Journa - California Dental Association · and tips for compliance to avoid license sanctions and lawsuits. Arthur W. Curley, JD Trigeminal Neuropathic Pain and Dental Care: Messages

JournaC A L I F O R N I A D E N T A L A S S O C I A T I O N

Licensure Limits

Trigeminal Neuropathic Pain

Hemifacial Spasm

July 2017

Ignorance Is No Excuse: Understand the Limits of Licensure

Changing employment laws and a litigation-conscious public can intimidate the most confident dentists. Especially when practice employees are prepared to take legal action

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July 2017

D E PA R TM E N T S

F E AT U R E S

Ignorance Is No Excuse: Understand the Limits of Licensure

This article reviews malpractice claims and the attendant laws and offers guidance and tips for compliance to avoid license sanctions and lawsuits.Arthur W. Curley, JD

Trigeminal Neuropathic Pain and Dental Care: Messages From Case Reports

This article describes cases of trigeminal neuralgia of various etiologies, which must be differentiated from pain of periodontal and/or pulpal origin in order to be effectively managed.Joel B. Epstein DMD, MSD; Alexa C. Martin, DMD; Ali M.M. Sadeghi, DMD, MD; and Gary D. Klasser, DMD

Hemifacial Spasm: A Case Report and Review of Literature

This article covers a case of a patient with twitching in the right lower eyelid with irradiated pain in the temple and upper lid edema.Mariela Padilla, DDS, MEd; Robert Alcala Utsman, DDS; and María José Brenes Castillo, DDS

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Guest Editorial/Prescribing Smarter: How We Can Have Great Infl uence on America’s Opioid Crisis

Impressions

RM Matters/Just Say No: How to Handle Demanding Patients

Regulatory Compliance/Radiation Safety Program

Ethics/Response to Online Reviews

Tech Trends

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Volume 45, Number 7July 2017

JournaC A L I F O R N I A D E N T A L A S S O C I A T I O N

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published by the California Dental Association 1201 K St., 14th Floor Sacramento, CA 95814 800.232.7645 cda.org

Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853.

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J U LY 2 0 1 7 341

Guest Editorial

This blog post, republished with permission, originally appeared in the ADA New Dentist Now, newdentistblog.ada.org, on March 8, 2017.

Pain killers.Opioids.Drugs.Are they on your mind today?

Because they’re on mine.With every walk-in. With every

extraction. With every patient who looks me in the eye and says, “Doc, can I get a little something for pain?”

“Sure,” I say. And then I walk back to my computer, stare at my screen and wonder what to do. What do I give? How much? Do they really need it?

I don’t know about you, but my answers have certainly changed.

A few months ago, my prescription pad was a carefree, generous space. I wanted my patients to be comfortable. I wanted them pain-free. I wanted a “good-experiences-only” policy. So I took care of their pain and in turn thought I was taking care of my patients.

I would prescribe Vicodin, Percocet, Norco, Oxy, hydro … usually whatever the patient requested. If I took a tooth out, they got a narcotic. If they walked in with pain, they got a narcotic. We’re not talking outrageous amounts here. But in these moments, this is what I thought good health care looked like.

Which didn’t last long. And now things look much different in the space where I practice. I still take teeth out every day. But opioids are few and far between.

Why?Well, it’s experience. Good ol’

anecdotal evidence. It’s discussions with

colleagues. And then it’s being a part of an organization that has committed to help control the opioid crisis in America.

In residency, we didn’t think about consequences. We didn’t even realize the consequences. And like a lot of dentists in our country, we didn’t think we belonged in a conversation about the opioid crisis. That’s a physician problem.

And then I saw a stat that said dentists prescribe 12 percent of America’s instant-release opioids. Only second to family physicians, who prescribe 15 percent.

And then I joined Neighborcare Health, which makes it their duty to help limit the amount of pills fl oating around Seattle. And so we greatly restrict our prescribing protocol.

And then four months ago, I found my hands pressing on the sternum of an unconscious woman as I gave her CPR while her 8-year-old son watched in tears from the corner of the room only minutes after fi nding his pale blue mother on the couch and yelling for someone to help.

And as the paramedics arrived and assessed her, I heard one of them ask for “Narcan” just before escorting me out of the room.

Narcan.It’s a reversal agent for opioid overdose.

And so only a few minutes kept this family of three from becoming a family of two.

It doesn’t take extremes like this to prove that opioid use and abuse is a real problem that affects our world every day. We can help. And we should help. How?

By caring enough not to over-prescribe. Avoid prescribing opioids to patients you haven’t treated. Never prescribe opioids without talking to a patient about what to do with the unused pills.

Don’t start with opioids, end there. There’s plenty of literature to suggest that ibuprofen and other NSAIDs are just as effective in post-extraction pain management. I always start with NSAIDs and then manage breakthrough pain with opioids on a limited basis. And nine times out of 10, ibuprofen proves to be enough.

At the end of the day, the decision is up to you, the doctor. But with those three letters after your name comes a lot of responsibility. Will you own it?

Just the other day a patient presented to me for extractions. I had already extracted four teeth from him and had prescribed ibuprofen each time. Up to this point, he had never returned after extraction asking for more meds. The ibuprofen was enough.

On this day, however, he told me that he went to the ER over the weekend, was seen by a dental resident and had a tooth removed.

Prescribing Smarter: How We Can Have Great Infl uence on America’s Opioid CrisisJoe Vaughn, DMD

At the end of the day, the decision is up to you, the doctor. But with those three letters after your name comes a lot of responsibility.


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J U L Y 2 0 1 7 G U E S T E D I T O R I A L

Out of curiosity, I asked him what type of pain meds they gave him.

“Percocet … 24 of them.”As tough as it is to admit, sometimes

we are part of the problem. And so today, I ask for the help of all the new dentists out there to show your patients compassion, not by prescribing more but by prescribing smart.

For more information on the topic, visit ADA.org/opioids and read the following resources:

1. ADA Statement on the Use of Opioids in the Treatment of Dental Pain

2. Prevention of prescription opioid abuse: The role of the dentist. ■

Joe Vaughn, DMD, is a New Dentist Now guest blogger and a member of the American Dental Association. He grew up in Alabama and graduated from the University of Alabama at Birmingham School of Dentistry in 2015. He now lives in Seattle and works at Neighborcare Health, a community health center in Seattle. Two cups of coffee, writing and indie music are everyday occurrences for Joe. Go Seahawks and Roll Tide!

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CORREC TION

Allen Wong, DDS, EdD, was an author on the June 2017 article “Special Smiles: Dentistry and the Special Needs Athlete” but was inadvertently left off of the byline.

Dr. Wong has taught postdoctoral general dentistry for 25 years in AEGD programs and is the director of the University of the Pacifi c, Arthur A. Dugoni School of Dentistry’s hospital dentistry program and director of the Highland Hospital restorative implant program.

We apologize for the error.


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The nub:

1. Power can be a substitute for ethics.

2. We may have had enough of soapbox ethics.

3. Those who are most likely to bring ethics to dentistry are not dentists.

David W. Chambers, EdM, MBA, PhD, is professor of dental education at the University of the Pacifi c, Arthur A. Dugoni School of Dentistry, San Francisco, and editor of the American College of Dentists.

Power EthicsDavid W. Chambers, EdM, MBA, PhD

Many journals are devoted to practical professional ethics. By rough count, there are 11 in bioethics, nine in medicine, six in business, three each in law, nursing and education and others in fi elds such as media, sports and the military. But there are none in dentistry, except for the recently introduced Journal of Dental Ethics published in India.

Several of the leading journals in dentistry offer regular columns. But much of what we write is editorial in nature and sometimes takes the form of scolding “others” by innuendo. To the best of my knowledge, there is no dental ethicist employed full time in a dental school, let alone several of them who could build an academic discipline.

Dentistry is unique among the professions in not having a cumulative scholarly base in ethics. Perhaps that is because dentists are just that much more ethical than are other professionals. Maybe it works fi ne to “borrow” the foundations for ethics from others. A case might be made that we pass ethics effectively to young practitioners in an informal way.

An alternative suggests itself in a recent article in a business ethics journal. It could be that there are “ethics substitutes.”

Individuals in the study were given an ethical dilemma to solve as a group exercise. The outcome factors were how certain the decision-makers felt that they were doing the right thing and how much they used input from their colleagues. The researchers were interested in the relationship between power and ethics. They manipulated power by giving subjects a quiz to measure management, not ethical, skill.

Subjects who thought of themselves as powerful were less likely to consider the views of others involved in an ethical dilemma and were more confi dent in their choices. But that was bogus because the experimenters lied and randomly told half of the subjects the test showed them to be skilled and powerful while the others were not.

Dentists are high-power folks. Neither patients nor staff nor anyone else second-guesses the decisions, including ethical ones, made by dentists in their offi ces. They defi ne ethics in the world where they live. This is in contrast to all the other professions that have their own dental ethics journals. Everywhere else, there are checks and balances as part of the practice routine. Medicine is hospital based, and business and law are played out in the give and take between equals.

If I am right in this analysis, we may begin to see some journals in dental ethics. The most powerful forces dentists interact with are their peers — including fellow dentists who may see things differently and owners, payers and regulators. Interacting with powerful others requires well thought-out justifi cations, and we need a team of qualifi ed individuals working together in a cumulative fashion to do that work. ■

Impressions


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J U L Y 2 0 1 7 I M P R E S S I O N S

When considering only those patients who took an opioid after third molar extraction, almost 90 percent reported adverse effects that impaired activities of daily living, including drowsiness, nausea and vomiting, confusion, constipation and feeling “spaced out.”

Among all survey respondents, almost 90 percent had heard or read about prescription drug or opioid abuse-related issues in the past year and up to 98 percent perceived the opioid epidemic as somewhat or very serious

in the U.S. More than 70 percent of patients said they would opt for a nonopioid medication for postextraction pain. “Clinicians can help address these concerns by offering effective nonopioid alternatives,” noted researchers Suzanne McCormick, DDS, in private practice in Encinitas, Calif., and Pedro Franco, DDS, of DFW Oral & Maxillofacial Surgery in Irving, Texas.

The results of the researchers’ full study will be presented this fall at the 2017 American Association of Oral and Maxillofacial Surgeons annual meeting.

Patients Prefer Nonopioids for Postextraction Pain

After third molar extractions, adult patients and parents of young patients overwhelmingly prefer nonopioid pain management, according to a study presented at the 2017 American College of Oral and Maxillofacial Surgeons annual meeting in Vancouver, British Columbia, and reported by drbicuspid.com.

The researchers conducted an online independent survey in the U.S. between June 23 and July 8, 2016. Survey participants were separated into two groups: Adults age 18 and older who underwent third molar extraction in the past 12 months and parents of patients ages 18 to 24 who had the surgery in the past 12 months or expected to have it in the next 12 months.

The researchers screened more than 26,500 responses and identifi ed more than 1,500 qualifi ed respondents, which included 1,000 patients, 251 parents of patients who had the surgery and 251 parents of patients who expected to have the surgery.

Among patients who had the surgery and their parents, almost 70 percent reported that the patient was prescribed an opioid. Only about 40 percent reported that their provider discussed potential adverse effects, and a majority (between 56 and 62 percent) would have liked more information on the topic. Almost half of the patients reported they were “worried” about the prescription.

Titanium Performs Better Than BiodegradeablesResearchers from the Netherlands found that a commercially available

titanium fixation system outperformed a biodegradable one, according to their long-term study published recently in the journal PLOS One.

“The performance of the Inion CPS biodegradable system was inferior compared to the KLS Martin titanium system regarding plate/screws removal in the [studied] surgical procedures,” the authors concluded.

The researchers, led by Bahez Gareb, MSc, from the department of oral and maxillofacial surgery at University Medical Center Groningen in the Netherlands, compared the long-term clinical performance of a titanium and a biodegradable system in oral and maxillofacial surgery.

More than 200 patients at four hospitals in the Netherlands were initially randomly assigned to receive either a titanium fixation system or a biodegradable system. However, 80 patients were lost to follow-up, so the study finished with 85 patients in the titanium group and 56 in the biodegradable group.

All patients were contacted by telephone more than five years after the surgery to evaluate the outcomes (December 2006 to June 2016), and each patient’s electronic medical records were checked for plate/screw removal. More than 16 percent of patients (22 of 134) in the titanium system group had their plates removed, compared with more than 26 percent (23 of 87) of those with the biodegradable system, according to the study. However, occlusion, VAS pain scores and mandibular functional impairment questionnaire responses showed good and almost pain-free mandibular function in both groups.

To learn more about this study visit PLOS One (2017); doi.org/10.1371/journal.pone.0177152.


J U LY 2 0 1 7 345

A new study published recently in the journal Internal Medicine examined the effects of periodontal interventions on cardiovascular disease (CVD) in patients with periodontitis and type 2 diabetes and found that some therapeutic treatments may reduce the risk of cardiovascular complications.

Researchers from Hungkuang University in Taiwan conducted a retrospective study of more than 15,000 patients to determine if undergoing subgingival

curettage or fl ap operations infl uenced the occurrence of cardiovascular disease, including myocardial infarction, heart failure and stroke, in patients with periodontitis and type 2 diabetes. They found that advanced periodontal therapy lowers the rate of CVD, especially myocardial infarction and heart failure.

“Dental management has a benefi cial effect on the health of patients with type 2 diabetes,” said lead author Chiung-Huei Peng, DDS, PhD.

Perio Treatment Aids Heart Health in People With Diabetes

Teeth Tell Story of Humans’ Relationship With SunThe story of humanity’s vital — and fragile — relationship with the sun has

been locked inside our teeth for hundreds of thousands of years. A new method is starting to tease out answers to questions of evolution and migration, using clues hidden just under the enamel.

A group of McMaster University researchers reveals the potential of the method in a paper in Current Anthropology. In 2016, the researchers first established that dentine carries a permanent record of vitamin D deficiency, which is also called rickets. During periods of severe deficiency, new layers of dentine cannot mineralize, leaving microscopic markers scientists can read like rings of a tree.

Those markers can tell the story of human adaptation as early man moved from equatorial Africa into lower-light regions and may explain changes in skin pigmentation to metabolize more sunlight or how indoor living has damaged human health.

Until now, there has been no reliable way to measure vitamin D deficiency over time. As the authors show with examples from ancient and modern teeth, the method is valuable for understanding a health condition that today affects more than 1 billion people.

“This is exciting because we now have a proven resource that could finally bring definitive answers to fundamental questions about the early movements and conditions of human populations and new information about the importance of vitamin D for modern populations,” said Megan Brickley, PhD, a McMaster anthropologist and lead author of the paper.

Learn more about this study at Current Anthropology (2017); doi: 10.1086/691683.

Through the Taiwan National Health Insurance program, researchers considered data for adults with the diagnoses of type 2 diabetes in 1999 through 2001 and periodontitis who had not been previously diagnosed with CVD and had outpatient periodontal treatment in the three years following the diabetes diagnosis. They assigned participants to an advanced or nonadvanced periodontal treatment group based on the most severe periodontal treatment they had undergone. Subgingival curettage and fl ap operations were defi ned as advanced periodontal treatments, resulting in 3,039 patients in the advanced treatment group. All patients were followed until the onset of CVD or Dec. 31, 2011.

