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EDITORIAL The Challenge of Mentoring Passing the torch to the next generation. HOMER’S “ODYSSEY” is the story of the warrior king Odysseus, Mentoring communication options are vast. Along with face- who, as he prepared to leave home for the Trojan wars, asked if to-face, structured encounters, the mentor should consider other Mentor, the son of his friend Alimus, would act as an advisor to his communication options as well. E-mail, videoconferencing, tele- own son, Telemachus, during Odysseus’s absence. Mentor educates phone, Web-based technologies and regular mail should figure in the young man, protects and nurtures Telemachus, while providing the overall mentoring communication effort. him with the needed skills to enable Telemachus to find his own Encouraging junior faculty to continue on their academic path path of wisdom and independence. within our dental institutions remains a vital goal of dental educa- In a similar fashion, the dental profession is both a science and tors. It is here that we witness the critical role that mentors must an art, and mentoring is an important element to ensure that the assume in this process. Goals relating to clinical and/or basic sci- next generation of dentists will be able to take their rightful place ence teaching, research (designing and implementing protocols, in the profession. Building upon past experiences and efforts, the grant writing, etc.), tenure and/or administrative track challenges next generation is expected to elevate the standards of dentistry are most effectively attained under the guiding hand of our acade- beyond today’s level, to preserve and expand our relevance in the mic mentors. Similar challenges exist in clinical practice and in overall health care structure and to provide future mentors in den- leadership roles within organized dentistry. Just as mentors should tal education and other important areas of dentistry. carefully choose who they will shepherd, so, too, should the protégé Successful mentoring outcomes are derived from both intuitive weigh his or her choice of a mentor. skills and documented adult learning principles. The mentor should Having attended quite a few organizational and academic take the time to learn as much as possible about the prospective awards ceremonies, there are few—if any—recipients of these mentee prior to the mentoring effort if the experience is to result in a honors who do not express their profound gratitude to their teach- meaningful outcome. Each individual has his or her own learning ers and mentors.What greater reward could any of us hope for than style and learning needs.The traditional product-oriented knowledge to have at least one colleague in our profession attribute his or her transfer and acquisition paradigm must be replaced with a process- success, in part, to our mentoring efforts? oriented critical reflection and application model. The mentor should A good place to start is by signing on with the mentor program assume a position greater than that of intellectual and professional being run by the New York State Dental Foundation. The program is authority.Rather,he or she should become,ultimately,a consequential modeled after a successful effort in the Bronx County. Madeline facilitator, resulting in a future, internally motivated mentee. Ginzburg, chair of the NYSDA Council on Dental Education and 4 NYSDJ • JUNE/JULY 2008 Licensure, who oversees the Bronx County pro- gram, is helping out with the NYSDF mentor pro- NYSDA D i r e c t o r y gram. Get in touch with the foundation if you want to be matched with a new dentist. OFFICERS Stephen B. Gold, President Steven Gounardes, Immediate Past President 8 Medical Drive, Port Jefferson Station, NY 11776 351 87th St., Brooklyn, NY 11209 Had an Interesting Case Lately? Michael R. Breault, President Elect Roy E. Lasky, Executive Director In this age of evidenced-based dentistry and 1368 Union St., Schenectady, NY 12308 20 Corporate Woods Boulevard, Albany, NY 12211 Robert Doherty, Vice President medicine, case reports in published journals have 280 Mamaroneck Ave., White Plains, NY 10605 received far less attention than before.And, yet, in Richard Andolina, Secretary-Treasurer William R. Calnon, ADA Trustee 3220 Chili Ave., Rochester, NY 14624 a clinical discipline such as dentistry, case reports 74 Main St., Hornell, NY 14843 still offer valuable information and insight into the care of individual patients. Reading them can BOARD OF GOVERNORS NY County-Lawrence Bailey 8- Jeffrey A. Baumler be both interesting and stimulating as we find 215 W. 125th St., New York, NY 10027 2145 Lancelot Dr., Niagara Falls, NY 14304 NY County-Matthew J. Neary 8- Kevin J. Hanley ourselves questioning whether we would have 501 Madison Ave., Fl. 22, New York, NY 10022 959 Kenmore Ave., Buffalo, NY 14223-3160 treated these cases in the same manner as the NY County- Robert B. Raiber 9-Edward Feinberg 630 Fifth Ave., #1869, New York, NY 10111 14 Harwood Ct., Ste. 322, Scarsdale, NY 10583 clinician author. Perhaps, we can offer justified 2-Craig S. Ratner 9-Malcolm S. Graham criticism of what was or was not considered in 7030 Hylan Blvd., Staten Island, NY 10307 170 Maple Ave., White Plains, NY 10601 the overall treatment plan. Although, on scales of 2-James J. Sconzo 9- Neil R. Riesner 1666 Marine Parkway, Brooklyn, NY 11234 111 Brook St., 3rd Floor, Scarsdale, NY 10583-5149 scientific credibility or the evidentiary pyramid, 3-Lawrence J. Busino N- Peter M. Blauzvern the case report ranks rather low—one level 2 Executive Park Dr., Albany, NY 12203 366 N. Broadway, Jericho, NY 11753-2032 3-John P. Essepian N-David J. Miller above published opinions or editorials—it fre- 180 Old Loudon Rd., Latham, NY 12110 467 Newbridge Rd., E. Meadow, NY 11554 quently offers an easy read of how an individual 4-Mark A. Bauman N-Frank J. Palmaccio 157 Lake Ave., Saratoga Springs, NY 12866 2 Bayard Drive, Dix Hills, NY 11746 patient was treated by a colleague. 4-James E. Galati Q-Chad P. Gehani The NYSDJ invites its readers to submit case Parkwood Plaza, 1758 Rte. 9, Clifton Park, 35-49 82nd St., Jackson Heights, NY 11372 NY 12065 reports for consideration for publication. We Q-Robert L. Shpuntoff 5-William H. Karp 28 Beverly Rd., Great Neck, NY 11021 hope that many of our colleagues in academic 472 S. Salina St., #222, Syracuse, NY13202 S-Paul R. Leary institutions and private practice will enthusiastically 5-John J. Liang 80 Maple Ave., #206, Smithtown, NY 11787 2813 Genessee St., Utica, NY 13501 S-Steven I. Snyder accept this invitation.Each case report manuscript 6-Robert W. Baker Jr. Suffolk Oral Surgery, 264 Union Ave., Holbrook, NY 11741 will be submitted to our reviewers depending 412 N. Tioga St., Ithaca, NY 14850 B-Stephen B. Harrison 6-Scott Farrell 1668 Williamsbridge Rd., Bronx, NY 10461 upon the particular discipline(s) associated with 39 Leroy St., Binghamton, NY 13905 B-Richard P. Herman the case report. 7-Robert J. Buhite II 20 Squadron Blvd., New City, NY 10956 Prospective authors are encouraged to review 1295 Portland Ave., Rochester, NY 14621 7-Andrew G. Vorrasi our Author’s Guidelines, which can be found on the 2005-A Lyell Ave., Rochester, NY 14606 NYSDA Web site,www.nysdental.org,in the period- icals section. Following these guidelines will great- COUNCIL CHAIRPERSONS Annual Meetings Governmental Affairs ly facilitate the review process and, we hope, accep- Alan L. Mazer Alan L. Mazer OFFICE tance of your manuscript for publication. P.O. Box 985, 140 Terryville Rd. P.O. Box 985, 140 Terryville Rd. Suite 602 Pt. Jefferson Station, NY 11776 Pt. Jefferson Station, NY 11776 20 Corporate Woods Blvd. Here is an opportunity for many more of our Awards Insurance Albany, NY 12211 colleagues to contribute to The Journal. Articles William R. Calnon Roland C. Emmanuele (518) 465-0044 3220 Chili Ave., Rochester, NY 14624 4 Hinchcliffe Dr. (800) 255-2100 describing novel techniques from the simple— Chemical Dependency Newburgh, NY 12550 “How to Fabricate a Temporary Crown”—to Robert J. Herzog Membership & Roy E. Lasky 16 Parker Ave., Buffalo, NY 14214 Communications Executive Director complex interdisciplinary cases are all welcome. Lidia Epel Carla Hogan Dental Benefit Programs And your editorial team at The NYSDJ is available Ian M. Lerner 165 N. Village Ave. #102 General Counsel One Hanson Pl., #2900 Rockville Center, NY 11570 Beth M. Wanek to assist prospective authors at any stage of man- Brooklyn, NY 11243-2907 New Dentist Associate Executive Director uscript preparation. Dental Health Planning/ David C. Bray Michael J. Herrmann Hospital Dentistry 18 Leroy St., Binghamton, NY 13905 Assistant Executive Director The NYSDJ believes that the case reports Robert A. Seminara Nominations Finance-Administration could develop into an interesting and ongoing 281 Benedict Rd., Staten Island, NY 10304 Steven Gounardes Judith L. Shub Dental Practice 351 87th St., Brooklyn, NY 11209 Assistant Executive Director section. This perception can only come to Steven L. Essig Peer Review & Health Affairs fruition if you, the reader, supports this effort.Are 33 Main St., Ravena, NY 12143 Quality Assurance Sandra DiNoto Dental Education & Licensure Steven Damelio Director you up to the task? Madeline S. Ginzburg 1794 Penfield Rd. Public Relations 2600 Netherland Ave., #117 Penfield, NY 14526 Mary Grates Stoll Riverdale, NY 10463 Relief Managing Editor D.D.S. M.Sd Ethics Anthony V. Maresca Kevin A. Henner 207 Hallock Rd. 163 Half Hollow Rd., #1, Deer Park, NY 11729 Stony Brook, NY 11790 NYSDJ • MARCH 2008 5 NYSDJ • JUNE/JULY 2008 5 Michael Monsegur, second grader at Holy Name of Mary in Rosendale, took first prize in state-sponsored creative contest. CHILDREN’S DENTAL HEALTH MONTH Launches Search for Healthy Smile Thousands of volunteers participate in events across the state during the month of February. THE NEW YORK STATE DENTAL ASSOCIATION Children’s Dental school curriculum. The Association also gave out free stickers and Health Month program focused on education and outreach this certificates for children. Large, four-color posters listing nutrition year, targeting children, educators, parents, coaches and cafeteria tips and the sugar content of various foods were provided free to staff through a creative contest, free oral health materials and spe- schools for posting on bulletin boards and in dining rooms. cial events. NYSDA created two slide shows for teachers and nurses to use Tying all the efforts together was a new CDHM logo that estab- during CDHM and beyond. “Healthy Teeth Keep Smiles Happy” lished a consistent identity for the printed materials, Web postings, teaches children in grades K-3 the basics of good oral care. “Oral advertisements and promotional items used during the observance Piercing—You Decide” is for teens and identifies the health risks of in February. The logo promoted the theme “In Search of a Healthy oral piercing. Smile” and featured children outfitted as dental explorers uncover- And NYSDA partnered with New York State Dairy Foods to create ing dental discoveries. milk carton slicks, which were distributed to dairies in the state. NYSDA sponsored its popular statewide “Keeping Smiles Messages on the slicks used the dental discovery theme with the explor- Brighter” creative contest for children in preschool through 12th ers encouraging dental visits. They also noted the link between mouth grade. Students were asked to come up with a placemat design with and body health and touted dairy foods as beneficial for oral health. a good oral health message. New in 2008 was a Web site category, added to involve older children, in grades 7-12. In all, 5,000 entries Spreading the Message Across the State were submitted to the contest. The Nassau County Dental Society hosted Give Kids A Smile at Sugarless Wednesday, a day devoted to making children more the Cradle of Aviation Museum in Garden City. Hundreds of dental aware of nutrition and its impact on oral and overall health, reached volunteers participated and screened more than 1,700 children. more than 50,000 children. NYSDA provided educators with a work- Elected officials,ADA leaders and corporate sponsors were on hand sheet printed with ideas on how to incorporate the event into the for the day’s events. 12 NYSDJ • JUNE/JULY 2008 The Sixth District Dental Society held a dental health fair at the Oakdale Mall in Binghamton. Volunteers distributed 1,000 tooth- brushes and conducted dental screenings. Visitors enjoyed a visit from the tooth fairy, received oral health care information and viewed a nutrition display. The Second District Dental Society joined with the Colgate Bright Smiles, Bright Futures team in hosting a Give Kids A Smile Day at the Beginning with Children Charter School in Williamsburg. The children received dental screenings, saw demonstrations and participated in dental-related activities. They also received free products and literature.Parents of children requiring follow-up den- tal care were contacted. Other venues in Brooklyn hosting Give Kids A Smile Day events were the New York City College of Technology Dental Hygiene Department, New York Methodist Hospital and Brookdale Hospital. A day devoted to dental health was observed at the Grand Angela DeBartolo, member, Second District, conducts screening on student from Beginning with Children Charter School in Brooklyn during Give Kids A Smile Day Army Plaza of the Brooklyn Public Library. It featured a magic event at school. show, nutritional counseling and brushing demonstrations. Representatives of the New York State Masons also participated The Fifth District Dental Society reached more than 4,000 chil- and conducted their Child Identification Program (CHIP). dren during the month of February. All third graders in Jefferson The Eighth District Dental Society sponsored three dental and Lewis Counties received toothbrushes, courtesy of the health fairs in February at malls in and near Buffalo.Volunteers dis- Jefferson/ Lewis counties Dental Society. The St. Lawrence County pensed oral health information and free products at the fairs. The Dental Society estimates that its members donated $17,000 worth dental clinic at the University at Buffalo School of Dental Medicine of dental care during its Give Kids A Smile Day program, with one- hosted a Give Kids A Smile Day. third of the county’s dentists participating. ■ NYSDJ • JUNE/JULY 2008 13 Forward Thinking NYSDA members reveal they’ve been planning for retirement for quite a while. Sandra DiNoto NYSDA DIRECTOR PUBLIC RELATIONS DESPITE AN UNCERTAIN ECONOMY, more than 60 percent of half of those surveyed feel knowledgeable about their retirement senior dentists in New York State feel financially prepared for their investments and have calculated how much income they will departure from the full-time practice of dentistry. This was among need in retirement. The percentage of income being saved annu- the findings of a first-ever retirement survey conducted by the New ally for retirement varied, with 81 respondents saving between 1 York State Dental Association among its members statewide. The percent and 5 percent, and 121 saving more than 20 percent. survey was conducted via e-mail in the first quarter of 2008. It was Stocks, bonds and mutual funds were listed as the largest distributed to 3,635 members age 50 or older. The survey was sources of investments. Social Security, income from a practice or viewed by 1,000 members, with 835 completing it fully. Members home sale and spouse pension were cited as other significant were polled about their practices, investments, and retirement sources of retirement income. Almost three-quarters of those plans and concerns. responding plan to live a life style similar to their non-retirement “More than 65 percent of our members are over the age of 50, standard of living. and this was a relevant sampling,” said Lidia Epel, chair of the Retirement—of their dentist—appears to be on the minds NYSDA Council on Membership and Communications. “We were of patients as well. Three hundred forty-two members reported happy with the good response, and feel fortunate that members their patients had expressed concerns about what will happen to were willing to share personal information about their finances and the practice when the dentist retires. Sixty-eight percent of those retirement concerns.” surveyed intend to sell their practice—18 percent to a partner Ninety-three percent of those who responded were male. The and 45 percent to a dentist not affiliated with the practice. majority of respondents listed their age as being between 50 and 60 More than three-quarters of those surveyed plan on having and said they were in a solo practice for 30 to 40 years. health insurance that will meet their needs in retirement. Thirty- Fifty-three percent of the survey participants said they one percent have purchased long-term care insurance, with anoth- began investing for retirement between age 25 and 35; but 41 er 12 percent planning on obtaining it. percent anticipate they will work for longer than they had ini- New York State dentists plan to keep busy in retirement with tially planned, with more than a third saying they planned to travel, hobbies, teaching and volunteering in their communities remain in a dental-related career well into their 70s. More than and abroad. More than 30 percent intend to continue part-time 14 NYSDJ • JUNE/JULY 2008 practice because they enjoy it, want to keep busy and for financial reasons, in that order. The sale of a practice, health insurance, long-term care insur- ance, investment advice and the transfer of patient records topped the list of subjects retiring dentists would like to know more about. More than 200 members expressed concerns about the continuity of care for their patients and requested resources about economic indicators. Reverse mortgages and continued investing once a prac- tice is sold were also on the minds of those approaching retirement. New York State’s senior dental professionals have prepared themselves and, overall, feel confident about their retirement. Dr. Epel said the information derived from the survey will be useful to all NYSDA members. It has already been shared with NYSDA Support Services, with an eye toward developing Association- endorsed programs and benefits geared specifically to retirement- minded members. “We are considering relevant programming and services for dentists who are retired or approaching retirement,” Dr. Epel said. “We feel our profession’s senior members have committed them- selves to retirement planning and will serve as an excellent resource for dentists new to practice who are beginning to make their own investment choices.Our youngest professionals practice in a very dif- ferent environment than their experienced colleagues, but the mes- sage remains the same: It is never too early to save for the future.” ■ NYSDJ • JUNE/JULY 2008 15 NYSDF Deans Award Recognizes Five Outstanding Dental Students FOR THE SECOND YEAR, the New York State Dental Foundation is Carrie Wanamaker, University at Buffalo School honoring students at all four of the dental colleges in New York of Dental Medicine. Ms. Wanamaker has played a State, as well as at Eastman Dental Center, with its NYSDF Deans leading role with the Buffalo Outreach and Award. The prize, valued at $5,000, is given to foster a growing and Community Assistance Program. She was president sustainable oral health work force, critical to expanding available elect of BOCA when a first-year dental student and oral health services for all New Yorkers. It is a need that has become now is its president.She was the first freshman den- more acute as the ranks of the underserved grow and culturally tal student to be included on a BOCA mission. She Ms. Wanamaker participated in dental outreach projects to the diverse communities within the state expand. This year, the Foundation Board of Trustees changed the crite- Bronx, NY, and Appalachia, and she has organized and participated in ria for the Deans Award. Previously, it was awarded to graduating two local outreach missions, including volunteering at soup kitchens. seniors. Now it is given to a third-year student or postdoctoral Ms.Wanamaker has organized multiple fundraisers for the BOCA pro- trainee who has demonstrated an exceptional level of achievement gram, and has made presentations about BOCA at various UB school as measured by the following criteria: events, including family day, orientation for new students, the ● Outstanding academic performance. University’s International Week and the Buffalo Niagara Dental Meeting. ● Demonstrated commitment to enhancing and improving the Laura Sotomayor, Columbia University oral health of underserved populations. College of Dental Medicine. As director of the ● Membership in the American Student Dental Association. Academic Success Program, Ms. Sotomayor Candidates for the NYSDF Deans Award must be nominated by coordinates review sessions and tutoring for the dean of each of the qualified academic dental institutions. They first-year dental students. She also serves as a are Columbia University College of Dental Medicine, New York teaching assistant in oral histology, growth and University College of Dentistry, University at Buffalo School of development.As a research assistant, she created Dental Medicine, Stony Brook University School of Dental Medicine Ms. Sotomayor and developed a fetal skill atlas using cone beam and the University of Rochester Eastman Dental Center. computed tomography. She later presented her research at the This year’s honorees are listed here. American Dental Education Association 86th Annual Session and 16 NYSDJ • JUNE/JULY 2008 Exhibition. Ms. Sotomayor is a member of the Columbia University in NYU’s Oral Cancer Walk through Harlem, an activity that provides Chapter of Smile Train. Among the many honors she has received free oral screenings and education to a population disproportionately are Columbia’s Dr. Marlene Klyvert Merit Fund Scholarship, the at risk for the disease. Just last month, Ms. Wright volunteered for an ADA Dental Student Scholarship, the Dean’s Scholarship, the outreach program in rural India, where she helped screen and treat Chancellor’s List, the NYS Scholarship for Academic Excellence, the hundreds of children who would not otherwise have access to care. NYIT Student Affairs Service to School Award, National Dean’s List Natalie Bitton,Stony Brook University Health Sciences Center. Honorary Award and inclusion in Who’s Who Among Students in Ms. Bitton entered SDM in 2005 after graduating from Binghamton American Universities and Colleges. Additionally, she has received University with a BA in biological sciences. While in college, she the NYIT Presidential Scholarship for Academic Merit and has been appeared on the Dean’s List multiple times, and was one of two stu- named to the Presidential Honor List all semesters. dents to receive the Terrana Pre-Dental Scholarship for an outstanding Maricelle Uy Abayon, Eastman Dental Center. academic record. She has continued her academic excellence at SDM. Graduating as one of the highest ranking students In her second year, she was one of two students selected to tutor first- at the University of the Philippines and ranked year students in basic sciences, dental didactic and clinical courses. highest in her dental school class, it would seem Recently, she was named to participate as a student representative to there is little left for Dr.Abayon to achieve.Yet,in less the Department of Admissions.In addition to these academic pursuits, than two years at Eastman Dental Center, Dr. Ms. Bitton has shown great interest in helping the underserved com- Abayon has demonstrated an ability to form excel- munity. She is one of six students selected to travel to Madagascar, a Dr. Abayon lent relationships with patients, administrators, highly sought after SDM outreach program that enables students to staff and faculty,while,at the same time,performing at the highest level provide oral health care to the underserved Malagasy populace. in the difficult master of science program at the University of Rochester. The advanced education in general dentistry program at Eastman has Former State Dental Official to Aid Foundation always been considered demanding because of the required literature in Implementation of Dental Screening Law reviews,case presentations,research seminars and