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August 2015
Seattle Care Pathway
Root Caries
Aging Periodontium
Apple Tree Dental



Part II

Susan Hyde, DDS, MPH,

PhD, FACD, and
Dick Gregory, DDS

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Aug. 2015

C D A J O U R N A L , V O L 4 3 , N 8


417 The Guest Editor/Collaborative Practice

Paving the Path to Success

419 Impressions
461 RM Matters/Accounting Controls Can Prevent
Dishonest Behavior

467 Regulatory Compliance/Marketing and

Advertising Rules

471 Periscope


476 Tech Trends

477 Dr. Bob/Aging Gracefully (and Other Indignities)

426 Dentistry for the Ages: Part II

An introduction to the issue.
Susan Hyde, DDS, MPH, PhD, FACD

429 The Seattle Care Pathway: Defining Dental Care for Older Adults
This article describes the evidence for, and the details of, the Seattle Care Pathway
to ensure older adults receive optimum dental care.
Iain A. Pretty, BDS, MSC, MPH, PhD, FDSRCS(ED)

439 Root Caries in Older Adults

Root caries is a major cause of tooth loss in older adults and the need for improved
preventive efforts and treatment strategies for this population is acute.
Dick Gregory, DDS, and Susan Hyde, DDS, MPH, PhD, FACD

447 Aging Periodontium, Aging Patient: Current Concepts

This paper presents the current state of knowledge and opinion on approaches to
periodontal diseases and periodontal treatment in the elderly with an emphasis on
consensus, conclusions and future directions for dental practitioners.
Mark Ryder, DMD

453 Apple Tree Dental: An Innovative Oral Health Solution

Apple Tree Dentals Community Collaborative Practice model illustrates a sustainable,
patient-centered approach to overcoming barriers to care across the lifespan.
Deborah Jacobi, RDH, MA, and Michael J. Helgeson, DDS

459 National Resources

A listing of websites on the oral health of older adults submitted by the authors of this issue.
Compiled by Susan Hyde, DDS, MPH, PhD, FACD

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C D A J O U R N A L , V O L 4 3 , N 8

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Volume 43, Number 8

August 2015


Journal of the California Dental Association (ISSN 1043-2256) is published monthly by the
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
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Copyright 2015 by the California Dental Association. All rights reserved.


C D A J O U R N A L , V O L 4 3 , N 8

Collaborative Practice Paving the Path to Success

Susan Hyde, DDS, MPH, PhD, FACD

any Native American

cultures teach that
caring for elders is a
blessing path in which
the whole community
should participate. Like many of us with
aging parents, I have provided a lot of
care to my parents, and oral health issues
always arose. My experiences dealing
with my fathers care-resistant behaviors
as he battled Alzheimers and difficulties
in obtaining dental treatment for my
stepmother, who was paralyzed and
unable to speak as the result of a stroke,
contributed greatly to my decision to
specialize in geriatric dentistry. Thanks
to the geriatric training I received,
when my mother moved into a longterm care facility, I immediately put her
on a three-month schedule for home
visits with a dental hygienist. Similarly,
when my father-in-laws face ballooned
because of multiple periapical abscesses,
I was able to raise the awareness of his
family, endocrinologist and orthopedic
surgeon that the needed dental treatment
wasnt elective but rather critical to the
resolution of his poor wound-healing
from a recent diabetic amputation. My
experiences are by no means unique.
Homebound and institutionalized older
adults lack access to dental care and
endure a great deal of untreated oral
disease, which affects their abilities to
eat and socialize, resulting in further
compromised overall health and function.1
Beginning with the Surgeon Generals
Report on Oral Health in America,
through 15 years of compelling research
publications and two seminal Institute of
Medicine reports on oral health, dentistry
has achieved national recognition
that oral health is necessary for overall
health. For the first time, access to

Inclusion of oral-systemic health data in risk

assessment and disease management plans
have resulted in improved collaboration and
referrals between dental-primary care providers.

dental care is one of the Leading Health

Indicators for Healthy People 2020.2
Additionally, oral health disparities in
older adults are now recognized to extend
beyond edentulism, as reflected by the
new Healthy People 2020 objectives
to reduce untreated coronal and root
caries in older adults, and decrease
the prevalence of moderate or severe
periodontal disease.3 Therefore, primary
care providers must obtain training in oral
health screening and referral, consider
oral health in disease management and
collaborate with the dental community
to develop home-based programs
for older adults in order to achieve
patient-centered, value-based care.1
An article in the October 2014 issue
of the Journal of the California Dental
Association described the National
Interprofessional Initiative on Oral
Health (NIIOH), established in 2008 to
launch a new standard of care for patient
oral health.4 The initiative espoused
primary care providers becoming skilled
at addressing the oral health needs of
their patients and effectively referring
to dentists. The traditional head, ears,
eyes, nose and throat (HEENT) physical
assessment performed by primary care
providers excludes examination of the
oral cavity and omits consideration of
oral-systemic linkages to overall health.
Incorporating the oral cavity into a revised
HEENOT examination affirms that oral

health is an important population health

issue for primary care providers.5 New
York University has successfully integrated
HEENOT in the comprehensive history
and physical examinations for nursing
and medical student clinics and faculty
practices. Inclusion of oral-systemic
health data in risk assessment and disease
management plans have resulted in
improved collaboration and referrals
between dental-primary care providers.6
Dentists and dental hygienists also
need to participate in the cycle of
interprofessional collaborative practice.
Healthy People 2020 objectives promote
collaborative practice with two new oral
health goals for increasing the proportion
of adults who receive tobacco cessation
information and who are tested or referred
for glycemic control by a dentist or dental
hygienist.3 Although previous studies
indicated both dentists and patients are
receptive to screening and managing
medical conditions in the dental
setting,7,8,9 a survey of North Carolina
dentists expressed reservations for taking
a more active role in the management
of patients systemic conditions through
risk behavior counseling, referral for
laboratory testing or in-office diagnostic
screening for medical conditions.10

1. Ornstein KA, et al. Signicant unmet oral health

needs among the homebound elderly. J Am Geriatr Soc
A U G U S T 2 015 417

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C D A J O U R N A L , V O L 4 3 , N 8

Our archives
are your archives.
Our archive is online for your research. Access every issue
of the Journal from the past 16 years at

2. U.S. Department of Health and Human Services. Healthy

People 2020: Leading health indicators. 2010. www.
3. U.S. Department of Health and Human Services.
Healthy People 2020: Oral health objectives. 2010. www.
4. Garland T, Smith L, Fuccillo R. Addressing oral health needs
through interprofessional education and practice. J Calif Dent
Assoc 2014;42(10):701-9.
5. U.S. Department of Health and Human Services,
Health Resources and Services Administration. Integration
of oral health and primary care practice. 2014. www.
6. Haber J, et al. Putting the mouth back in the head: HEENT to
HEENOT. Am J Public Health 2015;105(3):437-41.
7. Greenberg BL, Glick M, Frantsve-Hawley J, Kantor ML.
Dentists attitudes toward chairside screening for medical
conditions. J Am Dent Assoc 2010;141(1):52-62.
8. Greenberg BL, Kantor ML, Jiang SS, Glick M. Patients
attitudes toward screening for medical conditions in a dental
setting. J Public Health Dent 2012;72(1):28-35.
9. Marshall S. Evidence from ElderSmile for diabetes and
hypertension screening in oral health programs. J Calif Dent
Assoc 2015;43(7).
10. Paquette DW, Bell KP, Phillips C, Oenbacher S, Wilder
RS. Dentists knowledge and opinions of oral-systemic disease
relationships: relevance to patient care and education. J Dent
Educ 2014;79(6):626-35.

Susan Hyde, DDS, MPH, PhD,

FACD, chairs the division of oral
epidemiology and dental public health
at the University of California, San
Francisco, School of Dentistry. She is the
dental director of UCSFs multidisciplinary
fellowship in geriatrics and faculty lead
for interprofessional ed ucation for the
School of Dentistry. Dr. Hyde received
her dental degree from UCSF, Master of
Public Health and doctorate of philosophy
(epidemiology) from the University of
California, Berkeley, and certificates in dental
public health and geriatrics from UCSF.

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C D A J O U R N A L , V O L 4 3 , N 8

Autonomy and Agency

David W. Chambers, EdM, MBA, PhD

The nub:
1. Respect for autonomy is
nice, but a bit paternalistic
because either party alone
can make that determination.
2. Dentists and adult patients
and nonpatients are agents,
with the capacity to aect
each other.
3. Morality requires that the
same moral status as agents
be accorded all concerned.

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 Journal of the American College of Dentists.

Yogi Berra had it right: If the people dont want to

come, nothing can stop them. They are autonomous,
in the literal sense of the term self-governing.
Dentistry is one of the professions that has made quite
a bit out of this principle. Patients get to choose
even if the choices are limited for their own good.
Bioethicists ground informed consent in the norm
of respect for autonomy. Sometimes informed consent is
mistaken for a legal process. Sometimes it means little
more than making certain patients have a generally
favorable idea what is going to happen to them.
Respect for autonomy is an ethical pillar in most professions.
It just makes sense that when the professional sets up the ground
rules, patients should be allowed the opportunity to opt out.
But this is only half the story. What if we looked at it
from the perspective of potential patients? It is plausible, if
a bit uncomfortable, for others to set their own conditions
on whether or how they will participate (or not) in health
care. This is a free choice and involves no necessary prejudice
against the professional, even if it means a hit to prestige,
income, lost time and a ding on the self-concept of serving
the public. Others show respect for autonomy by not
forcing conformity. Respect for autonomy loses some of
its nobility unless we accept that it works both ways.
Agency is a sturdier moral concept. Agents have the
capacity and responsibility to affect others by their actions.
Both dentists and patients are agents. Patients are agents
when they refuse radiographs, choose less-than-ideal
treatment to remain within the limits of their insurance
coverage or decide not to go to the dentist at all.
Each dentist choice affects both the patient and the
dentist; each patient choice affects both the dentist and the
patient. Dentists and patients are (potentially) reciprocal
moral agents. The challenge is to find a common way forward
that neither party would have any reason to change.
In the traditional approach to ethics, dentists consider
only what they understand to be in patients best interests
and claim the moral high ground by reluctantly allowing
them to elect less than ideal care. The dentists interests
have been screened off from consideration as not belonging
to the sphere of professional ethics. Not so, of course, for
patients who judge their own and the dentists advantage.
Morality requires more than one person deciding whether
he or she has done right by private standards. Professionals
justify their standards by roughly conforming to what their
colleagues are doing. Morality requires that agents recognize
the valid claim of other moral agents to affect them.
A U G U S T 2 015 419

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A U G . 2 0 15

C D A J O U R N A L , V O L 4 3 , N 8

Cigarettes Linked to Half of Oral Cancer Deaths

Oral Surgery and

Anticoagulant Therapy
Researchers recently assessed the
incidence of postoperative bleeding in
patients who were highly anticoagulated
and in patients who underwent extensive
oral surgical procedures and who continued
using oral anticoagulant therapy. Published
in The Journal of the American Dental
Association, the study found that, in
patients who are highly or therapeutically
anticoagulated, dental extractions as
well as more extensive oral surgical
procedures can be performed safely without
interruption or modification of the therapy.
According to a summary of the
research, the authors divided 125 patients
receiving anticoagulant therapy into
three groups. Group A consisted of 54
patients who were highly anticoagulated
(international normalized ratio (INR)
3.5) and who had three teeth extracted.
For Group B, the authors stated that
this group consisted of 60 patients with
INR 2.0 to less than 3.5 in whom higherrisk dentoalveolar surgery (extraction
of more than three teeth or other oral
surgery procedure involving raising
a mucoperiosteal flap, osteotomy or
biopsy) was performed. Lastly, Group
C consisted of 11 patients whose INR
values were 3.5 or higher and who
required higher-risk dentoalveolar
surgery, and 85 healthy participants who
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In 2011, there were more than 8,500 deaths in the U.S. from cancers
of the oral cavity and pharynx. A recent study, published in JAMA Internal
Medicine, estimated the number of deaths attributable to cigarette smoking
for 12 smoking-related cancers and found that, among U.S. adults 35 years
and older in 2011, almost half (47 percent) of the deaths caused by cancers
of the oral cavity and pharynx were attributable to cigarette smoking.
Additionally, in the multi-institution research letter, the authors report that
the overall number of deaths from 12 smoking-related cancers was nearly
346,000. Of those, 48.5 percent were attributable to cigarette smoking.
Specically, the researchers linked smoking with 80.2 percent of lung,
bronchus and trachea cancer deaths, as well as 76.6 percent of deaths from
cancer of the larynx. Secondhand smoke exposure, which was estimated by
the 2014 U.S. Surgeon Generals report to cause an additional 5 percent
of lung cancer deaths, was not included in the analysis.
In the research letter, the authors stated that 44.8
percent of bladder cancer deaths, 19.6 percent of
stomach cancer deaths and 22.2 percent of cervical
cancer deaths were linked to smoking.
For more details and specic
breakdowns within each category, see
the full report published online ahead
of print in the journal JAMA Internal
Medicine, June 15, 2015.

underwent surgical procedures similar

to those performed in Group A and
Group B made up the control group.
The authors reported that 3.7
percent of Group A, 5 percent of
Group B and 18.2 percent of Group C
experienced postoperative bleeding,
while a single bleeding event (1.2
percent) occurred in the control
group. They concluded that dental
extractions in patients who are highly
or therapeutically anticoagulated could

be performed safely without interruption

or modification of the therapy.
Tooth extractions and even more
extensive surgical procedures can
be performed safely in patients who
continue using anticoagulant therapy
if proper local hemostatic measures are
used and if no other coagulopathies
are present, the authors wrote.
For more, see the study in The Journal
of the American Dental Association, June
2015, vol. 146, issue 6, pp. 375381.

C D A J O U R N A L , V O L 4 3 , N 8

Nanostructures in Dentin Make Teeth Crack Resistant

A team of international researchers
recently analyzed the complex structure
of dentin and discovered that the mineral
particles are precompressed. The internal
stress works against crack propagation and
increases resistance of the biostructure.
According to the study, published in
the journal Nano Letters, the researchers
used in-situ stress experiments and
examined the local orientation of the
mineral nanoparticles. They discovered
that when the tiny collagen fibers
shrink, the attached mineral particles

become increasingly compressed.

Our group was able to use
changes in humidity to demonstrate
how stress appears in the minerall in the
collagen fibers, said Paul Zaslansky,
Dr. med. dent., PhD, a researcherr at
Charit Berlin, in the news release.
The compressed state helps to
prevents cracks from developing and
we found that compression takess place
in such a way that cracks cannot easily
reach the tooth inner parts, which
could damage the sensitive pulp.

Four Out of 10 Pregnant Women Not

Seeing Dentist During Pregnancy
While the importance of oral health during pregnancy
has been shown, a new survey out recently has found
that 42.5 percent of expecting mothers in the United
States arent visiting a dentist during their pregnancy.
According to a news release about a recent dental
insurance survey, visiting the dentist during pregnancy
is a crucial step and can help identify key health issues
appearing specically during pregnancy. Additionally,
the California Dental Association says improving oral
health during pregnancy can prevent complications
associated with dental diseases, may reduce preterm
and low birth weight deliveries and has the potential
to prevent early childhood cavities in infants.
It is important for women who are pregnant or
planning to become pregnant to visit a dentist for routine
examination, cleanings and guidance about specic
oral health issues that may occur during pregnancy.
For more information, see the June and September
2010 issues of the Journal, available at

The scientists also analyzed what

happens if the tight mineral-protein
link is destroyed by heating. They
found that, in that case, dentin in
teeth becomes much weaker.
We therefore believe that the
balance of stresses between the particles
and the protein is important for the
extended survival of teeth in the mouth,
said scientist Jean-Baptiste Forien.
According to the authors, their findings
may help explain why artificial tooth
replacements usually do not work as well
as healthy teeth do they are simply
too passive, lacking the mechanisms
found in the natural tooth structures, and
consequently fillings cannot sustain the
stresses in the mouth as well as teeth do.
Our results might inspire the
development of tougher ceramic
structures for tooth repair or
replacement, Zaslansky said.
For more information, see the study
published in the journal Nano Letters,
May 2015, vol. 15:6, pp. 3729-373.
Illustration shows complex biostructure of dentin: The
dental tubuli (yellow hollow cylinders, diameters appr.
1 micrometer) are surrounded by layers of mineralized
collagen bers (brown rods). The tiny mineral nanoparticles are embedded in the mesh of collagen bers and
not visible here. Image: JB Forien @ Charit
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C D A J O U R N A L , V O L 4 3 , N 8

Dental Implants in Osteoporotic Women

Families of Orofacial Clefting,

No Higher Risk for Dental
Children with oral clefts show
a wide range of dental anomalies,
adding complexity to understanding
the phenotypic spectrum of orofacial
clefting. In a recent study, researchers
characterized the spectrum of cleft-related
dental anomalies and evaluated whether
families with clefting have a significantly
higher risk for such anomalies compared
to the general population. They found
that families of orofacial clefting are
not at higher risk for dental anomalies.
Published in the Journal of Dental
Research, the study included 3,811
individuals 660 cases with clefts,
1,922 unaffected relatives and 1,229
controls. Researchers identified dental
anomalies from in-person dental exams
or intraoral photographs and case-control
differences were tested. This is the
largest international cohort to date of
children with nonsyndromic clefts, their
relatives and controls, according to a new
release. The authors report that cases had
higher rates of dental anomalies in the
maxillary arch than controls for primary
and permanent dentitions but not in the
mandible. They also reported finding
dental anomalies were more prevalent
in cleft lip with cleft palate than other
cleft types and that more anomalies
were seen on the same side of the cleft.
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With age, postmenopausal women with osteoporosis are at greater risk of losing
their teeth. In a new study, researchers from Case Western Reserve University School
of Dental Medicine suggest dental implants may provide postmenopausal women
with osteoporosis with the highest degree of satisfaction in their work and social lives.
This investigation was initiated to incorporate oral health into womens health
promotion and to examine psychosocial outcomes associated with dental implant
supported rehabilitation, the authors wrote.
In the study, researchers surveyed 237 osteoporotic women with one or more
adjacent teeth missing. The survey consisted of 23 questions rating their satisfaction
with replacement teeth and how it improved their lives at work and in social
situations specically in regards to the work, health, emotional and sexual
aspects of their lives. Of the 237 participants, 64 had implant retained prosthetic
restorations, 60 had traditional xed partial dentures, 47 had removable partial
denture and 66 had no restoration to restore missing teeth. No signicant
dierence in age exists between groups, according to the study.
The authors found that women with dental implants reported a higher overall
satisfaction with their lives, according to lead researcher Christine DeBaz, who
personally interviewed each participant. Fixed dentures scored next highest in
satisfaction, followed by false teeth and then women with no restoration work.
In order to make decisions about the most
appropriate treatment option in rehabilitation a dentist
must understand not only the prosthetic therapeutic
specics such as chewing function and orofacial esthetics
but also the patient-centered specics of psychosocial
and overall well-being, the authors wrote.
For more, see the study in the International Journal
of Dentistry, vol. 2015, article ID 451923, 6 pages.

Compared to controls, unaffected

siblings and parents showed a trend for
increased anomalies of the maxillary
permanent dentition. Yet, these
differences were nonsignificant after
multiple-testing correction, suggesting
genetic heterogeneity in some families
carrying susceptibility to both overt
clefts and dental anomalies.
Collectively, the findings suggest
that most affected families do not have

higher genetic risk for dental anomalies

than the general population and that
the higher prevalence of anomalies
in cases is primarily a physical
consequence of the cleft and surgical
interventions, the authors concluded.
For more information, see the study
titled Spectrum of Dental Phenotypes
in Nonsyndromic Orofacial Clefting,
published online first in the Journal
of Dental Research, June 16, 2015.

C D A J O U R N A L , V O L 4 3 , N 8

Weight-Related Risk Factor for Periodontitis

According to the Centers for Disease
Control and Prevention, more than
90 percent of adults aged 20-64 have
experienced tooth decay and one in every
three adults is obese. In a recent systematic
review, authors indicate that obesity may
be one of a number of weight-related risk
factors for development of periodontitis.

In the new study, the authors note

that previous reviews were primarily
based on cross-sectional studies, with
only a few longitudinal or intervention
studies included. For their study, the
researchers examined the timedependent association between obesity
and periodontitis and how changes

Porcine Collagen Barrier Aids Bone Regrowth

Researchers examined a new type of barrier membrane, called
porcine collagen, to nd out how quickly a bone graft can develop with
this material placed over the grafted tooth socket. While they found bone
regeneration varied, the authors reported that porcine collagen showed
potential for promoting new bone growth.
The study, which was published in the Journal of Oral Implantology,
included 14 patients with a diagnosis of one or more unsalvageable
teeth and a treatment plan to replace them with implant-supported single
crown restorations. After the teeth were removed, the sockets were lled
with particulate allograft bone and covered with a layer of porcine
collagen. According to the study, the porcine collagen membranes were
cut to overlap the facial and lingual (or palatal) socket rim by at least 5
mm (or more if necessary) to cover bony wall fenestration or dehiscence
defects. Sixteen weeks later, researchers checked the sites and dental
implants were placed.
The formation of new bone in the treated sites averaged 11.2 percent,
with a range of 1.8 percent to 43 percent, in bone biopsies trephined from
the center of the grafted socket sites, the authors explained in the report.
The authors concluded that The resulting new bone regeneration varied
widely, but the barrier membranes showed potential
for promoting signicant bone regeneration.
They suggest a larger sample of treated cases
is needed to support their conclusion.
For more on this study, see the Journal
of Oral Implantology, June 2015, vol. 41,
no. 3, pp. 293297.

in weight may affect the development

and progression of periodontitis in the
general population. Searching studies
with overweight or obesity as exposure
and periodontitis as outcome, the
authors reviewed eight longitudinal
and five intervention studies that
assessed the association among
overweight, obesity, weight gain, waist
circumference and periodontitis.
Two of the longitudinal studies found
a direct association between degree of
overweight at baseline and subsequent risk
of developing periodontitis, and a further
three studies found a direct association
between obesity and development of
periodontitis among adults, the authors
summarized. Additionally, they found that
two of the reviewed intervention studies
on the influence of obesity on periodontal
treatment effects showed that the response
to nonsurgical periodontal treatment was
better among lean than obese patients
while the remaining three studies
did not report treatment differences
between obese and lean patients.
In conclusion, the authors stated
that their systematic review suggests
overweight, obesity, weight gain and
increased waist circumference may be risk
factors for development of periodontitis
or worsening of periodontal measures.
For more, see the study in the
Journal of Periodontology, June 2015,
vol. 86, no. 6, pp. 766-776.
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C D A J O U R N A L , V O L 4 3 , N 8

Dentistry for the Ages: Part II

Susan Hyde, DDS, MPH, PhD, FACD

Susan Hyde, DDS,
chairs the division of
oral epidemiology and
dental public health at the
University of California,
San Francisco, School
of Dentistry. She is the
dental director of UCSFs
multidisciplinary fellowship
in geriatrics and faculty
lead for interprofessional
education for the School of
Dentistry. Dr. Hyde received
her dental degree from
UCSF, Master of Public
Health and doctorate of
philosophy (epidemiology)
from the University of
California, Berkeley, and
certicates in dental public
health and geriatrics from
Conict of Interest
Disclosure: None reported.

Dick Gregory, DDS, is

the San Mateo Center
director for Apple Tree
Dental. He completed
his dental degree at the
University of California,
Los Angeles, School of
Dentistry in 1980 and a
two-year postgraduate
multidisciplinary geriatric
fellowship at the University
of California, San Francisco
in 2014. During the
intervening three decades,
he cared for his patients
while in private general
dental practice in Northern
Conict of Interest
Disclosure: None reported.

n this second of two issues

dedicated to the oral health of
older adults, the Journal presents
possible resources for general
dentists to consider when caring
for older adults. Iain A. Pretty, BDS,
writes about the Seattle Care
Pathway, which takes into
account the continuum of clinical
presentation of older adults, with the
resultant need for dentists to provide
oral health anticipatory guidance
for patients, and if appropriate,
their caregivers, as well as increased
communication with primary care
providers when developing care
plans. Mark Ryder, DMD, reviews
the roles of systemic disease,
pharmacological management,
immune response and functional
capacity in the development and
progression of periodontal disease

that supports a collaborative practice

approach to treatment decisions.
Guest editors Dick Gregory, DDS,
and Susan Hyde, DDS, MPH, PhD,
FACD, present alternative treatments
for root caries that could be delivered
bedside, such as silver diamine fluoride
cariostasis, partial caries removal and
glass ionomer restorations. Deborah
Jacobi, RDH, MA, and Michael J.
Helgeson, DDS, write about Apple Tree
Dental, a community collaborative
practice model, that will soon be
providing comprehensive care to
vulnerable populations in the Bay
Area and may become a statewide
model for delivering on-site dental
services within long-term care facilities.
Finally, the contributing authors to the
July and August issues of the Journal
have provided a national resource
section of organizations and websites
dedicated to the care of older adults.
A U G U S T 2 015 427

You are the reason people stand tall in front of the class,
grin widely for the camera and never cover their mouths
in shame. You are the champion of the smile and all the
possibility it represents. The confidence you instill in your
patients is one reason why CDA supports and protects
your profession. Because the world is a better place
when people are smiling, and thats thanks to you.