After adjusting for confounding variables, the researchers found that undergoing advanced periodontal treatment versus nonadvanced treatment did not signifi cantly affect the incidence of CVD. However, the incidences of myocardial infarction and heart failure, which are major components of CVD, were each signifi cantly lower in the advanced treatment group compared with the nonadvanced treatment group. The incidence of stroke was not affected.

“Our analysis revealed that advanced periodontal treatment effectively alleviated the incidence of myocardial infarction and heart failure (the latter to a greater extent), whereas it had no signifi cant effect on stroke,” the authors wrote. “These results indicate there might be some discrepancies between the pathogenesis of stroke and periodontitis-associated coronary artery disease.”

Learn more about this study in Internal Medicine 56 (9), 1015-1021 (2017).

Teeth from Dr. Megan Brickley’s lab at McMaster University. Image: McMaster University


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the global level,” Dye said. “Improving our understanding of the contribution behavioral and physiological risk factors, social and economic determinants and health delivery systems have to oral health and well-being at the population level may not be an easy task, but untangling this complex web will help reduce disease burden and enhance life.”

Read more of this analysis in the Journal of Dental Research, 96 (4), 380–387 (2017).

health goals are to be achieved by 2020, according to the analysis.

In an invited perspective article, Bruce A. Dye, DDS, MPH, of the National Institutes of Health, National Institute of Dental and Craniofacial Research stated that the sizeable burden of oral disorders and its socioeconomic impact makes it an important global public health issue.

“It is now evident that oral disorders are highly prevalent and a dental epidemiologic transition is underway at

Puff erfi sh, Humans Share the Same Genes for TeethHuman teeth evolved from the same genes that make the bizarre beaked

teeth of the pufferfish, according to new research by an international team of scientists. The pufferfish beak is composed of four elongated “tooth bands” that are replaced again and again.

The study, led by Gareth Fraser, PhD, from the University of Sheffield, U.K., Department of Animal and Plant Sciences, has revealed that the pufferfish has a remarkably similar tooth-making program to other vertebrates, including humans. Published in the journal PNAS, the research has found that all vertebrates have some form of dental regeneration potential. However, the pufferfish uses the same stem cells for tooth regeneration as humans do but only replace some teeth with elongated bands that form their characteristic beak.

The study’s authors, which include researchers from the Natural History Museum London and the University of Tokyo, believe the research can now be used to address questions of tooth loss in humans. “Our study questioned how pufferfish make a beak and now we’ve discovered the stem cells responsible and the genes that govern this process of continuous regeneration. These are also involved in general vertebrate tooth regeneration, including in humans,” Fraser said. “The fact that all vertebrates regenerate their teeth in the same way with a set of conserved stem cells means that we can use these studies in more obscure fishes to provide clues to how we can address questions of tooth loss in humans.”

Read more of this study at PNAS (2017); doi: 10.1073/pnas.1702909114.

J U L Y 2 0 1 7 I M P R E S S I O N S

25-Year Analysis Concludes Oral Health Did Not Improve

Due to demographic changes, including population growth and aging, the cumulative burden of oral conditions dramatically increased between 1990 and 2015, according to a systematic analysis published by the International and American Associations for Dental Research (IADR) in the Journal of Dental Research. The analysis, authored by Wagner Marcenes, BDS, MSc, PhD, of King’s College London Dental Institute in England, examines data to assess progress toward the Federation Dental International (FDI), World Health Organization (WHO) and IADR oral health goals of reducing the level of oral diseases and minimizing their impact by 2020.

Marcenes and his team of researchers found that the number of people with untreated oral conditions rose from 2.5 billion in 1990 to 3.5 billion in 2015, with a 64 percent increase in disability-adjusted life years due to oral conditions throughout the world. Hence, the team concluded that oral health did not improve in the 25-year time period studied and that oral conditions remained a major and growing global public health challenge in 2015.

While the age-standardized prevalence of oral conditions remained relatively stable between 1990 and 2015, population growth and aging have led to a dramatic increase in the burden of untreated oral conditions throughout the world. Greater efforts and potentially different approaches are needed if international oral


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Transplanted Third Molars an Implant Alternative?

Grape Seed Extract May Extend Life of Resin FillingsA natural compound found in grape seed extract could be used to strengthen

dentin and increase the life of resin fillings, according to new research published in the Journal of Dental Research.

In the research, Ana Bedran-Russo, DDS, PhD, associate professor of restorative dentistry at University of Illinois at Chicago College of Dentistry, describes how grape seed extract can make composite-resin fillings stronger, allowing them to last longer. The extract, Bedran-Russo said, can increase the strength of the dentin, forming the layer just beneath the hard external enamel. Resins have to bind to the dentin, but the area between the two, or the interface, is a weak point, causing restorations to breakdown.

“We want to reinforce the interface, which will make the resin bond better to the dentin,” Bedran-Russo she said.

Secondary caries and margin breakdown are the most frequent causes of failed adhesive restorations. Despite numerous advances in dental restorative materials, degradation of the adhesive interface still occurs. Bedran-Russo has discovered that damaged collagen can repair itself with a combination of plant-based oligomeric proanthocyanidins — flavonoids found in most foods and vegetables — and extracts from grape seeds. Interlocking the resin and collagen-rich dentin provides better adhesion and does not rely on moisture, according to the research.

“The stability of the interface is key for the durability of such adhesive joints, and hence, the life of the restoration and minimizing tooth loss,” Bedran-Russo said.

Learn more about this research in the Journal of Dental Research 96 (4), 406–412 (2017).

The autotransplantation of third molars has been called a feasible, fast and economical alternative to an implant when a suitable donor tooth is available. But how do these teeth hold up over the long term, and what kind of socket is best for their placement?

Researchers from Peking University School and Hospital of Stomatology in Beijing compared long-term outcomes of autotransplanted third molars in both surgically created sockets and fresh extraction sockets but found no

signifi cant differences in survival rates or infl ammatory root resorption for either placement, according to a study published in the International Journal of Oral and Maxillofacial Surgery. “These results suggest that the autotransplantation of third molars with completely formed roots is effective in both surgically created and fresh extraction sockets and provides a high long-term success rate if cases are selected and treated appropriately,” the authors noted.

In the study, a total of 65 third

molars with completely formed roots were autotransplanted in 60 patients. The teeth were divided into two groups: control and delayed autotransplantation.

The control group consisted of 29 third molars that were autotransplanted into fresh extraction sockets (immediate autotransplantation). The delayed autotransplantation group included 36 teeth that were autotransplanted into surgically created sockets with or without guided bone regeneration (GBR). All patients underwent annual clinical and radiographic examinations with an average follow-up of almost 10 years.

The survival rates for the control, GBR and no GBR groups were 93.1, 95.2 and 80.0 percent, respectively. The authors reported no signifi cant differences among the groups, including no statistically signifi cant differences with regard to the frequency of infl ammatory root resorption or root ankylosis. Age did not infl uence the clinical outcomes.

The authors noted that their study was limited by the small sample size and that changes in bone height and width were not analyzed through 3-D projection.

“The present study supports the hypothesis that mature third molar autotransplantation for the replacement of a missing or nonretainable posterior tooth is a reasonable alternative to implant treatment,” the authors stated.

Learn more about this study in the International Journal of Oral and Maxillofacial Surgery 46 (4), 531–538 (2017).


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l i c e n s u r e

AUTHOR

Arthur W. Curley, JD, is a senior trial attorney in the health care defense fi rm of Bradley, Curley, Barrabee & Kowalski, PC, and an assistant professor at the University of the Pacifi c, Arthur A. Dugoni School of Dentistry.Confl ict of Interest Disclosure: None reported

Ignorance Is No Excuse: Understand the Limits of LicensureArthur W. Curley, JD

The lawful duties of California dental auxiliaries have changed and grown signifi cantly in the past 20 years, in part as a response to the increasing need

for affordable access to care. However, as dentists work to provide the best care for their patients, sometimes the treatment performed can result in an auxiliary practicing outside the scope of his or her license. This is often unintentional and the result of some dentists and staff being unaware of laws and limitations.

The Dental Board of California requires all dental practices to post the table of permitted duties (dbc.ca.gov/formspubs/pub_permitted_duties.pdf) in a common area. Using this table will not only ensure that the practice is operating legally, but if a patient ever has a treatment delivery question, having this table at hand is very benefi cial and can elevate a patient’s trust in the dentist and staff.

While dentists are required to post the table of permitted duties and CDA provides this posting at no cost, the dental board is still receiving complaints and reports of auxiliaries practicing outside the scope of their licenses. Additionally, attorneys representing patients in claims of dental malpractice can use evidence of violation of postings to show that substandard care was provided. This article reviews those claims and the attendant laws and offers guidance and tips for compliance to avoid license sanctions and lawsuits.

Issues of ScopeThere is no defense for staff operating

outside the scope of license or registration. The law is specifi c and the dental board has an educational mandate. Furthermore, the board has promulgated that dentists make reference to a readily accessible table of permitted duties detailing what staff can and cannot do, at all levels, as well as associated supervision. Dentists may mistakenly believe that if patients are receiving quality care, it doesn’t matter who provides it. However, such practitioners can be cited and have license sanctions imposed by the dental board, even in the absence of a complication or failed treatment by staff. The dental board states: “Statutes and regulations specifi cally defi ne the duties that each category of auxiliary is allowed to perform, the level of dentist supervision required and the settings in which the duties may be performed. It is a criminal offense to perform illegal functions, as well as grounds for license discipline of both the person performing the illegal function and any person who aids or abets such illegal activity.” In addition, staff practicing beyond the scope of license may expose the offi ce, the supervising dentist and themselves to civil suits and claims of false billing.

Examples of staff performing duties outside the legal scope of their practice include:

■ Dental assistants performing coronal polishing and cementation of permanent crowns or making initial diagnoses.


350 J U LY 2 01 7

Violation Consequences Once a violation of scope of practice

by dental auxiliaries becomes known, the dentist, any supervisor and the staff person can be subject to license revocation, criminal prosecution, lawsuits by patients and insurance claims.

Presumption of Substandard CareThe Standard of Care is defi ned as such:

“A Dentist is required to possess and exercise, in both diagnosis and treatment, that reasonable degree of knowledge and skill which is ordinarily possessed and exercised by other members of his profession in similar circumstances.” (Landeros v. Flood (1976) 17 Cal.3d 399, 408 [131 Cal.Rptr. 69, 551 P.2d 389].)

All dental treatments performed by appropriately licensed health care professionals have known risks for complications and failure. The mere occurrence of a complication or failure ordinarily does not indicate the care was substandard or negligent.

“A doctor is not a warrantor of cures nor is he required to guarantee results and in the absence of a want of reasonable care and skill will not be held responsible for untoward results.” (Sanchez v. Rodriguez (1964) 226 Cal.App.2d 439, 449 [38 Cal.Rptr. 110].)

However, if the treatment is performed by a dentist or dental auxiliary without a license or beyond the scope of practice for their license, any complication or failure is presumed to be the result of negligent or substandard care as a matter of law. California Evidence Code section 669 states:

“(a) The failure of a person to exercise due care is presumed if: (1) He violated a statute, ordinance or regulation of a public entity; (2) The violation

a patient may develop an issue with billing or the esthetics of treatment and write a letter to the dental board, which in response to the complaint will open an investigation and request a copy of the records from the dentist. In many occasions, the dental board will also offer the doctor an opportunity to draft a response to the complaint. In some cases, the dental board investigator will ask for an explanation or transcript of the entries and who provided consultations, advice and/or treatment. California law requires

all dentists and supervisors to ensure that all chart entries are signed by the person making the entry. California Business and Professions Code section 1683 states:

“(a) Every dentist, dental health professional or other licensed health professional [RDA or RDH] who performs a service on a patient in a dental offi ce shall identify himself or herself in the patient record by signing his or her name or an identifi cation number and initials next to the service performed and shall date those treatment entries in the record. Any person licensed under this chapter who owns, operates or manages a dental offi ce shall ensure compliance with this requirement. (b) Repeated violations of this section constitute unprofessional conduct.”

■ Dental assistants or registered dental assistants (RDAs) doing prophylaxis.

■ Offi ce managers making initial diagnosis.

■ Registered dental hygienists making clinical and/or radiographic diagnosis.

■ Unlicensed foreign-licensed dentists performing RDA tasks, RDA treatment or dental procedures.

■ Billing that does not match records or imaging.

Specifi c instances include a case where a foreign-licensed dentist performed RDA duties for a general dentist without obtaining an RDA license. If prosecuted, this foreign-licensed dentist may never be allowed to apply for a California license. In another case, a group dental practice’s offi ce manager routinely received records from examining dentists and merely charted clinical and X-ray fi ndings. The offi ce manager determined diagnoses, made treatment recommendations, drafted treatment plans and signed patients up for credit payment programs. Following a complaint to the dental board from an elderly patient, the offi ce manager was arrested and charges were made against the owner dentist. The patient’s family also fi led a lawsuit alleging elder abuse. In another case alleging the onset of temporomandibular joint problems associated with occlusal adjusts, claims were leveled against an RDA. In this case, charting errors showed treatment was done on a day the dentist was not in the offi ce. The patient insisted the RDA had made the adjustments.

Notice of the Scope of Practice IssuesThe notice of a violation of the scope

of practice by staff most often comes either directly or indirectly from a patient complaining in writing to the dental board about treatment. For example,

l i c e n s u r e

The mere occurrence of a complication or failure ordinarily does not indicate the care was substandard or negligent.


J U LY 2 0 1 7 351

proximately caused death or injury to person or property; (3) The death or injury resulted from an occurrence of the nature which the statute, ordinance or regulation was designed to prevent; and (4) The person suffering the death or the injury to his person or property was one of the class of persons for whose protection the statute, ordinance or regulation was adopted.”

Therefore, if a patient experiences a failure of a cure of treatment or a complication of treatment performed by a staff person who was acting beyond or outside of his or her license, the patient does not have to prove negligence or substandard care in order to be awarded monetary damages. Further, a patient cannot consent to health care treatment by an unlicensed person and therefore can also bring suit for a refund of fees paid.

License Revocation or NonrenewalIf an investigation by the dental

board determines that a staff person performed treatment beyond or outside the scope of his or her license, that person’s license to practice or assist may be suspended or revoked. That sanction can also be applied to the supervising dentist who either knowingly promoted or allowed unlicensed treatment by staff, including unlicensed foreign-trained dentists, or made no effort to ensure compliance as required by the statute.

Criminal ChargesNumerous laws make it a crime

to practice any aspect of dentistry or perform treatments without appropriate licensure. When the unlicensed activity is performed knowingly, or with the recommendation or consent of the

supervising dentist, criminal intent is presumed. That is particularly the case where a dentist or supervisor fi nancially benefi ts from the unlicensed activities by way of compensation or increased profi t. The criminal consequences can include fi nes, penalties such as full restitution to all patients, and in some cases, even incarceration. It is important to note that a criminal conviction for practice without a license may prohibit future efforts to obtain the appropriate licensure.