academic classes,to Milton Lawney, former executive secretary of the State Board for say nothing of the patient component of the program. Dr. Abayon has Dentistry, has been recruited by the New York State Dental been an active participant in all of these areas and still finds time to Foundation to help implement the state’s new dental health screen- lend a hand to others. She has never refused a request to help with ing law. Dr. Lawney, who will serve as a consultant to the founda- emergency patients or to assist another resident in a difficult procedure. tion, will be responsible for enlisting and enrolling dentists Dr. Abayon’s unique ability to recognize the social, economic, psycho- throughout the state to conduct free dental health screenings for logical, medical and financial impediments to successful dental treat- school children in order to provide for an adequate supply of den- ment for her patients,and to do so with both an air of confidence and a tists when the law takes effect in September. sense of humility, evidence a maturity far beyond her years. The NYSDA-supported legislation was passed last year. It Collisha Wright, New York University College of Dentistry.A requires that school districts in New York State request a dental native of Kingston, Jamaica, Ms. Wright grew up in a family where health certificate from each matriculating student. It also mandates education, hard work, excellence and concern for the less fortunate that the Department of Education, working with the Department of were emphasized. After graduating from Wesleyan with a double Health, compile and maintain a list of dentists to which children major in molecular biology and studio arts (printmaking),Ms.Wright who need comprehensive dental examinations may be referred for enrolled at NYU College of Dentistry, where she is currently ranked in free or reduced-cost treatment. For their part, NYSDA and the the top five percent of her class (3.81 GPA).Based on her rank,she will Dental Foundation have committed to recruiting dentists who will most assuredly be inducted into the OKU Honors Society. Ms.Wright perform these exams and help motivate their patients to comply has long exhibited concern for the underprivileged. As a high school with the law. They also pledged to work with schools to help explain student, she attended weekend volunteering activities in her commu- the law to students and their families. nity.In college,she volunteered at several hospitals in Connecticut and The Dental Foundation has secured a $162,000 grant from the Brooklyn, where her parents moved and where she spent her vaca- ADA State Public Affairs Program to carry out its role in imple- tions. During summer breaks, she would volunteer at King’s County menting the dental health screening law. This includes creation of Hospital, working with elderly and destitute patients. At NYU, Ms. Dr. Lawney’s position as public advocacy coordinator. It is expected Wright joined ASDA, and has become a role model for female, that Dr. Lawney will be making presentations on behalf of the foun- African-American high school and college students.Her goal for these dation to the public and members of the dental community, includ- young students is to help them see dentistry as an attractive,high-pri- ing NYSDA components, and will also be a liaison on this issue to ority profession that gives one the opportunity to give back to the members of the State Legislature. He will be assisted by two region- community. Additionally, in the last three years, she has participated al public advocacy coordinators, who are yet to be named. ■ NYSDJ • JUNE/JULY 2008 17 Dentists’ Input Sought in Combating Early Childhood Obesity A RECENTLY PUBLISHED ARTICLE in the Journal of Pediatrics 1. Are you aware that there is a growing body of research indi- entitled “Integrating Oral Health to the Care of Overweight cating a strong correlation between early dental caries and Children: A Model of Care Whose Time Has Come”1 reports on the early childhood overweight and obesity? American Academy of Pediatrics (AAP) Oral Health Initiative. The Yes No initiative is being championed by several health groups, including 2. Have you observed an increase in overweight and obesity the Federal Maternal and Child Health Bureau, which is partnering among your 2- to 5-year-old patients? with the AAP on this project, the American Dental Association, the Yes No Don’t see children aged 2-5 American Academy of Pediatric Dentistry and supporting organi- 3. Are you currently providing any health prevention and zations such as Bright Futures. screening programs to your pediatric patients? The overall goal of the Oral Health Initiative is to provide sup- Yes No port and tools to community-based, collaborative-care providers 4. Does your practice have the ability to assess children’s weight? that will improve children’s oral health. The program is intended to Yes No Practice does not have a height/ encourage cooperation between pediatricians and dental profes- weight measurement tool sionals to increase awareness of the connection between oral health Practice staff does not have time to assess weight sta- and overall health. A main objective is to increase oral health tus of patients screening and referrals from pediatricians’ offices. Assessing weight is not an appropriate activity for a The recently funded Foundation for Health Living’s Center for dental visit Best Practice for the Prevention of Early Childhood Obesity and Other Overweight and the New York State Dental Foundation are working 5. Are you interested in learning more about the early child- together to examine this very issue, however, from a different angle. hood obesity epidemic and available educational materials They are exploring the possibility of developing and piloting an that promote early childhood obesity prevention and screen- early childhood obesity screening and prevention tool kit for pedi- ing programs? If so, please, complete the following: atric dentists to encourage strong, consistent messaging between pediatricians and dental professionals. Name Please take a few minutes to complete the survey presented Address here. Your responses will be tremendously helpful in determining how pediatricians and dental professionals can work together to help fight the rapidly increasing childhood obesity epidemic. E-mail Return your completed survey to Laura Beth Leon, executive director, New York State Dental Foundation, by fax (518-465-3219) or e-mail REFERENCES 1. Grossi SG, Collier DN, Perkin RM. Integrating oral health to the care of overweight chil- (firstname.lastname@example.org). dren: a model of care whose time has come. J Pediatrics 2008:52:451-2. 18 NYSDJ • JUNE/JULY 2008 Dentistry Managed Care RISING ENROLLMENT IN MANAGED CARE PLANS for medical coverage is changing patient expectations about their out-of-pock- et payments for health care. This trend has been accompanied by changes in the types of dental benefit plans available, with plan purchasers (employers) and patients seeking greater discounts for & An update on a difficult and complex relationship. Judith L. Shub, Ph.D. their dental care. These new types of dental plans are based on the An important aspect of managed care is the transfer of the financial liability borne by the patient and third-party payer (den- tal benefit plan) to the dentist. This transfer is a cost-control mech- anism that provides financial disincentives for over-treatment. Theoretically, managed care is a win-win situation. It results in health care costs that are controlled and predictable. The third- doctor entering into a contract with a third-party payer and accept- party payer’s financial risk is defined regardless of patient demand ing less than usual and customary fees.As such, they represent den- and the amount of treatment rendered. Patients receive care, and tistry’s movement into managed care. the doctors/providers continue to treat patients profitably. In reali- It’s a trend that is affecting all dental practices. Today, when ty, professional practices can be profitable or suffer economically patients ask, “Do you accept my insurance?” they may be asking based on whether they negotiate contracts that include clauses that more than whether the office will submit their claim and wait for are beneficial to their actual practice situations. their benefit. They may want to know whether the office will accept their insurance as payment in full. Dental Managed Care Corporations The managed care model was developed with two goals: In New York State, managed care dental plans typically contract 1. To improve health care delivery. with participating provider organizations (PPO), individual dental 2. To help control health care costs. practices, and—for HMOs—independent practice associations Although it has been widely used in medicine, the applicability of (IPA) to provide dental services to their members. These compa- this model to oral health care is questionable. There are notable differ- nies, in turn, contract with individual dentists. ences in the economics, epidemiology and approaches to prevention An IPA is a form of integrated group practice whose sole func- and treatment between medical and dental care. The overhead associ- tion, by law, is to enter into contracts with HMOs. A PPO is simply ated with dental visits can be far greater than that for most routine a participating provider panel operated by a company that enters medical office visits and procedures and, therefore, can limit the abili- into contracts with individual independent dentists. The PPO, in ty of dentists to discount treatment and still be profitable. Moreover, turn, contracts with benefit plans to provide a panel of dentists who dentists do not have or use auxiliaries, such as physician assistants, have agreed to accept a discounted fee schedule and other primar- nurse practitioners and nurses, to whom they can delegate treatment. ily payment-related restrictions. 20 NYSDJ • JUNE/JULY 2008 For most dentists, this is new and The most common forms of unfamiliar territory that requires dental managed care plans utilize expertise not acquired in dental PPOs to offer discounted dental school. Participation agreements treatment services to patients. are legally binding contracts. This model differs from more tra- There are few legal limitations on ditional insurance and benefit the terms these contracts include plans in that the participating den- other than those contained in the tists—as well as their patients— New York State Department of have contracts with the patients’ Health Managed Care Guidelines benefit providers. Dentists enrolled and the Public Health Law. in PPO plans are typically reim- However, neither of these fully bursed at a discounted rate on a addresses the financial terms, fee-for-service basis. Because PPO which most directly affect the plans appear to be like traditional profitability of a dental practice. indemnity plans, many doctors do not consider their contracts a form Discounted Fee-For- of managed care. Nonetheless, in a Service Dental Plans PPO, the dentist assumes some of A popular dental plan is the discount club. A search for dental ben- the financial liability that traditionally is borne by the patient and efit plans on the Internet brings patients information on a number third-party payer because the fees are less than the dentist’s usual of companies offering this type of plan. Similar plans are common- and customary fees; therefore, these plans significantly affect the ly available for prescriptions, vision, chiropractic, hearing and other profitability of a dental practice. health care. Upon their paid enrollment, prospective patients receive a list of dentists who agree to honor a discounted fee sched- Capitated Arrangements ule and an identification card to present to a participating health When evaluating a managed care contract, doctors should be care provider. The card entitles the holder to the discounted fee sure that they understand each of the clauses in the contract and schedule. These plans do not reimburse patients for any dental how they affect payment. Among other terms, these clauses usu- treatment costs. As a result, they advertise that they have none of ally stipulate that the managed care organization (MCO) may the “waiting periods” or exclusions typical of traditional indemnity unilaterally change the reimbursement terms upon prior notice insurance plans. Discount clubs also require the dentist to enter to the dentist. As a result, dentists complain that they signed con- into a contractual relationship with a third party. tracts that include fee-for-service fee schedules but then find the Most dentists in New York State who participate in managed MCO is changing the terms of reimbursement to a lower fee or care do so through agreements with established insurance compa- capitation basis. nies. These companies create discount benefit options by signing There are issues unique to capitated arrangements. Because up dentists in participating provider panels for their covered cus- the doctor does not receive reimbursement based on the number of tomers. In addition, government programs are enrolling recipients treatment services provided, there is an expectation that the in HMOs. Currently, most HMO-based dental treatment in New amount of unnecessary care provided will decrease. In theory, the York Sate is provided through the Medicaid program. In the mid- doctor can expect to receive a guaranteed amount each month for a 1990s, New York State obtained a federal waiver allowing it to con- portion of the patients in the practice. This should result in less tract with HMOs to provide care to Medicaid recipients. By doing financial uncertainty for the practice. In reality, patients can move so, New York hoped to improve access to health care services, from one doctor’s panel to another, making the size of a doctor’s improve the quality of care available to Medicaid recipients and panel and the period for payment uncertain. control program costs. Most of the HMOs that have contracts with Information on the per-patient/per-month rate alone is insuf- the New York State Department of Health now offer dental care ficient to enable the doctor to make a decision about the prof- through contracts with IPAs. itability of a capitation offer. Similarly, the profitability of a dis- New York’s Family Health Insurance and Children’s Health counted fee-for-service schedule is affected by the portion of Insurance Programs (Child Health Plus) purchase benefits for eli- patients in the practice in the plan and their potential need for gible recipients. They do so by paying all or part of the premium for treatment services, that is, utilization. (For more information on enrollment in HMOs. Thus, in order to provide dental care to Child this topic, see the article “Capitated Reimbursement: What You Health Plus enrollees, dentists must be under contract with a man- Need to Know Before You Sign a Contract” in the February 2008 aged care plan. NYSDA News.) NYSDJ • JUNE/JULY 2008 21 Evaluating Managed Care Contract Offers Contract limitations can result in forfeiture of payment. Dental The initial offerings dentists receive from managed care companies managed care plans only reimburse for services that are covered include a number of contract provisions that define the rights and and for patients who are eligible on the date of service.When claims obligations of each party to the agreement. With respect to reim- are denied, there may be contractual or practical limitations on the bursement, the contract includes either a discounted fee-for-service dentist’s ability to collect reimbursement from patients directly. For reimbursement schedule or a capitated per-member-per-month fee example, in the Medicaid managed care arena, plans can deny (pp/pm).As a rule,the fee-for-service rates are less than the dentist’s claims when the plan determines that the patient was not eligible usual and customary charges. for benefits on the date of service, regardless of whether the dentist Understandably, dentists first focus on the fee schedule and verifies patient eligibility at the time of treatment. Often plans are how it compares to their usual office fees. In reviewing any con- unable to maintain accurate real-time eligibility data. If the eligi- tract proposal, it is important to consider clauses that determine bility information is not current, the dentist may, nonetheless, be the actual reimbursement the dentist can expect to receive. contractually prohibited from seeking payment from the patient. Among other terms, these clauses usually stipulate that the In contrast, private pay patients are responsible for the den- MCO—HMO, PPO or IPA—with which the dentist is contracting tist’s fee regardless of whether their benefit plan approves or denies may unilaterally change the reimbursement terms upon prior their claims. notice to the dentist. Doctors are responsible for negotiating reimbursement rates Evaluating a Contract and terms that are adequate to enable them to continue to provide The first question to resolve when considering any participating necessary care to their patients profitably. Until a dentist signs a provider agreement is,“Why did the company send this contract to contract, it is in negotiation. Once the dentist has signed, it is me?” The answer is straightforward. The company needs dentists assumed that the dentist understands the terms of the contract and on its panel. The marketability of a discounted dental plan relies on accepts those terms. If something is not stated in the contract, it the number of dentists on the panel and the amount of the dis- does not exist. counts it can offer plan purchasers. 22 NYSDJ • JUNE/JULY 2008 Besides fees, there are other This has meant that when dentists important questions a dentist state a fee for a service, that fee needs to answer when evaluating represents the amount the dentist a contract offer. They include the is charging and expects to collect following. from the patient. The advisory ● What is the dentist’s office opinion contained in the Code of overhead? Ethics states: ● Would the plan’s initial fee ”Deliberately representing schedule be profitable for the treatment or fees in a false or mis- dentist? leading manner includes but is not ● Would the fee schedule cease limited to: to be profitable if more than a (g) indicating on an insurance defined percentage of patients claim form a fee other than that in the practice were enrolled actually charged the patient.” in the discount plan? Many managed care compa- ● When and how could the nies compile fee data by request- reimbursement change? ing that doctors record their ● Under what conditions will “usual” fees on claim forms. Is the dental office not be paid? this a deliberate misrepresenta- ● Are there circumstances where the dentist may seek payment tion since the doctor does not intend to collect the recorded fee from patients and, if so, at what rates? for patients enrolled in the MCO? Do doctors who participate in ● Does the contract contain clauses applicable to employees and managed care plans have “usual fees” or multiple fee schedules in practice associates, multiple practice locations or other char- their practices? acteristics of the dentist’s practice? ● How can either of the parties terminate the contract and what Conclusion are the repercussions for continuity of care and payment when Participating provider agreements are legal contracts that delineate a contract terminates? the rights and obligations of the dentist and the payer. They have ● Can the dentist comply with the terms of the contract without obvious implications for the business side of the dental practice violating the laws, regulations or the Code of Ethics governing and the dentist’s livelihood. As such, they should be taken serious- professional conduct? ly. Ultimately, dentists cannot predict the impact of any participa- ● What does the dentist receive in return for concessions sought tion agreement without a thorough understanding of their actual by the managed care company, that is, what benefits does the practice overhead and demographics. contract promise the dentist? It is advisable to negotiate any contract with good legal advice. ● Are there unanswered questions or situations that are not NYSDA provides its members with information on participation clearly delineated in the contract? agreements with third-party payers through its Contract Analysis Service and referrals to its Legal Services Panel. What is the Usual and Customary Fee? The time to check the contract and understand its terms is When a dentist in an MCO submits a claim for a member patient, before signing. The most frequently asked questions from NYSDA the rate of reimbursement is based on the contracted fee schedule, members who are dissatisfied with an MCO’s payment or other not the dentist’s usual office fees. Further, virtually all contracts practice are: “Is it legal?”