Journa

March 2017
Antibiotic Prophylaxis
Mandibular Fractures
Photodynamic Therapy

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

The Management
of Infections and
the Use of Antibiotic
Prophylaxis by
Dentists:
A Review of the Evidence
 Caution + control:
Reducing
employment
liability

The combination of changing employment laws and a litigation-conscious public

can be intimidating. And, its even more so when dental practice employees are prepared to
take legal action if they feel an employer breached their rights. Our latest seminar, designed from
TDICs Employment Practice Liability (EPL) claims experience and calls to our Risk Management
Advice Line, will show you how to handle employment concerns. Gain the caution and control
to navigate past potential employment practice violations such as pregnancy discrimination,
termination and sexual harassment.

Get expert advice while earning C.E. credits and a

5% Professional Liability premium discount for two years.

After course completion, you will better understand how to:

Establish effective hiring and performance review practices.
TDIC policyholders who
complete a seminar or Provide employees with a fair and rewarding work environment.
eLearning option will
receive a two-year, 5% Implement controls to prevent situations that lead to EPL claims.
Professional & Dental
Business Liability premium
discount effective their
next policy renewal. To
obtain the two-year, 5%
Reserve your space today at tdicinsurance.com/seminars
Professional & Dental
Business Liability premium Unable to attend in person? Visit tdicinsurance.com/eLearning
discount, California dentists
must successfully complete to explore convenient eLearning options.
the seminar by April 28,
*Due to the sensitive nature of the issues being addressed and our employer-oriented approach,
2017. Any eLearning tests
received after the deadline
this course is available to dentists and their spouses only.
will not be eligible for the
discount. Nonpolicyholders
who complete a seminar
or eLearning option and
are accepted for TDIC Protecting dentists. Its all we do.
coverage will also be
eligible for this discount. 800.733.0633 | tdicinsurance.com | CA Insurance Lic. #0652783
March 2017 C D A J O U R N A L , V O L 4 5 , N 3

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

151 Regulatory Compliance/Guide to Dental Practice

Act Compliance

156 Tech Trends

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

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

133 Management of Mandibular Fractures in Pediatric Patients With Conservative

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

139 Ex Vivo Assessment of Photodynamic Therapy in Achieving Microbial Reduction

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

M A R C H 2 0 1 7 111

CDA Classieds.
Free postings.
Priceless results.
CDA classieds work harder to
bring you results. Selling a practice
or a piece of equipment? Now you
can include photos to help buyers
see the potential.
And if youre hiring, candidates
anywhere can apply right from
the site. Looking for a job? You can
post that, too. And the best part
its free to all CDA members.
All of these features are designed to
help you get the results you need,
faster than ever. Check it out for
yourself at cda.org/classieds.
112M A R C H 2 01 7
C D A J O U R N A L , V O L 4 5 , N 3
JournaC A L I F O R N I A D E N TA L A S S O C I AT I O N
Volume 45, Number 3
March 2017
published by the Editorial Upcoming Topics Letters to the Editor
California
Dental Association
Kerry K. Carney, DDS, CDE
EDITOR-IN-CHIEF
April/Regulatory Issues
May/General Topics
www.editorialmanager.
com/jcaldentassoc
1201 K St., 14th Floor Kerry.Carney@cda.org
June/Lasers
Sacramento, CA 95814 Subscriptions
Ruchi K. Sahota, DDS, CDE
800.232.7645
Subscriptions are available
cda.org
ASSOCIATE EDITOR
Advertising
only to active members of
Brian K. Shue, DDS, CDE Doug Brown the Association. The
CDA Ocers ASSOCIATE EDITOR
ADVERTISING SALES
subscription rate is $18 and
Doug.Brown@cda.org is included in membership
Clelan G. Ehrler, DDS 916.554.7312
PRESIDENT Andrea LaMattina, CDE dues. Nonmembers can
president@cda.org PUBLICATIONS MANAGER view the publication online
Permission and at cda.org/journal.
Natasha A. Lee, DDS Courtney Grant
SENIOR COMMUNICATIONS
Reprints Manage your subscription
PRESIDENT-ELECT
Andrea LaMattina, CDE online: go to cda.org, log in
presidentelect@cda.org SPECIALIST
PUBLICATIONS MANAGER
and update any changes to
Andrea.LaMattina@cda.org your mailing information.
R. Del Brunner, DDS Kristi Parker Johnson
916.554.5950 Email questions or other
VICE PRESIDENT EDITORIAL ASSISTANT
vicepresident@cda.org changes to membership@
Blake Ellington Manuscript cda.org.
Richard J. Nagy, DDS TECH TRENDS EDITOR
Submissions
SECRETARY
Jack F. Conley, DDS www.editorialmanager.
secretary@cda.org
EDITOR EMERITUS com/jcaldentassoc
Kevin M. Keating, DDS, MS
TREASURER Robert E. Horseman, DDS
treasurer@cda.org HUMORIST EMERITUS
Stay Connected cda.org/journal
Craig S. Yarborough, DDS,
Production
MBA
Val B. Mina
SPEAKER OF THE HOUSE
speaker@cda.org SENIOR GRAPHIC DESIGNER
Go Digital cda.org/apps
Kenneth G. Wallis, DDS Randi Taylor
IMMEDIATE PAST PRESIDENT SENIOR GRAPHIC DESIGNER Look for this symbol, noting additional video
pastpresident@cda.org content in the ePub version of the Journal.
Management
Peter A. DuBois Journal of the California Dental Association (ISSN 10432256) is published monthly by the
EXECUTIVE DIRECTOR California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950.
Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal
Jennifer George of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853.
CHIEF MARKETING OFFICER
The California Dental Association holds the copyright for all articles and artwork published
Carrie E. Gordon herein. The Journal of the California Dental Association is published under the supervision of
CHIEF STRATEGY OFFICER
CDAs editorial sta. Neither the editorial sta, the editor, nor the association are responsible for
any expression of opinion or statement of fact, all of which are published solely on the authority
of the author whose name is indicated. The association reserves the right to illustrate, reduce,
Alicia Malaby
revise or reject any manuscript submitted. Articles are considered for publication on condition
COMMUNICATIONS
DIRECTOR
that they are contributed solely to the Journal.
Copyright 2017 by the California Dental Association. All rights reserved.
 Editor
Aliens Among Us
Kerry K. Carney, DDS, CDE
W
hen I was growing
up, there were two
popular science
fiction series: The
Twilight Zone and
Outer Limits. They both aimed to scare
the beegeebies out of the viewer. Outer
Limits relied on the hideous monster-
of-the-week theme. The Twilight Zone
was more subtle and much scarier. It relied
on placing every story in an everyday
setting with everyday characters who
slowly were revealed to be somehow
alien. It was that aliens among us aspect
that was so effective and unsettling.
Now there are new aliens among us.
They may look like us, but they are very
different. They are the millennials.
It seems that every meeting I attend
has an authority that expounds on the
unique characteristics of that generation of
individuals born between 1980 and 2000.
It is not the amusing anecdotes about how
millennials incorporate new technology
into their lives; it is the undercurrent of
strangeness, of foreignness attributed to
them that makes me uncomfortable.
When I see charts that tell me how
profoundly different millennials are and
how the baby-boom generation must
learn a new language to speak to them, I
become annoyed. It is not that I feel put
upon or challenged to become fluent in
a foreign language. My disquiet comes
from the implied insult to those folks born
between 1980 and 2000. We are told that
millennials need instant gratification. They
need constant recognition. They have a
sense of entitlement. They boomerang and
move back in with their parents rather
than independently striking out on their
own. They are not goal-oriented. They
choose fun over higher pay at work. They
are selfish and shallow. The list goes on
and on. They are so different; or are they?
When I see charts that tell me how profoundly
dierent millennials are and how the baby-boom
generation must learn a new language to speak
to them, I become annoyed.
Most generational comparisons
seem fatally flawed. They compare
groups of people across age ranges.
They are based on the assumption that
we do not change in our behavior or
beliefs as we age. But we do change.
When I reread a book or review a
film I first experienced as a young adult,
I seldom have the same appreciation the
second time around. I perceive it later
through the lenses of my experience.
The first time I saw The Graduate I
empathized with Benjamin Braddock.
Years later, on review, I empathized
with Elaine Robinsons father. The
movie did not change. I had changed.
Time even changes how we
experience language. Now, as a
homeowner, I can appreciate the phrase
get off my property, in a much different
way than I did years ago as a child
when a grouchy (my perception then)
neighbor used the phrase to advise my
playmates and me it was time to exit her
yard. Our perceptions are fluid over time.
My uncle told me years ago that
he had feared my siblings and I would
never learn to read or appreciate the
written word. He was from a time before
electricity in the home. As a child,
he had read his books by the light of
an oil lamp. He was sure that because
we spent so much time in front of the
television set, my generation would
be intellectually stunted and never
able to enjoy literature like he did.
C D A J O U R N A L , V O L 4 5 , N 3
Our childhoods were very different,
but it might have been interesting if
my uncle and I could have tampered
with the time continuum and met as
young adults. We would not have been
contemporaries, but we would have
both been standing in the same section
of the river of our lives. We might
have shared a common perspective.
We might have found we had many of
the same motivators. We might have
agreed on what makes a person good.
The baby boomers were subjected
to the same kind of alienating
criticisms when they were the new
generation. The lyrics in a popular
musical of the 1960s characterized
boomers as disobedient, disrespectful,
noisy, crazy, sloppy, lazy loafers. They
went on to describe the cohorts
inability to live up to our parents
generational expectations, with the
plaintive questions: Why cant they
be like we were, perfect in every way?
Whats the matter with kids today?
I agree with George Orwell when
he noted that, Every generation
imagines itself to be more intelligent
than the one that went before it, and
wiser than the one that comes after it.
Wisdom can flow in both directions.
The trick is to not overemphasize
the differences and to continue to
learn from one another. The process
of maturation requires modifying
opinions and perceptions based
M A R C H 2 0 1 7 113
 M A R C H 2 0 17 EDITOR
C D A J O U R N A L , V O L 4 5 , N 3

on experience and information.

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

Your library card Millennials are different. The

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

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

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

The Journal welcomes letters

We reserve the right to edit all
communications. Letters should discuss an
item published in the Journal within the last
two months or matters of general interest
to our readership. Letters must be no more
than 500 words and cite no more than five
references. No illustrations will be accepted.
Letters should be submitted at editorialmanager.
com/jcaldentassoc. By sending the letter, the
author certifies that neither the letter nor one
with substantially similar content under the
writers authorship has been published or is being
considered for publication elsewhere, and the
author acknowledges and agrees that the letter
and all rights with regard to the letter become the
property of CDA.

114M A R C H 2 01 7
You are the protector of the smile. You enable people to laugh
without shame, eat their favorite foods and age with grace. The
dignity you instill in your patients is just one reason why CDA
is passionate about your profession. From advocating for oral
health for all Californians to offering resources for every stage
of your career, were here to support and protect you.

Renew today.
cda.org/member
 Practice Support

Employment Practices

When it comes to employment practices,

theres one spot where CDA members can
get assistance with every nuance of running a
practice: CDA Practice Support. Download a
customizable employee manual or train your
staff with easy-to-use PowerPoint presentations.
There are even tips on setting staff rules around
piercings and tattoos. Whats more, if you need
personalized advice, our employment expert is
just a phone call away. CDA Practice Support.
Its where smart dentists get smarter.

800.232.7645 or cda.org/practicesupport
Impressions
The nub:
1. There is a secondary market for
professional ethics.
2. Ethics, as a cost of doing
business, can be subcontracted.
3. Laws can be written to shift and
disguise ethical risk.
David W. Chambers, EdM, MBA, PhD, is professor
of dental education at the University of the Pacic, Arthur
A. Dugoni School of Dentistry, San Francisco, and editor
of the American College of Dentists.
C D A J O U R N A L , V O L 4 5 , N 3
Brands and Independent
Contractors
David W. Chambers, EdM, MBA, PhD
Brands have value. That is certainly so for dentistry, where there
are 120 practices with fictitious business names in San Francisco.
That is part of the idea behind corporate dental practices.
The modern corporate business structure is a marvel because
it permits segmentation and separate ownership of various aspects
of the customer experience. The most successful limited liability
corporations own the controlling and most profitable aspects of
the enterprise and sell off the rest to independent contractors.
Ethics is one of those business assets or liabilities that
can be spun off to maximize profit. Responsibility for fixing
mistakes can be sold to others as easily as offering extended
warranties or subcontracting with other outfits that are willing
to buy ones boo-boos under their name. Companies can
actually sell their ethical liabilities. Read the fine print.
The current masters are in Big Pharma. Consider pay to delay
drug marketing settlements. A large firm faces revenue losses as its
patent is about to expire and a startup readies to introduce a generic
alternative. The business with a brand threatens a costly legal
action, which has little chance of prevailing in court but would
consume most of the small firms resources and some taxpayers
funding of our justice system. Constraint of trade is dodged by
reaching a court settlement where the generic manufacturer
agrees to delay introduction of the competitive product for a
period, say seven years, in exchange for several millions in cash
payments from the larger firm each year. Both companies and
their lawyers come out ahead, but at the expense of the public.
Specific case: The pharmaceutical company Aventis was
making little from an anti-inflammatory orphan drug called Acthar,
charging only $50 per vile. Protecting its brand image, it was afraid
to raise prices out of fear of acquiring a reputation for price gouging.
Aventis slithered out from under this ethical limitation by selling
the patent to Questcor, evidently an outfit with no reputation to
protect, for a nominal $100,000 plus a percentage on all future
sales. A single dose of Acthar now costs $28,000. Aventis sold its
ethical responsibility and got another company to do its dirty work.
Here is another trick where a company with a brand uses
an entity with a weak reputation to extract money from the
public. Insurance companies derive income from copayments on
expensive brand-name drugs that they cannot get from the less
expensive generics. Some manufacturers now offer to reimburse
patients the copayment for continuing to buy their brand-
name pills. Customers come out ahead. Manufacturers have to
pay the insurance company a few bucks, but they are able to
retain the much larger profit margin while using the insurance
company to collect from employers and the government that
underwrite the insurance contracts. Could happen in dentistry.
M A R C H 2 0 1 7 117
 M A R C H 2 0 17 IMPRESSIONS
Childrens Oral Health
Disparities Persist Despite
Equal Dental Care Access
Oral health of children who receive
dental care through Medicaid lags
behind that of their privately insured
peers although the children receive the
same amount of dental care, according
to a Columbia University College
of Dental Medicine study published
in Health Affairs in December.
The study considered data from the
20112012 National Survey of Childrens
Health, which included parent reports
of oral health and use of dental care for
79,815 children and adolescents (ages
1 to 17 years) of all social levels. No
differences were found between Medicaid-
insured and commercially insured
children in the odds of their having a
dental visit, preventive or otherwise.
However, parents of children enrolled
in Medicaid were 25 percent more likely
to report that their children did not
have an excellent or very good dental
condition and 21 percent more likely
to report that their children had dental
problems within the last year than were
parents of commercially insured children.
Burton L. Edelstein, DDS, MPH,
chair of the section of population oral
health, professor of dental medicine at the
College of Dental Medicine and professor
of health policy and management at
Columbias Mailman School of Public
Health, was the lead author of the study.
If poor and low-income children
now enjoy equal access to dental care
118M A R C H 2 01 7
C D A J O U R N A L , V O L 4 5 , N 3
Abnormal Salivary Glands Linked to Cleft Lip,
Palate Dental Problems
A new study in the Journal of Dental Research suggests that dental problems
associated with cleft lip and palate may be caused by abnormalities in salivary
glands and an imbalance of immune compounds in the mouth.
Timothy Cox, PhD, a craniofacial researcher at Seattle Childrens
Research Institute and lead author, found that mice with a gene mutation that
causes cleft lip and palate had problems in their salivary glands that
aected gum tissue and oral health.
We found that the cleft lip and palate gene mutation also resulted in
abnormal salivary glands, Cox said. The result was a mouth environment that
was too acidic and contained excess bacteria, which led to problems in the
gums and more rapid tooth decay.
In the study, the researchers oered mice with the cleft lip and palate
mutation and mice without the mutation a high-sugar diet. After just eight weeks
on this diet, the mice with the cleft lip and palate mutation had almost no molar
teeth left, while the mice without the mutation had only mild decay.
The researchers focused on the gene IRF6, which is most commonly
associated with cleft lip or palate. Many other genes have been linked to cleft
lip or palate, and the researchers hope to understand if these additional genes
are also associated with enhanced tooth decay.
We hope that as the research progresses, doctors and dentists can apply the
ndings in caring for cleft lip or palate patients
and protect their teeth starting in early childhood
and into adulthood, Cox said.
For more on the study, go to journals.sagepub.
com/doi/full/10.1177/0022034516679376.
but do not have equal oral health, then We cant segregate oral health
the remedy should focus more tightly from overall health, he said.
on the day-to-day factors that put them Evolving health systems that
at higher risk for dental problems, Dr. bring teams of providers together
Edelstein said. Low-income families to promote healthy behaviors can
often face income, housing, employment address common risk factors that
and food insecurities that constrain benefit a childs overall and oral
their ability to engage in healthy health. But if you segregate dentistry,
eating and oral hygiene practices. especially for Medicaid kids, then
Dr. Edelstein urged dentists to rethink you lose that opportunity.
the nature of oral health care by seeing To learn more about the study, go
it as part of a childs total health care. to healthaffairs.org.
 C D A J O U R N A L , V O L 4 5 , N 3

Study Estimates Health Impact of UK Soft Drinks Levy

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

lower-sugar drinks. For each response

they identified a realistic best- and
worst-case scenario for health, by
Impact of NIH Research Funding to Dental Schools estimating the likely impact on rates
Articles published recently by the International and American Associations for of obesity, diabetes and tooth decay.
Dental Research (IADR/AADR) in the Journal of Dental Research shed light on The study finds that an industry
the trends and impact of National Institutes of Health research funding to dental response that focuses on reducing
schools and institutions. sugar content is likely to have the
A study titled The NIHs Funding to U.S. Dental Institutions from 2005 to greatest impact on health. Researchers
2014 by researchers at the National Institute of Dental and Craniofacial estimate that a reduction of 30 percent
Research (NIDCR) examined NIHs investment in both extramural research in the sugar content of all high-sugar
drinks and a 15 percent reduction
projects and training at dental institutions. Over the 10-year span, 56 U.S. dental
in mid-sugar drinks could result in
institutions received approximately $2.2 billion from more than 20 institutes,
144,000 fewer adults and children with
centers and oces at the NIH, according to the study. The NIDCR is the largest
obesity, 19,000 fewer cases of type 2
NIH supporter of dental institutions, having invested 70 percent of the NIH total,
diabetes per year and 269,000 fewer
about $1.5 billion. The NIDCR is also the primary supporter of research training
teeth suffering from decay annually.
and career development. Adam Briggs, MFPH, of the
Recent Trends in Oral Cavity Cancer Research Support in the United University of Oxford and lead author
States by researchers from Wayne State University, Michigan, University of of the study, said research suggests
Pittsburgh and Medical University of South Carolina found that overall that the most likely industry responses
funding for oral cavity cancer research decreased considerably after 2009. to the tax have the potential to
Funding administered through the NIDCR was 6.5 times greater than dollars improve overall health. The extent
awarded by the NIH National Cancer Institute (NCI) in 2000; over the time of the health benefits of the tax
period evaluated, NIDCR support decreased in most years while NCI will depend on industrys response,
support increased and approached NIDCR funding levels. Briggs said. We must therefore be
AADR will continue to communicate to vigilant to ensure the food industry
Congress the importance of biomedical acts to remove sugar from soft drinks,
research for the health of the population, and that where the tax is passed
said AADR President Jack Ferracane. on to consumers, it increases the
To read the full articles, visit price of targeted products only
sagepub.com/toc/jdrb/current. drinks with high levels of sugar.
To learn more about this
study, see The Lancet, vol. 2,
no. 1 e15-e22 January 2017.
M A R C H 2 0 1 7 119
 M A R C H 2 0 17 IMPRESSIONS
Debbie Guatelli-Steinberg. (Image courtesy of
Ohio State University)
Fossilized Teeth Reveal Much
About Ancestors
A new book by anthropologist
Debbie Guatelli-Steinberg reveals what
scientists have learned about the life
history, growth and diet of primates
and our human ancestors by studying
fossilized teeth. The book, What
Teeth Reveal About Human Evolution
(Cambridge University Press, 2016),
also discusses what those findings say
about the teeth of humans living today.
Guatelli-Steinberg, a professor
of anthropology at The Ohio State
University, said modern humans have
teeth that were adapted for eating a very
different diet than the one currently
enjoyed by most Western societies. In
the book, she notes that 99 percent
of humans evolutionary history was
spent eating foods that were hunted
or gathered, much unlike current diets
of soft, processed and sugary foods.
Problems like cavities and
plaque buildup have been magnified
tremendously in humans today, she said.
Natural selection has not prepared us
well for the kinds of food we eat today.
In addition to having much higher
rates of cavities and plaque, modern
humans are much more likely to have
misaligned teeth that require orthodontic
treatment or surgery. Soft diets do
not stimulate jaw growth, and teeth,
especially our third molars, become
impacted, Guatelli-Steinberg said.
Teeth are the most preserved skeletal
120M A R C H 2 01 7
C D A J O U R N A L , V O L 4 5 , N 3
Scuba Divers Should Visit Dentist Before Diving
Recreational scuba divers who recently received dental care should
consider consulting with their dentists before taking their next plunge. A new
pilot study found that 41 percent of divers experienced dental symptoms in
the water, according to new research from the University at Bualo.
The study, Prevalence of dental problems in recreational scuba divers,
published last month in the British Dental Journal, was inspired by the lead
authors rst experience with scuba diving in 2013. Although she enjoyed
being in the water, Vinisha Ranna, BDS, a student in the UB School of Dental
Medicine and certied stress and rescue scuba diver, couldnt help but notice
a squeezing sensation in her teeth, a condition known as barodontalgia.
Published research on dental symptoms experienced while scuba diving is
scarce or focuses largely on military divers, said Ranna, so she crafted her
own study using an online survey that was distributed to 100 certied
recreational divers. Her goal was to identify the dental symptoms that divers
experience and to detect trends in how or when they occur.
Of the 41 participants who reported dental symptoms, 42 percent
experienced barodontalgia, 24 percent described pain from holding the air
regulator in their mouths too tightly and 22 percent reported jaw pain.
Another 5 percent noted that their crowns were loosened during their dive,
and one person reported a broken dental lling.
The potential for damage is high during scuba diving, said Ranna, who
has completed 60 dives. The dry air and awkward position of the jaw while
clenching down on the regulator is an
interesting mix. An unhealthy tooth
underwater would be much more
obvious than on the surface.
For more information, read the
study in the British Dental Journal
221, 577581 (2016).
remains found in fossils, making them species are related to one another.
easily available for discovery and Guatelli-Steinberg said she expects
studying. Small and very mineralized, future anthropologists will likely have
they are resistant to decomposition a field day studying modern human
and able to maintain their original teeth. In various cultures today, we have
qualities, Guatelli-Steinberg said. people who notch teeth, inlay them with
Teeth also contain records of their jewels or gold, lengthen them, file them
development, including their chemistry down and remove them altogether,
and pathology. For example, researchers she said. One can only imagine what
study the structure of teeth, such anthropologists will make of all the
as bumps and grooves, to see how things we do to our teeth today.
 C D A J O U R N A L , V O L 4 5 , N 3