Insurance ChargesPracticing dentistry without a license or

beyond the scope of license and charging the patient’s dental insurance carriers for those treatments can result in an audit by that company, either randomly or more often because of a complaint by a patient as to the services rendered. If the audit shows unlicensed treatments and associated billings, the carrier can make a claim for false billing and demand refunds of all fees. In addition, the offending doctor or supervising dentist may be decertifi ed and/or delisted as a provider and not eligible to see patients in that program for up to three years, if ever. In some cases, the billing by unlicensed staff can result in the fi ling of criminal charges for fraudulent insurance billing. The mere fi ling of such charges can trigger a dental board investigation and the potential for license revocation.

Risk Management and Avoidance ■ Maintain personnel fi les for all staff

that contain a signed application for employment, copies of their current licenses or registration and compliance with C.E. including the Dental Practice Act.

■ Post the table of permitted duties and have all staff sign off as having reviewed it. Check the dental board website annually for updates.

■ Have statements in the employment handbook that staff may not exceed the scope of their license or registration.

■ Document, document, document. Never take the word or mere representation of a dentist or dental auxiliary as to the status of his or her license.

■ Perform one to two audits a year; audit your own practice to ensure compliance with licensure limitations.

■ Temper yearly bonuses to not exclusively focus on production to reduce the risk of padding the records and charges by misrepresenting licensure.

■ Be the best example and do not allow exceptions.

Know that it is not a matter of if, but rather when, you are exposed. Just because you have gone years without being audited or investigated does not mean your practice is compliant. Think of it as like driving without a seat belt and going 75 mph in a 60 mph zone on a daily basis. You may go years without being pulled over, however, when it fi nally happens — and it will the longer you do it — it is not a defense to say that no one got hurt, you are a good driver or that no one has said anything for years. You will still get a sanction in the form of a ticket. The choice is yours: compliance now rather than fi nes and licensure sanctions later. ■

Just because you have gone years without being audited or investigated does not mean your practice is compliant.

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J U LY 2 0 1 7 353

t r i g e m i n a l n e u r a l g i a

AUTHORS

Joel B. Epstein, DMD, MSD, is a professor and medical director of oncology dentistry at the Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Health System Los Angeles and consulting staff in the division of otolaryngology and head and neck surgery at City of Hope National Medical Center in Duarte, Calif. He is a diplomate of the American Board of Oral Medicine, a fellow of the College of Dental Surgeons of Canada and a fellow of the Royal College of Surgeons of Edinburgh.Confl ict of Interest Disclosure: None reported.

Alexa C. Martin, DMD, is a general practice resident in hospital dentistry at Cedars-Sinai Medical Center in Los Angeles.Confl ict of Interest Disclosure: None reported.

Trigeminal Neuropathic Pain and Dental Care: Messages From Case ReportsJoel B. Epstein DMD, MSD; Alexa C. Martin, DMD; Ali M.M. Sadeghi, DMD, MD; and Gary D. Klasser, DMD

A B S T R AC T Dentists are subject to encountering cases involving orofacial pain unrelated to dental disease that may mimic common dental etiologies. Often, differential diagnosis can be made when classic symptoms of neuralgia are present, but diagnosis becomes more challenging with mixed and atypical symptoms. It is the goal of this article to describe cases of trigeminal neuralgia of various etiologies, which must be differentiated from pain of periodontal and/or pulpal origin in order to be effectively managed.

Orofacial pain is a primary reason for patients seeking oral health care services. The majority of patients with orofacial pain have

identifi able common dental diseases (most often of periodontal or pulpal origin) that can be confi rmed on history, clinical examination and/or dental radiographs as the cause of pain. When the cause of pain is addressed, pain is expected to resolve. However, in certain situations orofacial pain may be more complicated and have less obvious local, regional and central causes that must be distinguished from dental disease so that appropriate diagnosis and treatment can occur. Dentists are subject to encountering cases involving orofacial pain unrelated to dental disease that may mimic other common dental etiologies. It is the goal of this article to describe cases of trigeminal neuropathic pain (neuralgia and neuropathy) of various etiologies, which must be differentiated

from pain of periodontal and/or pulpal origin and correctly diagnosed in order to be effectively managed.

Neuralgia and neuropathic pain may cause orofacial pain and must be distinguished from pain related to dental disease.1 Trigeminal neuralgia (TN) is rare, with estimates of 2.5/100,000 in men and 5.7/100,000 in women and with a peak incidence between 50 and 60 years of age. Cases may be associated with vascular lesions on the trigeminal ganglion, demyelinating disease (e.g., multiple sclerosis) and central lesions or may be idiopathic. TN most often affects the second (V2) and/or third (V3) divisions of the trigeminal nerve (CN V) and hence is a pain condition that may present in the dental offi ce. Classical TN is characterized by paroxysmal, unilateral pain confi ned to the trigeminal distribution, which may be provoked by light touch of the trigger zones with an otherwise normal clinical sensory examination.2 Following onset of

Ali M.M. Sadeghi, DMD, MD, is a certifi ed oral and maxillofacial surgeon and the department head of oral and maxillofacial surgery at Lions Gate Hospital in Vancouver, B.C. He is a fellow of the Royal College of Dentists of Canada.Confl ict of Interest Disclosure: None reported.

Gary D. Klasser, DMD, is an associate professor in the department of diagnostic sciences at Louisiana State University, School of Dentistry, and is involved in predoctoral and postdoctoral clinical research and education.Confl ict of Interest Disclosure: None reported.


354 J U LY 2 01 7

symptoms, pain may increase in intensity and in frequency with variable remission. In some cases, TN may evolve from early-stage nerve dysfunction, referred to as pretrigeminal neuralgia, with more classic symptoms developing over time. Some may have autonomic features associated with pain, including nasal congestion, lacrimation, ptosis and facial sweating.

TN may be caused by vascular compression of the trigeminal ganglion, and it is now thought that microvascular compression of the ganglion accounts for 80–90 percent of cases.3 Neurovascular contact at the root entry zone with the trigeminal ganglion in classical TN is associated with the symptomatic versus the asymptomatic side (53 percent versus 13 percent; P < .001).4 This compression may lead to complete or partial loss of myelin surrounding the CN V root, especially in the area where the superior cerebellar artery may pass over and compress the nerve root. In these areas of damage, increased numbers of membrane sodium channels are generated, creating a higher probability of spontaneous depolarization. In addition, an ephaptic spread of impulses in the periphery may occur as signals jump from low-threshold, light touch, A-beta fi bers to damaged demyelinated A-delta or C fi bers, with the generation of a pain signal that goes on to second order neurons and then to the brain, which can interpret this light touch as a jabbing pain.2

TN must be differentiated from dental causes of pain. Dental management should only be considered once diagnosis of dental pathosis is defi nitively made. In cases of TN, any dental treatment, if indicated, should be managed by procedures that minimally involve nerves when possible.5 When TN is diagnosed, medical management, often the fi rst choice of treatment, is based upon centrally acting medications used in other chronic neuropathic pain states, such as anticonvulsant and antidepressant

drugs, and possibly adjunctive approaches such as acupuncture. For TN, the classic medication is carbamazepine, a membrane-stabilizing agent that decreases painful spontaneous nerve impulses, while other options include oxcarbazepine, gabapentin, pregabalin, lamotrigine and others. Medication trials should be provided prior to consideration for surgical intervention, and if effective, provide supporting evidence for the diagnosis and may be suffi cient for management. Neurosurgical treatment is reserved for cases of TN not effectively managed with medications and when specifi c fi ndings are noted on imaging. TABLE 1 summarizes the management approaches that should be considered for cases of TN.

There is an increase in the prevalence of traumatic neuropathy in the head and neck that may be due to the invasive nature of dental interventions as well as increased misdiagnosis by clinicians. This phenomenon is known as painful traumatic trigeminal neuropathy (PTTN), and its diagnosis is based on neuropathic pain criteria and management.6,7 PTTN is due to nerve injury that may be peripheral, arising in the ganglion and/or associated with

central pain states. Neuropathy is different from neuralgia in that it often presents with a continuous, persistent burning or aching with occasional throbbing or shooting pain, which can follow dental treatment such as endodontic and/or surgical procedures. It can be associated with medications and systemic conditions such as multiple sclerosis and endocrine disorders (diabetes, hypothyroidism, etc.) as well. This pain may follow endodontic therapy and implant placement with a reported incidence of 0.6–36 percent.8 PTTN has also been reported in 0.3–4 percent of lower third molar extractions.9,10 In post-endodontic pain, it is estimated that from 3–13 percent will experience neuropathic pain11 and direct injury to CN V may result in persisting pain in 3–5 percent.12,13 Infl ammation with or without direct injury may lead to neuropathy as well. Local anesthetic testing with regional anesthesia such as peripheral nerve block may have varying degrees of effect on remission of pain and may aid in the diagnosis of orofacial pain, including PTTN and TN. Risk factors for PTTN include painful treatment in the region, duration of pretreatment pain, prior


TABLE 1

Management Approaches for Trigeminal Neuralgia

Medications■ Classic fi rst-choice agent: carbamazepine■ Other centrally acting medications: anticonvulsants,

antidepressants, antispasmodics, miscellaneous agents

Surgery (when specifi c imaging fi ndings present on CNS imaging)■ Percutaneous procedures (procedures in the Gasserian ganglion)

• percutaneous retrogasserian glycerol rhizotomy • percutaneous microdecompression (balloon) • percutaneous radiofrequency trigeminal gangliolysis (thermocoagulation)

■ Craniotomy for microvascular decompression (preserves trigeminal nerve function)■ Stereotactic radiotherapy

• gamma knife surgery (multiple focused high-energy photon beams) • cyberknife radiosurgery (single high-energy photon beam)

Other approaches■ Acupuncture

Future considerations■ Raxatrigine (sodium channel blocker)■ Transcranial magnetic stimulation


J U LY 2 0 1 7 355

chronic pain, psychological factors such as anxiety and depression and impairment in general physical functioning.14,15 It is more common in females (60 percent), and the overall risk of PTTN is estimated at 3–5 percent of cases.16 One study found that lack of adequate informed consent regarding the potential for postoperative pain was present in more than 70 percent of patients who experienced neuropathy after implant placement.17 PTTN may be permanent, however, careful planning of invasive dental procedures, timely referral and systematic management may minimize symptoms.18

A recent review of a surgical database of patients referred for neuralgia management assessed the interventions conducted prior to surgical referral.19 Of 92 patients, 51 participated and two-thirds were pain-free following surgical care confi rming the diagnosis of TN and the nondental cause of pain. Of these, 82 percent had seen a dentist and 27 percent received invasive dental treatment (e.g., endodontics, extractions) without pain relief. It was noted that consultation with a dentist was common prior to referral for TN treatment, which emphasizes the need for accurate diagnosis

and awareness of symptoms of TN early on. Unfortunately, it is common that even when presenting with classic symptoms of TN, pain may be mistakenly attributed to dental disease. TABLE 2 summarizes the clinical characteristics that may present with TN, trigeminal neuropathy and dental pain. Often differential diagnosis can be made following careful history taking when classic symptoms of neuralgia are present, but diagnosis is more challenging with mixed and atypical symptoms.

Case Reports

Case OneA 42-year-old female developed severe

left-sided facial pain after receiving routine composite restorations in her lower left molars under mandibular block anesthesia. She had repeated dental follow-up examinations with initiation of endodontic treatment on the symptomatic teeth, followed by referral to an endodontist. The severity of pain interfered with all daily activities and led to an emergency department visit where she was prescribed oral morphine. Pain was rated as 10 of 10 (0 = no pain; 10 = severe pain,

unable to carry on any activity) and was described as sharp, stabbing, lightning pain, deep in the jaw, with throbbing/aching between sharp episodes. The teeth were hypersensitive to light touch, and pain was associated with same-side headache. Despite repeated attempts to continue endodontic treatment, which included the use of systemic antibiotics and steroids, it was not possible to complete the endodontic procedures due to severe pain.

One month after onset, she sought extraction of the painful teeth. At that time, in addition to tooth and jaw pain, she reported numbness, bad taste, redness, swelling, earache and headache extending from the lower left molar area. Pain severity was rated as 4–5/10; worst as > 10/10; and average 6–7/10. Her past medical history included infl ammatory bowel disease, sinusitis and depression. Examination did not identify an extraoral trigger of pain, although the left masseter muscle and sternocleidomastoid muscles were moderately tender. The differential diagnosis included TN with secondary myalgia. She was prescribed carbamazepine (200 mg once daily) and instructed to titrate weekly until pain control was achieved.

TABLE 2

Clinical Characteristics of Trigeminal Neuralgia, Trigeminal Neuropathy and Dental Pain

Characteristic Neuralgia Neuropathy Pulpal/Periodontal

Sharp, electric pain severe/common, triggered (hyperesthesia)

mild/rare moderate/uncommon (percussion and palpation tenderness)

Aching/burning pain mild/rare severe/common moderate/uncommon

Pain severity severe/common mild/rare moderate/uncommon

Constant mild/rare severe/common moderate/uncommon

Intermittent severe/common mild/rare moderate/uncommon

Unilateral severe/common mild/rare severe/common

Bilateral none/not applicable moderate/uncommon none/not applicable

Autonomic signs mild/rare moderate/uncommon none/not applicable

Pulpal/periodontal pathosis (clinically) none/not applicable none/not applicable severe/common

Pulpal/periodontal pathosis (radiographically)

mild/rare, magnetic resonance imaging and/or magnetic resonance angiography

none/not applicable moderate/uncommon, bitewing and/or periapical radiographs

Pain relief with topical anesthetic testing none/not applicable mild/rare mild/rare

Pain relief with local anesthetic testing severe/common mild/rare severe/common


356 J U LY 2 01 7

On follow-up three weeks later, pain had resolved with carbamazepine (200 mg tid), but she had reduced the dose due to skin rash, a known potential toxicity of carbamazepine, and pain recurred. Further history included report of numbness/tingling of legs and arms. Examination revealed triggering of pain with traction on the cheek during oral examination. The clinical diagnosis was TN with a need to rule out MS. Carbamazepine was discontinued, oxcarbazepine (300 mg 1/day increase by 1/wk up to 4/day (600 mg bid)) and baclofen (10 mg tid) were prescribed and a magnetic resonance image (MRI) was ordered to assess the brain and the trigeminal nerve.

Two months later, she noted her physician had discontinued the prior medications due to side effects and prescribed gabapentin (100 mg tid), following which pain had increased (7/10). She described episodes of sharp, stabbing pain with triggering and aching pain between episodes. No changes in previous fi ndings were identifi ed. Pregabalin (75 mg bid) and baclofen (10 mg tid) were prescribed. A neurosurgical consult was requested.

A noncontrast MRI of the brain and trigeminal ganglion showed normal brain parenchyma and normal morphology and no evidence of demyelinating disease. However, a small vessel was noted inferior to the cisternal portion of the left trigeminal ganglion entering Meckel’s cave medial to CN V (FIGURE 1).