“Isn’t there a law that they can’t do that?” provide that dentists cannot bill covered patients for the difference Usually, the answer is,“It’s contractual.” ■ between their usual fees and the allowable discounted fee. Problems often arise because most contracts do not fully address Dr. Shub is NYSDA Assistant Executive Director for Health Affairs. NYSDA General how benefits can be coordinated for patients enrolled in multiple Counsel Carla Hogan also contributed to this article. benefit plans. The fee a dentist charges most patients in the practice for a particular service is the dentist’s “usual and customary fee.” The NYSDA Code of Ethics Section 1-J states: “Representation of Care and Fees. Dentists shall not deliberately represent the care being rendered to their patients or the fees being charged in a false or misleading manner.” NYSDJ • JUNE/JULY 2008 23 Informed Consent and Professional Liability NYSDA Council on Insurance develops consent form for use by general dentists. May prevent legal problems after treatment. John W. VanDenburgh PATIENTS HAVE A RIGHT to make informed choices about their The Right to Reject Therapy dental or medical care and treatment. Dentists and other medical Lack of informed consent means the failure of the person provid- professionals have a corresponding obligation to provide the patient ing the professional treatment or diagnosis to disclose to the with the information necessary to make such an informed choice. patient treatment alternatives and the potential risks and benefits The concept of informed consent has its root in the common involved as a reasonable medical, dental or podiatric practitioner law. It evolved from the principle that it was not permissible for any under similar circumstances would have disclosed, in a manner individual, even a medical professional, to violate the “physical that allows the patient to make a knowledgeable evaluation.3 integrity” of another person without consent.1 When the common law concept of informed consent was writ- The doctrine of informed consent developed in the context of ten into law as an actual statutory obligation, drafters noted the personal-injury litigation, deriving from a combination of the con- evolution of the common principles of informed consent as follows: cepts of assault and battery with those of negligence and malprac- 1. In general, every person has a right to accept or reject any pro- tice. Ordinarily, like most of tort law, it called for the application of posed therapy (citations omitted). general principles to specific situations. A problem in informed 2. Each patient has a right to receive, and each therapist consent arises when a physician or other therapist obtains a con- (directly or through an agent) has a concomitant duty to sent to treatment adequate to insulate him or her from prosecution present, in a form comprehensible to a layman of average for criminal assault and from liability in a civil assault or battery intelligence, such information as is or should be known to action, but the patient contends the consent would have been with- the therapist, which a reasonable person would require to held if adequate disclosure had been made concerning the condi- form a judgment as to whether to accept or reject the pro- tion, the potential dangers of and alternatives to the proposed pro- posed therapy (citations omitted). The information commu- cedure or therapy.2 nicated to the patient should include, at an irreducible min- Ultimately, the common law concept of informed consent was imum: diagnosis, prognosis without the proposed therapy, codified into statutory law so that dentists and other medical pro- prognosis with the proposed therapy, significant risks and fessionals now have a statutory obligation in New York State to significant side effects of the proposed therapy, and alterna- obtain informed consent from their patients relative to any pro- tives available, if any.4 posed treatment. That consent must be obtained before the treat- These principles continue to be applicable even under existing ment is commenced. statutory law. 24 NYSDJ • JUNE/JULY 2008 A Signature May Not be Enough It is not the intention of the council to establish a specific stan- To recover damages for dental malpractice based on lack of dard of care relative to informed consent or to imply that a failure informed consent, the plaintiff was required to prove that the to use this, or any similar, form is a violation of the standard of care defendant failed to disclose to him or her the material risks, bene- for informed consent. It is hoped that the “General Dentistry fits of and alternatives to the [treatment] which a reasonable den- Consent Form” will prove to be a useful tool that creates a frame- tal practitioner ‘under similar circumstances would have disclosed, work within which the practitioner can review with his or her in a manner which permitted [the plaintiff] to make a knowledge- patient, most likely during the initial visit for new patients or dur- able evaluation,’ and that a reasonably prudent person in the plain- ing an annual review of medical history with existing patients, tiff ’s position would not have undergone the surgery if he or she information that may prove helpful to the patient in making an had been fully informed.5 informed choice regarding treatment recommendations that could It is critical to recognize that the most crucial component in arise during the course of their general dental care. It is suggested fulfilling a practitioner’s obligation to obtain informed consent is that the best use of the form is a review by the patient, in the pres- the actual discussion with and communication to the patient of the ence of the dentist, so that the dentist can explain the substance of diagnosis, risks, benefits and alternatives so that the patient can the form and answer any questions posed by the patient. The make an informed decision. patient could then initial each paragraph that has been reviewed Written consent forms, signed by the patient, provide evi- during the course of the discussion.Both the dentist and the patient dence that the discussion and communication took place, but the should sign the form. mere act of having a patient sign a consent form without providing A properly signed and initialed form provides objective evi- the accompanying discussion and communication is insufficient dence that the dentist and patient discussed the information con- to meet the practitioner’s burden. In fact, there have been a num- tained on the form on the date indicated next to the signatures. Best ber of cases in which the trial jury has concluded that the standard practice would suggest that, although the information was reviewed for informed consent was not met by the practitioner even though with the patient either as part of an initial office visit or an annual the patient had signed a written consent form. For example, in one review of medical history, the practitioner still go over with the case,6 an appeal level court concluded that it would be permissible patient, the diagnosis, risks, benefits and alternatives of specific under law for a jury to decide, based on the facts of the case, that treatment when that treatment is recommended and prior to com- informed consent had not been obtained, even where the patient mencement of that treatment. had signed a consent form acknowledging that the procedure car- ried a risk of the very injury ultimately complained of. In this case, Conclusion the plaintiff testified that the practitioner never personally dis- It must be remembered that informed consent involves the patient’s cussed with her the risks, benefits and alternatives of the treat- right to be advised, in understandable language, about his or her ment proposed. She further claimed that she did not read the con- diagnosis, the proposed treatment plan, the risks and benefits of the sent form before signing it and did not understand the contents of proposed treatment and alternatives to the proposed treatment. The the form because of the pain she was experiencing at the time it discussion the practitioner has with the patient to convey the fore- was presented. going information is what satisfies the obligation of informed con- sent. However, a properly signed and initialed consent form will A Good Starting Point serve as strong evidence, if ever needed, that the discussion and Obviously, even though a practitioner has the obligation to advise communication necessary to satisfy informed consent took place. ■ of the risks, benefits and alternatives relative to the diagnosis and treatment of a patient, there is also an interest, both on the part of Mr. VanDenburgh is a founding partner of the law firm of Napierski, Vandenburgh the practitioner and the patient, in not creating a circumstance in Napierski, LLP, and specializes in the defense of medical and dental malpractice claims. He can be contacted at (518) 862-9292. which a patient becomes unreasonably fearful or intimidated by the information provided and, as a result, chooses to forego neces- sary care and treatment. With that concern in mind, a subcommit- REFERENCES 1. See, Smith v Fields, 268 AD2d 579 (Second Dept. 2000). A violation of an individual’s tee of the NYSDA Council on Insurance has created a “General “physical integrity,” without consent, exposed the violator to criminal and civil allega- tions of assault and/or battery. Dentistry Consent Form” that can be used by dentists to assist in 2. See, Laskowitz v. CIBA Vision Corp., 215 A.D.2d 25 (2d Dept. 1995). providing information to their patients. The form can be a useful 3. New York State Public Health Law §2805-b(1). starting point for a general dentist to discuss with his or her 4. Memorandum of Henry D. Shereff (Bill Jacket, L. 1975, Chapter CH, 476). 5. DeVivo v. Birnbaum, 301 A.D.2d 622, 623 (2d Dept. 2003). patients various risks, benefits and alternatives that may become 6. Lowery v. Hise, 202 A.D.2d 948 (3d Dept. 1994). relevant somewhere during the course of the patient’s general den- tal care while permitting that information to be presented when the patient’s judgment and objectivity are unlikely to be affected by any fear or concern over imminent treatment. NYSDJ • JUNE/JULY 2008 25 GENERAL DENTISTRY CONSENT FORM (Printable copies of this consent form are available in the Members Only section of the NYSDA Web site, www.nysdental.org, under “Member Resources.”) Dentist: Patient: Dentistry is not an exact science and reputable practitioners cannot properly guarantee results. Despite the most diligent care and precaution, unanticipated complications or unintended results, although rare, may occur. A treatment plan is based on the best evidence available during the examination. There is no guarantee that this plan will not change. During treatment, it may be necessary to change or add procedures because of conditions that were not evident during examination, but were found during the course of treatment. For example, root canal treatment may be needed during routine restorative procedures. Any change in treatment plan may result in additional fees. Guarantees and assurances cannot be made by anyone regarding the dental treatment which you have request- ed and authorized. It is essential that you keep your appointments and cooperate in your treatment to help insure the best possible result. Please read the following and initial and sign where noted. 1. FILLINGS 5. ENDODONTIC TREATMENT (ROOT CANAL) Care must be exercised in chewing on filled teeth, especially on large Although over 90% effective, there is no guarantee that root canal fillings and during the first 24 hours, to avoid breakage. A more exten- treatment will succeed and complications can occur from the treat- sive restorative procedure than originally diagnosed may be neces- ment. Endodontic files and reamers are very fine instruments and can sary, due to more decay than anticipated. Sensitivity can occur fol- separate during use. Additional surgical procedures may be neces- lowing a newly placed filling and will usually go away with time. sary following root canal treatment. Despite all efforts to save it, the (Initials ) tooth may still be lost. (Initials ) 2. CROWNS, BRIDGES AND LAMINATES These restorations involve permanent alteration of the tooth structure. 6. REMOVAL OF TEETH (EXTRACTIONS) It is not always possible to match the color of the natural teeth exact- Teeth may need to be extracted for various reasons, such as non- ly with artificial teeth. Temporary restorations may come off easily. restorability, lack of bone support, part of orthodontic treatment, Care must be taken to insure that they are kept on until the permanent impactions, etc. There are alternatives to the removal of treatable teeth restorations are delivered. The final opportunity to make changes to and these options include root canal treatment, periodontal treatment the new crowns, bridges or laminates (including the shape, fit, size and crowns. Removal of teeth does not always remove the infection, if and color) will be before cementation. It is necessary to keep the present, and further treatment may be necessary. There are risks appointment for permanent cementation. Excessive delays may allow involved in having teeth removed, including, but not limited to pain, for tooth movement, necessitating the remaking of the restoration and swelling, spread of infection, dry socket, loss of feeling in the teeth, lips, additional charges may be incurred. tongue and surrounding tissues (which is usually temporary, but in rare (Initials ) cases is permanent), sinus involvement and jaw fracture. If complica- tions arise during or following treatment, referral to a specialist may be 3. DENTURES (FULL AND PARTIAL) needed, requiring further treatment and additional cost. The wearing of dentures can be difficult. Sore spots, altered speech (Initials ) and difficulty in eating are common problems. Due to jaw ridge loss, retention of full dentures can be a problem. Immediate dentures may 7. DRUGS, MEDICATIONS, AND ANESTHETICS require considerable adjusting and several relines. A permanent reline Antibiotics, analgesics, natural supplements and other medications will be needed later (this is not included in the denture fee). You are can cause allergic reactions such as redness and swelling of tissues, responsible to return for delivery of the dentures. Failure to do so may pain, itching, vomiting and/ or anaphylactic shock. Injections of local result in poorly fitting dentures and remakes will require additional anesthetics can cause paresthesia (numbness) of teeth, lips and sur- charges. Failure to wear partial dentures every day will likely lead to rounding tissues. Though quite rare, this numbness can sometimes be tooth movement, resulting in a partial that no longer fits. permanent. Studies have shown that Bisphosphonate (ex. Fosomax) (Initials ) therapy for osteoporosis can compromise treatment results. (Initials ) 4. PERIODONTAL DISEASE Periodontal disease affects the gums and bone which support the teeth. It is a serious, progressive infection, causing breakdown of the gums and bone and eventual loss of teeth. It is best treated in its early stage. Treatment options may include gum surgery, extractions and Signature of Patient Date replacements. Undertaking any dental procedure may have a future adverse effect on the periodontia. (Initials ) Signature of Dentist Date 26 NYSDJ • JUNE/JULY 2008 Immigrant Families Changing the Face of America And Delivery of Health Care Services H. Barry Waldman, D.D.S., M.P.H., Ph.D. Abstract While there are unique and complex issues in each immigrant 15.7 million U.S. children, including more than 1.5 million experience, there are many common health issues that impose unusual stresses on children and families, including the following: New York State children, live in immigrant families. These ● Depression, grief or anxiety associated with migration and newest arrivals are becoming a critical component of the acculturation. ● Separation from support system. changing demographics of the state’s—and nation’s— ● Inadequate language skills in a society that is not tolerant of evolving population. A complex set of economic, social linguistic difficulties. and cultural factors affect these youngsters and their fam- ● Disparities in social, professional and economic status between the country of origin and the United States. ilies, which, in turn, can have an impact on the delivery of ● Traumatic events, such as war or persecution, which may have health services. occurred in their native country.2 As to oral health status,“Dental problems are common among IN 2005, ALMOST ONE-THIRD (32%) of New York State children immigrant children. In elementary school, immigrant children lived in immigrant families, defined as including 261,000 children have been found to have twice as many dental caries in primary born in foreign countries and 1,187,000 who were born in this teeth as their US born counterparts.”2,4 country and who have at least one foreign-born parent. Throughout the country, there were 15.7 million children in National Highlights immigrant families. “If current immigration levels continue, chil- In 2005, among the 50 states, California (47%), Nevada (32%), New dren in immigrant families will constitute 30 percent of the nation’s York (32%), Texas (30%) and New Jersey (30%) had the highest school population in 2015.”1 Despite efforts to report accurately the proportion of immigrant children; West Virginia and Mississippi U.S. population, census figures are likely to under-report immi- had the lowest proportion (2%). One in every five children in grants because they often fear that participation in the count will immigrant families (2.2. million children) had difficulty speaking alert officials to their possible illegal status.2 Eighty percent of English, ranging as high as 29% in Arkansas. In addition, 4.3 mil- immigrant children were born in the United States (82% in New lion children lived in linguistically isolated households in which no York State) and are entitled to the same support other U.S. citizen person 14 years of age or older speaks English very well. children receive. However, “…linguistic isolation and lack of eco- The expansion of immigrants into new states beyond the tradi- nomic resource put children in immigrant families at greater risk of tional immigrant hubs over the past 10 to 15 years has placed immi- growing up without the opportunities they need to succeed.”1 grant issues on the agendas of policymakers and child advocates 28 NYSDJ • JUNE/JULY 2008 TABLE 1 throughout the nation, and on Children in U.S. Immigrant and Non-immigrant Families: 20051,3 the front pages of the newspa- Number of pers and in the evening news, Children in seemingly, on a daily basis. Immigrant Families Percent In Immigrant In Non- More than two-thirds Average (in 000s) of Children Families Range Immigrant Families (69%) of children in immi- Total 15,657 21% 2% (WV, MS) – 47% (CA) 79% grant families live with at least one parent who works full Below poverty level 3,493 22% 7% (VT)– 37% (NM) 17% Low-income time, year-round. However, for working family 4,953 32% 8% (VT) – 37% (AR) 18% many of these families, a single Single-parent family 3,466 23% 2% (ND) – 34% (RI) 34% job is not enough to provide for Difficulty speaking the family’s basic needs. Nearly English 2,227 20% 2% (ND) – 29% (AR) 1% one in three (32%) of children Median family income $46,500 $31,300 (NM) – $75,200 (NH) $54,700 in immigrant families live in Note: Immigrant children include children born in foreign countries and children born in this country who have at least one low-income working families foreign-born parent (that is, income that was below about $39,600 for a family of four). This compared with 18% of chil- pared to children in U.S. born families (8%).2 dren who live in U.S. born families (Table 1). Immigrant children, especially international adoptees, have The median income of an immigrant family with a child in high rates of developmental delays. Immigrant children often do 2005 was $46,500. Figures ranged from $31,300 in New Mexico to not meet established height-for-age and weight-for-age measures $75,200 in New Hampshire. This compared to a median income of at the time of their entry into the United States. $54,700 for a non-immigrant family with a child (Table 1). Health providers should be aware of the particular medica- A much higher proportion of immigrant children is living in tions or interventions the child is receiving and the family’s tradi- families where no parent has a high school diploma (27%), com- tional medical beliefs. Traditional beliefs that go unacknowledged NYSDJ • JUNE/JULY 2008 29 TABLE 2 may result in patient or family non- Children in New York State Immigrant and Non-immigrant Families: 20051 compliance with provider recommen- Number of dations. Immigrant families also may Children in access traditional health healers Immigrant Children in Children in before seeking the care of convention- Families Immigrant Families Non-Immigrant al practitioners. They may choose to (in 000s) Percent Families NY Ranking* use complementary remedies at any Total 1,448 32% 68% 2nd point in the U.S. health care delivery Below poverty level 319 22% 18% 25th system. In addition, immigrant chil- Low-income working dren might have diseases that are family 388 27% 16% 29th rarely diagnosed in the U.S., such as Single-parent family 441 31% 36% 2nd malaria or schistosomiasis, or dis- Children living in crowded eases that are more common in their households 431 30% 10% 7th country of origin, such as hepatitis A Difficulty speaking infection and amebiasis. English 145 14% 3% 39th Immigrant children may not Median family income $49,100 $60,100 20th have been screened at birth for dis- * Highest state ranking (1) represents highest percent or highest median income. Lowest ranking (50) represents lowest percent or lowest median income. In some categories, there are ties between New York and other states. eases such as congenital syphilis and Note: Immigrant children include children born in foreign countries and children born in this country who have at inborn errors of metabolism. And least one foreign-born parent. many foreign-born children have not been immunized adequately or lack eign-born population. Immigrants, who also tend to have higher documents verifying their immunization status.2 fertility rates than native-born Americans, have helped to offset large domestic migration losses in and around New York City. But New York State Highlights since foreign immigration is much less significant upstate, fewer of “New York City’s … public schools educate many… immigrants from those who leave that region for other states are ultimately replaced.7 more than 200 countries, speaking more than 120 languages.” 5 The major transformation in the state’s population may best be “Since 2005, New York City’s population barely recorded any illustrated by the 2000 Census finding that 28% of New York resi- gain… (but there was) a steady influx of immigrants and growth in dents age 5 and over, compared to 18% of the general U.S. popula- Manhattan and Staten Island.” 6 tion, spoke a language other than English at home.8 Nearly a quarter-million people left New York State for Specifically, regarding New York State children in immigrant other states between mid-2005 and mid-2006, continuing a families: long-term trend in which the state has been a leading demo- ● More than one-in-five (22%), compared to 18% of New York State graphic loser. Approximately 12 out of every 1,000 New York children in non-immigrant families, live below the poverty level. State residents moved elsewhere in the country in the one-year ● More than a quarter (27%), compared to 16% of New York period—nearly double the overall rate of out-migration for the State children in non-immigrant families, live in low-income slow-growing Northeast region. The state’s loss was exceeded working families. only by the out-migration totals for California and hurricane- ● 14%, compared to 3% of New York State children in non-immi- ravaged Louisiana. More than 1.2 million New York residents grant families, have difficulty speaking English. have moved to other states since 2000, the biggest such loss ● The median income of immigrant families with children is experienced by any state.7 $49,100, compared to $60,100 for non-immigrant families An influx of foreign immigrants—over the past six years, the with children (Table 2). state has become home to an additional 820,388 foreign immi- Compared to other states, New York ranks: grants—and the natural gain from births largely offset New York’s ● Second behind California in the highest proportion of children internal migration exodus in the past six years, allowing the popu- in immigrant families. lation to rise slightly, to about 19.3 million. But the state has been ● Second behind Rhode Island in the highest proportion of chil- growing at less than one-third the national rate in this decade. As a dren in immigrant single-parent families. result, the state is on track to slip from third to fourth in state pop- ● Seventh in the highest proportion of children living in crowd- ulation rankings within a few years. New York’s population growth ed immigrant households (Table 2). rate was 1.7% from 2000 to 2006. Only seven other states had lower rates of growth during this decade.7 The Challenge Twenty-one percent of New Yorkers were foreign born as of “US-born minority children were less likely to lack dental insurance 2005, up from 17% in 1995. Only California and Texas have taken in than US-born white children; however,foreign-born Hispanic children more immigrants since 2000, and only California has a larger for- were more likely to be uninsured (for dental services)…Children who 30 NYSDJ • JUNE/JULY 2008 lacked dental insurance were less likely to have received preventive care REFERENCES 1. Annie E. Casey Foundation. Kids Count Data Snapshot: One out of five U.S. children is and more likely to have unmet need for care.”9 living in an immigrant family. Available at: http:www.aecf.org/kidscount/sld/snap- New York City’s public schools may have the diversity of per- shot_immigrant.jsp. Accessed March 23, 2007. 2. DuPlessis HM, Cora-Bramble D. American Academy of Pediatrics Committee on sonnel to assist in the education of immigrants from more than 200 Community Health Services. Policy statement: Providing care for immigrant, homeless, countries, who speak more than 120 languages, and have variations and migrant children. Pediatrics 2005;115:1095-1100. in culture and religions. The same cannot be said for any individual 3. Annie E. Casey Foundation. Kids Count State-Level Data Online. Available at: http:www.aecf.org/kidscount/sld/compare.jsp. Accessed March 23, 2007. dental practice, or, for that matter, larger health facilities, including 4. Pollick HF, Rice AJ, Echenberg D. Dental health of recent immigrant children in the new- hospitals. Nevertheless, the challenge remains to provide needed comer schools, San Francisco. Amer J Public Health 1987;80:861-868. 5. Ellen IG, O’Regan K, Schwartz AE, Stiefel L. Immigrant children and New York City health to an increasing diverse population of patients. Do we really schools: segregation and its consequences. Available at: http://muse.jhu.edu/journals/ have any other choice? brookings wharton_papers_on_urban_affairs/v2002/2002.1ellen.pdf. Accessed March 26, 2007. I recently took a tour of the Lower East Side Tenement Museum 6. Roberts S. Census reports Arizona county still has biggest growth. NY Times, March 22, in Manhattan. The museum recognizes the nation’s urban working 2007; pA18. 