April 2016 - New York State Dental Association

Transcription

the new york state dental journal
Volume82 Number 3
April 2016
15Efficacy of a Prenatal Oral Health Program
Follow-up with Mothers and their Children
Charles D. Larsen, D.M.D., M.S.; Michael D. Larsen, Ph.D.; Terri Ambrose, D.D.S.;
Robert Degano, D.M.D.; Leonard Gallo, D.D.S.; Vito A. Cardo Jr., D.D.S.
Dental records of participants in Prenatal Care Assistance Program at Brookdale Hospital
and Medical Center are compared with those of nonparticipants. Evidence strongly suggests
PCAP can help improve oral health of young children.
21Goldenhar Syndrome and Pain-Related Temporomandibular Disorders
Cover: Intervening before a baby is born
appears to have a positive impact on the
outcome of the pregnancy and the oral
health of the maturing child.
2Editorial
Taking on a dental critic
5 Attorney on Law
Be educated about CE
8 Letters
9 Viewpoint
Insurance company blues
10 Association Activities
46 General News
50 Component News
57 Read, Learn, Earn
78 Classifieds
80 Index to Advertisers
84 Addendum
The New York State Dental Journal is a peer reviewed
publication. Opinions expressed by the authors of material
included in The New York State Dental Journal do not
necessarily represent the policies of the New York State
Dental Association or The New York State Dental Journal.
EZ-Flip version of The NYSDJ is available at www.
nysdental.org and can be downloaded to mobile devices.
Shehryar Nasir Khawaja, B.D.S., M.Sc.; Heidi Crow, D.M.D., M.S.; Yoly Gonzalez, D.D.S., M.S., M.P.H.
A development disorder, Goldenhar syndrome is characterized by incomplete development of
the craniofacial region. It can range from malocclusion and facial asymmetry to a more
complex phenotype with complete absence of the mandibular ramus and
temporomandibular joint. However, orthopedic symptoms have not generally been
considered part of the symptom complex. Case of teenage patient referred for evaluation
because of bilateral pain in masticatory muscles and temporomandibular joints is presented.
25Minimally Invasive Treatment of Temporomandibular Joint Ankylosis and
Fibrosis of Temporalis Muscle
Jungsuk Cho, D.M.D.; James Y. Kim, D.D.S., M.D.; Michael T. Wotman;
David A. Behrman, D.M.D.; Howard Israel, D.D.S.
Case of severe mandibular hypomobility due to fibrosis of left temporalis tendon and
ankylosis of temporomandibular joint emphasizes importance of reconstructing historical
timeline to establish correct diagnosis and appropriate treatment.
31Reasons for Apical Surgery Treatment in an Underserved New York City Population
Gunnar Hasselgren, D.D.S., Ph.D.; Patrick Patel, D.D.S.; Hashim Alhassany, B.D.S.;
Carol Kunzel, Ph.D.
Study retrospectively examines reasons for performing apical surgery in economically
deprived patient population. Findings suggest that economic factors play a major role in the
selection of surgical versus nonsurgical endodontic retreatment.
35Influence of Root Canal Tapering on Smear Layer Removal
Mina Zarei, D.D.S., M.Sc.; Maryam Javidi, D.D.S., M.Sc.; Farzaneh Afkhami, D.D.S., M.Sc.;
Behrad Tanbakuchi, D.D.S., M.Sc.; Zadeh Mohsen Movahed, D.D.S.; Marzieh Moghadam Mohammadi
Study was conducted to compare the influence of root canal taper on the efficacy of
irrigants and chelating agents in smear layer removal.
39The Impending Oral Health Crisis
Ensuring Quality Dental Care and Access for New York’s Most Vulnerable Patients
Carl H. Tegtmeier, D.M.D.; David J. Miller, D.D.S.; Judith L. Shub, Ph.D.
Report from two-day summit called to develop recommendations to ensure that patients with
intellectual and developmental disabilities, as well as an aging population with Alzheimer’s
disease and dementia, have access to appropriate oral health care in the years ahead.
Use your smartphone to scan this QR Code and access the current online version
of The New York State Dental Journal.
editorial
Who Gets to Whiten Teeth?
Washington columnist continues the controversy with attack on dental profession.
I
n an opinion piece that appeared recently in
the Washington Post, columnist George F. Will
took on the “teeth-whitening monopoly.” He cited
a case in Connecticut in which teeth-whitening
salons had sued the Connecticut State Dental
Commission for what amounted to restraint of
trade. The court disagreed, and the plaintiffs
appealed. The 2nd Circuit Court of Appeals ruled in
favor of the defendants. Now the plaintiffs have
appealed to the U.S. Supreme Court, which has
agreed to hear the case.
According to Mr. Will, this is just another case
of the haves getting what they want from government to the detriment of the have-nots. He makes
some pretty outlandish statements to prove his
point, accusing the Connecticut State Dental
Commission of trying to protect its own. It is true
that the commission is made up entirely of dentists,
so to an outsider, it might appear it’s a rigged game.
The commission is empowered to write laws governing the practice of dentistry in Connecticut. It is
Mr. Will’s contention that the commission writes
only laws to protect dentists’ incomes, with no
regard for what is good for the public. He sees this
as a purely economic problem, where “big dentistry” is interfering with the rights of teeth-whitening
salons—dentists charge $350 and up for teeth2
APRIL 2016 • The New York State Dental Journal
whitening, while the salons charge $150 for the
same treatment.
Mr. Will goes on to argue that teeth whitening
is a simple, safe procedure that patients can administer to themselves with materials they can purchase without a prescription. While this is true for
home whitening systems such as Crest White
Strips, I don’t know of any system available to consumers that uses a light to activate the product.
Most are simply 10% carbamide peroxide impregnated strips you leave on your teeth for approximately 20 minutes at a time. And, while most
whitening products are safe to use, there can be
serious side effects, tooth sensitivity being the most
significant. People with many restorations in their
mouths seem to be more prone to sensitivity reactions, particularly if there is recurrent decay under
these restorations. The 10% concentration of carbamide peroxide is for home bleaching kits you can
buy over the counter. The concentration in light or
laser-activated products is much higher. Without
proper supervision, this could lead to problems.
Mr. Will notes that in Connecticut, the commission can institute fines of up to $25,000 or up
to five years in jail per incident for assisting a
patron by placing the whitening products on the
teeth and positioning the light. He maintains this
THE NEW YORK STATE DENTAL JOURNAL
EDITOR
Kevin J. Hanley, D.D.S.
ASSOCIATE EDITOR
Chester J. Gary, D.D.S.
MANAGING EDITOR
Mary Grates Stoll
ADVERTISING MANAGER
Jeanne DeGuire
ART DIRECTORS
Kathryn Sikule / Ed Stevens
EDITORIAL REVIEW BOARD
Frank C. Barnashuk, D.D.S.
David A. Behrman, D.M.D.
Michael R. Breault, D.D.S.
Ralph H. Epstein, D.D.S.
Daniel H. Flanders, D.D.S.
Joel M. Friedman, D.D.S.
G. Kirk Gleason, D.D.S.
Brian T. Kennedy, D.D.S.
constitutes “a politically connected faction bending public power for its private benefit
by crippling competitors.” I’m sure that is the motivation behind the Connecticut State
Dental Commission and its regulation of the practice of dentistry in Connecticut. There
is absolutely no thought on its part for public safety. Of course, I’m joking, as I am sure
the sole motivation of the commission is to do exactly that, protect the public.
The whitening salons in Connecticut are represented by the Institute for Justice,
which is arguing that “it is unconstitutional to require someone to have eight years of
higher education before they can point a flashlight at someone’s teeth.” Where do I
start with that statement? Mr. Will called this a “patent truth.” Does this mean there
will be other areas of dentistry where our dental degrees will be meaningless? Is do-ityourself orthodontics and endodontics on the horizon? There are already do-it-yourself clear aligner treatments available. All you have to do is send in maxillary and
mandibular impressions and photos and a company will make a series of clear aligners
to straighten your teeth. There are two companies in the United States providing this
service. There are also YouTube videos describing how to close a maxillary midline
diastema with rubber bands. Both of these are fraught with danger. When I was in
dental school, one of the faculty members actually did an endodontic procedure on
himself, or so it was reported. That took a lot of bravery, but at least he had the necessary training.
Mr. Will argues that if the Supreme Court finds in favor of the defendants and upholds
the 2nd Circuit’s ruling, the rational basis test becomes meaningless, thereby ending judicial
review of economic activity. Again, in Mr. Will’s own words: “This will become an unlimited license for government to impede access to professions, reward rent seekers and punish
consumers, thereby validating Americans’ deepening disdain for government.”
I have to disagree with Mr. Will. Dental commissions are there for a purpose, and
that purpose is not to protect the dentists they serve but rather the public. In my experience, dentists are among the most altruistic professionals around. Sure, there are dentists
Stanley M. Kerpel, D.D.S.
Elliott M. Moskowitz, D.D.S., M.Sd
Francis J. Murphy, D.D.S.
Eugene A. Pantera Jr., D.D.S.
Robert M. Peskin, D.D.S.
Georgios Romanos, D.D.S.,
D.M.D., Ph.D., Prof.Dr.med.dent
Pragtipal Saini, B.D.S., D.D.S., M.S.D.
Robert E. Schifferle, D.D.S., MMSc., Ph.D.
PRINTER
Fort Orange Press, Albany
NYSDJ (ISSN 0028-7571) is published six times a year,
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and November, by the New York State Dental Association,
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York State Dental Association, Suite 602, 20 Corporate
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The New York State Dental Journal • APRIL 2016
3
more concerned with their bottom line and maximum profits.
Fortunately, they are the exception. Most dentists I know are caring, giving individuals who only have their patients’ best interests
at heart.
If I could address Mr. Will, I would tell him that states have
given dentists the right to oversee the practice of dentistry, not to
aggrandize themselves but to guard the public from abuses that
could occur if there were no oversight. In New York State, we have
a State Board of Dentistry, but our rules and regulations originate
from the Department of Education. The Board of Dentistry oversees licensed individuals providing dental services. Its goal is to
protect the oral health, safety and welfare of the citizens of New
York State. It does not exist to make sure there is no competition
to licensed dentists but, rather, to make sure licensed dentists provide the best possible, ethical care to their patients.
It may be difficult for Mr. Will to comprehend, but sometimes the people who provide treatment and have been trained to
provide treatment are also the ones who know best who can
provide that treatment. It isn’t always about limited government,
but what is best for the public. Sometimes the government
4
appoints boards of experts to oversee various fields of endeavors,
not because these boards want to control what goes on, but
because they truly are the ones who know what is best. In the
case of dentistry, that would be dentists. And when the whitening
process goes wrong, who do they seek first to correct the problem? Not the teeth-whitening salons, but the dentist. And correcting the problem can be worse for the patient than the original
desire for white teeth.
No, Mr. Will, this is not a David vs. Goliath situation, but
what is best for the public. Sometimes what seems like an innocuous process can become problematic. If you don’t have the
training necessary to handle complicated situations, you shouldn’t
be doing the procedure. The public deserves this protection. That
is why there are state boards of dentistry. Let’s hope the Supreme
Court sees it this way as well. If it doesn’t, we are headed down a
slippery slope indeed.
D.D.S.
Out on a Limb in Dutchess County
Michael J. Schwartz, D.D.S.
Just who is running the show? I noted in a recent edition of the
ADA News that United Concordia Insurance Co. will be denying
claims for periodic dental X-rays taken in the absence of patient
symptoms. Only X-rays taken with prior symptoms will be paid,
according to FDA guidelines. Nice that our ADA has opposed this
new policy, but a letter of disapproval will not stop these continual incursions into how we run our practices. We agree that
it is in our patient’s best interest to limit radiation exposure, on
any level, and both our profession and manufacturers have made
outstanding progress is this area.
In my 52 years of practice, like all practitioners, I have found
so much asymptomatic pathology simply by trying to be thorough
and do radiographs periodically. And that frequency can vary with
what we might be following. But the absence of symptoms is not
our criteria for not being thorough. Our patients expect nothing
less. Just think. Do you want your M.D. not to do diagnostic annual physicals, even though you feel O.K.? Does your M.D. do urine
analysis, bloodwork, pupil dilation, bladder ultrasound, calcium
scores, stool assay, cervical smears, nuclear stress tests, A1-C levels
check, EKG and palpate the abdomen? It would be irresponsible
and negligent to abdicate that responsibility to you because of an
insurance company limitation. Certainly, one does not need to do
every test known to man to feel that he or she has been thorough.
This whole business with insurance companies and X-rays
is a smoke screen and has little to do with patient radiation exposure, albeit, that is the reason given. It really has to do with
denying patients their rights to proper care and, thereby, increasing the profit bottom line. Does anyone really doubt that? The
insurance companies are just looking to make us the “bad guys”
by shifting costs.
To wit, in some states, insurers are denying claims for anterior restorations unless accompanied by postop radiographs. Why
is it okay to have dentists prove care was rendered with an X-ray
and, at the same time, deny diagnostic X-rays? So much for pa-
tient protection. The good news is that New York State law prohibits that practice, another feather in the cap for EDPAC and an
enlightened Legislature.
I get it that insurance companies sign contracts with employers to provide coverage for defined services. It is always their decision as to what gets included in coverage, based on appropriate
contractual agreements. But, entering into the field of medical/
dental decision-making for patients, that is where the line must
be drawn. We have the training and expertise; they do not. As long as I have been practicing, this attitude of incursion
and encroachment has been how insurance companies function. Their bottom line always takes precedence over patient and
doctor care. So, when your patients ask, “How come this wasn’t
covered?” Or want to know why the insurance company called
the treatment unnecessary or said it exceeded reasonable and
customary costs, your answer should simply be informative. Tell
your patients that what is covered is mostly a reflection of an employer/insurance contract, based on what the employer wishes to
spend. The insurance company then seeks to maximize its profits
within that guideline.
By denying coverage, we are not allies. Our interest is proper
care; theirs is profit. And, tell the insureds that they can register
their dissatisfaction by contacting the appropriate management
person. It is getting harder to run our own show. p
Dr. Schwartz is corresponding secretary of the Dutchess County Dental Society.
This article first appeared in the March Bulletin of the Ninth District Dental
Association.
9
caries prevention
Efficacy of a Prenatal Oral Health Program
Follow-up with Mothers and their Children
Charles D. Larsen, D.M.D., M.S.; Michael D. Larsen, Ph.D.; Terri Ambrose, D.D.S.;
Robert Degano, D.M.D.; Leonard Gallo, D.D.S.; Vito A. Cardo Jr., D.D.S.
ABSTRACT
Brookdale Hospital and Medical Center’s Prenatal
Care Assistance Program (PCAP) provides oral health
education and treatment to expectant mothers from
a minority, impoverished, high-risk population. A
chart review examined dental records for 42 children
of mothers who took PCAP training versus 49 children of mothers who did not. At age 2, the children
of PCAP mothers had fewer dental caries, less severe
dental caries and fewer extractions. When combining children at ages 2 and 3, results were statistically
significant and clinically important. Evidence strongly suggests the PCAP program can lead to vastly improved oral health of participants’ young children.
According to the Surgeon General, oral health education and
treatment during pregnancy is an important strategy to potentially improve maternal and infant health.1 Maintaining good
oral health has the potential to improve the overall health and
well-being of reproductive-aged women during pregnancy and
also later in life.2
In August 2006, the New York State Department of Health
(DOH) published guidelines for improved oral health of pregnant
mothers to reduce complications of oral disease during pregnancy
and childhood caries by limiting the transference of harmful bacteria that can cause dental caries from mother to child.3 Pregnant
women in New York State have dental insurance and, thus, access
to care.