800.232.7645 |

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C D A J O U R N A L , V O L 4 3 , N 8

The Seattle Care Pathway:

Dening Dental Care
for Older Adults
Iain A. Pretty, BDS, MSC, MPH, PhD, FDSRCS(ED)

A B S T R A C T It is well-recognized that the demographic shift in the population will

result in a larger proportion of older adults and those adults will live longer than ever
before. There is, therefore, a need to ensure dental services recognize this transition
and plan for the management of older adults in primary care dental practices. This
article describes the evidence for, and the details of, the Seattle Care Pathway to
ensure older adults receive optimum dental care.



Iain Pretty, BDS, MSC,

is a professor of public
health dentistry at the
University of Manchester
School of Dentistry and
co-director of Colgate
Palmolives Dental
Health Unit, a 45-year
collaboration between the
company and the university.
Dr. Pretty is working
on caries management
programs for older people
and, with international
colleagues, developed the
Seattle Care Pathway, an
evidence-based approach
to assessing and planning
the oral care of older
Conict of Interest
Disclosure: None reported.

The author would like

to recognize and thank
the original authors of
the pathway and their
contribution to the Seattle
conference: Roger P.
Ellwood, BDS, MSc, MDS,
PhD; Edward C.M. Lo,
BDS, MDS, PhD; Michael
I. MacEntee, LDS(I), Dip.
Prosth., PhD; Frauke Mller,
Prof. Dr med dent; Eric
Rooney, BDS, MSc, DDPH
RCS; William Murray
Thomson, BSc, BDS, MA,
MComDent, PhD; Gert-Jan
Van der Putten, PhD; Elisa
M. Ghezzi, DDS, PhD;
Angus Walls, BDS, PhD;
and Mark S. Wol, DDS.

n 2013, a group of interested

academicians, clinicians and
practitioners gathered in Seattle to
discuss the issues surrounding the
dental care of older adults. Many
recognized that while research was
available, it was difficult to consume
and there was little advice for dental
practitioners on how to manage
this increasing proportion of their
population. In an effort to provide such
guidance, the Seattle Care Pathway for
Securing Oral Health in Older Patients
was produced. Readers can access
all 12 papers, including the pathway
document1 itself, free of charge from
the Gerodontology website simply
search for Seattle Care Pathway
Gerodontology online. The purpose
of this article is to summarize the key
findings of the conference in a single
source that is accessible and relevant
to general dental practitioners.

The Shift
There is no doubt Western countries
are all experiencing a demographic shift
a change in the population profile
that will see a greater proportion of older
adults who will be living longer than
ever before.2,3 Such a shift has a profound
impact on many aspects of society, not
least the financial considerations, but
perhaps, one of the biggest concerns
is maintaining the health and wellbeing of an aging population in an
economically viable manner that does
not destabilize health care systems.4
Many could argue the shift is a perfect
storm older individuals with greater
and more complex health care needs
but no workplace medical insurance
will strain health care systems while
at the same time the proportion of
working-age, tax-contributing individuals
reduces. The obvious solution to these
issues would seem to be that prevention
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Drivers for vulnerability

Skills of parent, access to dental services
with eective prevention policies,
deprivation, health care system.
Not vulnerable

End of life

Start of life

Well-dened and integrated within
national schemes, such as health
visiting, HeadStart, childrens centers,
nurseries and schools. Clear and
consistent oral health promotion and
prevention messages linked with eective
interventions, therapies and treatments.
Good access to care generally.
Strong, evidence-based, with wide range
of clinical trials and numerous systematic
reviews to provide guidance to health
care systems. Evidence embodied within
national recommendations and endorsed
by governments and organized dentistry.

Drivers for vulnerability

General health, presence of chronic
diseases,activities of daily living (ADL),
performance, medication, burden,
deprivation, access to services, luck.


Population 1
Population 2
Population 3
Line of vulnerability

Poorly dened, often highly variable, even
within health care systems. Poor access to
services and service specications based
on the treatment aspirations of younger
adults rather than directed by the oral
health needs of the elder patients.
Evidence base is poorer, fewer
recommendations based on clinical trial
evidence, often focused on settings rather
than delivery.

FIGURE . Life course and health.

is key. If individuals can be helped to

keep healthy for longer, and if chronic,
debilitating diseases can be prevented,
then the burden on health and social
care systems can be reduced, quality of
life increased and the system maintained.
Such an approach requires a
different contextual framework for the
delivery of health care services and
resources. The FIGURE demonstrates
a life course model of health care.
We can consider this model for any
aspect of health care, and dentistry is
no exception. The three lines in the
model represent three hypothetical
individuals or populations:
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Population 1. The first population is

our ideal, the life course we hope for our
families and ourselves. It is an individual
born above a line of vulnerability,
who leads a long and healthy life and,
toward the end of life, suffers some
loss of function but remains vital and
with a good sense of well-being.
Population 2. The second line is a
worst-case scenario and perhaps seen
today in those individuals born with
life-threatening and altering conditions
that cause severe disability and require
constant medical attention and assistance.
Such patients are likely to be managed
by specialists in secondary care facilities.

Population 3. The third line is

perhaps the most reflective of the
Western population experience. We
are born and are vulnerable for a
period of time, and then, fortunately,
spend the majority of our lives fit
and well, but with an end of life
that may be affected by chronic
conditions, loss of cognitive ability
and other factors that impact quality
of life and make us increasingly
dependent and vulnerable.2
What we know from dental and
medical attendance and resource
allocation research is the vast majority
of resource is spent on the middle

C D A J O U R N A L , V O L 4 3 , N 8


Dental Challenges of the Older Adult

Tooth loss

While now far less common, incremental loss of teeth leading to the decision to render an individual edentulous is still a major challenge for
many older adults. The provision of complete prostheses is becoming more complex as patients typically lose their teeth at an older age and
have a reduced ability to cope with the challenges of managing a prosthesis.

Dental caries

Perhaps the most common challenge, in community-dwelling older adults, caries rates are similar to those in young children at about one
surface per year. While root caries are often considered the major issue in this age group, this appears to be largely a disease of adults
in residential and nursing homes, with coronal caries remaining the site of increment for older adults. Those in nursing homes will typically
experience a caries increment rate double that of their community-dwelling peers.


A highly prevalent condition in this cohort of patients but with most attachment loss being in the form of gingival recession rather than
increases in probing depth. The concept of health survivors is apropos here with teeth that remain into old age likely resilient to
periodontal disease. The changes in the immune system also contribute to the altered progression of the disease in this group, although this
must be set against the reduced ability to undertake some oral hygiene procedures that require ne motor skills.

Dry mouth

Both xerostomia and salivary gland hypofunction are seen in older patients, either together or alone, and can have a devastating impact.
Caries risk is increased either due to loss of the protective saliva or due to measures taken to stimulate salivary ow (often sucking candies),
and dry mouth is associated with a decrease in quality of life, diculty eating and wearing a prosthesis. Dry mouth is often associated with

Oral cancer/

Epidemiological data are scarce, but oral cancer and its precursors are generally seen in older populations and rates vary across developed
and developing nations. Given its devastating impact, however, clinicians should be vigilant for oral lesions in all patients, especially those
with recognized risk factors.


Many older adults nd it increasingly dicult to access care. This may be due to transport, cognitive ability or their own general health and
mobility. Dental oces may not cater well to wheelchair users or may not be located close to public transport links. In patient surveys, the
need to maintain access to dental care is often raised as older adults No. 1 concern with respect to their oral health.


Older adults living in nursing and residential care may be especially dicult to treat, especially if they cannot be easily transported to a
regular clinical setting. The need for mobile dental units and sta is clear but the provision of these is often sporadic.


For many adults, dental insurance ceases or is reduced at retirement and, combined with a lower overall income level, resources become
scarce. This is confounded by the fact that many of these patients will have received complex dental treatments that may require additional
resource to maintain and protect.

section of this life course with some

(increasing) emphasis on young
children (those younger than age 3)
and very little on end-of-life care.5
It should be noted that the life
course makes no reference to an
individuals age. While it is clear
individuals are aging, placing artificial
and arbitrary chronological metrics is
not helpful. We all know the 95-yearold man who we see out jogging and
we all, sadly, know of the 55-yearold man who has suffered a stroke
and is unable to walk. We must
consider our patients as individuals
and plan their care appropriately.2

Dentistry and Vulnerability

The FIGURE also defines the current
position of dental services, resources and
research. While this is a generalization,
it is largely applicable to all Western
health care models. For young children,
there is a wealth of services, strong
clinical trial evidence upon which
to base such services and, generally,
the political, social and professional
will to see oral health care improve.
The reasons for poor oral health in
young children are well understood,
as are the means on individual and
population levels to address them. This
is not to assert there is no longer an

issue in childrens oral health, but the

environment for change is present.2
Looking at the older population, we
are not in the presence of such clarity.
The reasons for poor oral health are more
complex, more interlinked and not as
well understood. There is little robust
clinical trial evidence that has examined
these populations in detail and it is often
necessary to extrapolate from studies
undertaken on adolescents or children.
Services are poorly defined, difficult to
access and often restricted, for example,
to older adults living in residential care.
It is important to remember that while
the media will often depict or report
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Definitions of Dependency Used in the Seattle Care Pathway

on the elderly living in nursing homes

less than 5 percent of older adults in
Western populations are in such housing
the vast majority is community
dwelling, living either with caregivers
(often partners) or on their own.
Speaking to older people, their
partners and caregivers, and thirdsector organizations, the medical terms
surrounding aging are often found
to be pejorative, for example, frailty.
Instead, the concept of dependency, or
indeed independency, was recognized
as a more acceptable means of defining
individuals as they age. This is important
for dentistry where we have the means
of implementing prevention at an early
stage to ensure that disease processes
can be arrested or even reversed. In the
context of the older adult, plans for this
approach need to be undertaken early in
a time best described as predependent.

Dental Challenges of Older Adults

These are well-described in a
multitude of publications and were
summarized by Thompson in his Seattle
conference presentation3 and shown in
TA BLE 1 . The major dental issues faced
by older people are broadly the same
as those of younger individuals. Many
dentists are surprised, however, to learn
the caries increment in older adults is
the same as in younger children, about
one surface increment per year, and,
often surprising, too, is that this is mainly
in coronal surfaces.6 Root caries, often
thought of as the major challenge of the
elderly, is a disease entity largely confined
to those in residential and nursing care.7
Tooth loss is typically an incremental
process that tends to occur throughout life
and is more common than edentulism.
Predicting it can be complex, and its
impact on the remaining dentition, the
provision of prosthesis and its effect
on quality of life can be substantial.8
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No dependency

Fit, robust people who exercise regularly and are in the most t group for
their age.


People with chronic systemic conditions, which could impact on oral health
that, at point of the presentation, are not currently impacting on oral health.
A comorbidity whose symptoms are well-controlled.

Low dependency

People with identied chronic conditions that are aecting oral health but
who currently receive or do not require help to access dental services or
maintain oral health. These patients are not frankly dependent, but their
disease symptoms are aecting them.


People with an identied chronic system condition that currently impacts on

oral health and who receive or do not require help to access dental services
or maintain oral health. This category would include patients who demand to
be seen at home or who do not have transport to a dental clinic.

High dependency

People with complex medical problems preventing them from going to receive
dental care at a dental clinic. They dier from patients categorized in medium
dependency because they cannot be moved and must be seen at home.

Periodontal disease is complex from

an epidemiological position, not least
because of the multitude of definitions,
indices and reporting mechanisms. Aging
was traditionally considered a risk factor
for periodontal disease, but the research
evidence is not clear.3 Longitudinal studies
suggest there is both a progression and
remission of the disease process over time
and in older adults, attachment loss is
often the result of gingival recession rather
than increases in periodontal pocket
depth.9 Nonetheless, plaque control and
the presence of florid, plaque-related
marginal gingivitis is often seen in older
adults, especially those with cognitive or
motor impairments.10 There is a concept
of healthy survivors, i.e., those teeth
present in older adults may be, for a
variety of reasons, less susceptible to
the disease and hence the overall risk
of progression is reduced. Those teeth
that were susceptible will have been
lost through incremental extraction.
Dry mouth is often cited as a
consequence of age that is exacerbated by
polypharmacy and other disease processes.
Remembering that xerostomia is the
subjective feeling of dry mouth, whereas

salivary gland hypofunction results in low

salivary flow rate, both can be a threat to
oral health and quality of life. Those with
low salivary flow rates have reduced salivary
buffering and remineralization abilities
and those with xerostomia will often seek
to reduce symptoms by sucking on sour
candies or something similar that provides
a source of fermentable carbohydrates
and, therefore, increased caries risk.
Oral precancer and cancer is also a
disease associated with older adults with
catastrophic consequences for those
affected. The ability to detect precancerous
lesions early, confirm diagnosis and
commence treatment (including risk factor
reduction) is key to positive outcomes.11

Meeting the Challenges: A Pathway

Pathways were originally developed in
industry, particularly Japanese automobile
production lines, where there was a focus
on clearly defined steps that resulted in
a consistent and predictable outcome.12
The adoption of care pathways in
medicine has been rapid over recent
years and they aim to collate best
evidence and present this to clinicians

C D A J O U R N A L , V O L 4 3 , N 8

in a supportive way so practitioners have

a more efficient and predictable means
of treating patients. The care pathway
represents a journey one that may
be paused, for example, while specialist
tests are conducted or a caregiver is
consulted, or one that may be deviated
from if clinical experience dictates it.
It is a journey that can be modified
based on local, regional and nationally
available guidance and resources.13
Pathways should therefore be viewed
as enablers documents or processes
that assist in clinical decision making
and, if followed correctly, can result in a
predictable outcome as well as providing
support for a clinicians approach to a
particular patient presentation. The
full Seattle Care Pathway considered
individuals, populations, treatments,
prevention and communication issues
for varying levels of dependency ranging
from no dependency through high
dependency. The dependency categories
were described as shown in TA BLE 2 1 and
the care pathway in full in TA BLE 3 .
These dependency categories were
developed to ensure critical elements
within the life course could be captured.
They were also felt to be tipping
points when approaches to care would
change. All but the highest level of
dependency may represent patients
seen in community dental practice. As
the definitions were discussed, many
in the group could identify these with
their own patients or family members.
Once the categories of patients were
determined, the evidence base around
their prevention and treatment options
could be collated. The pathway document
was presented in tabular form with the
main supporting evidence provided.1
Throughout the development of the
guidance, the authors worked on the basis
of dependency rather than a particular
chronological age. However, it was clear

the implicit rationale behind the work was

older patients, and it became clear there
had to be a trigger age, an age at which
patients should be considered against the
pathway to ensure a change in dependency
was not missed. An age of 55 years was
agreed upon, with the assumption that at
this chronological time point almost every
patient would be in the nondependent
category. Despite this stated trigger
point, dentists should remain vigilant to
the onset of dependency at any age.1

Implementing the Pathway

The care pathway describes the
assessment, preventive regime, treatment
and communication recommendations
for each level of dependency (TA B L E 3 ).
While the table is designed to be easy to
implement and understand, the authors
of the pathway determined that clinical
vignettes or examples might help the
application. A series of examples were
included in the article and some further
case scenarios, looking at no, pre- and
medium dependency, are described here.
The purpose is to place the pathway into
real-life context for dental practitioners,
considering those patients who are most
likely to present.

No Dependency
These are older individuals who are fit
and exercise regularly. An example of this
type of patient might be the following:
Arnold is a 75-year-old who lives
at home with his wife and three dogs.
He exercises regularly and is actively
involved in dog training for new dog
owners in his community. He attends
six-month recalls at your practice
and three-month cleanings with your
hygienist. When you review his chart,
the last treatment you provided was
a replacement restoration two years
ago. He is on a statin for cholesterol
but otherwise is on no medication.

One of the comments raised in the

conference was that this group was
commonly seen in general practice,
but often fell off the radar, meaning
they began to fail to attend and before
long were lost to the practice. This was
recognized as an important place to
start considering the impact of aging.
For this group, the importance is to
start the conversation about what may
happen in the future. How can we keep
in touch in case things change? It was
agreed that complex treatment plans
in this group were not contraindicated
but a conversation about implications
on the maintenance of such treatments
should things change was important.
These groups need, as all patients
do, a good home-care/self-care plan
with an emphasis on prevention. The
concept of protecting the investment
was raised. These patients have spent
considerable financial and time resources
on their oral health. As risk factors
may increase with age, we should
provide them with information and
guidance to help them maintain this.
Frequently reviewing medical history
and medicine will be important.

These patients present with a
chronic systemic condition with
potential impact on oral health,
which at point of presentation, is well
controlled. An example of this type
of patient might be the following:
Sarah is 66 years old and is a
widow living alone. She is active in
her community and attends church
regularly where she has an extensive
social network. She sometimes uses a
walking stick when she feels a little dizzy,
and is taking medications for diabetes
and high blood pressure but both are
well controlled. She recently had an
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The Seattle Care Pathway

Dependency Level



No Dependency

Routine processes in locality U.K. National Dental Assessment.

Locally derived guidance U.K. Delivering Better Oral Health.

Recall interval based on risk assessment (U.K. National Institute for

Health and Care Excellence (NICE) guidance).
Use of dependency checklist.
Assessment of long-term viability of oral health.*

Condition identied and risk assessment undertaken to inform any potential

increased frequency of contact.18

Based on assessment consider the following:

Consideration of additional diagnostics (for example salivary ow rate).19

Oral health care plan Strategy Treatment plan.20

Perio: Antibacterial toothpaste, professional cleaning,

chlorhexidine (not long-term use), oral hygiene instruction.

Recognition that risk may be greater as result of increasing dependency.

Oral cancer: Risk modication and education.11

Assessment of long-term viability of oral health.

Tooth service loss: Risk modication, sensitivity products

as indicating.23

Consideration of use of skill mix.21

Caries: High-uoride toothpaste, varnishes, gels and mouth rinses.22

Production of daily oral care plan (home care).

Low Dependency

Manifestation identied and risk assessment undertaken and increased

frequency of contact unless compelling reasons to maintain current

Assessment of the reason behind the impact prevention

based on mitigation of factors.22

Recognition that risk may be greater as result of increasing dependency.

Consideration of how these can be delivered for example

high-uoride25 toothpaste now combined with electric
toothbrush or modied brush.25,26

Assessment of long-term viability of oral health.

Oral health care plan Strategy Treatment plan.20**

Denitive move to evidence-based prevention products.24

Consider medication issues27 both in terms of systemic impact

and sugar free.28

Consideration of use of skill mix.21

Consider recommending gum chewing and/or salivary

substitutes if indicated.29
Production of daily oral care plan.
Medium Dependency

Usage of support identied and risk assessment undertaken and

increased frequency of contact unless compelling reasons to maintain
current frequency.18

Ensure that the prevention routine is both adequate

i.e., move from high- to very-high uoride toothpaste; that
routine can be delivered by others if required.25

Recognition that risk may be greater as result of increasing dependency.

Education of caregivers in delivery of prevention.

Assessment of long-term viability of oral health.

Consider increased use of professional applied products

utilization of increased patient contacts, i.e., nurse-applied

Oral health care plan Strategy Treatment plan.20

Consideration of use of skill mix.21

Consider recommending gum chewing and/or salivary

substitutes if indicated.29
Production of daily oral care plan.

High Dependency

Inability to receive care elsewhere identied and risk assessment

undertaken and increased frequency of contact unless compelling
reasons to maintain current frequency.18
Recognition that risk may be greater as result of increasing dependency.
Assessment of long-term viability of oral health.
Oral health care plan Strategy Treatment plan.
Consideration of use of skill mix.21


Focusing prevention on easily deliverable products and

therapies, emphasis on pain and infection management.14
Further move to professional products, including varnishes
and gels.
Consideration of prevention of disease complications
i.e., chlorhexidine use to prevent respiratory infections.30
Production of daily oral care plan.

2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2014; 31 (Suppl. 1): 7787.1 Reproduced with permission.
* Consideration of the long-term success, impact and maintenance of current restorative condition, oral health and prevention.
** Development or modication of this plan.

Contact is dened as an activity involving contact between patient and the wider dental team.

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Based on an assessment of patient need to secure oral health.

Speak to patient about long-term oral health issues especially when considering
complex treatment modalities that require replacement and/or maintenance.

Based on patient needs but with greater consideration of long-term

viability of treatments given assessment of likely dependency in the future
and impact on oral care.

Identication of the condition and its likely future impact on oral care
education of patient.

Consideration of the strategic importance of retaining teeth.31

Discussion around care plans, caregivers, social circumstances as appropriate.

Need for strategic approach to retaining functional occlusal contacts.

Shortened dental arch, and longevity and maintenance of more complex

Provision of implant support dentures where indicated.31

Communication with general care physician re: conditions.

Link in with wider health care team around medication management (sugar
in medicines).

Based on maintaining function and freedom from infection and pain

plan for failure.

Further consideration of strategic importance, repair rather than

replace, glass ionomer cement for uoride release in dry mouth,
adhesive bridgework.

Establish link with source of support to ensure that daily oral health plan can
be delivered and that prevention modalities are appropriately implemented.

Minimal intervention to preserve health but consideration of long-term

viability which may lead to more complex treatments being recommended,
for example implants to support lower denture.31
Use of simple restorative techniques such as atraumatic restorative
Change attachment types on implant or tooth supported overdentures.34

Palliative treatment based on patient demand ensuring freedom from pain

or infection, and esthetics where required.14

Ensure that the patient is at the center of discussions to ensure that what is being
delivered is what is needed.

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anterior tooth extracted following a

persistent periapical infection and this
was added to her partial denture. She
finds the additional tooth uncomfortable
and wants to know what can be done.
Sarah is considered predependant
as her diabetes and high blood pressure
could, if they became unstable, adversely
affect her oral health. She is struggling
with her adapted denture, which may
be affecting her ability to socialize or
eat. The care pathway for predependant
individuals advocates a candid approach
to communicating with the patient. It is
important to articulate the risks of poor
disease management with the patient,
in this case the polypharmacy, and this
should impact on the recall interval
for Sarah. Prevention should be the
centerpiece of a detailed home-care plan
and consideration should be given to the
inclusion of high-fluoride dentifrices, gels
or mouth rinses. In terms of the treatment
offered to Sarah, this must be considered
in the context of her potentially increasing
dependency and therefore should be easy
to maintain but may need adaptation
over time. Efforts should be made to
ensure that, within her care record, the
contact details for her family, or perhaps
someone in her church group, are recorded
so they may be contacted if Sarah fails
to attend her recall appointments.