7. McMahon EJ, McCall K. Migrating New York Residents Still Heading for the Exits. Empire class immigrant through exhibits based on the lives of the tene- Center for New York Policy. Research Bulletin No. 2, January 2, 2007. Available at: ment residents. Some 7,000 people from 20 countries occupied the http://www.empirecenter.org/pb/2007/01/migrating_new_y.php Accessed March 26, 2007. few apartments in this single building between the years 1863 and 8. Census Bureau. State and County Quick Facts: New York. Available at: http://quick- facts.census.gov/qfd/36000.html Accessed March 23, 2007. 1935. The 92-year-old guide’s words were particularly prophetic. 9. Probst JC, Marin AB, Wang JY, Salinas CF. Disparities in dental insurance coverage and She commented that, “Just like the thousands of immigrant resi- dental care among US children: the National Survey of Children’s Health. Pediatrics 2007, 119 (Suppl) 1:12-21. dents in this former tenement building, within two or three gener- ations, the descendents of today’s immigrants will become like the rest of us. They may even marry our children and grandchildren.” ■ Queries about this article can be sent to Dr.Waldman at email@example.com. NYSDJ • JUNE/JULY 2008 31 Components of oral health program developed by New York University College of Dentistry for New York City Head Start Children. A. Oral health education (tell-show-do). B. Residents teaching toothbrushing techniques. C. Fluoride varnish application. A. B. C. PUBLIC-PRIVATE COLLABORATION to Improve Oral Health Status of Children Enrolled in Head Start in New York City Jill B. Fernandez, R.D.H., M.P.H.; Neal G. Herman, D.D.S.; Linda R. Rosenberg, D.D.S.; Marcia Daronch, D.D.S., Ph.D.; Amr M. Moursi, D.D.S., Ph.D. Abstract Centers for Disease Control and Prevention report an increase in A comprehensive oral health care program for Head Start chil- dental caries in children between ages 2 and 5, from 24% (1988- 1994) to 28% (1999-2004).1 The vast majority of dental caries is dren in New York City is described. Head Start is a federally present in low-income children, who have limited access to treat- funded pre-school program for low-income families and their ment and care. Poor children suffer twice as much dental caries as children. It provides activities that help children grow mentally, children from families with higher incomes; and their disease is socially, emotionally and physically. In 1994, a public-private more likely to be untreated.2 partnership was created between New York Administration for Head Start is a federally funded pre-school program for low- income families and their preschool children. It provides activities Children’s Services and New York University College of that help children grow mentally, socially, emotionally and physi- Dentistry. The program consists of periodic visits to different cally.3 Head Start centers are expected to improve the child’s oral Head Start centers by a dental team composed of pediatric health by collaborating with local dentists or clinics to examine, dentists, residents, hygienists and students. At the center, the diagnose and treat existing oral conditions and by meeting all the Head Start Dental Oral Health Performance Standards.4 Head Start team provides diagnostic and preventive services to children programs have historically faced numerous barriers to accessing and oral health education to children, parents and staff. oral health care for enrolled children. These include limited access Referrals are then made to the College of Dentistry or to a to dentists willing and able to treat low-income children under 5, community provider for treatment and follow-up. Free trans- funding for treatment, transportation, and difficulty educating par- ents about proper oral health practices. portation is provided between Head Start centers and the col- It is imperative that strategies and partnerships be developed lege clinic. Over 13 years, 25,000 children have received to improve the oral health of those who still suffer disproportion- diagnostic, preventive and treatment services. ately from oral disease. New York University College of Dentistry (NYUCD) is the largest dental school in the country, with over 1,200 DENTAL CARIES continues to be the number-one chronic disease dental students and 20 pediatric dentistry residents in training. affecting children, starting at very early ages. Recent data from the The college has had a long history of providing community service 32 NYSDJ • JUNE/JULY 2008 TABLE 1 Description of Oral Health Program for New York City to New York’s neediest, which has always included public school Head Start Children children and Head Start programs. Since 1994, NYUCD has partic- Component Activities performed ipated in a collaborative agreement with the New York City Outreach Extra- and intraoral examination, diagnosis, and Administration for Children’s Services/Head Start to be the pre- treatment plan. ferred dental provider for Head Start children in the New York City Fluoride varnish application. vicinity. The goals of this partnership are: Inreach Comprehensive dental services provided at the NYUCD 1. Create a public/private collaboration to facilitate oral health pediatric dental clinic (or appropriate referral). Transportation: provided free by NYUCD to transport care for Head Start children in New York City. children from 12 sites to the College. 2. Assist in program compliance with Head Start’s federal man- Education Education workshops on oral health promotion to date for oral exams and follow-up care. children, parents and Head Start staff. 3. Educate dental and dental hygiene students and pediatric den- Developed an online interactive education course tal residents about the necessity and importance of communi- funded by NYS Dental Foundation for Head Start staff ty involvement through service learning. (www.nypartnersinoralhealth.com). 4. Increase the College of Dentistry pediatric patient pool. Training Service learning for dental students, dental hygiene students and pediatric dentistry residents. This article describes the program developed by NYUCD to Early clinical experiences with preschool, underserved improve New York City Head Start children’s oral health. population for 2nd-year dental students. CE courses for general practitioners in early childhood Methods oral health practice. The NYUCD developed a comprehensive oral health program for Advocacy Host annual orientation meeting at NYUCD for Head Head Start children, including educational, preventive and treatment Start directors and staff. services. The components of the program consist of the following: NYUCD representative on Head Start Health Services Advisory Committees. ● Outreach—performed on site at Head Start centers, with daily Provide free service for those unable to pay through visits scheduled every day from September through July. funds from the New York City Council. ● Inreach—treatment provided at the NYUCD pediatric post- graduate dental clinic. All services performed are billed through Medicaid, HMO or ● Education—to Head Start children, parents and staff. other dental insurance. Uninsured patients may be eligible for free ● Training—to NYUCD dental and dental hygiene students and care funded by a New York City Council grant. No child is excluded pediatric dentistry residents. from care because of an inability to pay for treatment. Billing helps A detailed description of each project component is described defray the cost of salaries, transportation and supplies. This has in Table 1. become a cost-effective model for delivery of care. Head Start cen- A team consisting of faculty of the Department of Pediatric ters assist with administration of paperwork, gathering billing Dentistry, pediatric dentistry residents and dental students provides information and providing a community service experience for our diagnostic and preventive services, such as oral examination, fluoride students and residents. varnish application and oral health education,to children from infancy to 5 years of age at Head Start centers in the New York City vicinity.We Results and Discussion often use the classroom or conference room where a team of six Since its inception in 1994, over 25,000 children have benefited providers can see up to 96 children in four hours.Appropriate treatment from the program, receiving oral examinations, preventive services referrals are made to either the College of Dentistry or a community and oral health education, with many children receiving follow-up provider.Oral health workshops are also offered to parents and staff.For families without a den- tal provider, NYUCD provides free transporta- tion to bring the children and their parents to the College of Dentistry for comprehensive care. The program has been expanded and the staff modified over the years to accommodate the increased demand of Head Start centers. The NYUCD administration supports this program by providing funds for salary,transportation and sup- plies.At this time,there is one full-time Head Start program administrator and one full-time dental hygienist under faculty supervision by the director of pediatric outreach and preventive programs. Figure 1. Number of New York City Head Start Children Examined and Needing Treatment Per Year NYSDJ • JUNE/JULY 2008 33 services at the College of Dentistry clinic. Figure 1 presents data on the number of children seen from 2000 to 2007. The dramatic increase in the number of children examined in 2003-04 was due to an increased number of providers dedicated to the program. Currently, over 70 Head Start centers are serviced, reaching approx- imately 5,000 children a year. The inreach component provides over 400 annual visits. Additionally, from a dental education perspec- tive, pediatric dentistry residents and dental students have gained valuable community-based training working in underserved areas with high-risk populations. The 2006-2007 New York State Head Start Program Information Report data indicated that nearly 93% of Head Start children received dental examinations, and that 20% needed follow-up treatment. Of these, 84% received some follow-up care. At the NYUCD Head Start sites, 25% of the children seen needed follow- up care. At this time, NYUCD services approximately 17% of chil- dren enrolled in New York City Head Start programs. Our goal is to help provide coverage to as many of these children as possible. Recently, the outreach program was expanded to include Head Start children in the U.S. Virgin Islands (USVI), as Head Start pro- grams there were unable to meet their federal mandates to have all children examined by a dentist and receive follow-up care if neces- sary. A collaboration of NYUCD, the Region II Office of Head Start, and the USVI departments of Human Services and Health was for- malized in March 2007 to ensure that more than 900 children in the programs would get the required oral health care services. As a short-term solution, NYU pediatric dentistry faculty and residents travel twice a year to the USVI to provide examinations, preventive interventions, and restorative and surgical care to the Head Start children, oral health education to parents and Head Start staff, and continuing dental education to the island’s dentists and other pedi- atric health care providers. Conclusions This program demonstrates a successful public-private partner- ship to reduce the barriers Head Start programs face in accessing oral health care for their children. It also helps Head Start programs comply with their national Oral Health Performance Standards. Additionally, the NYUCD benefits by increasing its pool of young dental patients and providing educational opportunities for pedi- atric dentistry residents and dental students. ■ The authors thank Ms. Elizabeth Best for her assistance in the preparation of this manuscript. Queries about this article can be sent to Ms. Fernandez at firstname.lastname@example.org. REFERENCES 1. Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, et al. Trends in Oral Health Status: United States, 1988–1994 and 1999–2004. National Center for Health Statistics, Vital Health Stat, 2007, series 11. 2. U.S. Department of Health and Human Services, Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000, p.2-3. 3. Head Start Bureau. About Head Start. In Head Start Bureau [Web site]. Cited November 19, 2007; available at www.acf.hhs.gov/programs/hsb/about/index.htm. 4. Head Start Bureau. Program Performance Standards and Other Regulations. In Head Start Bureau [Web site]. Cited November 19, 2007; available at www.acf.hhs.gov/pro- grams/ hsb/performance/index.htm. 34 NYSDJ • JUNE/JULY 2008 Oral Side Effects of Isotretinoin Chronic Intake Moacyr T.V. Rodrigues, D.D.S., M.Sc.; Danielle F. Albuquerque, D.D.S., M.Sc.; Ana Lúcia A. Capelozza, D.D.S., Ph.D.; Flávio A.C. Faria, D.D.S., Ph.D.; Carlos F. Santos, D.D.S., Ph.D. Abstract For many patients with severe conglobate disease, isotretinoin is a Isotretinoin (13-cis-retinoic acid) is a retinoid that has been miracle drug.1 It is usually administered for four to six months, and then is withdrawn; yet, often, the beneficial effects continue.1,2 This used for the past 20 years to treat a variety of dermatolog- agent brings about a dramatic reduction in size and output of seba- ic conditions. It is beneficial in many skin conditions, ceous glands, essentially reversing the effect of androgens on these structures. There is also a modulation in keratinocyte maturation although its side effects and toxicity require careful moni- and adhesion, which reduces the formation of comedones.2 toring by physicians and other health professionals, among Other diseases can also be treated with isotretinoin.Acneiform them, dentists, who should be prepared to manage an conditions, such as rosacea, inflammatory sequelae of rosacea, fol- liculitis and hidradenitis, respond to isotretinoin.3 Disorders of adverse occurrence. In this paper, the oral side effects of cornification, such as ichthyoses, keratodermas, Papillon-Lefevre isotretinoin are described; and some of them are illustrated. syndrome and Darier’s disease, also respond to oral isotretinoin.3 Psoriasis, lupus erythematosus, lichen planus, sarcoidosis, papillo- RETINOIDS, BOTH NATURALLY occurring and synthetic, are vit- matosis have been treated with this drug with varying degrees of amin A derivatives. The widespread use of retinoids requires that success.3,4 Neoplastic processes have improved during isotretinoin not only dermatologists but other health professionals, as well, treatment, which has also been safely used to treat various HIV- must be aware of the wide spectrum of side effects associated with associated dermatoses.3 their use. This includes dentists, who need to be particularly alert Retinoids are also effective in the treatment and reversal of to the mucocutaneous reactions that develop in almost all patients cutaneous damage from chronic sun exposure.5 Systemic retinoids who receive these drugs. have been used in chemoprophylaxis of skin cancer as a suppres- Isotretinoin is among the most orally prescribed retinoids. Its sive agent in cutaneous malignancies. Their ability to convert use has been successfully documented in the treatment of severe undifferentiated lesions have made them useful in many different nodular acne. It is a first-generation synthetic vitamin A derivative. fields of medicine, primarily to combat cancer.6,7 36 NYSDJ • JUNE/JULY 2008 1A Mucocutaneous Side Effects Mucocutaneous reaction is the most commonly observed adverse side effect of isotretinoin use. The majority of these symptoms are tolerable, treatable and dose-dependent. Cheilitis is the most com- mon manifestation and occurs in virtually all patients who receive isotretinoin therapy. It generally requires continual application of topical emollients.1,8 Cheilitis encompasses lip dryness, chapping and fissuring (Figures 1A, 2, 3A, 4). Lubrication of the anterior nares is often required to alleviate dry nasal mucosa, which may cause nosebleeds in up to two-thirds of patients during treatment. Less than one-half of patients will experience clinically significant xerosis, which is often associated with significant pruritus.1 1B Many of the acute mucocutaneous side effects (for example, cheilitis and xerosis) are dose-dependent. Atrophy and skin fragili- ty also occur during isotretinoin therapy. It is recommended that patients avoid dermabrasion for at least six months after comple- tion of isotretinoin therapy.2 Acne fulminans with destructive hem- orrhagic lesions, leukocytosis, polyarthralgia and fever are rarely precipitated by isotretinoin.9 Treatment should be halted in patients exhibiting mucocuta- neous reactions, and systemic steroids should be given in cases of acne fulminans.9 Diffuse thinning of the hair and increased brittle- ness of the nails can occur with isotretinoin therapy, although these symptoms are more common with acitretin. They generally occur within three to eight weeks of therapy and cease six to eight weeks after stopping the drug therapy. Persistent alopecia was reported in 2 out of 720 patients who were followed long term.10 Isotretinoin has a half-life of 22 hours; its bioavailability is Figure 1. 20-year-old man with nodular acne started oral daily regimen of isotretinoin (30 mg/day; 0.375 mg/kg) for 12 months. Clinical features 10 months after approximately 25%—however, this can be increased one- to two- beginning isotretinoin therapy: swelling of lips; chapping; fissures; soft fold by taking it with food. Although peak blood concentrations perioral erythema; edema (1A); and 1 month after end of treatment (1B). occur one to four hours after ingestion, the role of peak concentra- tion in the development of side effects is unknown.8 Vitamin E ( -tocopherol) administered at 800 IU daily has been reported to prevent many of the retinoid-induced mucocuta- neous side effects that occur during high dose (> 150 mg/day) oral retinoid therapy for myelodysplastic syndrome. Cheilitis decreased from 100% to 30%; and there was a 75% decrease in myalgias and arthralgias and a normalization of plasma transaminases and triglycerides. Anecdotal reports suggest that this combination is beneficial in cutaneous retinoid therapy; however, the effect of vit- amin E on isotretinoin efficacy has not been fully evaluated.11,12 Relief of Oral Side Effects Cheilitis affects 80% to 90% of patients treated with isotretinoin.13 Bland emollients, such as petrolatum, lanolin, dexpanthenol and chap sticks, are routinely recommended for every one of these patients. But these agents offer only mild and temporary relief.13,14 Concomitant administration of vitamin E has not been shown Figure 2. 16-year-old man with nodular acne started oral daily regimen of isotretinoin (20 mg/day; 0.285 mg/kg) for 5 months. Clinical features 3 months to be effective in decreasing mucocutaneous side effects associated after beginning isotretinoin therapy: swelling of lips; chapping; soft perioral with isotretinoin therapy.15 Some authors have observed great erythema; edema. NYSDJ • JUNE/JULY 2008 37 3A improvement in isotretinoin-associated cheilitis with the use of 5% dexpanthenol cream.15 The emollients are applied on the lips, two to three times a day, preferably after meals. Patients describing dry- ness of nasal mucosa or epistaxis are also instructed to apply the emollients on these areas. Extremely dry and scaly skin can be treated the same way during the entire course of treatment with isotretinoin.15 Discussion There is a paucity of data in dental literature regarding the oral side effects of systemic isotretinoin. It is important to clarify that not all patients will develop such symptoms. Isotretinoin has long been used to treat patients with acne and skin diseases.1,2,9 The onset of cheilitis, often described as the hall- 3B mark of isotretinoin therapy, generally occurs during the first few days of treatment and persists throughout the course of therapy.9 These mucocutaneous reactions are dose-dependent, and clinical features vary by individual. Severe mucosal reactions include mucosal denudation, exu- dation and secondary infection.16 Mild and moderate reactions are desquamation and xerosis in the lips, which eventually could develop fissures (Figures 1A, 2, 3A). These reactions should be managed only with topical emollients to prevent lip dryness and to protect the fissuring area. After one month of topical emol- lient, patients reported a reduction in pain and normal func- tion.3,9,16 Spontaneous regression of oral side effects is observed after the end of the treatment with systemic isotretinoin3,13,16 (Figures 1B, 3B). Adverse side effects are secondary to retinoid-induced changes Figure 3.18-year-old man with nodular acne started oral daily regimen of isotretinoin (40 mg/day; 0.5 mg/kg) for 8 months. Clinical features 3 months after in the skin and mucosa and profound decreases in sebum secretion. beginning isotretinoin therapy: swelling of lips; chapping; fissures; soft perioral Electron microscopic epidermal changes include: decreases in erythema; edema (3 A); and 3 months after end of treatment (3B). desmossomes; a disorganized, attenuated keratinized cell envelope; and increased intercellular deposits.16,17 The various biologic effects of retinoids are a result of their profound effects on DNA transcrip- tion.2,3,12 The activity of retinoids is mediated through the binding of nuclear retinoid receptors, which are functionally and structurally related to a superfamily of nuclear DNA transcription factors that includes steroids, vitamin D and thyroid hormone receptors. Therefore, retinoids act like hormones, producing a variety of cellu- lar modulations through alterations in DNA transcription.3 Adverse reactions involving skin and mucous membranes, cardiorespiratory, gastrointestinal, genitourinary, nervous and musculoskeletal systems, eyes, ears, anemia due to B12 and folate deficiency, and serum lipid level changes have been the most com- monly reported side effects.3,13,18-20 Depression, psychosis, fixation on suicidal thoughts, and aggressive and/or violent behaviors may occur during treatment with isotretinoin, and could continue after treatment has ended. In such cases, psychiatric evaluation may be necessary.3 Figure 4. 38-year-old woman with nodular acne started oral daily regimen of isotretinoin (20 mg/day; 0.333 mg/kg) for 3 months. Clinical features 1 month Finally, pregnant women must avoid isotretinoin intake due to after beginning isotretinoin therapy: chapping; soft swelling of lips. its teratogenicity.3,13 38 NYSDJ • JUNE/JULY 2008 Conclusions 7. DiGiovanna JJ. Retinoid chemoprevention in the high-risk patient. J Am Acad Dermatol 1998;39:S82-5. Dentists should be aware of the potential oral side effects of the sys- 8. Almond-Roesler A, Blume-Peytavi U, Bisson S, Krahn M, Rohloff E, Orfanos CE. temic use of isotretinoin. They also must be prepared to treat such Monitoring of isotretinoin therapy by measuring the plasma levels of isotretinoin and 4- oxo-isotretinoin. Dermatology 1998;196:176-81. manifestations, which include lip dryness, chapping, fissuring, 9. Jansen T, Pelwig G. Acne fulminans. Int J Dermatol 1998;37:254-7. mucosal denudation and exudation in severe cases. All of these 10. Silverman AK, Ellis CN, Voorees JJ. Hypervitaminosis A syndrome: a paradigm of reactions should be managed basically with topical emollients retinoids side effects. J Am Acad Dermatol 1987:16:1027-39. 11. De Marchi MA, Maranhão RC, Brandizzi LIV, Souza DRS. Effects of isotretinoin on the and/or corticosteroids. ■ metabolism of triglyceride-rich lipoproteins and on the lipid profile in patients with acne. Arch Dermatol Res 2006;297:403-408. 12. Georgala S, Papassotiriou I, Georgala C, Demetriou E, Schulpis KH. Isotretinoin therapy Queries about this article can be sent to Dr. Santos at email@example.com. induces DNA oxidative damage. Clin Chem Lab Med 2005;43:1178-82. 13. Maclane J. Analysis of common side effects of isotretinoin. J Am Acad Dermatol 2001;45:S188-94. REFERENCES 14. Romiti R, Romiti N. Dexpanthenol cream significantly improves mucocutaneous side 1. Leyden JJ. The role of isotretinoin in the treatment of acne: personal observations. J Am effects associated with isotretinoin therapy. Pediatr Dermatol 2002;19:368. Acad Dermatol 1998;39:S45-9. 15. Strauss JS, Gottlieb AB, Jones T, et al. Concomitant administration of vitamin E does not 2. Goldfarb MT, Ellis CN. The uses of retinoids in dermatology. Curr Opin Dermatol change the side effects of isotretinoin as used in acne vulgaris: a randomized trial. J Am 1997;4:236-40. Acad Dermatol 2000;43:777-784. 