The Prenatal Care Assistance Program (PCAP) at Brookdale
Hospital and Medical Center Department of Dental Medicine and
Oral Maxillofacial Surgery developed a program to provide such
care. The PCAP appointments provide education and anticipatory
guidance involving oral health care for both the mother and child,
whereby significant lifestyle changes may be initiated.4 The DOH advocates for oral health to be an integral component of prenatal care
and suggests that all prenatal care providers encourage oral health
exams for all pregnant women who have not received dental care in
the past six months. Access to oral care in this population has been
inadequate and, therefore, it seems appropriate for all women enrolled in PCAP to be referred for oral examinations and education.4
Acquiring harmful caries-causing bacteria earlier rather than
at an older age predisposes a child to a greater risk of developing
dental caries. Poor maternal oral health, poor oral hygiene behaviors and high sugar diets that promote high colonization with
S. mutans may increase contamination of the child’s oral cavity
and the presence of substrates for harmful bacteria growth.5 Maternal oral flora is one of the greatest predictors of the oral flora
of infants and children.5,6 Behavioral interventions involved in
PCAP dental appointments, such as smoking cessation, exercise,
healthy diet and maintenance of optimal weight, are also useful
tools for promoting overall systemic health for the mother.7
15
A woman’s knowledge and action for her own health are critical
to the oral health of her child and may be key to the prevention of
childhood caries.8 Although nurses are concerned with numerous
aspects of the health of pregnant women, the health of maternal
and fetal dentition may be overlooked.9 As a result of recent studies and findings that periodontal disease may be a risk factor for
preterm low birth weight, nurses and dentists are becoming more
concerned with oral health during pregnancy.9
The presence of maternal periodontal disease and active infection has been associated with adverse pregnancy outcomes,10
such as preterm birth,11,12 preeclampsia,13 gestational diabetes,14
delivery of a small for gestational age infant15 and fetal loss.16 Evidence exists that periodontal treatment during pregnancy leads to
a reduction in preterm birth risk.17
Optimal nutrition during pregnancy has been shown to enhance dental health for both mother and fetus by providing important nutrients necessary for gingival health and mineralization of the teeth.18 Fetal tooth development begins by week six of
gestation for the primary dentition and by week 10 for permanent
teeth. Tooth development can be affected by severe maternal malnutrition.9
The Surgeon General’s goal of improved access to oral health care
for all individuals, including pregnant women, needs to include
education of all health care providers. Barriers to care involving
lack of education, socioeconomic factors, myths of safety of dental care in pregnant women and lack of public support for providing oral health care to pregnant mothers and their children needs
to be addressed. It has been suggested that there is great difficulty
overcoming urban myths regarding dentists providing, and patients seeking, oral health care during pregnancy.19
Material and Methods
A Prenatal Care Assistance Program (PCAP) was developed in
2009-2010 at Brookdale Hospital and Medical Center, Brooklyn, NY. All expecting mothers were referred from obstetrician/
gynecologists to the pediatric dentistry residency program. The
PCAP offers comprehensive obstetric care and provides prenatal
care, employing obstetricians, nurses, social workers, a nutritionist, oral and maxillofacial surgeons, general dentists and pediatric
dentists, and a large constellation of support staff.
The PCAP gives dental education and care to a high-risk, impoverished, multicultural socioeconomic-challenged community.
Brookdale’s primary service area has an average median income
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16
of $32,000. Approximately 42% of residents live below the federal
poverty level, compared to 22% for the borough of Brooklyn and
19% for New York City overall. The community is designated as a
“health professional shortage area” by the Department of Health
and Human Services. The disease burden is high for early childhood caries. Maternal and newborn indicators are also poor. The
service area is plagued by crime, especially gun violence. The New
York City Police Department has designated our primary service
area as an “Impact Zone,” due to the high crime rate.20
An application for a new investigation was completed and
submitted to the Brookdale Hospital and Medical Center Research and Clinical Projects Committee (IRB). The retrospective
chart review was approved to analyze whether patients returned
for preventive and treatment visits, both for the mother and child,
following the initial prenatal dental screening. The purpose of
this data analysis was to determine the efficacy of a prenatal preventive and education program on the dental health of expectant
mothers and subsequent oral health of their newborn children.
This chart review would also determine the percent of mothers
who returned for care for themselves and if and when they returned to a pediatric dentist with their child. The retrospective
data from the prenatal preventive and education program would
be reviewed and evaluated to determine the level to which the
needs of both parent and child were met in this service project.
All protected health information was removed, and no patient
identifiers were accessible.
The aim of this study was to evaluate if prenatal counseling
and care for pregnant mothers promotes oral health in children.
A total of 289 mothers attended Brookdale Hospital and
Medical Center’s Prenatal Care Assistance Program (PCAP) and
received dental evaluation and consultation from 2010 through
2013. A supplement to this article, available from the authors,
describes the program. The number by year varies: 83 mothers in
2010; 74 in 2011; 47 in 2012; and 85 in 2013. Fifty-seven percent
(167 of 289) of the mothers have not returned for dental care
after the birth of their child. The percent not returning increases
with year: 34 (41%) from 2010 have not returned; 36 (49%)
from 2011; 31 (66%) from 2012; and 66 (78%) from 2013. It
is likely that the mothers’ return rates will become more equal as
the children born more recently grow older. Mothers who visited
the clinic during pregnancy and after received prophylaxis, scaling, restorations, extractions, preventive care and education.
Of the 122 PCAP mothers who returned for dental care, 45%
(55 of 122) have brought a child for dental examination and
care. Forty-eight out of the 55 charts were located: 21 (43% of the
returning mothers) from 2010; 17 (45%) from 2011; 7 (44%)
from 2012; and 3 (16%) from 2013. Missing charts could be simply missing, or purged for storage limitations. Six of the children
who were seen were older siblings rather than the recently born
child. Children received prevention, fluoride, restorations and, as
needed, extractions. Information from chart records on dental
caries and extractions were recorded for the 42 available children.
Because mothers of younger children have been less likely to return for dental care, the age of the children at their return visit is
skewed: 23 (55% of the children) were 3 years old; 16 (38%) were
2 years old; and 3 (7%) were 1 year old.
A comparison group was created by randomly sampling
charts of 55 children of mothers who did not participate in the
PCAP appointment during 2010-2013. Six of the charts were
missing or purged for storage limitations. Of the 49 children, five
(10%) were 0-1 years old, 12 (24%) were 2 years old, 19 (39%)
were 3 years old and 13 (27%) were 4 years old.
Statistical Methods
The numbers of children with and without caries and with and
without extractions were tabulated by age of child at visit and
mother’s PCAP participation status (yes/no). By age group, crossclassification by caries status (yes/no) and mother’s PCAP status
(yes/no) produces 2 x 2 tables. Similar tables were made by cross
classifying extraction status (yes/no) and mother’s PCAP status.
The statistical significance of the association between the two dimensions was assessed using Fisher’s exact test and a Chi-squared
17
TABLE 1
Number and Percent of Children with and without Caries by
Age and by Mother’s Participation in Prenatal Care Assistance
Program (PCAP) Dental Evaluation and Counseling
Children of PCAP Mothers
Children of Non-PCAP Mothers
No Caries
Caries
Total
No Caries
Caries
Total
Age 0-1
3 (100%)
0
3
5 (100%)
0
5
Age 2
11 (69%)
5
16
6 (50%)
6
12
Age 3
15 (65%)
8
23
5 (26%)
14
19
Age 4
0
0
0
3 (23%)
10
13
Total
29 (69%)
13
42
19 (39%)
30
49
TABLE 2
Number and Percent of Children with and without Extractions
of Four Teeth (DEFG) by Age and by Mother’s Participation in
Prenatal Care Assistance Program (PCAP) Dental Evaluation
and Counseling
Children of PCAP Mothers
Children of Non-PCAP Mothers
No
Extractions
DEFG
Extracted
Total
No
Extractions
DEFG
Extracted
Total
Age 0-1
3 (100%)
0
3
5 (100%)
0
5
Age 2
15 (69%)
1
16
8 (50%)
4
12
Age 3
21 (65%)
2
23
13 (26%)
6
19
Age 4
0
0
0
8 (23%)
5
13
Total
39 (69%)
3
42
34 (39%)
15
49
TABLE 3
Average Number of Teeth with Caries by Age and by Mother’s
Participation in PCAP for All Children and for Children with
Caries. (Two sample t-test p-values concatenate data for more
than one age group. Regression p-values fit linear regression
model with main effects for age and PCAP. )
Age 2
Age 3
Ages 2-3
Age 4
Ages 2-4
18
PCAP
Average
NonPCAP
Average
T-test
P-value
All children
1.93
3.17
0.37
Children with caries
5.40
6.33
0.59
All children
1.78
6.11
<0.001
5.13
8.29
0.041
All children
1.84
6.11
<0.001
0.001
5.23
7.70
0.033
0.041
All children
-
5.78
-
7.50
All children
1.84
5.20
<0.001
0.001
5.23
7.63
0.019
0.040
Regress
P-value
test (one degree of freedom) with a continuity correction. One
way to produce a p-value for the test of association using data
from children of two or more ages can be computed by adding
together cell by cell the tables for the various years and then performing Fisher’s exact or a Chi-squared test. Another way is to
use the Cochran-Mantel-Haenszel (CMH) test for stratified 2 x 2
tables. The CMH test can be computed exactly using combinatorial computations or by using a large-sample approximation.
The number of teeth with caries by child was recorded. A
two-sample t-test can be used to test the hypothesis of no difference in mean by mother’s PCAP participation status (yes/no) for
children age 2 or 3. Tests can be performed for all the children by
age group and then for those children with caries. The latter test
omits children without caries and assesses the amount of caries
among those with caries. One way to combine data from children
of different ages is to simply ignore the ages and concentrate the
data within groups defined by the mother’s PCAP status. Another
way is to fit a linear regression model with effects for mother’s
PCAP status and for age.
It is hypothesized that the group of children whose mothers
participated in PCAP will be less likely to have caries and extractions and will have fewer caries than the group of children whose
mothers did not participate in PCAP.
Results
Table 1 presents the number and percent of children with and
without caries by age and by the mother’s participation in Prenatal Care Assistance Program (PCAP) dental evaluation and
counseling. No children age 0-1 had caries. The rate of not
having caries is higher in the children of PCAP mothers than
in the children of non-PCAP mothers at age 2 (65% versus
45%, Fisher p-value 0.44, Chi-square p-value 0.54), at age 3
(75% versus 36%, Fisher p-value 0.016, Chi-square p-value
0.028), and overall (70% versus 39%, Fisher p-value 0.015,
Chi-square p-value 0.019, CMH p-value 0.021 approximate
and 0.016 exact). The rate of caries in the age 4 non-PCAP
children increased further. The analysis suggests that by age 3,
the children of PCAP mothers are statistically significantly less
likely to have dental caries.
Table 2 presents the number and percent of children with
and without extractions of four teeth (DEFG) by age and by
the mother’s participation in PCAP. No children age 0-1 had
extractions. The rate of not having extractions is higher in the
children of PCAP mothers than in the children of non-PCAP
mothers at age 2 (94% versus 67%, Fisher p-value 0.13, Chisquare p-value 0.18), at age 3 (91% versus 68%, Fisher p-value
0.11, Chi-square p-value 0.14), and overall (92% versus 68%,
Fisher p-value 0.013 Chi-square p-value 0.021, CMH p-value
0.023 approximate and 0.013 exact). The rate of extractions in
the age 4 non-PCAP children increased further (only 62% with-
Number of Caries by Age and Group in
Children with Caries
Caries
Caries
Number of Caries by Age and Group
Figure 1. Side-by-side box plots of number of caries in children by age and mother’s PCAP
status. All children included. Boxes PCAP2 and PCAP3 represent children of PCAP mothers aged
2 and 3, respectively. Boxes NONP2, NONP3, and NONP4 represent children of chosen control,
non-PCAP mothers aged 2, 3, 4, respectively. Boxes are box-and-whisker plots. Dark line is
median value. Upper and lower box sides are 75th and 25th percentiles, respectively. Dotted
lines indicate ranges of observed values, except for extreme values, which are denoted with
circles. In PCAP2 and PCAP3, median value is zero.
Figure 2. Side-by-side box plots of number of caries in children by age and mother’s PCAP
status. Children with caries included. Boxes PCAP2 and PCAP3 represent children of PCAP mothers
aged 2 and 3, respectively. Boxes NONP2, NONP3, NONP4 represent children of chosen control,
non-PCAP mothers aged 2, 3, 4, respectively. Boxes are box-and-whisker plots. Dark line is median value. Upper and lower box sides are 75th and 25th percentiles, respectively. Dotted lines
indicate ranges of observed values, except for extreme values, which are denoted with circles.
Values are positive, because all children included in this figure have caries.
out extractions). The analysis suggests that by age 3, the children of PCAP mothers are statistically significantly less likely to
need extractions of teeth DEFG.
Table 3 presents the average number of teeth with caries by
age and by the mother’s participation in PCAP. Results are presented for all children and for children with some caries. Averages are higher for children whose mothers did not participate in
PCAP. Results are highly statistically significant (p-value < 0.001)
for children age 3 and for groups of children, including those
who are age 3. Figures 1 and 2 illustrate differences by age and
mother’s PCAP status. Figure 1 presents side-by-side box plots of
children of PCAP mothers at ages 2 and 3 and children of nonPCAP mothers at ages 2, 3 and 4. Figure 2 is the same as Figure 1,
but is restricted to children with some caries. The figures illustrate
the substantial difference in distribution of the number of caries
in children between PCAP and non-PCAP mothers.
question is that prenatal counseling and care for pregnant mothers appear to promote oral health in children.
One factor that made the intervention possible in the first
place was convenient access to dental care and counseling of
pregnant mothers due to the location of the OB/GYN unit and
dental medicine and oral and maxillofacial surgery clinic within
one institution and building.
A primary limitation of this research was that mothers selfselected for participation in PCAP. There are likely to be several
confounding factors that affect results. For example, it is not possible to know if mothers had prior visits for dental care of children at this clinic or at other clinics. Information is not available
on household structure or stability. The apparent advantageous
impact of prenatal dental intervention with pregnant mothers
supports further study of dental counseling in this and other
populations. Previous work with school-age children has found a
clear benefit in providing dental care to children in a convenient
setting.21,22
One factor that can be partially examined is the age of the
mothers. Age information is available on mothers who attended
PCAP sessions and for some mothers who did not. Some of the
PCAP mothers returned to receive dental care for themselves and
their PCAP child (average age 26.75 years), whereas others came
only for themselves (28.00 years) or did not return (26.52 years).
Differences between PCAP groups are not statistically significant
Discussion
As children get older (age 3 or 4), if their parents do not instruct
them in proper dental hygiene and diet behavior (e.g., not going
to bed with a bottle with juice or milk), then they are at significant risk of multiple dental caries and of needing extractions of
primary maxillary incisors. In the setting of this study, counseling and care of mothers seem to be effective in reducing the most
egregious harmful effects. The answer to the primary research
19
(1-way ANOVA p-value 0.19). Non-PCAP mothers appear to be
a little bit older on average (32.92 years), and the difference between them and the PCAP mothers who returned for child care
was statistically significant (2-sample t-test p-value < 0.01). Ages
were missing for non-PCAP mothers when a foster parent or a
grandparent brought the child to the dental clinic.