Due to continuing pain and the imaging fi ndings, she completed surgical treatment involving microvascular decompression one month later. A clear indentation of the superior cerebellar artery on the trigeminal ganglion was identifi ed at the time of surgery. The vessel was released from the nerve and a Tefl on sponge was placed.

At the fi rst follow-up postsurgery two weeks later, she reported no facial pain with mild headaches since surgery and good range of motion of the neck. At follow-up six weeks following microvascular decompression, she reported that facial pain had essentially resolved, although she was aware of pressure on the lower left molars. She denied sharp, stabbing or burning pain. Localized molar tenderness was reported with light pressure applied to the crowns of Nos. 18 and 19. She was asked to continue pregabalin (150 mg/d) and ibuprofen (as needed). Mild tenderness was identifi ed in the left masseter muscle, and moderate tenderness was reported to palpation in the buccal vestibule adjacent to Nos. 18 and 19. Dental radiographs showed a diffuse radiolucency on the distal root of No. 18 with no abnormality in No. 19. It was evident that in the months since the last endodontic intervention there was progression of dental symptoms distinctive from the TN. Endodontics was then completed and symptoms resolved.

Case TwoA 68-year-old female with a history

of chronic orofacial pain was seen. The pain had started spontaneously eight years prior and was initially experienced as a sharp, electric-like pain that was intermittent throughout the day along the left lateral tongue. The pain gradually progressed to include severe burning in the left tongue as well as left lower lip sensitivity. She had prior evaluations by neurologists with pharmacologic treatments directed toward neuralgia/neuropathy. Despite these treatments, she reported increasing symptoms that included sharp, stabbing pain that lasted for 15–30 minute episodes most days, with aching, burning and hypersensitivity between the severe episodic pain.

When seen, she reported a constant baseline 5/10 burning in the V3 distribution. She also had a more severe intermittent pain, which was described as shooting and stabbing and was often stimulated by talking, eating and toothbrushing. She had a medical history of type 2 diabetes, hypertension, high cholesterol, prior breast cancer (treated with lumpectomy and radiation) and bilateral pulmonary emboli for which she was on an anticoagulant. She was on a statin and alprazolam for sleep. She had been a one-pack-per-week smoker for 10 years but had quit more than 30 years earlier. Clinical fi ndings included left masseter muscle tenderness. She had hyperesthesia of the lower left tongue and sensitivity of the left mandibular dentition to percussion.

The unilateral pain report suggested a neurologically mediated pain, with a mixed presentation of neuralgia and neuropathy. There was no tooth-related pathosis identifi ed on exam or dental imaging. The unilateral nature as well as history of progression of symptoms indicated the need for imaging of the cranial nerve distribution.

Initial management included gabapentin (300 mg increased 600 mg tid); however, this resulted in fatigue without signifi cant effect on facial pain and was discontinued. Pregabalin (75 mg bid) replaced gabapentin and she was started on carbamazepine (increase to a dose of 800 mg qd). Myalgia was felt to be secondary to the neuropathic pain.


FIGURE 1. MRI showing small vessel immediately inferior to the cisternal portion of the left trigeminal nerve at the root entry zone.


J U LY 2 0 1 7 357

The MRI revealed that the left superior cerebellar artery might have a loop abutting the left CN V at the root entry zone. There was evidence of possible mastoiditis and cystic-like structures in the white matter of the brain with questionable signifi cance.

On follow-up, blood study showed low therapeutic levels of carbamazepine, but pain continued. At this visit, the patient was switched to oxcarbazepine, with gradual withdrawal of carbamazepine. Alprazolam was replaced with clonazepam due to potential effect upon neuralgia while continuing to promote sleep. She was referred for neurosurgical consultation.

After six weeks on oxcarbazepine, dramatic improvement in facial pain occurred. The sharp, stabbing pain had essentially resolved, leaving her with a low-level, 2–3 out of 10 constant discomfort. No trigger sites for facial pain were identifi ed. She was limited in the amount of oxcarbazepine she could take due to dizziness and light-headedness. The plan was to reduce oxcarbazepine on a gradual basis to eliminate the light-headedness while continuing the low-dose carbamazepine, which she had not weaned off, and to continue gabapentin.

Surgical treatment options were presented and less-invasive percutaneous radiofrequency ablation was recommended due to the patient’s anticoagulation.

However, due to the success with the medication protocol, she elected to continue with medical management only. Two months later, she reported essentially complete resolution of facial pain with occasional mild, short-duration sensitivity when fi rst biting into food. Otherwise, she had no pain and did not report any side effects from her current medications. Continuing pharmacologic management was suggested, although she remained a candidate for neurosurgical management if pain control was not suffi cient.

Case ThreeA 68-year-old male was referred due

to right-sided intraoral pain confi ned to the marginal gingiva and right lateral tongue. The pain was described as a low-grade, steady, dull, constant discomfort in the mandible and warmth in the tongue with episodes of sharp, jabbing, knife-like pain that could be incapacitating and could extend into the neck. The pain had been present for 25 years with variable intensity but had recently progressed in severity. He was aware of no specifi c factors associated with increase in pain. Recently, he lost a crown and his temporary restoration on tooth No. 30, resulting in direct irritation of the adjacent right lateral tongue, which further complicated his pain presentation.

Head and neck exam did not reveal signifi cant fi ndings, although light touch in the lower right canine labial gingival region did trigger a sharp, short-duration pain. He received multiple dental interventions for these pain complaints without any change in his symptoms, and there did not appear to be a dental etiology for his current complaints.

The history and clinical fi ndings suggested neurologically mediated pain. It was suggested the patient start a trial of carbamazepine (400 mg bid); however, pain relief was not achieved and a skin rash developed. Carbamazepine was discontinued and baclofen (10 mg bid increase to tid) was prescribed.

A computed tomography scan with contrast was taken, revealing abnormal osseous expansion of the right maxilla and adjacent structures (FIGURE 2). The infraorbital canal on the right side was surrounded by thickened bone, narrowing the neural foramen for V2. The abnormal maxillary thickening was determined to most likely be due to fi brous dysplasia, although Paget’s disease could have a similar appearance. Due to these fi ndings, a nuclear bone scan (technetium 99 m MDP) was requested in order to assess bone activity, which was positive in the area of increased bone density (FIGURE 3). The interpretation

FIGURE 2. CT showing abnormal osseous expansion of the right maxilla, anterior wall of the right maxillary sinus, right nasal bone, inferior wall of the orbit and possible mild expansion of the right zygoma. The infraorbital canal on the right side was surrounded by thickened bone, narrowing the neural foramen for V2.

FIGURE 3 . Nuclear bone scan (technetium 99m MDP) positive in the right maxilla, anterior wall of the right maxillary sinus, right nasal bone, inferior wall of the orbit and right zygoma.


358 J U LY 2 01 7

was of a fi brous dysplasia-like lesion progressive in the region of the right CN V entry into the skull, suggesting this as the etiology of the pain.

At follow-up one month later, the patient had virtually complete resolution of pain with the use of baclofen. He did concurrently have discomfort in the right lower fi rst molar region, which had a large restoration in close proximity to the pulp. While it is possible that dental fi ndings could contribute to input along CN V, this appeared to be an incidental fi nding. It was suggested that the patient proceed with elective endodontics followed by a crown on this tooth as indicated.

Case FourA 64-year-old female was seen

on referral from her dentist for left-sided facial pain. The pain had started spontaneously two years prior as sharp, electric-like pain in her left cheek while washing her face. She initially saw her general dentist, who performed occlusal equilibrations, and after no relief, she was referred to an endodontist who performed endodontics on teeth Nos. 29–31. She began seeing a periodontist for dental cleanings on a four-month recall schedule. Despite dental treatment, she was still experiencing 30-second episodes of pain multiple times per day.

The patient had good overall health and excellent oral hygiene with regular dental visits and periodontal maintenance. She reported that she was gluten intolerant, with chronic diarrhea and anemia, and had a genetic Leiden factor V coagulopathy. Medications and supplements included calcium, vitamin D and iron and hormone replacement therapy.

Her pain was unilateral, involving her left cheek, maxilla and mandible

and posterior teeth. The pain was intermittent, although increasing in frequency over the prior six months to occur every hour. She described the pain mainly as sharp and electric but used pain descriptors such as throbbing, shooting, gnawing, tiring, tender, aching, exhausting and annoying. The pain limited her from chewing, drinking, kissing and washing her face. Triggering factors included use of an electric toothbrush, laughing and talking. Pain (8/10) awakened her during sleep and was present in the early morning.

At initial exam, she was diagnosed with TN with the need to rule out dental pain on her lower right molars. Her dentition was intact with excellent periodontal health. There was slight mobility and recession on her lower right molars with only minor occlusal attrition, but no history of clenching or grinding. She was started on carbamazepine (200 mg bid), sent for blood study, MRI/MR angiography and nuclear bone scan.

At follow-up three months later, she reported that her pain was almost eliminated with only mild sensitivity present one to two times per day. She reported slight fatigue following a glass of wine and reduction in carbamazepine dose to 100 mg bid was suggested. The clinical fi ndings and

response to carbamazepine supported a diagnosis of TN. At the next follow-up, six months after beginning carbamazepine, she had complete remission of pain with 100 mg bid without side effects. She had attempted to reduce this dose but pain recurred.

The MRI/MRA showed no vascular changes in the trigeminal ganglion as well as no changes in the CNS other than an incidental fi nding of an 11 mm pineal gland cyst. Lab studies were within normal limits and carbamazepine was at low therapeutic dosing.

At follow-up in an additional three months, she reported good pain control with occasional breakthrough, which she controlled by increasing her dosage of carbamazepine for a short period. Hence, the diagnosis of TN was confi rmed.

DiscussionThe cases presented highlight

the need to diagnose the cause of orofacial pain prior to irreversible dental procedures. In two of the cases, dental treatment was initiated without recognition of the neurologic symptoms. This emphasizes the need for comprehensive history and examination and accurate diagnosis before traditional dental intervention as well as the need to increase awareness of neurologic symptoms that can lead to misdiagnosis. Symptoms that may indicate neurologic pain include sharp, stabbing, intermittent pain with triggers of symptoms; numbness, tingling and burning pain should raise suspicion of nondental causes.

Further, these cases document several different potential causes of TN and demonstrate the need to investigate the underlying cause of the neurologic pain and determine the appropriate fi rst step in medical management. The potential complexities associated with medication management of TN are also demonstrated.

Symptoms that may indicate neurologic pain include sharp, stabbing, intermittent pain with triggers of symptoms.



J U LY 2 0 1 7 359

The fi rst case presented displayed characteristics of pain of odontogenic origin as well as neuralgia involving V3. The combined presentation and the potential overlap in symptoms led to challenges in diagnosis and management. The classic symptoms of TN, when recognized following referral, led to initial medical management with improvement confi rming TN as well as to specifi c imaging of the CN V with identifi cation of a vessel on the ganglion, ruling out MS and other conditions. Due to side effects associated with appropriate medication for TN and the fi ndings on MRI, specifi c surgical management was completed with resolution of TN pain. The surgical decompression of the vessel over the CN V root may allow the root to heal and remyelinate. The peripheral neuroinfl ammation present from C fi ber release of neuropeptides, such as Substance P and CGRP, may resolve after microvascular decompression surgery, decreasing pain.20 Completion of the endodontics was then necessary to treat the local dental condition. The history and fi ndings suggest that initial endodontic therapy may have been aggressive treatment; however, once initiated, completion of the dental procedure was needed. It is possible that the medical management of TN would have resolved the perceived persistent dental pain without need for endodontic therapy. Pain with light touch presented on multiple teeth initially, but the pain could not be localized to a certain tooth requiring root canal therapy, which should raise suspicion of a nondental cause. Although the pain quality was described as sharp, shooting pain stimulated in the teeth, there was no clinical swelling, no radiographic evidence of pathosis and no indication for endodontics at that time. Due to the history and presentation of symptoms,

it was necessary to complete a more thorough work up, investigate other etiologies and wait to see if the pain localized to a tooth before initiating endodontic therapy. If the teeth had been extracted, clearly pain would continue because the source of the pain was not treated and she would then have to address the need for dental prosthodontic management. Furthermore, the additional procedures could further aggravate the pain. Local anesthesia may block afferent signaling during treatment and is a helpful adjunct

during dental care; however, in an area of current or prior neurologic pain, the least invasive treatment should be provided.5 Dental prevention is important to reduce any future dental care needs for these individuals.

Although the second case presented with a complex medical history with multiple possible causes of chronic pain, a careful inspection of the details of the patient’s history of orofacial pain suggested the working diagnosis of TN. Multiple episodes of spontaneous, one-sided, electrical-type pain throughout the day are characteristic of TN. However, her pain was located in the V3 distribution, elicited by percussion to dentition and in the mental nerve distribution, therefore it was necessary to rule out pain of dental origin. It

is important to note that the patient also had other symptoms that were not explained radiographically or clinically by dental exam and further testing was necessary to arrive at a proper diagnosis. In this case, a complex medication protocol led to initial pain control without neurosurgical intervention, despite the fi ndings of vascular compression on imaging of the CN V.

The third case presented with the classical TN symptoms of unilateral, sharp, stabbing pain in the V3 area. When the symptoms were correctly identifi ed as characteristic of TN, the appropriate subsequent work-up could be performed to support the diagnosis and proper treatment could be initiated. The CT scan revealed the abnormal bone thickening that was compressing the entry of the trigeminal ganglion into the skull. Although the patient did have concurrent dental disease, the history of symptoms and clinical fi ndings allowed the physician to recognize a separate regional etiology of the patient’s orofacial pain. The pain in the lateral tongue as well as along the labial canine gingiva are details in the patient’s history that should not be overlooked when attempting to correctly diagnose this patient, as this is evidence of TN manifesting intraorally as opposed to odontogenic pain. This case is an example of bone growth most likely due to fi brous dysplasia and successful pain control with medications, thereby avoiding the risk of surgery, which is known to potentially stimulate progression of fi brous dysplasia.

The fourth case was ma naged exclusively with carbamazepine. The patient presented initially to a dentist with pain in and around her teeth, however, dental treatment did not resolve her symptoms. In fact, initial symptoms did not indicate a dental

If the teeth had been extracted, clearly pain would continue because the source of the pain was not treated.


360 J U LY 2 01 7

etiology. The allodynia (painful response to nonpainful stimulus) and pain triggered while washing her face are not consistent with a dental cause. MRI fi ndings were negative, and the success of carbamazepine confi rmed her diagnosis of TN.

Carbamazepine is commonly considered the fi rst-line therapy for management of TN. Regular lab studies to monitor blood levels of a drug are available, allowing assessment of absorption and of the therapeutic range of the drug. Use of this medication requires follow-up of complete blood count and liver function tests. Carbamazepine is associated with a large number of side effects, including dizziness, nausea, drowsiness and loss of balance as the patient adjusts to the medication; nonallergic skin rash, a common side effect, may also occur.

