. Ferric oxalates and potassium with a layer of polymer about 5-10
oxalates along with calcium ions in the Iontophoresis Requires µm thick and some primitive resin
dentinal fluid form insoluble calcium n A charged drug be delivered through tags are formed within open tubules.
oxalate and occlude dentinal tubules.34 the electrode of the same polarity; The long-term effectiveness of this
n The condition or disease under resin product may be limited by the
advantages treatment be delivered at the electrode inability of the resin tags to bond to
n Easy to apply of the same polarity; the walls of the peritubular dentine
n Inexpensive n The condition or disease under matrix lining most dentinal tubules.
n Well-tolerated by the patients treatment be at or near the surface; and
n A modern, sophisticated source of Glass Ionomer Cements
disadvantage direct current, with appropriate means of One of the first clinical evalua-
n Ferricoxalate forms black precipi- application, be used. tions of the use of glass ionomers
tate so it has been replaced by aluminum for the treatment of hypersensitive
oxalate. Hypothesis to Explain the Mechanism dentine in cervical abrasion lesions
of Iontophoresis was reported by Low in 1981 and re-
Fluoride Compounds n Induction of secondary dentin ported complete loss of hypersensitiv-
Lukomsky was the first to propose formation ity in 89.7 percent of all patients.42
sodium fluoride as a desensitizing agent.35 n Induction of paresthesia on
176 m a r c h 2 0 1 1
c da j o u r n a l , vo l 3 9 , n º 3
m a r c h 2 0 1 1 177
dentinal hypersensitivity
c da j o u r n a l , vo l 3 9 , n º 3
Anaheim.
Dent 10:50-4, 1999.
19. Zappa U, Self-applied treatment in the management of
dentine hypersensitivity. Arch Oral Biol 39:S107-112, 1994.
20. Nagata T, Ishida H, et al, Clinical evaluation of a potassium
San Francisco.
nitrate dentifrice for the treatment of dentin hypersensitivity. J
Clin Periodontol 21:217-21, 2003.
21. Schiff T, Zhang YP, et al, A randomized clinical trial of the
location:
frice: an eight-week clinical investigation. Compend Contin Educ
Dent 21(supplement 27):11-6, 2000.
23. Schiff T, Bonta Y, et al, Desensitizing efficacy of a new
cdapresents.com
dentifrice containing 5.0 percent potassium nitrate and 0.454
percent stannous fluoride. Am J Dent 13(3):111-5, 2000.
24. Sowinski JA, Bonta Y, et al, Desensitizing efficacy of Colgate
sensitive maximum strength and fresh mint Sensodyne denti-
frices. Am J Dent 13(3):116-20, 2000.
25. Sowinski JA, Ayad F, et al, Comparative investigations of the
C desensitizing efficacy of a new dentifrice. J Clin Periodontol
28:1032-6, 2001.
M
26. Wara-aswapati N, Krongnawakul D, et al, The effect of a
Y
new toothpaste containing potassium nitrate and triclosan on
gingival health, plaque formation and dentine hypersensitivity. J
CM Clin Periodontol 32(1):53-8, 2005.
27. Peacock JM, Orchardson R, Effects of potassium ions on ac-
MY
tion potential conduction in A- and C-fibers of rat spinal nerves.
CY
J Dent Res 74:634-41, 1995.
28. Markowitz K, Bilotto G, Kim S, Decreasing intradental nerve
CMY activity in the cat with potassium and divalent cations. Arch
Oral Biol 36(1):1-7, 1991.
K
29. Lawson Bf, Huff TW, Desensitization of teeth with a topically
applied glucocorticoid drug. A preliminary study. J Oral Ther
Pharmacol 2(4):295-9, 1966.
30. Ong G, Desensitizing agents. A review. Clin Prev Dent 8:14-8, 1986.
31. Greenhill JD, Pashley DH, The effects of desensitizing agents
on the hydraulic conductance of human dentine in vitro. J Dent
Res 60:686-98, 1981.
We’ve got a new website that has more style as well 32. Gottlieb B, Technique of impregnation for caries prophylaxis.
Wash State Dent J 16(3):7-9, 1947.
as more functionality. With searchable exhibitor 33. Bartold PM, Dentinal hypersensitivity: a review. Aus Dent J
51:212-8, 2006.
specials, available class schedules, photo galleries, 34. Trowbridge HO, Silver DR, A review of current approaches to
in-office management of tooth hypersensitivity. Dent Clin North
for the nation’s premier dental alveolar atrophy. J Dent Res 20:649, 1941.
36. Laufer B, Mayer I, et al, Fluoride-uptake and fluoride-resid-
conventions in Anaheim, or ual of fluoride-treated human root dentine in vitro determined
by chemical, scanning electron microscopy and X-ray diffraction
San Francisco, is a virtual snap. PRESENTS analysis. Arch Oral BioI 26:159-63, 1981.