Proper assessment, intervention and patient education focusing on dental and oral health problems during pregnancy can
help enhance pregnancy outcomes. The PCAP can assume vital
roles in screening and referral for dental problems during pregnancy and should also proactively teach patients about maintaining oral health during pregnancy.13
The relationship between maternal and child experience
with dental caries is well established. Therefore, regardless of
the potential for improved oral health to improve pregnancy
outcomes, public policies that support comprehensive dental
services for vulnerable women of childbearing age should be expanded.23 The PCAP promotes the mother’s own general health
and, in addition, reduces the caries risk for their children. By
embracing the concepts of the “dental home,” health care providers can implement preventive and treatment protocols. Partnerships with other health care professionals, with the aim of
providing preventive care for our high-risk populations, are necessary to achieve improved oral health outcomes in the future. p
15.
Queries about this article can be sent to Dr. Charles Larsen at [email protected]
Michael D. Larsen, Ph.D., is a professor, Department of Statistics, The George Washington University, Washington, DC.
REFERENCES
Terri Ambrose, D.D.S., is a resident in the advanced education program in pediatric dentistry,
Brookdale Hospital & Medical Center, Brooklyn, NY.
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U.S. Department of Health and Human Services. Oral Health in America: A Report of the
Surgeon General. Rockville (MD): U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
Boggess KA. Maternal Oral Health in Pregnancy Vol 111 (4), April 2008, P976-986.
New York State Department of Health. Oral Health Care during Pregnancy and Early Childhood. August 2006.
Kerpen, SJ, Burakoff, R. Providing oral health care to underserved population of pregnant
women: retrospective review of 320 patients treated in private practice setting. NYSDJ August/September 2013:45-47.
Caufield PW. Dental caries – a transmissible and infectious disease revisited: a position
paper. Pediatric Dent 1997;19:491-8.
Berkowitz RJ. Mutans streptococci: acquisition and transmission. Pediatric Dent 2006; 28:
106-9; discussion 192-8.
Al-Zahrani MS, Borawski EA, Bissada NF. Periodontitis and three health-enhancing behaviors: maintaining normal weight, engaging in recommended level of exercise, and consuming a high-quality diet. J Periodontol 2005;76:1362-6.
Boggess KA. Maternal oral health in pregnancy. Obstetrics & Gynecology April 2008;111(4):976986.
Winters Mills L, Moses DT. Oral health during pregnancy. Maternal Child Nursing (MCN)
September/October 2002:275-281.
Albandar JM, Brunelle JA, Kingman A. Destructive periodontal disease in adults 30 years of
age and older in the United States, 1988-1994. J Periodontol 1999;70:13-29.
Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al. Periodontal infection as
a possible risk factor for preterm low birth weight. J Periodontol 1996;67:1103-13.
Offenbacher S, Lieff S, Boggess KA, Murtha AP, Madianos PN, Champagne CM, et al. Maternal periodontitis and prematurity. Part I: Obstetric outcome of prematurity and growth
restriction. Ann Periodontol 2001;6:164-74.
Boggess KA, Lieff S, Murtha AP, Moss K, Beck J, Offenbacher S. Maternal periodontal disease
is associated with an increased risk for preeclampsia. Obstet Gynecol 2003;101:227-31.
Xiong X, Buekens P, Vastardis S, Pridjian G. Periodontal disease and gestational diabetes
mellitus. Am J Obstet Gynecol 2006;195:1086-9.
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194:1316-22.
Moore S, Ide M, Coward PY, Randhawa M, Borkowska E, Baylis R, et al. A prospective study
to investigate the relationship between periodontal disease and adverse pregnancy outcome.
Br Dent J 2004;197:251-8; discussion 247.
Lopez NJ, Smith PC, Gutierrez J. Periodontal therapy may reduce the risk of preterm low
birth weight in women with periodontal disease: a randomized controlled trial. J Periodontol 2002;73:911-24.
Fitzsimons D, Dwyer JT, Palmer C, Boyd LD. Nutrition and oral health guidelines for pregnant women, infants, and children. J Amer Dent Assoc 1998;132(7):182-189.
Sumuelson R, Guest Editorial. Grand Rounds in Oral-Systemic Medicine 2006;1(4):10-13.
www.brookdalehospital.org, 2013 community health needs assessment, 3. Description of
community, pp. 9-11.
Larsen CD, Larsen MD, Kim M, Yang E, Cunningham R. Sequential years of dental outreach
to Jamaica: gains toward improved caries status of children. NYSDJ 2014; 80(5): 40-45.
Larsen CD, Larsen MD, Handwerker L, Kim MS, Rosenthal M. A comparison of schoolbased and community-based dental clinics. J School Health 2009;79(3):116-122.
Boggess KA, Edelstein B. Oral health in women during preconception and pregnancy: implications for birth outcomes and infant oral health. Matern Child Health J 2006;10:S169-S174.
Dr. Charles Larsen
Dr. Michael Larsen
Dr. Cardo
Charles D. Larsen, D.M.D., M.S., is vice chair, Dental Medicine and Oral Maxillofacial Surgery
Department, and associate director, advanced education program in pediatric dentistry, Brookdale Hospital & Medical Center, Brooklyn, NY.
Robert Degano, D.M.D., is attending, advanced education program in pediatric dentistry, Brookdale Hospital & Medical Center, Brooklyn, NY.
Leonard Gallo, D.D.S., is director of the advanced education program in pediatric dentistry, Brookdale University Hospital & Medical Center, Brooklyn, NY.
Vito A. Cardo Jr., D.D.S., is chair of the Dental Medicine and Oral & Maxillofacial Surgery
Department and director of the oral & maxillofacial surgery residency program at Brookdale Hospital
& Medical Center, Brooklyn, NY.
orofacial pain
Goldenhar Syndrome and Pain-Related
Temporomandibular Disorders
A Case Report
Shehryar Nasir Khawaja, B.D.S., M.Sc.; Heidi Crow, D.M.D., M.S.; Yoly Gonzalez, D.D.S., M.S., M.P.H.
ABSTRACT
Goldenhar syndrome (GS) is a development syndrome, characterized by incomplete development of
the craniofacial region. The involvement is mainly
unilateral; it varies from being mild to severe; and it
can range from malocclusion and facial asymmetry to
a more complex phenotype with complete absence of
the mandibular ramus and temporomandibular joint.
However, orthopedic symptoms of orofacial pain and
dysfunction have not generally been considered as
part of the symptom complex in GS cases. The case
presented here is of a 15-year-old Caucasian patient,
who was referred for evaluation because of bilateral
pain in the masticatory muscles and temporomandibular joints.
Goldenhar syndrome (GS) is a development syndrome with heterogeneous etiology. The typical presentation of GS consists of
craniofacial anomalies, such as epibulbur dermoids, microtia,
auricular appendices, pretragal blind-ended-fistulas, mandibular
hypoplasia and vertebral anomalies. However, its clinical manifestations may also include anomalies of other systems as well,
such as skeletal, cardiac, renal and central nervous. The majority
of cases are sporadic; however, familial occurrences have also been
observed. The incidence of GS has been reported to be 1:3,500 to
1:26,550, with a male-female ratio of 3:2.1,2
The typical craniofacial presentation of GS is also referred to as
hemifacial macrosomia. It is caused most likely by the developmental defect of the first and second brachial arches. The craniofacial involvement is mainly unilateral; it varies from being mild
to severe, and can range from malocclusion and facial asymmetry to a more complex phenotype with complete absence of the
mandibular ramus and temporomandibular joint.1,3 Craniofacial
involvement of GS has been classified by Mulliken and Kaban3
into three types. Type I includes mild hypoplasia of the ramus,
with the body of the mandible minimally or slightly affected. Type
II includes a flattened condyle while the glenoid fossa and coronoid are absent. Type III includes a ramus that is reduced to thin
lamina or is completely absent, with no evidence of the temporomandibular joint (TMJ).
Temporomandibular disorders (TMD) encompass a group of
musculoskeletal and neuromuscular conditions that involve the
TMJs, the masticatory muscles and associated tissues.4 The pain-related TMD consists of myalgia, arthralgia and headaches attributed
to TMD.5 The prime manifestations of pain-related TMD are pain
of a persistent, recurring or chronic nature in the masticatory muscles, TMJ or adjacent structures, or limitation or other alterations
in the range of mandibular motion due to pain. The prevalence of
pain-related TMD is about 10% in the general population.6,7
The etiology of pain-related TMD is considered multifactorial,
resulting from a complex interaction among biological, psychological, social and environmental variables.4 Risk factors identified with pain-related TMD include the presence of psychological
symptoms, oral parafunctional behaviors, non-specific orofacial
symptoms and various comorbid pre-existing pain conditions.8-11
21
Figure 1. Panoramic view of patient at 15 years, indicating Type I discrepancy. Anatomy
of right and left temporomandibular joints is normal. However, hypoplasia of left ramus is
present. Cochlear implant is visible on left side.
Figure 2. Panoramic view of patient at 2-year follow-up. Patient still has Type I discrepancy.
Anatomy of right and left temporomandibular joints is normal. However, hypoplasia of left
ramus is present. Cochlear implant is visible on left side.
The case presented here is intended to illustrate an example of
compensatory behaviors developed because of facial asymmetry
associated with Type I Goldenhar syndrome and their possible
association in triggering the masticatory muscle and joint pain.
had previously undergone surgery for left cochlear and external
ear implants. She was not allergic to any known medications; and
there was no relevant family history or other medical concerns.
During the interview, she reported intermittent bilateral pain
localized to the masseter and temporalis muscles and the temporomandibular joints. She had been experiencing this pain for the last
six years. The pain was described as dull and achy in nature, taking
place multiple times during the day, with each episode lasting from
a few minutes to a few hours. In addition, the patient said her pain
was aggravated with opening and closing jaw movements and mastication; application of heat or ice alleviated her symptoms.
Case Report
A 15-year-old Caucasian patient was referred for evaluation because of bilateral pain in the masticatory muscles and temporomandibular joints. Her medical history was significant for Goldenhar syndrome. Associated anomalies consisted of left anotia,
bilateral vesicoureteral reflux disease and facial asymmetry. She
22
Bio-behavioral assessment using standardized self-reported instruments indicated that she was involved in multiple parafunctional
behaviors that included the following: unilateral chewing; clenching or pressing her teeth together when awake; clenching or grinding her teeth when asleep; holding her lower jaw forward to improve her appearance; holding her jaw in a rigid position; leaning
with her hand on the jaw; biting her finger nails; biting on her
tongue, cheeks, or lips; and pressing her tongue against the teeth.
Clinical examination indicated that the patient had bilateral
familiar pain in masseter muscles and TMJs during range of motion and palpation. A panoramic radiograph (Figure 1) showed no
structural abnormality in the anatomy of the right and left TMJs;
however, the height of the left ramus was shorter than the height
of the right ramus. According to the classification of mandibular
deficiency, proposed by Mulliken and Kaban,3 this patient had a
Type I discrepancy. Based on the patient’s history, standardized
clinical examination and radiographic report, she was diagnosed
as having myalgia and arthralgia (pain-related TMD diagnoses),
according to the Diagnostic Criteria for TMD (DC-TMD).5
A treatment plan focused on symptomatic care was designed
for her. She was given a comprehensive home care program, in
which she was educated about pain-related TMD, given dietary
instructions, asked to modify parafunctional habits, perform
thermal compressions, and do isometric and isotonic exercises
of the masticatory muscles. In addition, a soft maxillary 2 mm
splint was delivered for nocturnal wear, and physical therapy
techniques were performed on the masticatory muscles and TMJ.
After a month of engagement and compliance with the home
care program, physical therapy and nocturnal splint use, the patient said her symptoms had significantly reduced in frequency and
intensity. Such outcomes were still maintained at a two-year follow
up; however, she had stopped physical therapy and nocturnal use
of the splint. She now only occasionally engages in the home care
program. Furthermore, a panoramic radiograph showed the patient still had the Type I discrepancy on the left side. No structural
changes consistent with degenerative joint disease were observed.
Discussion
In the current literature, structural malformations such as those associated with GS have not been considered a risk factor for pain-related
TMD. Furthermore, orthopedic symptoms of orofacial pain and dysfunction are generally not considered part of the symptom complex in
Type I GS cases.12 However, pain and tenderness have been reported in
severe types (III) of GS.13 In this particular case, the patient reported
moderate-to-severe pain, attributed to pain-related TMD.
A possible common association between these two conditions
in this particular case may be the presence of parafunctional activity. The patient reported having developed waking-state behavioral
activities, such as protruding the mandible to compensate for the
facial asymmetry. Parafunctional oral behaviors have been hypoth-
esized to result in an abnormal, sustained contraction of the masticatory muscles, which could exert non-physiological forces on both
the muscles themselves and the temporomandibular joints.14 In
theory, this could result in damage, inflammation and nociceptor
sensitization.14,15 These changes can subsequently act as initiating,
aggravating and perpetuating factors in subgroups of TMD patients.8,16,17 Based on current literature, it appears that the presence
of parafunctional activity may be associated with the cause as well
as the consequence of the pain experienced in TMD.8,10 Another
proposed mechanism of association suggests that the contralateral
articular disc of the normal TMJ may become anteriorly displaced
due to the abnormal condylar rotation caused by the mandibular
asymmetry and functional overloading.13 However, limited evidence is available in the literature to support this association.
Goldenhar syndrome has a clinically heterogeneous presentation; there is no agreement in the literature regarding the diagnostic criteria. The spectrum of mandibular malformations range from
a small but normally shaped ramus and TMJ to complete absence
of these structures.1-3 The treatment of facial anomalies associated
with GS mainly consists of orthodontic treatment, surgical procedures (distraction osteogenesis, temporomandibular joint replacement), and cosmetic and orthognathic surgeries. However, in Type
I GS, a nonsurgical, conservative approach, such as orthodontic
treatment, may be preferred by the patients.11,18 Since pain is generally not a symptom, no specific recommendations for pain management are included in GS treatment protocols.
For pain-related TMD, it is recommended that the diagnosis be based on information obtained from the patient’s history, clinical examination and, when indicated, TMJ imaging.
The treatment of such patients should be based on the use of
conservative, reversible and evidence-based therapeutic modalities. Furthermore, it is recommended that professional treatment
be augmented with a home care program, in which patients are
taught about their disorder and how to manage their symptoms.4
Conclusion
In the current literature, structural malformations such as those
associated with Type I GS have not been associated as a risk
factor for pain-related TMD. A comprehensive history and examination during patient assessment, including pain characterization, associated signs and symptoms, bio-behavioral characteristics and a standardized clinical exam, can help clinicians
identify and characterize pain-related TMD. The treatment of
pain-related TMD in the aforementioned patient should be
based on the use of conservative, reversible and evidence-based
therapeutic modalities. p
The authors declare that there is no conflict of interests regarding the publication of this paper. Queries about this article can be sent to Dr. Khawaja at
[email protected].
23
REFERENCES
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24
Hartsfield JK. Review of the etiologic heterogeneity of the oculo-auriculo-vertebral spectrum
(Hemifacial Microsomia). Orthod Craniofac Res 2007;10:121-128.
Martelli H Jr, Miranda RT, Fernandes CM, Bonan PR, Paranaiba LM, Graner E, et al. Goldenhar syndrome: clinical features with orofacial emphasis. J Appl Oral Sci 2010;18:646-649.
Mulliken JB, Kaban LB. Analysis and treatment of hemifacial microsomia in childhood.
Clin Plast Surg 1987;14:91-100.
Greene CS. Diagnosis and treatment of temporomandibular disorders: emergence of a new care
guidelines statement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:137-139.
Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications:
Recommendations of the International RDC/TMD Consortium Network* and Orofacial
Pain Special Interest Groupdagger. J Oral Facial Pain Headache 2014;28:6-27.
Slade GD, Bair E, By K, Mulkey F, Baraian C, Rothwell R, et al. Study methods, recruitment, sociodemographic findings, and demographic representativeness in the OPPERA study. J Pain 2011;12:T12-26.
de Leeuw R, Klasser GD. Orofacial pain: guidelines for assessment, diagnosis, and management.