Medium Dependency
These are patients with an identified
chronic systemic condition that is
currently impacting oral health and who
receive or require support in managing
access to dental services or maintaining
oral health. This category would include
patients who demand to be seen at home
or who cannot get transportation to a
dental clinic. An example of this type
of patient might be the following:
John is living in residential care in
the same town as your dental practice.
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With assistance, he can attend the

practice, but these appointments
need to be scheduled carefully and his
caregiver must accompany him. John
has mild dementia and can consent to
his treatment but has poor short-term
memory and often repeats his questions.
He is on a range of medications that
have caused salivary hypofunction
and he complains of a dry mouth.
John consumes a large number of
candies in an attempt to stimulate
saliva and he has an extensively
restored dentition in which there is

Prevention should be the

centerpiece of a detailed homecare plan and consideration
should be given to the inclusion
of high-uoride dentifrices,
gels or mouth rinses.

evidence of new carious lesions and

failing extracoronal restorations. He
doesnt report any pain at present.
John is a patient who is on the
tipping point. His medications are
having a direct impact on his oral
health and he requires an immediate
and aggressive preventive approach.
Given his cognitive difficulties,
these need to be coordinated with
his caregiver and should include
high-fluoride products, for example,
5000 ppm toothpaste. Plaque control
measures should be discussed with him
and his caregiver, and his physician
should be contacted to see if it is
possible to alter his medication regime
to reduce the dry mouth symptoms.
Professional prevention, for example,
the application of fluoride varnish,

should be commenced with frequent

recalls that should be facilitated between
the dental office and the residential
home. Restorative treatment should
be designed with easy maintenance in
mind and it may be inappropriate to
consider complex work that may become
increasingly difficult to clean in the
future. Consideration could be given to
treatments that might be adapted in the
future, for example, fixed implant work
that might be changed to removable.14,15
Patients in the medium dependency
group, when questioned in focus
groups, placed access to care as their
top priority, followed by a pain-free,
functional dentition. They fear their
loss of independence will prevent them
from going to the dentist to receive the
care they need, therefore, assuring them
of continued access and facilitating this
are key. The importance of oral hygiene
measures should be made clear to care
personnel and a written plan is essential.
The full care pathway document
provides further examples of the
management of patients with
increasing dependency and should
be consulted by those practitioners
who serve such populations.1

Care pathways, such as the Seattle
Pathway, are designed to be generalizable
to a range of populations, health service
organizations and cultures. They should
be consistent with, or enable the
incorporation of, local, regional and
national guidance and regulations. They
should be operable in insurance and
state-funded systems. It is therefore a
requirement of practitioners to assess the
guidance and consider its implementation
within their practice population.
The impact of culture should not
be ignored when considering the needs
of patients in this group. Lo described

C D A J O U R N A L , V O L 4 3 , N 8

the differences between16 cultural

attitudes toward tooth loss, aging and
dental treatment. For example, in a
given culture, the ability to eat and
socialize may be more important than
preservation of individual teeth, whereas
for others the loss of teeth, and any
commensurate perceived esthetic impact,
would be considered unwanted.16
The conference also considered the
skill of the current dental workforce in
managing the increasing needs of older
dental patients.17 The pathway advocates
that much can be done for dependent
patients without the need to refer to
specialist services. However, research
suggests many dentists are concerned
with providing treatment to patients
with complex medical histories or those
with cognitive impairments. There is,
therefore, a need to ensure graduate dental
education and continuing professional
education courses address these concerns.17

The purpose of this article has been
to present and describe the rationale
behind the Seattle Care Pathway. The
authors recognize the pathway may be
a first step to providing an evidencebased approach to the management
of this increasingly complex group of
patients who are destined to become an
ever-greater proportion of our practice
populations. The overarching advice
is that prevention, both self care and
professional, is key for these patients
and the practitioners should be vigilant
about changes in the health and social
circumstances of their older adult patients.
While products and therapies exist for
this cohort of patients, there is a need for
robust clinical trials in this population,
as well as further consideration of how
dental service funding, either public or
private, can be leveraged to support the
implementation of effective prevention.


1. Pretty IA, Ellwood RP, Lo EC, MacEntee MI, Muller F, Rooney

E, et al. The Seattle Care Pathway for securing oral health in
older patients. Gerodontology 2014. 31 Suppl 1: 77-87.
2. Pretty IA. The life course, care pathways and elements
of vulnerability. A picture of health needs in a vulnerable
population. Gerodontology 2014. 31 Suppl 1: 1-8.
3. Thomson WM. Epidemiology of oral health conditions in
older people. Gerodontology 2014. 31 Suppl 1: 9-16.
4. Comlossy M, Walden J. The silver tsunami: States have a
fairly long to-do list to get ready for the health care needs of an
aging America. State Legis 2013. 39(10): 14-9.
5. Helgeson M. Oral Health Care Reform: Older Adults and
People With Special Needs. IOH 2010 Conference 2010.
6. Thomson WM. Dental caries experience in older people
over time: What can the large cohort studies tell us? Br Dent J
2004 196(2): 89-92; discussion 87.
7. Grin SO, Grin PM, Swann JL, Zlobin N. Estimating rates
of new root caries in older adults. J Dent Res 2004 83(8):
8. Drake CW, Hunt RJ, Koch GG. Three-year tooth loss among
black and white older adults in North Carolina. J Dent Res
1995. 74(2): 675-80.
9. Qian F, Levy SM, Warren JJ, Hand JS. Incidence of
periodontal attachment loss over eight to 10 years among
Iowa elders aged 71+ at baseline. J Public Health Dent 2007.
67(3): 162-70.
10. Walls A. Developing pathways for oral care in elders:
Challenges in care for the dentate the subject? Gerodontology
2014 31 Suppl 1: 25-30.
11. Hunter KD, Yeoman CM An update on the clinical
pathology of oral precancer and cancer. Dent Update 2013.
40(2): 120-2, 125-6.
12. Vanhaecht K, Panella M, van Zelm R, Sermeus W. An
overview on the history and concept of care pathways as
complex interventions. Int J Care Pathw 2010. 14: 117-23.
13. Rooney E. Developing care pathways Lessons from the
Steele Review implementation in England. Gerodontology
2014. 31 Suppl 1: 52-9.
14. Beck JD, Ettinger RL. Rational dental care in the long-term
care facility. J Am Health Care Assoc 1981. 7(3): 22-4,
15. Ettinger RL. Rational dental care: Part 1. Has the concept
changed in 20 years? J Can Dent Assoc 2006. 72(5): 441-5.
16. Lo EC, Tan HP. Cultural challenges to oral health care
implementation in elders. Gerodontology 2014. 31 Suppl 1:
17. Wol MS, Schenkel AB, Allen KL. Delivering the evidence
skill mix and education for elder care. Gerodontology 2014.
31 Suppl 1: 60-6.
18. Steele JG, Walls AW. Strategies to improve the quality of
oral health care for frail and dependent older people. Qual
Health Care 1997. 6(3): 165-9.
19. Cunha-Cruz J, Scott J, Rothen M, Mancl L, Lawhorn T,
Brossel K, et al. Salivary characteristics and dental caries:
Evidence from general dental practices. J Am Dent Assoc
2013. 144(5): e31-40.
20. Jenson L, Budenz AW, Featherstone JD, Ramos-Gomez
FJ, Spolsky VW, Young DA. Clinical protocols for caries
management by risk assessment. J Calif Dent Assoc 2007.
35(10): 714-23.
21. Gallagher JE, Lim Z, Harper PR. Workforce skill mix:
modelling the potential for dental therapists in state-funded

primary dental care. Int Dent J 2013. 63(2): 57-64.

22. Walls AW, Meurman JH. Approaches to caries prevention
and therapy in the elderly. Adv Dent Res 2012. 24(2): 36-40.
23. Burke FM, McKenna G. Tooth wear and the older patient.
Dent Update 2011. 38(3): 165-8.
24. Souza ML, Cury JA, Tenuta LM, Zhang YP, Mateo LR,
Cummins D, et al. Comparing the ecacy of a dentifrice
containing 1.5% arginine and 1450 ppm uoride to a
dentifrice containing 1450 ppm uoride alone in the
management of primary root caries. J Dent 2013. 41 Suppl
2: S35-41.
25. Gibson G, Jurasic MM, Wehler CJ, Jones JA. Supplemental
uoride use for moderate and high caries risk adults: A
systematic review. J Public Health Dent 2011. 71(3): 171-84.
26. Lynch E, Baysan A. Reversal of primary root caries using
a dentifrice with a high uoride content. Caries Res 2001 35
Suppl 1: 60-4.
27. Maupome G, Peters D, Rush WA, Rindal DB, White BA.
The relationship between cardiovascular xerogenic medication
intake and the incidence of crown/root restorations. J Public
Health Dent 2006. 66(1): 49-56.
28. Weeks JC, Dutt A, Robinson PG. Promoting sugarfree medicines: Evaluation of a multifaceted intervention.
Community Dent Health 2003. 20(4): 246-50.
29. Makinen KK, Pemberton D, Cole J, Makinen PL, Chen CY,
Lambert P. Saliva stimulants and the oral health of geriatric
patients. Adv Dent Res 1995. 9(2): 125-6.
30. Gluzman R, Katz RV, Frey BJ, McGowan R. Prevention
of root caries: A literature review of primary and secondary
preventive agents. Spec Care Dentist 2013. 33(3): 133-40.
31. Heath MR, Wright PS. The teaching of prosthodontic care
for older people: a non-rote philosophy. Gerodontology 1997.
14(2): 113-8.
32. Kanno T, Carlsson GE. A review of the shortened dental
arch concept focusing on the work by the Kayser/Nijmegen
group. J Oral Rehabil 2006. 33(11): 850-62.
33. Gil-Montoya JA, Mateos-Palacios R, Bravo M, GonzalezMoles MA, Pulgar R. Atraumatic restorative treatment and
Carisolv use for root caries in the elderly: Two-year follow-up
randomized clinical trial. Clin Oral Investig 2013.
34. Andreiotelli M, Att W, Strub JR. Prosthodontic complications
with implant overdentures: A systematic literature review. Int J
Prosthodont 2010. 23(3): 195-203.

Iain A. Pretty, BDS, MSC, MPH, PhD, FDSRCS(ED),

can be reached at

A U G U S T 2 015 437

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Check it out at

root caries
C D A J O U R N A L , V O L 4 3 , N 8

Root Caries in Older Adults

Dick Gregory, DDS, and Susan Hyde, DDS, MPH, PhD, FACD

A B S T R A C T Older adults are retaining an increasing number of natural teeth, and

nearly half of all individuals aged 75 and older have experienced root caries. Root
caries is a major cause of tooth loss in older adults, and tooth loss is the most significant
negative impact on oral health-related quality of life for the elderly. The need for
improved preventive efforts and treatment strategies for this population is acute.

Dick Gregory, DDS, is the
San Mateo Center director
for Apple Tree Dental. He
completed his dental
degree at the University of
California, Los Angeles,
School of Dentistry in 1980
and a two-year postgraduate multidisciplinary
geriatric fellowship at the
University of California, San
Francisco in 2014. During
the intervening three
decades, he cared for his
patients while in private
general dental practice
in Northern California.
Conict of Interest
Disclosure: None reported.

Susan Hyde, DDS, MPH,

PhD, FACD, chairs the
division of oral
epidemiology and dental
public health at the
University of California, San
Francisco, School of
Dentistry. She is the dental
director of UCSFs
multidisciplinary fellowship
in geriatrics and faculty
lead for interprofessional
education for the School of
Dentistry. Dr. Hyde received
her dental degree from
UCSF, Master of Public
Health and doctorate of
philosophy (epidemiology)
from the University of
California, Berkeley, and
certicates in dental public
health and geriatrics from
Conict of Interest
Disclosure: None reported.

ental caries is a transmissible

infection caused by specific
bacteria (Streptococcus
mutans, Streptococcus sobrinus,
Lactobacilli and others)
that colonize tooth surfaces, feed on
carbohydrates and produce acids as waste
products. These acids dissolve the mineral
content of the tooth, and if not halted
or reversed, a carious lesion is formed.1
The risk for dental caries persists
throughout life. A dynamic balance
exists between pathological factors
that promote caries and protective
factors that inhibit it. Pathological
factors include acid-producing bacteria,
frequent consumption of fermentable
carbohydrates, poor oral hygiene, as
well as subnormal salivary flow and
composition. Protective factors include
normal salivary function, fluoride,
daily thorough oral hygiene, casein
phosphopeptide-amorphous calcium
phosphate paste (GCs Tooth Mousse,
MI Paste and Recaldent) and extrinsic
topical antibacterial substances.1

Carious lesions are termed either

primary (new lesions on previously
unrestored surfaces) or secondary (new
caries around existing restorations).
They occur on the crowns of teeth and
exposed root surfaces. Periodontal disease
results in loss of gingival attachment and
exposure of the tooths root surface. Root
surface cementum and dentin are more
susceptible to cavitation because they are
less mineralized than enamel and begin
to demineralize at a higher salivary pH.
Older adults are retaining an
increasing number of natural teeth, and
nearly half of all individuals aged 75 and
older have experienced root caries. Root
caries is a major cause of tooth loss in
older adults, and tooth loss is the most
significant negative impact on oral healthrelated quality of life for the elderly.2
A false perception exists among dental
professionals and policy makers that dental
caries is, for the most part, only active in
younger people. Several of the clinical,
social and behavioral changes common to
aging predispose older adults to the highest
A U G U S T 2 015 439

root caries
C D A J O U R N A L , V O L 4 3 , N 8

FIGURE 1. Primary root caries under heavy plaque

accumulation: Teeth Nos. 2227.

rates of decay are discussed below. The

need for improved preventive efforts and
treatment strategies for this population
is acute. Better clinical surveillance by
public health agencies will drive decisions
about oral health policy and education.3,5

Prevalence and Risk Factors

The prevalence of untreated root
caries is 12 percent for adults aged
65-74 and 17 percent for those aged
75 and older.5 African Americans and
Mexican Americans experience more
oral health problems, including dental
caries, throughout the life course.
Lower educational attainment is also
strongly associated with increased
oral health problems at all ages
and across all races (FIGURE 1 ).
Aging is often associated with changes
in oral morphology, chronic systemic
disease such as diabetes and decreasing
dexterity, making personal oral hygiene
more difficult, particularly for the oldest
and most frail individuals. The pain
of arthritis and neuropathies make it
difficult to grasp or manipulate a manual
toothbrush. Patients with dementia
experience a higher prevalence of caries
than those without dementia, and the
rates are related to dementia type and
severity. Individuals needing assistance
with oral hygiene and whose caregivers
have difficulties providing effective oral
care experience the highest rates.6
Another risk factor that often
accompanies aging is patients taking
440A U G U S T

2 015

multiple medications. More than 500

medications have the potential to
decrease salivary flow, which leads to
xerostomia and subsequently dental
caries. Other social and behavioral
factors that contribute to the higher
frequency of root caries in older adults
include lack of a perceived need for
dental treatment and a history of
smoking and alcohol consumption.7,8,9
Good oral hygiene is also compromised
by existing dental restorations and the
presence of oral prostheses and appliances.
Wearing a removable partial denture is
associated with higher rates of dental
caries. It is unclear whether this is due to
the initial high caries rate which resulted
in tooth loss or if the denture has a role
in causing caries due to increased root
surface exposure on the abutment teeth,
food impaction and plaque accumulation.4

Caries Risk Assessment

Understanding factors and behaviors
that directly or indirectly impact caries
pathogenesis offers opportunities to
reduce the caries burden of the aging
population. Caries management by
risk assessment (CAMBRA) is a
conservative and effective approach
to prevention and treatment of the
disease across the life course.9 Caries
pathogenesis is recognized as a balance
between protective factors (fluoride,
calcium phosphate paste, sufficient
saliva and antibacterial agents) and
pathological factors (cariogenic bacteria,
inadequate salivary function, poor oral
hygiene and dietary habits especially
frequent ingestion of fermentable
carbohydrates).9 Correctly assessing caries
risk can identify a therapeutic treatment
regimen for effectively managing the
disease by reducing pathological factors
and enhancing protective factors,
resulting in fewer carious lesions.9 With
accurate risk assessment, noninvasive

care modalities (chlorhexidine and

fluoride rinse or varnish) can be used
proactively to prevent carious lesions
and therapeutically to remineralize early
carious lesions. Restorative procedures
for more advanced lesions can be
conservative, preserving tooth structure
and benefiting patient oral health.9
CAMBRA has proven to be a practical
caries risk assessment methodology and
a systematic and effective approach
to caries management. Targeted
antibacterial and fluoride therapy based
on salivary microbial and fluoride levels
has been shown to favorably alter the
balance between pathological and
protective caries risk factors. Caries risk
assessment with aggressive preventive
measures and conservative restoration
has been shown to result in a reduced
two-year caries increment compared
to traditional, nonrisk-based dental
treatment. Altering the caries balance
by reducing pathological factors and
enhancing protective factors, namely
antimicrobial and fluoride rinses, reduced
caries risk and resulted in fewer carious
lesions. Readers are encouraged to
further familiarize themselves with this
research and CAMBRA methodology.1
For the older adult population the
etiology and pathogenesis of dental caries
are known to be multifactorial, but the
interplay between intrinsic and extrinsic
factors is still not fully understood. Caries
research commonly tests an intervention
for a single pathological factor; however,
it is observed that effective caries control
requires a comprehensive and coordinated
approach. The predictors of root caries
most frequently reported in the literature
are caries history, number of teeth
and plaque index.10 In addition to the
pathological factors mentioned in the
introduction to this chapter, patients with
one or more existing carious lesions are
at risk for additional new carious lesions

C D A J O U R N A L , V O L 4 3 , N 8

FIGURE 2 . Tooth No. 11 shows secondary caries

apical to a root carious lesion previously restored

with amalgam.

in the future. Simply restoring a single

lesion does not reduce the bacterial loads
in the rest of the mouth (FIGURE 2 ).
Dental plaque is a complex biofilm
constantly forming and maturing.
It consists of microorganisms and
extracellular matrix including cariogenic
acid-producing bacteria. In high caries
risk individuals the bacterial challenge
must be lowered to favorably alter the
caries balance. Patients with moderate
to high levels of mutans streptococci
and lactobacilli require targeted
antibacterial treatment and fluoride to
combat growth and remineralize tooth
surfaces.1 Recommended regimens are
described in the next paragraph.
Evidence-based clinical
recommendations generally favor fluoridecontaining caries preventive agents,
however, chlorhexidine-thymol varnish
has also been shown to be effective in the
treatment of root caries.15 A 38% solution
of silver diamine fluoride (SDF) applied
annually (Saforide, Bee Brand Medico
Dental, Toyko), or 5% sodium fluoride
varnish applied every three months,11 or
1% chlorhexidine varnish applied every
three months,12 have all been found more
effective in preventing new root caries
than giving oral hygiene instruction
alone.13 Recent recommendations for the
prevention of primary root caries called for
the professional application of 38% SDF
solution annually and 22,500 ppm sodium
fluoride varnish applications every three
months to prevent secondary root caries.14

There is questionable evidence that

xylitol and sorbitol gum can be used
as an adjunct for caries prevention.15
Cariogenic bacteria prefer six-carbon
sugars or disaccharides and are not able
to ferment xylitol, depriving them of
an energy source and interfering with
growth and reproduction. Systematic
reviews of clinical trials have not
provided conclusive evidence that
xylitol is superior to other polyols such
as sorbitol 16 or equal to that of topical
fluoride in its anticaries effect.17

Pathological Factors Versus Protective

Factors Diet
A lifetime of caries and/or periodontal
disease frequently results in tooth loss.
In addition to the reduced masticatory
function accompanying tooth loss,
it is also common for older adults to
experience a diminished ability to taste
food. The resultant dietary shift from
complex to simple sugars promotes caries.
Cariogenic bacteria metabolize sucrose,
glucose, fructose and cooked starches to
produce organic acids that dissolve the
mineral content of enamel and dentin.
The amount, consistency and frequency
of consumption determine the rate
and degree of demineralization. Some
medications and dietary supplements
containing glucose, fructose or sucrose
also contribute to caries risk.15

Genetic Susceptibility
There appears to be variation in
individual susceptibility to caries. Intrinsic
host factors related to the structure
of enamel, immunologic response to
cariogenic bacteria and the composition
of saliva play key roles in modulating the
initiation and progression of the disease.
Genetic variation of the host factors
may contribute to an increased risk for
dental caries. However, the evidence
supporting an inherited susceptibility

to caries is limited. Utilizing the

human genome sequence to improve
understanding of a genetic contribution
to caries pathogenesis will provide a
foundation for future research.18

Saliva contains many important cariesprotective components, such as calcium,
phosphate and fluoride, which are essential
to tooth surface remineralization. Salivary
proteins and lipids form a protective
pellicle on the tooth surface, while other
proteins bind calcium, maintaining saliva
as a supersaturated mineral solution.
Bicarbonate, phosphate and peptides
in saliva provide a critical pH-buffering
function. With age, the amount of saliva
remains stable, however, saliva becomes
thicker due to a reduction in serous
flow relative to the mucous component,
resulting in decreased lubrication or
perceived decreased moistness.

Other than the pre-eruptive
mineralization of the developing
dentition, systemic benefits of fluoride
are minimal. The anticaries effects of
fluoride are primarily topical in adults.
The topical effect is described as a
constant supply of low levels of fluoride
at the biofilm/saliva/dental interface
being the most beneficial in preventing
dental caries. Therapeutic levels of
fluoride can be achieved from drinking
fluoridated water and the use of fluoride
products (toothpaste, rinse, gel, varnish).
Fluoride can inhibit plaque bacterial
growth, but more significantly, fluoride
inhibits demineralization and enhances
remineralization of the tooth surface.1
The most widely used forms of fluoride
delivery have been the subject of several
systematic reviews, providing strong
evidence supporting the use of dentifrices,
gels, varnishes and mouth rinses for the
A U G U S T 2 015 441

root caries
C D A J O U R N A L , V O L 4 3 , N 8

control of caries progression. Dentifrices

with fluoride concentrations 1,000
ppm and higher have been shown to be
clinically effective in caries prevention
when compared to a placebo treatment.
More evidence is needed to determine
the benefits of the combined use of
two modalities of fluoride application
as compared to a single modality.19
Considering the currently available
evidence and risk-benefit aspects,
brushing twice daily with a dentifrice
containing fluoride is one of the most
effective ways to control caries. However,
brushing alone does not overcome a
high bacterial challenge, and additional
fluoride therapy should be targeted toward
individuals at high caries risk. Frequent
topical application of fluoride appears to
be a successful treatment for incipient
root caries lesions by remineralizing
decalcified structure, irrespective of
the type of fluoride treatment used.1

The use of chlorhexidine for caries
prevention has been a controversial topic
among dental educators and clinicians.
Chlorhexidine rinses, gels and varnishes or
combinations of these items with fluoride
have variable effects in caries prevention,
and the evidence is regarded as suggestive
but incomplete. The most persistent
reductions of mutans streptococci have
been achieved, in order of more effective
to less effective, by chlorhexidine varnish
followed by gels and, lastly, mouth rinses.
While chlorhexidine had been widely used
in Europe before gaining FDA approval,
the only chlorhexidine-containing
products currently marketed in the
United States are 0.12% chlorhexidine
mouth rinses. The preferred dosage
regimen for rinsing is once a day with 5
cc of a 0.12% chlorhexidine gluconate
solution for one week every month for
a year.1 Patients should be informed
442A U G U S T

2 015

of the likelihood of dark staining of

their teeth during chlorhexidine use,
and that the staining is easily removed
during a dental prophylaxis. Bacterial
testing should be used to monitor
the clinical success of chlorhexidine
therapy.20 Better antibacterial therapies
for high caries risk individuals are
needed, and they must be combined
with remineralization by fluoride.1
Chlorhexidine is effective at
reducing the bacterial challenge in
high caries risk individuals even when
compliance is problematic. In the

new caries than fluoride varnish, and

may be a valuable caries-preventive
intervention. Possible mechanisms
for SDFs clinical success include its
antimicrobial activity against a cariogenic
biofilm of S. mutans or A. naeslundii
formed on dentin surfaces and slowing
down the demineralization of dentin.21
While SDF is available from international
chemists online and has been shown to
be as safe as fluoride varnish, effective
for treating carious lesions and is
widely used in other countries, it does
not currently have FDA approval.