Dental Implant Coatings Help Prevent Infection

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

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

The Management of Infections

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

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

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

AUTHOR

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

TABLE 1 TABLE 2

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

Fever, Endocarditis, and Kawasaki Disease Committee,

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

importance of optimum dental health and
oral hygiene. For these patients at risk, it
is important that the dentist inform the
patient about the need for maintaining
his or her dental condition at the highest
state of health possible1 (TABLES 13 ).
There is increased legal risk of
establishing guidelines. The ADA
Division of Legal Affairs has offered a
legal perspective on antibiotic prophylaxis
in order to assist dentists with questions
regarding the indications and necessity of
premedication. The ADA recommends
that each dentist use his or her professional
judgment in applying the ADA antibiotic
guidelines. It points out that occasionally
questions might arise when patients present
for treatment with a recommendation
from their physicians to use antibiotic
prophylaxis that is outside the guidelines.
The physicians recommendation may be
due to the patients medical condition or
risk factors not known to the dentist or
because the physician is not familiar with
the most recent prophylaxis guidelines.
In an updated opinion, the ADA
Division of Legal Affairs recommended
that the dentist and physician
communicate and try to reach agreement
on the management of the patient. If
consensus cannot be reached, the patient
should also be informed that the dentists
124M A R C H 2 01 7
recommendations differ from those of
the patients physician. The dentist
should also provide the patient with a
thorough informed consent so that the
patient can make his or her own decision
whether to use antibiotic prophylaxis. The
patient should be encouraged to discuss
the treatment options with his or her
physician before making a decision.2,3,4
The ADA Council on Scientific
Affairs published the most recent
version of its clinical practice guidelines
concerning prophylactic antibiotics
prior to dental procedures in patients
with prosthetic joints. It concluded, In
general, for patients with prosthetic joint
implants, prophylactic antibiotics are not
recommended prior to dental procedures
to prevent prosthetic joint infection. For
patients with a history of complications
associated with their joint replacement
surgery, the council recommends that
antibiotics should only be considered after
consultation with the patient and the
orthopedic surgeon. If it is determined
that antibiotics are indicated, the council
suggests that the orthopedic surgeon
recommend the appropriate antibiotic
and when possible provide a prescription.
In making that recommendation, the
council cited the increased risk of
antibiotic resistance and adverse effects.6
Use of Antibiotics in Other Clinical
Situations
For most clinical situations
encountered by dentists, antibiotics
are rarely indicated. In patients with
intact defense mechanisms, most of the
symptoms associated with these conditions
are inflammatory or immunologic in
nature. In 2001, the American Academy
of Pediatric Dentistry (AAPD) published
guidelines to be used by clinicians when
prescribing antibiotics to pediatric patients
based on their presenting condition.
These were revised in 2014. The AAPD
states that there are few indications
for the use of antibiotics in children.7
In the winter of 2012, the American
Association of Endodontists (AAE)
published Use and Abuse of Antibiotics to
educate the dental community on the
appropriate use of antibiotics for dental
conditions associated with endodontics.
The oral and maxillofacial surgery
and periodontal surgery literature are
replete with articles on the appropriate
management of infections and the
use of antibiotics8 (TABLE 4 ).
The dental pulp presents a unique host
environment. The circulation to the pulp
is limited and the bodys natural defense
mechanisms can be overwhelmed. In
spite of this, in the majority of infections,

TABLE 3
Regimens for a Dental Procedure
Situation
Oral
Unable to take medication
Allergic to penicillins or ampicillin
oral
Allergic to penicillins or ampicillin and
unable to take oral medication
IM indicates intramuscular; IV indicates intravenous
* Or other rst- or second-generation oral cephalosporin in equivalent to adult or pediatric dosage.
Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema or urticaria with penicillins or ampicillin.
Adapted from Prevention of Infective Endocarditis: Guidelines From the American Heart Association A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki
Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and
Outcomes Research Interdisciplinary Working Group. Circulation 2007;116:17361754.
patients with intact immune systems do
not require antibiotic therapy. Even in
situations of moderately severe localized
infections, these conditions can be
managed with incision and drainage and/
or removal of the source of the infection
(endodontics or tooth extraction) without
antibiotic treatment. During infections,
the patients own systemic defenses are
attracted to the area of damaged tissue.
In the normal process, an abscess forms
as a fibrocollagenous border around the
responsible microorganisms and immune
mediators isolating them. This border can
reduce circulation to the area and prevent
antibiotics from reaching the source of the
infection. Chronic apical abscesses that are
localized or have a draining sinus tract and
develop gradually often have only mild or
no symptoms. In these situations, the hosts
immune system has already contained the
infection. Studies have shown that in the
case of asymptomatic necrotic teeth, the use
of prophylactic antibiotics was not found to
be a benefit in reducing endodontic flare-
ups or in significantly improved resolution
rates.9 A second similar study of the
prophylactic administration of clindamycin
Regimen: Single dose 30 to 60 minutes before procedure
Agent Adults
Amoxicillin 2g
Ampicillin 2 g IM or IV
OR
Cefazolin or ceftriaxone 1 g IM or IV
Cephalexin* 2g
OR
Clindamycin 600 mg
OR
Azithromycin or clarithromycin 500 mg
Cefazolin or ceftriaxone 1 g IM or IV
OR
Clindamycin 600 mg IM or IV
found no statistically significant
difference in the rates of postoperative
infections after endodontic surgery.10
In localized acute periradicular
infections, bacteria gain access to the
periapical tissues. These infections have a
rapid progression and are associated with
pain and swelling. There may be purulent
drainage through a sinus tract or a localized
abscess. If pus is present, this is an indication
that the infection is being controlled.
These situations should be managed either
by incision, extraction of the tooth or
endodontic treatment. Again, antibiotic
treatment is generally not indicated.11,12
The AAPD recommends that for
children with pulpitis, apical periodontitis,
draining sinus tract or localized intraoral
swelling, the most appropriate treatment
is pulpotomy, polypectomy or extraction.
Patients should be assessed for signs of
systemic infection including fever and
facial swelling. If the patients condition
is localized and there are no signs of
systemic infection, it is the opinion of
the AAPD that antibiotic therapy is
usually not necessary.7 The AAE agrees
that antibiotics are not substitutes
C D A J O U R N A L , V O L 4 5 , N 3
Children
50 mg/kg
50 mg/kg IM or IV
50 mg/kg IM or IV
50 mg/kg
20 mg/kg
15 mg/kg
50 mg/kg IM or IV
20 mg/kg IM or IV
for surgical intervention (endodontic
treatment, incision and drainage or
extraction) to remove the source of
the infection. The AAE notes that
up to 60 percent of human infections
resolve by host defenses alone following
removal of the cause of the infection.8
According to Baumgartner,
erythromycin is not a good choice for
endodontics because it is not effective
against anaerobes. Clarithromycin
and azithromycin have a spectrum of
activity that includes facultative bacteria
and some anaerobes associated with
endodontic infections. Metronidazole is
active against anaerobes but not against
facultative bacteria and is typically
used in combination with penicillin
when penicillin alone is not effective.
Baumgartner states that cephalosporins,
ciprofloxacin, doxycycline and the
other tetracyclines are not indicated in
these types of infections. If there is a
cellulitis, this is an indication that the
host response has not yet controlled the
infection. In this situation, antibiotics
might be necessary though this hypothesis
has been extensively studied.15
M A R C H 2 0 1 7 125
 antibiotic prophylaxis
C D A J O U R N A L , V O L 4 5 , N 3

TABLE 4

Management of Patients With Prosthetic Joints Undergoing Dental Procedures

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

Minor Oral/Facial Injury

In those situations where endodontic
treatment is insufficient in controlling
endodontic infections, Baumgartner
et al.13 and Skucaite et al.14 reported
that penicillin and amoxicillin or
clindamycin for penicillin-allergic
patients should be considered.
In the event a patient fails to
improve, the initial diagnosis needs to
be reconsidered. The patient should
be re-evaluated to access the need for
further surgical intervention. Culturing
to determine antibiotic sensitivities
for infections is important and may
be necessary in instances of antibiotic
failure. Empirically, clindamycin
may be considered. Clindamycin is
given at a dose of 300 mg every six
hours with a 600 mg loading dose.
Large Odontogenic Infections With
Systemic Signs and Symptoms
In situations where the infection
has spread to adjacent areas, incision
and drainage, endodontic treatment
or extraction are considered primary
treatments. This may be sufficient, but
antibiotics may be necessary for patients
who present with systemic signs and
126M A R C H 2 01 7
symptoms (fever, lymphadenopathy,
trismus, malaise). In vitro, newer and
broader spectrum antibiotics were
more effective against typical bacteria
responsible for odontogenic infections.
In contrast, the use of amoxicillin,
clindamycin and azithromycin have
been shown to result in equal or better
clinical outcomes. For patients allergic
to penicillin, clindamycin, azithromycin,
metronidazole or moxifloxacin can be
used as alternatives (TA BLE 5 ). As for the
duration of antibiotic therapy, studies
have shown that at seven days, there was
no difference in clinical cure between
antibiotics given for short (one to three
days) or long (five to seven days) durations
when combined with appropriate surgery.16
Patients with large facial swellings or
infections need thorough assessment. A
complete medical history and physical
examination are necessary. These patients
may have compromised host defenses or
may have associated medical conditions
that may need to be addressed. There may
be airway concerns as well as the risk of
rapid spread through neighboring fascial
spaces to the neck and mediastinum,
orbits or brain. The cause of these
Management
Because of excellent blood supply to
the maxillofacial region, injuries to these
structures can often be managed without
antibiotics given appropriate wound
management. Patients with traumatic
injury should be evaluated with respect
to host risk (e.g., age, systemic illness,
malnutrition) and the nature of the
wound when determining the need for
antibiotics. Wounds should be classified
as either clean, potentially contaminated
or contaminated/dirty. Clean wounds
are those that are uninfected and show
no signs of inflammation. These wounds
can be closed primarily. There is no need
for antibiotic coverage in these patients.
Wounds that are exposed to intrinsic
bacteria are classified as potentially
contaminated. Examples of this type
of wound might be a traumatic self-
inflicted laceration from the patients
own teeth. The initial use of antibiotics
in these cases is not indicated, but the
wounds must be observed closely for
potential late infections. Wounds that
have obviously been contaminated
by extrinsic bacteria would be
classified as contaminated/dirty.17,18

TABLE 5
Empiric Antibiotics of Choice for Odontogenic Infections
Severity/Penicillin allergy Antibiotics of choice
Outpatient Amoxicillin, Clindamycin, Azithromycin
Penicillin allergy Clindamycin, Azithromycin, Metronidazole, Moxioxacin
Inpatient Ampicillin/sulbactam, Clindamycin, Penicillin + metronidazole, Ceftriaxone
Penicillin allergy Clindamycin, Moxioxacin, Vancomycin + metronidazole
Adapted from Flynn T R. What Are the Antibiotics of Choice for Odontogenic Infections and How Long Should the Treatment
Course Last? Oral Maxillofacial Surg Clin N Am 23 (2011) 519536.
Human or animal bites are considered
contaminated/dirty. Bite wounds are
at increased risk of infection, but
antibiotic prophylaxis continues to be
controversial. Early management is
important to decrease risk of infection.
If indicated, amoxicillin clavulanate
is considered the antibiotic of choice.
Tetanus and rabies prophylaxis should be
considered when appropriate and given
per accepted guidelines.17,19,20 These
wounds must be monitored closely. The
duration of antibiotics should be based
on healing. The route of administration
(intravenous, intramuscular or oral)
and duration of treatment would be
determined by the severity of the potential
contamination and patient host factors.
Traumatic injuries caused by linear
shear forces tend to have less risk of
contamination than deep or complex
lacerations. Bite or crush injuries are
more likely to involve tissue necrosis and
infection. In general, antibiotics can help
reduce infection risk and promote healing
of these types of injuries, but they are not
a substitute for vigorous irrigation, surgical
debridement and appropriate wound care.
Response to antibiotic therapy and wound
healing must be closely monitored.
Salivary Gland Infections
For suspected salivary gland
infections, it must first be determined if
the infection is of bacterial etiology. A
thorough history and examination must
be performed. Swellings in the gland may
be secondary to sialoliths, nonbacterial
organisms like viruses (mumps, HIV),
mycobacteria (e.g., tuberculosis), fungus
or, rarely, parasites. They may even
have an autoimmune etiology or be
associated with a neoplasm. Patients
with dehydration or hyposalivation are
at risk. This includes the elderly and
patients on certain medications (e.g.,
antihistamines diuretics, anticholinergics,
chemotherapeutics). Associated medical
conditions such as diabetes, Sjgrens
syndrome, malnutrition, anorexia/
bulimia, vomiting/diarrhea, HIV/AIDS,
renal failure, liver failure or patients who
have received head and neck radiation
therapy increase the risk of sialadenitis.
Clinically, patients will present with
salivary gland enlargement that may
or may not be painful. Any purulence
should be cultured and antibiotic
sensitivities obtained. If the condition
worsens while eating, it is suggestive but
not pathognomonic of sialolithiasis.
Acute salivary gland infections of
bacterial origin respond to antibiotic
therapy. Empirically, these conditions can
be treated with broad-spectrum penicillins
(amoxicillin, amoxicillin clavulanate),
first-generation cephalosporins
(cephalexin, cefadroxil), clindamycin or
a macrolide (erythromycin, azithromycin,
clarithromycin). Depending on the
severity of the infection, hospitalization
with incision and drainage and
intravenous antibiotics may be indicated.21
Periodontal Disease
Periodontal disease is a chronic
multifactorial condition. The bacteria
associated with periodontal disease are
usually divided microbial complexes
that live in biofilms.22 Not only is there
a bacterial component to periodontal
disease, there are also inflammatory
C D A J O U R N A L , V O L 4 5 , N 3
mediators (e.g., cytokines, interleukin-1 ,
tumor necrosis factor , prostaglandin E2,
IgG 2) that are involved in periodontal
disease. It is these inflammatory
mediators that are responsible for most
of the periodontal tissue destruction.
Concomitant systemic diseases,
along with the patients own dental
and osseous deformities, also affect the
progression of periodontal disease. In
addition, factors like smoking and stress
have an impact. Scaling and root planing
(SRP) have been shown to be the most
effective way of managing periodontal
disease. The goal of SRP is to disrupt the
biofilm and eliminate the inflammation.
However, SRP is not as effective deep
in periodontal pockets where bacteria
can invade the epithelium and where
there are architectural barriers (e.g.,
furcations, grooves, dentinal tubules). For
this reason, systemic combination drug
therapy has been advocated for patients
who have specific microbiological profiles
in their subgingival biofilm. There is
support for the use of systemic antibiotic
in the treatment of periodontal disease
that progresses in spite of conventional
mechanical treatment. These drugs enter
the periodontal tissues and the sulcus
via the bloodstream to areas that cannot
be reached by instrumentation.2327
Unfortunately, the subgingival biofilm
may be protective as the matrix can act
as a barrier to antibiotics and facilitate
horizontal resistance gene transfer.28
The American Academy of
Periodontology (AAP) addressed the
issue of the use of systemic antibiotics in
the treatment of periodontal disease in a
position paper. In that report, the AAP
stated that the use of systemic antibiotics
in the treatment of periodontal disease
is to reinforce mechanical treatment
and to support host defenses. The AAP
recommended that consideration should
be given to single or combination drug
M A R C H 2 0 1 7 127
 antibiotic prophylaxis
therapy based on the individual clinical
situation. If combination therapy is
indicated, they cautioned that care
must be taken to select combinations
that are not antagonistic. For example,
bacteriostatic tetracyclines halt bacterial
reproduction hindering the bactericidal
actions of -lactam antibiotics.
In the position paper, the AAP
provided clinicians with a list of frequently
prescribed antibiotics for the treatment of
aggressive periodontal disease (TA BLE 6 ).
The AAP report stated that the optimum
dosage of the antibiotics remains unclear
and that most antibiotic regimens for the
management of aggressive periodontal
disease have been developed empirically.29
Some studies have questioned whether
improvement in periodontal disease with
the adjunctive use of systemic antibiotics
was clinically meaningful.30,31 Because of
the wide variability of antibiotic-resistant
pathogens in periodontal disease, it has
been suggested that microbiological
analysis and antibiotic susceptibility
testing to determine antibiotic sensitivities
and the minimal inhibitory concentration
(MIC) be conducted when systemic
antibiotics are being considered.32 There
is no evidence that systemic antibiotics
are effective as monotherapy without
SRP in treating periodontal disease.33
A panel of experts was assembled
by the Council on Scientific Affairs of
the ADA to review the literature and
develop clinical practice guidelines on
nonsurgical treatments for patients with
chronic periodontitis with and without
adjuncts. The panel found that for patients
with chronic periodontitis, SRP showed a
moderate benefit as the initial nonsurgical
treatment of this condition. They suggested
the use of systemic subantimicrobial-dose
doxycycline (SDD), 20 mg twice a day
for six to nine months, as an adjunct to
treatment with SRP resulted in a small
net benefit (0.35 mm net gaining clinical
128M A R C H 2 01 7
attachment). The panel felt that there were
negligible adverse effects and that the risk
of antimicrobial resistance was not a factor.
The use of systemic antimicrobials like
amoxicillin, metronidazole, azithromycin,
clarithromycin, moxifloxacin and the
tetracyclines at higher doses was also
reviewed. Even though the net benefit
was the same as the use of SDD (mean
0.35 mm gain in clinical attachment), the
panel felt that these higher doses were not
justified because of the increased risk of
adverse effects and antibiotic resistance.
The panel recommended that these drugs
at higher doses should be reserved for
short-term (less than 21 days) use only.34,35
Extraction of Teeth
There are many indications for
the extraction of teeth. Some of these
extractions may or may not be associated
with infection. Some examples are
the extraction of impacted teeth,
supernumerary teeth or because of acute
fractures of roots or coronal portions.
Teeth are also extracted for prosthodontic
purposes, cosmetic concerns or as indicated
by orthodontic treatment. These extraction
sites are considered contaminated by
virtue of their exposure to the oral cavity.
Because the microorganisms involved are
part of the hosts normal oral flora, pre- or
postsurgical antibiotics are not indicated.
The use of prophylactic antibiotics
prior to tooth extraction has been
suggested if the patients immune status
is compromised (e.g., poorly controlled
diabetes, end-stage renal disease,
alcoholism, immune compromising
diseases). The literature does not
necessarily support the need for antibiotic
prophylaxis in these situations. Studies
have shown that there are no differences in
healing after routine extractions between
well-controlled and poorly controlled
diabetics. In addition, studies have shown
that patients with either alcoholic liver
C D A J O U R N A L , V O L 4 5 , N 3
TABLE 6
Common Antibiotic Therapies in the
Treatment of Periodontitis*
Antibiotic Adult Dosage
Metronidazole 500 mg/t.i.d./8 days
Clindamycin 300 mg/t.i.d./8 days
Doxycycline or 100200 mg/q.d./21 days
minocycline
Ciprooxacin 500 mg/b.i.d./8 days
Azithromycin 500 mg/q.d./47 days
Metronidazole + 250 mg/t.i.d./8 days of
amoxicillin each drug
Metronidazole + 500 mg/b.i.d./8 days of
ciprooxacin each drug
*The antibiotic regimens listed do not represent recommenda-
tions of the American Academy of Periodontology. Adapted
from Position Paper Systemic Antibiotics in Periodontics. J
Periodontol 2004:15531565.
disease, renal disease or patients who are
HIV positive with CD4 counts greater
than 200 are at low risk for postsurgical
infections for routine extractions.36
With respect to the extraction of
teeth in the presence of infection, early
extraction is associated with faster clinical
and biologic resolution of infection.37
Delay in the extraction of necrotic
teeth risks the spread of the infection.
Extraction of Impacted Third Molars
Postsurgical surgical site infection (SSI)
related to third molar surgery occurs at a
frequency of between 1.2 to 27 percent
with the most reported frequency at 5
percent. In spite of 60 years of clinical
experience and numerous clinical studies,
the indications for the use of prophylactic
antibiotics for the extraction of third
molar teeth remains unclear. Most of the
studies were not performed in the typical
outpatient oral surgery setting. There was
variability in the type of anesthesia provided
for these cases. Some of the procedures
were performed under local anesthesia
while others were performed under
general anesthesia. An additional variable
was the use of nonstandard antibiotic
regimens, dosing strategies and intervals.
There is some evidence that prophylactic
antibiotics reduced the risk of infection,