Fifth ed. de Leeuw R, Klasser GD, editors. Chicago, IL: Quintessence Publishing Co, Inc; 2008.
Ohrbach R, Fillingim RB, Mulkey F, Gonzalez Y, Gordon S, Gremillion H, et al. Clinical
findings and pain symptoms as potential risk factors for chronic TMD: descriptive data and
empirically identified domains from the OPPERA case-control study. J Pain 2011;12:T27-45.
Fillingim RB, Ohrbach R, Greenspan JD, Knott C, Dubner R, Bair E, et al. Potential psychosocial risk factors for chronic TMD: descriptive data and empirically identified domains
from the OPPERA case-control study. J Pain 2011;12: T46-60.
Ohrbach R, Bair E, Fillingim RB, Gonzalez Y, Gordon SM, Lim PF, et al. Clinical orofacial characteristics
associated with risk of first-onset TMD: the OPPERA prospective cohort study. J Pain 2013;14:T33-50.
Bair E, Ohrbach R, Fillingim RB, Greenspan JD, Dubner R, Diatchenko L, et al. Multivariable modeling of phenotypic risk factors for first-onset TMD: the OPPERA prospective
cohort study. J Pain 2013;14: T102-115.
Wolford LM, Morales-Ryan CA, Garcia-Morales P, Perez D. Surgical management of mandibular condylar hyperplasia type 1. Proc (Bayl Univ Med Cent) 2009;22:321-329.
Wolford LM, Bourland TC, Rodrigues D, Perez DE, Limoeiro E. Successful reconstruction of
nongrowing hemifacial microsomia patients with unilateral temporomandibular joint total
joint prosthesis and orthognathic surgery. J Oral Maxillofac Surg 2012;70:2835-2853.
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Scrivani SJ, Keith DA, Kaban LB. Temporomandibular disorders. N Engl J Med 2008;359:2693-2705.
Milam SB, Zardeneta G, Schmitz JP. Oxidative stress and degenerative temporomandibular
joint disease: a proposed hypothesis. J Oral Maxillofac Surg 1998;56:214-223.
Marklund S, Wanman A. Risk factors associated with incidence and persistence of signs and
symptoms of temporomandibular disorders. Acta Odontol Scand 2010;68:289-299.
Michelotti A, Cioffi I, Festa P, Scala G, Farella M. Oral parafunctions as risk factors for
diagnostic TMD subgroups. J Oral Rehabil 2010;37:157-162.
Iseri H, Kisnisci R, Altug-Atac AT. Ten-year follow-up of a patient with hemifacial microsomia treated with distraction osteogenesis and orthodontics: an implant analysis. Am J
Orthod Dentofacial Orthop 2008;134:296-304.
Dr. Khawaja
Dr. Crow
Dr. Gonzalez
Shehryar N. Khawaja, B.D.S., M.Sc., is a resident, orofacial pain, Department of Oral and
Maxillofacial Surgery, Massachusetts General Hospital, and former fellow, Department of Oral Diagnostics, University at Buffalo School of Dental Medicine, Buffalo, NY.
Heidi Crow, D.M.D., M.S., is director of the TMD and Orofacial Pain program and chair of the
Department of Oral Diagnostic Sciences, University at Buffalo School of Dental Medicine, Buffalo, NY.
Yoly Gonzalez, D.D.S., M.S., is a clinical assistant professor in the Department of Oral Diagnostic
Sciences, University at Buffalo School of Dental Medicine, Buffalo, NY.
oral surgery
Minimally Invasive Treatment of Temporomandibular
Joint Ankylosis and Fibrosis of Temporalis Muscle
Jungsuk Cho, D.M.D.; James Y. Kim, D.D.S., M.D.; Michael T. Wotman;
David A. Behrman, D.M.D.; Howard Israel, D.D.S.
ABSTRACT
A case of severe mandibular hypomobility due to fibrosis of the left temporalis tendon, combined with
ankylosis of the temporomandibular joint, is presented. This case emphasizes the importance of reconstructing the historical timeline to establish a
correct diagnosis, ultimately leading to appropriate
treatment. The use of minimally invasive surgical
techniques and the importance of postoperative rehabilitation are emphasized.
Temporomandibular joint ankylosis is a condition in which there
is extensive pathology of the articular tissues, which partially or
completely reduces mandibular mobility, affecting mastication,
speech and oral health.1 The inability to open the mouth normally is a significant disability that affects quality of life, nutrition
and the overall health of the affected individual. Additionally, the
severe limitation of mandibular mobility predisposes individuals
to oral infections due to reduced access to dental structures, with
decreased visualization of oral diseases impairing treatment of
dental and oral pathology.
Ankylosis of temporomandibular joint can be classified into
true ankylosis (intracapsular) or pseudoankylosis (extracapsular). The most common causes of true ankylosis of the temporomandibular joint are trauma, infection and systemic diseases that
cause damage to the intracapsular tissues.2-4 Systemic conditions
such as rheumatoid arthritis and psoriatic arthritis are associated
with severe inflammation, which damages the intra-articular tissues, often resulting in fibrosis and bone formation.
Pseudoankylosis causes limitation of mandibular mobility
due to extracapsular pathology. Common causes of pseudoanklyosis are masticatory muscle disorders (muscle spasm, myositis
ossificans), osseous disorders (coronoid hyperplasia), neurological disorders, psychiatric disease, radiation therapy, neoplastic
disorders affecting the muscles of mastication and postoperative
fibrosis from surgical procedures involving the head, neck and
intracranial structures.5
At times, it is difficult to categorize the type of ankylosis; and
there are circumstances in which both pseudoanklyosis and true
ankylosis exist simultaneously. The following case report demonstrates how both of these conditions can contribute to severe
mandibular hypomobility. It also provides insight into how such
patients can be treated using minimally invasive techniques.
Case Report
An 85-year-old female presented to the private office of an oral
and maxillofacial surgeon, an attending in the Division of Oral
and Maxillofacial Surgery, New York-Presbyterian/Weill Cornell,
in June 2014 with a chief complaint of severe limitation of jaw
opening. The patient reported that her problem began one year
ago and that prior to this, she never had problems opening her
25
jaw. In July 2013, she underwent a routine dental procedure involving preparation for a crown on the lower left second molar.
She reported that the procedure was relatively short (20 minutes)
and that nothing unusual occurred immediately following the
procedure. When the effect of the local anesthetic wore off, she
was able to open her mouth widely.
Approximately one week following the dental procedure, the
patient complained of swelling and redness of her left face, as well
as limited jaw opening. When she returned to her dentist, she
was placed on a course of antibiotics. The patient reported that
the face and jaw swelling improved, but the limited jaw opening
persisted. Approximately 14 days following the initial dental procedure, she presented to the emergency room of a local hospital.
A CT scan (August 2013) was performed, and the patient was told
she had a temporomandibular joint disorder.
The patient was referred to a dental practitioner, reportedly
with expertise in the diagnosis and treatment of temporomandibular joint disorders. At that time, the patient’s interincisal
opening distance was reported to be 6 mm. The dental practitioner concluded that the diagnosis was “temporomandibular joint
dysfunction” and recommended a three- to six-month treatment
26
with a “neuromuscular orthopedic mandibular repositioning”
appliance.
An MRI of the temporomandibular joints was obtained in
September 2013. The radiology report indicated that the right
joint had anterior disc displacement without reduction and the
left joint had decreased translation and normal disc position. The
patient underwent three months of physical therapy; however,
the severe limitation in mandibular range of motion persisted.
She was seen by another oral and maxillofacial surgeon, who performed arthrocentesis of the right temporomandibular joint in
May 2014. There was no improvement in the interincisal opening
distance following this and the patient was referred to the oral
& maxillofacial surgeon affiliated with New York-Presbyterian/
Weill Cornell.
In June 2014, at her initial presentation, the patient’s only
complaint was severe limitation in jaw opening. Clinical examination revealed the maximum interincisal opening distance to
be only 3 mm, with 4 mm left lateral excursion and 0 mm right
lateral excursion. Careful palpation of the mandibular condyles
revealed that the right condyle did have some ability to translate,
but the left condyle had no mobility. A cone beam CT scan of the
(A)
(B)
Figure 1. Cone beam CT coronal (A) and sagittal (B) images showing bony/fibrous ankylosis of left temporomandibular
joint nine months after onset of infection-related trismus.
temporomandibular joints revealed a bony/fibrous ankylosis of
the left temporomandibular joint (Figure 1).
Although the diagnosis of left temporomandibular joint
ankylosis was established, the history of acute limitation of jaw
opening associated with an acute extracapsular infection did not
support ankylosis as the sole cause of this patient’s severe limitation of mandibular mobility. Review of the August 2013 CT scan
clearly demonstrated that the left temporomandibular joint was
unremarkable, with no evidence of ankylosis (Figure 2). The September 2013 TMJ MRI was carefully reviewed for both the articular
and extra-articular structures. With a history consistent with a left
masticator space infection causing acute trismus, particular attention was focused on the muscles of mastication. When comparing
the right and left temporalis tendon, it was clear there was significant thickening on the left side compared to the right, as well as a
decrease in signal uptake, consistent with fibrosis (Figure 3).
A thorough review of the clinical findings, chronologic history of the progression of symptoms, along with the current and
(A)
Figure 2. Sagittal view of CT scan (August 2013),
two weeks after onset of infection-related trismus. No
evidence of ankylosis of left temporomandibular joint.
previous diagnostic images, helped establish the following diagnoses:
1. Fibrosis of the left temporalis tendon and surrounding soft
tissues of the masticator space.
2. Bony and fibrous ankylosis of the left temporomandibular
joint.
It was unclear as to how much of the restriction in mandibular range of motion was due to pathology of the right temporomandibular joint, as this joint also had the persistent lack of
mobility and, potentially, could have had fibrous adhesions.
Because of the patient’s age and severity of symptoms, it was
determined that the least invasive procedure possible to improve
her mandibular range of motion was indicated. Therefore, the
proposed surgical treatment plan was the following:
1. Examination under general anesthesia.
2. Left mandibular coronoidectomy via an intraoral approach.
3. Left temporomandibular joint operative arthroscopy designed to remove any intra-articular bony/fibrous adhesions.
(B)
Figure 3. MRIs of right and left mandible obtained two months following onset of infection-induced trismus. (A) Sagittal section of right temporalis tendon and muscle compared to (B) Sagittal section of left temporalis and muscle demonstrating thickening and fibrosis on left with presence of dark signal.
27
Figure 4. Preoperative maximum interincisal opening distance was 3 mm.
Figure 5. Intraoperative measurement of maximum interincisal opening
distance was 38 mm immediately following digital forced opening.
Figure 6. Arthroscopic debridement of
remnants of bony/fibrosis of left TMJ.
28
Figure 7. Arthroscopic appearance between disc (below) and articular eminence
(above) following removal of fibrous/bony
tissue. Note inflamed synovial tissue medial
and anterior aspect of superior joint space.
4. Re-examination to determine mandibular range of motion,
with the possibility of performing right temporomandibular
joint arthroscopy if required.
The patient was taken to the operating room and underwent
fiber-optic nasotracheal intubation. Examination under general
anesthesia revealed the maximum interincisal opening distance
to be extremely limited to only 3 mm (Figure 4). The right condyle was capable of translation, but the left condyle could not be
manipulated into any translation movement. The left coronoidectomy was performed through an intraoral approach.
Following the coronoidectomy, the mandibular opening distance increased to approximately 7 mm, but there was still significant restriction. Inspection of the soft tissues medial to the
mandible revealed significant fibrosis of the temporalis tendon
and muscle, as well as the medial pterygoid muscle. Temporalis tendon and muscle attachments were further stripped from
the medial ramus of the mandible. Using controlled digital pressure between the mandible and the maxilla to open the jaw, there
was a sudden release in resistance, and increased opening was
achieved with a maximum interincisal opening distance of 38
mm (Figure 5).
Left temporomandibular joint operative arthroscopy was
performed. Following routine superior joint space entry with
a trocar and cannula, initial examination revealed a specific
area of osteoarthritis and fibrosis in the anterior portion of
the superior joint space. It was assumed that this was the main
location of fibrous ankylosis, which had been released during
the intraoral procedure. Osteoarthritis with fibrillation of the
articular cartilage was present throughout the superior joint
space. A moderate synovitis was present in the posterior recess
of the superior joint space. Operative arthroscopy was performed, with placement of a second portal into the superior
joint space. Using a triangulation technique, adhesions were
removed, along with debridement of fibrillation tissue using
a motorized shaver, particularly in the region of the anterior
joint space (Figure 6). Inflamed synovial tissues of the posterior recess were localized. Under direct vision, a #25 gauge spinal
needle was inserted into the inflamed synovium and 3 mg of
Celestone Soluspan suspension (6mg/ml betamethasone) was
injected (Figure 7).
The patient’s postoperative course was uneventful. There was
particular emphasis on passive motion exercises 15 minutes four
times daily. The patient was seen 10 days postoperatively, at which
time, her maximum interincisal opening distance was 20 mm.
However, she had not been compliant with the passive motion exercises and the necessity of this was emphasized again. Following
this, the patient did demonstrate compliance with passive motion
exercises and at the two months postoperative appointment, her
maximum interincisal opening distance was 25 mm. She reported
having no pain, excellent function and a normal diet.
Discussion
This paper describes a case of an oral infection inducing fibrosis
of the temporalis muscle causing pseudoankylosis and eventually
leading to a bony and fibrous ankylosis of the temporomandibular joint. There is a paucity of information on the concomitant
presence of true ankylosis and pseudoankylosis of the temporomandibular joint. Furthermore, the use of minimally invasive
surgical techniques has not routinely been described in the treatment of these conditions.
Traditional treatment of temporomandibular joint ankylosis generally involves surgical therapy to remove the pathology
that is preventing mandibular mobility. A major challenge for
the treating surgeon is to identify the main source of the pathology, as well as any other additional anatomic barriers preventing
mandibular mobility. Another challenge is to perform the least
invasive surgical procedure possible to treat the source of restriction, whether intra-articular or extra-articular or both. The more
invasive the surgical procedure, the greater the amount of swelling and tissue damage, ultimately leading to fibrosis, which will
impede the postoperative rehabilitation and mobility. Mandibular
mobilization in the immediate postoperative period is necessary
to reduce the formation of intra-articular adhesions and extraarticular fibrosis. Therefore, the least invasive surgical procedure
that effectively releases the obstruction to mandibular movement
will tend to facilitate the postoperative rehabilitation designed to
maximize mobility.
There is a wide range of surgical treatment options available,
depending on the etiology, diagnosis and experience of the surgeon. Treatment for intracapsular ankylosis includes: gap arthroplasty; interpositional arthroplasty with autogenous or allogenic
materials; and total joint replacement with autogenous tissues
or alloplastic materials (Karamese).6 Each surgical intervention
has advantages and disadvantages. The major challenge for the
oral and maxillofacial surgeon is to prevent a recurrence of the
ankylosis.
An interpositional arthroplasty is designed to prevent recurrence of ankylosis by placing a tissue graft or an autogenous material between the surfaces of the surgically created gap. A total
joint replacement is designed to completely remove the pathologic joint with either autogenous or alloplastic materials and offers
the advantage of enabling the surgeon to improve the occlusion if
the pathology has resulted in altered significant condylar resorption. Regardless of the surgical technique chosen, healing can be
impeded by complications, such as infection, foreign body reaction and displacement of the prosthesis or graft.6 Additional potential complications of arthroplasty and total joint replacement
include facial nerve injury, malocclusion, recurrence of ankylosis
and persistent neuropathic pain.