Recognition and accurate diagnosis is critical in leading to necessary and appropriate care. Clinical characteristics of orofacial pain of different etiologies are summarized in TABLES 1 and 2. Pain diagnosis, even of an odontogenic nature, may be challenging. However, due to the uncommon incidence of neuralgia and neuropathy, the diffi culty is increased. It is the dentist’s professional obligation to not only recognize and treat dental pathosis when it presents but to recognize when dental disease is not the cause and to direct the patient to follow up with the appropriate specialists for further evaluation. The dentist must always be aware of the need to make diagnosis based upon thorough history taking, clinical fi ndings and diagnostic testing as indicated prior to proceeding with an intervention. Diagnosis of specifi c dental causes of pain is required before consideration of irreversible, invasive dental procedures. ■

REFERENCES

1. Zakrzewska JM, Linskey ME. Trigeminal neuralgia. BMJ 2014 Feb 17;348:g474. doi: 10.1136/bmj.g474.2. Scrivani SJ, Mathews ES, Maciewicz RJ. Trigeminal neuralgia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005 Nov;100(5):527–38.3. Love S, Coakham H. Trigeminal Neuralgia: Pathology and Pathogenesis. Brain 2001 Dec;124 (Pt 12):2347–360.4. Maarbjerg S, Wolfram F, Gozalov A, Olesen J, Bendtsen L. Significance of neurovascular contact in classical trigeminal neuralgia. Brain 2014;138(Pt 2):311–19.5. Klasser GD, Gremillion HA, Epstein JB. Dental treatment for patients with neuropathic orofacial pain. J Am Dent Assoc 2013;144(9):1006–8.6. Treede RD, Jensen TS, Campbell JN, Cruccu G, Dostrovsky JO, et al. Neuropathic pain: Redefinition and a grading system for clinical and research purposes. Neurology 2008 Apr 29;70(18):1630–5. Epub 2007 Nov 14.7. Benoliel R, Kahn J, Eliav E. Peripheral painful traumatic trigeminal neuropathies. Oral Dis 2012 May;18(4):317-32. doi: 10.1111/j.1601-0825.2011.01883.x. Epub 2011 Dec 27.8. Gregg JM. Neuropathic complications of mandibular implant surgery: Review and case presentations. Ann R Austral Coll Dent Surg 2000 Oct;15:176–80.9. Valmaseda-Castellon E, Berini-Ayetes L, Gay-Escoda C. Inferior alveolar nerve damage after lower third molar surgical extraction: A prospective study of 1,117 surgical extractions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001 Oct;92(4):377–83.10. Fried K, Bongenhielm U, Boissonade FM, Robinson PP. Nerve injury-induced pain in the trigeminal system. Neuroscientist 2001 Apr;7(2):155–65.11. Polycarpou N, Ng YL, Canavan D, Moles DR, Gulabivala K. Prevalence of persistent pain after endodontic treatment and factors affecting its occurrence in cases with complete radiographic healing. Int Endod J 2005 Mar;38(3):169–78.12. Benoliel R, Birenboim R, Regev E, Eliav E. Neurosensory changes in the infraorbital nerve following zygomatic fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005 Jun;99(6):657–65.13. Jasskelainen SK, Teerijoki-Okas T, Virtanen A, Tenovuo O, Forssell H. Sensory regeneration following intraoperatively verified trigeminal nerve injury. Neurol 2004 Jun8;62(11):1951–7.14. Al-Sabbagh M, Okeson JP, Khalaf MW, Bhavsar I. Persistent pain and neurosensory disturbance after dental implant surgery: Pathophysiology, etiology and diagnosis. Dent Clin North Am 2015 Jan;59(1):131-42. doi: 10.1016/j.cden.2014.08.004. Epub 2014 Oct 11.15. Benoliel R, Heir GM, Eliav E. Painful traumatic trigeminal neuropathy. Pain: Clinical Updates 2014;22(4):1–5.16. Maarbjerb S, Gozalov A, Olesen J, Bendtsen L. Trigeminal Neuralgia — a Prospective Systematic Study of Clinical Characteristics in 158 Patients. Headache 2014 Nov–Dec;54(10):1574–82. doi: 10.1111/head.12441. Epub 2014 Sep 18.17. Renton T, Dawood A, Shah A, Searson L, Yilmaz Z. Post-implant neuropathy of the trigeminal nerve. A case

series. Br Dent J 2012 Jun 8;212(11):E17. doi: 10.1038/sj.bdj.2012.497.18. Steinberg MJ, Kelly PD. Implant-related nerve injuries. Dent Clin North Am 2015 Apr;59(2):357–73. doi: 10.1016/j.cden.2014.10.003. Epub 2014 Dec 15.19. Von Eckardstein KL, Keil M, Rohde V. Unnecessary dental procedures as a consequence of trigeminal neuralgia. Neurosurg Rev 2015 Apr;38(2):355–60.20. Nurmikko T, Haggett C, Miles J. Neurogenic vasodilation in trigeminal neuralgia. Prog Pain Res Manag 2000;16:747–56.

THE CORRESPONDING AUTHOR, Alexa C. Martin, DMD, can be reached at [email protected].



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AUTHORS

Mariela Padilla, DDS, MEd, is the assistant director of online programs at the Herman Ostrow School of Dentistry of USC.Confl ict of Interest Disclosure: None reported.

Robert Alcala Utsman, DDS, is an assistant professor and director of research at Universidad Latinoamericana de Ciencia y Tecnología (ULACIT) in San José, Costa Rica.Confl ict of Interest Disclosure: None reported.

Hemifacial Spasm: A Case Report and Review of LiteratureMariela Padilla, DDS, MEd; Robert Alcala Utsman, DDS; and María José Brenes Castillo, DDS

A B S T R AC T A hemifacial spasm is characterized by the presence of tonic or clonic, intermittent and involuntary unilateral contractions of the muscles supplied by the facial nerve, usually around the eyes, cheeks, mouth and neck. A case is presented in a patient with twitching in the right lower eyelid with irradiated pain in the temple and upper lid edema. Causative factors and management strategies are emphasized to enhance the recognition and understanding of this condition.

Ahemifacial spasm is a condition characterized by the presence of tonic or clonic, intermittent and involuntary unilateral contractions of

the muscles supplied by the facial nerve, usually starting around the eyes before progressing to the bottom of the cheek, mouth and neck.1 Although it affects mostly females, there are reports of the condition in males. The condition has been reported mainly on the left side with a progressive evolution starting in the orbicularis oculi and orbicularis oris muscles.2,3 These symptoms can be motor or nonmotor, producing movements and autonomic signs. The intensity of this disorder can vary and intensify with factors such as stress, intense light and masticatory movements. On average it affects people around the age of 44 and incidence has been reported in 9.8–11/100,000 persons.4,5

The cause seems to be of neuronal origin and is most often attributed

to compression of the facial nerve or damage to the brain stem. In cases where there is a confi rmed lesion, treatment is decompression or removal of structures. However, sometimes no specifi c cause is identifi ed. This complicates the therapeutic approach, which should be directed to the recovery of function and aesthetics.6

Other conditions reported as causative agents are the aneurysm spasm,7 occupying masses8 and neuronal hyperactivity.9–10

Dentists have a role in the diagnostic process due to the possibility that the initial symptoms are related to discomfort and dysfunction of the jaws. Additionally, episodes of spasm can cause damage to oral tissue, making the dentist an important part of the treatment plan. The purpose of this article is to review the signs and symptoms, as well as management of hemifacial spasms. This case of a nonspecifi c cause is presented to enhance understanding of hemifacial spasms and the treatment approach.

María José Brenes Castillo, DDS, is a graduate of Universidad Latinoamericana de Ciencia y Tecnología (ULACIT) and works in private practice in Costa Rica.Confl ict of Interest Disclosure: None reported.


362 J U LY 2 01 7

Case ReportE.C.F. is a 62-year-old male who was

seen at the Orofacial Pain Clinic, Dentus Group in Costa Rica. His chief complaint was a twitching in the right lower eyelid (FIGURES 1A, 1B), with irradiated pain in the temple and upper lid edema that he had experienced for four years but that had worsened the last two years. Imaging studies (CAT scan and MRI) were noncontributory. The cranial nerves examination showed a CNII with smooth extraocular movements, no double vision and CNIII, CNIV and CNVI within normal limits. There was equal pupil reaction to light. CNV had symmetrical and normal response to light touch and pinprick with normal motor function. Regarding facial expression, there was lacrimation and ptosis in the right eye and asymmetrical pull of the upper lip on the right side. The patient’s forehead was fl at. There was a reduction of hearing of the right side, which was confi rmed by audiometry. Palatal elevation was equal and the uvula was located at the midline. His fi nger-nose coordination was normal. His masticatory muscles were not tender to palpation, range of jaw motion was normal and there were no intraoral lesions. The differential diagnosis included benign essential blepharospasm,

Bell’s palsy, trigeminal neuralgia, damage in the facial nerve and cluster-tic syndrome. However, based on the clinical presentation and evolution, a diagnosis of hemifacial spasm was favored because he had had episodic pain accompanied by ptosis and twitching of the eye.

He had been treated by a neurologist and an otolaryngologist and had pharmacotherapy (carbamazepine 200mg qid, pregabalin 150 mg hs, sodium valproate 500 mg hs, clonazepam 0.5 mg hs, lorazepam 1 mg hs), but the medications were discontinued either because of the side effects at the indicated doses or because the patient got no relief. He also received a series of three botulinum toxin injections four months apart in the temporalis and orbicularis oculi. No signifi cant changes with these approaches were reported.

Considering the possible contribution of the autonomous nervous system, a calcium channel blocker (verapamil 160 mg) was prescribed together with a muscle relaxant (cyclobenzaprine, 10 mg hs) to address the stress-triggered contraction. A series of four physical therapy sessions were performed, including the use of electric stimulation, ultrasound and facial massage. None of the described treatments produced a change in the symptoms.

The case was presented in a roundtable session of neurologists, and a decompression surgery was recommended considering the possibility of compression of the trigeminal root not evident in the MRI of the cranial region. However, considering the risks of the surgery and the uncertainty of the results, the patient declined this procedure. In order to help the patient with the episodic twitching, biofeedback intervention was suggested with the hope of him being able to control his musculature. The patient is now under the care of the psychologist.

DiscussionAs in this case and many others, the

causes of the disease are not clear and may be multiple,11 including vascular compression, movement disorders, neuronal demyelination and the presence of other diseases. One of the most common theories is that the facial nerve is pressed by blood vessels at the level of output from the nerve to the central nervous system.12 This etiology is also supported by other studies.13 Castiglione et al.8 state the facial nerve compression is by the lower anterior cerebellar artery, although one must rule out a pathological condition. Another possible cause of facial nerve compression has been linked to a blood defect in the sensory root of the nerve.14 An alternative theory is the possibility of artery and vein compression at the spinal cord level.15

Genetic and psychological factors have also been linked to hemifacial spasms,14 and in this case there was no family history reported. In cases with atypical features, psychogenic etiologies should be considered.14 Although the patient in this case reported no psychogenic conditions, the psychological impact of this

s p a s m

FIGURES 1. The pictures show an interval of two seconds, where the patient goes from open eyes to a sudden twitch of the right eye. (Patient consented to the use of these photos.)

FIGURE 1A . FIGURE 1B .


J U LY 2 0 1 7 363

condition is very important because the patient tends to move away from daily activities as a result of functional and aesthetic alterations that occur with the spasms.16 Interference with social life has been reported in up to 90 percent of the cases, leading to isolation and depression.17 In this case, the patient reported an impact on social and daily activities because of the spasms that could occur at any moment. For example, if a spasm occurred when he was driving he would have to pull over because his vision was affected.

There was a documented coexistence of hemifacial spasms with migraine headaches among the cases reported in the literature. Spasms can behave as activators thus complicating the management of headaches; however, they are not a causal element if one has predisposing features.18 The patient in this case did not have migraine or other headache issues.

As with any medical condition, the diagnosis process should include history, clinical examination and the use of additional diagnostic tools. In this case, a bone scan and neuroimaging enabled us to rule out potential underlying conditions that were unremarkable in the findings. In the case of a hemifacial spasm, other imaging tools can be useful. Functional magnetic resonance imaging can detect changes in neuronal activity. Voxel-based morphometry can assess changes in gray matter, thalamus, putamen and dorsolateral spinal region, which are areas that have an impact on motor control.19

Treatment depends on the diagnosis and identifi cation of causal or etiological elements. In general, hemifacial spasms are addressed with surgical options, radio frequency, pharmacotherapy, a behavioral

approach and complementary or alternative techniques. In this case, pharmacotherapy was one of the fi rst lines of treatment, although medications tend not to be effective long-term treatments of hemifacial spasms. Baclofen, clonazepam, carbamazepine, gabapentin, phenytoin or orphenadrine are considered fi rst-line medications that may be used to provide transient relief.20,21 Membrane stabilizers or drugs related to gamma aminobutyric acid (such as carbamazepine and

gabapentin), which can be used as both monotherapy and complementary to other techniques, have been described as an alternative therapy.21,6

Botulinum toxin is also reported as an alternative therapy, but its effectiveness is limited in controlling symptoms.4 It has been indicated that after application of botulinum toxin, there is an improvement ranging from eight days to 14.8 weeks in approximately 73.7 percent of patients.22 The most common adverse effects reported were erythema (5 percent), facial asymmetry (3.6 percent), ptosis (3.4 percent) and diplopia (3.2 percent), which are conditions that sometime accompanied hemifacial spasms from the start.5 It is important to point out that the botulinum toxin effect is temporary; the procedure must

be repeated periodically. In this case, pharmacotherapy has been ineffective in managing the patient’s symptoms.

Microvascular decompression is the surgical treatment of choice for hemifacial spasm. It is considered a safe and effective alternative, although complications as a result of the procedure include facial paralysis and hearing loss.2,3,7,23 Other techniques have been reported that separate the vessels, such as placing Tefl on between the vein and facial nerve. This procedure generally improves the condition, but there is a lengthy recovery time of up to 10 months.15,24,25 Sometimes it is necessary to repeat these procedures because of small vessels that are not identifi ed in the fi rst approach.26 Improvement because of these surgical procedures can last up to fi ve years.9 The use of radiofrequency is another alternative that damages the nerves directly by reducing their fi repower. This approach is considered conservative and has been described for refractory spasms and in cases where decompression surgery has not been effi cient.27

Complementary therapies, such as acupuncture, biofeedback and facial massage, have also shown benefi ts.18,28 Biofeedback interventions using electromyography have suggested that the length of the spasms are reduced but not the frequency.28 Although there are insuffi cient data on its effectiveness, it has been observed that individuals whose symptoms have greater severity are the ones who tend to seek these alternatives. However, in this case physical therapy, including the use of electric stimulation, ultrasound and facial massage, was unsuccessful. The biofeedback and psychological intervention results in this case are too early to tell.

Interference with social life has been reported in up to 90 percent of the cases, leading to isolation and depression.


364 J U LY 2 01 7

ConclusionsIn the case presented, the patient

had experienced hemifacial spasms for more than four years. The necessity of implementing a detailed history and comprehensive examination with the adjunctive diagnostic instruments, such as radiographic imaging, cannot be overemphasized. Imaging studies have been noncontributory and treatments to date unsuccessful. The cause in this case, although not clear, appears to be of neuronal origin. In these cases, it is important that dentists have knowledge of the treatment and diagnostic processes to correctly guide patients. ■

ACKNOWLEDGMENT

The authors thank Dr. Robert Merrill for taking the time off his trip to Costa Rica to give his input on this case.