3. Ellis CN, Krach KJ. Uses and complications of isotretinoin therapy. J Am Acad Dermatol 16. Graham BS, Barret TL. Mucosal denudation of the lips from isotretinoin therapy. Arch 2001;45:S150-7. Dermatol 1999;135:349-50. 4. Scardina GA, Messina P, Carini F, Maresi E. A randomized trial assessing the effective- 17. Elias PM. Epidermal effects of retinoids: supramolecular observations and clinical ness of different concentrations of isotretinoin in the management of lichen planus. Int implications. J Am Acad Dermatol 1986:15:797-809. J Maxillofac Surg 2006;35:67-71. 18. Magin P, Adams J, Heading G, Pond D, Smith W. Patients’ perceptions of isotretinoin, 5. Pirard GE, Kligman AM, Stoudemayer T, Leveque JL. Comparative effects of retinoic depression and suicide. Aust Fam Physician 2005;34:795-7. acid, glycolic acid and a lipophilic derivative of salicylic acid of photo-damaged epider- 19. Jasim ZF, McKenna KE. Vitamin B12 and folate deficiency anaemia associated with mis. Dermatology 1999;199:50-3. isotretinoin treatment for acne. Clin Exp Dermatol. 2006 Jul;31(4):599. 6. Craven NM, Griffiths CE. Retinoids in the management of non-melanoma skin cancer 20. Yazici AC, Baz K, Ikizoglu G. Recurrent herpes labialis during isotretinoin therapy: is and melanoma. Cancer surv 1996;26:267-88. there a role for photosensitivity? J Eur Acad Dermatol Venereol. 2006 Jan;20(1):93-5. NYSDJ • JUNE/JULY 2008 39 Sinus Graft Complications P R O B L E M S O LV I N G Ira D. Zinner, D.D.S., M.S.D.; Herbert J. Shapiro, D.D.S.; Scott D. Gold, M.D. Abstract tions may be recognized during the initial laryngologist. No grafting should be Restoration of the posterior maxilla diagnostic phase. A CT scan of the posteri- attempted until any sinus problem is or maxilla is essential to rule out maxillary resolved. Resolution may involve antibi- involving sinus bone grafting demon- sinus disease and to determine the quanti- otics as well as endoscopic sinus surgery. In strates both surgical and prosthetic ty and quality of residual bone beneath the the event of an inadvertent laceration or sinuses. This scan should include the puncture of the Schneiderian membrane problems that treating clinicians osteo-meatal complex, since the proposed and inoculation of the maxillary sinus with should recognize and explain to graft must not encroach on this area. The oral bacteria, a healthy sinus with a patent osteum is usually 35 mm superior to the osteo-meatal complex will usually remove patients prior to any invasive treat- floor of the maxillary sinus. Radiographic the offending bacteria and remain healthy. ment. If a sinus graft is lost, the alter- imaging of the osteo-meatal complex is A similar scenario with entry into the natives to treatment are explained. crucial in order to fully evaluate the physi- maxillary sinus in a patient with a blocked ologic health of the maxillary sinus and its osteo-meatal complex often leads to chron- However, if the practitioners follow a likelihood of avoiding infection following ic infection and may require endoscopic step-by-step protocol and use retriev- maxillary bone grafting. surgical correction and restoration of Maxillary sinus health depends on the patency of the blocked osteo-meatal com- able prostheses, a long-term, favor- normal mucociliary flow that transports plex. When the osteo-meatal complex is able prognosis results. the protective mucous blanket lining the patent, the sinus will usually heal unevent- maxillary sinuses along with trapped cont- fully, including spontaneous closure of any THERE ARE NUMEROUS publications aminants, including bacteria, viruses and oral antral fistula (Figures 1-4). devoted to the surgical and prosthetic reha- mold, to the superiorly placed osteo-meatal The patient should be told at the bilitation of the posterior maxilla. If there complex and then into the nasal cavity and, beginning of treatment about a long-term are no complications during and after a eventually, into the stomach for destruction treatment plan/schedule. The risks and sinus bone graft, there is a favorable prog- and elimination. benefits of restoration of the posterior nosis for long-term survival of the implants If there is any acute or chronic sinus maxilla need to be explained clearly to the and prostheses. However, future complica- disease, this should be treated by an oto- patient. It should not be assumed that sinus 40 NYSDJ • JUNE/JULY 2008 lift implants are a one-shot experience. three weeks of initial healing. According to They involve long-term treatment with the consensus, loss of implants usually step-by-step advancement to ascertain suc- occurs prior to loading because of encroach- cess before any thought is given to placing ment by the removable prosthesis on the the definitive prosthesis. surgical sites. Other causes of failure include smoking, bruxism and occlusal trauma from Figure 1. Panorex radiograph illustrating three Minimizing Invasion the provisional prosthesis.1,2 implants displaced into sinus by patient inserting complete maxillary denture immediately after leaving If there is enough residual bone beneath the surgeon’s office on day of simultaneous graft and implant placement. maxillary sinus to stabilize the implant bod- Step-by-Step Procedure ies, then simultaneous surgical placement of The following protocol should be followed in the selected graft material and implants may order to reduce or avoid complications. be performed. The advantage of this partic- Smoking is a contraindication for sinus lift ular surgery is that the patient has only one procedures. If the patient does not or cannot invasive experience.The graft used is a com- stop smoking for a period of time, then sinus posite of autogenous bone, Bio-Oss and a grafting should not be attempted.Peter Moy et Bio-Gide membrane (Osteo Health Inc., Shirley, al.2 created a smoking cessation protocol to NY), using a modified Caldwell-Luc surgical allow sinus grafting in smokers. A diagnostic approach. Sinus graft surgery has advanced wax-up is created of the desired result prior to in the past few years with the use of PRP any surgery.From this accepted wax-up,a sur- Figure 2. Preoperative panorex radiograph of patient requiring bilateral sinus grafts and complete (plasma rich protein), different graft materi- gical template is fabricated with buccal groov- maxillary arch implant-supported prosthesis. als and Piezo surgery; it may soon use BMP- ing to guide the surgeon in implant place- 2 (bone morphogenic protein). ment.This will permit the occlusion to be fab- The use of PRP has made grafts more ricated so it can be directed in the long axes of stable in the sinus even if perforations do the implant bodies and, thus, will reduce occur, which is not usual. The use of Piezo bending moments around these implants. surgery has allowed for the opening of the If possible, a fixed, first-stage metal- lateral window and made lifting of the and-acrylic-cemented provisional prosthe- sinus membrane easier and with fewer per- sis should be used. This is inserted the forations. The graft should be 18 mm high. same day as the surgery. Its use has several Figure 3. Panorex radiograph after bilateral sinus The implants used are 15 mm-by-4 mm. major advantages, such as protection of the lifts and placement of three implants into each maxil- lary sinus. Metal-and-acrylic-cemented fixed provi- They must be allowed to integrate without surgical site and prevention of micro move- sional prosthesis is inserted after surgery and loading for nine months. The implant bod- ment of the freshly placed implants.3 If a relieved so as not to touch on surgical sites. ies used may be either screw-type or press- removable transitional prosthesis is used, fit, depending upon the choice of the sur- it should have a cobalt-chrome framework geon. Problems may occur if the implants and the denture base area should be able to are TPS or HA-coated. Once there is soft be relined frequently with tissue condition- tissue recession and the coating is exposed ers or soft liners. In addition, it must not be to the oral fluids, loss of the graft material inserted for three weeks after surgery in around these implant bodies will occur. order to allow for initial healing and, thus, The Academy of Osseointegration held avoid micro movement of the implants and a Sinus Lift Consensus Conference in 1996. dehiscence of the soft tissues around these It was determined that use of a first-stage implants bodies, created by pressure from Figure 4. Panorex radiograph after losing right removable provisional prosthesis created the removable partial denture base. maxillary implants and graft, result of surgery being performed when there was presence of right chronic problems and/or implant failures if it was Periodic observation of the surgical maxillary sinusitis and tearing membrane, and not inserted too soon after surgery—less than sites needs to be done to ensure that the repairing it prior to graft and implant placement. Maxillary right bicuspid implant was not removed at three weeks minimum. This occurred usu- bone is healing and no infection occurs this time, to support provisional prosthesis until ante- rior implants were placed, integrated and incorporat- ally when the prosthesis was not repeatedly around the newly installed implants and ed into prosthesis. Right bicuspid implant was refitted with soft tissue conditioners after graft. This monitoring should be done by removed and bone graft placed. NYSDJ • JUNE/JULY 2008 41 then accomplish the same procedure out- The impact of functional and parafunc- side the mouth. However, because of inac- tional forces of occlusion on a sinus bone curacies of the impression materials and graft requires that the restorative dentist transfers, the prosthesis should be sec- ensure that the definitive implant prosthe- tioned, the portions screwed in place and sis does not increase it.8 Therefore, since then luted intraorally. histomorphic biopsies have shown that With both methods, the finishing of the there is 55% new bone growth after three Figure 5. Panorex radiograph after placement of prosthesis is accomplished outside of the years2 and following the protocol originally 18 mm pterygoid plate implant to salvage right pos- patient’s mouth. The occlusion is carved so, devised by Branemark and Skalak, the terior section. Patient never told surgeon she had chronic maxillary sinusitis, which required sinus at first, there is light contact only in centric veneering material on the occlusal surface surgery. Porcelain-fused-to-gold retrievable occlusion and no contact in eccentric move- of the definitive prosthesis should be heat- prosthesis was fabricated and inserted. Right posterior section will be restored and incorporated ments. The prosthesis should then be rein- cured acrylic resin.7,9-12 The centric occlusal into porcelain-fused-to-gold prosthesis after forced with a stiff metal lingual reinforce- contacts at the occlusal vertical dimension exposing pterygoid plate implant. ment bar to avoid changes in the positions of are maintained by the gold screw access the provisional cylinders. Vertical bitewing channels, which have been waxed into parallel cone radiographs should be taken to occlusion. The occlusal tables are nar- verify the prosthetic interface. Screw access rowed, the cusp heights are minimal, and channels are sealed with cotton and tempo- the eccentric contacts reduced or eliminat- rary stopping, Cavit or Fermat. ed. This is in reality a complete denture, and the occlusal scheme should simulate a Need for Provisional Prosthesis lingualized denture occlusion.13,14 This provisional prosthesis should be worn Occlusal forces are directed within the for at least one year to permit the composite long axes of the implant bodies.13 After a Figure 6. Panorex radiograph of maxillary implant- graft to mature. It allows time for graft mat- period of time, over 6 to 10 years, the supported prosthesis inserted over 20 years ago. Left pterygoid plate implant was placed after loss uration and for healing of the soft tissues. It occlusal surfaces can be changed into gold, of left maxillary sinus implant. also acts as a fail-safe method for the den- as long as there has been no appreciable tist in case one of the implants starts to fail bone loss. For patients and/or dentists who and the graft or maxillary sinus becomes desire to use facial porcelain, the procedure the surgeon and the prosthodontist and/or infected. If the patient begins smoking published by Fredrickson et al. may be restorative dentist. again, this sinus and the graft can become used.15 It involves casting the prosthesis in Depending upon the graft material infected and implants may be lost. gold-palladium ceramic alloy. The occlusal used, the implant bodies are usually uncov- The contours of the provisional pros- and palatal surfaces are prepared to receive ered after six or nine months.4 On the day thesis should be carved to simulate the heat-cured acrylic resin and the facial sur- of second-stage surgery, abutments are contours and embrasures of the planned- face is carved to have porcelain veneering. installed and a new screw-retained, metal- for definitive prosthesis. Two or three After soldering the cast individual reinforced provisional prosthesis should be weeks following insertion of the provision- units together and verifying the occlusion fabricated and inserted. The acrylic portion al prosthesis, impressions are taken with an and connections with the one-screw test, of this provisional prosthesis is created open tray, and waxing pins are used to the facial surface may have the appropri- prior to second-stage surgery by using secure the transitional prosthesis. A cast is ate shade of porcelain baked on. This heat-cured acrylic resin. poured and mounted on a semi-adjustable should be checked intraorally and alter- After installing abutments, the restora- articulator using verified maxillo- ations made where needed. Then heat- tive dentist uses manufactured metal alloy mandibular records. The occlusion is then cured acrylic resin of the same shade is cylinders, and sandblasts and paints acrylic refined on the articulator and the prosthe- baked on the occlusal and palatal sur- opaque over the outside metal to mask the sis is reinserted intraorally. The patient faces. To avoid problems while curing the silver color. The cylinders are screwed in should be monitored for one year.5,6,7 acrylic resin during the flasking and place with the appropriate waxing pins. The Ideally, any problems resulting from deflasking procedures, silicone or plaster previously fabricated acrylic resin portion the surgery or from the prosthesis will indices are used after waxing the palatal of the prosthesis is cut to fit around the occur prior to beginning the definitive and occlusal surfaces. No processing flask metal cylinders intraorally. They are then implant prosthesis so that corrections can is used, thus eliminating the problems luted to the cylinders with auto-polymeriz- be made then. If the beginning of a prob- inherent in the deflasking procedure. The ing acrylic resin intraorally. An alternative lem is noted, the use of the second-stage acrylic resin is processed in a heat- and method is to take an impression of the abut- provisional prosthesis should be extended compressed-air machine such as the ments after installation, pour a cast and until all problems are resolved. Ivomat (Ivoclar/Vivadent Corp.). On average, 42 NYSDJ • JUNE/JULY 2008 the occlusal acrylic is usually reprocessed Summary 11. Skalak RS. Biomechanical considerations in osseointe- after 10 years, or this surface may be Problems associated with restoration of the grated prostheses. J Prosthet Dent 1983; 49:843-848. 12. Skalak R. Aspects of Biomechanical Considerations. In rebuilt into cast gold alloy. posterior maxilla to rehabilitate this dental Branemark P-I, Zarb GA, Albrektsson T, eds. Tissue- Problems can occur following inser- arch to optimum function and achieve a Integrated Prostheses: Osseointegration in Clinical Dentistry. Chicago:Quintessence, 1985:117-128. tion of the prosthesis, as well as after surgi- favorable prognosis requires that the prac- 13. Gracis SE, Nicholls JI, Chalupnik JD, Yuodelis RA. cal placement of the implant bodies. titioner use a step-wise protocol in order to Shock-absorbing behavior of five restorative materials avoid complications during the several used on implants. Int J Prosthodont 1991; 4:282-291. Preciseness of the prosthetic interface is a 14. Lang BR, Razzoog ME. Lingualized integration: tooth necessity,16 as is the skill of graft and phases of reconstruction. The fail-safe for molds and an occlusal scheme for edentulous implant the clinician is use of long-term, provision- patients. Implant Dentistry 1992;1:204-211. implant placement by the surgeon. A surgi- 15. Fredrickson EJ, Stevens PJ, Gress ML. Implant Prostho- cal template is needed to avoid implant ally fixed, retrievable prostheses. ■ dontics, Clinical and Laboratory Procedures. St Louis: placement that creates a restorative and Mosby, 1995:84-113. Queries about this article can be sent to Dr. Zinner at 16. Binon PP. Evaluation of machining accuracy and consis- longevity problem. Retrievability is neces- tency of selected implants, standard abutments and 115 E. 61st St., New York, NY 10021. sary to avoid problems and to enable the laboratory analogues.Int J Prosthodont 1995; 8:162-178. 17. Finger IM, Block MS, Salinas TJ. Treatment of a practitioner to inspect the implant compo- resorbed maxilla with sinus grafting, implants and a nents periodically. Gingival recession REFERENCES spark erosion overdenture: a clinical report. Implant 1. Jensen O.Report of the Sinus Graft Consensus Conference. Dent 1992;1:150-153. occurs after several years. The patient Presented at the Academy of Osseointegration Annual 18. Graves, SL. The pterygoid plate implant: a solution for should be told this prior to implant place- Meeting, San Francisco. March 1997. restoring the posterior maxilla. Int. J Periodont Rest 2. Bain CA, Moy PK. The association between the failure Dent 1994;14:6:513-523. ment. The patient also needs to be told of dental implants and cigarette smoking. J Oral 19. Stella JP, Warner MR. Sinus slot technique for simplifi- about the risks and benefits of incorporat- Maxillofac Implants 1993; 8:609-615. cation and improved orientation of zygomaticus dental ing a sinus graft surgically; and the pros- 3. Small SA.Troubleshoot and Managing Surgical Problems. implants: a technical note. Int J of Oral Maxillofac In Zinner, Panno, Small, Landa, eds. Implant Dentistry: Implants 2000;15(6):889-93. thetic reconstruction, either in a partially From Failure to Success. Carol Stream, IL: Quintessence 20. Boyes-Varley JG, Howes DG, Lownie JF. The zygomati- edentulous or completely edentulous max- Publishing Co, Inc 2004, Chapter 4, pages 51-59. cus implant protocol in the treatment of the severely 4. Small SA, Zinner ID, Panno FV, Shapiro HJ. resorbed maxilla. SADJ 2003; 58(3):106-9, 113-4. illary arch, should be explained carefully to Augmentation of the maxillary sinus for implants: 21. Bedrossian E,Stumpel L 3rd,Beckely ML,Indresano T.The the patient. report of 27 cases. Int J Oral Maxillofac Implants 1993; zygomatic implant: preliminary data on treatment of 8:523-528. severely resorbed maxillae. A clinical report (erratum If a sinus graft does fail, there are four 5. Zinner ID, Landa, LS. Second-stage, Screw-retained appears in Int J Oral Maxillofac Implants.2003; 18(2):292). methods for management. First, the area Provisional Prostheses.In Zinner,Panno,Small,Landa,eds. Intl J of Oral Maxillofac Implants.2002;17(6):861-5. Implant Dentistry: From should be cleaned out and any infection Failure to Success. Carol cleared up, surgically and with medication. Stream IL: Quintessence Ensure that the sinus did not become Publishing Co, Inc, 2004, Chapter 5,pages 61-80. infected. If it did, then this must be treated 6. Zinner ID, Small SA. by an otolaryngologist prior to further den- Maxillary Sinus Grafts and Prosthetic Management.In tal treatment. Zinner ID,Panno FV,Small Once the area is infection free and SA,Landa LS,eds.Implant Dentistry: From Failure to healed, the patient can have one of the fol- Success. Carol Stream, IL: lowing: a removable prosthesis to restore Quintessence Publishing Co, Inc. 2004: pages 33-49, the posterior maxilla;17 a fresh sinus graft 61-80,99-115. and implant placement; a pterygoid plate 7. Zinner ID, Small SA. implant;18 or a zygomaticus implant may Sinus-lift graft: using the maxillary sinuses be surgically placed and the arch restored to support implants. J with a retrievable prosthesis.19,20,21 If the Am Dent Assoc 1996; 127:51-57. span from the most posterior maxillary 8. Tatum H Jr.Maxillary and implant that is remaining is in the first or sinus implant reconstruc- tions. Dent Clin North second bicuspid region, then it is prefer- Am 1986; 30:207-229. able to use a pterygoid plate implant17 and 9. Zinner ID. Provisional and definitive sinus lift not invade this maxillary sinus (Figures prosthodontics. Presented 5, 6). After uncovering this 18 mm or 20 at the International mm long screw type implant, the patient’s College of Prosthodon- tists Biennial Meeting, second-stage provisional prosthesis San Diego, 1995. should be altered and added to include 10. Misch CE. Density of bone: effect on treat- the new implant or implants. This is again ment plans, surgical worn for about one year prior to refur- approach, healing and progressive bone load- bishing and adding to the patient’s defin- ing. Int J Oral Implantol itive prosthesis. 1990; 6(2):23-31. NYSDJ • JUNE/JULY 2008 43 Hidden Occlusal Caries Challenge for the Dentist Yehuda Zadik, D.M.D.; Ron Bechor, D.M.D. Abstract DENTAL CARIES LESIONS are classified according to their sites— Hidden occlusal caries was defined 20 years ago as a for example, pits and fissures caries, root caries and secondary caries—or according to the time of their appearance and progres- dentinal caries lesion near the occlusal surface of the tooth, sion—early childhood caries, rampant caries and arrested caries. visible on a radiograph, where in visual examination the In the 1980s, a new type of lesion was added to the lexicon of occlusal enamel is seen intact or minimally perforated. dentistry, namely, the hidden caries1 (previously called, for a short time, fluoridated2 or occult3 caries). The hidden caries is a subtype of Hidden caries present the dentist with challenges in pre- the occlusal pit and fissure caries type and is defined as a dentinal vention, diagnosis, treatment planning, patient education caries lesion near the occlusal surface of the tooth, seen on a radi- ograph, where in visual examination the occlusal enamel is seen and research. This article describes these challenges and intact (Figure 1) or is minimally perforated (Figure 2).1 Between 15% offers solutions. and 33% of teeth deemed clinically sound are found to have hidden, In trying to prevent the formation of hidden caries trapped carious lesions upon histological examination.4 The proposed patho-physiology of hidden caries is based on lesions, the dentist should consider using fissure sealants, reinforcement and re-mineralization of the outer enamel layer by which have already proved to be an efficient way of pre- topical fluoride.2 The cariogenic bacteria penetrate into the enamel venting fissure caries. Diagnosing hidden caries is a chal- through a minimal hole in the enamel surface, but once it reaches the softer dentine, its progression is less restricted. Meanwhile, the lenge for the dentist, who is used to detecting fissure caries enamel undergoes re-mineralization and covers the traces. solely by visual examination and probing, because, by defi- Hidden caries challenge the dentist with regard to prevention, diagnosis, treatment planning, patient education and research, nition, hidden caries should be diagnosed by radiographs. especially because of their “hidden” nature. When the dental pro- However, in order to diagnose occlusal carious lesions accu- fession overcomes these obstacles, the condition will no longer be rately, the practitioner must look for them on radiographs. In termed “hidden.”5 The objective of this article is to present these challenges to the dentist and to offer practical solutions. cases of inconclusive radiographic examinations and a stained fissure, an operative diagnosis approach should be Prevention Challenge From our experience in a central multidisciplinary clinic, hidden employed. In treating hidden caries, the dentist should con- occlusal caries lesions are prominent even in low- and moderate- sider, according to clinical and radiographic examinations, caries-risk patients (Figures 1-3). As previously mentioned, the an observation-only approach or a preventive resin restora- topical fluoride-induced, reinforced outer enamel layer constitutes the difference between a “regular” occlusal lesion and a “hidden” tion. The dentist should become familiar with this type of car- lesion. Thus, people who suffer from hidden lesions are probably ious lesion and learn how to prevent, diagnose and treat it. getting enough topical fluoride. 