Clinical Decision Making

Brushing alone does not

overcome a high bacterial
challenge, and additional
uoride therapy should be
targeted toward individuals
at high caries risk.

absence of regular professional teeth

cleaning and oral hygiene instruction,
chlorhexidine varnish may provide
a beneficial effect for frail elders and
patients with xerostomia.20 Cervitec Plus
(Ivoclar Vivadent Inc., Amherst, N.Y.),
a chlorhexidine-thymol varnish, may
help to control established root lesions
and reduce the incidence of new root
caries among institutionalized elderly.
It is the only nonfluoride caries agent
to receive a favorable recommendation
from a panel for caries prevention.13

Silver Diamine Fluoride

Recent interest in the antimicrobial
use of silver compounds suggest that silver
nitrate (SN) and silver diamine fluoride
(SDF) are more effective at arresting
active carious lesions and preventing

Diagnosis of a carious lesion on a

root surface raises ethical and practical
questions. Can the lesion be remineralized
with fluoride therapy or does it require
a restoration? Is it an active or arrested
carious lesion? Is the root caries causing
or likely to cause pain? How do the
risks and benefits to the patient of not
treating a carious lesion compare to those
associated with restoring it? Does the
patient have access to follow-up care?
If the lesion is to be restored, what
technique and material will result in
the best outcome for the patient? What
is the patients ability to maintain the
restoration and what is the future caries
risk? Systemic disease burden, xerogenic
medications, diet quality, salivary function,
manual dexterity, cognitive ability, the
need for caregiver assistance and access
to care all contribute to caries risk.
The literature suggests that there is
a fair agreement between visual/tactile
appearance of caries and the severity/
depth of the lesion. No single clinical
predictor is able to reliably assess the
activity of a carious lesion.10 However, a
combination of predictors increases the
accuracy of lesion activity prediction for
both primary coronal and root lesions.
Three surrogate methods have been used

C D A J O U R N A L , V O L 4 3 , N 8

for evaluating lesion activity (construct

validity); all have disadvantages. If
construct validity is accepted as a gold
standard, it is possible to assess the
activity of primary coronal and root
lesions reliably and accurately at one
examination by using the combined
information obtained from a range of
indicators, such as visual appearance,
location of the lesion, tactile sensation
during probing and gingival health.10
Treating root caries can be technically
challenging. The location of the root
caries may be difficult to access. It often
may extend below the gingival margin,
making it necessary to retract the gingiva
with a clamp, pack retraction cord to
expose the cervical margin of the lesion,
or utilize laser or electrosurgery to
recontour the gingiva and obtain access
to the lesion. One important and relevant
diagnostic consideration is, What is
the clinicians ability to successfully
restore a particular carious lesion? The
location of the carious lesion on the
tooth, the tooths location in the mouth
and the patients ability to cooperate all
contribute to the challenge of placing a
successful restoration. How extensive and
close to the pulp is the carious lesion?
How likely is a pulp exposure and the
subsequent need for root canal therapy?
Will the operator be able to achieve a
dry field and have adequate visualization
and access with a handpiece and/or
instruments? Will conservative caries
removal result in a better outcome for
the patient than aggressive treatment?

Caries Removal
Partial caries removal has been
found to greatly reduce the risk of pulp
exposure.22 For asymptomatic teeth, partial
caries removal generally results in no
detriment to the patient from increased
pulpal symptoms, decay progression
under restorations or premature loss of

restorations.22 When pulpal exposure is a

concern in treating deep lesions, partial
caries removal is the preferred approach.22
In the absence of clinical symptoms
of pulpal involvement, stepwise caries
excavation to stained but firm dentin
followed by the placement a thin liner
of calcium hydroxide or antimicrobials
such as chlorhexidine-thymol varnish
or polycarboxylate cement combined
with a tannin-fluoride preparation,
are all effective in reducing bacteria
and promoting remineralization
of any carious dentin that remains
after the stepwise excavation.23
There is limited scientific evidence
for laser treatment being as effective
as a rotary bur for removing carious
tissue. However, treatment time with
lasers is prolonged compared to using a
traditional handpiece, and to date no
conclusions can be drawn regarding
biological or technical complications or
the cost-effectiveness of the method.24

Restorative Materials: Amalgam,

Composite and Glass Ionomer
The longevity (failure rate, median
survival time, median age) of silver
amalgam fillings has been compared to
direct composite fillings in permanent
teeth. Amalgam fillings have been
shown to have greater longevity than
composite fillings. However, composites
and their adhesives are frequently
replaced by the next generation of
materials with improved properties,
making periodic revisions of these
conclusions necessary.25 Economic
analyses report lower costs for amalgam
fillings because of the higher complexity
of and time needed to place composite
fillings. Resin bonding to dentin or
enamel requires adequate isolation
and saliva contamination control.
This is time consuming and often
difficult to achieve in restoring root

caries lesions at or near the gingival

margin where most occur. Selfetching adhesives provide decreased
clinical application time and reduce
the risk of saliva contamination.25
A 2009 Statement on Dental
Amalgam released by the American
Dental Association Council on
Scientific Affairs remains consistent
with a more recent review of the
international literature on amalgam
toxicity. Various anecdotal complaints
of systemic toxicity because of mercury
release from dental amalgam do not
justify the discontinuation of amalgam
use from dental practice or the
replacement of serviceable amalgam
fillings with alternative restorative
dental materials.26 Available scientific
data show that the mercury released
from dental amalgam restorations does
not contribute to systemic disease
or systemic toxicological effects. No
significant effects on the immune
system have been demonstrated with
the amounts of mercury released
from dental amalgam restorations,
and only very rarely, have there
been reported allergic reactions to
mercury from amalgam restorations.26
No evidence supports a relationship
between mercury released from dental
amalgam and neurological diseases.26
Glass ionomer, resin-modified glass
ionomer and composite resin have been
compared in high caries risk patients.
Both glass ionomer and resin-modified
glass ionomer restorations contain
fluoride and release it into the saliva
and adjacent tooth structure. While
no significant difference in caries
prevention between the two materials
has been observed, reduction in new
caries formation for glass ionomer and
resin-modified glass ionomer restorations
was more than 80 percent greater
than for composite resin restorations
A U G U S T 2 015 443

root caries
C D A J O U R N A L , V O L 4 3 , N 8

FIGU R E S 3AC . Root caries are clinically detectable on most remaining teeth. The clinical crown on tooth No. 11 is completely missing due to caries. The arrow points to

an example of root caries.

caries.30 ART uses a high-viscosity glass

ionomer restoration to restore singlesurface lesions in permanent posterior
teeth, including root carious lesions. There
appears to be no difference in the survival
of single-surface, high-viscosity glassionomer ART restorations and amalgam
restorations in permanent posterior teeth
including Class V root surface lesions.30

Clinical Scenario

FIGURE 4 . Radiographs taken to determine the extent of the carious lesions (see clinical scenario for details).

in the treatment of cervical caries for

head and neck radiation patients with
xerostomia who did not adhere to a cariespreventive fluoride rinse protocol.26,27
Glass ionomer is particularly suitable
for restoring root carious lesions. It
has good esthetic and anticariogenic
properties, allows for chemical bonding to
teeth and has gained wide acceptance in
restoring carious lesions on the accessible
buccal and lingual root surfaces. Minimally
invasive techniques for restoring more
difficult to access interproximal root
surfaces with glass ionomer have been
developed demonstrating a survival rate
of 77.4 percent at 80 months. Caries
removal, complete filling of the resulting
cavity preparation and marginal integrity
444A U G U S T

2 015

as demonstrated by radiographic quality

is the single most important predictor for
restoration survival.23,28 When compared
to amalgam, significantly less secondary
caries has been observed at the margins of
single-surface glass ionomer restorations
in permanent teeth after six years.29

Atraumatic Restorative Treatment

Atraumatic restorative treatment
(ART) is an essential caries management
technique for improving access to oral
care. The approach, initiated 25 years
ago in Tanzania, has evolved into a caries
management concept for improving
quality and access to oral care globally.
Local anesthesia is seldom needed and
only hand instruments are used to remove

The director of nursing in a local

residential care facility requests a
consultation with a dentist for Mrs.
Switzer, who is 86 years old and has a
fractured maxillary left lateral incisor.
Mrs. Switzer was admitted to the facility
three weeks previously with moderate
Alzheimers disease, depression and
severe hypertension. Mrs. Switzer
attended her dentist one month before
entering the facility but did not follow
the dentists recommendations for
periodontal debridement, intracoronal
restorations and a fixed partial denture.
Before this appointment, Mrs. Switzer
had not been to the dentist in two years,
although she claimed to have visited her
dentist frequently over the years before
then. Consequently, she is referred to
the care facilitys dentist for further
assessment and treatment of the fractured
tooth. The dentist examines Mrs.
Switzer to confirm that the maxillary
left canine has an asymptomatic but
complete coronal fracture due to root
caries (F I G U R E S 3AC ). He notes also
that there is copious plaque and food
debris throughout the teeth and mouth.

C D A J O U R N A L , V O L 4 3 , N 8

On questioning, Mrs. Switzer reveals

that she drinks tea sweetened with
sugar constantly for energy and to
be sociable in the facility, and she
takes multiple medications for blood
pressure, depression and occasional
memory loss. The dentist requests the
radiographs be taken before she enters
the facility to determine the extent
of the carious lesions (F I G U R E 4 ).
A diagnosis of extensive root caries
involving all previously restored teeth
is made. A treatment plan of extraction
of the fractured maxillary left lateral
incisor and replacement using an
acrylic removable partial denture is
made. The carious lesions are scheduled
for restoration using resin-modified
glass ionomer material. The patients
daughter is warned that excavation
of the root caries might result in
tooth fracture. If this occurs, then the
fractured teeth would require extraction,
denture teeth could be added to the
acrylic removable partial denture in the
maxilla and/or an additional prosthesis
would be needed for the mandible.
Personalized diet and daily mouth care
counseling is provided to the patient,
daughter and nursing staff. Daily use
of 0.2% neutral sodium fluoride is
prescribed for prevention of root caries.

Future Directions
ART is expected to play a significant
part in essential caries management for
the frail elderly, especially as additional
scopes of practice are more widely
included in an expanded clinical care
team. One of the indications for the
appropriate use of the ART approach
is for the elderly who are homebound
or living in institutions. More studies
are needed to investigate the potential
of ART in providing essential caries
management in this population. However,
field trials report two-year survival

rates of 90 percent with no significant

difference between ART restorations
using high-viscosity glass ionomer and
those produced through the traditional
approach of complete caries removal
using rotary instruments, resulting in a
higher risk of pulp exposure.31 Anecdotal
clinical reports of dentists and expanded
function hygienists and assistants
providing on-site care for nonambulatory
older adults provide support from the field
for this clinical approach. More research
is needed in a clinical randomizedcontrolled trial environment to provide
systematic evidence for this approach.
Reprinted from Geriatric Dentistry: Caring for Our Aging
Population (9781118925454/1118925459) with
permission from John Wiley and Sons.

1. Featherstone JDB, et al. A Randomized Clinical Trial of

Anticaries Therapies Targeted According to Risk Assessment
(Caries Management by Risk Assessment). Caries Res
2. Saunders RH Jr., Meyerowitz C. Dental caries in older adults.
Dent Clin North Am vol. 49, no. 2, pp. 293-308, 2005.
3. Grin S, et al. Estimating rates of new root caries in older
adults. J Dent Res 2004 Aug;83(8):634-8.
4. Thomson WM. Dental caries experience in older people
over time: What can the large cohort studies tell us? Br Dent J
2004 Jan 24;196(2):89-92.
5. Dye BA, et al. Trends in oral health status: United States,
1988-1994 and 1999-2004. National Center for Health
Statistics. Vital Health Stat 11. 2007; Apr(248):1-92.
6. Rethman MP, et al. Nonuoride caries-preventive
agents: Executive summary of evidence-based clinical
recommendations. Dental Association Council on Scientic
Aairs Expert Panel on Nonuoride Caries-Preventive Agents. J
Am Dent Assoc 2011;142;1065-71.
7. Featherstone JDB, et al. Caries risk assessment in practice for age
6 through adult. J Calif Dent Assoc 35(10):703-7,710-3, 2007.
8. ten Cate JM, Featherstone JD. Mechanistic aspects of the
interactions between uoride and dental enamel. Crit Rev Oral
Biol Med 1991;2:283-296.
9. Featherstone JD. The caries balance: the basis for caries
management by risk assessment. Oral Health Prev Dent
2004;2(suppl 1):259-264.
10. Topping GV, et al. Clinical visual caries detection. Monogr
Oral Sci 2009; 21:15-41. Epub 2009 Jun 3.
11. Synopsis of Fluoride Varnishes (Project 06-16) (2/07).
12. Cervitec Plus.
13. Slot DE, Vaandrager NC, Van Loveren C, Van Palenstein
Helderman WH, Van der Weijden GA. The eect of

chlorhexidine varnish on root caries: a systematic review.

Caries Res 2011; 45(2):162-73. Epub 2011 Apr 27.
14. Rosenblatt A, et al. A Critical Summary of: Silver
diamine uoride: a caries silver-uoride bullet. J Dent Res
15. Tan HP, et al. A randomized trial on root caries prevention
in elders. J Dent Res 2010 Oct;89(10):1086-90. Epub 2010
Jul 29.
16. Gluzman R, et al. Prevention of root caries: A literature
review of primary and secondary preventive agents. Spec Care
Dentist 10 Dec 2012.
17. Mickenautsch S, Yengopal V (2012). Eect of xylitol
versus sorbitol: A quantitative systematic review of clinical
trials. Int Dent J 62 (4): 175-88.
18. Shuler, C.F. J Dent Educ. Inherited risks for susceptibility to
dental caries. 2001 Oct;65(10):1038-45.
19. Pessan JP, et al. Topical use of uorides for caries control.
Mono Oral Sci 2011; 22:115-32.
20. Autio-Gold J. The Role of Chlorhexidine in Caries
Prevention. Oper Dent November 2008, vol. 33, no. 6, pp.
21. Chu CH, et al. Eects of silver diamine uoride on
dentine carious lesions induced by Streptococcus mutans and
Actinomyces naeslundii biolms. Int J Paediatr Dent 2012
22. Walls AW, Meurman JH. Approaches to caries prevention
and therapy in the elderly. Adv Dent Res 2012 Sep;24(2):3640. doi: 10.1177/4.
23. Ricketts DN, et al. A Critical Summary of: Complete or
ultraconservative removal of decayed tissue in unlled teeth.
Cochrane Database Syst Rev 2006;3():CD003808.
24. Jacobsen T, et al. Application of laser technology for
removal of caries: A systematic review of controlled clinical
trials. Acta Odontol Scand 2011 Mar;69(2):65-74.
25. Antony K, et al. Longevity of dental amalgam
in comparison to composite materials. Int J Dent
2011;2011:981595. GMS Health Technol Assess 2008 Nov
13;4:Doc12. Epub 2011 Nov.
26. Uar Y, Brantley WA. Biocompatibility of dental amalgams.
Int J Dent 2011;2011:981595. Epub 2011 Nov 23.
27. McComb D, et al. A clinical comparison of glass ionomer,
resin-modied glass ionomer and resin composite restorations
in the treatment of cervical caries in xerostomic head and neck
radiation patients. Oper Dent 2002 Sep-Oct;27(5):430-7.
28. Gilboa I, et al. A longitudinal study of the survival of
interproximal root caries lesions restored with glass ionomer
cement via a minimally invasive approach. Gen Dent 2012
29. Mickenautsch S, et al. Absence of carious lesions at
margins of glass-ionomer cement (GIC) and resin-modied GIC
restorations: a systematic review. J Prosthodont Restor Dent
2010 Sep;18(3):139-45.
30. Frencken JE, et al. Twenty-ve year atraumatic restorative
treatment (ART) approach: A comprehensive overview. Clin
Oral Investig 2012 Oct;16(5):1337-46. doi: 10.1007/
s00784-012-0783-4. Epub 2012 Jul 24.
31. Honkala S, Honkala E. Atraumatic dental treatment among
Finnish elderly persons. J Oral Rehabil 2002;29:435440.
doi: 10.1046/j.1365-2842.2002.00903.x.

Dick Gregory, DDS, can be

reached at
A U G U S T 2 015 445

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C D A J O U R N A L , V O L 4 3 , N 8

Aging Periodontium, Aging

Patient: Current Concepts
Mark Ryder, DMD

A B S T R A C T A functioning natural dentition is essential to maintaining overall

health in the elderly patient. While age-related alterations in periodontal tissues and
the immune system may make an elderly patient more susceptible to periodontal
breakdown, age itself is not a major risk factor for periodontal diseases. Rather,
individual age-associated factors such as systemic diseases, medications and changes
in behavior, motor function and cognitive function should be considered for each
elderly patient when making treatment decisions.

Mark Ryder, DMD, is
the chair of the division of
periodontology and director
of the postgraduate program
in periodontology at the
University of California,
San Francisco, School of
Conict of Interest
Disclosure: None reported.

n the U.S. and most of the developed

and developing world, there is an
increased proportion of the population
that is considered elderly. Numerous
factors, including declining birth rates
and longer life spans because of improved
treatment and prevention measures, have
played a major role in this demographic
shift.1 Along with this demographic
shift there has been a physiological,
psychological and philosophical shift
among practitioners and the public with
the perception of what is considered old
age. Such changes are apparent in the
emergence of concepts of healthy aging2
and the goal of adding life to years rather
than years to life.3 Part of these new
attitudes in improving the quality of the

life for the elderly is the maintenance of a

healthy and functional natural dentition.
Maintenance of a healthy dentition
requires an understanding of the causes,
diagnosis, risk assessment and timely
treatment of the two primary causes of
tooth loss, periodontal disease and caries.
This paper presents the current state of
knowledge and opinion on approaches
to periodontal diseases and periodontal
treatment in the elderly with an emphasis
on consensus, conclusions and future
directions for dental practitioners.
The central question in addressing
the role of aging in periodontal disease
is whether aging itself is a risk factor for
the incidence, severity and progression
of periodontal disease. In other words,
A U G U S T 2 015 447

C D A J O U R N A L , V O L 4 3 , N 8

is periodontal disease a risk factor for

periodontal disease initiation and/or
disease progression? By risk factor we mean
a condition or factor that is associated
with the disease after adjusting for other
contributing factors, such as tobacco use,
plaque levels and systemic conditions, and
has been demonstrated in longitudinal
studies. While it has been demonstrated
from large epidemiological surveys that
the elderly have a higher prevalence
and severity of periodontal diseases,4-6
particularly among African-Americans
and Hispanics,7 as measured by level of
loss of periodontal support when compared
to a younger cohort, these observations
need to be interpreted with caution.
Firstly, employing levels of loss of support
of alveolar bone, clinical attachment
loss, recession, etc. for determining the
incidence and/or severity of periodontal
disease at a single observational time
point does not indicate the presence of
active periodontal breakdown, or the
rate of periodontal breakdown itself.
Determination of active disease or
rate of breakdown would be the most
accurate measures of the presence of
periodontal disease itself. Rather, these
measures from surveys of larger general
populations at a single time point reflect
the long-term cumulative effects of past
periodontal inflammation from bacterial
plaque, as well as the cumulative effects
of physiological and nonphysiological
occlusal forces, psychological stress, oral
habits and hygiene techniques, tobacco
use, medications, compensation for
occlusal wear, continued tooth eruption
and gingival recession.8-10 Secondly,
the attitudes toward the importance of
oral hygiene and importance of both
maintenance by the patient and regular
maintenance by the dental practitioner
have improved over successive generations
of patients.11 Therefore evidence of
loss of periodontal support among
448A U G U S T

2 015

the elderly may reflect in large part

these differences in attitudes in their
younger years with an accumulated
effect toward their current condition.
Thus, the prevailing opinion among
the periodontal research community is
that age alone is not a major risk factor
for the incidence of new destructive
periodontal disease or in its rate of
progression. In a periodontally healthy
elderly patient some gingival recession
and slight horizontal bone loss may be
observed as part of the normal aging
process. However, the susceptibility

Age alone is not a major

risk factor for the incidence
of new destructive
periodontal disease or
in its rate of progression.

of an individual elderly patient to

periodontal breakdown from inflammatory
periodontal diseases is more dependent
on that individual patients biological,
behavioral, medical and pharmacological
considerations that accompany aging.
Specifically, the dental practitioner should
consider four broad areas when assessing
periodontal risks in the elderly patient:
The effects of aging on the
integrity and function of the
periodontal tissues themselves.
The effects of aging on the local and
systemic response to periodontal
plaque biofilm and how this may
manifest in clinical signs of disease.
The effects of systemic conditions
and medication associated with
aging on the incidence, severity and
progression of periodontal diseases.

The effects of aging on motor

function, cognitive function and
behavioral changes that could
affect the ability to remove
bacterial plaque deposits.
Aging and the periodontal tissues. It is
well-known that with aging, the ability
of tissues in the body to regenerate and
repair diminishes over time.12,13 This is
due in part to the reduced ability of cells
to divide, leading to a reduction in the
number of cells in the full range of tissues
in the body. These changes have been
observed in periodontal tissues including
the gingival epithelium, connective
tissues and bone that form the
periodontal complex.12,13 In particular,
the reduction of numbers of fibroblasts
to maintain and repair both gingival
connective tissues and periodontal
ligament may lead to an increase rigidity
and/or loss of elasticity in these tissues.
This loss of elasticity could lead to
a reduced ability of the periodontal
tissues in general and the periodontal
ligament complex in particular to absorb
both natural and nonphysiological
occlusal forces. In addition, the natural
longer-term exposure of collagen in
periodontal connective tissues to free
radicals could lead to damage, reduced
function and/or death of epithelial
cells and to fibroblasts, osteoblasts
and cementoblasts of the periodontal
tissues,13,14 as well as cross linking of
collagen fibers with reduced elasticity
in the periodontal ligament support.
These normal aging changes may
contribute to a small and gradual
reduction in the periodontal support
in the elderly, even in the absence of
a history of periodontal inflammation
due to plaque inflammation.
Aging and host response in periodontal
diseases. As with other tissues of the
body, periodontal tissues require a fully
functional host defense in general,

C D A J O U R N A L , V O L 4 3 , N 8

and immune response in particular, to

defend against microbial pathogens.
A reduction in these host defenses,
or immunosenescence,15 has received
considerable attention over the past
several decades. The rapid first line
of defense against bacterial plaque
known as the innate immunity system,
which includes the epithelial barrier
and normal function of neutrophils to
migrate, engulf and break down bacteria,
as well as the adaptive immune system,
which includes a variety of T and B
lymphocyte responses with production of
antibodies, cytokines and chemokines,
are reduced in the aging process itself.15,16
However, it remains unresolved as
to whether diminished function in
these two immune systems and other
protective host responses in a medically
healthy elderly patient leads to more
severe forms of periodontal disease. In
addition, there are conflicting reports
as to whether older patients have an
altered gingival inflammatory response
in experimental gingivitis studies when
compared to a younger population.13,17
Systemic diseases, conditions and
medications in the elderly and implications
for periodontal diseases. When considering
that the prevalence of chronic
conditions and diseases in the elderly are
higher and that most of these conditions
and diseases require treatment by
medication,3,18 it is understandable that
many of these conditions are associated
with a higher prevalence and severity of
periodontal diseases in this population.
While a complete discussion of these
associations would be beyond the
scope of this review, several examples
can be discussed to demonstrate the
full range of these associations.
For example, with increasing age, the
prevalence of type II diabetes increases.
It is now well-established that less than
optimal glycemic control with these

patients is associated with a higher

incidence and prevalence of periodontal
disease.19 Hormonal changes in elderly,
postmenopausal women increase the
incidence of osteoporosis, which has
also been observed in the alveolar
supporting bone.20 It is associated with
an increased loss of alveolar bone
support while other studies found no
such association in this population.
Medications taken for a variety of
chronic conditions and diseases are
associated with reduced salivary flow18
and increased susceptibility to plaque

The chronological age of

the elderly patient may not
reect the actual overall
physical health, cognitive
function and motor functions
of that particular patient.

accumulation. Older patients may

also exhibit the accumulative effects
of stress, which are associated with an
increased loss of alveolar bone support
and reduced immune function.21 In
addition, the increased prevalence
of depression in the elderly3 may be
associated with both reduced immune
function and poorer plaque control.
Motor function, dementia and
periodontal disease. With the increase
of the proportion of very elderly in the
general population, the prevalence of
impaired mental and motor functions
can lead to both impaired physical and
mental abilities to practice effective
plaque control measures. In addition
to these objective declines in motor
and cognitive abilities in some elderly,
the more subjective self-efficacy of

the individual aging patient should

be taken into consideration.11 Selfefficacy is defined as the self-perception
of the individual patient to control
and modify his or her respective
behaviors to treat and prevent his or
her respective conditions and diseases.
For periodontal diseases, these include
following plaque control regimens,
seeking dental care on a regular basis
and following through on proposed
treatments from the dental practitioner.
Several considerations should
be kept in mind when considering
changes in prevention and therapy of
periodontal diseases for the elderly.
Perhaps the most important of these
is that the chronological age of the
elderly patient may not reflect the
actual overall physical health, cognitive
function and motor functions of that
particular patient. Some clinical thought
leaders have proposed a multipletiered system of the elderly patient,
such as young-old aged, middle-old
aged and old-old aged patient, based
on specific age brackets and/or specific
quality of life and quality of function
measures. It is important to keep in
mind from the previous discussion of
other factors associated with aging,
particularly medical and pharmacological
considerations, that these should be
addressed in any periodontal treatment
plan for the elderly patient.
Among these considerations are
maintaining adequate dietary and
nutrient intake to prevent premature
loss of alveolar bone density and support
through recommended dietary intake
of calcium or calcium supplements
and vitamin D.22 In addition, for
postmenopausal women, there is
sufficient evidence that an estrogen
supplement has beneficial preventive
effects for alveolar bone loss.20 However,
because of the risk of reported adverse
A U G U S T 2 015 449

C D A J O U R N A L , V O L 4 3 , N 8

side effects and events for estrogen,

estrogen supplementation should be
determined for such patients at risk by
their physicians. In addition, chronic
medical conditions that increase
in prevalence with aging and are
associated with increased periodontal
disease and loss of support should also
be controlled in collaboration with
the elderly patients physician. When
considering the strong association of
poor glycemic control with type II
diabetes with periodontal disease,21
appropriate measures should be taken to
assure this condition is under control.
As the prevalence of one or more
chronic conditions requiring medication
becomes increasingly common in this
population, the dental practitioner
should be aware of potential adverse
effects some of these medications have
on the oral cavity in general and the
periodontal tissues in particular.18,23 These
include the range of medications that
result in a reduced salivary flow, which
would make the patient more susceptible
to both periodontal diseases, and
coupled with the increased prevalence
of gingival recession, root caries. Highfluoride rinses, dentifrices and topical
application of fluorides may have
beneficial preventive effects for both root
caries and periodontal diseases. If the
patient is taking a medication such as
some classes of calcium channel blockers
that are associated with the gingival
enlargement, the dentist should also
consult with the physician to explore
alternative medications with the same
systemic beneficial effect but with less
adverse effects on the periodontal tissues.
A second major consideration for
treatment decisions for the elderly
patient is the actual treatment approach
itself. Several practitioners have proposed
the concept that the principal goal of
periodontal therapy in the elderly patient
450A U G U S T

2 015

should focus on maintaining a functional

dentition as opposed to restoring all
teeth to full periodontal health.23,24 This
treatment philosophy implies that given
a young and an old periodontal patient
with the same clinical levels of loss
of periodontal support, the treatment
approach of frequent debridement and
frequent maintenance would be the
preferred approach for the elderly patient
as opposed to debridement followed
by some form of periodontal surgery
for the younger patient. However, this
philosophy should be tempered by the

The dental practitioner

should be aware of potential
adverse eects some of these
medications have on the oral
cavity in general and the
periodontal tissues in particular.

fact that a healthy elderly patient may

have several more decades of a high
quality of life. Furthermore, consensus
opinion from studies comparing the
healing response to periodontal surgical
procedures between older and younger
patients is that the healing responses are
comparable.24 Therefore age itself should
not be a contraindication for performing
surgery, placement of implants, etc.
Nevertheless, medications, oral
habits, systemic factors associated with
the incidence and severity of periodontal
disease in general, and the ability of the
patient to perform regular and effective
mechanical plaque control regimens
still need to be taken into consideration
for treatment decisions. These include
the elderly patients motor ability to
maintain such a plaque control regimen.