The use of minimally invasive techniques has not routinely
been described in the treatment of ankylosis and pseudoanky-
losis. Coronoid hyperplasia, one potential cause of pseudoankylosis, is routinely treated surgically with coronoidectomy or
coronoidotomy,7 via an intraoral approach. Robiony et al.8 have
reported on the technique of endoscopically assisted intraoral
coronoidectomy to provide a less invasive approach to this procedure. The authors indicate that the advantage of this minimally
invasive technique using the endoscope is that it allows the surgeon to create the coronoid osteotomy, avoiding a large incision
and wide dissection.8 Consistent with the trend for minimally
invasive surgery, McCain et al.9 have demonstrated arthroscopic
temporomandibular joint surgery as a highly effective technique
for treatment of a variety of intra-articular pathologies. The major
advantage to arthroscopic surgery is that there are no incisions or
significant dissection, limiting the amount of tissue trauma and
secondary fibrosis created to treat the intra-articular pathology.
Although arthroscopic surgery is not considered a mainstay
in the treatment of ankylosis, Moses et al.10 reported on a case
of arthroscopic laser treatment of fibrous and bony ankylosis of
the temporomandibular joint. The postoperative course following
arthroscopy is associated with decreased swelling and pain and a
more rapid recovery, facilitating rehabilitation, which is essential
for restoration of mandibular mobility. Obviously, when there is
a full bony ankylosis, arthroscopic surgery is not possible and,
thus, there is a paucity of information on the use of arthroscopic
surgery for the treatment of bony ankylosis. However, when the
intra-articular fibrosis and bone formation is at an early stage
and/or in an isolated location, as demonstrated in this case report, using a minimally invasive approach with arthroscopic surgery is possible and offers great advantages.
The orthopedic literature has demonstrated the deleterious
effects of lack of mobility on synovial joints, resulting in muscle
atrophy, cartilage breakdown and intra-articular adhesions.11-13
Thus, it is likely that the lack of the physical stimulus of motion itself can lead to further pathology in both intra-articular
and extra-articular locations. The case presented here represents
a perfect example of how lack of mobility from an extra-articular
site can lead to intra-articular pathology. This patient initially
developed trismus from an infection of the masticator space. Although the acute infection eventually resolved with a course of
antibiotics, the trismus persisted, most likely due to persistence
of a chronic infection and/or inflammation involving the masticator space, which resulted in fibrosis of the temporalis tendon.
Unfortunately, this patient was misdiagnosed and treated for
a temporomandibular joint disorder because of a multiple series
of incidences that confounded its original source.
Although a direct reading of diagnostic images is routinely
required by all oral and maxillofacial surgeons at our institution,
in this particular case, it was essential to establish the correct
diagnosis and course of treatment. The CT scan taken within two
weeks of the onset of the masticator space infection clearly shows
29
the left temporomandibular joint to be normal, without any evidence of ankylosis (Figure 2). The MRI of the temporomandibular
joints and surrounding structures, taken two months after the
onset of symptoms, demonstrates reduced signal uptake of the
left temporalis muscle and tendon compared to the right, highly
suggestive of fibrosis (Figure 3). Most importantly, the cone beam
scan of the left temporomandibular joint taken over one year after the initial CT scan, clearly demonstrates formation of a bony
ankylosis in the left temporomandibular joint (Figure 1).
Thus, the hypomobility caused by the fibrosis of the temporalis tendon ultimately caused intra-articular fibrosis, cartilage
breakdown and, eventually, bony ankylosis of the left temporomandibular joint. The combination of pseudoankylosis from fibrosis of the left temporalis tendon and muscle (caused by the
masticator space infection) and the secondary progression of
an intra-articular bony ankylosis of the left temporomandibular
joint ultimately led to a severe limitation in interincisal opening
distance of 3 mm when the patient presented to our institution
for treatment.
This case demonstrates the importance of carefully putting
together a timeline of the patient’s history, including retrieval
and review of prior records and diagnostic imaging. The chronologic review of the initial CT scan, the MRI and the cone beam
scan in this case, along with correlation of the patient’s clinical
course, permitted the correct diagnosis leading to treatment. p
Queries about this article can be sent to Dr. Cho at [email protected]
REFERENCES
1. Chidzonga MM. Temporomandibular joint ankylosis: review of thirty-two cases. Br J Oral
Maxillofac Surg 1999;37(2):123-6.
2. Das UM, Keerthi R, Ashwin DP, VenkataSubramanian R, Reedy D, Shiggaon N. Ankylosis of
temporomandibular joint in children. J Indian Soc Pedod Prev Dent 2009;27(2):116-20.
3. Kaban LB, Bouchard C, Troulis MJ. A protocol for management of temporomandibular joint
ankylosis in children. J Oral Maxillofac Surg 2009;67(9):1966-78.
4. Bulgannawar BA, Rai BD, Nair MA, Kalola R. Use of temporalis fascia as an interpositional
arthroplasty in temporomandibular joint ankylosis: analysis of 8 cases. J Oral Maxillofac
Surg 2011;69(4):1031-5.
5. Guruprasad Y, Chauhan DS, Cariappa KM. A retrospective study of temporalis muscle and
fascia flap in treatment of TMJ ankylosis. J Maxillofac Oral Surg 2010;9(4):363-368.
6. Karamese M, Duymaz A, Seyhan N, Keskin M, Tosun Z. Management of temporomandibular joint ankylosis with temporalis fascia flap and fat graft. J Craniomaxillofac Surg
2013;41(8):789-93.
7. Mulder CH, Kalaykova SI, Gortzak RA. Coronoid process hyperplasia: a systematic review of
the literature from 1995. Int J Oral Maxillofac Surg Dec 2012;41(12):1483-9.
8. Robiony M, Casadei M, Costa F. Minimally invasive surgery for coronoid hyperplasia: endoscopically assisted intraoral coronoidectomy. J Craniofac Surg 2012;23(6):1838-40.
9. McCain JP, Sanders B, Koslin MG, Quinn JH, Peters PB, Indresano AT. Temporomandibular
joint arthroscopy: a 6 year multicenter retrospective study of 4,831 joints. J Oral Maxillofac
Surg Sept 1992;50(9):926-30.
10. Moses J, Lee J, Arredono A. Arthroscopic laser debridement of temporomandibular joint
fibrous and bony ankylosis: case report. J Oral Maxillofac Surg 1998;56:1104-6.
11. Akeson WH, Akeson WH, Amiel D, Abel MF, Garfin SR, Woo SL. Effects of immobilization
on joints. Clin Orthop Jun 1987;219:28-37.
12. Salter RB. The biologic concept of continuous passive motion of synovial joints. The first 18
years of basic research and its clinical application. Clin Orthop Relat Res 1989;242:12-25.
13. Ellis E 3rd, Carlson DS. The effects of mandibular immobilization on the masticatory system. A review. Clin Plast Surg 1989;16(1):133-46.
30
Dr. Cho
Dr. Kim
Mr. Wotman
Dr. Behrman
Dr. Israel
Jungsuk Cho, D.M.D., is a PGY-1 resident at New York-Presbyterian Hospital/Weill Cornell Medical
Center, Department of Surgery, Division of Oral and Maxillofacial Surgery and Dentistry, New York, NY.
James Y. Kim, D.D.S., M.D., is a PGY-6 resident at New York-Presbyterian Hospital/ Weill Cornell
Medical Center, Department of Surgery, Division of Oral and Maxillofacial Surgery and Dentistry, New
York, NY.
Michael T. Wotman is an undergraduate student, Cornell University, New York, NY.
David A. Behrman, D.M.D., is associate professor of surgery/associate attending oral and maxillofacial surgeon, division chief, New York-Presbyterian Hospital/Weill Cornell Medical Center, Department of Surgery, Division of Oral and Maxillofacial Surgery and Dentistry, New York, NY
Howard Israel, D.D.S., is professor of surgery/associate attending oral and maxillofacial surgeon,
New York-Presbyterian Hospital/Weill Cornell Medical Center, Department of Surgery, Division of Oral
and Maxillofacial Surgery and Dentistry, New York, NY.
dentistry and economics
Reasons for Apical Surgery Treatment in an
Underserved New York City Population
Gunnar Hasselgren, D.D.S., Ph.D.; Pratik Patel, D.D.S. ; Hashim Alhassany, B.D.S.; Carol Kunzel, Ph.D.
ABSTRACT
Endodontic retreatment often involves remaking restorations. The total cost may steer the treatment towards
surgery. The aim of this study was to retrospectively
record the reasons for performing apical surgery in an
economically deprived patient population. The clinical
reasons (59%) for apical surgery were most common,
but the nonclinical (financial) reasons (41%) emerged
as a major cause. The finding that 41% of the apicoectomies were performed because of nonclinical constraints is a high figure and may not reflect the situation generally. Still, economic factors potentially play
a major role in the selection of surgical versus nonsurgical endodontic retreatment.
Endodontic treatment has a good outcome, but, like all clinical
treatment modalities, occasionally it may fail. A revision, or orthograde retreatment, will mostly take care of the problem.1,2,3
However, in some cases, an orthograde retreatment may not be
possible, or is not likely to have a good prognosis. In these cases,
apical surgery, including placement of a retrograde filling, is performed to save the tooth.4,5
There are many reasons for choosing a surgical approach instead of retreatment of the root canal filling. They are, among
others: canal blockage in the form of large posts or separated endodontic instruments; damage to the apical canal portion during
the first treatment; perforation of the root; non-healing periapical lesion after seemingly good endodontic treatment; or lingering clinical symptoms after treatment.4,5 In other words, the common reasons for surgical retreatment are clinical.
Orthograde endodontic retreatment often involves the removal of posts, cores and crowns to obtain access to the root
canal and make the retreatment possible. In addition, when the
retreatment is completed, it is necessary to place a new post with
core and a new crown to restore the function of the tooth. This
markedly increases the costs of the endodontic retreatment, and
many patients hesitate for economic reasons. A surgical approach
may be chosen to leave coronal restorations intact to make the
overall therapy less costly. This adds a nonclinical factor to the
reasons for apical surgery treatment, and this may be accentuated
in a patient population with no or few financial means.
Our dental school patient population mainly comes from
the Washington Heights and Inwood areas in the northern part
of Manhattan in New York City. Compared to other communities in New York City, the Washington Heights and Inwood areas
are characterized by high rates of poverty and families receiving
public assistance, old and poorly-maintained housing stock and a
relatively high proportion of undocumented immigrants not eligible for government benefits. Low levels of English proficiency,
low educational levels and lack of job skills combine to make a
large proportion of the members of this community ill-equipped
31
TABLE 1
Reasons for Apical Surgery
Teeth
(n=108)
59%
41%
98 patient charts involving 108 teeth
64/108 teeth -- clinical reasons
44/108 teeth -- nonclinical reasons
Clinical Reasons for Apical Surgery
Large/long post
19%
Pain and/or swelling; remaining symptoms; exploratory surgery
14%
Apical canal anatomy destroyed by instrumentation
(transportation, perforation)
10%
Separated instrument in canal
5.5%
Retreatment of failed apicoectomy therapy
5.5%
Large overfill
3.0%
Calcified canals
2.0%
TABLE 2
Subject Characteristics by Reason for Apical Surgery (N=98)
Clinical
reasons
Nonclinical
reason
Overall
p-value
Number of subjects (n=98)
56 (57.1%)
42 (42.9%)
Mean age (years )
47.0 ± 16.5
47.5 ±
13.3
0.87
Gender (female)
40 (71.4%)
28 (65.1%)
0.62
Health status (non-contributory)
35 (63.0%)
20 (47.6%)
0.16
Race/ethnicity
Hispanic
Black
Asian
White
None given
19 (33.9%)
2 (3.6%)
7 (12.5%)
18 (32.1%)
10 (17.95%)
14 (33.3%)
3 (7.1%)
0 (0.0%)
19 (45.2%)
6 (14.3%)
0.21
Multiple teeth involved (yes)
7 (12.5%)
2 (4.8%)
.17
(Fisher’s
exact test)
Data shown as mean ± SD or n (%); overall p-values from Pearson independent samples
t-test or Chi-square test.
TABLE 3
Bivariate Logistic Regression of Reason for Apical Surgery
Likelihood
had nonclinical
reason
for apical
surgery
Odds Ratio
Sig.
Patient ethnicity (Hispanic = 1; Other =0)
3.302
0.137
Patient race (White = 1; Other = 0)
4.267
0.063#
Multiple teeth involved (yes = 1; no=0)
.243
0.107#
Gender (1 = female)
.581
0.325
Non-contributory health condition (yes = 1)
.678
0.428
Older in age (50 & over = 1)
.854
0.751
[1=non-clinical reason; 0= clinical reason]
#p-value < = .10
32
to compete for higher-paying jobs. Influenced by such factors as
restricted access to health insurance among recent immigrants,
residents of the Washington Heights and Inwood areas have been
found to have a low level of health care. The community faces
numerous socio-environmental risk factors that make it a particularly opportune location from which to examine the issues
associated with oral health disparities.6,7
The aim of this study was to carry out a retrospective chart
review to record the reasons for performing apical surgery in a
northern Manhattan dental patient population attending a dental school clinic.
Material and Methods
Charts from a 10-month period at a postdoctoral endodontics
clinic were screened and the cases involving apicoectomy treatment were selected. The total number of charts was 1,502, out
of which, the number of surgical patients was 98, involving 108
teeth. The study was approved by the Columbia University Medical Center Institutional Review Board.
The 98 charts with digital radiographs were simultaneously
read by two examiners. The tooth/root and clinical reasons for
the treatments were recorded, together with the patients’ gender,
age and ethnicity. The examiners also evaluated and recorded for
each case whether orthograde (nonsurgical) or retrograde (surgical) retreatment would in their minds have been the preferred
therapy from a clinical standpoint. Cross-tabular analyses and
Fisher’s exact test were used to examine associations between
the two treatment categories and demographic variables available in the patient record. Pearson independent samples t-test
was used to assess mean differences between the two treatment
groups. Logistic regression was used, regressing the presence of
a nonclinical reason for apical surgery on the variables available
on the patient record. The statistical analysis program SPSSS
21.0 was used for conducting all statistical analyses.8 We have
used the p<=.1 statistical significance level when considering the
role of multiple teeth; the study was regarded as exploratory.
The study is likely to be under-powered to discover statistically
significant relations.
Results
The clinical reasons for apical surgery were most common, but
the nonclinical (financial) reasons emerged as a major reason
category of treatment choice in this study. The two groups, clinical and nonclinical, did not differ in terms of their basic demographic and health status characteristics. Having multiple teeth
involved made it 76% less likely that the patient would have a
nonclinical reason for apical surgery.
The results are summarized in Tables 1-3.
Discussion
The restorative status of a tooth in need of retreatment appears to
be a major deciding factor when it comes to the choice between
an orthograde or a retrograde approach. An immaculate restoration will steer the clinician towards surgery, whereas a restoration
that needs to be remade will often justify the nonsurgical endodontic retreatment. Today’s apical surgery treatment has a good
prognosis.9 And the treatments performed, even if an orthograde
approach was preferred, saved the teeth from extraction. Still, in
many instances, it left the patients with solved endodontic problems, but with various restorative needs.
Authors have called attention to the substantial variation
among clinicians’ management of treatment planning. A number
of factors, clinical and nonclinical, potentially contribute to the
variation noted. Among the clinical, oral health factors considered
have been diagnosis, risk assessment, clinical environment, cognitive factors and dental treatment planning.9-14 Nonclinical sources
of variation considered have included patient preferences, time
availability and monetary interests; provider capability, equipment
accessibility, practice busyness;15,16 and cost considerations.17,18
That cost and financial factors at times play a major role reflects the influence of economic factors in dentistry, often regarded as an optional, market-sensitive health care service.19 A dental
school clinic may be chosen by patients, as the fees are lower than
in private practice. However, basing treatment preferences largely on cost considerations raises quality-of-care issues19 and has
the potential to lead to divergent clinician-patient interests.17 In
the private sector, nonclinical considerations, e.g., resource constraints (i.e., the patient’s ability to pay) may be more balanced
with clinical considerations such as oral health status.