46 NYSDJ • JUNE/JULY 2008 Figure 1a. There is no doubt that fissure sealant is the best method for pre- venting occlusal lesions, achieving up to 100% success. Periodic professional application of fluoride varnishes—for example, Duraphat—at three- to six-month intervals can reduce fissure caries prevalence by a third.6-8 Diagnostic Challenge It seems that correctly diagnosing hidden caries is the most difficult challenge for the dentist. Currently, the most important elements in diagnosing and planning treatment for pit and fissure caries are clinical judgment and experience.9 Comparison of the sensitivity (the probability of detecting an existing caries lesion) and the speci- ficity (the probability of detecting a tooth as healthy in cases of truly Figure 1b. sound teeth) of the common methods for detecting dentinal non- cavitated occlusal caries lesions reveals that visual examination has a low sensitivity (37%) but a high specificity (87%), and bite-wing radiograph examination has a moderate sensitivity (53%) and a high specificity (83%). On the other hand, a probing (visual-tactile) examination has a very low sensitivity (19%) but a very high speci- ficity (97%).10 In other words, probing during a caries examination can mislead the practitioner and reduces the probability of detect- ing an existing lesion in comparison to other methods. Moreover, insertion of the probe into tooth fissures and sus- pected areas, as has been taught in dental schools for a long time,9 was reported to be a potential cause of mechanical damage in young teeth or cavitation of the incipient lesion, thus, preventing re- mineralization of the lesion.11,12 In addition, inserting the probe into Figure 1. Bite-wing radiograph showing dentinal lesion on lower 2nd premolar (a) and in contrast to clinical appearance of intact tooth (b). Continuum of this infected lesions can transfer pathogens from diseased teeth to case is detailed in Figure 6. other teeth.13 This is the basis of the current controversy over whether “to probe or not to probe.”14,15 Although, by definition, hidden occlusal caries can be detected The differential diagnosis of radiolucent spots overlapping the more easily by radiographs and less so by the traditional visual-tac- dentine near the occlusal DEJ includes hidden caries, caries lesions tile examination, the currently accepted rule of “do not probe” pre- on the buccal or lingual/palatal surfaces (Figure 4), as well as other sents clinicians with another obstacle, because they must rely on morphological or regressive lesions on the buccal or lingual/palatal radiographs alone. surfaces (Figure 5) and artifacts. The three potential diagnostic errors regarding hidden caries According to the guidelines that have been adopted at our are failure to diagnose, false-positive diagnosing and misdiagnosing. institute, when there is doubt as to whether there is a hidden lesion Failure to diagnose a hidden lesion (undertreatment) can be prevented (Figures 3,4), an additional radiograph with an altered angle by systematically evaluating radiographs of the occlusal surfaces of (according to Clark’s rule: “same lingual, opposite buccal”)18 has to the teeth. To do so, it is necessary to obtain high-quality radiographs be taken. If the additional radiograph is of no diagnostic value and that present all premolar and molar teeth crowns (Figure 3). there is a stained pit or fissure (Figure 4), an operative diagnosis (or Experienced practitioners who have been taught that radiographic conservative operative exploration)4 approach must be employed. evaluation of occlusal surfaces is of minimal diagnostic value in In this method, the clinician carefully cleanses and opens the sus- detecting caries9,16 and got used to looking only for inter-proximal pected pit/fissure area, using a very small bur. If there is no appar- lesions on radiographs (and periodontal changes) must now improve ent lesion beneath, sealant is placed over the occlusal pits and fis- their practice and look for occlusal lesions as well. sures system. In case a dentinal lesion is discovered, a restoration is False-positive diagnosing (overtreatment) is the mirror result placed in the tooth. The options will be discussed later. of not diagnosing. Instances of undiagnosed lesions that were even- Several new methods are offered for detecting carious lesions, tually discovered as deep lesions may result in an undesirable over- using light and fluorescence, laser, digital radiography and tomog- compensatory tendency of the clinician to provide routine operative raphy, and operative microscopy.4,19 Because they are expensive and intervention for all questionable sites.17 only occasionally used in research settings, these methods are in NYSDJ • JUNE/JULY 2008 47 Figure 2a. Figure 3a. Figure 3b. Figure 2b. Figure 3c. Figure 2c. Figure 3d. Figure 3. Case of undiagnosed hidden caries. 19-year-old patient came to clinic complaining of toothache in left posterior region of lower dentition. Visual exami- nation of dentition (a) and radiological examination, including bite-wing radi- ograph (b), did not reveal source of pain. Patient returned to clinic 2 weeks later Figure 2. Hidden occlusal caries lesion on mandibular premolar of 20-year-old with same complaint. Long bite-wing radiograph was taken (c). Image showed low-caries-risk patient. (a) Innocent occlusal pit on the 2nd premolar. (b) Bite-wing dentinal lesion on 3rd molar, which was not covered by first short bite-wing. radiograph showing dentinal lesion. (c) After removal of enamel layer, dentinal Lesion was surgically removed (d) and tooth was restored. Patient has not lesion is revealed. complained of toothache. 48 NYSDJ • JUNE/JULY 2008 Figure 4a. limited use in private practice. But they seem to be more promising and less invasive than the traditional visual-tactile method. Treatment Challenge The clinician has several alternatives regarding treatment of the diagnosed hidden lesion without a pulpal involvement or symp- toms. The first is periodic observation only. This option should be considered only in cases where an intact, non-cavitated enamel layer covers the lesion and the patient is diligent in appearing for periodic examinations. If the clinician has decided to surgically treat the lesion, Figure 4b. apparently composite material restoration is indicated.20 In our institute, preventive resin restoration (PRR) is the treatment of choice in these cases (Figure 6).9,17 The PRR technique is based on filled resin restoration of the cavity and overlying sealing of the occlusal fissure system, as well as resin restoration, thereby preventing bacterial colonization on the rest of the fissure and probably reducing the leakage between the resin restoration and the tissue. Additional advantages of PRR are preservation of sound tooth structure—compared with amalgam restoration—and needless occlusal adjustment, owing to the self-wear nature of the unfilled resin sealant material in physiological occlusal forces. Figure 4. (a) Bite-wing radiograph showing radiolucent spot on distal part of In cases of deep carious lesions, an indirect pulp capping tech- occlusal DEJ of 2nd lower molar. (b) Careful observation revealed buccal caries lesion. Clinician must decide whether there are 2 lesions at 2 sites—occlusal and nique should be employed. Following this technique, the firm and buccal surfaces—or whether radiological appearance results from buccal lesion leathery/softened and wet pulpal dentine is not removed, but is and there is no occlusal lesion. sealed by appropriate restoration and/or sealant. Review of the lit- Figure 5a. erature revealed supportive evidence for using this method.21 This is another innovation for the experienced clinician, since complete removal of carious dentine has been a fundamental principle of the dental profession for many years. Patient Education Challenge Because the hidden lesion is radiologically apparent only in rel- atively advanced stages, when a deep restoration or even endo- dontic treatment is needed, clinicians can find themselves in a difficult situation trying to explain to the patient why the deep lesion was not revealed in the periodic examinations and only Figure 5b. detected when it reached the advanced stage. This task is even more difficult in a low-caries-risk patient who takes meticulous oral hygiene measures and has dental examinations at six- month intervals. Another difficulty confronting clinicians is when they try to explain the “operative diagnosis to patients. Many patients demand a thorough diagnosis from their dentist before he or she treats the tooth. Research Challenge The classic DMF (decay/missing/filled) index is still one of the Figure 5. (a) Bite-wing radiograph showing radiolucent spot on 2nd lower molar most common methods for assessing caries prevalence and treat- (arrow head). (b) Clinician must rule out that radiological appearance results from ment needs among various populations. This index is based on in- buccal chipping of enamel layer (arrow head) before removing occlusal enamel. Operative diagnosis approach can be taken instead, in which occlusal fissure field clinical examination of individuals by using a probe, mirror sealant is used, unless caries lesion is discovered during fissure preparation, and cotton rolls. Because the DMF index is done without X-ray then removal of lesion and restoration of tooth are indicated. NYSDJ • JUNE/JULY 2008 49 Figure 6a. Figure 6. Proposed treatment imaging, it underestimates real caries prevalence and treatment for hidden occlusal caries (same case as in Figure 1). (a) Isolation needs.22 The new appearance of hidden occlusal caries, which by of tooth. No apparent pit or pen- definition is diagnosed by radiographs, may cause the DMF index etration hole on occlusal surface of tooth. (b) After removal of to become even more irrelevant.23 enamel, dentinal lesion is discov- ered. (c) View after surgical removal of soft tissue. Brownish Conclusions but hard tissue on floor of prepa- ration was not removed. (d) Final The clinician must be familiar with this emerging type of lesion. view after full etching of prepara- Moreover, he or she must carefully examine the bite-wing radi- tion and occlusal surface, one- step of primer and bonding, and ographs, especially for low- and moderate-caries-risk patients, preventive resin restoration of the along with conducting an adequate visual examination of the teeth tooth: composite material in preparation and fissure sealant surfaces. In addition, the dental surgeon must be familiar with the over composite restoration and other aspects of hidden caries management, as were previously occlusal fissure. detailed. ■ Figure 6b. The authors wish to thank Steve Manch (Rehovot, Israel) for his editorial assistance. Queries about this article can be sent to Dr. Zadik at firstname.lastname@example.org. REFERENCES 1. Weerheijm KL, van Amerongen WE, Eggink CO. The clinical diagnosis of occlusal caries: a problem. ASDC J Dent Child 1989;56:196-200. 2. Lewin DA. Fluoride syndrome. Br Dent J 1985;158:39. 3. Ball IA. The ‘fluoride syndrome’: occult caries? Br Dent J 1986;160:75-6. 4. Strassler HE, Porter J, Serio CL. Contemporary treatment of incipient caries and the rationale for conservative operative techniques. Dent Clin North Am 2005;49:867-87. 5. Ricketts D, Kidd E,Weerheijm K, de Soet H. Hidden caries: What is it? Does it exist? Does it matter? Int Dent J 1997;47:259-65. 6. Chu CH, Lo EC. 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Caries Res 1987;21:368-74. 12. van Dorp CS, Exterkate RA, ten Cate JM. The effect of dental probing on subsequent enamel demineralization. ASDC J Dent Child 1988;55:343-7. 13. Loesche WJ, Svanberg ML, Pape HR. Intraoral transmission of Streptococcus mutans by a dental explorer. J Dent Res 1979;58:1765-70. 14. Hamilton JC. Should a dental explorer be used to probe suspected carious lesions? An explorer is a time-tested tool for caries detection. J Am Dent Assoc 2005;136:1526, 1528, 1530. 15. Stookey G. Should a dental explorer be used to probe suspected carious lesions? Use of an explorer can lead to misdiagnosis and disrupt remineralization. J Am Dent Assoc Figure 6d. 2005;136:1527, 1529, 1531. 16. Atchison KA. Guidelines for prescribing dental radiographs. In: Goaz PW,White SC. Oral Radiology: Principles and Interpretation. 3rd edition. St. Louis: Mosby, 1992;70-75. 17. McComb D. Conservative operative management strategies. Dent Clin North Am 2005;49:847-65. 18. Goaz PW, White SC. Projection geometry. In: Oral Radiology: Principles and Interpretation. 3rd ed. St. Louis: Mosby, 1992;97-105. 19. Pretty IA, Maupome G. A closer look at diagnosis in clinical dental practice: part 5. Emerging technologies for caries detection and diagnosis. J Can Dent Assoc 2004;70:540, 540a-540i. 20. Heymann HO, Sturdevant JR, Roberson TM, Sockwell CL. Tooth-colored restoration for classes I, II and VI cavity preparations. In: Sturdevant CM (ed.). The Art and Science of Operative Dentistry. 3rd ed. St. Louis: Mosby, 1995;586-625. 21. Kidd EA. How ‘clean’ must a cavity be before restoration? Caries Res. 2004;38:305-13. 22. Becker T, Levin L, Shochat T, Einy S. How Much Does the DMFT Index underestimate the need for restorative care? J Dent Educ. 2007;71:677-681. 23. Burt BA. How useful are cross-sectional data from surveys of dental caries? Community Dent Oral Epidemiol 1997;25:36-41. 50 NYSDJ • JUNE/JULY 2008 Treatment of Peri-implant Defect with Modified Sandwich Bone Augmentation Case Report and Follow-up Tolga Fikret Tözüm, D.D.S., Ph.D.; Hüseyin Gencay Keçeli, D.D.S Abstract PERI-IMPLANTITIS is an inflammatory process that affects the This report describes correction of an osseous defect surrounding tissues of an osseo-integrated implant and causes the loss of marginal osseous support.1 Depending on the clinical and around a dental implant with a modification of a sandwich radiographic diagnosis, a protocol of therapeutic measures has bone augmentation (SBA) technique. It gives detailed been designed to intercept the peri-implant lesions. This system is information about preparation and application of the autol- called cumulative interceptive supportive therapy (CIST).2 It ogous platelet rich plasma (PRP). A 58-year-old female includes mechanical debridement, antiseptic and antibiotic treat- ment, and regenerative or resective therapy. Additional treatment patient complaining of halitosis, function loss and dis- modalities include air-powder abrasives,3,4 citric acid or tetracy- charging pus at her right lateral dental implant was cline application3,4 and surgical laser techniques.5 referred to the Department of Periodontology at Hacettepe When peri-implant infection has been controlled successfully, University. An implant had been placed two years prior; a it is reasonable to discuss treatment to restore the bony support of the dental implant by regenerative techniques. porcelain restoration was completed a year after surgery. The concept of guided bone regeneration (GBR) was developed An advanced peri-implant problem was noticed, and an for implant dentistry based on promising results achieved by using SBA technique modified with PRP and tri-calcium phos- guided tissue regeneration (GTR) for periodontal defects.6 GBR proce- phate application was subsequently performed. Clinical dures attempt to regenerate or augment alveolar bone for proper den- tal implant treatment.7 After debridement of the peri-implant lesions, parameters and radiological evaluations were performed different techniques, including various regenerative bone substitutes at baseline, 3, 6 and 12 months following the procedure. A and/or barrier membranes, are performed for optimal wound healing 2 mm attachment gain, 3 mm reduction in probing depth and regeneration of the alveolar bone around dental implants.8 and 2 mm alveolar bone gain were achieved a year after Tri-calcium phosphates (TCP) behave mostly as osteoconduc- tive materials that permit bone growth on their surfaces or into the surgical procedure. SBA technique modified with PRP their pores, channels or pipes.9 Some of the calcium phosphates are application resulted in clinical benefits. Early wound heal- non-resorbable or partially resorbable, while the -TCP is ing was achieved without any postoperative bleeding. resorbable. In a qualitative histological study, a relatively new mate- Peri-implantitis defect treated with SBA technique with rial—porous pure -TCP (Cerasorb, Curasan, Pharma Gmbh AG, Kleinostheim, Germany)—was investigated. The results did not demon- autologous PRP and tri-calcium phosphate application strate any significant difference in bone density volume between appears to improve early wound healing and may influ- the defect augmented with -TCP and the control defect augment- ence acceptable regeneration. ed with autologous bone.10 52 NYSDJ • JUNE/JULY 2008 Furthermore, collagen is a hemostatic agent and possesses the abil- human subjects and demonstrated that PRP was an adjunct to ity to stimulate platelet aggregation and enhance fibrin linkage, enhance alveolar bone formation.41 which may lead to initial clot formation, stability and maturation.11 Sandwich bone augmentation (SBA) is a new technique It is also regarded as chemotactic for fibroblasts.12 Besides, collagen described by Wang and colleagues.42 This approach consists of can enhance cell migration; promote regeneration; increase the different bone substitutes, including autografts, DFDBA or osteoblast proliferation, collagen synthesis, alkaline phosphatase hydroxyapatite bone grafts for the treatment of peri-implantitis activity; and transform growth factor beta (TGF- ) secretion by defects. The bone substitutes were applied over the dental implant inducing the periodontal ligament cells.13-15 Many studies about col- defect and then covered with a bioabsorbable regenerative colla- lagen membranes with different bone substitutes, including dem- gen membrane. Six-month follow-up results demonstrated ineralized freeze-dried bone allograft (DFDBA), porous bone graft improved alveolar bone regeneration around the implant using and inorganic bovine bone graft, were used to treat periodontal SBA technique.42 defects. The results of these studies showed successful outcomes Several techniques and augmentation materials were intro- compared to the control groups, which were treated with collagen duced to treat periodontal and peri-implant defects. However, to membrane or DFDBA alone.16-18 Proussaefs and Lozada19 applied the authors’ knowledge, this is the first clinical report of treatment autogenous bone graft and inorganic bovine bone mineral in con- of a peri-implant defect using SBA technique with PRP. The case junction with resorbable collagen membrane for alveolar ridge aug- presented here describes the augmentation of an osseous defect mentation. The results from seven consecutively treated patients around a dental implant using SBA technique with 12 months of demonstrated 34% new bone formation clinically, radiographically follow-up. It further provides detailed information about the chair- and histologically.19 side preparation and application of autologous PRP. Increasing interest has focused on the regeneration and early wound healing of supporting structures, where it was speculated Case Report that platelet-rich plasma (PRP) served as a promoter of tissue Diagnosis regeneration and alveolar bone formation.20-24 PRP is the compo- A 58-year-old Caucasian female with no contraindication to dental nent of blood in which the platelets are concentrated in a limited treatment presented to the Department of Periodontology at volume of plasma.20-27 Medical literature provides evidence that Hacettepe University with a dull and persistent pain in the right platelets contain many growth factors, including platelet-derived premaxillary area. The pain had increased in severity and now was growth factor (PDGF), insulin-like growth factor (IGF), TGF- and resistant to analgesics. She reported halitosis, function loss and pus bone morphogenetic proteins (BMPs), which regulate key cellular formation at her right upper lateral dental implant. She also com- events in tissue regeneration, including cell proliferation, chemo- plained about bleeding when brushing her teeth. taxis, differentiation and matrix synthesis.28,29 The patient’s dental history indicated that she had lost tooth #7 Platelet membranes have been shown to stimulate the mito- as the result of traumatic injury; the tooth had been extracted a genic activity of human bone cells, thereby contributing to the couple of days following the injury. A screw-shaped titanium den- regeneration of mineralized tissues in vitro.30 The stimulator effects tal implant was placed into the extracted area; it was restored with of PRP in collagen synthesis and the proliferation of osteoblastic a porcelain crown one year after dental implant surgery. She had cells were also demonstrated.31,32 This autologous plasma is a rich good oral hygiene and did not present any periodontal problems or source of growth factors, and its application is effective in inducing any carious lesions. Periodontal probing was performed, and 6 mm early tissue healing and regeneration.27,33-35 probing depth was found with pus formation at the vestibular In 1998, the first successful clinical dental results achieved by region of the dental implant located at tooth #7 (Figure 1). Bleeding using PRP were reported by Marx and colleagues. They suggested on probing was also noticed at the vestibular region of the dental an accelerated rate and degree of bone formation in human implant. The implant was not mobile. However, upon radiographic mandibular defects treated with PRP.27 Encouraging effects of PRP evaluation, proximal bone defects were observed around the dental use have been shown in many different surgical procedures, includ- implant (Figure 2). ing ridge or sinus augmentations,36,37 periodontal flap surgery,22,26 esthetic periodontal surgery,35 periapical surgery38 and treatment of Treatment Protocol peri-implantitis.39 According to the CIST protocol described by Lang and colleagues, Recent studies also provide evidence about the use of PRP in scaling, followed by periodontal prophylaxis, was performed as the the augmentation of peri-implantitis defects. Yamada and col- first stage of the treatment approach.2 The patient was prescribed leagues reported that PRP could be used with mesenchymal stem 0.2% chlorhexidine gluconate twice daily for three weeks. After a cells, and promising results were achieved to cover the peri-implan- three-week healing period, the inflammation symptoms were titis defects using an injectable, tissue-engineered bone regenera- resolved. Because of deep pocketing and alveolar bone resorption tion technique.40 Mazor and colleagues also said PRP could be used around the dental implant, it was decided to perform the last step in the augmentation of severely atrophic maxillae. They treated 105 of CIST—regenerative therapy. NYSDJ • JUNE/JULY 2008 53 Prior to surgery, the patient was told about the possible consequences of the procedure following debridement, such as gingival recession around the dental implant. The patient said she did not want to lose her implant and that esthet- ic results were not as important as using her tooth functionally. After she was given local anesthesia at her maxillary anterior area, a full thickness flap was reflected by a sulcular incision, extend- ing to the distal of tooth #9 and the mesial of tooth #5. Complete loss of a Figure 1. Deep pocketing was determined during clinical examination. Figure 2. Proximal alveolar labial cortical plate and a large periapical bone resorption was noticed defect were noticed. The deepest point of in