37. Gangarosa L, Park NH, Practical considerations in ionto-
phoresis of fluoride for desensitizing hypersensitive dentin. J
Prosthet Dent 39:173-8, 1978.
38. Corona SA, Nascimento TN, et al, Clinical evaluation of
low-level laser therapy and fluoride varnish to treating cervical
178 m a r c h 2 0 1 1
c da j o u r n a l , vo l 3 9 , n º 3
m a r c h 2 0 1 1 179
acne vulgaris
c da j o u r n a l , vo l 3 9 , n º 3
Intraoral
Radiographic Findings
in Acne Calcification:
A Case Report
gurminder sidhu, bds, dds, ms; jaswinder sandhu, bds;
and william carpenter, dds, ms
abstract The authors present a case report of a 52-year-old Hispanic female who
presented for a routine dental exam at the Arthur A. Dugoni School of Dentistry in
San Francisco. Incidental findings of multiple, calcified acne vulgaris lesions were noted
in the soft tissues of the cheek that were viewed in the periapical radiographs. The
findings were confirmed by a clinical evaluation of the patient’s skin and past history.
A
authors
Gurminder Sidhu, bds, Jaswinder Sandhu, bds, cne vulgaris (AV) is a disease of The authors report on one such case
dds, ms, is director of the is a visiting researcher, adolescence and early adult- detected by full-mouth radiographs.
radiology division at the Department of Dental
hood and only occasionally
Department of Dental Practice, Arthur A. Dugoni
Practice, Arthur A. Dugoni School of Dentistry in
persists into adult life, more Case Report
School of Dentistry in San Francisco. commonly in females. AV A 52-year-old Hispanic female pre-
San Francisco. chiefly affects the face, upper back, and sented to the Arthur A. Dugoni School of
William Carpenter, chest and produces two types of lesions: Dentistry in San Francisco for a routine
dds, msc, is chairman,
comedones and inflammatory lesions. AV dental exam. The patient had a positive
Department of Pathology
and Medicine, Arthur
is a multifactorial condition initially requir- medical history for arthritis and severe
A. Dugoni School ing sex hormone release in the activation AV as an adolescent. She had no other sig-
of Dentistry in San of the sebaceous glands. Three major nificant medical conditions. A full-mouth
Francisco. factors are concerned with the develop- series of radiographs were made for the
ment of this condition: androgens, sebum, initial clinical examination. The poste-
and a bacterium, propionibacterium rior periapicals and bitewings, bilaterally
acne. The inflammation in acne lesions is revealed multiple, small, circumscribed
derived from the breakdown products of radiopacities superimposed over the
sebaceous lipids from the byproducts of soft tissue of the cheeks (figures 1-3 ).
the P. acnes organisms and also by various No external swelling or change
immunological mechanisms produced in the color of the skin was noted. A
against these organisms. Occasionally, pitted appearance of the superficial
these chronic inflammatory conditions skin, with scarring, was noted in the
can undergo dystrophic calcification. cheek, nose, and chin area (figure 4 ).
180 m a r c h 2 0 1 1
c da j o u r n a l , vo l 3 9 , n º 3
figure 2. Bitewing radiograph of the right premolar area. figure 3. Bitewing radiograph of the left premolar area.
figure 1. Periapical radiograph of the maxillary right
premolar area.
m a r c h 2 0 1 1 181
acne vulgaris
c da j o u r n a l , vo l 3 9 , n º 3
182 m a r c h 2 0 1 1
Professional Practice Sales of The Great West
5980 LAKE TAHOE $850,000+ per year. Attractive Profits. Beautiful 6002 SAN JOSE’S SILVER CREEK Located in San Jose’s most
6-Op suite. 4-days of Hygiene. 20+ new patients per month. desirable neighborhood. Well established, maintains 4-day
Low AR balance. per week Hygiene Schedule. Averages $600,000 year in
collections with attractive Profits. Housed in new 3-year old
5993 SAN FRANCISCO’S FINANCIAL DISTRICT – “JUST SOLD”
suite. 4-Ops with computers. Lots of patients here.
The Financial District is the most densely populated area in SF
during work day. 3-days of Hygiene. $350,000/year. 3-Op 6003 PINOLE - HERCULES AREA Cornerstone here is 4-day
suite. Great California Street location. Hygiene Department & 90%+ effective Recall. Produced
$740,000 and collected $709,500. Low AR balance. Endo
5997 FREMONT- “JUST SOLD” Store front on busy boulevard. 2009
referred, and only PPO Plan is Delta Premiere.
collected $360,000 with Profits topping $143,000 on 3-days.
6-months ended 6/30/10 collected $170,700 with Profits of 6004 SAN JOSE’S SANTA TERESA AREA “Signature” facility with
$80,000. 5-Ops, 3-equipped. 600 patient files for little more than what it would cost to replicate
this office today. Digital and paperless 3-Op office. 40+ new
5999 PLEASANTON Located at intersection of I-580 & I-680 patients per month. 2010 produced $385,000 with collections of
adjacent to Hacienda Business Park. Highly visible suite in $277,000 and Profits of $190,000+. Gorgeous 1,024 sq.ft. facility
busy shopping center. 3-Ops with 4th wired and plumbed. leases for $2,000/month. Lease allows occupancy here thru
Computerized Ops, intraoral cameras, digital radiography. 9/30/2024.