REFERENCES

1. Degirmenci E, Oguzhanoglu A, Atalay N, Sahin F. Hemifacial spasm and postural abnormalities; clinical and posturographical analyses. Acta Neurol Belg (2015) 115:317. doi:10.1007/s13760-014-0358-z.2. Soriano H, Vales O, Revuelta R. Hemifacial spasm: 20-year surgical experience, lesson learned. Surg Neurol Int 2015 May 20;6:83. doi: 10.4103/2152-7806.157443. eCollection 2015.3. Liu J, Yuan Y, Fang Y, Zhang L, Xu XL, Liu HJ, Zhang Z, Yu YB. Microvascular decompression for atypical hemifacial spasm: Lessons learned from a retrospective study of 12 cases. J Neurosurg 2016 Feb;124(2):397–402. doi: 10.3171/2015.3.JNS142501. Epub 2015 Sep 4.4. Lu AY, Yeung JT, Gerrard JL, Michaelides EM, Sekula R Jr., Bulsara KR. Hemifacial spasm and neurovascular compression. Scientifi c World J 2014:349319. doi: 10.1155/2014/349319. Epub 2014 Oct 28.5. Rosenstengel C, Matthes M, Baldauf J, Fleck S, Schroeder H. Hemifacial spasm: Conservative and surgical treatment options. Dtsch Arztebl Int 2012 Oct;109(41):667–73.6. Abbruzzese G, Berardelli A, Defazio G. Hemifacial spasm. Handb Clin Neurol 2011; 100:675–80.7. Lee MH, Jee TK, Lee JA, Park K. Postoperative complications of microvascular decompression for hemifacial spasm: Lessons from experience of 2,040 cases. Neurosurg Rev 2016 Jan;39(1):151–8; discussion 158. doi: 10.1007/s10143-015-0 666-7. Epub 2015 Sep 18.8. Castiglione M, Broggi M, Cordella R, Acerbi F, Ferroli P. Immediate disappearance of hemifacial spasm after partial removal of pontomedullary junction anaplastic astrocytoma: Case report. Neurosurg Rev 2015 Apr;38(2):385–90.9. Chang WS, Chung JC, Kim JP, Chung SS. Delayed recurrence of hemifacial spasm after successful microvascular decompression: Follow-up results at least fi ve years after surgery. Acta Neurochir (Wien) 2012

Sep;154(9):1613–9 doi: 10.1007/s00701-012-1424-z. Epub 2012 Jul 28.10. Barahona-Hernando R, Cuadrado ML, García-Ptacek S, Marcos-de-Vega A, Jorquera M, Guerrero A, Ordás CM, Muñiz S, Porta-Etessam J. Migraine-triggered hemifacial spasm: Three new cases. Cephalalgia 2012 Mar;32(4):346–9.11. Kongsengdao S, Kritalukkul S. Quality of life in hemifacial spasm patient after treatment with botulinum toxin A; a 24-week, double-blind, randomized, crossover comparison of Dysport and Neuronox study. J Med Assoc Thai 2012 Mar;95 Suppl 3:S48–54.12. Park JS, Koh EJ, Choi HY, Lee JM. Characteristic anatomical conformation of the vertebral artery causing vascular compression against the root exit zone of the facial nerve in patients with hemifacial spasm. Acta Neurochir (Wien) 2015 Mar;157(3):449–54.13. Liang Q, Shi X, Wang Y, Sun Y, Wang R, Li S, Chang JW. Microvascular decompression for hemifacial spasm: technical notes on pontomedullary sulcus decompression. Acta Neurochir (Wien) 2012 Sep;154(9):1621–6.14. Yaltho TC, Jankovic J. The many faces of hemifacial spasm: Diff erential diagnosis of unilateral facial spasms. Mov Disord 2011 Aug 1;26(9):1582–92.15. Swiątnicki W, Heleniak M, Komuński P. Hemifacial spasm caused by the cross-compression of the vertebral artery loop — a case-centered report of a stitched sling retraction technique. Bull Soc Sci Med Grand Duche Luxemb 2014;(3):73–82.16. Bao F, Wang Y, Liu J, Mao C, Ma S, Guo C, Ding H, Zhang M. Structural changes in the CNS of patients with hemifacial spasm. Neuroscience 2015 Mar 19;289:56–62.17. Rudzińska M, Wójcik M, Malec M, Grabska N, Szubiga M, Hartel M, Szczudlik A. Factors aff ecting the quality of life in hemifacial spasm patients. Neurol Neurochir Pol 2012 Mar-Apr;46(2):121–9.18. Peeraully T, Hameed S, Cheong PT, Pavanni R, Hussein K, Fook-Chong SM, Tan EK. Complementary therapies in hemifacial spasm and comparison with other movement disorders. Int J Clin Pract 2013 Aug;67(8):801–6.19. Tu Y, Yu T, Wei Y, Sun K, Zhao W, Yu B. Structural brain alterations in hemifacial spasm: A voxel-based morphometry and diff usion tensor imaging study. Clin Neurophysiol 2015 Aug 22. pii: S1388-2457(15)00754–3.20. Daniele O, Caravaglios G, Marchini C, Mucchiut L, Capus P, Natale E. Gabapentin in the treatment of hemifacial spasm. Acta Neurol Scand 2001;104:110–112.21. Li XH, Lin SC, Hu YF, Liu LY, Liu JB, Hong YC. Effi cacy of carbamazepine combined with botulinum toxin A in the treatment of blepharospasm and hemifacial spasm. Eye Sci 2012 Dec; 27(4):178–81.22. Sorgun MH, Yilmaz R, Akin YA, Mercan FN, Akbostanci, MC. Botulinum toxin injections for the treatment of hemifacial spasm over 16 years. J Clin Neurosci 2015 Aug;22(8):1319–25. 23. Thirumala P, Frederickson AM, Balzer J, Crammond D, Habeych ME, Chang YF, Sekula RF Jr. Reduction in high-frequency hearing loss following technical modifi cations to microvascular decompression for hemifacial spasm. J Neurosurg 2015 Oct;123(4):1059–64.24. Feng BH, Zheng XS, Wang XH, Ying TT, Yang M, Tang YD, Li ST. Management of vessels passing through the facial

nerve in the treatment of hemifacial spasm. Acta Neurochir (Wien) Nov;157(11):1935–40; discussion 1940. doi: 10.1007/s00701–015–2562-x. Epub 2015 Sep 2.25. Oh CH, Shim YS, Park H, Kim EY. A case of hemifacial spasm caused by an artery passing through the facial nerve. J Korean Neurosurg Soc 2015 Mar;57(3):221–4.26. Zhong J, Xia L, Dou NN, Ying, TT, Zhu J, Liu MX, Li ST. Delayed relief of hemifacial spasm after microvascular decompression: Can it be avoided. Acta Neurochir (Wien) 2015 Jan;157(1):93–8.27. Park HL, Lim SM, Kim TH, et al. Intractable hemifacial spasm treated by pulsed radiofrequency treatment. Korean J Pain 2013 Jan;26(1):62–4.28. Stanwood JK, Lanyon RI, Wright MH. Treatment of severe hemifacial spasm with biofeedback. A case study. Behav Modif 1984 Oct;8(4):567–80.

THE CORRESPONDING AUTHOR, Robert Alcala Utsman, DDS, can be reached at [email protected].

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RM Matters

Patient satisfaction is the ultimate goal of any dentist and most will do whatever it takes to keep their patients happy, confi dent and pain-free. But what

happens when a patient’s expectations are unrealistic? What if a patient is impossible to please? At what point should you say “enough is enough”?

Patients often walk into a dental offi ce with specifi c ideas about how their care should be delivered and how the end result should look. When those expectations are not met, dentists can be left with an uncomfortable choice: try again or throw their hands up in defeat.

This is especially common with restorations. All too often, patients have unrealistic expectations regarding the size, shape and color of their teeth. Patients don’t always consider the technical and clinical limitations of restorations, yet they expect dentists to deliver nonetheless.

The Dentists Insurance Company reports a case in which a dentist made an anterior bridge for a patient. The patient was extremely particular and was unhappy with the shade, so the dentist remade the bridge at the patient’s request. The patient was still not satisfi ed, so the dentist attempted to remake the bridge for the third time. Although the patient initially approved the aesthetics of the bridge, she did so only verbally. There was no written approval.

While the permanent bridge was being fabricated, the patient reported that her provisional bridge was in need of repair. She made an appointment to have it fi xed but was an hour late to her appointment and failed to call the offi ce in advance. The dentist was unable to see her due to other appointments. The patient became angry and left the offi ce without scheduling another appointment. The

Just Say No: How to Handle Demanding PatientsTDIC Risk Management Staff

patient called the next day and demanded a full refund, stating she was not returning. The dentist was willing to provide a full refund in an attempt to resolve the matter and avoid further escalation.

Had the dentist obtained the patient’s written approval at the delivery of the bridge, this situation could have been avoided. TDIC recommends dentists get written aesthetic approval on all restorations, including bridges, dentures, partials, crowns and veneers. A verbal approval is not enough. In addition, a written form demonstrates that the

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patient accepted the restoration. Dentists should abide by the assumption that “if it’s not documented, it did not occur.” TDIC has sample aesthetic approval forms available at tdicinsurance.com.

“During the initial appointment, it is important to determine whether the patient is realistic in his or her treatment expectations,” said Taiba Solaiman, senior risk management analyst with TDIC. “Look for red fl ags, such as a patient bringing in pictures of celebrities or photos of the patient’s high school graduation 20 years earlier.”


368 J U LY 2 01 7

Another case reported to TDIC illustrates the importance of heeding red fl ags. In this case, a 40-year-old patient presented to a general dentist for a consultation regarding full mouth reconstruction. The patient had provisionals placed by another dentist but refused to go back to the treating dentist because the dentist failed to meet his esthetic demands.

The general dentist agreed to treat the patient, dismissing his concerns that the patient already revealed a prior failed doctor-patient relationship. The treatment coordinator went over the

treatment plan and fi nancial arrangement with the patient and the patient paid the entire treatment fee up front.

The dentist worked with a reputable lab, but the patient couldn’t agree with the wax-up. The patient eventually agreed to the wax-up and the lab fabricated the provisionals. When the lab was unable to meet the patient’s aesthetic demands, the patient proposed switching labs to the one that his previous dentist worked with. The dentist agreed, despite not having any prior experience of working with this lab.

In the meantime, the patient was becoming impatient with the amount of

time involved to fabricate the provisionals and demanded the treatment to be provided at a discount. The dentist tried working with yet a third lab, but that lab was also unable to meet the patient’s expectations. At this point, the patient was adamant about receiving all of his money back, as he had lost confi dence in the dentist. TDIC reviewed the history of the case with the dentist and agreed that the best approach would be to refund the patient’s money. TDIC provided the dentist with a release of liability form confi rming the agreement and suggested the patient continue treatment elsewhere.

Turning away overly demanding patients is the best way to avoid these scenarios in the fi rst place. Don’t be infl uenced by the potential income that could be derived from a case; consider the possibility of losing money in the long run. You are not obligated to accept every patient who walks through the door. Establish boundaries, clearly outline the process and be upfront with patients about what is and isn’t possible.

“At the beginning of the case, ask yourself, ‘Is this patient a good candidate for the treatment he or she desires? Can I achieve the results the patient is anticipating? Will the outcome mirror what the patient wants?’” Solaiman advises. “Answers to these questions will help determine the patient’s treatment expectations, if treatment is appropriate and if you should accept the case.” ■

TDIC’s Risk Management Advice Line at 800.733.0633 is staffed with trained analysts who can answer patient satisfaction and other questions related to a dental practice.

J U L Y 2 0 1 7 R M M A T T E R S

“Matching the Right Dentist tothe Right Practice”

4166 PALO ALTO GPWell established practice serving young professionals andtheir families looking to transition to a confident dentistcapable of handling a busy schedule. $1M+ average GR.Asking $800K.

4155 SAN MATEO GPGeneral family and restorative practice with specialemphasis on esthetic dentistry. Established over 38 years indesirable San Mateo neighborhood. 1,060 square foot hasbeen continuously upgraded and has 3 fully-equipped opsand 3 digital x-ray units. Average gross receipts $558K+with just 3 doctor days and 3 hygiene days per week.100% of patients are private pay. Asking $379K.

4145 ROSEVILLE GPWell-established GP offering 27+ years of goodwill. Ownerrelocating out of the area. General & Cosmetic Practicewith 6 fully equipped ops. Lots of upgraded/newerequipment. Opportunity to purchase single story 2,700 sq.ft. stand-alone professional bldg. Asking price for thePractice $520K.

4129 PETALUMA GPGP located in stunning 1,856 sq. ft. seller owned facility.State-of-the-art office includes 6 ops, staff lounge,reception area, private office, business office, lab area,sterilization area, consult room, separate storage area,bathroom plus private bathroom. Asking $525K.

4169 NAPA GPGeneral practice in seller owned building in a prime location.Remodeled, state-of-the-art, 2,000 square foot, beautifuloffice with 7 ops. Experienced & dedicated staff. Averagegross receipts $1.1M+ with just 3 doctor days/week & 8hygiene days/week. Over 2,000 loyal patients. Asking$817K. Owner will work back for approx. 2 years.

4168 SAN JOSE GPGreat location with ez freeway access in the Almaden Valleyarea of San Jose off Almaden Expressway/Branham Lane.Approx 150-200 active patients (no Delta Premier). 45+years of goodwill and long term staff willing to stay withBuyer. Restorative practice with most specialties referredout. Priced to sell at $125K.

4093 SAN JOAQUIN ORTHOEstablished over 35 years with a solid reputation, nearseveral referral sources in seller owned building. 2,500 sq.ft. office with 7 chair open bay in professional center. Avg.Gross Receipts $763K. Asking $561K. The building isavailable to purchase as well for $608K.

4108 HUMBOLDT COUNTY GPWell-established, high performing general practice boasts 6fully equipped ops. in 2,900 sq. ft. free standing office w/Digital X- ray, 2 platinum Dexis sensors, & Cerec Omnicam& MCXL units. Loyal & stable pt. base in charmingcommunity, w/ a small town feel. Perfect for a dentist whowants to escape the grind and live along the coastline.2016 GR $1.5M+. Seller willing to help for smoothtransition. Asking $995K.

4171 PLEASANTON GPPut the "pleasant" in Pleasanton. Well-established, 25 yearfamily practice in a rapidly growing community with smalltown flavor. Seasoned and dedicated staff. Stable patientbase. Beautifully remodeled office with 5 ops., receptionarea, business office, private office, staff lounge anddedicated parking. Seller transitioning to retirement, working4 doctor days per week. 5 year average GR $509K+.Seller owned 1,700 square foot condominiumized suite forsale with practice. Asking price for practice $313K. Price forbuilding TBD.