periapical radiography. the lesion was 3 mm; the width of the lesion was 5 mm (Figure 3). Debride- ment of the tissues at the defect site was followed by irrigation with a sterile saline solution. After debridement, the body of the dental implant was exposed. Implant detoxification was performed by using tetracy- cline-HCl solution at a concentration of 50 mg/ml, and the exposed vestibular body of the implant was burnished with sterile cotton pellets with tetracycline-HCl for three minutes.43 During this peri- od, PRP was prepared by another practitioner according to the Weibrich-Kleis method. The color-coded PRP kit (Curasan, Pharma Gmbh AG, Lindigstrab, Germany) was used. The SBA technique was per- formed as follows. One-third of the total PRP gel was placed at the bottom of the defect (Figure 4). Commercially available -TCP bone substitute (Cerasorb 500–1000 µm, Curasan, Pharma Gmbh AG, Figure 3. Severe alveolar bone destruction was found at vestibular region of screw-shaped dental implant during surgical procedure. Kleinostheim, Germany) was packed into the defect as a second layer (Figure 5). The last one-third of the PRP gel was placed over the Figure 4. synthetic bone graft substitutes (Figure 6). A resorbable collagen membrane (Biomend 15x20, resorbable collagen membrane, Zimmer Dental, Carlsbad, CA, USA) was placed over the graft material.And wound clo- sure was obtained with 4–0 silk sutures without any tension. PRP Preparation 44 PRP was prepared from blood collected in the immediate preoper- ative period. The color-coded kit was used for preparing the PRP. The blood sample was drawn into a citrated tube. The sample tube was then spun in a standard centrifuge (Heraeus Labofuge 300, Kendro Laboratory Products, D-37520 Osterrode, Germany) for 10 minutes at 2,400 rpm to produce platelet-poor plasma (PPP). The PPP was taken up into a syringe with a long cannula and an additional air-intake can- nula. A second centrifugation (15 minutes at 3,600 rpm) was per- formed to concentrate the platelets. The second supernatant was also taken up by a long cannula and an air-intake cannula. For each 8 ml of blood, the volume of supernatant was about 0.6 ml to 0.7 ml. The supernatant part was the PRP; it was used for the surgical procedure.At the time of appli- Figures 4-6. One-third of PRP gel was placed at bottom of defect. Commercially available -TCP bone substitute was packed into defect as second layer, and last cation, the PRP was combined with an equal volume of a sterile one-third portion of PRP gel was placed over synthetic bone graft substitutes. saline solution containing 10% calcium chloride (a citrate inhibitor 54 NYSDJ • JUNE/JULY 2008 Figure 5. that allows the plasma to coagulate) and 0.1 ml of blood that was obtained from the surgical area. It included thrombin, which is an activator that allows polymerization of the fibrin into an insoluble gel. This caused the platelets to degranulate and release growth fac- tors into the surgical area. The sticky gel was then ready to be applied easily to the surgical area.22,26,33 Postoperative Care and Follow-up Following surgery, the patient was given a cold compress extraoral- ly to minimize swelling and bleeding. She was prescribed 0.2% chlorhexidine gluconate and instructed to rinse gently twice daily for three weeks. She was also prescribed antibiotics (amoxicillin, 500 mg, four times daily) for seven days. During this time, tooth- brushing was discontinued. A week after regenerative surgery, the sutures were removed. The patient was seen at 2 and 3 weeks, and 3, 6 and 12 months. These follow-up visits included routine intrao- ral examinations and professional plaque control. Periapical radi- ographs were taken at 3, 6 and 12 months. Figure 6. At postsurgical follow-up visits, there was no pain, inflamma- tion or discomfort. Although gingival recession was observed dur- ing the follow-up period, the patient was satisfied with the results of the treatment; she did not want to receive any other periodontal plastic surgeries to augment the vestibular area. Clinical and Radiographic Parameters2, 45 Clinical parameters, including mobility, plaque index (PI), modi- fied gingival index (mod GI), bleeding on probing (BOP), probing depth (PD) and clinical attachment level (CAL), were evaluated at baseline at 3, 6 and 12 months postoperatively. As a landmark, the gingival margin was employed for PD, and the implant shoulder was selected for the evaluation of CAL. Radiographically, alveolar bone level (ABL) was measured from the first thread of the implant to the top of the interproximal bone. Treatment Outcome The patient tolerated the surgical procedure without complication. Figure 7. Figure 8. No postoperative pain, discomfort or bleeding was observed fol- lowing regenerative surgery. Clinical and radiological parameters determined at baseline, 3, 6 and 12 months later are presented in Table 1. Periapical radiographic examination demonstrated that TCP particles were available at six months (Figure 7). However, they were almost resorbed and replaced by new bone at 12 months post- surgery (Figure 8). TABLE 1. Clinical and Radiographic Parameters During 12-month Follow-up Month PI mod GI CAL PD ABL Baseline 2 2 6 6 3 6 0 0 3 3 2 12 0 0 3 3 0.5 Figures 7 and 8. Six-month postsurgical periapical radiography demonstrated Significant improvement was achieved in peri-implant indices, and that TCP particles were still visually noticed. 12-month periapical radiography radiographic evaluation resulted in highly successful outcome. showed uneventful healing; TCP particles were totally resorbed. NYSDJ • JUNE/JULY 2008 55 The patient was satisfied with the results of the procedure one year autologous bone or TCP material six months following surgery.47 later; and she reported she could function with her dental implant Grafted areas were covered with absorbable collagen barrier as with her natural dentition. membranes to avoid the migration of soft tissue cells into the wound. Use of barrier membranes in bone augmentation procedures enhances Discussion the amount of bone formation.16,48-51 Lang and colleagues measured the This clinical report introduces autologous platelet gel application in amount of alveolar bone that could be regenerated with non- combination with SBA technique described by Wang and col- absorbable membranes following different healing periods. They leagues.42 The radiological data obtained in this case indicated a found that membranes removed between three and five months result- noticeable growth of alveolar bone at the proximal surfaces of the ed in regeneration of up to 60%, whereas membranes left six to eight dental implant. A significant reduction in probing depth (3 mm), months regenerated between 90% and 100% of the possible volume.52 clinical attachment level (3 mm), and alveolar bone gain (2.5 mm) Absorbable membranes are preferred in periodontal surgeries, were achieved 12 months postsurgery. since they do not require additional surgical interventions for Regenerative therapies are preferable methods for treating removal and they can maintain undisturbed wound healing until peri-implant defects. TCP bone substitutes have been used success- bone maturation is completed. Collagen membranes are preferable fully in different surgical procedures. Some of the calcium phos- because of their physiologic absorption process and high biocompat- phates are non-resorbable or partially resorbable, while the -TCP ibility with oral tissues. Furthermore, collagen has hemostatic prop- is resorbable. The TCP activates bone formation by osteoconduc- erties and chemotactic effects on fibroblasts; therefore, they promote tion. It resorbs and is progressively replaced by alveolar bone. Zerbo primary wound closure.53 Even when the membranes become and colleagues compared the quantity and quality of bone after exposed during the healing process, appreciable results are obtained augmentation with -TCP and compared it with autogenous with collagen membranes in ridge augmentation procedures.54 In bone.46 After six months of healing, histological results demonstrat- this report, the surgical area was sealed with a collagen membrane ed that the -TCP bone substitute was capable of producing bone and membrane exposure was not observed. Uneventful healing with height similar to the control group (the autologous bone graft).46 a successful wound closure was achieved during the follow-up peri- Szabo and colleagues augmented the maxillary sinuses with autol- od. This may promote bone formation around the dental implant. ogous bone or TCP bone substitute in a split-mouth design. Their PRP is a rich source of growth factors, such as platelet PDGF, results demonstrated similar bone volume augmented either with IGF, TGF- and BMPs, and it is a widely accepted method and 56 NYSDJ • JUNE/JULY 2008 biotechnology for dental practitioners in oral and periodontal surgical which may be counted as one of the advantages of PRP application. procedures.21,27 In a controlled trial, Camargo and colleagues suggest- The advantages of PRP are:21-27 ed that PRP increased the clinical attachment level, and significant ● Decreases the frequency of intraoperative and postoperative bone fill was achieved in periodontal intrabony defects compared to bleeding. the control defects treated with GTR at six months.22 The differences ● Facilitates rapid soft tissue healing. at the defect fill between PRP and the control group was 2.5 mm on ● Decreases incidence of postoperative pain at recipient site by buccal and 2.4 mm on the lingual sites. Their results suggested that facilitating rapid healing and maturation. PRP may have regenerative effects on intrabony defects.22 ● May promote rapid vascularization by delivering growth factors. Kassolis and colleagues presented the regenerative effects of PRP ● Contains dense fibrin network that is osteoconductive. in alveolar ridge defects where an enhanced amount of bone regener- ● Aids in initial stability of bone substitutes at recipient site ation was achieved in patients treated with PRP and freeze-dried bone because of its cohesive and adhesive nature. allograft.55 Kim and colleagues suggested that bone defects around ● Is safe procedure because it has autologous preparation technique. titanium dental implants could be treated successfully with bone sub- stitutes and that the outcome could be improved if PRP was also Conclusions employed.56 Similarly improved clinical results were achieved in the Treatment of peri-implantitis using SBA technique with PRP had a case presented here where reduced probing depth, increased attach- promising effect on clinical and radiological findings with 12 ment level and significant gain at bone level were demonstrated. months of follow-up. Although improved results were found in this Recently, Wang and colleagues introduced the SBA technique case, controlled clinical trials are needed for evaluating the influ- to treat peri-implant defects. They said autograft DFDBA or ence of this treatment approach. Moreover, histological findings hydroxyapatite with a collagen membrane application maximized should also be studied in peri-implant defects treated with SBA and the outcomes of GBR. Promising results were achieved in clinical PRP to understand the stages of wound healing and augmented parameters, such as an increase in the alveolar bone level.42 bone regeneration. ■ The case presented here similarly resulted in a gain at the alveo- lar bone level,improvement in clinical attachment level,and reduction Queries about this article can be sent to Dr. Tözüm at email@example.com. in probing depth during 12 months of follow-up. Additionally, early Copies of the extensive references that accompanied Dr. Tözüm’s and Dr. Keçeli’s wound healing was achieved without any postoperative bleeding, manuscript are available upon request to The NYSDJ Managing Editor. NYSDJ • JUNE/JULY 2008 57 The Use of Resorbable Hardware for Fixation of Pediatric Mandible Fracture C AS E R E P O RT Matthew C. Poore, D.D.S.; Kevin J. Penna, D.D.S. Abstract pediatric patients. These treatments have ranged from conservative The diagnosis and management of mandible fractures in options, such as simple observation and soft diet, to more invasive procedures, such as open reduction internal fixation with the use of the pediatric patient population can pose multiple chal- wires, arch bars, plates and screws.1-3,5,6 Although the majority of lenges to the oral and maxillofacial surgeon. Resorbable surgically reduced fractures of the mandible are internally fixated with titanium plates, a considerable body of literature has been plates and screws for fixation in this population are both amassed reporting on the success and potential advantages of well tolerated and effective. They enable realignment and using resorbable or biodegradable fixation hardware, particularly stable positioning of rapidly healing fracture segments, in the pediatric population.1,2,6,7 while obviating any potential impediments to long-term Case Report metal retention. A 4-year-old boy presented to the emergency room of our institu- tion after having been struck by a vehicle at low speed and subse- THE DIAGNOSIS AND MANAGEMENT of mandible fractures in quently dragged for several feet. The child was conscious on arrival the pediatric patient population can pose a daunting challenge to to the ER, but in considerable distress. Advanced trauma life sup- the oral and maxillofacial surgeon. Besides the behavioral and psy- port (ATLS) protocol, as outlined by the American College of chological issues inherent in treating this patient cohort, there are Surgeons (ACS), was enacted and the child was stabilized. A thor- also anatomical and developmental factors that may further com- ough history and physical examination were completed and full plicate matters.1,2 The smaller physical size of the pediatric body CT scans were done. The patient was diagnosed with multiple mandible, the presence of developing tooth buds and the potential abrasions and lacerations of the upper and lower extremities, for growth disruption all contribute to the complexity of this surgi- mandibular fractures and avulsed maxillary incisor teeth. The cal endeavor.1-4 patient was then transferred to the pediatric intensive care unit Several modalities and materials with which to carry out these (PICU), which consulted the oral and maxillofacial surgery service procedures have been used to treat fractures of the mandible in for diagnosis and treatment of the patient’s maxillofacial injuries. 58 NYSDJ • JUNE/JULY 2008 The patient’s history was positive for gastroesophageal reflux dis- ease, for which he was medicated with Zantac. The patient had no known drug allergies and had a past surgical history positive for bilateral myringotomies (two separate procedures) and adenoidec- tomy. Initial clinical exam revealed mild lower facial swelling, consid- erable pain on palpation of the mandible, presence of a full primary dentition with the exception of the traumatically avulsed primary maxillary central incisor teeth E and F, dental malocclusion, mod- erate trismus, ecchymoses of the floor of the mouth, and gross seg- mental mobility of the mandible between primary central incisor teeth O and P. There was no evidence of any neurosensory deficit of cranial nerve V3. The initial CT scans of the maxillofacial region revealed the presence of a displaced bicortical fracture of the symphysis of the mandible, as well as bilateral intracapsular condylar head fractures of the mandible without displacement from the glenoid fossae. The clinical and radiographic data both supported a diagnosis of bilat- eral intracapsular condylar head fractures and a symphyseal frac- ture of the mandible. Initial stabilization of the patient’s mandible fractures was instituted at bedside in the PICU under intravenous deep sedation and local anesthesia. The patient’s dental occlusion was manipulat- Figure 1. CT Scan–Axial View. Displaced mandibular symphysis fracture. ed and an ideal interocclusal relationship was achieved. The patient was then placed into intermaxillary fixation (IMF) via use of bilat- eral 24-gauge stainless steel intermaxillary wires. A plan for a definitive open reduction internal fixation (ORIF) of the symphy- seal fracture and closed reduction/IMF of the bilateral intracapsu- lar condylar head fractures under general anesthesia in the operating room was finalized. Informed consent for the procedure was obtained from the patient’s parents. Approximately three days after the initial closed reduction and IMF placement completed in the PICU, the patient was brought to the OR and induced to general anesthesia for the definitive planned surgery. The patient’s dental occlusion was verified to be in its ideal IMF relationship. The symphyseal fracture was opened via a mandibular vestibular approach. Once the fracture was visualized and noted to be anatomically reduced and the dental occlusion was again verified as ideal, the reduced symphyseal fracture was inter- nally fixated via use of a five-hole resorbable 1.5 mm inferior bor- der plate secured with four 4 mm-long resorbable monocortical screws (Stryker-Leibinger; Portage, MI). The surgical incision was then closed in layers with resorbable sutures and the IMF was left intact to facilitate healing of the bilateral intracapsular condylar head fractures. The patient was returned to the care of the pediatrics ser- vice, where he remained for two days postoperatively before being discharged to home. After discharge, the patient was followed in the oral and max- illofacial surgery outpatient clinic. The IMF was removed from the patient 13 days postoperatively, and he was referred for physical therapy for his jaw. There were no postoperative complications, and NYSDJ • JUNE/JULY 2008 59 Fractures of the mandible comprise the most com- mon facial skeletal injury among hospitalized pediatric trauma patients. They are the second most common facial skeletal injury, behind nasal fractures, in the general pediatric population.1-3,5 Figure 2. Five-hole resorbable 1.5 mm inferior border plate secured with four 4 mm-long resorbable monocortical screws. the patient soon regained full range of motion of his jaw. The patient has been seen for follow-up 2-, 3-, 6-, and 12-months post- operatively with no evident complications. Discussion Fractures of the mandible comprise the most common facial skele- tal injury among hospitalized pediatric trauma patients. They are the second most common facial skeletal injury, behind nasal frac- tures, in the general pediatric population.1-3,5 Boys outnumber girls in the incidence of mandible fractures by a ratio of two-to-one, with falls, blunt trauma and motor vehicle accidents cited as the most common causes.3,6 The areas of the pediatric mandible that are most frequently fractured are the condyles, subcondylar and angle regions (80%), and the symphysis/parasymphyseal area (15% to 20%).3 Fractures of the body of the mandible are rare in the pediatric population.3 Since the mandible is the final facial bone to complete normal growth, there is a longer window of potential growth disturbance that can be caused by surgical intervention.3,6 The thin and hypo- dense cortical bone; the presence of deciduous teeth with short, stubby crowns; and the underlying developing tooth buds must also be taken into consideration when planning and undertaking surgery on the pediatric mandible.3,5,6 Any slight discrepancies in the dental occlusion of the pediatric patient with a mandible fracture will tend to resolve and self-correct via eruption of the permanent teeth and Figure 3. One-year postop showing maximum opening of mandible. remodeling of the bone with increasing mandibular function.3 Therefore, transfer of increasing load to the mandible as it heals should be permitted to foster normal functional development.1,8 The use of resorbable materials in human medicine has been reported in the literature for over 30 years.7,8 The resorbable hard- ware used in craniomaxillofacial surgery today is composed pri- marily of homopolymers or copolymers of polydioxanone sulfate (PDS), polylactic acid (both the D- and L- isomers, PDLA and PLLA, respectively) and polyglycolic acid (PGA).4,7,8 PDS is found mainly as a suture material but has also been used to make surgical pins and screws.1 PLA is characterized as slow degrading and non-water-sol- uble, whereas PGA is more rapidly degrading and water soluble.7 Figure 4. One-year postop panorex shows no radiographic evidence of The degradation process of these materials can be broken down into resorbable plate. two phases.2,8,9 The first phase is a simple chemical hydrolysis of the 60 NYSDJ • JUNE/JULY 2008 chemically unstable backbone of the polymer.2,8,9 The second phase 2. Haug RH, Cunningham LL, Brandt MT. Plates, screws, and children: their relationship in craniomaxillofacial trauma. Journal of Long-Term Effects of Medical Implants is an active metabolism characterized by the recruitment of 2003;13(4):271-287. enzymes, polymorphonuclear neutrophils, macrophages and other 3. Baumann A, Troulis MJ, Kaban LB. Facial trauma II: dentoalveolar injuries and mandibular fractures. Pediatric Oral and Maxillofacial Surgery, Philadelphia: Saunders. metabolic mediators to degrade the polymer into monomeric acids 2004, 441, 445-461. that then enter the citric acid cycle and are broken down into water 4. Kumar AV, Staffenberg DA, Petronio JA, Wood RJ. Bioabsorbable plates and screws in pediatric craniofacial surgery: a review of 22 cases. The Journal of Craniofacial Surgery and carbon dioxide and excreted.2,6,9 This entire degradation process 1997;8(2):97-99. occurs over approximately 12 to 18 months.4,9 5. Myall RWT, Dawson KH, Egbert MA. Maxillofacial injuries in children. Fonseca Oral and The use of resorbable fixation hardware in the treatment of Maxillofacial Surgery, Vol. 3. Philadelphia:WB Saunders Co: 2000;423-426, 431-435. 6. Posnick JC, Costello BJ, Tiwana PS. Pediatric craniomaxillofacial fracture management. pediatric mandible fractures has several advantages and disadvan- Peterson’s Principles of Oral and Maxillofacial Surgery, Second Edition,Vol. 1. Hamilton: tages over its more traditional titanium counterpart.2,4 The BC Decker. 2004;528-532, 538-542. 7. Eppley BL, Prevel CD, Sadove AM, Sarver D. Resorbable bone fixation: its potential role resorbable fixation hardware degrades as the bone heals, thereby in cranio-maxillofacial trauma. The Journal of Cranio-Maxillofacial Trauma 1996;2(1): permitting increased functional loading of the mandible and 56-60. 8. Yerit KC, Enislidis G, Schopper C, Turhani D, Wanschitz F, Wagner A, Watzinger F, Ewers avoiding the phenomenon of stress shielding.1,8 The use of R. Fixation of mandibular fractures with biodegradable plates and screws. Oral Surgery resorbable hardware obviates the need to perform a secondary Oral Medicine Oral Pathology Oral Radiology Endodontology 2002;94:294-300. 