It is widely accepted that the success

of any form of nonsurgical and surgical
treatment is primarily dependent on a
patients plaque control regimen. Use of
antimicrobial rinses with demonstrated
antiplaque and antigingivitis activity
can be valuable adjuncts for elderly
patients, particularly those with reduced
motor and/or cognitive function.
Another major consideration for the
decision to perform periodontal surgery
on an elderly patient is whether that
patient is currently taking or has taken
some form of bisphosphonates to protect
against fractures associated with loss of
bone mineral density. Such patients may
be at risk for postoperative osteonecrosis
of the jaw. As most periodontal
surgical procedures are elective, special
considerations and precautions should
be taken in consultation with the
patients physicians for those patients on
intravenous bisphosphonates or for those
patients who are currently taking or have
taken bisphosphonates intravenously,
have taken oral bisphosphonates over a
three year period or longer, have a history
of diabetes or an immunosuppressive
condition or who are taking or
have taken corticosteroids or other
immunosuppressive medications.20
In conclusion, the diagnosis,
treatment planning and treatment
decision for the elderly patient should
take into consideration the known
risk factors for periodontal disease that
are prevalent with higher frequency
in the elderly patient. At present, the
prevailing view is that age itself in a
medically healthy and functional elderly
patient may be of minimal significance
in the treatment of periodontal diseases.
While the American Academy of
Periodontology (AAP) has published
statements and/or position papers on
periodontal considerations in the child
and adolescent population, no similar

C D A J O U R N A L , V O L 4 3 , N 8

resources are currently available from

the AAP for periodontal treatment
considerations for the elderly.
Nevertheless, for the individual elderly
patient, the dental practitioner should
understand and assess the role of other
age-related conditions such as systemic
diseases, concomitant medications
and reduced motor and/or cognitive
function as well as the overall goals or
therapy for that individual patient. Such
an understanding of these treatment
considerations for the elderly patient will
help that patient maintain a functioning
dentition for a higher quality of life.

the intersection of aging and disease. Periodontol 2000 Feb

15. McArthur WP. Eect of aging on immunocompetent and
inammatory cells. Periodontol 2000 Feb 1998;16:53-79.
16. Hajishengallis G. Too old to ght? Aging and its toll on
innate immunity. Mol Oral Microbiol Feb 2010;25(1):25-37.
17. Fransson C, Berglundh T, Lindhe J. The eect of age on
the development of gingivitis. Clinical, microbiological and
histological ndings. J Clin Periodontol Apr 1996;23(4):379385.
18. Ciancio SG. Medications: a risk factor for periodontal
disease diagnosis and treatment. J Periodontol Nov
2005;76(11 Suppl):2061-2065.
19. Boehm TK, Scannapieco FA. The epidemiology,
consequences and management of periodontal disease in
older adults. J Am Dent Assoc Sep 2007;138 Suppl:26S33S.
20. Reddy MS, Morgan SL. Decreased bone mineral density
and periodontal management. Periodontol 2000 Feb

21. Doyle CJ, Bartold PM. How does stress inuence

periodontitis? J Int Acad Periodontol Apr 2012;14(2):42-49.
22. Krall EA, Wehler C, Garcia RI, Harris SS, Dawson-Hughes
B. Calcium and vitamin D supplements reduce tooth loss in the
elderly. Am J Med Oct 15 2001;111(6):452-456.
23. Kamen PR. Periodontal care. Dent Clin North Am Oct
24. Wennstrom JL. Treatment of periodontal disease in older
adults. Periodontol 2000 Feb 1998;16:106-112.
THE AUTHOR, Mark Ryder, DMD, can be reached at mark.


1. Harper S. Economic and social implications of aging

societies. Science Oct 31 2014;346(6209):587-591.
2. Caero C, Matarasso M, Marenzi G, Iorio Siciliano V,
Bellia L, Sammartino G. Periodontal care as a fundamental
step for an active and healthy ageing. ScienticWorldJournal
3. Sternberg SA, Gordon M. Who are older adults?
Demographics and major health problems. Periodontol 2000
Feb 1998;16:9-15.
4. Locker D, Slade GD, Murray H. Epidemiology of
periodontal disease among older adults: A review.
Periodontol 2000 Feb 1998;16:16-33.
5. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ.
Prevalence of periodontitis in adults in the United States:
2009 and 2010. J Dent Res Oct 2012;91(10):914-920.
6. Renvert S, Persson RE, Persson GR. Tooth loss and
periodontitis in older individuals: Results from the Swedish
National Study on Aging and Care. J Periodontol Aug
7. Kim JK, Baker LA, Seirawan H, Crimmins EM. Prevalence
of oral health problems in U.S. adults, NHANES 1999-2004:
Exploring dierences by age, education and race/ethnicity.
Spec Care Dentist Nov-Dec 2012;32(6):234-241.
8. Burt BA. Periodontitis and aging: Reviewing recent
evidence. J Am Dent Assoc Mar 1994;125(3):273-279.
9. Nunn ME. Understanding the etiology of periodontitis:
An overview of periodontal risk factors. Periodontol 2000
10. Ajwani S, Ainamo A. Periodontal conditions among the
old elderly: Five-year longitudinal study. Spec Care Dentist
Mar-Apr 2001;21(2):45-51.
11. Kiyak HA, Persson RE, Persson GR. Inuences on the
perceptions of and responses to periodontal disease among
older adults. Periodontol 2000 Feb 1998;16:34-43.
12. Van der Velden U. Eect of age on the periodontium. J
Clin Periodontol May 1984;11(5):281-294.
13. Huttner EA, Machado DC, de Oliveira RB, Antunes AG,
Hebling E. Eects of human aging on periodontal tissues.
Spec Care Dentist Jul-Aug 2009;29(4):149-155.
14. Reynolds MA. Modiable risk factors in periodontitis: At

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health solutions
C D A J O U R N A L , V O L 4 3 , N 8

Apple Tree Dental: An

Innovative Oral Health Solution
Deborah Jacobi, RDH, MA, and Michael J. Helgeson, DDS

A B S T R A C T The Surgeon Generals Report on Oral Health called attention to

the silent epidemic of dental disease. Older adults and other vulnerable people
continue to suffer disproportionately from dental disease and inadequate access to
care. As a society and as dental professionals, we face multiple challenges to care
for our aging patients, parents and grandparents. Apple Tree Dentals community
collaborative practice model illustrates a sustainable, patient-centered approach
to overcoming barriers to care across the lifespan.

Deborah Jacobi, RDH,
MA, is the policy director
for Apple Tree Dental. She
holds degrees in sociology
and public policy and
health administration from
the University of Wisconsin,
Conict of Interest
Disclosure: None reported.

Michael J. Helgeson,
DDS, is the CEO and
co-founder of Apple Tree
Dental. He completed
his dental degree and a
two-year postgraduate
fellowship in geriatric
dentistry at the University
of Minnesota.
Conict of Interest
Disclosure: None reported.

he July and August issues of the

Journal highlight the multiple
challenges we face as a society
and as dental professionals to
care for our aging patients,
parents and grandparents. We
undoubtedly possess sufficient expertise
to successfully prevent and treat dental
diseases. And yet, older adults and other
vulnerable people continue to suffer
disproportionately from dental diseases.
Apple Tree Dentals (Apple Tree)
Community Collaborative Practice
model illustrates a sustainable, patientcentered approach to overcoming
barriers to care across the lifespan.

Why Apple Tree Dental?

Multiple national organizations
and initiatives have highlighted oral
health as essential to overall health
and called for the development
of safe, effective, accessible and
affordable systems of care (TABLE ).

Driven by unsustainable costs and

unsatisfactory health outcomes, the
three goals for health reform, often
called the triple aim, are to:
Improve the experience of care.
Improve the health of populations.
Reduce per capita costs
of health care.1
Achieving the triple aim for oral
health depends on providing both
appropriate dental care and effectively
influencing the key factors that produce
and maintain health over the lifespan.
These factors include common medical
conditions, health literacy of older adults
and their caregivers and the effectiveness
of daily mouth care routines. While
children and pregnant women have
long been the primary beneficiaries of
most publicly funded dental programs,
and the value of a healthy start for
children is indisputable, there are
multiple reasons that a limited focus on
pediatric benefits is ultimately costly.
A U G U S T 2 015 453

health solutions
C D A J O U R N A L , V O L 4 3 , N 8


Reports Calling for Action on Oral Health



Oce of the Surgeon General. National Call to Action to

Promote Oral Health, 2003

A State of Decay: Are older Americans coming of age without

oral health care? Oral Health America

Dental Crisis in America, Report to the Subcommittee on Primary

Health and Aging From Bernie Sanders

Improving Access to Oral Health for Vulnerable and

Underserved Populations. Institute of Medicine and National
Research Council

Policy Options to Increase Access to Oral Health Care and

Improve Oral Health by Expanding the Oral Health Workforce
Network for Public Health Law Oral Health Care Science and
Law Brief

As baby boomers reach the age of 65,

there are many more elders who have
kept more of their natural teeth and have
much higher expectations regarding dental
care in their old age than did previous
generations.2 Older adults, particularly
those who live in long-term care settings,
suffer disproportionately from active and
untreated mouth infections, aging and
ill-fitting dentures, and impairments in
salivation and masticatory functions. Many
are more dependent upon others for help
with daily mouth care than children are.
They are also more likely to have chronic
conditions, such as diabetes and heart
disease, which are negatively affected by
mouth diseases. Aspiration pneumonia,
a leading cause of hospitalization and
death in elders, has been directly linked
with bacteria from the mouth.3 For
multiple reasons, institutionalized and
community dwelling elders are often
unable to access traditional dental offices
and clinics to the same degree as younger
and much healthier population groups.4
Such access disparities, in combination
with the significant health and financial
consequences of untreated mouth diseases
in vulnerable adults, have come to the
attention of policymakers and funders and
resulted in calls for sustainable oral health
454A U G U S T

2 015

FIGURE 1. Apple
Trees Centers for Dental
Health also serve as
regional hubs for onsite services and care

care delivery models that meet the needs

of underserved populations, including
the rapidly growing population of older
adults and people with disabilities. The
following describes the development and
impact of a successful, replicable approach.

What Is Apple Tree Dental?

Apple Tree is a nonprofit group dental
practice founded in 1985 to address the
unmet dental needs of individuals living
in Minnesota. The mission of Apple
Tree is to improve the oral health of

C D A J O U R N A L , V O L 4 3 , N 8

Number of patients all programs



28,401 individual patients treated in 2014

79,943 dental visits and screenings provided









< 21





FIGURE 2 . 2014 Patients age distribution. Originally founded to serve nursing facility residents, Apple Tree now

serves patients of all ages.


Dollars in millions
















FIGURE 3 . Dental care value: 1986 to 2014. Sustained growth demonstrates the viability of Apple Trees

patient-centered approach to overcoming barriers to care across the lifespan.

all people, including those with special

dental access needs who face barriers to
care. Apple Trees staff works to achieve
its mission by delivering education,
prevention and restorative dental
services to vulnerable populations and
by providing leadership and innovation
to transform the health care system.
Inspired by the Mayo Clinics
nonprofit group medical practice model,
Apple Trees interdisciplinary group
dental practice includes clinical and
support staff working together on the
patients behalf. These teams collaborate
with teachers, nurses, physicians, family
members and other caregivers to restore

and maintain patients oral health

and to share their interprofessional
knowledge and experience.
A volunteer board of directors is
responsible for strategic planning to
meet Apple Trees mission, contributing
expertise in health care administration and
research, dentistry, public policy, nonprofit
governance, early childhood development
and epidemiology. Apple Trees executive
and administrative staff has expertise
in program planning, management and
evaluation, fundraising, finance and
administration, implementing internal
and external education programs, and
promoting policy development and dental

access legislation. Staff work collaboratively

within Apple Tree and create strong,
long-lasting community partnerships to
achieve a common goal of strengthening
and creating healthy communities.
Originally focused on nursing facility
residents, Apple Trees programs have
expanded to reach other underserved
populations in response to requests from
local community leaders. In addition to
establishing its own regional programs
in Minnesota, Apple Tree has assisted
local leaders in Louisiana and North
Carolina to replicate aspects of its model.5
Apple Tree currently has more than
200 paid employees who serve low-income
children and families in rural and urban
areas, veterans, adults with disabilities,
minorities and new immigrants, mental
health patients and elders living in nursing
and long-term care facilities. Apple Tree
provides dental care at regional Centers
for Dental Health (Centers) in Mounds
View, Coon Rapids, Hawley, Madelia,
Fergus Falls and Rochester, Minn., and
recently opened a Center for Dental
Health in San Mateo, Calif. (FIGURE 1 ).
Apple Tree also delivers on-site
dental services year-round at more
than 130 community oral health care
sites including Head Start centers,
schools, nursing facilities and other
long-term care settings. With seamless
integration between care provided
at the Centers and on-site locations,
Apple Tree provides a comprehensive
range of oral health care services
including diagnostic consultations,
preventive, educational and restorative
services. Advanced services provided
include periodontics, endodontics,
prosthodontics and oral surgery. In
2014, Apple Tree provided nearly
80,000 dental visits and screenings for
28,400 patients (F I G U R E 2 ). The value
of dental services delivered in 2014
exceeded $22 million (F I G U R E 3 ).
A U G U S T 2 015 455

health solutions
C D A J O U R N A L , V O L 4 3 , N 8

Partnerships, Policy and Advocacy

Partnership is a hallmark of
Apple Trees approach to care
delivery and policy development.
Successful collaborations with longterm care facilities helped identify
a solution for long-standing barriers
to dental care. For young children,
a partnership with the Minnesota
Dental Association, Minnesota Dental
Hygienists Association and the
Minnesota Head Start Association
expanded the use of collaborative
practice and improved access to care
for Head Start preschoolers statewide.
This effort helped federal officials
recognize the need for new staffing
and care delivery models and allowed
local private dentists and hygienists
to establish collaborative practices
to serve local Head Start programs.
This effort increased the percentage
of Head Start children obtaining
examinations statewide from less than
70 percent to nearly 90 percent.6
Apple Tree is actively involved
in policy development at the state
and national levels including:
California Dental Associations
Phased Strategies for Reducing
the Barriers to Dental Care
in California Access Report
citing Apple Tree Dental
as a potential solution.
Minnesota Dental Association
supporting legislation to improve
public program reimbursement
and workforce innovations.
Minnesota Oral Health Coalition
raising awareness about the
importance of oral health.
American Dental Associations
National Elder Care Advisory
Committee advancing
dental care delivery, education
and research to improve the
oral health of older adults.
456A U G U S T

2 015

FIGURE 4 . Dr. Michael Helgeson, Apple Trees

CEO, with a Mobile Dental Oce used to provide
comprehensive dental care in a variety of settings.

FIGURE 5 . Specially equipped trucks are used to

Administration for Community

Living (formerly the U.S.
Administration on Aging)
Oral Health for Older Adults
Subject Matter Expert Group
developing best practice models.
Special Care Dentistry Association
advocating for dental care for
people with disabilities, older
adults and people requiring
hospital-based dental care.
Apple Tree has been recognized as
a leading model by the American and
California Dental Associations, in the
Surgeon Generals Call to Action and by
national foundations including the Robert
Wood Johnson and Kellogg Foundations.7

From its inception in 1985, Apple

Tree has been recording diagnostic
codes along with billing information
in its custom information systems. The
result is an unprecedented longitudinal
database, which has been used by
researchers to understand the impact of
prevention and treatment on oral health
outcomes for institutionalized elders.8

Education and Research

Michael Helgeson, DDS, the CEO
and co-founder, has lectured widely on
geriatric and special needs dentistry as well
as on the Apple Tree model. With support
from multiple Minnesota Department
of Health Clinical Dental Education
Innovation grants, Apple Tree has offered
new learning experiences in partnership
with the University of Minnesota School
of Dentistry, Minnesota State Colleges and
Universities and other dental education
programs. Dental, dental therapy, dental
hygiene, dental assisting and nursing
students have experienced interprofessional
care for elders and children, oral health
screening and assessment, safe patient
handling, dental laboratory procedures
and the use of telehealth technologies.

transport multiple Mobile Dental Oces to community

sites. On-site care eliminates transportation barriers
common amongst older adults.

How Does Apple Tree Deliver Care?

Although often referred to as a
safety net provider, Apple Tree is
not content to catch people who have
already fallen into a dental access chasm.
Instead, Apple Tree utilizes a proactive,
prevention-oriented, patient-centered
practice approach, called community
collaborative practice, to deliver dental
care and education. Apple Trees delivery
system goal is to reach at-risk individuals
when they are healthy and to provide
education, prevention and restorative
care to keep them healthy. Apple Trees
philosophy is to practice dentistry as an
integrated team of professionals focused
on meeting the needs of children,
adults and elders across the lifespan.
Apple Tree employs unique workforce
teams that include dentists, oral surgeons,
nurse anesthetists, advanced dental
therapists, dental hygienists, dental
assistants, community care coordinators
and lab technicians. Through
collaborative practice, dental hygienists
are able to serve as front line clinicians in
community settings as described below.

C D A J O U R N A L , V O L 4 3 , N 8




FIGURES 6A6C . Apple Trees Centers for Dental Health are equipped to serve people with special needs. Shown here is a ceiling lift used to transfer nonambulatory

patients into a dental chair.

Delivering On-Site Care

Apple Trees on-site services can
be delivered at a wide variety of
community sites within a 60-minute
travel time radius of each Center for
Dental Health (F I G U R E S 4 and 5 ).
Community partnerships allow Apple
Tree to co-locate on-site dental services
within long-term care facilities and other
settings where people live, learn and
receive other health and social services.
Sometimes described as a hub and spoke
delivery system, the model creates an
accessible care network linked via a fully
certified electronic health record (EHR)
and allows multiple points of accessible
care for patients and communities.
Apple Tree uses both lightweight
portable equipment and heavier custom
mobile units to provide on-site care in
shared spaces within long-term care
facilities and other community settings.
Portable dental units are transported
in a car or minivan and used by dental
hygienists to provide preventive services.
For restorative and surgical services,
specially designed trucks can transport
multiple complete Mobile Dental
Offices. In a carefully planned route,
staff truck drivers pick up and drop off
one or more complete Mobile Dental
Offices at each scheduled location in
the afternoon and evening, outside of
normal business hours. On-site dental
care teams provide dental care at each
location for one or more days according
to the number of patients due to be seen.

The Apple Tree Mobile Dental Office

is nearly identical ergonomically and
functionally to the equipment in Apple
Trees Centers. One difference is that
the dental chair and other units are on
wheels so they can be spread out, making
it easier to safely transfer patients to
and from wheelchairs. Dental treatment
may also be provided at a Center, where
operatories are designed to accommodate
wheelchairs, have specialized lifts to
transfer patients into the dental chair
and are equipped for sedation if required
for a successful visit (F I G U R E S 6 A 6 C ).
Long-term care residents in facilities
served by Apple Tree enter the
dental care system through a program
established for all residents and managed
by a dental director. Similar to a nursing
facilitys medical director, Apple Tree
takes on the role of dental director,
working closely with nursing facility staff
to establish programs and processes that
help ensure that every residents oral
health needs are met. The Minimum
Data Set (MDS) is a standardized health
assessment instrument used to assess the
overall health of older adults admitted
to nursing facilities. Research has
documented that oral health conditions
are typically underreported when the
MDS is completed by nurses or aides,
that the majority of dependent residents
are resistant to daily oral care and also
suggests that most receive inadequate
oral health care.9 To provide accurate
oral health assessments, Apple Trees

on-site dental hygienist becomes part

of the nursing facilitys assessment team
and is responsible for completing the oral
health portions of the MDS. In addition,
the hygienist develops a personalized
daily mouth care plan for each new
resident, coaches facility caregivers on
how to care for residents teeth and
dentures, triages residents needing
follow-up care and provides periodic inservice education for the facilitys staff.
For nursing facility residents choosing
Apple Tree as their dental provider,
community care coordinators on staff
at Apple Tree take all necessary steps
to obtain consent for treatment from
the responsible party, facilitate and
document needed medical-dental
consultations and schedule on-site
dental appointments for treatment.
On-site dental treatment is scheduled
on a regular basis throughout the year
by a consistent team ensuring timely
care and strong patient-provider
relationships. When residents have
extensive disease or special needs,
they may also be scheduled at a nearby
Apple Tree center, where care can be
seamlessly provided using the same EHR.

A Sustainable Solution
High levels of uncompensated care
associated with Medicaid and uninsured
populations make it difficult or impossible
for most private practices to accept
significant numbers of public program
and low-income patients. In order to
A U G U S T 2 015 457

health solutions
C D A J O U R N A L , V O L 4 3 , N 8



Grants and gifts





Private pay



FIGURE 7A . 2014 gross revenues by source.


FIGURE 7B . 2014 net revenues by source.

FIGURES 7A and 7B . Comparison of gross and net revenue sources reveals the low reimbursement levels paid
by public insurance programs.

serve these populations, Apple Tree has

developed multiple funding streams to
support a sustainable business model.
Earned revenue, including insured
and full-pay patients, is supplemented
with federal, state and local foundation
grants, corporate support and individual
gifts (FIGURES 7A and 7B ).
Apple Trees nonprofit status
and delivery model keep costs low
and allow fundraising efforts to help
fill the uncompensated care gap.
Innovative collaborative practices
allow services to be provided in shared
spaces, with shared staffing leveraging
community resources and eliminating
transportation barriers (F I G U R E 8 ).
According to the Institute of
Medicines 2011 report, Improving
Access to Oral Health for Vulnerable
Populations,10 to be successful, an
evidence-based oral health system will:
Eliminate barriers that contribute
to oral health disparities.
Prioritize disease prevention
and health promotion.
Provide oral health services
in a variety of settings.
Rely on a diverse and expanded array
of providers who are competent,
compensated and authorized to
458A U G U S T

2 015

provide evidence-based care.