dry socket and pain following third molar
extraction. The estimated adverse effect
(diarrhea, nausea, rashes, vomiting,
vaginitis) rate was 1 to 3 percent. The
authors of this study suggest that because
of the risk of adverse effects and antibiotic
resistance it may not be appropriate to
treat 12 healthy people with antibiotics
in order to prevent one infection.38
The American Association of Oral
and Maxillofacial Surgeons (AAOMS)
is currently conducting a prospective
study concerning the use of antibiotics
for third molar extractions. The purpose
of the study is to determine the effect of
the use of antibiotics on clinical outcomes
associated with the extraction of soft tissue
or partial or full bony third molar teeth.
Implants
The placement of dental implants
has become a predictable method of
replacing teeth. The question is whether
antibiotic prophylaxis is indicated for
implant placement to reduce the chance
of implant failure or postsurgical infection.
Esposito et al. performed systemic reviews
and analysis of randomized control trials
of healthy participants given preoperative
amoxicillin versus placebo prior to
implant placement. Their last report
was an analysis that included six trials
that showed that there was a statistically
significant higher percentage of implant
failures in the placebo group versus the
antibiotic group. This finding translated to
the number needed to treat (NNT) with
prophylactic antibiotics for one additional
beneficial (prevention of one failure)
outcome was 25. They reported that
that there was no statistically significant
difference for postsurgical infections.39,40,41
Another independent systemic review
and meta-analyses had similar findings.42
Finally, in a study of 2,973 implants,
the Dental Implant Clinical Research
Group found significantly higher survival
rates for dental implants if patients
were given presurgical antibiotics.43
There are also studies that do not
support presurgical antibiotics prior
to implant placement. These clinical
trials found that there was no significant
difference in postoperative infections,
adverse events or implant failures in
patients given preoperative antibiotics.4446
The effectiveness of postsurgical antibiotics
on implant survival rates has also been
questioned when single-dose preoperative
antibiotics was compared with one
week of postoperative antibiotics.4750
In a study of 2,973 implants,
the Dental Implant Clinical
Research Group found
signicantly higher survival rates
for dental implants if patients
were given presurgical antibiotics.
In practice, there is significant
confusion concerning the effectiveness
of antibiotic therapy in dental implant
success. So much so that a study of 217
oral and maxillofacial surgeons found
no consensus concerning the use of
preoperative antibiotics. Though most
studies only support the use of presurgical
antibiotic prophylaxis prior to implant
placement to reduce failures, a significant
number prescribed postsurgical antibiotics.51
With respect to intraoral bone grafting,
there are few studies on this subject. A
prospective placebo-controlled, double-
blind pilot study of 20 patients reported that
there was a statistically significant decrease
in infections after intraoral bone grafting
if 2 g of pheneticillin (a semisynthetic
acid-resistant analog of penicillin) was
administered one hour before surgery.52
C D A J O U R N A L , V O L 4 5 , N 3
Another study of 23 subjects failed to find
a significant benefit.53 Because of the lack
of research, the benefit of antibiotics and
implant placement and intraoral bone
grafting is also unclear. Further research
needs to be performed on the most effective
antibiotic dosing regimen and whether
postsurgical antibiotics are beneficial.
Medication-Related Osteonecrosis
of the Jaw
In 2014, the AAOMS published
a position paper, Medication-Related
Osteonecrosis of the Jaw (MRONJ).
This condition, originally named
bisphosphonate-related osteonecrosis of
the jaw (BRONJ), involves osteonecrosis
related to the use of bisphosphonates.
The name was changed to MRONJ
because a large number of osteonecrosis
cases began to be identified involving
other antiresorptive (denosumab) and
antiangiogenic (bevacizumab, sorafenib,
sunitinib, pazopanib, everolimus)
medications. Intravenous forms of these
medications (zoledronate, ibandronate) are
used to treat hypercalcemia of malignancy,
bone metastasis of breast, prostate and lung
cancers and multiple myeloma. Intravenous
and oral bisphosphonates (alendronate,
ibandronate, risedronate and zoledronic
acid) are approved for the treatment of
osteoporosis and osteopenia. Patients are
considered to have MRONJ if they have
exposed bone in the maxillofacial region
that can be probed either intraorally or
extraorally and that has been present
for at least eight weeks, currently or
previously treated with antiresorptive or
antiangiogenic medications and have
no history of radiation therapy to the
jaws or metastatic disease in the jaws.
In its position paper, the AAOMS
made stage specific MRONJ treatment
recommendations. For patients in early
stages (Stage 0) of MRONJ, there may
be a role for systemic antibiotics. No
M A R C H 2 0 1 7 129
 antibiotic prophylaxis
C D A J O U R N A L , V O L 4 5 , N 3

TABLE 7

Staging and Treatment Strategies

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

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

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

antibiotics are necessary for asymptomatic
patients with exposed bone without
signs of infection (Stage 1). In patients
in intermediate stages (Stage 2), oral
antibiotics and oral antibacterial mouth
rinses should be considered. Similarly, in the
most advanced cases (Stage 3), adjuvant
antibiotic therapy and antibacterial
mouth rinses are considered along with
surgical debridement or resection. The
position paper stresses the importance of
cultures in the selection of antibiotics.
Bacteria cultured from exposed bone are
typically sensitive to the -lactamase
antibiotics. Quinolones, metronidazole,
clindamycin, doxycycline and erythromycin
have been successful for patients who
are allergic to penicillin54 (TABLE 7 ).
Osteoradionecrosis of the Jaw
Dentists may encounter patients
who have received radiation therapy
for oral pharyngeal malignancies.
Some of these patients who received
high doses of radiation are at risk for
130M A R C H 2 01 7
developing osteoradionecrosis of the
jaw (ORN). The use of hyperbaric
oxygen (HBO) therapy was proposed
for the prevention and management
of ORN by Marx based on his theory
of hypoxichypocellularhypovascular
tissue after radiation therapy (> 6000
cGy).55 Bacterial infections are not
the cause of ORN, but are considered
a contaminant or superinfection.56 At
best, the use of antibiotics should only be
used to prevent or manage infection of
impaired tissue. In infections associated
with ORN, cultures and determination
of antibiotic sensitivities are important.
Health Care-Associated Infections
Health care-associated infections refer
to infections associated with health care
delivery in any setting (e.g., hospitals,
long-term care facilities, ambulatory
settings, home care). Health care workers
and patients may be colonized with, or
exposed to, potential pathogens outside
of the health care setting before receiving
care or may develop infections caused
by those pathogens when exposed to
the conditions associated with delivery
of health care. Dentists must recognize
their role in transmission of disease.
Organisms (bacteria, fungi and
viruses) can be spread from patient to
patient from contaminated health care
workers. Close attention should be
paid to asepsis and infection control.
This includes standard precautions like
hand hygiene, surface disinfection and
sterilization procedures, the possibility
of cross-contamination and following
strict surgical protocols. Policies
should be in place for handling and
processing patient care equipment and
devices contaminated with blood or
body fluids. Staff members must have
the appropriate personal protective
equipment (gloves, gowns, face and eye
protection) and protocols for prevention
of sharps injury. Antibiotics should not
be used as an excuse for inadequate
infection control procedures.57

Conclusions
In treating infections, an accurate
diagnosis needs to be made to determine if
there is a need for antibiotic therapy. The
acute or chronic stage of the infection may
dictate whether antibiotics are indicated.
Antibiotics cannot be a substitute for
conventional therapy including indicated
surgical procedures. Patient host factors
and immune status need to be determined.
Antibiotics should only be used to support
the patients immune system in controlling
infection. The use of antibiotics should
only be considered if there is an inadequate
host immune response with systemic signs
or progression of the infection beyond
the source to adjacent tissues or spaces.
The use of these drugs is not indicated to
control pain in the absence of signs and
symptoms of a progressive infection.
Dentists are fortunate in that most
odontogenic infections requiring treatment
with antibiotics respond well to penicillin.
For this reason, the choice of antibiotics
can frequently be made empirically. Based
on each patients presenting condition and
comorbidities, adjustments may be necessary
when considering antibiotic therapy. It
is important that the dentist be familiar
with the characteristics and effects of an
antibiotic so they are used appropriately.
Antibiotics should be prescribed at
dosages that rapidly achieve high serum
concentrations. The most appropriate
dosing schedules must be prescribed
based on the antibiotics mechanism
of action. Except in some severe
infections and aggressive or refractory
periodontal conditions, it is rare that
multiple antibiotic therapy is indicated.
It is important that antibiotics are not
used beyond the resolution of the infection.
Any patient who is prescribed antibiotics
for infection must be monitored closely for
improvement. If the condition improves
sufficiently, antibiotic therapy should be
discontinued. Changes in antibiotic use
should not be performed too quickly. At
least 48 to 72 hours may be necessary
for an antibiotic to have an effect.
Prior to using antibiotics for infection
management, patients must receive
a thorough informed consent of the
risks and benefits of using antibiotics.
This must include possible antibiotic
effects on medical and dental conditions
they may have, age-related effects,
drug interactions, the risk of allergies,
other possible adverse effects, the
likelihood of improvement and cost.
There may be some usefulness in
long-term, low-dose antibiotic therapy for
chronic progressive periodontal disease.
Preoperative antibiotics may minimize the
chance of postsurgical wound infections
and wound healing complications
associated with the extraction of impacted
third molars. In addition, preoperative
antibiotics may decrease dental implant
and intraoral bone failure rates. It appears
that postoperative antibiotic therapy is
generally not indicated for an otherwise
immune competent patient to prevent
postsurgical wound infection or as pain
medication. There is a role for antibiotics in
the management of opportunistic infections
related to MRONJ and osteoradionecrosis.
Antibiotic medications should never
be used for preventing medicolegal
claims.58 It is incumbent upon the dentist
to inform the patient of the importance
of strictly following dosing schedules. A
lack of patient compliance with dosing
schedules can contribute to antibiotic
failure and the risk of bacterial resistance.
Considerations should be given to using
antibiotic preparations that have dosing
intervals that are easier to follow or use.
Recommendations and antibiotic
prophylaxis guidelines can change rapidly.
It is important that dentists keep abreast of
the literature and any changes in guidelines.
Dentists should work cooperatively with
their medical colleagues concerning the
C D A J O U R N A L , V O L 4 5 , N 3
most appropriate antibiotic prophylaxis
for each patient. Each patient has a role
in making decisions concerning his or
her care. Prescribing stewardship is one
of the main ways dentists can reduce
the risk of antibiotic resistance. With
each antibiotic prescription, the patients
individual risk and the communitys risk of
antibiotic resistance must be weighed.
ACKNOWLEDGMENT
The author thanks Dr. Melanie Gullet, Dr. Jean Creasey, Dr.
Rick Nagy and Dr. Kevin Keating for their invaluable comments
and insight in writing this article.
REFERENCES
1. Wilson W, Taubert KA, Gewitz M, et al. Prevention
of infective endocarditis: Guidelines from the American
Heart Association A guideline from the American Heart
Association Rheumatic Fever, Endocarditis and Kawasaki
Disease Committee, Council on Cardiovascular Disease in the
Young, and the Council on Clinical Cardiology, Council on
Cardiovascular Surgery and Anesthesia, and the Quality of
Care and Outcomes Research Interdisciplinary Working Group.
Circulation 2007;116:17361754.
2. A legal perspective on antibiotic prophylaxis. American
Dental Association Division of Legal Aairs J Am Dent Assoc
vol. 134, issue 9, p 1260.
3. A legal perspective on antibiotic prophylaxis. American
Dental Association Division of Legal Aairs. J Am Dent Assoc
vol. 138, issue 6, p 746.
4. An updated legal perspective on antibiotic prophylaxis.
American Dental Association Division of Legal Aairs. J Am
Dent Assoc vol. 139, S10.
5. American Academy of Orthopaedic Surgeons, American
Dental Association. Prevention of Orthopaedic Implant Infection
in Patients Undergoing Dental Procedures: Evidence-Based
Guideline and Evidence Report. Rosemont, Ill.: American
Academy of Orthopaedic Surgeons. American Dental
Association; 2012:325.
6. Sollecito TP, Abt E, Lockhart PB, Truelove E, Paumier TM,
Tracy SL, Tampi M, Beltrn-Aguilar ED, Frantsve-Hawley J. The
use of prophylactic antibiotics prior to dental procedures in
patients with prosthetic joints. Evidence-based clinical practice
guideline for dental practitioners A report of the American
Dental Association Council on Scientic Aairs. J Am Dent
Assoc January 2015 vol. 146, issue 1, pp 1116.
7. Guideline on the use of antibiotic therapy for pediatric dental
patients. AAPD Reference Manual vol. 36/no. 6 14/15.
8. American Association of Endodontists. Use and abuse of
antibiotics. Endodontics: Colleagues for Excellence newsletter.
Winter 2012.
9. Pickenpaugh L, Reader A, Beck B, Meyers WJ, Peterson LJ. Eect
of Prophylactic Amoxicillin on Endodontic Flare-Up in Asymptomatic,
Necrotic Teeth. J Endod January 2001 vol. 27, issue 1, pp 5356.
10. Lindeboom JA, Frenken JW, Valkenburg P, van den
Akker HP. The role of preoperative prophylactic antibiotic
administration in periapical endodontic surgery: A randomized,
prospective double-blind placebo-controlled study. Int Endod J
2005 Dec;38(12):87781.
M A R C H 2 0 1 7 131
 antibiotic prophylaxis
11. Skucaite N, Peciuliene V, Maciulskiene V. Microbial infection
and its control in cases of symptomatic apical periodontitis: A
review. Medicina (Kaunas). 2009;45(5):34350.
12. Cope A, Francis N, Wood F, Mann MK, Chestnutt IG.
Systemic antibiotics for symptomatic apical periodontitis and
acute apical abscess in adults. Cochrane Database Syst Rev
2014 Jun 26;6.
13. Baumgartner JC, Xia T. Antibiotic susceptibility of bacteria
associated with endodontic abscesses. J Endod 2003;29:447.
14. Skucaite N, Peciuliene V, Vitkauskiene A, Machiulskiene
V. Susceptibility of endodontic pathogens to antibiotics in
patients with symptomatic apical periodontitis. J Endod 2010
Oct;36(10):16116. doi: 10.1016/j.joen.2010.
15. Baumgartner JC. Ingles Endodontics 6. 2008. Ingle JI,
Bakland LK, Baumgartner JC eds. Chapter 21 p 695. BC
Decker Inc.
16. Flynn TR. What Are the Antibiotics of Choice for
Odontogenic Infections and How Long Should the Treatment
Course Last? Oral Maxillofacial Surg Clin N Am 23 (2011)
pp 519536.
17. Herford A, Ghali GE. Soft tissue injuries. Miloro M ed.
Petersons Principles of Oral and Maxillofacial Surgery 3rd
ed. Oak Park, Ill., Peoples Medical Publishing House, 2004,
pp 357362.
18. Booth PW, Eppley BL. Maxillofacial Trauma and Esthetic
Facial Reconstruction. Churchill Livingstone 2004 pp 445447.
19. Stefanopoulos PK, Tarantzopoulou AD. Facial bite wounds:
Management update. Int J Oral Maxillofac Surg 34:464, 2005.
20. Ruskin JD, Laney TJ,Wendt SV, Markin RS. Treatment of
mammalian bite wounds of the maxillofacial region. J Oral
Maxillofac Surg 51:174, 1993.
21. Carlson ER. Diagnosis and management of salivary gland
infections. Oral Maxillofac Surg Clin N Am 2009;21(3):293312.
22. Socransky SS, Haajee AD, Cugini MA, et al. Microbial
complexes in subgingival plaque. J Clin Periodontol
1998;25:13444.
23. Slots J, van Winkelfo AJ. Antimicrobial therapy in
periodontics. J Calif Dent Assoc 1993 Nov:21(11):516.
24. Slots J, van Winkelfo AJ, Rams TE, Slots J. Systemic
antibiotic therapy in periodontics. Periodontol 2000. 1996;
10:4578. Systemic antibiotics in the treatment of periodontal
disease. Slots J, Ting M. Periodontol 2000 2002:28:10676.
25. Herrera D, Sanz M, Jepsen S, Needleman I, Roldan S. A
systemic review on the eect of systemic antimicrobials as an
adjunct to scaling and root planing in periodontitis patients. J
Clin Periodontol 2002; 29 (suppl 3): 136162.
26. The use of two antibiotic regimens in aggressive
periodontitis: Comparison of changes and clinical parameters
and gingival crevicular uid bile markers. Quintessence Int
2008; 39:811819.
27. Systemic antibiotics in the treatment of aggressive
periodontitis. A systematic review and a Bayesian Network
meta-analysis. Rabelo CC , Feres M, Goncalves C, Figueiredo
LC, Faveri M, Tu Y-K, Chambrone L. J Clin Periodontol 2015;
42: 647657. doi: 10.1111/jcpe.12427.
28. Jolivet-Gougeon A, Bonnaure-Mallet M. Biolms as a
mechanism of bacterial resistance. Drug Disc Today: Technol
vol. 11, March 2014, pp 4956.
29. Position Paper Systemic Antibiotics in Periodontics. J
Periodontol 2004:15531565.
30. Bonito AJ, Lohr KN, Lux L, Sutton S, Jackman A, Whitener
L, Evensen C. Eectiveness of Antimicrobial Adjuncts to Scaling
and Root Planing Therapy for Periodontitis vol. 2. Evidence
132M A R C H 2 01 7
Tables. Evidence Report/Technology Assessment No. 88
(Prepared by RTI International-University of North Carolina
Evidence-Based Practice Center under Contract No. 290-97-
0011) AHRQ Publication No. 04-E014-3. Rockville, Md.:
Agency for Healthcare Research and Quality. March 2004.
31. Bonito AJ, Lux L, Lohr KN. Impact of Local Adjuncts to
Scaling and Root Planing in Periodontal Disease Therapy: A
Systematic Review. J Peridontol 2005 Aug 76(8):122736.
32. Rams TE, Degener JE, van Winkelho AJ. Antibiotic
resistance in human chronic periodontitis microbiota. J
Periodontol 2014 Jan;85(1):1609. doi: 10.1902/
jop.2013.130142. Epub 2013 May 20.
33. Haajee AD, Socransky SS, Gunsolley JC. Systemic
anti-infective periodontal therapy: A systematic review. Ann
Periodontol 2003;8:11581.
34. Smiley CJ, Tracy SL, Abt E, Michalowicz BS, John MT,
Gunsolley J, Cobb CM, Rossmann J, et al. Evidence-based
clinical practice guideline on the nonsurgical treatment of
chronic periodontitis by means of scaling and root planing with
or without adjuncts. J Am Dent Assoc vol. 146, issue 7,
p 525535 July 2015.
35. Smiley CJ, Tracy SL, Abt E, Michalowicz BS, John MT,
Gunsolley J, Cobb CM, Rossmann J, et al. Systematic review
and meta- analysis on the nonsurgical treatment of chronic
periodontitis by means of scaling and root planing with or without
adjuncts. J Am Dent Assoc vol. 146, issue 7, pp 508524.e5.
36. Laskin DM. Should Prophylactic Antibiotics Be Used for
Patients Having Removal of Erupted Teeth? Oral Maxillofacial
Surg Clin N Am 23 (2011) 537539.
37. Igoumenakis D, Giannakopoulos NN, Parara E, Mourouzis
C, Rallis G. Eect of Causative Tooth Extraction on Clinical and
Biological Parameters of Odontogenic Infection: A Prospective
Clinical Trial. J Oral Maxillofac Surg 73:12541258, 2015.
38. A critical summary of Lodi G, Figini L, Sardella A,
Carrassi A, Del Fabbro M, Furness S. Antibiotics to prevent
complications following tooth extractions. Cochrane Database
Syst Rev 2012;11:CD003811.
39. Esposito M, Grusovin MG, Talati M, Coulthard P, Oliver
R, Worthington HV. Interventions for replacing missing teeth:
Antibiotics at dental implant placement to prevent complications.
Cochrane Database of Systematic Reviews 2008, issue 3. [doi:
10.1002/14651858.CD004152.pub2].
40. Esposito E, Worthington HW, Loli V, Coulthard P, Grusovin
MG. Interventions for replacing missing teeth: Antibiotics at
dental implant placement to prevent complications. Cochrane
Database Syst Rev 2010, issue 7. [doi: 10.1002/14651858.
CD004152.pub3].
41. Esposito M, Grusovin MG, Worthington HV. Interventions
for replacing missing teeth: Antibiotics at dental implant
placement to prevent complications. Cochrane Database Syst
Rev 2013 Jul 31;7:CD004152. [doi: 10.1002/14651858.
CD004152.pub4].
42. Chrcanovic BR1, Albrektsson T, Wennerberg A.
Prophylactic antibiotic regimen and dental implant failure: A
meta-analysis. J Oral Rehabil 2014 Dec;41(12):94156.
43. Laskin DM, Dent CD, Morris HF, et al. The inuence of
preoperative antibiotics on success of endosseous implants at
36 months. Ann Periodontol 5:166, 2000.
44. Abu Taa M, Quirynen M, Teughels W, van Steenberghe
D. Asepsis during periodontal surgery involving oral implants
and the usefulness of perioperative antibiotics: A prospective,
randomized, controlled clinical trial. J Clin Periodontol 35:58,
2008.
C D A J O U R N A L , V O L 4 5 , N 3
45. Anitua E, Aguirre JJ, Gorosabel A, et al. A multicenter
placebo-controlled randomized clinical trial of antibiotic
prophylaxis for placement of single dental implants. Eur J Oral
Implantol 2:283, 2009.
46. Caiazzo A, Casavecchia P, Barone A, Brugnami F. A pilot
study to determine the eectiveness of dierent amoxicillin
regimens in implant surgery. J Oral Implantol 37:691, 2011 9.
47. Binahmed A, Stoykewych A, Peterson L. Single preoperative
dose versus long-term prophylactic antibiotic regimens in dental
implant surgery. Int J Oral Maxillofac Implants 2005 Jan
Feb;20(1):1157.
48. Sharaf B, Jandali-Rifai M, Susarla SM, Dodson TB. Do
Perioperative Antibiotics Decrease Implant Failure? J Oral
Maxillofac Surg 69:23452350, 2011.
49. Tan WC, Ong M, Han J, et al. Eect of systemic antibiotics
on clinical and patient-reported outcomes of implant therapy
A multicenter randomized controlled clinical trial. Clin Oral
Implants Res 25:185, 2014.
50. Esposito E, Worthington HW, Loli V, Coulthard P, Grusovin
MG. Interventions for replacing missing teeth: Antibiotics at
dental implant placement to prevent complications. Cochrane
Database Syst Rev 2010, issue 7. [doi: 10.1002/14651858.
CD004152.pub3].
51. Deeb GR, et al. Antibiotic Prescribing Habits and Routine Dental
Implant Placement. J Oral Maxillofac Surg 73:19261931, 2015.
52. Lindeboom JA, van den Akker HP. A prospective placebo-
controlled double-blind trial of antibiotic prophylaxis in intraoral
bone grafting procedures: A pilot study. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2003 Dec;96(6):66972.
53. Lee JW, Lee JY, Kim SM, Kim MJ, Lee JH. Prophylactic
antibiotics in intraoral bone grafting procedures: A prospective,
randomized, double-blind clinical trial. J Korean Assoc Oral
Maxillofac Surg 2012;38:905.
54. Ruggiero SL, Dodson TB, Fantasia J, Goodday R, Aghaloo
T, Mehrotra B, ORyan F. American Association of Oral and
Maxillofacial Surgeons Position Paper on Medication-Related
Osteonecrosis of the Jaw 2014 Update. J Oral Maxillofac
Surg 72:19381956, 2014.
55. Marx RE. Osteoradionecrosis: A new concept of
its pathophysiology. J Oral Maxillofac Surg 1983; 41:
283288. Marx RE, Johnson RP. Studies in the radiobiology
of osteoradionecrosis and their clinical signicance. Oral Surg
Oral Med Oral Pathol 1987; 64:379390.
56. Marx RE, Johnson RP, Kline SN. Prevention of
osteoradionecrosis: A randomized prospective clinical trial of
hyperbaric oxygen versus penicillin. J Am Dent Assoc 1985;
111: 4954.
57. Klevens RM, Gorwitz RJ, Collins AS. Methicillin-resistant
Staphylococcus aureus: A primer for dentists. J Am Dent Assoc
2008 Oct;139(10):1337.
58. Holmes SM. What Are the Lessons We Can Glean From a
Review of Recent Closed Malpractice Cases Involving Oral and
Maxillofacial Infections? Oral Maxillofacial Surg Clin N Am
23 (2011) 601607.
THE AUTHOR,
George Maranon, DDS, can be reached at
drm@drmaranon.com
 pediatric fractures
C D A J O U R N A L , V O L 4 5 , N 3