9. Landes CA, Kriener S, Menzer M, Kovacs AF. Resorbable plate osteosynthesis of dislo- implant removal surgery.1,8,9 The commonly used resorbable fixa- cated or pathological mandibular fractures: a prospective clinical trial of two amor- tion hardware degrades into physiologically inert compounds.9 In phous L-/DL-lactide copolymer 2mm miniplate systems. Plastic and Reconstructive addition, there is no interference with postoperative imaging, as is Surgery 2003;111(2):601-610. the case with titanium and other metallic implants.6,8,9 The holes that are drilled for the screws are the only radiographically evident aspect of the fixation, appearing as circular radiolucencies.1,8 In a similar way, resorbable materials do not interfere with postopera- tive radiation treatment.6,8 The main disadvantage of resorbable fixation hardware when compared to titanium materials is its considerably lower mechanical strength across a fracture site.6 There is also the potential for an inter- nal conformational memory of resorbable hardware, which may cause distortion in the plate and disrupt the bony union across the fracture site. And there is the potential for an adverse reaction to any of the compounds formed as a result of the degradation of the resorbable hardware.6,8,9 Finally, the actual intraoperative time is increased with the use of resorbable fixation materials as elements. For example, preparing the hardware in hot water baths and the necessity of screw- tapping are imperative steps in the overall process.2,6,7 Conclusion The decision to employ resorbable hardware for the fixation of the reduced symphyseal fracture of our patient satisfied our treatment objectives and those of the patient and his family. The results of this case support the viability of resorbable materials as an effective alternative to the more traditionally used titanium materials in the management of pediatric mandible fractures. Although further research and clinical investigation of the long-term results of such cases must be carried out, the potential certainly exists for resorbable fixation materials to eventually be regarded as the ideal implant for the fixation of pediatric mandible fractures. ■ Queries about this article can be sent to Dr. Penna at firstname.lastname@example.org. REFERENCES 1. Yerit KC, Hainich S, Enislidis G, Turhani D, Klug C,Wittwer G, Ockher M, Undt G, Kermer C,Watzinger F, Ewers R. Biodegradable fixation of mandibular fractures in children: sta- bility and early results. Oral Surgery Oral Medicine Oral Pathology Oral Radiology Endodontology 2005;100:17-24. NYSDJ • JUNE/JULY 2008 61 Prosthodontic Management of Patient with Cleft Lip/Palate Using Maxillary Overdenture and Swing-Lock Attachment Mechanism CLINICAL REPORT Ilser Turkyilmaz, D.D.S., Ph.D. Abstract able appliances, including partial and complete overdentures; thus, The oral rehabilitation of cleft lip and palate (CLP) patients preservation of their natural dentition is important.7 Edentulous cleft palate patients present with restorative difficulties because of is challenging; and many of these patients are suffering their compromised maxillary arches and the presence of scar tissue because they received insufficient dental treatment. in their palates and lips.A relatively new technique for treating CLP patients is implant-supported overdenture.8-11 However, this alter- Several techniques, including surgeries, alveolar bone native treatment is not available to CLP patients who don’t have grafts, orthodontic appliances and advanced prosthodon- alveolar bone for the dental implants. tic rehabilitation, have been proposed for the oral rehabil- Reports describing conventional removable overdentures for CLP patients are available in the dental literature.7 However, no itation of CLP patients. This case report describes a max- reports describing the use of the overdenture with swing-lock illary overdenture that is supported by both teeth and soft attachment mechanism for the CLP patients are currently available. This case report describes a maxillary overdenture with swing-lock tissue. Additional retention and stability have been attachment mechanism. obtained by a swing-lock attachment mechanism. Case Presentation WHEN COMPARED TO OTHER PATIENTS with congenital defects, A 42-year-old woman, self-referred to our clinic, presented com- those with cleft lip and palate (CLP) are seen relatively frequently. plaining of difficulty in chewing due to the movement of her However, dental rehabilitation of these patients is still very poor, removable partial denture. She was also dissatisfied with her and many of them grow up suffering dental neglect.1 appearance. Her medical record revealed a history of congenital Several techniques have been proposed for the oral rehabilita- unilateral cleft lip and palate (Figures 1a,b). The panaromic radi- tion of CLP patients.2-6 Although CLP patients, especially children, ograph also confirmed her cleft lip and palate (Figure 2). can be treated with surgeries, alveolar bone grafts and orthodontic The patient was born with a left complete unilateral cleft lip appliances,2,3 adult CLP patients often need advanced prosthodon- and palate, and her maxillary left lateral, canine and premolar teeth tic rehabilitation.4-7 They are treated with tooth-supported remov- missing. The first and second molar teeth were lost during ortho- 62 NYSDJ • JUNE/JULY 2008 Figure 1a. Figure 1b. Figure 1. Intraoral views of patient before prosthodontic treatment. dontic treatment. She underwent cheiloplasty at 3 months of age At the one-year follow-up recall, she said she had no functional and and palatoplasty at 1 year of age. An additional palatoplasty was aesthetic complaints with her maxillary overdenture, including the performed at 6 years of age because of partial failure in the palatal swing-lock attachment mechanism. closure. Orthodontic intervention using a chin retractor was start- ed at 7 years of age to control mandibular growth, and a lingual Discussion arch appliance was used at 8 years of age to improve a collapsed The number of CLP patients is significant. Each of these patients is maxillary arch. unique and presents with his or her own diagnostic and prostho- Orthodontic repositioning of the teeth and use of a chin cap appliance were continued up to 17 years of age.The maxillary left two molar teeth were lost during the orthodontic treatment.At age 18,the patient showed a negative horizontal overlap as the required maxil- lary expansion was not achived. She underwent rhinoplasty, includ- ing a cartilage graft at 18 and 24 years of age. She has been wearing a removable partial overdenture since 19 years of age, and she has had persistent functional and aesthetic problems during this period. After the intraoral evaluation, it was determined that the new maxillary overdenture needed to include an additional retentive part, as all the patient’s maxillary left teeth were missing. A swing- lock attachment system that provided extra retention and stability was considered, which also let us place the maxillary artificial teeth anteriorly for Class I relationship. A preliminary impression was taken with a stock tray using alginate (Cavex, CA37, Haarlem, Netherlands). A secondary impression was taken with a custom-made resin tray using Coltex Medium impression material (Coltex® Medium, Coltene/Whaledent AG, Altstatten, Switzerland). The metal-framework casting procedures for the main part and anterior part, including the swing-lock attach- ment of the overdenture, were performed separately, and the two parts were connected to each other after finishing and polishing. The bilateral balanced articulation was developed using anatomic acrylic resin teeth (Major Dent, Moncalieri, Italy). Maximal soft tissue coverage was used for the maxillary overdenture (Figures 3a,b). The patient was examined 24 hours later for post-insertion adjustment and then followed at three-month intervals (Figure 4). NYSDJ • JUNE/JULY 2008 63 dontic problems. Edentulous CLP patients in particular present with restorative difficulties because of their compromised maxil- lary arches and the presence of scar tissue in their palates and lips.7 Several techniques have been suggested for the oral rehabilita- tion of CLP patients.2-6 They can be treated with either tooth-sup- ported removable overdentures or implant-supported overden- tures. The report by Tejani et al.2 involved the oral rehabilitation of Figure 2. Panaromic radiograph of patient before prosthodontic treatment. two children with CLP using the overdentures. They reported that use of overdentures is an alternative if surgery is contraindicated or Figure 3a. unsuccessful. A relatively recent technique for CLP patients is the implant- supported overdenture.8-11 Fukuda et al.9 reported the dental reha- bilitation of two CLP patients using endosseous implants. Treatment of the patients included orthognathic surgeries, alveolar bone graft and orthodontic treatments, respectively. After these treatments, the patients were treated successfully with implant- supported fixed prostheses. However, this alternative treatment is not possible for CLP patients with no available alveolar bone for the dental implants. Conclusion The case reported here describes treatment of a CLP patient with a Figure 3b. maxillary overdenture with swing-lock attachment mechanism for additional retention and stability. It has been concluded that the maxillary overdenture with swing-lock attachment mechanism may be a feasible alternative for CLP patients with no available alveolar bone for dental implant placement. ■ Queries about this article can be sent to Dr. Turkyilmaz at email@example.com. REFERENCES 1. De Rezende ML, Amado FM. Osseointegrated implants in the oral rehabilitation of a patient with cleft lip and palate and ectodermal dysplasia: a case report. Int J Oral Maxillofac Implants 2004;19:896-900. 2. Tejani Z, Kok EC, Mason C, Griffiths B. The use of overdentures in children with cleft lip and palate: a report of two cases. J Clin Pediatr Dent 2005;29:299-306. 3. Artopoulou II, Higuera S, Martin JW, Stal S, Chambers MS. Postsurgical use of prosthet- ic palatal appliances. J Clin Pediatr Dent 2005;30:105-108. 4. Moore D, McCord JF. Prosthetic dentistry and the unilateral cleft lip and palate patient. The last 30 years. A review of the prosthodontic literature in respect to treatment Figure 3. Views of overdenture from inner side (a) and outer side (b). options. Eur J Prosthodont Restor Dent 2004;12:70-74. 5. Ramstad T, Semb G. The effect of alveolar bone grafting on the prosthodontic/recon- structive treatment of patients with unilateral complete cleft lip and palate. Int J Prosthodont 1997;10:156-163. 6. Ramstad T, Jendal T. A long-term study of transverse stability of maxillary teeth in patients with unilateral complete cleft lip and palate. J Oral Rehabil 1997;24:658-665. 7. Sykes LM. Prosthodontic treatment of the edentulous adult cleft palate patient. SADJ 2003;58:64,68-72. 8. Kramer FJ, Baethge C, Swennen G, Bremer B, Schwestka-Polly R, Dempf R. Dental implants in patients with orofacial clefts: a long-term follow-up study. Int J Oral Maxillofac Surg 2005;34:715-721. 9. Fukuda M, Takahashi T,Yamaguchi T, Kochi S, Inai T,Watanabe M, Echigo S. Dental reha- bilitation using endosseous implants and orthognathic surgery in patients with cleft lip and palate: report of two cases. J Oral Rehabil 2000;27:546-551. 10. Pham AV, Abarca M, De Mey A, Malevez C. Rehabilitation of a patient with cleft lip and palate with an extremely edentulous atrophied posterior maxilla using zygomatic implants: case report. Cleft Palate Craniofac J 2004;41:571-574. 11. Laine J,Vahatalo K, Peltola J, Tammisalo T, Happonen RP. Rehabilitation of patients with congenital unrepaired cleft palate defects using free iliac crest bone grafts and dental Figure 4. Intraoral view of patient after overdenture delivery. implants. Int J Oral Maxillofac Implants 2002;17:573-580. 64 NYSDJ • JUNE/JULY 2008 Oral Lichen Planus A R EV I EW Ch. Anuradha, M.D.S.; B.Venkat Ramana Reddy, M.D.S.; S.R.K.Nandan, M.D.S.; Shamala Ravi Kumar, M.D.S. Abstract abbreviation often used to recall the constellation of symptoms and Lichen planus is a unique but common inflammatory dis- skin findings that characterize lichen planus.1 Up to 65% of patients with cutaneous LP will manifest concurrent OLP.Oral lesions comprise order that affects the skin, mucous membranes, nails and the sole manifestation of LP in approximately 15% to 35% of cases.2 hair. Oral lichen planus (OLP) is among the more common Historical Aspects mucosal conditions a clinician is likely to encounter in his In 1869, Erasmus Wilson delineated and named the condition or her practice. The etiology is unknown. Immunofluorescence lichen planus. Wickham, in 1895, described the characteristic studies have provided some insight into a proposed appearance of whitish striae and punctuations that develop atop the flat-surfaced papules. The histologic findings were elaborated immunopathogenesis. Buccal mucosa, tongue and by Darier in 1909.1 gingiva are more commonly involved. The question of Clinical Features malignant transformation of OLP remains controversial. LP is a chronic mucocutaneous disease. It generally develops Management of lichen planus can be challenging and dis- between the ages of 40 and 70; and it is more common in females couraging for both the patient and physician. Treatment than males. Skin and oral lesions of LP are rare in children. Oral manifestations occur in approximately 2.0% of the general popula- options should be assessed for attendant risks and bene- tion, while cutaneous lesions occur in 0.4%. Ten percent to 20% of fits, and tailored to the extent and severity of disease. patients with LP demonstrate both oral and cutaneous lesions.3 OLP may present anywhere in the oral cavity. The buccal LICHEN PLANUS (from the Greek leichen—“tree moss”—and the mucosa, tongue and gingiva are the most common sites; palatal Latin planus—“flat”) is the most common dermatological disease with lesions are uncommon. They are usually symmetrical and bilateral oral manifestations.It is an immunologically based,chronic,inflamma- lesions or multiple lesions in the mouth.4 In about 10% of cases, tory, mucocutaneous disorder of undetermined etiology. Oral lichen lesions are confined to the gingival tissues exclusively. Up to six dif- planus (OLP) is estimated to affect about 0.5% to 2.3% of the general ferent clinical patterns of OLP are recognized: reticular; popular; population. The four P’s—purple, polygonal, pruritic, papule—is the plaque; atrophic; erosive; and bullous.2 66 NYSDJ • JUNE/JULY 2008 Reticular Oral Lichen Planus Etio-Pathogenesis The reticular form of OLP is thought to occur most frequently. It is In the past, speculation about the etiology of OLP covered a wide characterized by mucosal keratotic lines arranged in a characteris- range of possibilities, including trauma, specific bacteria, syphilis, tic lacy pattern (Wickham’s striae). The buccal mucosa is the site parasites, viruses, mycotics, allergies, toxicity, neurogenic, heredi- most commonly involved. The striae are typically bilateral in a tary and psychosomatic disorders. symmetrical form on the buccal mucosa. They may also be seen on Basal cells are the prime target of destruction in OLP. The mech- the lateral border of the tongue and less often on the gingiva and anism of basal cell damage is related to a cell-mediated immune the lips. Reticular LP is likely to resolve in 41% of cases.4 process involving Langerhans cells,T lymphocytes and macrophages. Langerhans cells and macrophages in the epithelium are the anti- Papular Lichen Planus gen producers that provide the antigenic information for T lymphocytes. The papular form of LP presents as small white pinpoint papules Histochemical studies have identified a T-cell origin with CD4 measuring about 0.5 mm in size. The lesions are small, and it is and CD8 subsets in OLP. There are fewer CD4 helper/inducer cells possible to overlook them during a routine oral examination. It is than CD8 cells, and the CD8 cells are those that are associated with rarely seen.4 the basal layer. The CD4 cells act as helper cells, and the destroyer CD8 cytotoxic T-cells damage the basal layer. After a proliferation Plaquelike Oral Lichen Planus phase, T8 lymphocytes become cytotoxic for basal keratinocytes. These lesions occur as homogenous white patches and resemble The role of Langerhans cells is to contact and recognize the oral leukoplakia. The plaque-like form may range from slightly ele- antigen and then to process and present appropriate antigenic frag- vated and smooth to slightly irregular and may be multifocal. The ments (epitopes), together with Class II major histocompatability most common sites are over the dorsum of tongue and the buccal complex to CD4 cells after the T lymphocytes have been attracted mucosa. This form resolves in only 7% of cases and is more com- by interleukin-1. Interleukin-1 is the lymphokine of the mon in tobacco smokers. Langerhans cells and macrophages and stimulates the T lympho- Plaque-like OLP, like reticular OLP and papular LP, is generally cytes to produce interleukin-2, which cause T cell proliferation. asymptomatic and may require no treatment. Activated lymphocytes are cytotoxic for basal cells. They secrete gamma-interferon, which induces keratinocytes to express the Atrophic Oral Lichen Planus Class II histocompatability antigens HLA-DR and increases their This form of LP is diffuse, red, and there are usually white striae rate of differentiation. This results in thickening of the surface, around the lesion. Such striae that radiate peripherally are usually which is seen clinically as a white lesion. Langerhans cells and evident at the margins of the atrophic zones of the lesion. The macrophages transfer the antigenic information when there is a attached gingiva is commonly involved and is referred to as “chron- mutual expression of HLA-DR antigens. During this mutual ic desquamative gingivitis.” expression between keratinocytes and lymphocytes that normally The atrophic form can display a symmetrical patchy distribu- express HLA-DR antigens, lymphocytes may make contact with tion over all four quadrants.This condition can cause a burning sen- epithelial cells and take the inappropriate epithelial antigenic infor- sation. About 12% of atrophic lesions will resolve spontaneously.4 mation by HLA-DR linkage. Self antigens may, therefore, be recog- nized as foreign and cause an autoimmune response. Bullous Oral Lichen Planus Diabetes mellitus and hypertension have been described as Bullous LP appears as small bullae or vesicles that tend to rupture “Grinspan syndrome”4 when associated with OLP. Over the past easily. When they rupture, they leave an ulcerated, painful surface. decade, an association between OLP and hepatitis C virus (HCV) This form is rarer than other forms of LP and is commonly seen in infection has been demonstrated in several studies.5 posterioinferior areas of the buccal mucosa, adjacent to the second and third molars. The next most common site is the lateral margin Histopathology of the tongue. The classical histopathological features of LP include the following:2,6 ● Hyperorthokeratosis or hyperparakeratosis. Erosive Lichen Planus ● Acanthosis. This type is the second most common form of OLP. The lesions are ● Thickening of the granular cell layer. usually irregular in shape and covered with a fibrinous exudate. ● “Saw tooth” configuration of the rete pegs. The periphery of the lesion is frequently surrounded by reticular or ● Liquefaction of the basal cell layer and apoptosis of the basal finely radiating keratotic striae. It is a painful condition. It has a keratinocytes. greater potential to undergo malignant transformation. It has been ● Homogenous eosinophilic colloid bodies (civatte bodies), reported that only atrophic and erosive forms of LP undergo malig- which represent degenerating basal keratinocytes, may be nant change. This may be because of the atrophic nature of the visible. mucosa rather than the specific disease.4 ● Dense subepithelial bandlike infiltrate of T- cells. NYSDJ • JUNE/JULY 2008 67 Immunofluorescence Retinoids OLP may sometimes pose histopathologic problems regarding Topical retinoic acid (tretinoin gel) has been shown to be effective diagnosis, especially when mucosal lesions are ulcerated with sec- in treating erosive and plaquelike oral lesions. Irritation often ondary inflammation. Direct immunofluorescence (DIF) testing makes this localized approach to therapy less attractive. has proved to be a valuable tool in diagnosing bullous, erosive and Isotretinoin gel is also effective, especially in nonerosive oral ulcerative diseases of the oral mucosa.7 lesions. Improvement is noted after two months. Topical retinoids DIF shows shaggy deposition of fibrinogen along the base- are often used in conjunction with topical glucocorticoids. ment membrane zone (BMZ), and colloid bodies stain for Etretinate administered orally has been used at 75 mg/day (0.6 immunoglobulins IgA, IgG and IgM.2,4 to 1.0 mg/kg per day) in treating erosive OLP; significant improve- ment has been seen in the majority of patients. Relapses are com- Malignant Potential mon following discontinuation of medication. Several studies have reported a significant risk (0.4% to 3.7%) for the malignant transformation of OLP to squamous cell carcinoma Cyclosporine, Tacrolimus, Pimecrolimus (SCC), consequently, many authorities consider OLP to be a prema- Topical application of cyclosporine (100mg/ml) 5ml three-times lignant condition. The associated risk appears to be most strongly daily has shown benefit in the treatment of OLP. Application related to cases of atrophic or erosive OLP.3,6 There seems to be a modalities include mouthwashes and manual administration with slightly higher incidence of oral squamous cell carcinoma in local massage. Topical cyclosporine washes seem to be effective in patients with OLP than in the general population.2,8 treating OLP, especially the severe erosive forms. Alternate topical immunosuppressive agents, tacrolimus and pimecrolimus, are use- Differential Diagnosis ful substitutes to topical cyclosporine. The clinical differential diagnosis includes lichenoid reactions, leuko- plakia, squamous cell carcinoma, pemphigus, chronic cheek biting Miscellaneous and candidiasis. The histopathological differential diagnosis includes The polyene antifungal griseofulvin has been used empirically for lichenoid reaction, mucous membrane pemphigoid, graft versus host treatment of oral and cutaneous lichen planus. Newer antifungal disease, lupus erythematosus and erythema multiforme.2,4 agents (for example, fluconazole and itraconazole) may be useful in treating OLP, with evidence of candida overgrowth, especially con- Management comitantly with systemic glucocorticoids.1 For OLP, good oral hygiene and regular personal and professional dental care need to be encouraged. Several treatment approaches Summary are useful for oral or mucous membrane lichen planus. They are OLP is a chronic mucocutaneous disease of unknown etiology. Oral listed here. manifestations occur in approximately 2% of the general popula- tion. Up to six different clinical patterns of OLP are recognized. Topical Steroids Diagnosis of OLP is based mainly on clinical features, histopathol- Topical steroids are first-line therapy in mucosal lichen planus. A ogy and direct immunofluorescence. Management of OLP can be variety of glucocorticoids have been shown to be effective. challenging and discouraging for both the patient and physician. Occlusive materials suitable for mucous membranes, such as Treatment options should be assessed for attendant risks and ben- Orabase, may provide protection and sustained tissue contact efits and tailored to the extent and severity of the disease. Patients with the glucocorticoid and alleviate the discomfort associated should be observed periodically, particularly those with erosive and with erosive lesions. Fluocinonide in an adhesive gel or base, atrophic forms, since these two forms have a greater potential to 0.1% fluocinolone acetonide and 0.05% clobetasol propionate in undergo malignant transformation. ■ Orabase showed good results. Application four- to six-times a day is recommended. The use of chlorhexidine gluconate mouth- Queries about this article can be sent to Dr. Anuradha at firstname.lastname@example.org washes and topical anti-candidal medications is recommended during therapy. REFERENCES 1. Feedberg IM, Eisen AZ, Wolf K, Fitzpatrik TB, Austen F. Dermatology in General Medicine.Vol. 1, 4th Ed. USA: MacGraw Hill, Inc. 1993;463-473. Systemic Glucocorticoids 2. Huber MA. Oral lichen planus. Quintessence Int 2004;35:731-752. 3. Academy report.Oral features of mucocutaneous disorders.J Periodontol 2003; 74:1545-1556. Systemic glucocorticoids are effective in treating erosive oral and 4. Moliaoglu N. Oral lichen planus: a review. Brit J Oral & Maxillo Surgery 2000; 38:370-377. vulvovaginal lichen planus. Systemic dosing can be used alone, or, 5. Gandolfo S,Carbone M,Carrozzo M,Gallo V: Oral lichen planus and hepatitis C virus (HCV) infection: is there a relationship? A report of 10 cases. J Oral Pathol Med 1994; 23:119-22. more commonly, in conjunction with topical glucocorticoids. A 6. Scully C,El-Kom M.Lichen planus:review and update on pathogenesis.J Oral Path 1985;14:434-458. dose range of from 30 mg to 80 mg/day, tapered over three to six 7. Laskaris G, Sklavounou A, Angelopoulos A. Direct immunofluorescence in oral lichen planus. Oral Surg 1982;53;5:483-487. weeks shows benefit. Relapses are common after dose reduction or 8. Barnard NA, Scully C, Eveson JW, Cunningham S, Porter SR. Oral cancer development in discontinuation. Oral candidiasis is a common complication. patients with oral lichen planus. J. Oral Pathol Med 1993;22:421-4. 68 NYSDJ • JUNE/JULY 2008
"The Challenge of Mentoring"