Include collaborative and
multidisciplinary teams working
across the health care system.
Foster continuous improvement
and innovation.
All these markers of success are
evident in Apple Trees founding
mission and the evolution of its model.
With a culture of patient-centered
innovation, Apple Tree has continually
incorporated new providers, new
technologies and evidence-based
services into its practice. The provision
of on-site care by interdisciplinary
teams eliminates transportation
barriers and helps integrate oral health
with other health care services.


FIGURE 8 . 2014 expenses by category.

Management and fundraising make up a small portion
of Apple Trees expenses.

4. Dolan TA, Atchison K, Huynh TN. Access to Dental Care

Among Older Adults in the United States. J Dent Educ 2005
69(9), 961-974.
Accessed April 30, 2015.
Page.html. Accessed April 30, 2015.
7. U.S. Department of Health and Human Services. A
National Call to Action to Promote Oral Health. Rockville,
Md.: U.S. Department of Health and Human Services, Public
Health Service, Centers for Disease Control and Prevention,
National Institutes of Health, National Institute of Dental and
Craniofacial Research. NIH Publication No. 03-5303, May
8. Smith BJ, Shay K. What predicts oral health stability in a
long-term care population? Spec Care Dentist 25(3): 150157, 2005.
9. Thai PH, Shuman SK, Davidson GB. Nurses dental
assessments and subsequent care in Minnesota nursing
homes. Spec Care Dentist 1997 Jan-Feb;17(1):13-8.
10. Institute of Medicine and National Research Council
(2011). Improving Access to Oral Health for Vulnerable
and Underserved Populations. The National Academies
Press, Washington D.C.
oralhealth/improvingaccess.pdf. Accessed April 30, 2015.


1. Berwick DM, Nolan TW, Whittington J. The Triple Aim:

Care, Health and Cost Health A (Millwood). 2008 MayJun;27(3):759-69. Institute for Healthcare Improvement
(IHI), The Triple Aim Initiative.
Initiatives/TripleAim/Pages/default.aspx. Accessed April
30, 2015.
2. CDC. Public health and aging: Retention of natural
teeth among older adults United States, 2002. MMWR
3. van der Maarel-Wierink CD, Vanobbergen JN,
Bronkhorst EM, Schols JM, de Baat C. Oral health
care and aspiration pneumonia in frail older people:
A systematic literature review. Gerodontology 2013


Deborah Jacobi, RDH, MA, can

be reached at

C D A J O U R N A L , V O L 4 3 , N 8

National Resources for the

Oral Health of Older Adults
Compiled by Susan Hyde, DDS, MPH, PhD, FACD




ADAs Dentistry in Long-Term Care (LTC) Course

Online C.E. course on how to successfully practice in LTC facilities.

Geriatric Oral Health

Online learning and case studies on various geriatric oral health topics.

Oral Health and the Older Adult

Online C.E. oered by Crest and Oral-B.

Nursing Home Oral Health

How to train caregivers to provide daily mouth care.

Oral Care in Continuing Care Settings

Oral care for frail and dependent older adults.

American Geriatrics Society Beers Criteria

Medications that older adults should avoid or use with caution.

Cognitive Status: Legal Implications and Informed Consent

Surrogate decision-makers with legal guardianship or durable health
care power of attorney.

Incurred Medical Expense Regulations

How to bill Medicaid for dental services for long-term care residents.


Smiles for Life: A National Oral Health Curriculum

Interprofessional modules on oral health across the lifespan.

Association for Prevention Teaching and Research

Interprofessional modules on oral health across the lifespan.

Portal of Geriatrics Online Education

Interprofessional evidence-based educational materials for
teaching geriatrics.


Patient Education for the Older Adult

Age-related mouth changes, oral-systemic connections, access to care,
caregiver oral hygiene instructions.

A U G U S T 2 015 459

Specializing in selling and appraising dental practices for over 40 years!



CANOGA PARK (GP) Price Reduced!! Seller is

currently working 1 day/wk with day of hygiene. 2
equipped operatories. Property ID #4357.

ANAHEIM Leasehold Improvements & Equipment

Only! 4 equipped operatories in a 1,680 sq oce.
Property ID #4535.

CHATSWORTH (GP) Price Reduced!! 5 equipped

operatories. Grossed $918K in 2013. Projec ng
approx. $948K for 2014. Buyers net of $398K.
Property ID #4537.

ALISO VIEJO (Pedo) 3 chairs in open bay, 1

plumbed not equipped op. Grossed approximately
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FULLERTON (GP) Established in 2002. Projec ng
$554K for 2014. Buyers net of $189K. Property ID

LOS ANGELES 65 years of goodwill Grossed approximately $350K in 2013. Buyers net of $71K.
Please contact your CPS Agent for more details.
Property ID #5008.

FULLERTON Leasehold Improvement and Equipment! On one the busiest intersec ons of Fullerton.
3 equipped operatories. Some pa ent charts included. Property ID #5028.

LOS ANGELES - This prac ce with over 30 Years of

goodwill, and approximately 60% of it's income
comes from capita on. Property ID #5012.

MISSION HILLS - Leasehold Improvements & Equipment Only! 8 equipped Property ID #5014.
MONTEREY PARK (GP) Leasehold Improvements
& Equipment Only! 3 equipped operatories.
Property ID #4449.
PASADENA (GP) - 3 equipped ops. Grossed approximately $335K for 2014. Property ID #5035.

SAN DIEGO COUNTY - Mul -Specialty prac ce. 7

equipped operatories in an approximately 4,464
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IRVINE - Leasehold Improvement and Equipment!

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RANCHO SANTA MARGARITA Leasehold Improvement Only!! 4 plumbed not equipped operatories.
Property ID #4483.

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Reestablished the prac ce in September 2013.
Great opportunity for a 1st me buyer. Property ID


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ORANGE COUNTY PERIO Price Reduced!! Grossed

approximately $972K in 2013 and projec ng approximately $1,016,000 for 2014 with a Buyers net of
$260K. Please contact your CPS Agent for more
details. Property ID #5005.

ROSEMEAD 2 equipped operatories, lab/

steriliza on room, x-ray room, dark room and
private oce in a 790 sq suite. Projec ng approximately $119K for 2014. Low Sale Price! Property ID

TORRANCE 5 equipped ops. Grossed approximately $493K for 2014. Property ID #5036.

EL CENTRO (GP) This prac ce is located in a

single story building. Building is for sale. 5
equipped operatories. Grossed approximately
$304K for 2014. Buyers net of $132K. Property ID

HUNTINGTON BEACH - Leasehold Improvement and

Equipment Only! Modern Design. 3 equipped ops, 1
plumbed not equipped. Was built in June 2014.
Property ID #5032.

LAGUNA HILLS 2 equipped ops. Approximately 2025 new pa ents/mo. Ins/Cash/Cap (~$500/mo).
Grossed approximately $319,024 in 2014. Property
ID #5033.

RESEDA 3 equipped operatories (stand up den stry). Projec ng approximately $292,796 for 2014
with monthly revenues of $24K. Property ID#5017.

TORRANCE 3 equipped operatories, Grossed

$321,051 in 2013. Prac ce is averaging $28K in
monthly revenue. Property ID #4477.

VISTA - 35 years of goodwill. 4 fully computerized

equipped operatories. Grossed approximately
$883K in 2013. Has monthly revenues of $73K.
Property ID #4507.

GARDEN GROVE 4 equipped ops and 1 plumbed

(not equipped) op. Grossed approximately $436K in
2014 Property ID #5043.

LOS ANGELES (GP) - 3 equipped operatories with

digital x-rays in a 1,000 sq . oce. The recep on
area was recently remodeled. Grossed approximately $277,130 in 2014. Property ID #5040.

SANTA MONICA - 3 equipped operatories. Grossed

$265,485 in 2013 and projec ng approximately
$265,796 for 2014. Property ID #5022.



SAN LUIS OBISPO COUNTY 6 equipped ops. Has
monthly revenues of $90K. Property ID #5037.
VENTURA (GP) - 4 fully equipped operatories in a
1,862 (+ free bonus room) sq suite. Each operatory
has floor to ceiling windows for plenty of natural light .
Grossed approximately $423K in 2014. Property ID

Visit our Website and Social Media

pages for Pracce Photos and Videos

HESPERIA (GP) 4 equipped operatories. Seller

works 3 days/wk with 3 days of hygiene Grossed
$260K in 2013 and projec ng approximately $336K
for 2014. Property ID #5007.
INDIAN WELLS Leasehold Improvements and
Equipment Only!! Great opportunity for a TMJ,
Sleep Apnea and GP. 4 equipped ops. Property ID
PALM DESERT 5 equipped ops. Have monthly
revenues of approximately $28K/mo. Property ID
PALM SPRINGS 3 equipped operatories with
Prac ce Web so ware and digital x-ray. Major
equipment is approximately 2 years old. Suite is
1,200 sq . Seller is working 5 days/wk and sees
approximately 8-10 pa ents/day. Income source is
approximately 25% insurance, 65% cash and 10%
Den -cal. Does li le adver sing. Please contact
your CPS Agent for more informa on. Property ID
RIVERSIDE 6 ops. Projec ng approximately $550K
for 2014. Property ID # 5006.



Phone: (714) 639-2775

CA DRE #00491323

RM Matters

C D A J O U R N A L , V O L 4 3 , N 8

Accounting Controls Can Prevent Dishonest Behavior

TDIC Risk Management Sta

mbezzlement is typically
defined as the theft of money
or property by a person trusted
with those assets. It usually
occurs in employment settings,
and small businesses suffer more losses
from fraud than larger organizations,
according to the Association of
Certified Fraud Examiners.
Analysts with The Dentists
Insurance Company say dentists may
inadvertently put their practices at risk
for fraud by trusting a single employee
with sole financial responsibility or
by not reviewing accounts payable
and receivable. However, this
vulnerability can be reduced through
awareness of red flag behaviors and
a few key accounting protections.
Fraudulent activity can happen
in a number of ways, and TDIC case
studies show instances of employees
deleting appointment and ledger entries,
endorsing patient checks to personal
accounts, forging payroll checks,
modifying payroll, misappropriating
a credit card and using a signature
stamp without authorization.
Jennifer Duggan, a Northern
California attorney specializing in
business and employment law, says
there are also more sophisticated
schemes in which employees fabricate
fictitious vendors, create nonexistent
employees, receive kickbacks from
patients or from vendors for awarding
company contracts or actually coerce
subordinate employees to carry out theft.
Sometimes employees forge
signatures on checks and sometimes
the employees are authorized
signatories, said Duggan.
Duggan notes that the thief is more
often than not a highly trusted employee.

The employee is viewed

within the practice as
a loyal, trusted, giving
individual and would be
last on a list of people
you might suspect.

The prototypical thief is a longtime employee who is extremely

familiar with the financial aspects
of your business. He or she interacts
with clients and vendors, and may
handle or process accounts receivable,
accounts payable or banking
functions for the practice, she said.
The employee is viewed within the
practice as a loyal, trusted, giving
individual and would be last on a
list of people you might suspect.

You are not a policy number.

And at The Dentists Insurance Company, we wont treat you like
one because we are not like other insurance companies. We were
started by, and only protect, dentists. A singular focus that leads
to an unparalleled knowledge of your profession and how to best
protect you. It also means that TDIC is in your corner, because with
us, youre never a policy number. You are a dentist.

Contact the Risk Management Advice Line at 800.733.0634.

Protecting dentists.
Its all we do.

A U G U S T 2 015 461

A U G . 2 0 15

C D A J O U R N A L , V O L 4 3 , N 8

This creates a delicate situation

for practice owners, but experts say
basic awareness of red-flag behavior
keeps employers from having to be
unnecessarily suspicious. Red flags
include an ever-present employee
who comes in early or stays to close
up after everyone else has gone home
or someone who regularly refuses to
take a vacation. Illicit activity may
surface if the employee is required to
be away from work for a week or two
and is not able to cover up the trail
of fraud. Other things to be aware of
are financially frustrated employees
who are always short on cash or
territorial employees who refuse to

cross-train coworkers. Analysts say

one red flag is not typically cause
for alarm, but a combination of
these behaviors warrants concern.
TDIC analysts say practice
owners lose more than money when
fraud shatters the family feeling
and trust in the office. When an
employee steals from the practice
owner, the owner feels betrayed and
can have a hard time recovering
from that, notes a senior analyst.
By implementing accounting
controls, small business owners
can significantly reduce the
chances of becoming a victim of
employee theft, Duggan says.

Simply reviewing your bookkeeping structure and implementing

accounting measures will greatly
reduce the probabilities of falling
victim to employee theft, she
said. Instituting controls also
communicates to employees that you
are paying attention and discourages
even the thought of stealing.
Accounting controls for dental
practice owners include:
Avoiding single-person control
of all of the practices financial
dealings. Separating tasks,
such as opening incoming mail
and data entry for deposit and
receivable information, minimizes
the possibility of an employee
manipulating account information.
Separating job functions of
reviewing monthly bank statements
and preparing monthly bank
reconciliations. If you have
multiple authorized signers,
separating the job functions of
preparing the checks and signing
the checks reduces risk. If you use
online banking, separating the job
functions of entering payments and
reconciling monthly activity is key.
Requesting that the bank mail
statements to your home or
personal email address and
reviewing statements regularly
for unusual accounts payable
names or other inconsistencies.
Securing company checks
in a location accessible only
to authorized employees.
Requiring supporting
documentation (a vendor invoice
or credit card statement, for
example) for every check you
sign and reviewing supporting
documentation to ensure the
expenditure is justified.

462A U G U S T

2 015


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

If I decide to assist the Buyer with financing, how can I be
guaranteed payment of the balance of the sales price?
Can I sell my practice and continue to work on a part time basis?
How can I most successfully transfer my patients to
the new dentist?
What if I have some reservation about a prospective
Buyer of my practice?
How can I be certain my Broker will demonstrate
absolute discretion in handling the transaction in all
aspects, including dealing with personnel and patients?
What are the tax and legal ramifications when a
dental practice is sold?



Can I afford to buy a dental practice?


Can I afford not to buy a dental practice?


What are ALL of the benefits of owning a practice?




What kinds of assets will help me qualify

for financing the purchase of a practice?
Is it possible to purchase a practice
without a personal cash investment?


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


What are the tax consequences for the Buyer when purchasing a practice?

Lee Skarin & Associates have been successfully assisting Sellers and Buyers
of Dental Practices for nearly 30 years in providing the answers to these and other
questions that have been of concern to Dentists.
Call at anytime for a no obligation response to any or all of your questions
Visit our website for current listings:


CA DRE #00863149

A U G . 2 0 15

C D A J O U R N A L , V O L 4 3 , N 8


Running an accounts payable

history to review invoice
numbers and amounts.
Providing specific instructions
or guidelines to your bank
including a list of your approved
vendors and authorized signers.
Watching for an increase in
patient refunds, adjustments or
bad-debt write-offs. An unusual
number of accounts turned over to
a collection agency and a decline
in the gross income or profitability
of the practice is suspicious.
Discrepancies between accounts
receivable records and patient

statements should also be suspect.

Noticing any increase in patient
complaints regarding their
accounts, which could indicate
fraudulent activity or a need
to develop a policy clarifying
account procedures with patients
and staff. Reviewing and
responding to patients concerns
personally is recommended.
If you discover facts indicating
that you are the victim of employee
fraud, call TDIC immediately. Trained
analysts will discuss the situation with
you, including documentation of the
fraud. Practice owners with evidence

of fraud should also be prepared to call

the police. TDIC offers identity theft
recovery for the individual dentist
under its Professional Liability policy.
The business owners property policy
covers employee dishonesty. In order
for coverage to be effective, practice
owners must file a police report and
submit it to the claims department.
Contact TDICs Risk Management
Advice Line at 800.733.0634.

Visit ZZZ'HQWDO3RVWQHW to learn more

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464A U G U S T

2 015

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Specialists in the Sale and Appraisal of Dental Practices

Serving California Dentists since 1966

How much is your practice worth??

Selling or Buying, Call PPS today!


Visit us at CDA Booth #1414


(415) 899-8580 (800) 422-2818
Raymond and Edna Irving

) 832-0230
832 0230 (800)
(800 695-2732
Thomas Fitterer and Dean George

California DRE License 1422122

California DRE License 324962

6090 SANTA ROSA Entry level opportunity includes 1,200 sq.ft. condo.
On relaxed schedule, PPO practice collected $274,000 in 2014 with Profits
of $154,000 with no rentH[SHQVH. Near Memorial Hospital.
6089 MOUNT SHASTA Small town living renowned for mountain
recreation, lakes & streams, fishing, golfing and abundant culture. Perfect
escape from the Rat Race and corporate intrusion. On 3-day week,
revenues topped $800,000 in 2014.
6088 SANTA CRUZ Well established, lots of patients. Strong Hygiene
Department with 6.5 days of hygiene per week. Collected $600,000 in
2014. 2015 trending $675,000+. Full Price $375,000.
6087 LAKE TAHOE - NEVADA'S STATELINE Located adjacent to
California's South Lake Tahoe. Out-of-Network practice. Collections
last year topped $600,000 with Available Profits of $220,000. 3.5 days of
hygiene per week. Escape California income taxes!
$2 Million. 7 Doctor days per week. Seller can work back. Beautiful 8-Op office.
6081 SANTA CLARA El Camino Real location. 2014 collected
$687,000. Available Profits of $305,000. 2-days of Hygiene. 5-ops in
1,700 sq.ft. Extend hours and revenues shall increase.
6080 SAN RAMON 8+ days of Hygiene. $450,000 invested in 6-Op
office. Consistent $900,000+ per year performer. Attractive transition
arrangements available.
Strong performer on Owners 24 hour week. 2014 collected $676,500.
Patient foundation anchored by 4-days of Hygiene. Endo and OS referred.
Renowned Medical Village has regional draw.
6078 FRESNO Strip center practice on West Shaw Avenue. 2014s
Collections totaled $383,000 with Profits of $192,000. Practice will do better
with Successor who devotes full attention here. 4-Ops. Full Price $245,000.
Highly regarded and located in desirable family area. On 3.5 day week,
revenues were $1 Million in 2014 with profits of $400,000. Beautiful facility
with 4-Ops.
6075 MONTEREY BAY AREA SOLD Digital, paperless and well
positioned for future. 2014 collected $1.47 Million with Profits of
$690,000. 7+ days of Hygiene. First Quarter of 2015 collected $449,000.
Extremely unique opportunity.
6071 CHICO Strength is 4-day Hygiene schedule. Retiring DDS focuses
on restorative. Endo, OS, Perio & Pedo referred. 2014 collected $450,000.
Beautiful 4-Op office. Full Price $150,000.
6070 VISALIA Strong foundation and well-positioned for ambitious
successor. Strong Hygiene Department, beautiful facility, well equipped.
Digital throughout. Not a Delta Premiere practice.
Strong foundation for DDS desiring quality restorative practice. $310,000
invested here. Digital and paperless. 2014 collected $400,000. 2XWRI
Network practice. Considerable transition assistance available. Full
Price $185,000.

ANAHEIM HILLS Group member wanted. Hi identity. GP has

space to share with Specialist. Pedo, Ortho or ?
ARROWHEAD Great mountain practice. Hi identity location.
Conservative part-time owner with Associate grosses $4250,000. 3,000
patients. 4-ops. Digital x-rays. Practice $350K and RE $250K.
BAKERSFIELD AREA Small town. 4-op practice with building. Full
Price $350,000 includes real estate. Renovations make property look
BAKERSFIELD Lady DDS grosses $800,000. Low overhead. Full
Price $550,000.
CLAREMONT-UPLAND  Gross $500,000+. Refers $250,000 in
Ortho, OS, Endo. Hi identity. Seller can work back if acquired by
DENTAL LOCATIONS Bell and Bell Gardens.
DENTURE PRACTICE Sees 30 denture patients per day. Perfect
for Prosthodontist.
DIAMOND BAR Part-time practice. Grosses $400,000. Great
opportunity. Full Price $360,000.
HAWTHORNE Located in strip center at busy intersection. 6-ops,
2 equipped in 1,600 sq.ft. suite. Full Price $95,000.
IRVINE Part-time practice is grossing $400,000. Beautiful office.
Full 3rice $360,000.
LAKE FOREST 7 ops across street from major employer in
Orange County.
LOS ANGELES HMO practice doing $4.15 Million. $33,000 per
month in cap checks. Includes real property.
MISSION HILLS Grossed $350,000, nets 50%. Senior DDS wants
to work-back 2.5 days. Seller will finance.
REDLANDS Full 3rice $35,000. 25-year phone number and fictitious
business name. Great rehab opportunity which will grow with TLC.
REDLANDS Low overhead. 5- Ops. Should do $300-to-$400K first
year with little marketing. Great Lease at $1.00 sq. ft. FP $250,000.
RIALTO Dental building on 2.3 acres. Land shall soon have
$8,000SHUmonth in rental income.
RIVERSIDE Walmart Location.
SAN DIMAS HMO $8,000 month in cap checks. Hi Identity
shopping center. Refers a lot. Specialist OK.
TORRANCE Grosses $300,000 with older DDS. 3-ops plumbed,
2 equipped. Beautiful A Class building. Full Price $250,000.
TUSTIN Free standing dental building with 5 ops. Full Price $1.4
TUSTIN Best Location in city Hi identity corner. Double your volume.
WEST L26$1*(/(6 Grosses $1.2 Million. Seeks Korean Lady
DDS for specialty team. Plan to grow to $2 Million per year. Quality
office. Full Price for 1/3 of goodwill $350,000.
YUCCA VALLEY Hi identity location. Small office. Used to do
$500,000. Needs TLC. Full Price $150,000 includes building.


120+ years of combined expertise and experience!

3,000+ Sales - - 10,000+ Appraisals
PPS Representatives do not give our business name when returning your calls.


Making your transition a reality.