4127 MENLO PARK GPGP offering 35+ yrs of goodwill, this gem on the Peninsulais truly a find. Incredible downtown location in upscaleoffice with ample onsite parking. 4 ops in 950 sq. ft.2016-2014 average GR $567K with average adj. net of$156K. Most services other than crown & bridge arereferred out. 750+ active patients. 4 hygiene days a weekgenerate 40-45% of the revenue. Owner will help for asmooth transition. Resume must be provided. Asking$417K.

4150 SANTA CRUZ COUNTY GPSeller retiring from successful 33 year general practice. Fee-for-service only practice. Fully-equipped 4 op facility inbeautiful, remodeled Seller owned building. Asking 654K.Buliding also for sale.

UPCOMING:SANTA ROSA GPSONOMA COUNTY PERIO

P (650) 362-7004 F (650) 362-7007www.carrollandco.info [email protected]

Carroll & CompanyP (650) 362-7004F (650) [email protected] #00777682

Mike Carroll Pamela Carroll-Gardiner

CARROLL& C O M P A N YC

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6126 FRESNO Located at busy intersection. Collected $616,000 with profits of $364,000. 4-Ops.

6125 OAKLAND Firmly entrenched in one of the most vibrant urban settings in the Bay Area. Collections average $735,000 per year. High income zip code with well employed Millennials next door. 10+ new patients per month. Digital and paperless.

6124 SAN RAMON 100% Out-of-Network. 5- ps. 6-days of Hygiene. $700,000 per year performer.

6122 SANTA CLARA Great exposure, fantastic curb appeal. Office just remodeled. 5-Ops. 2016 topped $700,000 on 4-day week. Perfect platform to operate 6-days a week. With focus and youthful enthusiasm, practice easily tops $1+ Millionyear in short order.

6121 NAPA VALLEY FAMILY PRACTICE Highly respected community asset. Collections last 5-years have averaged $1.28 Million per year. Beautiful facility. Condo optional purchase.

6120 OAKLAND’S PIEDMONT AREA Highly coveted area. Right off Highway 13. 3-days of Hygiene. 4-Ops with 5th available. 2016 collected $650,000+.

6119 NORTH BAY ORTHO Desirable family community. Best technology, cone beam and paperless. Owner works part-time. Revenue streams averaged $775,000/year in past. Strong profits. Does no marketing to local Dental Community.

6118 SAN FRANCISCO’S EAST BAY Forty percent partnership in well positioned and branded practice. 2016 produced $2.64 Million collected $2.53 Million, reflecting 10% improvement over 2015. Full complement of specialties. 300+ new patients in 2016. 6-month Trial Association wherein interested Candidate shall see ability to $350,000+ per year.

6112 HEALDSBURG Ideal as part-time practice in desirable locale or nice foundation to grow. 100% Out-of-Network. 2016 topped $210,000 in collections. Full Price $30,000.

6107 EUREKA 100% Out-of-Network with insurance industry. 2016 collected $930,000+ on Doctor’s 20-hour week. Doctor's schedule booked 3-months out. 7+ days of Hygiene. Highly respected. Full Price $250,000. Condo is optional purchase.

6098 WEST PETALUMA Petaluma has become the business center of the North Bay! Business parks are growing and young families are drawn to this great family community per unique amenities of this istoric iver ity. Collected $468,000 with Profits of $212,500. 4-days of Hygiene.

6089 MOUNT SHASTA Small town living renowned for outdoor lifestyle. 3-day week collected $950,000. Very strong bottom line. Digital including Pano. Full Price $350,000.

ESNO Located at busy intersection. Collected

NORTHERN CALIFORNIA(415) 899-8580 – (800) 422-2818

Raymond and Edna [email protected]

California DRE License 1422122

SOUTHERN CALIFORNIA(714) 832-0230 – (800) 695-2732Thomas Fitterer and Dean George

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California DRE License 324962

ANTELOPE VALLEY Prior tenant grossed $1.8 Million. 60,000 autos pass this intersection each day. $80 Billion in new government contracts will make this the highest growth area in SoCal for next 10-years. New DDS overwhelmed. Will work back for MSO or Specialist to build to $1.5 Million. Renovated 8 Op office. Working Owner will net $500,000 at $1.5 Million, and $800,000 when Grossing $2 Million. BELLFLOWER Starter or 2nd office. Low rent. Do $500,000+ first year. Lots of patients. 6 Ops. Full Price $195,000.CERRITOS – EMERGENCY SALE Grossing $450,000. 3 Hygiene days. Digital with Pano. Well-equipped for Implants. Full Price $350,000.DIAMOND BAR 5 Ops. Grosses $500,000.GLENDALE High identity corner location. Absentee Seller. 6 ps plus separate 850 sq. ft. Grosses $1 Million. Refers do, OS and mplants. Full Price $950,000.INLAND EMPIRE - EMERGENCY SALE Shopping Center. Operated by part-time Associate. Fantastic staff. Grossing $350,000. Owner-Operator will do $500,000+. 5 Ops plumbed, 3 equipped. Gorgeous office. Full Price $350,000.INLAND EMPIRE - EMERGENCY SALE High identity Target Center. Grosses $1 Million. No marketing. 5 days hygiene. 200,000 autos pass daily. Recently renovated at cost of $300,000. Full Price $950,000.LAKE ELSINORE - HMO Established 40 years. Popular Seller wants to work back 2 days. Grossing $550,000. Lots of room to go to $800,000 first year. 6 Ops. Low rent.LOS ANGELES BEACH CITY Grossing $2.4 Million. Private & PPO. Building available. Seller requires work back contract. Take home Net of $1 million. Full Price $2.4 Million. Bank approved Financing.

ORANGE COUNTY BEACH CITY - HMO Grossing $4.4 Million at two locations. Cap checks $23,000 per month. Absentee Owner. Full Price $4.4 Million. Hands-on Owner will do $5.5 Million.PEDO - PASADENA AREA Refers 30-to-40 ortho patients month. Grossing $450,000. Low overhead. Fantastic for GP Group. Full rice $390,000. Building available.RIVERSIDE Location to share. 4- ps, nice corner suite. Share $1,500

rent. Investment required or Seller willing to sell facility and work-back. Many options. Full Price $90,000.SAN DIEGO Grosses $1.8 Million.SAN DIEGO COUNTY Interstate 15 and Highway 76. Gorgeous office. Grosses $600,000.SAN FERNANDO VALLEY Established 40-years. Recently renovated with the best. Absentee Owner. Previously did $1 Million. 6 Ops. Grossing $550,000.TEMECULA Grosses $1.5 MillionTORRANCE Strip Center on Hawthorne. 3 Ops. Gross $300,000. Refers Endo, OS, Implants, Perio Ortho. Close to Palos Verdes. Full Price .

MORE OPPORTUNITIES AVAILABLE Bellflower, Corona, Dana Point, East L , Ladera Ranch, Norco San Juan Capistrano established 40 years, Lawndale Galleria, Anaheim, Irvine, Orange/Tustin.

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J U LY 2 0 1 7 371

All facilities with radiographic equipment must develop, maintain and annually review a written radiation safety program. An inspector

from the California Department of Public Health (CDHP) or local enforcement agency will ask for it and other documentation when an on-site inspection is conducted. To develop the required document, a dentist may choose to use the template found at the back of Radiation Safety in Dental Practice, a guide that can be downloaded from the CDA Practice Support website, or the dentist can create his or her own written safety program. This article reviews the required components of the written program.

Required ContentThe written radiation safety program

should be appropriate to the scope and extent of dental practice and be suffi cient to ensure compliance with record-keeping requirements. The document should describe the procedures and devices (engineering controls) that dental professionals use to ensure occupational doses and doses to members of the public are as low as is reasonably achievable (ALARA principle).

The CDA-provided template allows a dental practice to adopt the radiation safety guide into its written program by checking the “yes” box and fi lling in the dental practice name. The guide includes a copy of the state (Title 17) and federal (10 CFR 20) regulations applicable to dental practices. It summarizes standard practices and requirements in the following areas:

■ Responsibilities of the licensed dentist and radiographic machine registrant.

Written Radiation Safety Program CDA Practice Support Staff

■ Requirements for dental radiographic machines.

■ Patient protection. ■ Responsibilities of dental personnel

operating radiographic equipment. ■ Quality assurance and

quality control. ■ Equipment quality assurance

requirements. ■ Guidelines for prescribing

radiographs. ■ Occupationally exposed

women of childbearing age.

Regulatory Compliance

A dentist may choose to use the template found at the back of Radiation Safety in Dental Practice, a guide that can be downloaded from the CDA Practice Support website.


372 J U LY 2 01 7

JULY 2017 REGUL ATORY COMPL IANCE

■ Protective barriers.The practice owner needs to

identify the person responsible for the radiation safety program. The owner should review the guide and then describe in the template any additional responsibilities and procedures or devices not included in the radiation safety guide. The owner should also include a description of procedures or devices that are described in the guide but are not applicable in the practice.

Dosimetry and Occupational Exposure Documentation

Each facility with radiographic equipment must keep records of occupational exposure. If a facility can document that annual occupational exposure is less than 10 percent of the allowable exposure limit (5 rems), then continuous monitoring is not required. Monitor again if equipment has changed, facility has remodeled or more than three years has passed. The three-year period is a recommendation, not a requirement.

A dental practice should indicate in the template whether it is currently monitoring occupational exposure. If the practice is monitoring, include information on the dosimeter’s use. Provide to employees a report of individual exposure. Additionally, if employees work at other dental practices, collect information on exposure in those locations. Use the form “Employee Occupational Exposure to Radiation,” available on cda.org/practicesupport, to assist in collecting that information. Provide the second page of the form to employees who work at other locations. Each employee should complete the information and return it to the practice.

Postings and DocumentationMaintenance records must be

kept. Record in the template how equipment is maintained and the name of all service providers, including service providers for the electronic image receptor and software.

“Caution X-rays” signs must be posted where radiographs are taken. Record in the template the locations of the signs and the name of the individual responsible for maintaining those signs. That individual should also ensure a copy of the applicable radiation regulations and copy of operating and emergency procedures applicable to radiation sources. Provision of the Radiation Safety in Dental Practice guide satisfi es this requirement. The CDA-provided poster set has a place to write in the location of the guide. “Notice to Employees” (RH-2364) is included in the CDA-provided poster set. If the practice has received a notice or order related to radiological work, it must be posted in the facility along with any required response.

Training documentation must be kept. Train all staff on safety procedures whether or not staff works with radiology equipment. Train staff on appropriate operating procedures upon assignment to taking radiographs. Retain copy of successful completion by unlicensed dental assistants and

of Dental Board of California-approved radiation safety course.

Document procedures followed for quality assurance. Such procedures are described in the Radiation Safety Guide. Facilities that process fi lm must comply with quality assurance regulations that include using a reference fi lm and keeping a log of corrective actions.

Finally, all X-ray machines must be registered with CDPH. Any changes in ownership, discontinued use or facility relocation must be reported to CDPH using forms available on the department’s website, cdph.ca.gov/Programs/CEH/DRSEM/Pages/RHB-X-ray/Registration.aspx. ■

Regulatory Compliance appears monthly and features resources about laws that impact dental practices. Visit cda.org/practicesupport for more than 600 practice support resources, including practice management, employment practices, dental benefi ts plans and regulatory compliance.

Training documentation must be kept. Train all staff on safety procedures whether or not staff works with radiology equipment.

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J U LY 2 0 1 7 375

Our code also stresses patient confi dentiality (Section 1E). Dentists are obligated to safeguard the confi dentiality of our patient’s health information. Without explicit written consent from the patient, disclosing any patient information not only violates our code of ethics but also the federal Health Insurance Portability and Accountability Act and the California Confi dentiality of Medical Information Act. It is a misconception that when patients divulge personal health information in their initial posting, their disclosure protects you from violating their privacy rights when you respond. Breaching patient confi dentiality or making a libelous statement could easily happen if you are not careful. Ignorance of the law has resulted in dentists being fi ned, disciplined and reprimanded and their reputations tarnished.

After consulting with CDA’s practice support center, I came to my senses and chose not to respond to the online posting. Unfortunately, there are only a few options available to us in removing undesirable postings. You can approach the website directly and inquire if it has an established protocol for removing a potentially libelous posting. Your liability insurance carrier may also provide advice on remedies that may be available to you. However, if you do decide to respond online, be cognizant of the CDA Code of Ethics as well as

state and federal laws. Consider your reply carefully. A suggested response may be phrased as follows: “Our practice policy is to refrain from public discussion of individualized patient care. If you are in fact a patient of record with our practice, please contact us directly so that we may address your concerns.” The message is generic and professional, while encouraging patients to maintain open communication with the offi ce privately so an amicable resolution to the patient’s grievance can be found.

These options do not absolve you from ignoring the causative factors of negative online reviews. Proper interpersonal communication skills when treating patients is critical in reducing the likelihood of a patient posting a negative review. In retrospect, if my interactions with my new patient were more respectful, and I was just a little more responsive to the patient’s concerns, maybe I would not be writing this article right now. ■

Chuck Wang, DDS, is a general dentist in Los Angeles and a member of the CDA Judicial Council. For more information or further guidance, contact your local ethics committee or Brittney Ryan, CDA judicial council manager, at 800.232.7645.

Ethics

Response to Online ReviewsChuck Wang, DDS

This man thinks he’s God’s gift to dentistry. Tried to get me to pay for a procedure I didn’t need and wouldn’t give me proper basic care when I said no.” The rant went

on and on. A few years back, a colleague discovered this review while looking for my practice online and brought it to my attention. Wasting no time, I used the “fi ve Ws” of information gathering. I worked on the where, the when, the who and the “what the heck?!” I determined the posting was authored by a new patient who was dissatisfi ed with my diagnosis and treatment recommendation after the initial visit. As I progressed through my Kübler-Ross model of the fi ve stages of grief, I just couldn’t seem to get past the anger stage. With the obvious clinical evidence, how dare the patient make such an accusation? My urge to lash back was overwhelming. Unqualifi ed criticism is always diffi cult to swallow; and our reactionary response to online reviews is often where dentists get into trouble with our professional ethics and the law.

The CDA Code of Ethics encompasses several ethical principles. Integrity is the ethical principle that requires dentists to behave with honor and decency. The dentist who practices with a sense of integrity recognizes when words, actions or intentions are in confl ict with one’s core values and conscience. While serving the public, a dentist also has the obligation to act in a manner that maintains or elevates the esteem of the profession (Section 1A). Engaging in a war of words with the public damages the professional reputation we have established and worked hard to maintain. It feels unjust that health professionals can’t fi ght back on equal footing. An old saying comes to mind: “To whom much is given, much is required.” Along with the professional privilege we are granted in society is the expectation that we practice with the highest moral standards.

“ Unqualified criticism is always difficult to swallow; and our reactionary response to online reviews is often where dentists get into trouble with our professional ethics and the law.