In this study “nonclinical” emerged as a major reason category
of treatment choice. A large part of the clinic’s patient population
depends upon Medicaid/state-financed assistance for dental care.
Also, those who pay for their own treatment may have selected the
dental school clinic because of its relatively low fees. The patient
pool from the northern Manhattan communities of Washington
Heights and Inwood is predominantly Hispanic (73%), and 73%
of these are of Dominican origin,7 with the majority of them being first- or second-generation Dominican immigrants.6 Income
is lower, and the need for social services higher here than in New
York City as a whole.7 As of 2006, 31% of Washington Heights
and Inwood residents were living below the federal poverty level.6
These numbers exceed the 21% poverty rate for all of New York
City,6 a city known for its high cost of living. Median income in
this community is among the lowest in the city, with 48% receiving income support in 2005.7 The patients describing themselves as
white were four-times more likely to have a nonclinical reason for
apical surgery. This appears consistent with the fact that patients
who described themselves as Hispanic, among whom many may
have described themselves as white, also were 3.3-times more likely
to have a nonclinical reason for apical surgery. Since the study is
likely to be under-powered to discover statistically significant relations, again, we have used the p<=.1 statistical significance level in
the case of race because we regard the study as exploratory.
The finding that 41% of the apicoectomies were performed
because of nonclinical constraints is a high figure and may not reflect the situation in private practice. Still, it suggests that economic factors potentially play a major role in the selection of surgical
versus nonsurgical endodontic retreatment and will be the topic of
another study of reasons for apicoectomies in private practice. p
Queries about this article can be sent to Dr. Hasselgren at [email protected].
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Friedman S. Management of post-treatment endodontic disease: a current concept of case
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Brennan DS, Spencer AJ. Factors influencing choice of dental treatment by private general
practitioners. Int J Behav Med 2002;9(2):94-110.
Maryniuk GA. Practice variation: learned and socio-economic factors. Adv Dent Res
1990;4:19-24.
Bader JD, Shugars DA. Variation in dentists’ clinical decisions. J Public Health Dent 1995a; 55:181-8.
Bader JD, Shugars DA. Variation, treatment outcomes, and practice guidelines in dental
practice. J Dent Educ 1995b;59:61-95.
Gunnar Hasselgren, D.D.S., Ph.D., is a professor in the Division of Endodontics, Columbia
University College of Dental Medicine, New York, NY.
Pratik Patel, D.D.S., is a former postdoctoral student, endodontics, Columbia University College
of Dental Medicine, New York, NY.
Hashim Alhassany, B.D.S., is a postdoctoral student, Endodontics, Columbia University College
of Dental Medicine, Columbia University, New York, NY.
Carol Kunzel, Ph.D., is associate professor of dental community health (in dental medicine) and
associate professor of sociomedical sciences at the Columbia University Medical Center, New York, NY.
endodontics
Influence of Root Canal Tapering on
Smear Layer Removal
Mina Zarei, D.D.S., M.Sc.; Maryam Javidi, D.D.S., M.Sc.; Farzaneh Afkhami, D.D.S., M.Sc.;
Behrad Tanbakuchi, D.D.S., M.Sc.; Mohsen Movahed Zadeh, D.D.S.; Marzieh Moghadam Mohammadi
ABSTRACT
The purpose of the study presented here was to compare the influence of root canal taper on the efficacy
of irrigants and chelating agents in smear layer removal. Eighty mesial roots of molar teeth were selected and prepared with rotary instruments. In group A,
file 30/0.02 and in group B, file 30/0.4 were placed
at working length and the smear layer was removed.
In groups C and D, root canal preparation was the
same as in groups A and B, respectively, except that
the smear layer was not removed. The amount of the
smear layer was quantified using a scanning electron
microscope. Greater smear layer was detected in the
apical portion of each group, whereas no significant
difference was detected between groups in other portions. No statistical difference was found between canals with different tapers.
The goal of root canal therapy is to clean and disinfect the root
canal system.1 Many studies demonstrate that regardless of the
mechanical instruments and techniques, irrigation solutions are
required to improve lubrication and canal cleaning.2,3
Mechanical instrumentation of root canals produces a smear
layer that covers root canal walls and consists of inorganic debris
and organic constituents.4 This layer may prevent penetration of
intracanal disinfectants into root canal irregularities or dentinal
tubules. Flushing the canal with 17% EDTA and 5.25% NaOCl is
known to be the most effective way to remove the smear layer in
clinical practice.5 Various factors, such as activation of irrigants
with ultrasonic instruments,6 use of delivery systems or syringes,7
the size and position of the syringe,8-10 and the volume of irrigation11 may affect cleaning efficacy of the irrigant. It has been
shown that the irrigant exchange is limited to 1 mm from the needle tip apically.6 On the other hand, many studies have concluded
that canal size and taper significantly increase the volume and exchange of irrigants at the apical part of the canal.12,13 Brunson et
al.14 found that an increase in the preparation size or taper of the
root canal resulted in an increase in the irrigant volume.
Previous SEM studies have evaluated smear layer scores after
canal preparation using two different rotary systems, as well as rotary files and hand instruments.15,16 However, to our knowledge,
no study in the literature has directly evaluated the influence of
different taper of the rotary system on smear layer removal.
This study sought to assess the effect of canal taper on the
efficacy of irrigants and chelators on smear layer removal.
Materials and Methods
Preparation of Specimens
In this in-vitro study, 80 mesial roots of freshly extracted mandibular molars or the mesiobuccal root of maxillary molar teeth
with mature apices and 15- to 30-degree curvature (according to
Schneider et al.17) were selected.
Before preparation, a radiograph was taken for each tooth
(in order to ensure they had two separate canals in each root).
35
Figure 1. Representative images (1250× magnification). (A) Smear layer score 0. (B) Smear layer score 1. (C) Smear layer score 2. (D) Smear layer score 3.
The teeth were stored in 5.25% NaOCl for one hour and then
were cut perpendicularly to their long axis using a diamond disk
14 mm from the root tip. A ?10 K-file (Dentsply Maillefer, Ballaigues,
Switzerland) was advanced into the canal until the file tip was visualized within the apical foramen; then 1 mm of its length was
subtracted to provide the working length.
The roots were randomly divided into four experimental
groups (n=20 each). The teeth were prepared by one operator
with RaCe rotary files (FKG; Dentaire, La-Chaux-de-Fonds, Switzerland) in a crown down manner using an Endo IT motor (VDW,
Munich, Germany). Rotational speed was set at 600 rpm and
torque was adjusted according to the manufacturer’s instruction. The coronal part of the canals was flared using Gates-Glidden drills #2 and #3 (Dentsply, Maillefer, Ballaigues, Switzerland). In
group A, the canals were prepared in the following sequence:
Pre-RaCe 40/0.1, 35/0.08; then 30/0.06, 30/0.04 were placed
10 mm or 12 mm inside the canal, respectively; and, finally,
30/0.02 at the working length. Irrigation with 30 ml of 5.25%
NaOCl (Pakshoma, Tehran, Iran) was used throughout the instrumentation, and RC- Prep (Vericom, France) was used as a lubricant
with each file.
After completion of root canal preparation, the smear layer
was removed via 1 ml of EDTA (Ariadent, Asia Shimiteb, Tehran, Iran)
with a 27-gauge needle for two minutes and a final irrigation using 5 ml 5.25% NaOCl. In group B, preparations were made as
described for group A, except a 30/0.4 instrument reached working length.
In groups C and D, root canal preparation was as described
for groups A and B, respectively, except the smear layer was not
removed and the final irrigation was 5.25% NaOCl. All root canal
preparations were done by one operator.
SEM Evaluation
The teeth were split longitudinally with a diamond disk (D&Z,
Diamont, Germany) in a mesio-distal direction, dried for 24
hours, then sputter coated for SEM analysis. SEM was performed using Leo SEM Microscope (Leo-5360-S.E.M-England)
at 1250× magnification. For each specimen, the photomicrographs were exposed from the center of the middle and apical
thirds. The images (Figure 1) were scored according to Zand et
al.18 using the following criteria:
l Score 0: presence of smear layer that covers 0% - 25% of the
canal wall.
l Score 1: presence of smear layer that covers 25%- 50% of the
canal wall.
l Score 2: presence of smear layer that covers 50%- 75% of the
canal wall.
l Score 3: presence of smear layer that covers 75%- 100% of
the canal wall.
36
The scoring was performed by three examiners who were blinded to the preparation, and irrigation regimens were employed
for each groups. Two splits of each root were evaluated and the
mean score was recorded. The final record was agreed on by the
examiners.
Statistical analysis with the non-parametric Kruskal-Wallis
test was performed to detect statistical differences in the presence of smear layer between experimental groups; the Wilcoxon
test was used to assess the differences between the apical and the
middle thirds of each group. The significance for statistical tests
was P#0.05.
Results
A statistically significant difference between the apical and the
middle thirds was detected, as the middle thirds were significantly
cleaner in all groups (P<0.05). However, there was no significant
difference in the remaining smear layer in the apical (P=0.98) or
middle (P= 0.72) thirds between the four groups (Table 1).
Wilcoxon’s test showed a significant difference between apical and middle thirds in groups treated with EDTA and the groups
not irrigated with EDTA (Table 2).
The difference between the apical and middle thirds was significant in the groups prepared using 0.02 taper or 0.04 taper
instruments (Table 3), but no statistically significant differences
could be found between the groups prepared with different tapers
in the apical (p=0.948) or middle thirds (p=0.970).
TABLE 1
Mean Scores for Presence of Smear Layer
Mean
score±SD
Group A
Group B
Group C
Group D
Apical third
2.25±1.21
2.40±0.82
2.28±1.26
2.33±1.23
Middle third
1±0.95
1.26±1.03
1.21±1.31
0.83±1.028
TABLE 2
Mean Scores for Presence of Smear Layer According to EDTA Application
Mean score±SD
Middle
Apical
P-value
With EDTA
1.14±0.98
2.33±1
0.000<0.05
Without EDTA
1.038±1.18
2.30±1.22
0.001<0.05
TABLE 3
Mean Scores for Presence of Smear Layer According to Canal Taper
Mean score±SD
Middle
Apical
P-value
Taper 0.02
1.11±1.14
2.26±1.21
0.002<0.05
Taper 0.04
1.07±1.03
2.37±1.00
0.00<0.05
Discussion
Complete elimination of debris from the root canal is very difficult because of canal complexity.19 The smear layer contains inorganic and organic substances and acts as a reservoir for microorganisms;20 thus, its removal enhances disinfection of the root
canal. Crumpton et al.21 found that chelator volume greater than
1 ml did not improve smear layer removal; therefore, in our study,
1 ml of EDTA and finally 5 ml NaOCl was used.
Albrecht et al.22 showed that larger preparation of the apical
portion resulted in less residual debris. Also, Usman et al.23 found
that instrument size had a predictable influence on apical third
cleanliness. Thus, in this study, all experimental groups were instrumented to the same master apical file (MAF) size.
Two taper sizes (0.02 and 0.04) were used for comparison.
As in curved root canals, achieving a great taper may involve procedural errors. Therefore, in the study presented here, the maximum apical taper was 0.04.
The result of this study showed that in all groups, the difference between apical and middle thirds was significant, but the
different canal tapers had no effect on smear layer removal. This
finding is in contrast with Vander Sluis et al.,24 who concluded
that canal taper was positively correlated with canal debridement.
The possible explanation of this effect may be based on root selection. The selected roots in this study were molar roots, but they
used maxillary and mandibular canines with less curvature, so the
penetration of chelator may be less affected by canal tapering in
the present study. Another reason could be the difference between
the sizes of MAF used in these studies. Our result is in agreement
with Arvaniti et al.,25 who showed that root canal preparation
with tapers 0.04, 0.06 or 0.08 did not affect canal cleanliness.
The result of this study demonstrated that the remaining smear
layer with or without a flush of EDTA was not significantly different. This finding is not in agreement with Peters et al.,26 who found
that the combination of NaOCl and EDTA was more effective in
smear layer removal. This effect may be based upon the curvature
of the roots, which may reduce the volume of irrigants reaching
the apical part of the canal. In each group, mean smear layer scores
were significantly different at the apical and middle levels. This is in
accordance with most studies on smear layer removal.25,27,28
As the largest amount of smear layer was found in the apical portion of the canal regardless of the taper or application of
EDTA, it seems that the volume of irrigant and chelator was not
sufficient to effectively remove the smear layer. Needle penetration may differ according to the root canal taper, but we did not
measure this in our study. Smear layer removal relationship with
penetration of chelator could also be assessed by measuring the
penetration of the needle tip in different canal tapers. A study
could be designed to assess the relationship between the canal
tapering and the volume of irrigants in the apical portion and its
effect on bacterial reduction.
37
Conclusion
According to the results of this study, different tapers of canal
preparation had no effect on the efficacy of irrigants for smear
layer removal. p
This study was supported by a grant from the vice chancellor of the Research
Council of Mashhad University of Medical Sciences, Iran. Queries about this
article can be sent to Dr. Javidi at [email protected].
9.
10.
11.
12.
13.
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van der Sluis LW, Gambarini G, Wu MK, Wesselink PR. The influence of volume, type of
irrigant and flushing method on removing artificially placed dentin debris from the apical
root canal during passive ultrasonic irrigation. Int Endod J 2006;39:472-476.
Huang TY, Gulabivala K, Ng YL. A bio-molecular film ex-vivo model to evaluate the influence of canal dimensions and irrigation variables on the efficacy of irrigation. Int Endod J
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de Gregorio C, Arias A, Navarrete N, Del Rio V, Oltra E, Cohenca N. Effect of apical size
and taper on volume of irrigant delivered at working length with apical negative pressure at
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Brunson M, Heilborn C, Johnson DJ, Cohenca N. Effect of apical preparation size and
preparation taper on irrigant volume delivered by using negative pressure irrigation system.
J Endod 2010;36:721–723.
Zand V, Bidar M, Ghaziani P, Rahimi S, Shahi S. A comparative SEM investigation of the
smear layer following preparation of root canals using nickel titanium rotary and hand
instruments. J Oral Sci 2007;49:47-52.
Shahi S, Yavari HR, Rahimi S, Reyhani MF, Kamarroosta Z, Abdolrahimi M. A comparative
scanning electron microscopic study of the effect of three different rotary instruments on
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Schneider SW. A comparison of canal preparations in straight and curved root canals. Oral
Surg Oral Med Oral Pathol 1971;32:271-275.
Zand V, Lotfi M, Rahimi S, Mokhtari H, Kazemi A, Sakhamanesh V. A comparative scanning
electron microscopic investigation of the smear layer after the use of sodium hypochlorite
gel and solution forms as root canal irrigants. J Endod 2010;36:1234-1237.
Zamany A, Spångberg LS. An effective method of inactivating chlorhexidine. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2002;93:617-620.
Violich DR, Chandler NP. The smear layer in endodontics - a review. Int Endod J 2010;43:2-15.
Crumpton BJ, Goodell GG, McClanahan SB. Effects on smear layer and debris removal with
varying volumes of 17% REDTA after rotary instrumentation. J Endod 2005;31:536-638.
Albrecht LJ, Baumgartner JC, Marshall JG. Evaluation of apical debris removal using various
sizes and tapers of ProFile GT files. J Endod 2004;30:425-428.