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

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

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

AUTHORS

Manisha Sahni
Prabhakar, MDS, is
a professor, head and
postgraduate teacher
and guide at Gian
Sagar Dental College
and Hospital Ludhiana
in Punjab, India. She is a
renowned pediatric dentist
with more than 20 years
of teaching experience
in reputed professional
colleges and has served as
principal, director, professor,
head and dental practice
manager.
Conict of Interest
Disclosure: None reported.
A
Khushboo Kansal, BDS, fracture is a complete or
is an MDS student at Gian incomplete break in the
Sagar Dental College
continuity of bone or
and Hospital Ludhiana in
Punjab, India.
cartilage. Fractures in children
Conict of Interest younger than 5 years of age are
Disclosure: None reported. always challenging to the pediatric dentist.
Most commonly, facial fractures occur due
Arjun Chawdhry is
to falls (64 percent) followed by traffic-
a BDS student at Gian
Sagar Dental College
(22 percent) and sports-related accidents
and Hospital Ludhiana in (9 percent).1 Facial fractures account
Punjab, India. for less than 5 percent of all fractures in
Conict of Interest children, and this percentage drops down
Disclosure: None reported.
to 1 percent for ages less than 5.2 Among
all facial fractures, the most common
fracture is mandible (32.7 percent)
followed by nasal (30.2 percent) and
maxillary/zygoma (28.6 percent).3 Boys
are more commonly affected than girls
and the ratio is 2:1.4 In children, condylar,
subcondylar and angle fractures account
for 80 percent of mandibular fractures,
whereas symphyseal and parasymphyseal
fractures account for 15-20 percent
and body fractures occur very rarely.5
Nondisplaced body or symphysis
fractures in adult patients can be treated
by close observation, avoidance of
physical activity and a soft diet.6 If a
displaced fracture is present, reduction
by open method can be performed.7
On the contrary, the management of
mandibular fractures in children is
complex compared to that of adults due
to greater elasticity of bone, the presence
of tooth buds, a faster healing rate, the
potential for future growth and a lesser
cooperative ability.8 All these issues
complicate the management of pediatric
mandibular fractures, so the treatment
of fractures in pediatric patients is to be
carefully planned and executed giving
due consideration to the above factors.
M A R C H 2 0 1 7 133
 pediatric fractures
In pediatric patients generally,
undisplaced body, symphysis and
condylar fractures can be treated with
close observation, blenderized diet and
avoidance of physical activities.9 But if
fractures are displaced, close reduction
with or without immobilization should
be considered.10 The exact method of
immobilization depends on the childs
chronological age and stage of dental
development.11 If the teeth are inadequate
to support wiring or splints, the fracture
site should be immobilized and stabilized
with acrylic or lingual splint for three
to four weeks.12 Intermaxillary fixation
might be required if the fracture is not
adequately immobilized by splint.
An understanding of all the
treatment options is essential for optimal
management of these injuries. This
paper reports two pediatric cases of
mandibular fractures that were treated
with acrylic splint using a modified
circummandibular wiring method.
Conventionally, circummandibular
wiring is performed with a mandibular
awl, but a wound created by awl is quite
conspicuous.13 In this article, we are using
a variation of this technique by using a
20-gauge spinal needle with 26-gauge
orthodontic wire for stabilization of
the splint.14 This method is simple,
conservative and easy to fabricate,
causes minimal trauma to surrounding
tissues, is cost effective and has good
stability during the healing period.
Discussion
The management of jaw fractures
in cases of pediatric patients is very
challenging to dentists. Although the
signs and symptoms in pediatric patients
are the same as those in adults, the
treatment plan changes due to the growth
of jaws and the developing dentition.2
Treatment of a pediatric patient
depends on the stage of skeletal and
134M A R C H 2 01 7
FIGURE 1. A parasymphyseal fracture is present
between teeth O and N.
dental development, keeping in mind
the type of fracture. Fractures without
displacement can be managed by close
observation, soft diet, restriction of
physical activities and analgesics.8
But in fractures with displacement
and deranged malocclusion, management
with either closed or open reduction
has to be done by splints and arch bars
for two to three weeks. Rarely, where a
fracture is limited to alveolar process,
long-term mono-maxillary immobilization
(via splinting) is indicated for up to two
months to prevent malocclusion.6
Intermaxillary fixation using arch
bars and eyelets can also be used
for the management of mandibular
fractures. It is a noninvasive, simple
and low-cost technique, but the
arch bars and wires cause irritation
to the supporting tissues and lead to
periodontal problems. The foundation
for the arch bars is technically very
challenging due to the conical and
tapered shape of crown and wide
cervical area. The primary teeth can
be avulsed out during the procedure.
Also, the wires restrict the diet of
the child, leading to weight loss.16
Open reduction rigid internal fixation
(ORIF) using plates and screws is also
one of the options in which fixation is
achieved under direct vision and with
better approximation. Zimmerman et al.
said in 2006 that in pediatric fractures
ORIF provides stable three-dimensional
reconstruction, promotes primary bone
healing, shortens treatment time and
eliminates the need for or permits early
release of maxillomandibular fixation.6
C D A J O U R N A L , V O L 4 5 , N 3
FIGURE 2 . A CT scan was taken to rule out any
head injury.
But this treatment modality remains
controversial in pediatric patients. The
mandibular cortex is thin and less dense
than in adults. This could lead to the
plates being visible or palpable through
the childs skin or the screws and plates
could migrate as the teeth are in an
eruptive stage. Also, the danger of damage
to the permanent tooth buds during
the placement of screws, restriction of
growth of the jaws because of periosteal
stripping, pain and secondary infection
preclude the use of ORIF as treatment of
choice. ORIF in parasymphysis fractures
can safely be done after 9 years of age
when the permanent buds of the canines
have moved up from their inferior
position at the mandibular border.6
The need for open reduction in
pediatric fractures is minimal because
malunion or nonunion in children is rare
due to their greater osteogenic potential
and faster healing rates.6 Keeping in mind
all the above factors, mandibular fractures
in children are best treated by conservative
methods. We were able to successfully
manage the cases by using acrylic cap
splints with modified circummandibular
wiring. An acrylic cap splint is cost
effective, easy to fabricate, requires less
chair time, provides adequate stability to
fragments and causes minimal trauma to
supporting tissues. The modified technique

FIGURE 3 . Preoperative orthopantomoradiogram showing the fracture line between the left lateral and
central incisors and fracturing of the left parasymphyseal region of mandible.
of circummandibular wiring using a
20-gauge spinal needle and orthodontic
wire was atraumatic and led to a smaller
wound with a resultant smaller scar.
Reduction of fractured segments by splints
was achieved as close as possible to the
original positions and gave us satisfactory
results in both cases posttreatment.
Case Reports
Case One
A 5-year-old boy reported to
the department of pedodontics and
preventive dentistry in Gian Sagar
Dental College and Hospital in Rajpura,
Punjab, India, with the chief complaint
of facial injury due to a fall from
height. There was no history of loss
of consciousness, vomiting or seizures,
bleeding from the nose or ears or any
other injuries, as elicited by the mother.
The patient was conscious, cooperative
and well oriented in time and place.
On extraoral examination, there
was swelling on the left side of the face
and lacerations near the angle of the
mouth and left side of the forehead.
Intraoral examination revealed
bleeding within the mouth, limited
mouth opening and deranged occlusion
with a displaced fracture between
teeth O and N (FIGURE 1 ).
C D A J O U R N A L , V O L 4 5 , N 3
FIGURE 4 . A mandibular cast was split into two
fragments at the fractured site.
A CT scan of the head was taken to
rule out any component of head injury
(FIGURE 2 ). Panoramic radiograph
confirmed the diagnosis of parasymphyseal
fracture (fractures present lateral to mental
prominences in mandible). A fracture line FIGURE 5 . The cast segments were joined with sticky
was seen commencing superiorly between wax in a reduced position.
mandibular left central and lateral incisors
and extending up to the inferior border of
the mandible on the same side (FIGURE 3 ).
Primary treatment was instituted
and lacerated wounds were sutured.
Informed consent was obtained from
the parents prior to treatment. Maxillary
and mandibular impressions were made in
alginate and casts were poured in dental
stone. For the mock surgery, the fractured
site was marked on the mandibular cast
and then split into two segments with
an electric saw (FIGURE 4 ). The cast
segments were then joined with sticky FIGURE 6 . An interocclusal splint was fabricated
using clear self-cure acrylic.
wax in a reduced position simulating the
intact arch and after achieving proper
occlusion with maxillary cast (FIGURE 5 ). The splint was disinfected by overnight
The casts were mounted on an articulator immersion in 2% gluteraldehyde.
(three point or mean value articulator). The patient was recalled on the
After the blockage of undercuts, an next day and premedicated with oral
interocclusal splint was fabricated using midazolam in a dosage of 0.5mg/Kg
clear self-cure acrylic on the mandibular body weight.15 The premedication was
cast (FIGURE 6 ). An arch wire was administered using clear apple juice as
incorporated into the splint in order to the carrier vehicle 30 minutes before
facilitate doing intermaxillary fixation surgery. Under local anesthesia, the
on this patient if required at a later stage. mandibular arch was manually reduced
M A R C H 2 0 1 7 135
 pediatric fractures
Buccinator
muscle
26-gauge
wire
Spinal needle
Sublingual gland
FIGURE 7. In step one, a 20-gauge spinal needle
was introduced through the skin and removed lingually
close to the body of the mandible.
FIGURE 10 . The stabilized splint in the oral cavity.
FIGURE 12. Postoperative photograph after 21 days.
and a splint was tried for stability taking
occlusion as a guidance. To stabilize
the fracture segments with the splint,
circummandibular wiring was done
(steps 13). The 20-gauge spinal needle
was introduced through the skin and
taken out lingually close to the body of
the mandible (F I G U R E 7 ). A 26-gauge
orthodontic wire was then inserted
136M A R C H 2 01 7
Buccinator
muscle
26-gauge
wire
Spinal needle
Skin
Sublingual gland
FIGURE 8 . In step two, the spinal needle was
passed on the buccal side through the same puncture
hole in proximity to the bone.
FIGURE 11. Postoperative radiograph shows the acrylic splint secured with circummandibular wiring.
into the lumen of the spinal needle
and clamped intraorally. The spinal
needle was then passed on the buccal
side through the same puncture hole
in proximity to the bone (F I G U R E 8 ).
Both buccal and lingual ends of wires
were held together, freed from skin over
the mandible by a sawing motion (pulling
the two free ends alternatively) and the
splint was stabilized by twisting the wire
in a clockwise direction (FIGURE 9 ). This
procedure was repeated on the other side
C D A J O U R N A L , V O L 4 5 , N 3
Soft tissue
Buccinator
muscle
Splint
26-gauge
wire
Alveolar bone
Skin
Sublingual gland
FIGURE 9. In step three, the splint was stabilized by
twisting the wire in a clockwise direction.
(FIGURE 10 ). Finally, stability of the splint
was verified (FIGURE 11 ). Postoperative
instructions were given to the patient
and medications were prescribed.
After 21 days, the splint was
removed as healing had occurred
satisfactorily and uneventfully without
any complications. Masticatory functions
were restored and the minimally
invasive treatment proved quite effective
(FIGURE 12 ). The patient was kept
under supervision for three months.

FIGURE 13 . CT scan shows the
fracture in the symphyseal region.
Case Two
A 2-year-old boy reported with the
chief complaint of trauma due to a fall
from height. The patient had no history
of loss of consciousness and no bleeding
from nose or ears. A CT scan was advised
for the patient. The CT revealed that
there was no head injury but a bony
fracture was found in the symphyseal region
of the mandible (FIGURES 13 and 14 ).
On extraoral examination, there was
swelling of upper and lower lips. Intraoral
examination revealed deranged occlusion
with step deformity and spacing between
the maxillary central incisors. Informed
consent was obtained from the parents.
Oral premedication was given 30 minutes
prior to taking impressions. Maxillary and
mandibular impressions were made and
cast fabrication was done. Mock surgery
was done and casts were then mounted on
an articulator. After the blockage of
undercuts, a cap splint was fabricated
using clear self-cure acrylic.
Under premedication and local
anesthesia, the mandibular arch was
manually reduced and a splint was tried
for stability. Modified circummandibular
wiring was done with the splint in position
(FIGURE 15 ) and stability of the splint was
verified. Postoperative instructions and
medications were given to the patient.
After 21 days, the splint was
removed. In the postoperative
orthopantomogram, fracture reduction
occurred satisfactorily and masticatory
functions were restored subsequently.
C D A J O U R N A L , V O L 4 5 , N 3
FIGURE 14 . Preoperative CT scan FIGURE 15 . Postoperative photograph with the
shows fracture in the symphyseal region splint in position.
Conclusion 11. Hooda A, Kumar A. Management of mandible fractures in
pediatric patients. Acta Biomedica Scientia 2015;2(4):173
The management of mandibular
176.
fractures in children is complex and 12. Kruger GO. Fractures of the jaws. In: Kruger GO, ed.:
conventionally done by circummandibular Textbook of Oral and Maxillofacial Surgery. 6th ed. St. Louis:
Mosby; 1989:364433.
wiring with a mandibular awl. The twisted
13. Thomas S, Yuvaraj V: Atraumatic placement of
ends of the awl could cause trauma to circummandibular wires: A technical note. Int J Oral Maxillofac
the surrounding soft tissues because of its Surg 2010;39:8385.
14. Kapoor V. Injuries of the maxillofacial region. In: Kapoor V,
sharpness and thickness. In this case, a
ed.: Textbook of Oral and Maxillofacial Surgery 2nd ed. New
modified atraumatic technique of placing Delhi: Arya; 228318.
circummandibular wiring was used, in 15. McMillan CO, Spahr-Schopfer IA, Sikich N.
Premedication of children with oral midazolam. Can J Anaesth
which a 20-gauge spinal needle along
1992;39(6):545550.
with a 26-gauge orthodontic wire were 16. Singh J, Khadka R, Chaturvedi PC. Circummandibular
used to stabilize the splint. Not only is it wiring made easy: A case report. Rev Esp Cir Oral Maxilofac
2014;36(4):191195.
economical and disposable, this technique,
being sharp in nature, also leaves a smaller THE CORRESPONDING AUTHOR, Manisha Sahni Prabhakar, MDS,
wound leading to a smaller scar. can be reached at prof.manisha@gmail.com.
REFERENCES
1. Kale TP, Urologin SB, Motwani NB. Management of
mandibular fracture in children with open cap splint: A
treatment modality. Int J Contem Dent 2011;2(1):6972.
2. Aizenbud D. The management of mandibular body fractures
in young children. Dental Traumatol 2009;25:565570.
3. Boyette JR. Facial Fractures in Children. Otolaryngol Clin N
Am 2014;47:747761.
4. Maranoa R, Netoa PO, Sakugawab KO, et al. Mandibular
fractures in children under 3 years: A rare case report. Rev Port
Estomatol Med Dent Cir Maxilofac 2013;54(3):166170.
5. Adlakha VK, Bansal V, Chandna P, et al. Mandibular
fracture in an 18-month-old child. Ind J Dent Res
2011;22(5):723725.
6. Zimmermann CE, Troulis MJ, Kaban LB. Pediatric facial
fractures: Recent advances in prevention, diagnosis and
management. Int J Oral Maxillofac Surg 2006;35:213.
7. Vasconcelos et al. Mandibular Fracture in a Premature Infant.
J Oral Maxillofac Surg 2009;67:218222.
8. Kaban LB. Facial trauma II: Dentoalveolar injuries and
mandibular fractures. In: Kaban LB, ed.: Pediatric Oral and
Maxillofacial Surgery. Philadelphia: WB Saunders 199:233260.
9. Stacey DH. Management of Mandible Fractures. Plast
Recons Surg 2006;117(3):4860.
10. Khatri A. A conservative approach to pediatric mandibular
fracture management: Outcome and advantages. Ind J Dent
Res 2011;22(6):873876.
M A R C H 2 0 1 7 137
Get free, early delivery
to a device near you.