2010 collected $692,000. Profits of $402,800.
6005 FAIRFIELD - WEST OF I-80 Craves attention of full-time
6000 MILLBRAE Great location, computer charting, digital Successor. Operating on 2.5 week schedule by Owner with other
radiography, strong patient base. 2010 collected $725,000. commitments, practice has averaged $470,000 in collections last
1,180 sq.ft. suite has 4-Ops, 3-equipped. High-end features 3-years. 2-days of Hygiene, averages 20 new patients/month.
make for a truly enjoyable patients experience. Attractive 3-Op suite. High visibility location.
PPS of The Great West’s reputation is built upon grounded ethics and effectiveness. Our trademark "client services" include accurate assessments,
impeccable marketing plans, complete transparency, generating quick responses, realizing multiple Offers, securing 100%+ financing in days, expert
papering of our transactions and sound counsel. Everything is done to protect our Client and to effect a successful transfer. Our intent is simply to
provide the best service imaginable for this very important engagement.
* UNDER OFFER
Call us about Debt Consolidation & Retirement Planning
VISIT OUR WEBSITE WWW.CALPRACTICESALES.COM
CA DRE #00491323
John Knipf Also serving you: Robert Palumbo, Executive V. P. /Partner, Alice C. King, V.P.,
(Neff)
President Greg Beamer, V.P., Tina Ochoa, V.P., & Maria Silva, V.P.
Classifieds c da j o u r n a l , vo l 3 9 , n º 3
How to Place a
Classified Ad
m a r c h 2 0 1 1 185
c da j o u r n a l , vo l 3 9 , n º 3
leasehold/leasehold with
equipment — Nicely equipped 1,250 sq.
ft. four operatory office with nice cabin-
etry and full digital in the heart of the hip
Mission district in San Francisco. Dentist
moving into newly purchased building
and is extremely motivated. Save tens of
thousands. Very reasonable lease. Call
415-507-7593 or e-mail ericdebb@msn.com.
opportunities available
9LHZDOORIRXUDYDLODEOHSUDFWLFHVDW
Z H V W H U Q S U D F W L F H V D O H V F R P
#
$
@41
->@ G>?@/8-?? 2-/585@E C5@48->31;<?
<B@ >;;9? 5: - C188 @>-B1810 ->1- 81B18
?4;<<5:3 /1:@1> -89;?@ 2A88E
1=A5<<10 ;2G/1
C5@4 4534 B5?5.585@E ?53:? :1-> -<5@-8
D<>1??C-E-:0
2 E;AC-:@1D<;?A>1 @45?
5?@41<8-/1@;.1?75:3
(A>:
71E @>-05@5;:-8 01:@-8 <>-/@5/1 C5@48;E-8
?@-22 -:0?1:?1;2 /;99A:5@E*1889-5:@-5:10
?= 2@ @-?@12A88E 01/;>-@10 ;2G/1 C5@4
2A88E
1=A5<<10 ;<?
&
<>;61/@10 & -? ;2 A3
C5@4
-B3 ;B1>41-0 #C:1> >1@5>5:3 -:0 C5885:3 @;
418<2;>-?9;;@4@>-:?5@5;:?75:3
<-@51:@?1 5??1885:36A?@@4131:1>-8;<1>-@5B1
;B1>41-0?75:3 ! "
<;>@5;:;2 @41<>-/@5/1-:05?C5885:3@; 418<2;>
- ?9;;@4 @>-:?5@5;: 01-8 2;> -: 1D<1>51:/10
"
01:@5?@?8;;75:3@;91>31-:1D5?@5:3<>-/@5/1
*188 1?@ $8-/1> ;A:@E 1:1>-8 ;?91@5/
$>-/@5/1 2A88E
1=A5<<10 ?@-@1
;2
@41
->@ ;<?
#C:1> >1@5>5:3 2>;9 - ?9-88 C188
1?@ <>-/@5/1
?= 2@ ?@-:0 -8;:1
5: ?5:381 ?@;>E
<>;21??5;:-8 .A5805:3 B3 & 2;> <-?@E1->?
?= 2@ ;2G/1
C5@4 3>1-@ A<?501 <;@1:@5-8
/1:@1> > 0-E?
"C5@4;B1>41-0-:06A?@0;/@;>
9105/-8
C5@4 ;<? :1-> 0-E?C117 '1881> ;C:? @41 .A5805:3 -:0 C588
C117 #C:1> C5885:3 @; 418< 2;> - ?9;;@4 <>;B501.AE1> C5@4-2-5>9->71@81-?1;>?188@41
@>-:?5@5;:?75:3 !!!
.A5805:3@;.AE1>?75:3