Usman N, Baumgartner JC, Marshall JG. Influence of instrument size on root canal debridement. J Endod 2004;30:110 -112.
van der Sluis LW, Wu MK, Wesselink PR. The efficacy of ultrasonic irrigation to remove
artificially placed dentine debris from human root canals prepared using instruments of
varying taper. Int Endod J 2005;38:764-768.
Arvaniti IS, Khabbaz MG. Influence of root canal taper on its cleanliness: a scanning electron microscopic study. J Endod 2011;37:871-874.
Peters OA, Barbakow F. Effects of irrigation on debris and smear layer on canal walls prepared
by two rotary techniques: a scanning electron microscopic study. J Endod 2000;26:6-10.
Scelza M, Antoniazzi J, Scelza P. Efficacy of final irrigation-a scanning electron microscopic
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removal using different salts of EDTA. J Endod 2000;26:739-743.
Mina Zarei, D.D.S., M.Sc., is associate professor of endodontics, Dental Material Research Center, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran.
Maryam Javidi, D.D.S., M.Sc., is professor of Endodontics, Dental Material Research Center,
Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran.
Farzaneh Afkhami, D.D.S., M.Sc., is assistant professor, Department of Endodontics, School of
Dentistry, Tehran University of Medical Sciences, International Campus, Tehran, Iran.
Behrad Tanbakuchi, D.D.S., M.Sc., is assistant professor, Department of Orthodontics, School
of Dentistry, Tehran University of Medical Science, Tehran, Iran.
Mohsen Movahed Zadeh, D.D.S., is a postgraduat student of prosthodontics, Mashhad University of Medical Sciences, Mashhad, Iran.
Marzieh Moghadam Mohammadi is a postgraduat student of periodontics, Mashhad University
of Medical Sciences, Mashhad, Iran.
38
The Impending Oral Health Crisis
Ensuring Quality Dental Care and Access for New York’s Most Vulnerable Patients
Carl H. Tegtmeier, D.M.D.; David J. Miller, D.D.S.; Judith L. Shub, Ph.D.
ABSTRACT
Last May, the New York State Dental Association and
model, a loss of service providers and the need for ex-
the New York State Dental Foundation convened the
panded training programs. They heard from speakers
first “Oral Health Stakeholders’ Summit on the Fu-
representing a broad spectrum of those involved in
ture of Special Needs Dentistry, Hospital Dentistry
the oral health care of patients with intellectual and
and Dental Education.” The summit was chaired by
developmental disabilities, the Alzheimer’s Associa-
David J. Miller, then NYSDA President Elect, and Carl
tion, dental educators and researchers, hospital den-
H. Tegtmeier, then chair of the NYSDA Council on
tistry and the benefits industry, whose presentations
Dental Health Planning and Hospital Dentistry. It
focused on a looming oral health crisis threatening
brought together experts, called to frame the issues
access to dental care for patients with disabilities.
and provide information necessary for a reasoned
response. And it sought input from attendees to develop recommendations to ensure that patients with
intellectual and developmental disabilities, as well as
an aging population with Alzheimer’s disease and dementia, have access to appropriate oral health care in
the years ahead.
Over 100 participants, representing dentistry,
hospital training programs, third-party payers, state
government offices and related patient support associations, attended the two-day event in Albany. They
focused on the impact of reductions in funding, the
transition of Medicaid services into a managed care
The dental profession, advocacy groups and public health agencies have long focused on the issue of access to care and the factors that prevent patients from engaging in effective preventive
oral health strategies and taking advantage of dental treatment
services. The access issue is all the more vital when considering
the needs of patient populations with concurrent health issues,
physical limitations and more complex preventive and treatment
concerns. Existing obstacles to oral health are compounded by an
increasing emphasis on reducing health care costs.
What is the impending crisis? It is uncertainty about the
continued viability of hospital-based dental programs and residencies, the lack of new dentists providing care to patients with
special needs, the decreasing number of special needs facilities,
long waiting times to access operating rooms for dental cases and
the increasing number of patients requiring the services of dentists with special skills.
39
There are an estimated 300,000 people with an intellectual
or developmental disability (ID/DD) in New York State. Fortunately, most practicing dentists can treat many of these patients with minimal advanced training and with few treatment
modifications in patient management. However, approximately
60,000 people with ID/DD have resistive behaviors that require
treatment from dentists with expertise in behavioral intervention techniques. The New York State Office for People with Developmental Disabilities (OPWDD) estimates that there now
are only 300 dentists with expertise in treating patients with
resistive behaviors. The challenges are to change the emphasis in
public policy and to evaluate the efficacy of cost-neutral changes
to health care spending.
Changing Reimbursement Models
Current trends in funding and delivery models penalize people
who face obstacles in their ability to access oral health care, including patients with complex medical diagnoses, physical or
developmental disabilities, and dementia. The barriers to access
for these patient populations are economic and systemic, exacerbated by a growing population with even greater service needs.
The existing provider network has been underfunded through a
“one size fits all” reimbursement methodology despite years of
inflationary cost increases. In the national dialogue about health
care, patients with physical and developmental disabilities generally are marginalized or overlooked altogether in emerging delivery models. There is a homogenization in the funding models for
public health care programs that allocate reimbursement for a
fixed set of services at a defined frequency for all patients, regardless of individual treatment needs.
Decreasing reimbursement already has resulted in a reduction in both facilities and providers available to meet the treatment needs of patients with dementia and ID/DD. The decline in
available facilities and qualified dentists correlates directly with
reductions in Medicaid payment rates. It has resulted in less access to training for dentists in the skills necessary to meet the
needs of patients in the Medicaid program, as well as the most
challenging and vulnerable patients in the general population.
History has shown that reductions in funding for hospital dental
programs result in fewer available services, less operating room
(OR) availability for dental cases, and fewer training opportunities to ensure an adequate professional workforce.
The Centers for Medicare and Medicaid Services (CMS) has
approved waivers enabling New York State to transition its Medicaid program into a managed care model. The transition has
achieved its main goal of cutting costs. In coming years, New
York will transition its Medicaid long-term care, dentistry and,
ultimately, medicine into the new managed care entities known
as FIDA IDD and DISCOs. Individuals with ID/DD who are eligible for both Medicaid and Medicare may join a fully integrated
40
duals advantage (FIDA IDD) organization. Those who are eligible
for Medicaid only will join a developmental disabilities individual
services care coordination organization (DISCO). These managed care entities will receive a per-member/per-month capitation payment to provide long-term care, as well as dental and
medical care. Like health maintenance organizations (HMO),
the FIDA IDD and DISCOs will subcontract with other long-term
care agencies and dental managed care organizations to provide
dental services.
This plan has raised concern among patients with intellectual and developmental disabilities and their families, dentists
with expertise in treating this population, dental educators and
OPWDD. Patients, caregivers and dental professionals already
face obstacles in accessing timely, appropriate dental treatment
and are uncertain about the impact of the new model on their
continued ability to access oral health care services.
OPWDD, the primary agency responsible for overseeing supports and services provided for people with ID/DD,
formed the Task Force on Special Dentistry in 2002. The goal
of the task force is to improve the equity, effectiveness and
efficiency of dental services for New Yorkers with ID/DD. The
task force’s initial concern was to assure that the transition
for those with ID/DD to managed care for long-term supports and dental care maintain, at a minimum, the present
network of dental providers and their facilities. Its members
emphasized the need to consider the complexity of the health
care system, including financial and other levers that support
the training and financial viability of dentists with expertise
in treating patients with special needs and the facilities in
which they work. 1
The task force considered how the provision of dental care is
different from that of medical care. It underscored that the behavioral component for dental treatment is intensified for people
with ID/DD and many dementia patients, resulting in the need
for added time for behavior management and treatment. With
these understandings, the task force produced specific recommendations to be incorporated into the DISCO model contract,
including:
l The establishment of reimbursement rates relative to the
needs of patients.
l The establishment of reimbursement levels sufficient to compensate for the time necessary for behavior management and
to assure instruction of dental residents in special needs dentistry.
l Credentialing dentists with expertise in serving special needs
populations and developing criteria for designated “centers
of excellence.”
l Requiring that dental networks:
a. Include a sufficient ratio of dentists with expertise in
treating special needs patients.
b. Ensure sufficient operating room block time availability.
c. Ensure dental networks include sufficient anesthesiologists and other dental specialists.
d. Guarantee timely access to care and geographic accessibility.
l Modify allowable services to include pre-approved reimbursement for:
a. Four appointments (exam and cleaning) per year.
b. Oral sedation.
c. Behavior management for patients with ID/DD.
d. Removal of age limitations for fissure sealants.
e. Fluoride varnish application up to four times a year.
f. Six desensitization visits.
An Escalating Patient Population with Greater Needs2
Another variable contributing to the growing crisis is that the
patient population is increasing as resources diminish. The demand for services by patients requiring behavioral management,
anesthesia, OR services and other special skills is expected to
grow as life expectancies increase and more people maintain
their own natural teeth. In addition, the aging population with
Alzheimer’s disease and dementia that will require an enhanced
range of special patient and disease management skills is growing. Alzheimer’s disease is a progressive, neurodegenerative disease that currently affects an estimated 5.2 million Americans,
380,000 of whom live in New York State. In 2015, total payments for persons with Alzheimer’s disease and dementia are
estimated at $214 billion, with Medicare and Medicaid covering
70% of that cost.
One in six individuals age 65 and older now has Alzheimer’s
disease. Among those 85 and older, there is an increase in incidence to 49%. Currently, there are 142,500 New York residents in
the moderate stage of the disease. In the moderate stage, 70% of
Alzheimer’s patients present with challenging behaviors. Most of
these patients, as well as those with late stage Alzheimer’s disease,
should be seen by a dentist with expertise in treating special needs
patients. The number of Alzheimer’s patients who are difficult to
treat far exceeds the 60,000 patients with ID/DD with resistive
behaviors that currently are cared for by the 300 dentists statewide with expertise in treating this population.
Beginning in 2020, baby boomers will dominate the elderly
population, with a massive increase in those aged 65 and older
increasing from 35 million in year 2000 to 86.7 million by 2050.
The numbers of elders will double substantially, increasing the
health care needs of those confined to home and institutions. By
the year 2050, the number of patients with the moderate stage
of the disease, i.e., with resistive behaviors, is estimated to grow
from 100,000 patients to 280,000 patients. This is a looming crisis the profession and the current safety net system of care are not
prepared to handle.
The Challenges of Behavioral Management3
This patient population presents unique behavior management
challenges that require increased treatment time, supplemental
resources and greater costs beyond those necessary for the provision of routine preventative, diagnostic and treatment services.
Those providing treatment to patients with highly resistive behaviors in hospital settings employ a range of services necessary
to safely and effectively provide oral health care to patients with
complex medical and behavioral issues. Patients presenting to the
hospital may have extreme anxiety and/or irrational fear of oral
health care as well.
Ultimately, the most effective way to reduce Medicaid expenditures for medical and dental care is prevention. One study cited
shows that patients who are seen regularly in the OR, those with
the most resistive behaviors, actually have the lowest cavities incidence because of proactive preventive measures. Further, when
programs provide multidisciplinary treatment to patients in the
OR, costs can be significantly reduced, and patients can receive
more comprehensive care with less potential trauma and disruption to their daily routine.
Hospital dentistry is a critical piece of the dental care mosaic
for people with ID/DD. It falls under the umbrella of special care
dentistry, in that it is the referral site for patients whose health issues exceed the level of expertise of the community dentist. Hospital dental programs also play a critical role in the education
of future dentists. About one-quarter of these 60,000 patients
require that their dental treatment be performed in a hospital
operating room under general anesthesia. There now are 30 programs across New York State that offer access to hospital operating rooms for comprehensive dental treatment. The 300 dentists
with this expertise practice in 48 offices or facilities. Twenty six
of these are hospital outpatient dental programs, according to an
OPWDD internal report. The 48 offices and facilities, along with
the 30 hospital operating room programs, are located in the cities
and suburbs of Buffalo, Rochester, Binghamton, Utica/Syracuse
and Albany; the counties of Rockland, Westchester, Suffolk and
Nassau; and the five boroughs of New York City.
There are 40 hospital outpatient dental programs that provide ongoing dental care to almost 20% of the 126,000 individuals with ID/DD who receive supports and services from
OPWDD. These hospital dental programs, along with other
freestanding diagnostic and treatment centers, are an integral
component of the safety net for people with ID/DD. These
institutions have been under increasing financial pressure for
years because of a “one size fits all” reimbursement mechanism
that has perpetuated flat funding to these facilities for 20 years,
based on information from the New York State Department of
Health (DOH).
For the 15,000 patients requiring operating room services,
only about 3,000 visit an operating room for their dental care an-
41
nually. Waiting times to access care in an operating room can be
between one and two years in much of the state, as it is becoming
increasingly difficult for dentists to access operating room time.
The Threat to Hospital Dental Programs
Hospital dental programs are pivotal sites that ensure access to
safe, effective dental treatment and training for dentists in the
specialized skills necessary to handle resistive behaviors and complex health issues. Changes in health care delivery and funding
offer opportunities for hospital dentistry but also pose a threat to
their continued existence. Hospital dentistry is locked in a health
care system that is expanding and merging in an environment
where public and commercial third-party payers are focused on
the bottom line of profit and loss.4
The services provided by dentists in the hospital setting extend to all areas of care beyond the dental clinic itself, including
in-patient services, emergency departments, surgery and oncology.
Nonetheless, hospitals fail to
reimburse dentists for services
rendered outside of those traditionally thought of as dental in
nature. Medical insurance does
not pay for dental procedures,
and dental insurance does not
pay for medical services. This
puts hospital dental programs
at risk, because if there is not a
dollar number assigned to the
service, from the hospital administrators’ perspective, the
service never happened.
Hospitals have replaced
doctors who understand the inner workings and relationships of
different hospital services with MBAs. The metrics used are based
on the system of payments. There is a move toward value-based
payments and capitation, where a whole segment of a population
is given a “global payment.” It is not known whether there are
accurate enough cost-to-resource data to properly provide quality medical/dental care for specific patient cohorts. The problem
evolves from the fact that, while dentists in the hospital serve patient needs by supporting medical care in a wide range of settings,
most services are not counted because they are not reimbursable in
the current accounting systems.
Without hospital dentistry, some segments of the patient
population would not have access to ongoing dental care, including, primarily, the most vulnerable, i.e., those with special needs,
the medically fragile and the financially vulnerable. Without hospital dentistry, the entire community would not have access to
a unique “medical subspecialty” that other medical specialties
and community dentists sometimes require for the proper care of
42
their patients. A method must be found to demonstrate in a measurable way what dentists do outside of the hospital dental clinic.
Training Dentists to Care for Patients with ID/DD
Delivery models, funding and policy changes cannot improve access to oral health care or the health of patients with ID/DD
or dementia without a well-trained professional workforce with
the skills necessary to meet the unique demands of these patient
populations. Reductions in reimbursement and the resulting loss
of hospital-based allocated operating room and anesthesiology
services and dental training programs are resulting in fewer dentists willing and able to meet the oral health demands of these
growing patient populations. How effective are the Commission
on Dental Accreditation (CODA) mandates for training dental
students in special needs dentistry?
CODA implemented Special Needs Standard 2-24 in 2006:
“Graduates must be competent in assessing the treatment needs
of patients with special needs.”
The standard was intended to
expand the range of assessment
and care options for patients
presenting with various medical,
physical, psychological and social situations. It was to include
people with ID/DD, cognitive
impairment, complex medical
problems, physical limitations
and vulnerable elderly. While
dental school curricula nationally include training in related
skills, fewer than three-quarters
of the schools actually treat patients with ID/DD. “Special needs” is a broad definition encompassing a wide range of disabilities. There are marked differences
between care for a patient with diabetes and quite another for
patients with profound ID/DD who will not open their mouths,
thrash about in the dental chair and cannot understand the doctor’s requests.5
The CODA mandate requires “assessing treatment needs”
but not “treating.” This sets the standard of care that applies to
all practitioners who, by virtue of the Americans with Disabilities
Act, must see patients with ID/DD in their practices because they
are places of public accommodation, but do not necessarily have
to treat them in their practices.