Available for iPad, iPhone, Android or Kin

Kindle
ndle Fire.
Check it out at cda.org/apps
 photodynamic therapy
C D A J O U R N A L , V O L 4 5 , N 3

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

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

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

AUTHORS

I
Rodrigo Rodrigues Maria Eugnia Alvarez- Martinho Campolina Frank Ferreira Silveira, n the last several decades, endodontics
Amaral, DDS, MS, is in Leite, DDS, MS, PhD, is in Rebello Horta, DDS, MS, DDS, MS, PhD, is has evolved substantially along with
the department of dentistry the department of dentistry PhD, is in the department an adjunct professor
the development and adoption of
at Pontifcia Universidade at Pontifcia Universidade of dentistry at Pontifcia of endodontics at the
Catlica de Minas Gerais Catlica de Minas Gerais Universidade Catlica University of the Pacic,
new technologies and materials. The
in Belo Horizonte, Brazil. in Belo Horizonte, Brazil. de Minas Gerais in Belo Arthur A. Dugoni School of quality of endodontic treatment has
Conict of Interest Conict of Interest Horizonte, Brazil. Dentistry in San Francisco. been maximized, and the time required
Disclosure: None reported. Disclosure: None reported. Conict of Interest Conict of Interest to accomplish it has been substantially
Disclosure: None reported. Disclosure: None reported.
reduced. Most therapeutic failures
Eduardo Nunes, DDS, Jos Cludio Faria
MS, PhD, is in the Amorim, DDS, MS, PhD, Maria Ilma de Sousa Stephen Cohen, MA,
are associated with the persistent
department of dentistry is in the department of Corts, DDS, MS, PhD DDS, is an adjunct presence of microorganisms, which
at Pontifcia Universidade dentistry at Itana University is in the department of professor of endodontics at are able to survive chemomechanical
Catlica de Minas Gerais in Itana, Brazil. dentistry at Pontifcia the University of the Pacic, preparation or intracanal medication.1
in Belo Horizonte, Brazil. Conict of Interest Universidade Catlica Arthur A. Dugoni School of
Protected by the favorable anatomy
Conict of Interest Disclosure: None reported. de Minas Gerais in Belo Dentistry in San Francisco.
Disclosure: None reported. Horizonte, Brazil. Conict of Interest
of the root canal system (RCS),
Conict of Interest Disclosure: None reported. microorganisms cannot be reached by the
Disclosure: None reported. hosts defenses or systemic antibiotics.
Microorganisms are eliminated by the
mechanical action of instruments, the
irrigation process and the action of
antimicrobial irrigants and intracanal
medication. Several studies have shown
M A R C H 2 0 1 7 139
 photodynamic therapy
that chemomechanical preparation in
combination with sodium hypochlorite
solution at different concentrations does
not completely eliminate microorganisms
from the RCS, which can still be
found in 40-60 percent of teeth and
thus represent a negative factor for the
success of endodontic treatment.25
The microorganism Enterococcus
faecalis (E. faecalis) has been reported
as the most prevalent species associated
with endodontic treatment failure
and was isolated in 70 percent of such
cases.1,4,6 E. faecalis is resistant to most
intracanal medications, including calcium
hydroxide, tolerates pH levels up to 11.57
and can lead to mono-infection, which
is extremely difficult to eradicate by
conventional methods. The presence of E.
faecalis at the time of root canal obturation
can be a continuing source of infection.8,9
Photodynamic therapy (PDT) has
emerged as a promising antimicrobial
treatment. PDT involves the use of a
photosensitizer (dye) that is activated
by light at a specific wavelength in the
presence of oxygen. Energy transference
from the activated photosensitizer to
available oxygen results in the formation
of toxic oxygen species, such as singlet
oxygen and free radicals. These oxygen
species are highly reactive and harm
proteins, lipids, nucleic acids and other
microbial cellular components.10
To assess the effectiveness of
photodynamic therapy in achieving
microbial reduction in root canals
contaminated by E. faecalis, our study
employed an ex vivo comparative design.
Materials and Methods
The sample consisted of 28
human single-root teeth extracted
for several reasons and freely and
spontaneously donated by patients
who signed an informed consent
form. The research ethics committee
140M A R C H 2 01 7
at Pontifical Catholic University of
Minas Gerais approved the study.
The teeth were stored in 0.5%
sodium hypochlorite solution for two to
four weeks. The crowns were removed
at the cementoenamel junction using
a diamond disk. The canals were
instrumented sequentially using #15 to
#20 K-type files (Dentsply Maillefer,
Ballaigues, Switzerland) at the level
of the apical foramen, as established
by direct visualization. Preliminary
instrumentation was facilitated by
irrigation with 1 mL of 5.25% sodium
hypochlorite (NaOCl) solution. To
remove the smear layer, the root
canal was flooded with 1 mL of 17%
ethylenediaminetetraacetic acid
(EDTA) solution, pH 7.4, for three
minutes followed by final irrigation
with 5.25% NaOCl solution. After the
canals were dried with size 20 Endo
Points absorbent paper points, (Endo
Points Industrial da Amaznia Ltda.,
Manacapuru, Brazil) a #20 K-type file
was stabilized at working length (WL)
that was established 1 mm short of the
apical foramen. Subsequently, the apical
foramen and the final 3 mm of the root
were sealed with two cyanoacrylate
layers (Super Bonder, Henkel Loctite
Adhesives Ltd., Itapevi, Brazil). Each
root was coupled to the central section
of the rubber lid of a glass container, and
these experimental units were sterilized
with ethylene oxide gas (Curar Centro
de Esterilizao Ltda., Belo Horizonte,
Brazil) and appropriately packaged.
The root canals were contaminated
with a suspension of E. faecalis (ATCC
4083, American Type Culture Collection,
Manassas, Va. ). Microorganisms were
seeded in Brain Heart Infusion Agar
(BHI) solid medium (Difco Laboratories,
Detroit). To prepare the suspension,
three to five colonies from a 24-hour
culture were added to 5 mL of distilled
C D A J O U R N A L , V O L 4 5 , N 3
FIGURE 1. Photodynamic therapy as a supplement
to instrumentation.
water and were adjusted to McFarland
turbidity standards (3 x 108 cells/mL).
One milliliter was removed from the
initial suspension to prepare another
suspension in 10 mL of BHI broth. After
five hours of incubation at 37 degrees
Celsius in aerobiosis, approximately
20 mL of the bacterial suspension was
applied to each experimental unit by
being smoothly injected into each root
canal using a plastic syringe. Subsequently,
a #15 K-type file was used to drive
the bacterial suspension to WL. Each
experimental unit was placed in a sterile
plastic flask with a screw cap and was
incubated for 24 hours at 37 degrees
Celsius in aerobiosis. The root canals
were reinoculated over 21 days at 48-hour
intervals with fresh E. faecalis suspensions
that were prepared as described above.
The teeth were divided randomly
in two experimental groups and two
(one positive and one negative)
control groups. In group one (n = 10),
chemomechanical preparation was
performed using 5.25% NaOCl solution
as an irrigant. In group two (n = 10),
chemomechanical preparation was
performed by irrigation of the canals with
5.25% NaOCl solution followed by PDT.
The positive control group consisted of
four teeth instrumented and irrigated
with 0.85% saline solution and the other
four teeth were allocated to the negative
control group, which was not inoculated
with the indicator microorganism.
All root canals were instrumented
sequentially up to WL by means of

TABLE 1
Mean and Standard Deviation of the Values of CFU Assessment (Log 10)
Saline solution (positive control group)
NaOCl (group one)
NaOCl + PDT (group two)
A,B Within rows, means followed by the same uppercase letter are not signicantly dierent from each other (p > 0.05). P values were obtained by using repeated measurements one-way ANOVA
followed by Tukeys post-hoc test.
a,bWithin columns, means followed by the same lowercase letter are not signicantly dierent from each other (p > 0.05). P values were obtained by using one-way ANOVA followed by Tukeys
post-hoc test.
TABLE 2
Qualitative Data Evaluation (Medium Turbidity)
Saline solution (positive control group/n = 4)
NaOCl (group one/n = 10)
NaOCl + PDT (group two/n = 10)
Positive (+)/Negative (--)
A,B Within rows, values followed by the same uppercase letter are not signicantly dierent from each other (p > 0.05). P values were obtained by using the Fischer exact test.
a,b Within columns, values followed by the same lowercase letter are not signicantly dierent from each other (p > 0.05). P values were obtained by using the Fischer exact test.
a rotary instrumentation technique
using ProTaper S1, S2, F1, F2 and F3
files (Dentsply Maillefer, Ballaigues,
Switzerland); ProTaper F4 (#0.40 mm)
was used to finish the preparation.
Irrigation with 1 mL of 5.25% NaOCl
solution was performed after each
change of instrument all throughout the
preparation using a sterile, disposable
plastic syringe. At the end of preparation,
root canals were irrigated with 1 mL of
17% EDTA solution, pH 7.4, for three
minutes followed by a final irrigation
with 1 mL of 5.25% NaOCl solution.
For the PDT group, a 0.005%
methylene blue solution (Chimiolux,
Hypofarma, Belo Horizonte, Brazil)
was used as a photosensitizer for 5
minutes11 and Twin Flex laser equipment
(MMOptics, So Carlos, Brazil) at a
660-nm wavelength and 40 mW of
power to a total energy density of 1.8 J/
cm.2 A 300-m optic fiber (MMOptics)
was coupled to the diode laser and was
inserted into the root canal 2 mm short
of WL, where it was set to allow for
better diffusion of light (FIGURE 1 ).
Before placing the photosensitizer,
the canals were irrigated with 1 mL of
Pre-instrumentation Post-instrumentation
A,a B,a
6.40 0.22 1.76 0.19
5.78 0.47 A,a 0.19 0.61 B,b
5.77 0.62 A,a 0 0 B,b
Pre-instrumentation Post-instrumentation
4(+) and 0(--)A,a 4(+) and 0(--)A,a
10(+) and 0(--)A,a 3(+) and 7(--)B,a,b
10(+) and 0(--)A,a 2(+) and 8(--)B,b
0.85% saline solution and dried with
Endo Points size FM absorbent paper
points. The photosensitizer was placed
inside the canals using a sterile disposable
syringe and a 23-gauge needle and
left for five minutes of pre-irradiation
time. Next, irradiation was performed
with optic fiber for 180 seconds.
Microbiological samples procedures
were blinded and collected before,
immediately after and 72 hours after
instrumentation. The canals were filled
with 0.85% saline solution by means of
a sterile, disposable plastic syringe and a
23-gauge needle. Each microbiological
sample was collected using FM absorbent
paper points previously sterilized with
ethylene oxide, left in the canals for
one minute. The canals were filled
again with 0.85% saline solution and
were kept sufficiently hydrated to allow
for the collection of samples. The
absorbent paper points were transferred
to test tubes containing 2 mL of 0.85%
saline solution, which were agitated
for one minute in a Vortex (Eletrolab,
So Paulo, Brazil). For quantitative
assessment, the dilutions were performed
in triplicate, and 1-mL aliquots of the
C D A J O U R N A L , V O L 4 5 , N 3
72 hours
1.95 0.24 B,a
0 0 B,b
0 0 B,b
72 hours
4(+) and 0(--)A,a
0(+) and 10(--)B,b
0(+) and 10(--)B,b
pure samples and the dilutions of 101
to 104 were sown in BHI medium and
incubated at 37 degrees Celsius for 48
hours in aerobiosis. Subsequently, the
culture growths were counted and the
typical morphological characteristics
of E. faecalis colonies were sought.
For qualitative assessment, the
microbiological samples were collected
using a similar procedure as the pure
samples using three absorbent paper
points before, immediately after and 72
hours after instrumentation, seeded in
triplicate in BHI broth, incubated as
described above and assessed regarding the
presence or absence of medium turbidity.
To identify the morphological
and tinctorial characteristics of the
recovered microorganisms, the samples
were stained using Grams method.
The quantitative data (colony-
forming unit counting) were statistically
analyzed by one-way ANOVA followed
by Tukeys post-hoc test. The qualitative
data (medium turbidity) were evaluated
by Fishers exact test. Tests were
performed by using GraphPad software
(GraphPad Software, San Diego) at
significance level of 5 percent.
M A R C H 2 0 1 7 141
 p h o t o d ye n
y eabmrioc wt h e r a p y
Results
Effective colonization was confirmed
by colony-forming unit (CFU) count
and medium turbidity assessment
of the samples collected before
instrumentation (TABLES 1 and 2 ).
In quantitative analysis,
microorganisms were recovered from all
samples of the positive control group, from
one single sample from group one and no
micro-organisms measured as CFUs were
recovered from samples from group two. In
all groups, the CFU count was lower
immediately after and 72 hours after
instrumentation when compared to the
CFU count before instrumentation with
no difference between the first (TABLE 1 ).
When the groups were compared, no
difference was observed in the CFU count
before instrumentation (TA BLE 1 ).
Moreover, the CFU count was lower in
groups one and two when compared to the
positive control group, immediately after
and also 72 hours after instrumentation
(TA BLE 1 ). In both collection times, no
differences were observed between groups
one and two (TA BLE 1 ).
In qualitative analysis, medium
turbidity was positive in three samples from
group one and in two samples from group
two after instrumentation (TABLE 2 ).
Microorganisms were not observed in these
two groups 72 hours after instrumentation
(TABLE 2 ). In the positive control group,
no differences were observed in medium
turbidity between the collection times
(TABLE 2 ). In groups one and two, medium
turbidity was lower immediately after and
also 72 hours after instrumentation when
compared to medium turbidity before
instrumentation with no difference
between the first (TABLE 2 ). When the
groups were compared, no difference was
observed in the medium turbidity before
instrumentation (TABLE 2 ). Immediately
after instrumentation, medium turbidity
was lower in group two when compared to
142M A R C H 2 01 7
the positive control group with no
difference among the other groups (TABLE
2 ). Finally, 72 hours after instrumentation,
medium turbidity was lower in groups one
and two when compared to the positive
control group with no difference between
the first (TABLE 2 ).
Discussion
The aim of this study was to assess
the effectiveness of photodynamic
therapy in achieving microbial
reduction in root canals contaminated
by E. faecalis with conventional
E. faecalis was observed
in a remarkable proportion
of teeth exhibiting persistent
periapical lesions,
despite well-performed
endodontic treatments.
endodontic treatment. Thus to
evaluate the effect of PDT alone was
not the purpose of the study because
PDT is not a substitute for NaOCl.
PDT seems to be a promising
adjuvant therapy to endodontic
treatment to eliminate the
microorganisms that remain after
chemomechanical preparation. PDT
is easy to apply in clinical practice,
and it might be indicated in single or
multiple-session endodontic treatments.
Several studies using PDT1219 have
suggested that it might be employed as
an adjuvant to endodontic treatment
to achieve significant reduction of
microorganisms. PDT can destroy
the remaining microorganisms
inside the RCS after conventional
chemomechanical preparation.
C D A J O U R N A L , V O L 4 5 , N 3
Microorganisms located in
ramifications, isthmus and dentinal
tubules can escape the effects of the
instruments and irrigants used during
chemomechanical cleansing of RCS20
and can eventually lead to late failure of
endodontic treatment.21 The use of EDTA
during cleaning of the root canal seems to
improve the microorganisms reduction.2
E. faecalis was selected due to its
ability to survive without synergism
with other microorganisms, and it
seems to tolerate ecological changes in
the root canal and to exhibit greater
persistence than other species.22 E.
faecalis was observed in a remarkable
proportion of teeth exhibiting persistent
periapical lesions, despite well-performed
endodontic treatments,23 as well as in
treatments with inappropriate obturation
of the root canal.6 Similar to other
facultative anaerobic microorganisms,
E. faecalis can exhibit resistance to
antimicrobial agents, endodontic
procedures and intracanal medication.24
The antimicrobial property of sodium
hypochlorite solutions are proportional to
its concentration. E. faecalis are resistant
to NaOCl in low concentrations.2527
The ideal concentration of sodium
hypochlorite to achieve antimicrobial
activity against E. faecalis was 5.25
percent when the time needed for
microbial elimination was considered.28
In this study, the previous enlargement
of the root canal was limited to the action
of #15 and #20 K-type instruments, as
in a previous study,29 aiming to maintain
the experiment as close as possible to
actual clinical conditions. Other studies,
however, have performed full preparation
of the root canal before the inoculation of
microorganisms and have applied average
inoculation and incubation times of 48
or 72 hours.12,13,15,16,30 The microbial load
inoculated in most studies, including this
one, corresponds to McFarland standard 1.

Different from other studies, in this study,
inoculation and incubation were performed
over 21 days at 48-hour intervals and
with 24-hour reinoculation seeking to
accomplish complete contamination of the
RCS, which was confirmed by the average
values in the samples collected before
instrumentation (TABLE 1 ). Therefore, this
study found an initial microbial load in the
samples collected before the endodontic
procedures, which was different from
other similar studies.12,13,15,16,30
Photosensitizers derived from
phenothiazines, tricyclic heteroaromatic
compounds and blue dyes, such
as toluidine blue O (TBO) and
methylene blue (MB), have been widely
used in endodontic research using
PDT.13,15,16,19,30,31 MB has been used as
a target for endodontic microbiotic
microorganisms13,15,19,30 and compared
to a novel photosensitizer (Rose Bengal
functionalized chitosan nanoparticles).32
MB at a concentration of 0.005%
was used in this study, because of its
hydrophilic nature and low molecular
weight.33 The reduced amount of MB
was shown to be effective against the E.
faecalis.34 The dye exhibits an absorption
band resonant with the wavelength
of the employed light source. The
present study applied the same pre-
irradiation times as similar studies.13,19,30
The study by Souza et al. did not find
a significant effect on the reduction of
E. faecalis with either MB or TBO.35
The optic fiber used in this study was
55 mm in length; its initial diameter was
1 mm and it decreased gradually to reach
0.3 mm at the opposite end. According to
the manufacturer, the optic fiber output
power was 10 mW. Because the equipment
power was adjusted to 40 mW, there was a
30-mW power loss. Therefore, by applying
a 180-second exposure time, energy
density of 1.8 J was attained at the spot in
keeping with the results obtained in the
study by Silva Garcez et al.12 In addition,
no difference was shown in the use of PDT
in periods one, two and four minutes.36
Quantitative analysis of the
positive control group made evident
the importance of using an irrigant
exhibiting antimicrobial action, such
as NaOCl. Reduction of the microbial
load was observed with 0.85% saline
solution, which was probably due to the
physical effects of irrigation. This finding
is in agreement with Bystrms and
Sundqvists observations.37 Nevertheless,
bacterial growth was observed 72
This study found an initial
microbial load in the
samples collected before
the endodontic procedures,
which was dierent from
other similar studies.
hours after instrumentation, which
indicates the presence and viability
of the remaining microorganisms.
In qualitative assessment, the
presence of microorganisms was
confirmed in all of the samples by
means of medium turbidity.
Microorganisms were not found
in the negative control group upon
assessing medium turbidity, which
confirms the sterilization of the specimens
accomplished by ethylene oxide.
The experimental group treated with
5.25% NaOCl exhibited a dramatic
reduction of microorganisms after
instrumentation. Quantitative analysis
revealed that microorganisms were
recovered from one single sample in
terms of CFU count. When PDT was
used as an adjuvant to chemomechanical
C D A J O U R N A L , V O L 4 5 , N 3
preparation, the microbial load
measured by CFU count decreased by
100 percent, thus suggesting the absence
of cultivable microorganisms. These
two experimental groups exhibited
different results in the assessment
of medium turbidity, although not
statistically significant. In the group
receiving 5.25% NaOCl only, three
specimens remained contaminated after
instrumentation, thereby attaining
a 70 percent reduction. In the group
treated with 5.25% NaOCl followed
by PDT, microorganisms were found in
two specimens after instrumentation,
thereby attaining an 80 percent
reduction. Microorganisms were not
found in both groups when assessed
72 hours after instrumentation.
Although qualitative and
quantitative analyses exhibited
diverging results, this finding can be
explained. E. faecalis might be present
in numbers below the number detected
by CFU counting when assessing
the culture method. The relatively
frequent occurrence of E. faecalis was
investigated38 in primary infections
when polymerase chain reaction was
used as an identification method, and
these researchers compared it to the
conventional culture method; E. faecalis
was found in 82 percent versus 4 percent
of cases, respectively. Assessment by
medium turbidity might reveal the
presence of possibly viable E. faecalis
after chemomechanical preparation and
PDT, albeit in numbers that cannot be
detected in solid medium (Agar BHI).
Under the investigated conditions, the
light parameters, photosensitizer, power,
energy and pre-irradiation time outlined
in this study were able to promote
additional reduction of the microbial load
after chemomechanical preparation; the
application time was shorter compared
to other suggested protocols.13,15,16,30
M A R C H 2 0 1 7 143
 photodynamic therapy
Conclusion
This study confirmed that the
procedures of instrumentation and
irrigation using NaOCl were efficient in
accomplishing microbial reduction of E.
faecalis biofilm; however, they were not
able to promote its full eradication from
the RCS. Despite the use of PDT with
the described light parameters promoting
additional microbial reduction, the
overall effect did not exhibit statistically
significant reduction. Further studies are
needed to establish the best protocol for
PDT regarding light parameters, type
and concentration of photosensitizer,
pre-irradiation time and energy to
maximize reduction or even achieve
full elimination of microorganisms.
REFERENCES
1. Siqueira JF Jr, Ras I. Clinical implications and microbiology
of bacterial persistence after treatment procedures. J Endod
2008;34(1):12911301.
2. Bystrm A, Sundqvist, G. The antibacterial action of sodium
hypochlorite and EDTA in 60 cases of endodontic therapy. Int
Endod J 1985;18(1):3540.
3. Sjgren U, Figdor D, Persson S, et al. Inuence of infection
at the time of root lling on the outcome of endodontic
treatment of teeth with apical periodontitis. Int Endod J
1997;30(5):297306.
4. Siqueira JF Jr, Magalhes K, Ras I. Bacterial reduction in
infected root canals treated with 2.5% NaOCl as an irrigant
and calcium hydroxide/camphorated paramonochlorophenol
paste as an intracanal dressing. J Endod 2007; 33(6):667
672.
5. Waltimo T, Trope M, Haapasalo M, et al. Clinical ecacy
of treatment procedures in endodontic infection control
and one year follow-up of periapical healing. J Endod
2005;31(12):863866.
6. Peciuliene V, Balciuniene I, Eriksen H, et al. Isolation of
Enterococcus faecalis in previously root-lled canals in a
Lithuanian population. J Endod 2000;26(10):593595.
7. Siqueira JF Jr., Lopes H. Mechanisms of antimicrobial
activity of calcium hydroxide: A critical review. Int Endod J
1999;32(5):361369.
8. Figdor D, Davies J, Sundqvist G. Starvation survival, growth
and recovery of Enterococcus faecalis in human serum. Oral
Microbiol Immunol 2003;18(4):234239.
9. Sedgley C, Lennan S, Appelbe O. Survival of Enterococcus
faecalis in root canals ex vivo. Int Endod J 2005;38(10):735
742.
10. Konopka K, Goslinski, T. Photodynamic therapy in dentistry.
J Dent Res 2007;86(11):694707.
11. Pagonis TC, Chen J, Fontana CR et al. Nanoparticle-Based
Endodontic Antimicrobial Photodynamic Therapy. J Endod
2010;36(2):322328.
12. Silva Garcez A, Nez S, Lage-Marques J, et al. Eciency
144M A R C H 2 01 7
C D A J O U R N A L , V O L 4 5 , N 3
of NaOCl and laser-assisted photosensitization on the
reduction of Enterococcus faecalis in vitro. Oral Surg Oral
vitro. Lasers Surg Med 2007;39(10):782787.
31. Seal G, Ng YL, Spratt D, et al. An in vitro comparison of
Med Oral Pathol Oral Radiol Endod 2006;102(4):9398. the bactericidal ecacy of lethal photosensitization or sodium
13. Soukos N, Chen P, Morris J, et al. Photodynamic therapy hypochlorite irrigation on Streptococcus intermedius biolms in
for endodontic disinfection. J Endod 2006;32(10):979984. root canals. Int Endod J 2002;35(3):268274.
14. Garcez A, Ribeiro M, Tegos G, et al. Antimicrobial 32. Shrestha A, Kishen A. Antibacterial ecacy of
photodynamic therapy combined with conventional endodontic photosensitizer functionalized biopolymeric nanoparticles
treatment to eliminate root canal biolm infection. Lasers Surg in the presence of tissue inhibitors in root canal. J Endod
Med 2007;39(1):5966. 2014;40(4):566570.
15. Fimple J, Fontana C, Foschi F, et al. Photodynamic 33. Wainwright M. Photodynamic antimicrobial chemotherapy
treatment of endodontic polymicrobial infection in vitro. J (PACT). J Antimicrob Chemother 1998;42(1):1328.
Endod 2008;34(6):728734. 34. Komine C, Tsujimoto Y. A small amount of singlet oxygen
16. Fonseca M, Jnior P, Pallota R, et al. Photodynamic therapy generated via excited methylene blue by photodynamic
for root canals infected with Enterococcus faecalis. Photomed therapy induces the sterilization of Enterococcus faecalis. J
Laser Surg 2008;26(3):209213. Endod 2013;39(3):411414.
17. Garcez A, Nuez S, Hamblin M, et al. Antimicrobial eects 35. Souza LC, Brito PRR, Oliveira JCM, et al. Photodynamic
of photodynamic therapy on patients with necrotic pulps and therapy with two dierent photosensitizers as a supplement to
periapical lesion. J Endod 2008;34(2):138142. instrumentation/irrigation procedures in promoting intracanal
18. Garcez A, Nuez S, Hamblin M, et al. Photodynamic reduction of Enterococcus faecalis. J Endod 2010;36(2):292
therapy associated with conventional endodontic treatment in 296.
patients with antibiotic-resistant microora: A preliminary report. 36. Yildirim C, Karaarslan ES, Ozsevik S, et al. Antimicrobial
J Endod 2010;36(9):14631466. eciency of photodynamic therapy with dierent irradiation
19. Ng R, Singh F, Papamanou DA, et al. Endodontic durations. Eur J Dent 2013;7(4):469473.
photodynamic therapy ex vivo. J Endod 2011;37(2): 37. Bystrm A, Sundqvist G. Bacteriologic evaluation of the
217222. eect of 0.5 percent sodium hypochlorite in endodontic
20. Nair P, Henry S, Cano V, et al. Microbial status of apical therapy. Oral Surg Oral Med Oral Pathol 1983;55(3):307
root canal system of human mandibular rst molars with 312.
primary apical periodontitis after one-visit endodontic 38. Gomes B, Pinheiro E, Sousa E, et al. Enterococcus faecalis
treatment. Oral Surg Oral Med Oral Pathol Oral Radiol in dental root canals detected by culture and by polymerase
Endod 2005;99(2):231252. chain reaction analysis. Oral Surg Oral Med Oral Pathol Oral
21. Vieira AR, Siqueira JF Jr., Ricucci D, et al. Dentinal tubule Radiol Endod 2006;102(2):247253.
infection as the cause of recurrent disease and late endodontic
treatment failure: A case report. J Endod 2012;38(2): THE CORRESPONDING AUTHOR, Frank Ferreira Silveira, DDS, MS,
250254. PhD, can be reached at frankfoui@uol.com.br.
22. Fabricius L, Dahln G, Holm S, et al. Inuence of
combinations of oral bacteria on periapical tissues of monkeys.
Scand J Dent Res 1982;90(3):200206.
23. Sundqvist G, Figdor D, Persson S, et al. Microbiologic
analysis of teeth with failed endodontic treatment and the
outcome of conservative retreatment. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 1998;85(1):8693.
24. Evans M, Davies J, Sundqvist G, et al. Mechanisms
involved in the resistance of Enterococcus faecalis to calcium
hydroxide. Int Endod J 2002;35(3):221228.
25. Baumgartner J, Cuenin P. Ecacy of several concentrations
of sodium hypochlorite for root canal irrigation. J Endod
1992;18(12):605612.
26. Heling I, Chandler N. Antimicrobial eect of irrigant
combinations within dentinal tubules. Int Endod J
1998;31(1):814.
27. Ayhan H, Sultan N, Cirak M, et al. Antimicrobial eects of
various endodontic irrigants on selected microorganisms. Int
Endod J 1999;32(2):99102.
28. Gomes B, Ferraz C, Vianna M, et al. In vitro antimicrobial
activity of several concentrations of sodium hypochlorite and
chlorhexidine gluconate in the elimination of Enterococcus
faecalis. Int Endod J 2001;34(6):424428.
29. Siqueira JF Jr., Ras I, Favieri A, et al. Chemomechanical
reduction of the bacterial population in the root canal after
instrumentation and irrigation with 1%, 2.5% and 5.25%
sodium hypochlorite. J Endod 2000;26(6):331334.
30. Foschi F, Fontana C, Ruggiero K, et al. Photodynamic
inactivation of Enterococcus faecalis in dental root canals in
 +@5391<9I9>7
9>
B5<<9>7
1>4
1@@A19B9>7
45>C1<
@A13C935B
6?A
?E5A