Dr. Lee
LIC #01801165

Dr. Thomas
LIC #01418359

Dr. Dennis
LIC #0123804

Dr. Russell
LIC #01886221

LIC #01898522

LIC #01382259

LIC #01423762

LIC #01927713

LIC #00411157

LIC #01863784

(949) 675-5578
25 Years in Business

(916) 812-3255
40 Years in Business

(209) 605-9039
36 Years in Business

(619) 694-7077
33 Years in Business

(925) 330-2207
42 Years in Business

(949) 566-3056
35 Years in Business

(949) 675-5578
35 Years in Business

(949) 675-5578
26 Years in Business

(951) 314-5542
25 Years in Business

(949) 675-5578
11 Years in Business


BAY AREA: Perio Practice. 2,120 sq. ft.
w/6 Ops, Digital, Endoscope, Piezosurgery,
Dentrix. #CA167
CASTRO VALLEY: Practice & Building.
Approx. 1,800 sq. f.t, 3 Ops, 1 addl
Plumbed. 2014 GR $373K, 4 day week.
ft. w/3 Ops, Digital X-rays & Pano, new
compressor #CA209
Practice. 7 Ops, 3,079 Sq. Ft. (Shared w/2nd
DDS Separate Practices), 2013 GR $974K.
GREATER SAN JOSE: Perio Practice.
Fiscal-year GR $1.3MM. 5 Ops, 2 addl
Plumbed, in same loc. 28 years. #CA219
MARIN COUNTY: Mill Valley 1,260 sq.
ft. 3 Ops, 1 addl Plumbed. Dentrix, Digital,
Intra-Oral. #CA224 IN ESCROW!
MENDOCINO COAST: General Practice.
4 Ops, 2,376 Sq. Ft. Dentrix, CAD/CAM.
2013 GR $1M+. #CA181
with 5 Ops, 1 additional Plumbed, state-ofthe-art equipment. 2014 GR $670K. #CA262
N. COAST: Endo Practice. 6 Ops, 5
Plumbed 3,300 sq. ft. Digital, Microscopes,
EndoVision. #CA214
General Practice + Bldg. 7 Ops. 2,324 Sq. Ft.
2012 GR $885K. #CA108
Practice, Partnership Position. 6 Ops, 1,500
Sq. Ft. Dentrix. Owner Financing Available.
Practice. 3 Ops, 1 Plumbed, 1,200 Sq. Ft.
2 Microscopes, Digital. 2013 GR $319K+
Practice. 4 Ops, 1 Addl Available, 1,021 Sq.
Ft. 2013 GR $337K #CA169
w/4 Ops. Intra-Oral, Digital X-ray, Pano,
Laser, CAD-CAM, Dentrix software.
2014 GR $1M. #CA260
PLEASANTON: Facility Only, Former
Endo Ofc, Good GP Startup. 2 Ops, 1
Plumbed & Partially Eq. 975 Sq. Ft. #CA195
SACRAMENTO: 7 Equip Ops in 2,400
sq. ft., 1 addl Op Plumbed. Pano, Softdent,
Digital. 2014 GR $626K+. #CA250
SACRAMENTO: Prosth. Practice. OWNER
DECEASED. 4 Ops, 2,075 sq. ft. w/Digital
Pano & Mac Practice software. 2014 GR
$960K+. #CA247

SACRAMENTO: 7 equip Ops in 2,400

sq. ft., 1 addl Op Plumbed. Pano, Softdent,
Digital. 2014 GR $626K+. #CA250
SAN FRANCISCO: Practice and
Eaglesoft software. 2014 GR $650K.
Dentistry. 3 Ops, 1,100 Sq. Ft., Schick
Digital. Dentrix. GR $338K #CA550
SANTA ROSA: General Dentistry &
Building. 3 Ops. 2013 GR $542K w/Adj. Net
$182K #CA200



Prosth Practice. 3 Ops, Full Lab. 2013 GR
$399K w/Adj. Net $143K #CAM540

CENTRAL COAST: 6 Ops, 8 days of
hygiene/wk. 2013 GR of $2.3M and $804K
in adj. net. Dentrix, Digital, Paperless.
FRESNO: General Dentistry Partnership.
2013 Partnership GR $4.7M. Selling Partner
2013 Net Inc $368K. #CA196

FRESNO: 5 Ops, 4 Equipped, 1,400 sq.

ft. w/Pano, Dentrix, all digital. 3 years GR
averaging $409,000. Priced to sell. #CA243



Ops, Pano, established for 50+ years. GR of
$246K in 2014. #CA265
PORTERVILLE: General Dentistry, 6 Ops.
2014 GR $555K, 7 year old equipment, retail
center. #CA223

ANAHEIM: General Practice & Bldg.
6 Ops, 3 Equipped, 3 Plumbed. Near
Disneyland. Est. 39 years. #CA186
ANAHEIM: 4 Ops, 5 addl available,
SoftDent, Digital X-Rays and Digital Pano.
2013 GR 237K. #CA207
BAKERSFIELD: General Practice. 4 Ops.
Pano. Est. 20+ Years. 2013 GR $521K.
BALDWIN PARK: General Practice. 5
Ops, 4 Equipped. 2014 GR $276K. #CA176
BANNING: General Practice. 6+ Ops.
Paperless, Digital, EagleSoft. 8 Days Hyg/
Week. 2014 GR $1.4MM+. #CA183
BEVERLY HILLS: Small boutique
practice, 2 Ops, 1 Equipped, Open Dental,
Digital, 2014 GR $120K on 3 days/wk..
BEVERLY HILLS: 5 Ops, EagleSoft,
Digital, CEREC. Long-term staff, newer
equipment. 2014 GR 1.07MM, Adj. Net of
$406K. #CA210



Henry Schein Corporate Broker #01230466



Practice, 5 Ops, 35 years of Goodwill.7 days
Hygiene per week, most spec. work referred.
$948K GR. #CA257
5 Ops. 34 Years of Goodwill. Dentrix, Digital,
Laser, great referral base. #CA173
LISTING! 5 Ops, 28 years of Goodwill,
Digital, GR of $1.1MM+. #CA263
HUNTINGTON BEACH: General Practice.,
3 Ops. Dentrix, Digital, Laser, Intra-Oral. Est.
23 Years. #CA194 IN ESCROW!

TORRANCE: General Dentistry. 3 Ops,

2 Equipped. Est 19+ years. 2013 GR of
$333K with $176K adj. net. #CA213
Practice. 4 Ops, 3 Equipped. 25+ years of
Goodwill. 2014 GR of $221K with room to
grow. #CA254
VICTORVILLE: General Practice. 3
Ops, 3 Plumbed, 2,150 sq. ft. Est. 34 Years,
SoftDent. 2014 GR $273K. #CA149
WEST COVINA: General Practice with
4 Ops in a retail center location. Dentrix,
Digital, 35 years of goodwill. 2014 GR of
$402K #CA233

LOS ANGELES: General Dentistry, 6 Ops,

5 Equipped, Est. 50+ years, SoftDent, Digital.
2014 GR $591K. #CA255

WEST LOS ANGELES: General Practice,

4 Ops, newly built-out suite, desirable high
rise. 50+ years goodwill. FFS. 2014 GR
$651K. #CA226


practice, 4 Ops, Cone Beam, 2014 GR of
$360K on 21 hours/week. #CA259

WEST HOLLYWOOD: General Practice,

4 Ops, Mediadent, Intra-Oral Camera,
Digital, Laser, 5 yr old equip. 2014 GR of
$613K . #CA212 IN ESCROW!

LOS ANGELES: General Practice. 4 Ops,

3 Equipped, Est. 60+ years in prof. bldg. 2013
GR of $824K with $355K adj. net. #CA211


N. ORANGE COUNTY: General Practice.

7 Ops, 6 Equipped, EagleSoft, Digital, Seller
works 2 days with GR of $542K. #CA248


LISTING! Very busy 6 Op General Practice
with room to expand to 9 Ops. PPO, Dentrix,
Digital. 2014 GR 1.7M. #CA231

N. ORANGE COUNTY: General Practice.

4 Ops, Beautiful design, great location near
freeway & shopping #CA234 IN ESCROW!

CHULA VISTA: General Practice, est. 50+

years. 4 Ops, 3 days of Hygiene, Dentrix.
$493K GR in 2013. #CA109


Perio Practice. Easy freeway access. 30 years
of Goodwill. 6 Ops, 5 equipped. 2014 GR of
$468K. #CA264
Implant Practice. 6 Ops, 5 Equipped, Dentrix,
Digital, Pano, 20+ years of goodwill. 2014
GR $805K with $386K Adj. Net #CA245
General Practice, 5 Ops, Est. for 32 years,
6 days of hygiene/week/ GR of $824K and
$339K adj. net. #CA245
Dentistry, 6 Ops, Est. in 1960. DentiSoft,
Pano, 4 days of hygiene per week. 2014
GR of $690K. #CA258
S. ORANGE COUNTY: Pedo Practice with
4 Ops, 1 year new equipment, digital, Pano/
$236K GR with room to grow. #CA222
Dentistry. 4 Ops, Dentrix, Dexis, Pano,
mostly FFS, 8 days hyg/week. $1.1M+ GR in
2014. #CA218
General Dentistry. 4 Ops, 3 Equipped,
paperless, digital, est. 37 years. 2014 GR
$856K with $271K adj. net. #CA244


Leasehold sale. Modern and chic downtown
expand. #CA232
LA MESA: General Practice. 4 Ops.
3 Equipped, FFS/PPO, Dentrix, Digital.
2014 GR $340K. #CA227 IN ESCROW!
LISTING! General Practice, 3 Ops, Digital,
Dentrix, FFS/PPO. 2014 GR of $530K with
$228K adj. net. #CA253
General Practice & Bldg, 4 Ops, PPO/FFS,
Digital, Pano, Cerec. GR over $1M. #CA216
SAN DIEGO: General Practice. 3 Ops.
FFS, PracticeWorks. Located in Central San
Diego. 2014 GR $187K. #CA161
PPO Practice, 6 Ops, retail center, Dentrix,
Digital, $780K GR in 2014. 7 days of hyg/
week, long-term staff. #CA228
Dentistry, 3 Ops, 4 days hyg/wk. Retail
center, Dentrix, Digital Pano, PPO & FFS.
GR 2014 $524K. #CA206

General Practice. 4 Ops, Approx. 1,200 Sq.
Ft. GR $636K #20101



Regulatory Compliance

C D A J O U R N A L , V O L 4 3 , N 8

Marketing and Advertising Rules

CDA Practice Support
Marketing and advertising are key to
the success of any dental practice. Dentists
and their marketing consultants need to
be aware of marketing and advertising
rules to ensure their ventures are
compliant. The state Dental Practice Act
(DPA), Health Insurance Portability and
Accountability Act (HIPAA) and state
privacy laws apply, and dentists also should
keep the CDA Code of Ethics in mind.

practice, or any printing or writing on

novelty objects or dental care products.
Advertising does NOT include (1) any
printing or writing used on buildings or
uniforms where the purpose of the writing
is for identification or (2) any printing
or writing on memoranda or other
communications used in the ordinary
course of business other than solicitation
or promotion of the dentists practice.

How does the state Dental Practice Act

(DPA) affect marketing and advertising?
In general, the DPA:
Defines advertising
or advertisement and
states what dental practice
advertising may include.
Prohibits the use of false,
misleading or deceptive
statements, images or claims.
Prohibits the advertisement of a
guarantee of any dental service.
Prohibits compensation
(including thank-you gifts) and
inducements for patient referrals.
Requires a permit if the dental
practice uses a name other
than the name under which a
dentist is licensed to practice
(fictitious name permit).
Establishes rules for group
advertising and referral services.
Establishes rules for advertising
fees, discounts and dentures.

What are the rules for advertising fees

and discounts?
Any fee advertisement shall be exact,
without the use of phrases, including,
but not limited to, as low as, and up,

What is considered advertising?

The DPA defines advertising
or advertisement as any written or
printed communication for the purpose
of soliciting, describing or promoting
a dentists licensed activities, or any
directory listing caused or permitted
by a dentist that indicates his or her
licensed activity, or any radio, television,
or airwave or electronic transmission
that solicits or promotes the dentists

lowest prices or words or phrases of

similar import. Any advertisement that
refers to services, or costs for services,
and that uses words of comparison shall
be based on verifiable data substantiating
the comparison. Any advertising shall
be prepared to provide information
sufficient to establish the accuracy of that
comparison. Fee advertising shall not
be fraudulent, deceitful or misleading,
including statements or advertisements
of bait, discount, premiums, gifts or
any statements of a similar nature. In
connection with fee advertising, the
fee for each product or service shall be
clearly identifiable. The fee advertised

When Looking To Invest In Professional

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Linda Brown
30 Years of Experience Serving
the Dental Community Proven
Record of Performance

For your next move,

contact: LINDA BROWN
Direct: (818) 466-0221
Office: (818) 593-3800
Email: LindaB@TOLD.COM
Cal BRE: 01465757

Dental Office Leasing and Sales

Investment Properties
Owner/User Properties
Locations Throughout
Southern California

A U G U S T 2 015 467

AU G . 2 015 R E G U L ATO RY C O M P L I A N C E
C D A J O U R N A L , V O L 4 3 , N 8



Paul Maimone

ARCADIA (4) op comput G.P. Located in a well known Prof. Bldg. on a main thoroughfare.
Cash/Ins/PPO pt base. Annual Gross Collect $300K+ on a (3) day week. NEW
BAKERSFIELD #29 - (4) op comput G.P. (3) ops eqtd, (1) add. plumbed. Located in a free
stand bldg. Cash/Ins/PPO. Digital x-rays. Annual Gross Collect $300K+ p.t. Seller moving.
CULVER CITY (3) op Turnkey Office with included charts. In free standing Bldg. NEW
LOS ANGELES - (3) op computerized G.P. located in a Landmark Medical/Dental Bldg. on a
main thoroughfare. Cash/Ins/PPO pt base. No HMO & No Denti-Cal. Digital X-rays. Annual
Gross Collections $600K+. NEW
MONTEREY PARK (6) op comput G.P. located in a street front suite on a main thoroughfare
w exposure & visibility. Cash/Ins/PPO & small % Denti-Cal. Annual Gross Collect $250K+ p.t.
Seller retiring but will assist with Transition. NEW
PASADENA Nearly New Turnkey Office w some charts. Newer eqt. Gorgeous!
RANCHO CUCAMONGA - (4) op comput. G.P. in a strip ctr. w visibility. (3) ops eqtd (4th) op
plumbed. Annual Gross Collect $185K+ on 2.5 days/wk. Cash/Ins/PPO pts. Seller moving.
SANTA BARBARA COUNTY (3) op comput G.P. & 1,900 sq ft Bldg. Cash/Ins/PPO pts. No
HMO and No Denti-Cal. 2015 Projected Gross Collections $250K on a very relaxed 3
day week. Seller refers all O.S., Perio, Ortho and Endo. Also refers implant placement. Seller is
retiring but will assist with a short transition prior to moving out of state. NEW
SHERMAN OAKS (3) op comput G.P. in a well known, easily accessible Med/Dental bldg.
Cash/Ins/PPO. Annual Gross Collect $180K+ p.t. Great Starter or Satellite. Seller retiring.
So. KERN COUNTY (6) op comput. G.P. located in a Bakersfield suburb in a small strip ctr. w
exposure/visibility. Pano eqtd. Limited competition. Cash/Ins/PPO pts. Annual Gross Collect.
Approx. $350K p.t. Seller is moving and is motivated.
SANTA ANA - absentee owned (6) op fully eqtd G.P. First floor street front location on a main
thoroughfare. Exposure/visibility/signage. Cash/Ins/PPO. No HMO & No Denti-Cal. Pano eqtd
& Computerized. 2014 Gross Collect. of $549K+ on a (3) to (4) day Associate run week. NEW
SOUTHWEST RIVERSIDE COUNTY - (5) op comput. G.P. (4) ops eqtd/5 th plumbed. 2015
Project Gross Collect $400K+. Cash/PPO. Located in a smaller prof. bldg. in a condo which can
be purchased or leased. Seller giving up private pract. to accept institutional position. NEW
TUSTIN - (4) op comput. G.P. (3) eqtd/4th plumbed. Located in a busy shop ctr. on a main
thoroughfare. Exposure, visibility & signage. Digital x-rays & CEREC. Annual Gross Collect
$460K+ on an easy 4 day week. Cash/Ins/PPO. No Denti-Cal or HMO. Growth potential. NEW
WEST SAN FERNANDO VALLEY - (4) op comput. G.P. w modern equipt. Located in a
smaller prof. bldg. on a main thoroughfare. Cash/Ins/PPO pts. Annual Gross Collect $750K+ on a
(4) day week. Excell. long term lease, outstanding signage, & great off street parking. SOLD
UPCOMING PRACTICES: Bakersfield, Beverly Hills, Central Coast, Covina, Montebello,
Oxnard, Pomona, San Gabriel, SFV, Temecula, Thousand Oaks, Torrance, Visalia & Valencia.
Q Practice Sales and Appraisals
Q Practice Search & Matching Services
Q Practice and Equipment Financing Q Locate and Negotiate Dental Lease Space
Q Expert Witness Court Testimony
Q Medical/Dental Bldg. Sales & Leasing
Q Pre - Death and Disability Planning Q Pre - Sale Planning

P.O. Box #6681, WOODLAND HILLS, CA. 91365

Toll Free 866.425.1877 Outside So. CA or 818.591.1401
Serving CA Since 1994 CA BRE Broker License # 01172430

CA Representative for the National Association of Practice Brokers (NAPB)

468A U G U S T

2 015

for products shall include charges

for any related professional services,
including dispensing and fitting services,
unless the advertisement specifically
and clearly indicates otherwise. Fee
advertising for a dental service must
fully disclose all services customarily
included by the dental profession as
part of the advertised service, including
but not limited to necessary diagnoses,
radiographs, restorative treatment, drugs,
local anesthesia or analgesia, materials,
laboratory fees and postoperative
care. The advertisement must also
disclose any additional services, not
part of the procedure but for which
the patient will be charged, together
with the fees for such services.
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.
Identify specific groups that qualify
for the discount or any other
terms, conditions or restrictions
for qualifying for the discount.
What about programs that reward
patients or others for referrals of new
patients to the practice?
This question comes up a lot in
CDA Practice Support. Dentists
and other health care providers are
required to comply with Business and
Professions Code Section 650(a),
which states, Except as provided
in Chapter 2.3 (commencing with
Section 1400) of Division 2 of the
Health and Safety Code, the offer,
delivery, receipt, or acceptance by any

& C O M P A N Y

Matching the Right Dentist

to the Right Practice

Complete Evaluation of Dental Practices & All Aspects of Buying and Selling Transactions


Well established Perio practice in desirable South
Bay location. Approx. 1,700 sq. ft. facility w/4
fully-equipped ops. in a professional dental
building. 2014 GR $800K+. 3 doctor days per
week. Practice sees 30-40 new pts. per month.
Cone beam scanner & panoramic x-ray purchased
recently. Seller willing to help in the transition.
Asking $460K.

Mike Carroll & Pamela Carroll-Gardiner

Established GP located in Petaluma in stunning
1,856 sq. ft. seller owned facility in class A, 2 story,
10 year-old professional building. 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. 4 doctor-days &
4 hygiene days/wk. Avg. GR $640K. Asking
Seller re-locating out of state.   Offering turn-key
GP in San Jose's Willow Glen neighborhood.  4
fully equipped ops with 2 additional ops (plumbed
but not fully equipped) in approx 2,000 sq. ft.
Plentiful parking and easy freeway access from
Hwy 280. Approx 300+ active patients. 2014 GRs
$167K. Asking price for practice only $100K.
Well-established, well respected general dental
practice located within a lovely professional center
in the heart of town.  Beautifully landscaped
LD parking, Condo is also
grounds with
available for purchase.   Gross receipts average
$750-$800K every year. Asking price for practice
only $495K.
4019 SF GP
Retiring owner offering well-established, hygiene
driven GP w/focus on Restorative care. Excellent
l o c a t i o n i n t h e MG
arina/Cow Hollow
PEN3 fully equipped ops in approx.
700 sq. ft.  2014 GR $426K with adj. net of
$175K.  Well-trained & seasoned staff.  Asking


Absolutely beautiful and modern; established
practice in well-known Professional Center. StateLD in approx. 1,000 sq. ft. 3 fully
equipped ops, with room for a 4th op. 300+ active
patients. Gross Receipts approx. $245K. Ideal
turn-key operation. Asking $215K.
Well-est. GP in single story professional dental
building located on a heavily traveled main artery
between downtown San Mateo and downtown
Burlingame. 4 fully-equipped ops in modern office
w/digital x-ray, inter-oral camera, laser & Cerec.
2014 GR $673K+ w/adjusted net of $232K+.
Asking $459K.
Seller retiring from successful GP with welltrained, seasoned staff. 4 fully-equipped ops. w/
several equipment upgrades in seller owned
building. Practice averages over $1M/year w/
adjusted net of $334K+ averaging 4 doctor days
per week & 6 hygiene days per week. All fee-forservice. Asking price for practice only $732K.
Building is also available for purchase.
Well-established practice located in Californias
gorgeous Central Coast area. Beautifully
appointed, spacious 1,568 sq.ft. office with 4 fully
equipped ops, pros lab and other amenities.
Situated just minutes from the ocean and <5
miles away from one of Californias historic
Mission Cities, this practice is nestled in a highly
desirable community. 2013 gross receipts were
$1.2M+ and 2014 is annualized at $1.3M+ on a
4 day doctor workweek, w/4 days of hygiene/
week. Approx. 15 new patients a month and
~1,500 active patients (all fee-for-service).
Owner/doctor is willing to help Buyer for
smooth transition.
SF GP, San Jose GP, Marin County GP

Carroll & Company

2055 Woodside Road, Ste 160
Redwood City, CA 94061


CA DRE #00777682

AU G . 2 015 R E G U L ATO RY C O M P L I A N C E
C D A J O U R N A L , V O L 4 3 , N 8


person licensed under this division or

the Chiropractic Initiative Act of any
rebate, refund, commission, preference,
patronage dividend, discount, or
other consideration, whether in
the form of money or otherwise, as
compensation or inducement for
referring patients, clients, or customers
to any person, irrespective of any
membership, proprietary interest, or
co-ownership in or with any person
to whom these patients, clients, or
customers are referred is unlawful.
What are the limitations established
by HIPAA and state privacy laws?
State and federal laws overlap in
the regulation of a dental practices use
of patient information for marketing
purposes. The federal HIPAA Privacy
Rule and the state Confidentiality of
Medical Information Act (CMIA)
require a dental practice to obtain
a patients authorization prior to
using patient health information to
communicate about a product or service
that encourages a recipient of the
communication to purchase or use the
product or service, or to give to another
entity to market its product or service.
Patient authorization is not required for
the following types of communications
for which the practice is not financially
remunerated by a third party:
Making a patient aware of a
health-related product or service
(or payment for such product or
service) that is included in the
patients dental benefit plan.
Providing patient treatment.
Coordinating care with other
providers, such as nursing homes.
Providing inexpensive items
with the practice name and
contact information.
Face-to-face communication.
If a dental practice receives financial
remuneration, including, but not limited
470A U G U S T

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to, gifts, fees, payments, subsidies

or other economic benefits, from a
third party for making any marketing,
treatment or health care operations
communication, the practice must
obtain authorization from the patient
prior to making that communication.
Additionally, state law requires
the dental practice to:
Notify the individual receiving
the marketing communication in
typeface no smaller than 14-point
type of the fact that the practice
has been remunerated and the
source of the remuneration.
Provide the individual with
an opportunity to opt out of
receiving future remunerated
The communication must contain
instructions in typeface no smaller
than 14-point type describing
how the individual can opt out of
receiving further communications
by calling a toll-free number of
the dental practice making the
remunerated communications.
No further communication may
be made to an individual who
has opted out after 30 calendar
days from the date the individual
makes the opt-out request.
How does the CDA Code of Ethics
govern dental marketing and advertising?
Section 6 of the CDA Code of
Ethics advises that dentists have the
obligation to represent themselves in a
manner that contributes to the esteem
of the profession. The standard for
judging the ethical propriety of any
dentists advertisement to the public
is whether the ad, taken as a whole,
is false or misleading in any material
respect. A dentist should always ask,
Could my ad be misinterpreted or
potentially misleading to someone who
knows nothing about my practice or

my profession? The rationale for the

standard is protection of the public;
a dentists advertising should contain
any information that a patient would
consider necessary to make informed
choices about practitioners and
services. The CDA Code of Ethics,
Advisory Opinion 1.G.1, also advises
dentists that, in many circumstances,
promotional activities on school
grounds are considered unethical.
Information on additional marketing
and advertising rules can be found in
the article, Dental Practice Marketing
and Advertising 101. The article and
sample patient authorization forms are
available at
Regulatory Compliance appears monthly
and features resources about laws and
regulations that impact dental practices. Visit for more than 600
practice support resources, including practice
management, employment practices, dental
benefit plans and regulatory compliance


C D A J O U R N A L , V O L 4 3 , N 8

Periscope oers synopses of current ndings in

dental research, technology and related elds


Parents in the operatory and childrens

dental procedures
Shro S, Hughes C, Mobley C. Attitudes and Preferences of
Parents About Being Present in the Dental Operatory. Pediatr Dent
Purpose: The purposes of this study were to determine if the type
of dental procedure being performed on children had an eect
on parents desire to be present in the operatory and to determine
if the percentage of parents desiring to be present for their childs
treatment had remained consistent over the past two decades.
Materials and methods: A survey was conducted with
parents of children who presented for dental appointments at
three sites: a pediatric clinic at the University of Nevada, Las
Vegas, School of Dental Medicine and two private practice
settings in southern Nevada. Parents or caretakers were asked
to complete a three-section, 20-item survey. The sections were
demographic information, past medical and dental history, and
dierent scenarios commonly associated with treatment in a
pediatric oce (i.e., examination and radiographs, restorative
treatment, exodontia, conscious sedation and protective
stabilization). The parents were asked whether they had
observed the procedure before, would prefer to be present or
absent during the procedure, if their opinion would change if
their child were struggling or crying during the procedure and
if they preferred that the dentist make the decision whether they
remained in the room during the procedure. The survey was eld
tested and approved by the Institutional Review Board of UNLV.
Results: Three hundred and thirty-nine parents completed the
survey. Demographic information was as follows: 73 percent
female parent, 60 percent Hispanic, all between 25 and 40
years old and have a high school education. Majority of the
responders had a household income less than $50,000 annually.
More than half of the children were between 4 and 9 years old
and healthy. Seventy-nine percent of parents said that their child
had never had a bad experience with the dentist. Seventy-eight
percent of parents would prefer to be present during their childs
treatment. Sixty-two percent of the parents indicated that the
primary reason they want to be present is they feel their child
is more comfortable with their presence. The majority of the

parents wanted to be present for the dental procedures mentioned

above. Only 38 percent of parents would let the dentist decide
whether they should be permitted to remain during treatment.
Statistically signicant ndings included the following: female
and parents who were 31-40 years old stated that their childs
well-being was the reason they wanted to be present during
treatment. Parents with a high school education or greater chose
being unfamiliar with the dentist as a signicant factor in wanting
to be present. Married parents chose wanting to obtain more
information about the procedure so they could explain it to their
spouse as a factor for being present in the operatory.
Conclusion: Most parents preferred to be present during
their childs treatment regardless of the dental procedure.
More than one-third of the parents do not want the dentist
to be the sole person to determine their involvement in their
childs dental visit. Parental desire to be present during
dental treatment has not changed over the last 20 years.
Reviewers comments: Parental presence is a behavior
guidance technique endorsed by the American Academy of
Pediatric Dentistry. As parenting styles and societal attitudes
change, more parents want to be involved with the treatment
decisions for their child. Parents want to be present to support
and ensure that their child is comfortable during treatment. This
study also conrms that the more educated the parents are,
the more likely they want to be present if they are unfamiliar
with the dentist. Parental presence during treatment can be
a good practice builder but it will only work if the dentist
establishes expectations and builds trust with the parents.
Thomas S. Tanbonliong Jr., DDS