CODA lacks a standard definition for “competence.” Surveys of dental students report that they receive little preparation
in treating difficult patients. Dental schools struggle to obtain
knowledgeable and experienced faculty with expertise in treating
these patients. With only 300 such safety net dentists in New
York State, it is a difficult challenge to tap this very limited re-
source. Further, dental schools find it hard to fit training in “special needs” care into their existing curricula, and the cost to run
such programs is high. As a result, students continue to graduate
who are unprepared to care for these populations.
It is evident that the current CODA standards fall short in
preparing graduates by failing to require that they be competent to treat patients with ID/DD and failing to define competency. There is no standardization of the types of patient
populations to which dental trainees are exposed. Dentists can
graduate with little or no experience with patients with ID/DD
or Alzheimer’s disease.
Beyond what is received in dental school, what training do
general practice and pediatric dentistry residents in New York
State receive in the care of patients with ID/DD?6 Based on a
survey of New York State residency directors, currently, there are
45 general practice residencies (GPR) offering 452 positions, 18
pediatric dental residencies offering 89 positions, 9 advanced education in general dentistry (AEGD) programs offering 59 positions and 1 postgraduate fellowship in the care of special needs
patients that offer opportunities to care for underserved patient
populations. Twenty-five percent of AEGD and pediatric residents
spend fewer than five hours in didactic instruction on special
needs dentistry; 38% spend 6 to10 hours in didactic instruction;
and 38% spend more than 10 hours. Ninety-four percent of the
GPR programs have access to an OR; 100% of the pediatric programs have access to an OR but report waiting times extending
into months.
Looking Forward: Policy Changes
How Oral Health Care Can Help Reduce Medical Costs7
Chronic disease accounts for three of every four dollars spent
on health care in the United States. Are there cost-neutral
ways to increase funding for oral health care? Increasing evidence from the medical insurance industry suggests that expenditures on oral health reduce the medical costs associated
with chronic diseases. Major health insurers, including Blue
Cross Blue Shield of Massachusetts, are looking at the impact
of oral health care on the costs associated with treatment of
major chronic illnesses. The summit’s keynote speaker, Robert
Lewando, looked at medical and dental claims information,
comparing medical costs for members with certain conditions
against whether the member was using his or her dental insurance for services that may help to control oral infection
or inflammation. His contention is oral health is a risk factor
in chronic disease management. The connections are critical
both from the perspectives of public health and health care financing. The major health care insurers have documented that
access to dental care and better oral health saves medical dollars. This suggests that cost-neutral funding for expanded oral
health care could be derived from some of the monies saved.
Reinvesting saved Medicaid dollars in dental care should result
in even greater cost-savings over the long term.
Blue Cross Blue Shield of Massachusetts 2014 claims data
demonstrate that BCBS members with coronary artery disease
who received a dental cleaning and/or periodontal treatment had
$530 per member/per month lower medical costs than members
who did not receive dental treatment. There were similar savings
of medical dollars for members who had diabetes, chronic heart
failure, chronic renal disease and dementia, with a total dollar
savings for these policyholders with good periodontal health of
$3,676 per year.
Over six million New Yorkers now receive Medicaid benefits. While not all have chronic diseases, the state could gauge
the potential savings through improved oral health using existing data. The link between oral health and overall health has become more definitive. An article in the September 2015 Journal
of Infection and Immunity brought it down to the cellular/biochemical level explaining the results of a litany of studies showing this relationship. That oral health has an effect on overall
health given all the recent studies has to be accepted in looking
at overall patient care.
Controlling Health Care Costs through Prevention
The prevalence of dental disease in this population far exceeds the
Healthy People 2020 goals for the general population of 20% untreated cavity experience for people 35 to 74 years old. Prevention
has continually proven to be among the most effective strategies
to reduce the need for—and cost of—dental treatment. Recent research demonstrates a link between social determinants and oral
disease prevention interventions that lead to better oral health
outcomes for this vulnerable population.8 Evidenced-based oral
disease management strategies have been identified that have the
potential for long-term improvement in oral health outcomes.
Researchers have found that the living arrangement of patients
with ID/DD correlates with their oral health and preventive behaviors. In a recent study by Drs. Morgan and Minihan at Tufts,
people living independently had the highest percentage of cavities
(52.3%), while those living in a supervised facility had the lowest
percentage of cavities (18.8%).8 Those living with family had the
second highest percentage of cavities, double the amount of those
living in a supervised facility.
Drs. Morgan and Minihan’s research found correlations between oral health status and the type of residence, cooperation
level, level of disability and age. They recommend a shift in policy
aimed at improving oral health through interventions of prevention and disease management. Such efforts would begin at home
with paid and family caregivers and would include programs to
provide structured training and oversight for family caregivers as
a priority to make meaningful changes in the oral health of a
majority of people with ID/DD.
43
Changing Public Policy
that can track patients’ health and health behaviors facilitates
It is evident that the present system of dental care for vulnercorrelation between this information and the patient’s dental exable populations and educational requirements both need to be
amination outcomes, providing continuous health guidance to
changed to meet the growing access crisis. Caswell A. Evans Jr.
the patient. This is a logical approach to improve collaboration
maintains that changing public policy requires a definition of
between patients and their dentists.
terms, a clear statement of need and rationale, and a compelling
Poor oral health is the most common chronic health concern
articulation of the value proposition.9 Policy change invariably
nationally. The risk factors for poor oral health include habits,
lifestyle choices, diet, self-care, dependent-care and childcare.
entails collaboration in the context of a broad coalition that
These are well understood and are linked to overall health and
includes inter-professional partnerships and community interwellness. Dr. Ferguson utilizes “smart data” derived directly from
est groups.
patients and their dental exams.
Changing public policy first needs to garner the interest of
While patients and caregivers often complain about a lack
policymakers. This requires that advocates make the issue compelof dental care, access problems begin with a lack of health literaling by framing it in the context of “social justice.” Advocating for
cy, healthy lifestyles, primary prevention and timely dental care.
“dental care” and advocating for “oral health” are different. AdvoWith data, payers could improve access and utilization because
cating simply for dental care could appear to be self-serving. The isthey will be better able to hold patients accountable. Most imporsue of underserved and unserved is powerful in making change. Dr.
tantly, the data will facilitate patients,
Evans views issues of access to care and
providers and payers working together to
health disparities as issues of social injustice and social discrimination. “Equality”
Attention to detail, focus on protect long-term health and cost reduction.
is “even balance,” i.e., everyone gets the
When patients, payers, providers and
same. “Equity” involves making up for
goals, cooperation between all
policymakers collaborate with the transshortcomings that prevent everyone from
getting the same opportunity. People in
stakeholders and committed parency available through an interactive,
health management record, we will get a
underserved groups will require more releaders at the highest levels of handle on increasing costs through presources to achieve the same access to care
ventive measures specific for each indiand outcomes.
government are required to
vidual’s lifestyle, health and dental issues
Advocacy involves engagement by
to achieve the goals of effective managed
the dental profession with communities
ensure
access
to
quality
care
care.
with a common vision. One obstacle to
engagement is the absence of a model.
and improved health.
Conclusions
There is a marked “silo” approach to
The information and wide range of perpatient care. In most discussions, denspectives presented during the summit
tistry is simply not invited to the table.
conveyed the consistent theme that the barriers to access for these
Through its presence, dentistry can establish alliances with other
patient populations are both economic and systemic. Further, these
professional and lay communities, which can be a source of supexisting barriers will be exacerbated by the growing patient populaport for issues prioritized by dentistry.
tion of older adults with more intensive service needs. Assuring
that appropriate services are available to patients with ID/DD and
A Collaborative Model to Reduce Health Care Costs
dementia will require trained professional personnel and facilities
Once there is agreement that policy needs to change to ensure
equipped to address intensive medical and behavioral conditions.
everyone’s overall health and well-being, achieving major policy
10
These facilities fulfill the role of service provision and serve as the
change will require collaboration by all parties involved.
source of training to ensure an adequate professional workforce
Fred Ferguson considered solutions to the escalating costs
prepared to meet patients’ oral health needs.
of health care, health disparities and poor utilization. He cited a
With the transition into a managed care model, there is a
lack of collaboration among patients, payers, providers and polirisk that the emphasis on cost-containment will result in the
cymakers as the cause. He considers patient behavior to be the
continued attrition of services and a disenfranchisement of both
primary obstacle to collaboration. His solution is to develop a
patients and providers. Attention to detail, focus on goals, coophealth care system based on an online “oral health home.” Useration between all stakeholders and committed leaders at the
ing this tool, patients, payers, health providers and policymakers
highest levels of government are required to ensure access to qualcould collaborate to manage oral health to promote long-term
ity care and improved health.
health and reduce health care costs. Providing an online interface
44
Each presentation at the Stakeholders’ Summit underscored
concerns with the potential impact of the managed care transition on the vulnerable ID/DD and aging populations exhibiting
symptoms of dementia. Hospital dentistry, special care dentistry
and dental education are all interconnected, and meaningful
change to meet this crisis in care must be accomplished within
each individual area, otherwise we will fail to meet the dental
needs of New York State’s most vulnerable citizens, as well as
the general population.
The presentations made at the summit support two noteworthy conclusions. These conclusions must be the basis for changes
in the health care system moving forward if the goals truly are
better health, increased access to care and fiscal prudence.
First, there is increasing recognition outside of the dental
profession that good oral health has an impact on overall health.
Data, like that included in the report presented by Dr. Lewando
of BCBS, demonstrates that utilizing dental treatment results in
improved general health and lowers health care costs for people
with serious chronic conditions. Taxpayers and policyholders
face a huge financial burden when oral health is ignored. Policymakers must recognize and consider this relationship in order to bring about effective changes in the health care system.
The value to individuals and society is enormous and offers the
potential to bring dental care to the underserved and unserved
through savings in medical expenses. The savings realized can
be reinvested in dental health care systems that ensure all have
access to dental care—and equality in improved overall health.
Second, dentistry has been undervalued for too long. As a result, hospital dental programs and existing special care dentistry
“centers of excellence” are in financial difficulty and in danger of
closing. This will continue the further disenfranchising of these
underserved and unserved populations, especially those with ID/
DD. This erosion of resources comes at a time when an aging
population with more disabilities and patients with Alzheimer’s
disease and other dementias are in need of these facilities and
providers. More facilities and providers with expertise in treating special needs patients are required to meet the growing need
as shown in demographic projections. There is no mechanism
in place—or under consideration—to shift saved medical dollars
to fund oral health services. New York’s Medicaid managed care
program lacks protocols to facilitate the reinvestment in effective
prevention, oral health literacy, school-based programs, hospital
programs and special care dentistry centers of excellence needed
to improve overall health and meet the treatment needs of people
in New York State. With the growing dialogue about “outcomesbased” health care, such protocols should be a fundamental part
of any planned shift in reimbursement models.
The relationship of oral health to overall health is a game
changer that turns all previous reimbursement systems for dental care upside down. It is both fiscally and medically prudent to
rethink the medical/dental provision of care to better assure the
best possible outcomes for all concerned. p
Copies of a white paper containing reports on each of the presentations included in the Summit are available from NYSDA.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
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Goldstein GS, Tegtmeier CH. Transitioning Patients with Developmental Disabilities into
Managed Care. Oral Health Stakeholder’s Summit on the Future of Special Needs Dentistry,
Hospital Dentistry and Dental Education: The Impending Crisis: Ensuring Quality Dental
Care and Access for New York’s Most Vulnerable Patients. Albany NY. 14 May 2015. Lecture.
Smith-Boivin E. Preparing for Increases in Alzheimer’s Disease and Dementia Patients. Oral
Health Stakeholder’s Summit on the Future of Special Needs Dentistry, Hospital Dentistry
and Dental Education: The Impending Crisis: Ensuring Quality Dental Care and Access for
New York’s Most Vulnerable Patients. Albany NY. 14 May 2015. Lecture.
Speisman Richard A. Dental Care for Patients with Complex Treatment Needs. Oral Health
Stakeholder’s Summit on the Future of Special Needs Dentistry, Hospital Dentistry and
Dental Education: The Impending Crisis: Ensuring Quality Dental Care and Access for New
York’s Most Vulnerable Patients. Albany NY. 14 May 2015. Lecture.
Stewart WJ. The Role of Hospital Dentistry: The Challenges of Meeting a Growing Demand.
Oral Health Stakeholder’s Summit on the Future of Special Needs Dentistry, Hospital Dentistry and Dental Education: The Impending Crisis: Ensuring Quality Dental Care and Access for New York’s Most Vulnerable Patients. Albany NY. 15 May 2015. Lecture.
Cinotti D. Training of Predoctoral Dental Students in the Care of Patients with Developmental and Intellectual Disabilities. Oral Health Stakeholder’s Summit on the Future of
Special Needs Dentistry, Hospital Dentistry and Dental Education: The Impending Crisis:
Ensuring Quality Dental Care and Access for New York’s Most Vulnerable Patients. Albany
NY. 15 May 2015. Lecture.
Dougherty Nancy J. Training of General Practice and Pediatric Dental Residents in the Care
of Patients with Intellectual and Developmental Disabilities: A Survey of Residency Directors in NYS. Oral Health Stakeholder’s Summit on the Future of Special Needs Dentistry,
Hospital Dentistry and Dental Education: The Impending Crisis: Ensuring Quality Dental
Care and Access for New York’s Most Vulnerable Patients. Albany NY. 15 May 2015. Lecture.
Lewando R. Linking Oral Health and General Health: How Oral Health Can Help Reduce
Medical Costs. Oral Health Stakeholder’s Summit on the Future of Special Needs Dentistry,
Hospital Dentistry and Dental Education: The Impending Oral Health Crisis: Ensuring
Quality Dental Care and Access for New York’s Most Vulnerable Patients. Albany NY. 14
May 2015. Lecture.
Morgan J, Minihan PM. Identifying Effective Interventions for Improved Oral Health for
Adults with Intellectual and Developmental Disabilities: Community, Dental Provider,
Caregiver and Patient Level Influences. Oral Health Stakeholder’s Summit on the Future of
Evans CA Jr. Changing Public Policy. Oral Health Stakeholder’s Summit on the Future of
Ferguson FS. Collaborative Model to Reduce Health Care Costs. Oral Health Stakeholder’s
Summit on the Future of Special Needs Dentistry, Hospital Dentistry and Dental Education: The Impending Crisis: Ensuring Quality Dental Care and Access for New York’s Most
Vulnerable Patients. Albany NY. 14 May 2015. Lecture.
Carl H. Tegtmeier, D.M.D., is representative to and former chairman of the NYSDA Council on
Dental Health Planning and Hospital Dentistry and co-chair of the New York State Office for People with
Developmental Disabilities’ Task Force on Special Dentistry.
David J. Miller, D.D.S., is NYSDA President and Chairman of the Department of Dental Medicine at
Interfaith Medical Center in Brooklyn. He maintains a private general practice in East Meadow, NY. For
over 30 years, Dr. Miller has focused on treating patients with intellectual and developmental disabilities in
both his private practice and hospital settings. He now serves on the Board of Directors and is a past chair
of the Council of Hospital Dentistry in the Special Care Dental Association (SCDA), a national organization
utilizing education and networking to increase access to oral health care for patients with special needs.
Judith L. Shub, Ph.D., is NYSDA Assistant Executive Director for Health Affairs.
45

April 2016 - New York State Dental Association

Transcription

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