H51AB

$'+
&$+
'-&,0 '*&
'-&,0 *!.*+!

+&
*&*!&'
'-&,!+

.*$0
!$$+J":=9.;A (2?6< (?<@A5
<33602
9<0.A21 !*.!&H%<12?;
12@64;21
(
6;

@A<?F
:2160.9  !&'J
 


.
?.?2
<==<?AB;6AF
A<



6;
.

=?2@A646<B@

@A<?F
/914


!.@

2>
<=@
D
C62D@ =?<32@@6<;.9
/B6916;4
!.@

F2.?@
<3
4<<1D699
"& =B?05.@2
.
0<;1<
9<0.A21
6;
.
@6;492
@A<?F
@A?6=
:.99
A<
A52
06AF
(('

.@5
<;9F
BF2?I@
;2A
<3
# 

@>
3A
@B6A2
D

2>
<=@ &5C
?6
#
(A?@
!.@
/22;
.
12;A.9
=?.0A602
3<?

F2.?@ (A?@5ACH
!
(A?@5ACH
!

 5ACH
!

 
-&,!&,'&
(*#  (  
F2.?@
<3
4<<1D699 D>C9>7C?>
5138H$2.@25<91
":=?<C2:2;A@



>B6=:2;A
';9F
%<12?;
12@64;21
<33602
D

2>  !&'

(
D

F2.?@
<3
4<<1D699
6;
3?22
@A.;16;4
9<0.A21
6;
@A?6=
@5<==6;4
02;A2?

2>B6==21
<=@
<=@
.;1

=9:/1
;<A
2>
6;
.

@A<?F
:21
/914 :2160.9
/914
!.@

2>
<=@
6;
.


@>
3A
@B6A2
*<:2
2;A60.9
BF2?I@
&2A
<3
# (A?@5ACH
!
(A?@5ACH
!
 )2.@<;./92
?2;A
(?<720A6;4
.==?<E
#
6;

 
&+
#
?2.A
60<;
6;
A52
0<::B;6AF (A?@5ACH
$-&
!$$+J ,6A5
<C2?

F?@
<3
4<<1D699
A56@
$
*+&,J '*, '
(,!&,
 *,+
'&$0 
(
6@
9<0.A21
6;
.

@A<?F
:21
/914
!.@

2>
<=@
6;
$
%!*
(
2@A./96@521
06?0.

9<0.A21
6;
. .


@>
3A
@B6A2
*22
.;
.C.?.42
<3

;2D '&,&H (

)2.9
@A.A2 (?2:62?
<33602
D6A5

@A<?F
:21
=?<3
/914
<;@6@A@
<3

2>
<=@
(?<720A =.A62;A@ :<
(?<720A6;4
.==?<E
#
3<?


F2.?@
<3
4<<1D699
";
.



@>
3A
/914
D6A5

2>
6;4
.==?<E
#
3<?
 (A?@5ACH
 (A?@5ACH
!

<=@

!.@
A52
9.A2@A
A205;<9<4F
(?<720A6;4
.==?<E
$
(-&,J (

914 'C2?

F?@
<3
4<<1D699
$-&
!$$+
(
6;
@6;492
@5<==6;4
02;A2?
?645A %
3<?

&2A
<3
# (A?@5ACH
!
 
<33
A52
3?22D.F
6;
.
4?<D6;4
.?2
<3
$ 
@A./96@521


A56@
=?.0A602
6@
9<0.A21
6;
.
@6;492
@A<?F
3?22
@A.;16;4
6;

D

2>
<=@
!.@
1646A.9
-?.F
D6A5
.492 '*'&J (

D
<C2?

F2.?@
<3
4<<1D699
6;
@6;492
/914
!.@

2>
<=@

*<:2
!%'
.;1
2;A60.9
@<3A
@<3AD.?2 &5C
?6
#
(A?@5ACH
!
 @A<?F
:2160.9
/914
&2.?
;2D
12C29<=:2;A@
!.@

2>
?<@@21
.==?<E
#
6;
 &5C
#
(A?@

<=@

BF2?I@
;2A
#
# :< (A?@5ACH
!

5ACH
!
  %!++!'&
.!"'
,-*&
#0 %<12?;
12@64;21
(
9<0.A21
6;
.

@A<?F
:21 12;A
/914
!.@

2>

 
$'+
&$+
'-&,0  (2?6<

":=9.;A
=?.0A602 =9:/1
3<?
2E=.;@6<; (A?@5ACH
!

%, (

<;1<
*B6A2

!.@
<C2?


F2.?@
<3
D6A5
<C2?

F2.?@
<3
4<<1D699
6;
.
@6;492
@A<?F
=?<


32@@6<;.9
/B6916;4
>B6==21
D6A5

<=2?.A<?62@
6;
.


@>
3A
<33602
?<@@21
#
6;

&2A
#
%!++!'&
.!"'H ?<B=
@<9<
=?.0A602
6;
.

@A<?F
:2160.9
/B6916;4
@A./96@521
6;

!.@


2>
<=@
4<<1D699
A<
<33602?
"0<;
6;
A52
0<::B;6AF
$<0.A21
6;
.
@6;492
@A<?F
A?6=92E
0<;1<
/914
!.@

2>
<=@

&<
(A?@5ACH
!
  D6A5
1646A.9
E?.F

((' *! *'%
!%' &,
' 2;A60.9
&2A
<3
# (A?@5ACH
!

 #
(A?@5ACH
!

$'+
&$+  (
D

F2.?@
<3
4<<1D699
";
.
 $
)-!&,J,299
2@A./96@521
=?.0A602
D6A5

F?@
<3
@A<?F
:2160.9 12;A.9
/914
!.@

2>
<=@
D6A5
C62D@ &/('*,
 J 2;2?.9
(?.0A602

D
<C2?

4<<1D699
6;
5645
2;1
;2645/<?5<<1
%<12?;
12@64;21
F2.?@
9<0.A21
6;
:B9A6
@A<?F
/B6916;4
D6A5
/2.BA63B9


A<
A52
:<B;A.6;@
((' .@5 %2160.9 (
?<@@21
C62D@
A<
A52
<02.;

!.@

<=@
$<;4
A2?:
92.@2 <33602
D

@=.06<B@
<=@ (A?:53C9>7
1@@A?G

%
#
6;

&2A
<3
# (A?@5ACH
!
 
BF2?I@
;2A
#
 (A?@5ACH
!
 (A?@5ACH
!
 
(+&  $<0.A21
6;
A52
52.?A
<3
(.@.12;.
D

F2.?@
<3
4<<1D699
(?<720A6;4
.==?<E
#
!.@
 +&,
&J (
9<0.A21
6;
.
:B9A6@A<?F
%2160.9 '&,*!'
(  @A./96@521
6;

D

2>
<=@
6;
2>@
<=@
6;
.


@>
3A
@B6A2 (A?@5ACH
!


.&
&-0+  2;2?.9
(?.0A602
D

F2.?@
<3
4<<1



(?<3
914
<;@6@A@
<3

2>
<=@
@A./96@521
6;

(?<7
.==?<E
#
3<?
 (A?@
!
/B@F
@6;492
@A<?F
@5<==6;4
02;A2?
!.@
@<:2
2;A60.9
.;1
!%'
(?<7
.==?<E
#
BF2?I@
# (A?@

D699
!.@

2>
<=@
(?<720A6;4
.==?<E
#
&2A
<3   5ACH
!


# (A?@5ACH
!


+
'*&
'-&,0H @A./96@521
6;

D6A5
 ($%
+(*!&+ G  

 2;2?.9
=?.0A602
2>
<=@
6;
.
/B@F
@5<==6;4
02;A2?
(?<720A6;4
# D6A5

2>B6==21
<=@
9<0.A21
6;
.
3?22
@A.;16;4
/914
3<?
 &5C
?6
#
(A?@5ACH
!

 @A./96@521
6;

*B6A2
6@
.==?<E



*2992?
#*&
.&,-*

+&
$-!+
'!+('
'-&,!+
D<?8

1.F@ D8 -0*K+
&,
'
#
(A?@5ACH
&5F2DAH
(1A;

,8?DB1>4
'1;BH 2;2?.9
(?.0A602 !

2@A./96@521
6;

+56@
:<12?;
12@64;21
<33602 +&
!'
'-&,0 *!.*+!H (

)2.9
@A.A2 @A./96@521
6;

6;
0<;@6@A@
<3

<=2?.A<?62@
6;
.


@>
3A
@B6A2 3?22
@A.;16;4
56@A<?60
/914
!.@

2>
<=@
6;
.


@>
BF2?I@
;2A
<3
#
%<;A59F
?2C2;B2@
<3
# $
%*J 

 @A./96@521
6;

+56@
3A
<33602
(?<720A6;4
.==?<E
#
3<?
 (A?@5ACH
?2.A
<33602 (A?@5ACH
!
  


2>
<=
<33602
6@
9<0.A21
6;
.

B;6A
=?<3
/B6916;4
!.@
C62D@
A<
A52
<02.;
)2.@<;./92
?2;A (A?@5ACH
! !

 
.&,-*H 2.BA63B9
(
D

F2.?@
<3
4<<1D699
6; ,%-$J%<12?;
12@64;21
=?.0A602
D

2>
<=@
.

@A<?F
:2160.9
/914
!.@

2>B6==21
<=@
?<@@ $
&,*'  ( G  

 +56@
=?.0A602
6@ (?<720A6;4
.==?<E
%

&2A
<3
# (A?@5ACH
!
6;4
.==?<E
#
&2A
<3
# (A?@5ACH
! 9<0.A21
6;
.
@6;492
@A<?F
/B6916;4 B6916;4
6@
3<?
@.92 
 
2>B6==21
<=2?.A<?62@
?<@@21
#
3<?

DH5AKB
>5C
?6
#
(A?@5ACH
!
 

.9B9C
?DA
/52B9C5
1>4
+?391<
%5491
@175B
6?A
(A13C935
(8?C?B
1>4
.945?B H?DCD253?==H3@BC51= 61352???;3?==H3@BC51=

 



 

 
  ,,,$()+"*$*'%
(5<;2

 
)

C CARROLL
&COMPANY
Complete Evaluation of Dental Practices & All Aspects of Buying and Selling Transactions
4103 SAN FRANCISCO GP
Vibrant downtown location in historic high-rise bldg. Retiring
doctor offering 30+ years of goodwill. 4.5 days of hygiene,
1,500+ active patients, 20-25 new patients/mo. Gorgeous,
spacious facility in approx. 2,500 sq. ft. 2015 GR $796K.
2014 GR $768K. Average adjusted net income $274K+
Asking $599K.
4133 NAPA GP
Napa County GP in newly furnished, fully equipped 2 op
facility with digital x-ray. 4 doctor day/week with 3 hygiene
days. Monthly average revenue of $36K. Seller willing to
help for a smooth transition. Asking $331K.
4139 MILPITAS GP
4 fully equipped ops in 1,300 sq. ft. Attractive office with
G
newer equipment, new flooring, etc. Great location with
N SO
DI
easy freeway access off 680. Average gross receipts
N
PE
$616K. Asking $450K.
4135 CAMPBELL OPPORTUNITY
Join a well-run solo group practice in a highly desirable
location near Westfield Valley Fair Mall. Each doctor has a
N G
separate practice in a spacious and modern facility with 14
DI
ops. and 6 additional hygiene ops. plus in house dental lab.
P EN
Seller offering interest plus one fifth group assets. Asking
$154K.
4131 PETALUMA FAMILY PRACTICE
Well established family practice located in charming
downtown Petaluma. More than 1,300 sq. ft main floor
facility with 4 spacious fully equipped operatories in
professional building, reserved staff parking, friendly team,
many years of patient goodwill, low overhead. Asking
$375K.
4108 HUMBOLDT COUNTY GP
Well-established, high performing general practice boasts 6
fully equipped ops. in 2,900 sq. ft. free standing office w/
Digital X- ray, 2 platinum Dexis sensors, & Cerec Omnicam
& MCXL units. Loyal & stable pt. base in charming
community, w/ a small town feel. Perfect for a dentist who
wants to escape the grind and live along the coastline. Avg.
GR $1.4M+, 2016 on schedule for $1.5M+. Seller willing to
help for smooth transition. Asking $1,041,000.
4140 SAN FRANCISCO GP
Seller offering 37 year family practice. Prime location in the
heart of San Francisco's financial district. Modern 1,537
square foot office built out in 2005. 3 year average gross
receipts $735K with 4 doctor days and 4 hygiene days per
week. Lease expires 2025 with option to extend. Asking
$601K. Contact Carroll & Company at (650) 362-7004 for
details.
www.carrollandco.info dental@carrollandco.info
Matching the Right Dentist to
the Right Practice
4160 SONOMA COUNTY GP
Prime well-travelled downtown location, close to highly-rated
wineries in seller owned re-designed building. 35 year-old
practice, averaging $569K w/4 doctor-days. Asking $393K.
4129 PETALUMA GP
GP located in stunning 1,856 sq. ft. seller owned facility.
State-of-the-art office includes 6 ops, staff lounge, reception
area, private office, business office, lab area, sterilization
area, consult room, separate storage area, bathroom plus
private bathroom. Asking $525K.
4134 MENLO PARK GP
Open bay style practice on second floor of professional
office building in the heart of downtown Menlo Park.
L D
Established in 1982, well-trained, seasoned and loyal staff.
Average Gross Receipts $726K. Asking $338K.
4138 SOUTH SAN FRANCISCO GP
1,100 sq. ft. beautifully appointed, state-of-art 4 op office
located near Tanforan in modern professional building.
NG
2016 annualized gross receipts $415K with adj net income
I
ND
of $166K. Doctor works 4 day work week. 3 hygiene days.
PE
Approx 1,000 active patients. Asking $327K.
4091 SOUTH VALLEY - HOLLISTER GP & PEDIATRIC
Country living at its best ~ small town community feel with
affordable housing. Fully-equipped 1,600 sq. ft. office with
2 enclosed adult ops and 3 open pedo ops. Great
opportunity with trained staff and approximately 550 active
patients. 2014 GR $228K. Seller is willing to help for a
smooth transition. Asking price only $125K.
4093 SAN JOAQUIN ORTHO
Established over 35 years with a solid reputation, near
several referral sources in seller owned building. 2,500 sq.
ft. office with 7 chair open bay in professional center on a
well-travelled street with many retailers. Avg. Gross Receipts
$763K. Seller retiring and willing to help for smooth
transition. Asking $561K. The building is available to
purchase as well for $608K.
UPCOMING: San Mateo GP, Santa Rosa GP
Petaluma GP & Santa Cruz County GP
Carroll & Company
P (650) 362-7004
F (650) 362-7007
dental@carrollandco.info
www.carrollandco.info
BRE #00777682
Mike Carroll Pamela Carroll-Gardiner
P (650) 362-7004 F (650) 362-7007
 RM Matters C D A J O U R N A L , V O L 4 5 , N 3

Thorough Treatment Plans Build Patient Trust

TDIC Risk Management Sta

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

to seat the permanent crown. Instead, he

Protecting dentists. Its all we do.
800.733.0633 | tdicinsurance.com | CA Insurance Lic. #0652783
disputed the charge with his credit card
company, which initiated a chargeback to
the dentists merchant account. The credit
M A R C H 2 0 1 7 147
 M A R C H 2 0 17 RM MAT TERS
mentioned the possibility the tooth may
need a crown, he did not inform the
patient that should he need a crown, it
would be significantly more expensive.
The patient felt ambushed,
Cervantes said. Had he known earlier,
he could have saved up the money,
waited until he was in a better financial
situation or set up a payment plan. Rather,
he felt he was taken advantage of and
questioned the need for the crown at
all since it was not causing him pain.
Unfortunately, this is a common
scenario. Far too often, dentists either
fail to provide a thorough treatment
plan or fail to update the plan once the
recommended treatment changes. The
reasons for this are varied. Some dentists
148M A R C H 2 01 7
are so focused on clinical care that they do
not consider the financial impact for the
patient. Others assume that patients are
as versed in the cost of dental treatment
as they are; to a dentist, it makes sense
that a crown would cost more, but the
difference is not so obvious to a layperson.
What is clear to a dentist is not
necessarily clear to a patient, Cervantes
said. If it is not outlined in a treatment
plan, patients may not understand
what their financial obligations are.
Cervantes says communication is key
to avoiding misunderstanding. Providing
detailed treatment plans outlining all
options and the costs associated with
them can help mitigate any potential
risk. Dentists can easily get caught up in
C D A J O U R N A L , V O L 4 5 , N 3
the moment when the patient is in the
chair. But even when the treatment plan
changes course midtreatment, a revised
treatment plan should be printed and
signed by the patient before proceeding.
Clear communication is critical to
transparent practices, especially when
money is involved, Cervantes said. It
is important that dentists and staff get in
the habit of confirming that the treatment
plan is reviewed and accepted by the
patient prior to performing the work.
TDIC recommends keeping a signed
copy of the treatment plan on file. In
fact, Cervantes says having a signed
treatment plan and consent form is the
first line of defense should a lawsuit arise.
It is up to the dentist to outline the
risks associated with not following through
with proposed treatment, she said. You
cant make the patient get the work done,
but you can show evidence of reviewing
these risks and trying to get the patient
back in the office to complete treatment.
Another consequence of poor doctor-
patient communication is a breakdown
of trust. Patients can begin to question
whether the treatment was needed or
whether the dentist was simply trying
to make a quick and easy buck. In
some cases, unhappy patients have
filed complaints with the dental board,
placing a practice under unwanted
scrutiny and causing avoidable headaches.
In other cases, patients turn to social
media to voice their dissatisfaction
through negative comments.
Providing patients with detailed
treatment plans with cost breakdowns
is essential for any practice owner.
Communication and transparency allow
patients to make informed decisions about
their oral health, meet patient expectations
and minimize patient complaints.
TDICs Risk Management Advice Line at
800.733.0633 is staffed with trained analysts
who can answer treatment planning and
other questions related to a dental practice.
QUESTIONS MOST OFTEN ASKED BY SELLERS:

& ASSOCIATES INC.