A U G U S T 2 015 471

A U G . 2 0 15

C D A J O U R N A L , V O L 4 3 , N 8



Oral microora eect on bone levels

Surgical periodontal therapy

together is better

Irie K, Novince CM, Darveau RP. Impact of the Oral

Commensal Flora on Alveolar Bone Homeostasis. J Dent Res
93(8): 801-806, 2014.
Background: It has long been known that the commensal oral
microora plays a role in homeostatic regulation of alveolar bone.
However, little is known regarding the underlying mechanisms of
alveolar bone loss mediated by the commensal oral microora.
Methods: Histomorphometric analyses of alveolar bone
loss in specic-pathogen-free (SPF) mice and germ-free (GF)
mice were carried out. Immunohistochemical staining of
neutrophil markers, T-cell markers and receptor activator of
nuclear factor kappa B (RANKL) were conducted to identify
the cellular compositions within junctional epithelium (JE).
Tartrate-resistant acid phosphatase (TRAP) staining for the
identication of osteoclastic cells was also carried out.
Results/Discussion: SPF mice revealed increased alveolar bone
loss and increased numbers of both TRAP+ osteoclastic cells and
RANKL+ cells at the alveolar bone surface than GF mice. This
was associated with increased numbers of neutrophils, CD3+,
CD4+ and interleukin-17+ cells in the JE of SPF mice compared
to GF mice. These results suggested that the host-commensal oral
microora interactions result in the release of osteoclastogenic
molecules from the host, leading to the alveolar bone loss seen
in the clinically healthy periodontium. Since RANKL has been
known to be expressed by neutrophils and activated Th17
cells, it is possible that increased alveolar bone loss caused
by the commensal oral microora in SPF mice was due to the
activation of both innate and adaptive immune systems.
Conclusions: An alveolar bone loss occurring in clinically healthy
periodontium is mediated, at least in part, by the immunomodulately
eects of commensal oral microora on host cells.
Takahiro Chino, DDS, MSD, PhD

Aljateeli M, Koticha T, Bashutski J, Sugai JV,Braun TM,Giannobile

WV, Wang HL. Surgical periodontal therapy with and without
initial scaling and root planing in the management of chronic
periodontitis: a randomized clinical trial. J Clin Periodontol
2014, 41 (7): 693700.
Aim: To compare the outcomes of surgical periodontal
therapy with and without initial scaling and root planing.
Methods: Twenty-four patients with severe chronic periodontitis
were divided into two treatment groups, both who had modied
Widman ap surgery but only one preceded the surgery with
scaling and root planing (control group). The test group had
surgery only. Clinical parameters evaluated included probing
depths, attachment levels, bleeding on probing and radiographic
evidence of bone level changes from base level to six months.
Inammatory biomarkers of wound healing were also assessed.
Results: Both groups showed improvement in attachment
levels at three and six months compared to baseline. No
statistically signicant change in biomarkers was shown
between the groups. There was a statistically signicant
improvement in probing depth reduction in favor of
the control group at both three and six months.
Conclusion: Combining scaling and root planing with
surgery yielded greater probing depth reduction than
surgery without initial scaling and root planing.
Clinical relevance: Scaling and root planing is an important
component of periodontal therapy, helping to resolve
inammation, reduce pockets and gain clinical attachment,
even if surgery needs to be performed. Based upon this
study scaling and root planing might contribute to a more
favorable outcome when performed prior to surgery in the
form of improved pocket depth reduction. Proponents of a
direct-to-surgery approach should keep this in mind.
Gerald Drury, DDS

472A U G U S T

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What separates
us from other
brokerage firms?

Our extensive buyer

database and
unsurpassed exposure
allows us to oer you a

Be er

Be er
Be er
We are a proud member of:



AC-335 SAN FRANCISCO: Two great practices for

the price of one! Now Only $475!
AG-053 SAN FRANCISCO: 3,000 sf w/ 9 ops + 1
addl. PRIME LOCATION! $475k
BN-183 HAYWARD: Kick it up a notch by increasing the current very relaxed work schedule!
1,300 sf w/ 3 ops $150k
BN-279 CONTRA COSTA COUNTY: Excellent Merger
Opportunity! 2-story. 1,350 sf w/ 3 ops +1 addl
BC-361 OAKLAND: Established for over 23+ years!
2,200 sf w/ 7 ops. Now Only: $385k
BC-381 PLEASANT HILL Facility: Open Floor Plan!
1,852 sf w/ 6 equipped ops! Move in Ready! $80k
BG-407 SAN LEANDRO: Prof bldg. Great signage!
1200 sf w/ 3 ops $140k
BN-426 BERKELY: Step into this quality pracce
and youll know you belong here! 1,386 sf w/ 3
ops. $495k
BC-432 PITTSBURG: Own this family-oriented
Pracce! 1,640 sf w/ 6 ops. $350k
BG-444 FREMONT: Presenng a remarkable opportunity and quality pracce! 3,200 sf w/ 10 ops.
CC-390 SOLANO COUNTY: Near Travis AFB! Highly visible location! 950 sf w/ 3 ops REDUCED!
CG-366 SONOMA CO.: Vibrant, growing community! 1,300+ sf w/ 4 ops. Over $760k in collections! $450k
CG-449 SANTA ROSA: Vibrant, highly desired
town! Prof Bldg 1860 sf w 4 ops + 1 addl $250k
DC-370 SAN JOSE Facility: Location, Location,
Location!! Move in Ready! Only $120k
Contact our office for details. $605k
DG-396 SERRAMONTE AREA: Small Town Feel in
Heart of SF. 850 sf & 4 ops $485k
DN-312 LIVERMORE Facility: Dont miss out on this
one! 1,070 sf w/ 3 ops. REDUCED! $75k
DC-403 SANTA CRUZ: Well-established, modern,
quality pracce! 1,335 sf w/ 4ops. $725k
DC-419 NEWARK Facility: Locaon, Locaon, Locaon! 1,400 sf w/ 4 op. $140k
DC-406 SAN JOSE: Amazing opportunity in Westgate Shopping Center. 6 ops + 80 mall hours per
week $400k
DG-434 MENLO PARK: Well-Established. Near
Facebook, Stanford, Google and Tesla! 1702 sf w/ 5
ops. Excellent Opportunity! $1.2m
DN-447 SUNNYVALE: Quality, family-oriented
opportunity awaits your talent and skill. 1,400 sf w/
3 ops + 1 addl. $395k

EN-340 SACRAMENTO: Large HMO pracce! 3,400

sf w/ 10 ops and Plumbed for 1 addl $950k
EN-350 SACRAMENTO: The Perfect Merger Opportunity! Old-fashioned values and philosophy! 674
sf w/ 1 op. $85k
EN-378 LINCOLN: quality pracce with a wonderful
paent base! 1,369 sf w/ 2 op + 3 addl. $170k
EN-379 ROSEVILLE: An amazing opportunity in the
locaon of your dreams! 1,040 sf w/ 3ops. $295k
EN-423 FOLSOM Oral Surgery Facility: Primed for
success! 3,450 sf w/ 2 Lrg. Treatment Rooms. Now
Only $50k!
EN-430 SIERRA FOOTHILLS: Pracce in one of the
most desirable places to live in N. CA! 1,050 w/ 3
ops. $475k
FN-299 FERNDALE: Live and practice on the
beautiful North Coast! 1,300 sf w/ 3 ops $195k
(Real Estate: $309k)
FC-334 NORTHERN CA: Emphasis on prevenon.
1,200 sf w/ 4 ops $480k / Real Estate Also Available!
FC-343 NORTHERN CA: Quality & locaon are the
keys to success! 1,200 sf w/ 3 ops + 1 addl & 1 hyg.
Op. $500k (Real Estate $375k)
FC-415 FT. BRAGG: An excellent pracce, located
in a peaceful, family-oriented community! 1,800 sf
w/ 5 ops + 1 hyg. Op. $425k
GG-320 CHICO: Large, Unique, Originally designed
for more than 1 dds! 5,000 sf w/ 7 ops (+2 addl)
GG-386 REDDING: Practice & Real Estate! 2,860 sf
w/ 4 ops. Plumbed for 2 addl! PR: $330k / RE:
GN-201 CHICO: Beautiful practice, major thoroughfare, stellar reputation! 1,400 sf w/ 4 ops &
room for another $425k
GN-244 OROVILLE: Must See! Gorgeous, Spacious. 2,500 sf w/5 ops! Collections over $450k in
2013. Only $315k
GN-258 REDDING: Prisne and aracve! Conveniently located! 1,050 sf w/ 2 ops. $215k
GN-399 REDDING: Loyal paent base and relaxed
workweek schedule. 1,440 sf w/3 ops. $150k
GN-418 REDDING: Goodwill Galore! Established
for ~37 years and the seller is rering! 3,200 sf w/6
ops +2 addl. $495k
SALE! Includes Cerec! 2,000 sf w/ 5 ops. Pracce
$100k / Real Estate $250k
HN-213 ALTURAS: Close to Oregon Border. FFS
practice is 2,200 sf w/ 3ops +1 addl $115k
HN-280 NORTHEASTERN CA: Only Practice in
Town 900 sf w/ 2 ops $110k

HN-290 PLACERVILLE: Excellent Merger Op!
Embrace the lifestyle and build your success
story here! FFS. 1,400 sf w/ 4 ops $210k
HG-448 S. LAKE TAHOE: 2 Story, Rustic dcor. Upscale Family Practice. 3400sf w 6 ops
IG-067 STOCKTON: Fully computerized, paperless, digital. 5,000 sf w/10 ops Steal of
the Century! Now ONLY $240k
IG-367 MERCED: Newly Remodeled, Paperless. 1,550 sf w/4 ops REDUCED! $325k
IN-345 MODESTO: Long-standing tradion of
quality care. 3016 sf w/ 5ops + 1 addl. $495k
IN-358 MODESTO: Pracce nets over 50%!
1,200 sf, 3 ops+1 addl. REDUCED! $275k
IN-397 FRESNO/MADERA: the Perfect
Locaon! 2,000 sf w/5ops. NOW ONLY:
IN-429 TRACY Facility: Move-in ready
Hesitate and you might miss out! 2,488 sf, 5
ops $245k/RE: $650k
JC-349 FRESNO Facility: Doctor is rering
and is movated! Step right in and make
yours! Call for Details!
CG-431 FAIRFIELD Perio: Priced to sell!
1400 sf w/ 3 ops. Plumbed for 2 addl $60k
I-7861 CENTRAL VALLEY Ortho: 2,000 sf,
open bay w/ 8 chairs. Fee-for-Service.
I-9461 CENTRAL VALLEY Ortho: 1,650 sf w/5
chairs/bays & plumbed for 2 addl $180k
DG-264 SAN JOSE Ortho: $300-400k in
build-outs alone! 1800 sf w/ 5 chairs. REDUCED! $195k
CC-346 SO MARIN CO Perio: 1,142 sf w/ 3
ops. Meticulously maintained! REDUCED!
BN-393 PINOLE Pedo: Streamlined pracce,
where every child counts themselves lucky to
be a paent here! 2,000 sf w/ 5 ops. $1.2m
CG-424 NAPA Prostho: Ready for Experienced, high-end Prosthodonst! One track to
collect just under $1m $725k
CC-405 SOLANO CO. Endo: Endodonc Pracce in a vibrant community! 1,250 sf w/ 4
ops. $485k

Timothy G. Giroux, DDS

is currently the Owner &
Broker at Western Practice
Sales and a member of the
nationally recognized dental
organization, ADS Transitions.
You may contact Dr Giroux
at: or

Should there be a reduction in the value of

a Delta Premier only dental office?
First, Lets define the problem, as there is a great deal of misunderstanding on this
issue. About four or five years ago, Delta decided that all new contracts with dentists
would include both the Premier and the PPO contract. There was no choice on the
matter from the dentist. On face value, this did not seem like a big deal in practice
transitions as the assumption was that the buyer would keep all the premier patients
on the higher fee schedule and that he would acquire many more new patients on the
PPO fee schedule, albeit at a lower fee schedule. In fact, it seemed like a good way to
grow the practice after the transition.
The first time we discovered this assumption was incorrect, was upon listing a practice
that voluntarily added the PPO product to his office. He also assumed that his current
Premier patients would keep their fee schedule. He soon found that Delta was paying
25 to 30 percent less on about 90% of his past Delta Premier patients. However, he
finished off that year with his highest production ever, due to the increased patient

What we did not fully comprehend is that Delta has not really sold any new Premier
plans for many years. Each year, the percentage of Delta Premier patients is reduced
compared to the PPO plans. Currently the percentage of Delta Premier patients is
approximately 7%. Todays current Premier Only doctors normally do not realize
that as much as 93% of their Delta Premier patients are really what we refer to as
PPO Plus, meaning that Delta has agreed to pay the Premier fee schedule for the time
being, but any change in the contract will reduce all of these patients to the standard
PPO fee schedule.
We have also witnessed transitions over the years where the practices gross receipts
did suffer after the buyer was forced to take the lower fee schedule. However, since
2011 when we began following this phenomenon, I can say that there is no direct
correlation to declining revenue just because of the Delta fee change issue. We recently
sold a predominately Delta practice that had 1.7 Million in gross receipts. We expected
this practice would suffer as this practice did not need to grow their patient base with
the additional PPO patients. Six months after the sale the monthly collection numbers
were actually greater!
It is imperative that buyers understand this issue and find out how much of the
revenues are generated by a Delta Premier only office. However, it is just one of the
many variables a buyer should understand in making a good decision to purchase a

Jon B. Noble, MBA

Mona Chang, DDS

John M. Cahill, MBA

Edmond P. Cahill, JD

Tech Trends

C D A J O U R N A L , V O L 4 3 , N 8

A look into the latest dental and

general technology on the market

Google Photos (Google Inc., Free)

HEALTHYDAY (McNeil-PPC Inc., Free)

Google Photos for iOS provides all users with cloud storage backup
for photos and videos on mobile devices. The application and service
is also available for Mac, PC and Android devices. Once logged
in with a Google account, Google Photos works seamlessly in the
background by continuously backing up all photos and videos on the
iOS device through a Wi-Fi connection. When backups are complete,
users are free to delete photos and videos from their camera rolls
on their iOS devices. All photos and videos are available to view
on the cloud through the Google Photos app. Within the Google
Photos app, users can view their photos sorted by date or collections
based on photo location data. Tapping on any item enlarges it to
full screen, where users can share, edit, view info or delete the item
from cloud storage. Users can apply lters and use simple editing
tools for their photos and videos. Google oers two storage options
for this service: Original and High Quality. The Original storage
option backs up and syncs photos and videos at their full resolution
and quality. This option counts against the standard storage quota
for a Google account, which is 15GB and is shared amongst other
services such as Gmail and Google Drive. The High Quality storage
option provides unlimited storage for photos and videos that are
equal to or less than 16MP or 1080p resolution. For most users, the
High Quality option will more than suce.

HEALTHYDAY is a new app that uses crowdsourcing data to

provide real-time tracking status of health trends in any location.
HEALTHYDAY works by gathering location and reports from its
users. When the app determines its location, it asks the user simply,
How are you feeling today? A color feeling indicator face can be
cycled through green (good), yellow, orange and red (bad). If a
user is not feeling well, the app will try to determine what the user
is most likely suering from using the trends of reports in the area.
If the app is incorrect in determining what a user is suering from,
he or she can choose from a list of common ailments that he or she
thinks may be the cause of their illness. Each user report is combined
with reports from other users to create a local dashboard, which
shows the trends and risks of allergies, colds and u in the area.
An Illness Map provides locations and reports of what is going
around in the neighborhood so that users can be on the alert when
common illnesses are on the rise. In addition to providing real-time
reports and trends in the area, HEALTHYDAY provides 30-Second
Solutions, which are helpful tips and answers to the most common
health questions people ask.

Hubert Chan, DDS

70 Percent of World Using

Smartphones by 2020
Smartphones have become part of most peoples day-to-day lives
and that trend is expected to increase over the next ve years,
according to a study by Ericsson Mobility Report. Specically, 70
percent of the worlds population will have a smartphone by 2020.
The study went on to state that mobile trac in the rst quarter of
2015 was 55 percent higher than the rst quarter of 2014 and that
by 2020, 80 percent of mobile trac will be from smartphones.
Video continues to be the key growth factor, with 60 percent of
all mobile data trac forecast to be from online video by 2020,
according to the study. The study also states that those who use
larger screens with their mobile devices (tablets) spend 50 percent
more time watching videos.
Blake Ellington, Tech Trends editor
476A U G U S T

2 015

Hubert Chan, DDS

Adding Photo Filters Boosts Social

Adding lters to photos on social media is something amateurs
and more advanced photographers do, but what does it do to
enhance social interaction? Yahoo! Labs released a study aimed
at determining how lters aect photo engagement such as likes,
comments and views. The study analyzed 7.6 million public photos
on Flickr, an online photo management and sharing application,
which resulted in the nding that ltered photos saw a 21 percent
increase in views and 45 percent increase in comments. Filters
that increase contrast and correct exposure can help a photos
engagement, and lters that create a warmer color temperature are
more engaging than those with cooler color eects, according to
the study.
Blake Ellington, Tech Trends editor

Dr. Bob

C D A J O U R N A L , V O L 4 3 , N 8

Aging Gracefully
(and Other Indignities)

The following Dr. Bob column was originally printed in the March 2010 issue of the Journal.

My knees, unlike some of

my other body parts, had
not communicated with me
for more than eight decades.

Robert E.

When I pay one of my infrequent visits

to my primary care guy, I make certain
to get my $10 co-payments worth by
saving up symptoms until Im sure I have
enough to command his attention for
at least 10 minutes. These are carefully
recorded on a list I bring with me.
My left knee has begun to hurt. My
knees, unlike some of my other body
parts, had not communicated with me
for more than eight decades. I compared
the ailing knee with its mate. Although
they are both the same age and appear to
be dimpled twins, the complainant had
taken on a life of its own, either refusing
to bend comfortably or threatening to flex
both ways without advance warning.
After six weeks of ignoring it, I finally
managed to accumulate a qualifying
number of unrelated complaints, including

a twinge in my right shoulder and two

suspicious spots on my right forearm at
least 4 microns in width. In addition,
an annoying extra trip to the bathroom
around 4:30 a.m. convinced me that at
least one or two of these symptoms confirm
the presence of a fatal disease requiring
surgical intervention immediately. Time
to shell out the $10 co-pay.
My instinctive distrust of general
anesthesia was intensified by the
probability of the operating surgeon
assigned to save my life being revealed
as a head case on the verge of going
postal from stress and fatigue. You
need to make an appointment, I told
myself. I did the following spring.
An overhead wide-angle shot of a
surgical amphitheater overflowing with
students and resident doctors forms clearly
A U G U S T 2 015 477

A U G . 2 0 15

C D A J O U R N A L , V O L 4 3 , N 8

in my mind. Gathered from as far away as

Rochester, the assemblage leans forward in
hushed reverence to witness my surgeons
legendary expertise. I had just become
aware of two morgue attendants standing
expectantly in the background beside their
gurney when I hear a female voice announce, Robert, you may come in now.
I try to respond in kind by attempting
to read her name tag pinned to her blouse
just south of her left clavicle, but realize
that staring any longer to make out the
words would not be in my best interests.
Laying aside the article I had been reading
in Womans Day on how to cope with
those pesky postpartum stretch marks, I
trail after the paisley-topped assistant into
the inner sanctum. Young enough to be
my granddaughter, she is preternaturally
cheerful as she confides that we will
pause for a moment to weigh me.
At the end of the hall is the scale,
impossible to circumvent. The drill is
always the same and her buoyancy is
ill-suited for the occasion. Hop on, she
trills cheerfully. Every time I have ever
mounted one of these doctor scales it is
obvious the patient before me could not
have weighed more than 110 pounds.
There follows a deliberate, prolonged
humiliation during which the weights are
slowly advanced along their tracks almost
to the end before balance is achieved. My
shoes weigh at least five pounds each, you
know, I always offer, feeling this should
be taken into account as a truer indication
of my poundage. I could be wearing a
full-length raccoon coat, pockets loaded
with enough lead weights to anchor the
QE2 and the results would be carefully
recorded in my chart. Technically, one
should be weighed in the buff. If nothing
else, the procedure would add interest to
an otherwise dull day at the office. If an
inaccuracy of this magnitude is tolerated,
the requisite recording of my vitals that
follows is subject to plus or minus 35
478A U G U S T

2 015

Whats the matter with

your knee? he asks.
Well, duh! At $10 I have
to do my own diagnosis?
percent errors and are meaningless except
to satisfy blank places on the chart.
It seems under-the-tongue
thermometers are an anachronism. A
hand-held electronic probe is inserted
three inches into my ear, beeps once and
immediately withdrawn. I assume this is
a rejection because of the wax buildup,
but Paisley dutifully notes the 98.6 on
my chart and takes my blood pressure.
Blood pressure taken in an examination
room automatically initiates the white
coat syndrome and elevates itself to near
fatal limits. I also believe if I hold my
breath, close my eyes and roll my eyeballs
upward in their sockets, then focus on
arbitrary numbers like 120 and 75, I can
achieve any reading I please commensurate
with my age. Or better yet, some kid
about 25 who has matured in every way
except for calling everybody Dude!
and wearing a baseball cap incorrectly.
Paisley smiles benignly at me. Were
the room to be suddenly bathed in
ultraviolet light, a little thought bubble
would appear over her head containing
the words What a porker! In any event,
Paisley is satisfied with my BP, thinking,
not bad for a geezer with one foot in.
She departs to fetch the doctor,
taking my 2-inch thick folder with
her lest I sneak a peak at my own
records that I couldnt read anyway,
written as they are in Physicianese!
Modern medicine has streamlined the
whole medical appointment experience
to the point where the doctor is the
last person encountered. When I was
younger, the next step would be the

entrance of the doctor, an older man

radiating compassion and wisdom, sort
of like my grandfather, only richer.
In time (this is Doctor Time, different
from Patient Time), the doctor breezes
in. A substantial part of my wardrobe is
older than he. He gets right to the point,
the meter is running. Whats the matter
with your knee? he asks. Well, duh! At
$10 I have to do my own diagnosis?
It hurts when I do this, I explain,
flexing my left leg gingerly.
Then dont do that. His eyes
grow pensive. How long?
Six weeks. He palpates the joint in a
doctorly manner. A stretched ligament or
tendon, he says, conserving unnecessary
words as if texting me. Nothing to
worry about. Take a while to disappear.
Couple of Advil or Aleve are OK.
But, I It is too late. Obviously,
administering extreme unction to my
knee is premature and the problem
is too intricate and inconsequential
to warrant recapitulating.
You need a flu shot and a pneumonia
shot, he states. Take this form to
the lab. See you in two weeks.
Hes out the door and I am left sitting
on the crinkly paper-covered table,
as my list of assorted ailments flutters
to the floor. Left knee, CHECK.
What a nice man! Not once did he
mention the fact that at my age it would
be unrealistic to expect anything less
than a yard-long grocery list of physical
woes. Maybe Ill come back next fall after
a summer of reckless hedonism. I should
have a list to reckon with by then.

Were taking your requests

If you have a favorite Dr. Bob column
you want to see again, email Publications
Specialist Andrea LaMattina at andrea.
lamattina @ We will oblige by
reprinting those requested favorites interspersed
with any new Dr. Bob submissions.

Your convention.Your rst look.

With approximately 400 companies showcasing their latest products and services,
the exhibit hall at this years convention is the perfect place to see and try exciting
innovations in dentistry for yourself. CDA Presents The Art and Science of Dentistry.
Yeah, this is your convention.

August 2022

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