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BAY AREA CONTINUED CC-632 SAN RAFAEL: Small town life in vibrant, growing city. 3 ops in 800sf office. Beautiful bldg $$145k CC-661 SAN RAFAEL: Starter practice in beauti-ful location w/ like-new equipment. 3 ops, 900sf $$190k CC-676 NOVATO: Busy location in well-known retail center. 4 ops w/1900sf $$600k CG-616 NAPA: State-of-the-Art practice. Seller moving out of state! $$425k DC-480 SILICON VALLEY: Multi-Specialty prac-tice. 14+ ops in 7500sf. Owner financing availa-ble $$1.075M DC-671 SAN JOSE: Starter prac ce. Desirable area. 6 npts/mo, 3 ops in 900sf $$150k DC-692 DUBLIN Facility: Modern digital office. 5 ops 1800sf $$210k w/ Cone Beam Unit or $165k without DG-519 SANTA CLARA Facility: Move-in ready! 2240sf w 6 fully equipped ops $225k DG-635 CASTRO VALLEY: Excellent loca on & stellar reputa on! Solo Group Prac ce $$650k DG-691 SAN JOSE: One of the most unique prac ces you will ever see! 1450sf w/ 5 ops $985k DN-665 SANTA CRUZ AREA: Loyal, stable, mul-

-genera onal pa ent base. FFS. 1460sf w/ 4 ops $$540k DN-693 SAN JOSE Facility: A rac ve & spa-cious! Faces one of the city’s major thorough-fares. 1080sf w/4 ops $$150k DN-713 CASTRO VALLEY Lease: Well main-tained, attractive, “Move-In Ready” dental office. 1500sf w/ 5ops CCall for details!

NORTHERN CALIFORNIA EC-531 GREATER SACRAMENTO: Beau ful! 1750sf w/ 4 ops + 1 add’l office $$800k for Prac ce & Real Estate EG-673 SACRAMENTO: Beau ful established dental prac ce lease opportunity! Call for Details!

BAY AREA AC-566 SAN FRANCISCO: Spectacular views of Washington Square. 3 ops +2 add’l, 1400sf $200k AC-624 SAN FRANCISCO: Wonderful patients, solid income in great stand-alone bldg $$475k AC-640 SAN FRANCISCO: On 23rd Floor of prestigious bldg, 2 ops in 700sf. Seasoned Staff. Seller Retiring $$175k AC-649 SAN FRANCISCO Facility: Richmond District, 3 ops+1 add’l, Equipment less than 5yrs old $$155k AG-645 SAN FRANCISCO: Low Overhead, com-pact practice ready for expansion or reloca-tion. Retail/Commercial area. 2nd Floor $$125k AG-669 SAN FRANCISCO: RARE opportunity in the heart of the city! 2 ops LOW OVERHEAD! $88k AN-513 REDWOOD CITY: Prac ce of your dreams! 900sf w/ 4 ops + 2 add’l $$350k AN-686 SAN FRANCISCO: Office designed w/ pa ent flow & maximum office efficiency. 1000sf w/ 4 ops $$825k AN-712 SAN FRANCISCO: Easy accessibility, excep onal visibility, free parking & eextremely low rent! 1000sf w/ 2 ops + 2 add’l $$89.5k BC-662 HAYWARD: Starter practice in the “Heart of the Bay” near hospital, 3 ops in 1056sf $75k BC-663 DANVILLE: Seller retiring from this family-oriented practice. 4 ops in 1262sf $240K BC-681 WALNUT CREEK: Remodeled office located in semi-rural community, 1000sf w/ 4 ops $$432k BC-682 CONCORD: Located in desirable, bus-tling community w/ seasoned, caring staff. 836sf w/ 3 ops $$224k BC-710 WALNUT CREEK: Desirable location in stand-alone, single-story bldg. 1313sf w/ 3 ops $$150k / RE $850k BN-504 RICHMOND: Established Practice & Real Estate! 1450sf w/ 2 ops + 2 add’l $100k / RE $700k

NORTHERN CALIFORNIA CONTINUED EG-685 LINCOLN/ROCKLIN:

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$270k EN-625 SACRAMENTO:

$450k EN-626 CARMICHAEL:

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$268k EN-628 ORANGEVALE:

375k EN-651 SACRAMENTO:

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$150k EN-660 ROSEVILLE:

$995k EN-664 SACRAMENTO Facility:

$55k EN-689 SACRAMENTO Facility:



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$350k for the Prac ce & $400k for the Real EstateFC-677 FORT BRAGG:

$500k GC-472 ORLAND:

$160k GG-453 CHICO:$200kGG-454 PARADISE:

$525kGN-244 OROVILLE: $315k GN-399 REDDING:

$150k GN-606 BUTTE COUNTY:

$125k GN-656 NO. TEHAMA CO: Great Loca on!

$275k

NORTHERN CALIFORNIA CONTINUED GN-667 OROVILLE: Great place to work & play!

$295k GN-668 BUTTE COUNTY:

$95k GN-717 YUBA CITY:

Building available for purchase! $475k HN-213 ALTURAS: Collected ~$760 in 2016! $195k HN-280 NORTHEAST CA: $60k HN-618 SIERRA FOOTHILLS:

$95k

CENTRAL VALLEY IC-468 SAN JOAQUIN VALLEY

$425k IC-715 TRACY

$435k IG-687 TURLOCK:

$298k IN-569 MADERA:

$634kJN-690 LINDSAY

Prac ce $150k/ Real Estate $150k

SOUTHERN CALIFORNIA

KC-678 LOMPOC & SANTA MARIA: $240k

SPECIALTY PRACTICES BC-600 CONCORD Ortho/Pedo Charts Only:

$400k BC-709 HAYWARD Ortho:

$215k IC-543 CENTRAL VALLEY Ortho:

$125k

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BAY AREA CONTINUED CC-632 SAN RAFAEL:

$145k CC-661 SAN RAFAEL:

$190k CC-676 NOVATO:

$600k CG-616 NAPA:

$425kDC-480 SILICON VALLEY:

$1.075M DC-671 SAN JOSE:

$150k DC-692 DUBLIN Facility:

$210k w/ Cone Beam Unit or $165k without DG-519 SANTA CLARA Facility:

$225k DG-635 CASTRO VALLEY:

$650kDG-691 SAN JOSE:

$985k DN-665 SANTA CRUZ AREA:

$540k DN-693 SAN JOSE Facility:

$150k DN-713 CASTRO VALLEY Lease:

Call for details!

NORTHERN CALIFORNIA EC-531 GREATER SACRAMENTO:

$800k for Prac ce & Real Estate EG-673 SACRAMENTO:

BAY AREA AC-566 SAN FRANCISCO:

$200k AC-624 SAN FRANCISCO:

$475k AC-640 SAN FRANCISCO:

$175k AC-649 SAN FRANCISCO Facility:

$155k AG-645 SAN FRANCISCO:

$125kAG-669 SAN FRANCISCO:

$88kAN-513 REDWOOD CITY:

$350k AN-686 SAN FRANCISCO:

$825k AN-712 SAN FRANCISCO:

extremely low rent $89.5kBC-662 HAYWARD:

$75kBC-663 DANVILLE:

$240KBC-681 WALNUT CREEK:

$432k BC-682 CONCORD:

$224k BC-710 WALNUT CREEK:

$150k / RE $850kBN-504 RICHMOND:

$100k / RE $700k

Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA

NORTHERN CALIFORNIA CONTINUED EG-685 LINCOLN/ROCKLIN: Perfect loca on in amazing community! Retail Shopping Center w/ 4 ops $$570k EG-716 ELK GROVE: Remarkable poten al for growth w/ a en on to marke ng & increased office hours! 1200sf w/3 ops $$270k EN-625 SACRAMENTO: Looking for an HMO prac ce in a great Loca-

on? 2500sf w/5 ops $$450k EN-626 CARMICHAEL: Lifestyle you just can’t be beat! HMO 1250sf w/ 3 ops $$300k EN-627 CARMICHAEL: Remarkable HMO opp. awaits your talent & skill! 1200sf w/3 ops + 1 add’l $$268k EN-628 ORANGEVALE: Great place to work, play & live. HMO 1310sf w/ 4 ops + 1 add’l $3375k EN-651 SACRAMENTO: Well known for delivering excellent & com-passionate care. 1750sf w/ 4 ops $$150k EN-654 CITRUS HEIGHTS: Well established & loaded with 30+ years of goodwill! 1300sf, 3 ops + 2 add’l. $$150k EN-660 ROSEVILLE: Highly-esteemed, well-respected, fee-for-service prac ce w/ loyal pa ent base. 2950sf w/ 5 ops $$995k EN-664 SACRAMENTO Facility: Great corner loca on, excellent visi-bility & easy access! 2300sf w/ 4 ops $$55k EN-689 SACRAMENTO Facility: Bring your talent, hang your sign & make it your own! 2000sf w/ 4 ops $$150k EN-702 SACRAMENTO: Long-established prac ce w/ emphasis on preventa ve vs reac ve den stry! 1600sf w 4 ops + 1add’l. $$495k EN-708 SACRAMENTO: Family-oriented prac ce with apprecia ve & loyal pa ent base. 1600sf w 4 ops + 1add’l. $$150k FC-650 FORT BRAGG: Family-oriented prac ce. 5 ops in 2000sf, 6 npts/mo $$350k for the Prac ce & $400k for the Real Estate FC-677 FORT BRAGG: Beau ful, FFS Prac ce, 4 ops +1 add’l, in 2375sf, Gross $1M+/yr $$500k GC-472 ORLAND: Live & practice in charming small town community. 1000sf w/ 2 ops. Seller Retiring $$160k GG-453 CHICO: 5000sf w/ 7 ops. Perfect for 1 or more dentists! $200k GG-454 PARADISE: 2550sf w/ 9 ops. 40 yrs goodwill! Amazing Op-portunity! $$525k GN-244 OROVILLE: Must See! Gorgeous, spacious 2500sf w/5 ops! $315k GN-399 REDDING: Loyal patient base & relaxed workweek schedule. 1440sf w/3 ops $$150k GN-606 BUTTE COUNTY: Hesitate & you’ll miss out on this one-of-a-kind opportunity! 1700sf w/ 4 ops $$125k GN-656 NO. TEHAMA CO: Great Loca on! Ideal place to work, live & raise a family! 2468sf w/ 5 ops $275k

NORTHERN CALIFORNIA CONTINUED GN-667 OROVILLE: Great place to work & play! Constant growth a rac ng an influx of residents! 1000sf w/ 3 ops $$295k GN-668 BUTTE COUNTY: Remodeled in 2010! Well-maintained, long-established professional complex. 1200sf w/ 2 ops $$95k GN-717 YUBA CITY: Seller Re ring. All reasonable offers consid-ered. BBuilding available for purchase! 2400sf w/ 5 ops $$475k HN-213 ALTURAS: Well managed w/consistent revenues! CCollected ~$760 in 2016! 2200sf w/ 3 ops + 1 add’l. $$195k HN-280 NORTHEAST CA: Only Practice in Town! 900sf w/ 2 ops $60k HN-618 SIERRA FOOTHILLS: Seller Retiring! Huge opportunity for growth by increasing office hours! 750sf w/ 2 ops $$95k

CENTRAL VALLEY

IC-468 SAN JOAQUIN VALLEY: High-end restora ve prac ce! 6 ops in 2500+sf office. Call for Details! $$425k IC-715 TRACY: 30+npts/mo. 1600sf, 5 ops +1 add’l. Seller star ng new career $$435k IG-687 TURLOCK: Established quality prac ce - remarkable oppor-tunity! 2000sf w/ 5 ops $$298k IN-569 MADERA: Stellar reputa on & loaded with goodwill! 2900sf w/ 7 ops $$634k JN-690 LINDSAY: Stable, mul -genera onal, loyal & apprecia ve pa ent base. 1700sf w/ 3 ops PPrac ce $150k/ Real Estate $150k

SOUTHERN CALIFORNIA

KC-678 LOMPOC & SANTA MARIA: Live & practice along the central coast. Plenty of room for growth, Call for Details! $$240k

SPECIALTY PRACTICES BC-600 CONCORD Ortho/Pedo Charts Only: Continue treatment to these Ortho/Pedo patients Call for Details! $$400k BC-709 HAYWARD Ortho: Provide personalized care to wonderful patient base. 5-8 npt exams/mo, 4 chairs/bay, 1948sf $$215k IC-543 CENTRAL VALLEY Ortho: 1650sf w/ 5 chairs in open bay & plumbed for 2 add’l. Strong referrals and PT base $$125k

Edmond P. Cahill, JD Timothy Giroux, DDS


378 J U LY 2 01 7

A look into the latest dental and general technology on the market

Dental Simulator (Free, PanArt Studios)

With millennials quickly becoming the next generation of oral health professionals, dental education must stay relevant and adapt to new teaching modalities. Augmented reality (AR) has gained popularity recently, namely in the form of video games. Placing virtual elements in a live, direct physical view of a real-world environment provides an immersive experience that can potentially bring content to an entirely new level of learning. Dental Simulator is a fresh introduction of AR and its promising use in dental education and the profession.

The app revolves around a fully rendered interactive three-dimensional model of the oral cavity and facial structures that can be controlled using gestures. Pinching zooms and rotates the model while swiping controls the mouth opening and closing. Entering the view study mode allows the user to control the transparency of the soft tissue and bone structures of the model, revealing the nerves, blood supply and the teeth. Labels for the diff erent anatomical landmarks are marked in their respective locations for reference.

AR mode is where this app takes learning to the next step. Users can download and print AR trackers on paper, which are then cut out and used as a location reference in the real-world environment for the app to display the same three-dimensional model and a syringe for learning how to perform local anesthesia right on the mobile device using its built-in camera. When the app detects these trackers, users can see the fully interactive model superimposed in a live environment and, with their virtual syringe, attempt to deliver anesthesia to the proper location. Additional modules for the various types of local anesthesia injections are available as in-app purchases and more content is being developed.

With AR becoming increasingly prevalent and more aff ordable, it is only a matter of time before dental education and patient education shifts to newer innovations. Dental Simulator is certainly an incredible view of what the future holds with the technology that is available today.

— Hubert Chan, DDS

ER Doctors Can Discharge Patients Faster Using SmartphonesER physicians who get push-alert notifi cations are able to discharge patients with chest pain faster, according to a new study by the University of Toronto. The study, which was published in the Annals of Emergency Medicine, analyzed 1,554 patients discharged with chest pain who were divided into control and intervention groups. Discharge decisions for these patients are largely dependent on troponin results. Physicians in the study received troponin results via push alerts. The study found that this allowed for a quicker discharge time by 26 minutes. For more information, visit annemergmed.com.

— Blake Ellington, Tech Trends editor

Study: Apple Watch Can Track Abnormal Heart Rhythms With 97 Percent AccuracyAccording to a new study conducted by the University of California, San Francisco utilizing the Cardiogram app, the Apple Watch can detect abnormal heart rhythms with 97 percent accuracy.

This number, which is a result of the pairing with an algorithm, came from a study that involved 6,158 people. Most of the people who downloaded the app had abnormal heartbeats. The researchers believe this research, which began in 2016, could lead to further developments in predicting strokes. The study certainly illustrates how wearable technology can help track the need for medical care in humans.

— Blake Ellington, Tech Trends editor

Would you like to write about technology?Dentists interested in contributing to this section should contact Andrea LaMattina, CDE, at [email protected].

Tech Trends

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