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

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

guaranteed payment of the balance of the sales price?

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

4. How can I most successfully transfer my patients to

the new dentist?

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

6. How can I be certain my Broker will demonstrate

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

7. What are the tax and legal ramifications when a

dental practice is sold?

QUESTIONS MOST OFTEN ASKED BY BUYERS:

1. Can I afford to buy a dental practice?

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

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

4. What kinds of assets will help me qualify

for financing the purchase of a practice?

5. Is it possible to purchase a practice

without a personal cash investment?

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

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

%S
5IPNBT
%S
%FOOJT


.BEEPY 8BHOFS )PPWFS
-*$
 -*$
 -*$



 

 

 

 

 

 

 

 

 



:FBST
JO
#VTJOFTT 
:FBST
JO
#VTJOFTT 
:FBST
JO
#VTJOFTT 
:FBST
JO
#VTJOFTT 
:FBST
JO
#VTJOFTT 
:FBST
JO
#VTJOFTT 
:FBST
JO
#VTJOFTT 
:FBST
JO
#VTJOFTT 
:FBST
JO
#VTJOFTT 
:FBST
JO
#VTJOFTT
PRACTICE SALES PARTNERSHIPS MERGERS VALUATIONS/APPRAISALS ASSOCIATESHIPS CONTINUING EDUCATION
NORTHERN CALIFORNIA
ALAMEDA: 2IILFHZHTXLS2SVUG
SOXPEHGLQDSSUR[VTIWEHORZ
PDUNHWUHQWDGMXVWHGQHWRQ
*52ZQHUUHWLULQJ&$
BERKELEY:VTIW2SV'HQWUL[
6RIWZDUH'LJLWDO;5D\/DVHU*5
DGMXVWHGQHWIHH
IRUVHUYLFH&$ 6$&5$0(172: New Listing! 2SRIILFH
%5(17:22': New Listing! VTIW
2SV'HQWUL['LJLWDO;UD\3DQR,QWUD
2UDO&DPHUD(QGR2UDO6XUJHU\ LPSODQWV
UHIHUUHGRXW*5.&$
CASTRO VALLEY: VTIWRIILFHZ
2SV*5(DJOHVRIW306
'LJLWDO;5D\)LEHU2SWLFV /DVHU2ZQHU
UHWLULQJ&$
&+,&2: New Listing! 2SV'LJLWDO
'HQWUL[3DQR3UDFWLFHKDVEHHQHVWDEOLVKHG
\HDUVZLWKORQJWHUPRZQHUVGD\V
+\JZN*5.&$
CONTRA COSTA COUNTY:2S(QGR
RIFHZ'LJLWDO;UD\0LFURVFRSHVDQG
3%6(QGRLQDSSUR[VTIW*5
.&$
EL DORADO COUNTY: VTIWZ
2SVLQWUDRUDOFDPHUDGLJLWDO[UD\3UDFWLFH
:RUNVVRIWZDUH*5.&$ ZKLJKHQG3HOWRQ &UDQH(TXLSPHQW
(/'25$'2&2817<: New Listing!
VTIW2SVZLWK3DQR(=
VRIWZDUH*5.RQGD\ZHHN
&$
GREATER EL DORADO HILLS:
VTIWRIFH2SV'LJLWDO3DQ'LJLWDO
6HQVRUV(DJOHVRIWVRIWZDUH*5.
&$
GREATER SACRAMENTO:
VTIW3URVWKRGRQWLFRIILFH2SV
)LEHU2SWLF(DJOHVRIWVRIWZDUH*5
.RQGD\ZHHN&$
*5($7(56$6&5$0(172: New
Listing! VTIW2SV,QWUD2UDO
'LJLWDO;5D\(DV\'HQWDOVRIWZDUH
3UDFWLFHHVWDEOLVKHG\HDUV.
&$
MARIN COUNTY:VTIW
RSHUDWRULHV)HHIRUVHUYLFH*5.
RQSDFHIRUVDPHLQ&$
0,/3,7$6: New Listing! VTIW
2SV,QWUD2UDO&DPHUD3DQR.RGDNGLJLWDO
[UD\V*5DGMQHW
GD\VRIK\JLHQH&$
0719,(::VTIW2SV
HTXLSSHG'HQWUL[6RIWZDUH'H[LV'LJLWDO
;5D\/DVHU,2&DPHUD*5
GD\VZHHN&$
OAKLAND:RSVLQVTIWPRGHUQ
RIFH*5RIZLWK332+02
DQG))6SDWLHQWV&$
2$./$1': New Listing! *5.
RQGD\ZRUNZHHN$SSUR[VTIW
2SV'H[LV'LJLWDO;5D\&DUHVWUHDP306
2ZQHUUHWLULQJ&$

1.800.519.3458

%S
3VTTFMM
+JN


0LJIBSB &OHFM
-*$
 -*$

SACRAMENTO:  VT IW RIILFH Z
(TXLS 2SV  DGGO 3OXPEHG 'HQWDO0DWH
VRIWZDUH*5&$
6$&5$0(172: New Listing! VT
IW2SVLQWUDRUDOGLJLWDO[UD\2SHQ
'HQWDOVRIWZDUH+02SUDFWLFH*5
.ORZRYHUKHDG&$
LQSURIHVVLRQDOEXLOGLQJGHVLUDEOHORFDWLRQ
(DJOHVRIWVRIWZDUH$YDJHRIHTXLSPHQW
\HDUV6HOOHU5HWLULQJ&$
SAN FRANCISCO: )LQDQFLDO'LVWULFWRIFH
2SVURRPIRUWKVTIW*5
PLO$GM1HW&$
SAN FRANCISCO: 3HULRGRQWDO3UDFWLFH 
&RQGR8QLWVTIWZ2S*5
.Z.$GM1HW&$
SAN JOSE: CANT RENEW LEASE! 
*5.RQGD\ZHHN(TXLSSHGRSV
DGGO3OXPEHG6T)W(='HQWDO
'H[LVOPEDVHG3DQRUDPLF&$
Some equipment also for sale!
6$1-26()$&,/,7<:IXOO\HTXLSSHG
2SVVTIW3DQR'LJLWDO6FDQQHU
'LJLWDO6HQVRU'HQWUL[306VRIWZDUH
+RXVHGGHQWDOSUDFWLFH\HDUV&$
SAN RAMON-FACILITY: 2SIDFLOLW\
'LJLWDO;5D\'LJLWDO3DQ,2&DPHUDV
VTIWFRUQHUVXLWH&$
SANTA ROSA: *HQHUDO'HQWLVWU\ 
%XLOGLQJ2SV*5.Z$GM
1HW.&$
STOCKTON: 2SVVTIWJUHDW
OHDVHDQGRSWLRQVWRUHQHZ*5
ZLWK332+02DQG))6SDWLHQWV&$
9$&$9,//(: New Listing! VTIW
2SVLQWUDRUDOFDPHUD*HQGH[GLJLWDO[
UD\3DQR/DVHU'HQWUL[VRIWZDUH
*5GD\ZHHN&$ &DOOIRUPRUHLQIRUPDWLRQ
CENTRAL CALIFORNIA
FRESNO: *UHDWVWDUWXSRUVDWHOOLWHRIFH
2SVVTIWJUHDWOHDVH*5
DQGSULFHGWRVHOO&$ ZRUNZHHN*5.&$
MODESTO: New Listing! *5
DGMQHWVTIW
2SVGLJLWDO[UD\V3DQR'HQWUL[6RIWZDUH
2ZQHUUHWLULQJ&$
MODESTO: VTIWRSV6FKLFN
'LJLWDO;UD\V&HUHF3DQRJUDSKLF;
5D\(DJOHVRIW*5.2ZQHU
UHWLULQJ&$
MODESTO: 'HQWDO$LU6SDFH&RQGRPLQLXP
VTIWGHQWDOFRQGRXQLW6DOHSULFH
&$
SOUTHERN CALIFORNIA
ALISO VIEJO: 7XUQNH\/HDVHKROGV
6DOH2SV(TXLSSHG5HWDLO3OD]D
*UHDW6LJQDJHPRYHLQUHDG\,QFOXGHV
FRPSXWHUV[UD\V LQVWUXPHQWV&$
www.henryscheinppt.com
DENTAL PRACTICE BROKERAGE
Making your transition a reality.
,FSSJ

(JOB
+BDJ


.D$VMMPVHI .JMMFS )BSEJTPO
-*$
 -*$
 -*$

%$.(56),(/': New Listing! 2SV
(VW\HDUV'HQWUL['LJLWDO;UD\V
$YJ(TXLS$JHLVa\HDUVROG*5
.6HOOHUUHWLULQJ&$
%(//:2SV'HQWUL['LJLWDOLQDIUHH
VWDQGLQJEXLOGLQJ332'HQWL&DO*5
.ZLWK.$GM1HW&$
BEVERLY HILLS:2SV(DJOH6RIW
'LJLWDO&(5(&/RQJWHUPVWDIIQHZHU
HTXLSPHQW*50&$
BURBANK:*HQHUDO3URVWK,PSODQW
SUDFWLFH\HDUVRIJRRGZLOOUHWDLOFHQWHU
2SVHTXLSSHG(DV\'HQWDO'LJLWDO
*5..$GM1HW&$
CARSON:2SV3DSHUOHVV(DJOH6RIW
'LJLWDO3DQR$OO(TXLS\UVROG
*5.&$
&(175$/25$1*(&2817<2SV
3DSHUOHVVGLJLWDOEXV\UHWDLOFHQWHU
*5RI.ZLWK.$GM1HW&$
&2$67$/25$1*(&2817<2SV
(TXLSSHG'HQWUL['LJLWDODQGDOOKLJK
HQGHTXLSPHQWWKDWLVOHVVWKDQ\HDUV
ROG(VW\HDUV&$
ENCINO: 2SV(VW\HDUV(DJOH6RIW
'LJLWDOLQWUDRUDOFDPHUD*5RI
.DQG.$GMXVWHG1HW&$
FULLERTON: 2SV(TXLSSHG\HDUV
RI*RRGZLOO'HQWUL['LJLWDO3DSHUOHVV
*UHDWORFDWLRQ*5RI.&$
GREATER LOS ANGELES: 3HULR
3UDFWLFH2SV<UVRI*RRGZLOO'HQWUL[
'LJLWDO/DVHU*UHDW5HIHUUDO%DVH*5
.$GM1HW.&$
+817,1*721%($&+: 2SVGD\VRI
K\JLHQHZN'HQWUL[GLJLWDO[UD\VLQWUDRUDO
FDPHUD*5RI.&$
/26$/$0,726: 8SFRPLQJ/LVWLQJ!
INLAND EMPIRE: 2SV'HQWUL['LJLWDO
3DQR\UVJRRGZLOOGD\VRI+\JLHQH
&$
LONG BEACH: 2SV(TXLSSHG(VW
IRU\HDUVVTIWGLJLWDO*5
.&$
1257+($6725$1*(&2817<:
New Listing! 2SVDIIOXHQWDUHD(VWRYHU
\HDUVGD\VRIK\JLHQHZN*5RI
.ZLWK.$GM1HW&$
LOS ANGELES: 2SV\HDUVRI
*RRGZLOO3DQR'LJLWDO/DVHU*5
.DQG$GM1HWRI.RQGD\VZN
&$
NEWPORT BEACH: 2SV(TXLSSHG
(DJOH6RIW'LJLWDO3DSHUOHVV3DQR,QWUD
2UDO&DPHUD*5.&$
1257+($6725$1*(&2817<:
New Listing! 2SVDIIOXHQWDUHD(VWRYHU
\HDUVGD\VRIK\JLHQHZN*5RI
.ZLWK.$GM1HW&$
ORANGE COUNTY: (QGRSUDFWLFHZLWK
2SV'LJLWDODQG3DSHUOHVV\HDUROG
HTXLSPHQW6WURQJUHIHUUDOEDVHIRU\HDUV
&$

37B2FWREHU
4UFWF

5IJOI


$BVEJMM 5SBO
-*$
 -*$

25$1*(&2817<: FKDLU2UWKR
SUDFWLFH2SV&RQVXOWURRP3DSHUOHVV
'LJLWDO3DQ&HSK*5RI.DQG
.$GM1HW&$
2;1$5': New Listing! 2SV3DSHUOHVV
'HQWUL['H[LV'LJLWDO[UD\VGD\VRI
+\JLHQHSHUZHHN6HOOHUUHWLULQJ)DYRUDEOH
OHDVH*5RI.&$
3$/0'(6(57: New Listing! 2SV
HTXLSSHGKLJKHQGEXLOGRXWZLWK'HQWUL[
'LJLWDO3DQR/DVHUV*500
&$
PALM SPRINGS: 2SV \HDUVRI
JRRGZLOO*RRGORFDWLRQ'RFWRUZDQWVWR
UHPDLQDQGZRUNSDUWWLPHLISRVVLEOH
*5.&$
6$1%(51$5',12: New Listing! )DFLOLW\
2QO\1R3DWLHQWVLQFOXGHVHTXLSPHQW
%HDXWLIXO2SRIILFHQLFHO\GHFRUDWHGVDPH
ORFDWLRQ\HDUV6HOOLQJDVLV&$
SANTA BARBARA: 2SVHVWIRU
\HDUVGD\V+\JLHQHZHHNORQJWHUPVWDII
))6*5RI.&$
9$/(1&,$: 7ZR8SFRPLQJListingV! &DOO
IRUPRUHLQIRUPDWLRQ
:(67(516$1)(51$1'29$//(<:
New Listing! 3HGR3UDFWLFHLQXSVFDOH
ORFDWLRQ2SV(DJOH6RIW,QWUD2UDO
&DPHUD3DQR\HDUV*RRGZLOO&$
SAN DIEGO
LA JOLLA:2SV))6DQG'HOWD3UHPLHU
*5RI.2ZQHUUHWLULQJ&$
NORTH COUNTY, SAN DIEGO:
2SV\HDUV*RRGZLOO332VRPH+02
*5RI.ORZRYHUKHDG&$
NORTH COUNTY, INLAND:
2SV'LJLWDO;5D\V(DJOH6RIW([FHOOHQW
/RFDWLRQ%ULJKWDQG0RGHUQ)DFLOLW\
*5RI.&$
SAN DIEGO: +LJKJURVVLQJSUDFWLFH
\HDUVRI*RRGZLOO6KRSSLQJFHQWHUORFDWLRQ
&$
6$1',(*2: New Listing! 2SV
(DJOH6RIW'LJLWDO3DSHUOHVV/DVHUGD\
SAN DIEGO: 0RGHUQ5HVWRUDWLYH,PSODQW
6WDWHRIWKHDUW'LJLWDOL&$7/DE2SV
6SHFLDOW\5RRPV+LJKJURVVLQJ&$
OUT OF CALIFORNIA
CENTRAL OAHU, HAWAII: 2SVLQ
&HQWUDO2DKX'HQWUL['H[LV3DQR
*5.+,
HONOLULU, HAWAII: 2SV
(TXLSSHG'HQWUL['LJLWDO&(5(&%OXH
&DP(VW\HDUV*5
.+,
+212/8/8+$:$,,: New Listing! 
2SV3OXPEHG(TXLSSHG332))6
'HQWUL[([FHOOHQW/RFDWLRQDQG9LVLELOLW\
(VWDEOLVKHGIRU\HDUV+,
MAUI, HAWAII: 2SV(TXLSSHG
0RGHUQ'HVLJQ&(5(&*5
00+,
1.888.685.8100
 Regulatory Compliance C D A J O U R N A L , V O L 4 5 , N 3

Guide to Dental Practice Act Compliance

CDA Practice Support Sta

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

by following these three actions:

M A R C H 2 0 1 7 151
 M A RC H 2 017 R E G U L ATO RY C O M P L I A N C E
Identify specific groups who
qualify for the discount or
any other terms, conditions
or restrictions for qualifying
for the discount.
(CCR 16 Section 1051)
Corporation Name
Business and Profession
Code Section 1804 states that:
Notwithstanding subdivision (i) of
Section 1680 and subdivision (g) of
Section 1701, the name of a dental
corporation and any name or names
under which it may be rendering
professional services shall contain
and be restricted (emphasis added)
to the name or the last name of one
or more of the present, prospective or
former shareholders and shall include
the words dental corporation or
wording or abbreviations denoting
corporate existence, unless otherwise
authorized by a valid permit issued
pursuant to Section 1701.5.
Dental Materials Fact Sheet
A dentist is required to provide
a Dental Board-approved dental
materials fact sheet to new patients
and at least once to a patient before
performing a restorative procedure.
The dentist should obtain patients
acknowledgement of receipt of the fact
sheet and place the acknowledgement
in the patient record.
The current fact sheet is dated
2004. The fact sheet may not be
altered but dentists may provide
patients with supplemental information
(B&P 1648.10-1648.20).
Electronic Records
The safety and integrity of all
patient records, including both hard
copies and electronic files, must be
152M A R C H 2 01 7
ensured. If electronic record-keeping
systems only are utilized in the
dental office, the office must use an
offsite backup storage system, an
image mechanism that is able to copy
signature documents and a mechanism
to ensure that record is unalterable
once it is input. The electronic health
record system also must automatically
record and preserve any change or
deletion of electronically stored
health information and requires
the record to include, among other
things, the identity of the person who
accessed and changed the information
and the change that was made to
the information. The dentist must
develop and implement policies and
procedures to include safeguards for
confidentiality and unauthorized
access to electronically stored records,
authentication by electronic signature
keys and systems maintenance. Original
hard copies of patient records may be
destroyed once the record has been
electronically stored. The printout
of the computerized version shall
be considered the original (H&S
123149 and Civil Code 56.101).
Place of Practice
A licensed dentist is required to
register his or her place or places of
practice or if he or she has no place
of practice. Such registration must be
done within 30 days of obtaining his or
her license (B&P 1650 and 1655). A
dentist must register any new place of
practice within 30 days (B&P 1651).
Prior to opening an additional
place of practice, a licensee or
dental corporation must apply and
receive permission from the Dental
Board for the additional place of
practice. This additional office permit
requirement applies to a licensee who
C D A J O U R N A L , V O L 4 5 , N 3
has proprietary interest or right to
management or control in the practice.
This requirement does not apply to
licensees who practice dentistry outside
of his or her registered place of practice
in specified settings, such as licensed
health facilities, schools and the homes
of nonambulatory patients (B&P 1658,
CCR 16 Sections 1045 and 1057).
A licensee who transfers an
additional office to another licensee
must notify the Dental Board
within 30 days of the transfer
(CCR 16 Section 1048).
A dentist maintaining more than
one office in this state must assume
legal responsibility and liability for the
dental services rendered in each office
and ensure each office complies with
supervisory requirements and posts in
an area likely to be seen by all patients
a sign with the dentists name, mailing
address, telephone number and dental
license number (B&P 1658.1).
Regulatory Compliance appears
monthly and features resources about laws
that impact dental practices. Visit cda.org/
practicesupport for more than 600 practice
support resources, including practice
management, employment practices, dental
benefits plans and regulatory compliance.
 Specialists in the Sale and Appraisal of Dental Practices
Serving California Dentists since 1966 Practices
How much is your practice worth?? Wanted
Selling or Buying, Call PPS today!

NORTHERN CALIFORNIA SOUTHERN CALIFORNIA

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

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

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

SOLDSuccessor should open 4th day.

