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The Challenge of Mentoring

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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-
(lbleon@nysdental.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 hwaldman@notes.cc.sunysb.edu.




                                                                                                                                          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 jbf2@nyu.edu.

                            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 jaos@usp.br.                                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 yzadik@gmail.com.

                                                                  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. A review of sodium fluoride varnish. Gen Dent. 2006;54:247-53.
                                                                  7. Helfenstein U, Steiner M. Fluoride varnishes (Duraphat): A meta-analysis. Community
                                                                      Dent Oral Epidemiol 1994;22:1-5.
                                                                  8. Petersson LG, Twetman S. Dahlgren H, Norlund A, Holm AK, Nordenram G, Lagerlof F,
Figure 6c.                                                            Soder B, Kallestal C, Mejare I, Axelsson S, Lingstrom P. Professional fluoride varnish
                                                                      treatment for caries control: A systematic review of clinical trials. Acta Odontol Scand
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                                                                  9. Hicks MJ, Flaitz CM. The acid-etch technique in caries prevention: pit and fissure
                                                                      sealants and preventive restorations. In: Pinkham JR (ed.). Pediatric Dentistry: Infancy
                                                                      Through Adolescence, 3rd edition. Philadelphia: W.B. Saunders, 1999;481-521.
                                                                  10. Bader JD, Shugars DA, Bonito AJ. Systematic reviews of selected dental caries diagnostic
                                                                      and management methods. J Dent Educ 2001;65:960-8.
                                                                  11. Ekstrand K, Qvist V, Thylstrup A. Light microscope study of the effect of probing in
                                                                      occlusal surfaces. 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 ttozum@hacettepe.edu.tr.
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 kjpenna@verizon.net.


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 ilserturkyilmaz@yahoo.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 drramanabv@yahoo.com
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

				
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