6105 MODESTO Collected $430,000+ on 3-day week. 3-days of
Hygiene. 5-ops. Central location.
6103 SAN FRANCISCOS UNION SQUARE Opportunity to
S O L D
acquire highly regarded practice with condo. Beautiful 5-ops, digital
and paperless. 6th op available. 2015 collected $658,000.
6098 WEST PETALUMA THE business center of the North Bay!
Business parks are growing and young families are drawn to this
great family community per the unique amenities of this historic river
city. Collected $468,000 with Profits of $212,500. 4-days of Hygiene.
6089 MOUNT SHASTA Small town living renowned for outdoor
lifestyle. 3-day week collected $950,000. Very strong bottom line.
Digital including Pano. Full Price $350,000.
$250,000. Full Price $195,000.
TUSTIN Dental building. Full Price $1.5 Million.
VENTURA - OXNARD 5-ops. Grossing $850,000. High identity. Full
Price $685,000.
YUCCA VALLEY 8/10th of an acre. Great highway visibility. Full
Price $250,000.
Seeking Senior Dentists wishing to have more time to enjoy life, be free
of management & overhead to join a Dental Cooperative. Call Tom
Fitterer at 714-832-0230 or cell 714-345-9659.
**FOUNDERS OF PRACTICE SALES**
120+ years of combined expertise and experience!
3,000+ Sales - - 10,000+ Appraisals
**CONFIDENTIAL**
PPS Representatives do not give our business name when returning your calls.
 BAY AREA
Largest AC-566 SAN FRANCISCO: Spectacular views of
Washington Square. 3ops +2 addl, 1400 sf $225k
Broker in AC-578 SAN FRANCISCO Patient Charts: near Un-
ion Sq., 7 Doctor pts/day and 8 Hygiene pts/day
$190k
Northern AC-624 SAN FRANCISCO: Wonderful Patients,
solid income in great stand-alone bldg. $475k
AC-640 SAN FRANCISCO: On 23rd Floor of Prestig-
ious SF Bldg, 2ops in 700sf. Seasoned Staff, Seller
California Retiring $175k
AC-649 SAN FRANCISCO Facility Only: Richmond
District, 3 ops+1 addl, Equipment less than 5yrs
old $155k
AG-564 SAN FRANCISCO: 25 + yrs goodwill. Large
Extensive Buyer 5600+ sf w/ 9 ops near Lands End $2.225M
AG-645 SAN FRANCISCO: Low Overhead, compact
practice ready for expansion or relocation. Retail/
Database & Commercial area. 2nd Floor $125k
AG-648 SAN FRANCISCO: Newly Built Dental Space
Unsurpassed now Available for Rent! Call for Details!
AN-514 SAN FRANCISCO Facility: Located in the bus-
tling financial district! 1007 sf w/4 ops Only $75k
Exposure allows AN-565 SAN FRANCISCO: Remarkable opportunity
2067 sf w/ 6 ops $1.05M
us to offer you AN-592 SAN FRANCISCO: Easy accessibility, visibility
& free parking! 1000sf w/ 2 ops + 1 addl $100k
AN-513 REDWOOD CITY: The prac ce of your
dreams! 900 sf w/ 4 ops + 2 addl $375k
AN-642 SAN BRUNO: Dont miss this one! FFS, 5 ops
1950 sf $740k (Real Estate $1.2M)
BC-432 PITTSBURG: Family-oriented Practice! 1640
sf w/ 6 ops. Seller retiring. $350k
BC-520 HAYWARD Facility: Located in Downtown,
1500 sf, 4 equipped ops, X-Rays in 3 ops. $65k
BC-646 ORINDA: Well-established, family-oriented
Prac ce, Word-of-Mouth Refs, 4ops in 1080sf.
$825k
BN-504 RICHMOND: Established Practice & Real
Estate! 1450 sf w/ 2 ops + 2 addl $100k /RE
$700k
CC-567 ST. HELENA: Live & Practice in beautiful Wine
Country, 5 ops 1842 sf single-story bldg $790k
CC-599 SANTA ROSA: Stable pts base, Well-
respected Practice, 3 ops in 1040 sf $250k
CC-611 S. MARIN CO: Desirable, well-established
neighborhood, 20npts/mo 3ops, 1100 sf $650k
800.641.4179
BAY AREA CONTINUED
CC-632 SAN RAFAEL: Small town life, vibrant-growing
city, 6-8 pts/day, 3ops in 800sf office in beautiful
bldg $165k
CC-661 SAN RAFAEL: Starter Practice in beautiful
location w/ like-new Equipment hardly used, 3 ops,
900sf $250k
CG-616 NAPA: State of the Art Practice - Seller mov-
ing out of state! Call for Details!
DC-480 SILICON VALLEY: Multi-Specialty Practice,
14+ops in 7500 sf, Owner Financing avail-Terms
$1.075M
DC-604 LIVERMORE Facility: Turn Key Facility, fast
growing city, 3ops +3 addl plumbed in 2380 sf mod-
ern office $110k
DC-623 MENLO PARK: LOTS of room for GROWTH w/
close proximity to Facebook, Stanford, Google &
Telsa $380k
DN-497 PLEASANTON Facility: Great Location! 870 sf
w/ 3 ops + 1 addl. Owner Financing w/10% Down!
$95k
DN-631 CAMPBELL: Rare Opportunity! 1100 sf w/
3 ops, busy retail shopping center $249k
DG-519 SANTA CLARA Facility: Move In Ready! 2240
sf w 6 fully equipped ops $225k
DG-530 SAN JOSE: Dentrix JUST Installed! Highly
respected prac ce! 2015 collec ons $1M+ $795k
DG-635 CASTRO VALLEY: Excellent Loca on & Stellar
Reputa on! Solo Group Prac ce $690k
DG-643 SAN JOSE: Seller Mo vated! 3,300 sf w/ 4
ops + 2 addl available! Call for Details! Only $65k
DG-581 SAN JOSE: Must See to Appreciate! Gor-
geous Prac ce, stable pa ent base & loyal sta
$496k
DG-619 SAN JOSE: One of the most unique prac c-
es you will ever see! 1450 sf w/ 5 ops $1.1M
DG-620 SAN JOSE: Loca on, Stable Educated Pa-
ent Base, Spacious 2100 sf 3 op oce! $290k
DG-657 SARATOGA: Once in a Life me Opportuni-
ty! 1750sf 6 ops. Steadily increasing annual collec-
ons! $1.05M
DN-647 SANTA CRUZ: Family-Oriented with low
overhead! 850 sf w/3 ops $210k
NORTHERN CALIFORNIA
EC-525 SACRAMENTO: Great Location! Excellent
Visibility! 1500 sf w/ 3ops, 10-15 new pts/mo. Mo -
vated Seller $195k
WPS@SUCCEED.NET
Timothy Giroux, DDS Jon B. Noble, MBA Mona Chang, DDS
NORTHERN CALIFORNIA CONTINUED
EC-531 GREATER SACRAMENTO: Prac ce & Real Estate 1750 sf w/ 4ops +
1 addl, 8npts/mo $800k
EN-464 ROCKLIN Facility: Dont miss out on this remarkable opportunity!
2150 sf w/ 4 ops $100k
EG-638 CITRUS HEIGHTS: Focus on Crown & Bridge. 1,680 sf w/ 2 ops.
Plumbed for 1 addl & Room to expand. (Real Estate also Available) CALL
for DETAILS!
EG-639 CITRUS HEIGHTS: Real Estate for Sale Call for Details!
EN-625 SACRAMENTO: Looking for a HMO prac ce in a great Loca on?
2,500 sf w/5 ops $450k
EN-626 CARMICHAEL: Lifestyle you just cant be beat! HMO 1,250 sf w/ 3
ops $350k
EN-628 ORANGEVALE: Great place to work, play & live. HMO 1,310 sf w/ 4
ops + 1 addl $3375k
EN-627 CARMICHAEL: Remarkable HMO opp. awaits your talent & skill!
1,200 sf w/3 ops + 1 addl $268k
EN-634 ROSEVILLE: Beau fully designed, well-appointed and fully digital!
2352 sf w/4 ops + 2 addl $235k
EN-660 ROSEVILLE: Highly-esteemed, well-respected, fee-for-service prac-
ce w/ loyal pa ent base. 2,950 sf w/ 5 ops $995k
EN-654 CITRUS HEIGHTS: Well-Established, & loaded with 30+ years of
goodwill! 1300 sf, 3 ops + 2 addl. $150k
EN-651 SACRAMENTO: Well-known for delivery excellent & compassionate
care. 1750 sf, w/ 4 ops. $150k
FC-489 CLEARLAKE: Great lifestyle. 2015 Gross $915k on 3 day week,
4ops. Real Estate 3600 sf shared, interest Pride Instute designed
oce $470k
FN-527 TRINITY COUNTY: Be the only dentist in town! Pride Ins tute de-
signed! 2350sf w/ 5 ops +1 addl. $250k
GC-472 ORLAND: Live & Practice in charming small town community. 1000 sf
w/ 2ops, Seller Retiring. $160k
GG-453 CHICO: 5000 sf w/ 7 ops Perfect for 1 or more dentists! $325k
GG-454 PARADISE: 2550 sf w/ 9 ops, 40 yrs goodwill! Amazing Opportunity!
$525k
GG-617 YUBA CITY: Rare Opportunity to purchase Dental Facility with
REAL ESTATE! $275k
GN-244 OROVILLE: Must See! Gorgeous, Spacious 2500 sf w/5 ops!
$315k
GN-399 REDDING: Loyal patient base & relaxed workweek schedule, 1440 sf
w/3 ops $150k
GN-546 CHICO AREA: Catering to fearful pa ents, oering quality seda on
den stry, 2600 sf w/ 4 ops $350K
GN-606 BUTTE COUNTY: Hesitate & youll miss out on this one-of-a-kind
opportunity! 1700 sf w/ 4 ops Reduced $125k
GN-641 YUBA CITY: Fantas c signage & visibility. Building available for pur-
chase! 2,400 sf w/ 5 ops $475k
GN-656 NO. TEHAMA CO: Great Loca on! Ideal place to work, live and raise
a family! 2,468 sf w/ 5 ops $275k
ASK THE BROKER CAN NOW BE FOUND AT WWW.WESTERNPRACTICESALES.COM
John M. Cahill, MBA Edmond P. Cahill, JD
NORTHERN CALIFORNIA CONTINUED
HN-213 ALTURAS: Well managed, consistent revenues! Collected ~$760 in
2016! 2200 sf w/ 3 ops + 1 addl. $195k
HN-280 NO EAST CA: Only Practice in Town 900 sf w/ 2 ops REDUCED! ONLY
$60k
HN-618 SIERRA FOOTHILLS: Seller Retiring! Much room for growth by in-
creasing office hours! 750 sf w/ 2 ops $95k
HN-633 AUBURN VICINTY: Loaded w/ warmth, charm & goodwill galore!
1,430 sf w/ 4 ops $525k
CENTRAL VALLEY
IC-468 SAN JOAQUIN VALLEY: High-End Restore Prac ce! 6 ops in 2500+ sf
oce. Call for Details! $425k
IN-569 MADERA: Stellar reputa on and load with goodwill! 2,900 sf w/ 7
ops $634k
JC-541 FRESNO Facility: 1210 sf & consists of 2 fully equipped ops &
plumbed for addl op Call for Details!
JN-551 COALINGA AREA: Serving community of working families! Paper-
less Prac ce. 1200 sf w/ 3 ops $395k
SPECIALTY PRACTICES
BC-600 CONCORD Ortho/Pedo Charts Only: Continue treatment to these
Ortho/Pedo patients Call for Details! $400k
BC-612 CONTRA COSTA COUNTY Ortho: Just of the I-80 commuter corri-
dor! Call for Details! Only $40k
CG-424 NAPA Prostho: Digital X-ray & NEW 3D Imaging Unit! On track to
collect just under $1m $690k
EG-637 CITRUS HEIGHTS (Prostho): 1,680 sf w/ 2 ops. Plumbed for 1 addl
& Room to expand. $390k (Real Estate Also Available)
FN-536 LAKE COUNTY Pedo: Focusing on Prevent dental problems before
they begin! 1750 sf w/ 3ops $225k
HG-644 NORTH AUBURN (Ortho): 1750 sf w 5 chairs in open bay! Call for
Details!
IC-543 CENTRAL VALLEY Ortho: 1650 sf w/ 5 chair bays & plumbed for 2
addl, Strong Refs & Satisfied Pts Base $125k
JC-540 FRESNO Sleep Apnea: Mo vated Seller re ring! Step right in &
make it yours! Call for Details!
 Tech Trends
A look into the latest dental and
general technology on the market
CDC DentalCheck (Centers for Disease Control and
Prevention, Free)
Dental health care facilities must perform routine audits of
infection prevention compliance and keep detailed records of
these reviews on site. This responsibility typically is assigned to
a qualied team member who coordinates policies, procedures,
education and training for continuous improvement to maintain
compliance with Centers for Disease Control and Prevention (CDC)
recommendations and ensure quality control. This task may be
dicult to organize, as there are many elements to assess, both
administratively and in the clinical practice setting. DentalCheck
from the CDC is a tool that dental practices can use to automate
this monitoring process and keep records to assure compliance with
CDC recommendations as contained in the Guidelines for Infection
Control in Dental Health Care Settings.
To begin a routine audit from the home screen, users simply start
a new checklist, which contains a series of elemental questions
categorized by Policies and Practices, followed by Direct
Observation of Personnel and Patient-Care Practices. For each
subcategory, users assess elements, or statements in the CDC
recommendations in their dental health care facility, and answer
Yes, No or N/A. An area to input notes or areas of improvement is
provided for each element. Once users complete the entire checklist
series of assessment questions, the audit is complete and recorded
in the app. The entire history of assessments can be accessed from
the home screen, where users can edit, preview, email or delete
individual checklists. Additional resources from the CDC regarding
infection control can be directly opened from the home screen.
Having a safe health care and working environment is vital to any
dental care setting. Members of the dental team responsible for
compliance in their own facilities need every tool at their ngertips
to organize and keep track of these reviews. DentalCheck enables
these team members to easily monitor and maintain records to
ensure that their facilities are doing their best to maintain safety for
patients and sta.
Hubert Chan, DDS
156M A R C H 2 01 7
C D A J O U R N A L , V O L 4 5 , N 3
Epson Home Cinema 3100 Projector
(Epson, $1,299)
The Home Cinema 3100 Full HD 1080p 3LCD projector is a new
addition to Epsons line-up of projectors geared toward the home
theater enthusiast. Boasting optimized brightness and contrast,
this projector features 2,600 lumens of both color brightness
and white brightness, as well as up to a 60,000:1 dynamic
contrast ratio providing rich detail during dark scenes. What that
translates to is an incredibly bright, crisp and detailed image,
eliminating the need for blackout viewing conditions.
The 3LCD, 3-chip technology provides 3-D in full 1080p high
denition and the projector is capable of projecting a 110
image from only 10.5 away. The ability to position both the
mounting of the projector as well as the projected image on the
screen is made much easier given both vertical and horizontal
lens shift, plus a 1.6x zoom lens. The 3100 provides dual HDMI
inputs, with one oering MHL to allow for the direct-streaming of
movies, games and more from MHL-enabled devices (such as a
Roku Streaming Stick.) As for lamp life, Epson touts up to 3,500
hours in normal mode and up to 5,000 hours in ECO mode.
The unit itself is solidly built (weighing in at nearly 15 pounds),
and the default image was impressive right out of the box.
While calibration is always recommended, and it takes quite a
bit of ne-tuning to dial in the projected image to just the right
proportions (given the many adjustable settings that are included
with this projector), the end result is an image that looks fantastic.
However, the projector does not have a 12v screen trigger port
(for the automatic triggering of the screen rolling up or down
based on projector turning on or o ), but thats easily remedied
by an add-on wireless unit for your screen.
Blaine Wasylkiw, CDA director of online services
Would you like to write about technology?
Dentists interested in contributing to this section should contact
Andrea LaMattina, CDE, at andrea.lamattina@cda.org.
 Dr. Bob
Snakes: The Stu of
Nightmaresssssss
As every Boy Scout worthy of
his Tenderfoot badge soon
learns, snakes present such
a life-threatening hazard
that an entire section in the
BSA Handbook is devoted
to coping with anticipated
encounters with them.
Robert E.
Horseman,
DDS
ILLUSTRATION
BY VAL B . MINA
The following Dr. Bob column was
originally printed in the April 2006 issue of
the Journal.
C
all me prejudiced. Call
me paranoid, biased
and ignorant if you like,
especially if you are larger
than I am, but the fact
of the matter is, I dont like snakes. This
reptilian anathema goes back to the early
days of my Boy Scout career. Prior to my
induction into the BSA, I considered
snakes to be just overachieving worms,
just as a rat was a buff mouse. But as every
Boy Scout worthy of his Tenderfoot badge
soon learns, snakes present such a life-
threatening hazard that an entire section
in the BSA Handbook is devoted to coping
with anticipated encounters with them.
Our motto Be Prepared was not a
hollow challenge. We had our tourniquet
(neckerchief) and our Boy Scout knife
(precursor of the Swiss Army knife)
C D A J O U R N A L , V O L 4 5 , N 3
with its leather punch for punching
leather and its main blade, so dull from
playing mumbly peg and carving trees
that it couldnt slice margarine. Armed
with this snakebite armamentarium, our
instructions were clear: The moment
one of the 42 million species of snakes
bites you or a friend, apply the tourniquet
between the bite and the victims heart.
The handbook assumes the snake has had
the decency to not go for a midsection
or butt bite. Tighten until the extremity
turns indigo, then grasping the Scout
knife firmly, slice an X over each fang
puncture until the area hemorrhages freely.
Sometimes a sock stuffed into the
victims mouth helps reduce distractions.
The rescuer, assuming there is one and
the bitten person is experiencing syncope
by this time, places his mouth over
the puncture/slice wounds and sucks
out the snakes venom, being careful
not to swallow it. It is then discreetly
expectorated in a downwind fashion as
M A R C H 2 0 1 7 157
 M A R C H 2 0 17 DR. BOB
approved by the EPA. By this time, the
snake, not being of a poisonous variety
in the first place, has laughed itself
to death and is no longer a threat.
I understand this technique is
no longer in common use. Even
12-year-old boys not subject to the
civilizing influences of society found
this procedure disquieting, so it has
been supplanted with a more modern
treatment wherein the offending
snake is counseled and given a severe
reprimand. The victim may or may
not be covered by his HMO at the
discretion of his primary care provider.
Too late for me, however. My antipathy
toward snakes is too deeply rooted to be
influenced by herpetologists unconvincing
explanations of their gentleness and
general benefit to the ecology.
In my view, every snake is a flexible,
protein-based tube of neurotoxins. Its
one purpose in life is to propel itself
straight for my jugular where the
tourniquet/Scout knife technique is
not applicable. The fact that I have
not seen a snake for upward of 30 years
is no excuse to relax my vigilance.
All of which explains why I was
visibly shaken when my granddaughter
announced that if we expected her to
emerge from her high school biology class
with anything more than a C, it would
be expedient to purchase a snake for her
and a receptacle to contain it. What role
the snake would play in the furtherance
of her education was not clear, but its
procurement was not to be denied.
There are actually reptile stores, up-
scale boutiques where exotic vertebrates
are offered to reptilian aficionados at
equally exotic prices. My granddaughter
and I peered gingerly at a colorful
variety of snakes, lizards, chameleons
and turtles. The captive denizens stared
back, transfixed as if fashioned of stone.
Heres a nice corn snake, said not pals is that they are inarticulate.
158M A R C H 2 01 7
Forever vivid in my memory
is the vision of the unhinged
jaw, the slow, peristaltic
bulge moving tailward, the
mouses tail still signaling
fruitlessly as it disappears.
the ponytailed, eyebrow-pierced youth
serving us. The snake is about 18 inches
long, banded orange and white. I
conceded that it might be considered as
attractive as a four-alarm fire silhouetted
against an evening sky enthralling an
arsonist. Another snake of the opposite
gender might even offer a judgment
of Hubba, Hubba! The snake and I
maintained our distance and regarded
each other with mutual loathing.
My dislike for snakes is scientifically
based on the following factors: No. 1:
Locomotion. The verb slither had
to be coined for snakes. Should it ever
become necessary for you to inspect
the underside of a snake, even though
common sense dictates otherwise,
youll notice it has no legs or feet. If it
were human, it would be a quadriplegic
and could park in restricted zones.
In spite of this handicap, a really fast
snake on Full Red Alert has been
clocked at 8 mph. I realize this doesnt
seem too impressive compared to
the human he was chasing who was
hitting 52 mph on the straightaways.
The slithering is accomplished by one
of four methods: The Undulating Crawl or
Serpentine, the Caterpillar or Rectilinear,
the Sidewinder and the Concertina.
All four methods of locomotion are
unnatural, if not actually obscene, and I
dont want to talk about them anymore.
Reason No. 2 why snakes and I are
or night will deliver; 5551212.
C D A J O U R N A L , V O L 4 5 , N 3
They do not bark, moo, meow, chirp
or quack. Compared to a snake, a
mime is a regular chatterbox. You cant
call, Here, boy! Cmon lets go for
a slither. No. They hiss. They stare
at you with those slit eyes, flick that
forked tongue and they hiss. I cannot
be simpatico with anything that hisses
and slithers. Or scuttles. A forthright
animal worthy of trust does not scuttle.
Assuming that the snake, in order
to survive even one semester of biology,
must eat something, I questioned the Snake
Man about the dietary requirements of our
purchase. I figure a corn snake eats corn,
right? Wrong. Mice. He eats mice, he said.
Well, thats unfortunate, we
dont have any mice. Lets go, I
whispered to my granddaughter.
Not a problem, interrupted
the Snake Man. We have plenty of
mice right here. He indicated a cage
where dozens of tiny mice, hairless,
sightless and unsuspecting, stumbled
around in sweet rodent innocence.
Out of respect for your sensibilities,
I will spare you the gruesome details,
but take my word, there is no sight
more hurtful to the human psyche
than witnessing a snake devouring
a live mouse. Forever vivid in my
memory is the vision of the unhinged
jaw, the slow, peristaltic bulge
moving tailward, the mouses tail still
signaling fruitlessly as it disappears.
Its the stuff of nightmares and the orgy
repeats every week as long as the snake
is our responsibility. We are petitioning
the guidance counselor for a transfer
to Early American Folk Dancing.
FREE TO GOOD HOME: Corn
snake, like new. Lo miles; ideal pet; loves
children and mice. Easily trained to slither
and hiss on command. Complete with
cage and subscription to Rodent Raising
for Fun and Profit. Call anytime, day
 Discover your talent. Get your skills polished. Earn C.E.
credits learning cutting-edge techniques
in hands-on workshops. See your talent,
tools, inspiration and community in a
new light at CDA Presents.

The Art
ThursdaySaturday Anaheim Register today and Science
May 46, 2017 Convention Center cdapresents.com of Dentistry
 BRIGHT
T SMILE T O G O

Part of the Opalescence family, Opalescence

Go prefilled, disposable trays are a professional
take-home whitening system. Offering a
prescription-strength formula at an affordable Before wearing
price, Opalescence Go whitening is easier to use UltraFit tray in
the mouth UltraFit tray after
than over-the-counter products, and its available just 10 minutes
in the mouth
in three concentrations and three delicious flavors.

800.552.5512
0.552
52.5512 | ultradent.com
om
2017 Ultradent
ennt Products,
Product Inc. All Rights Reserved.
served.