2019 Adso Members

1300 Smiles
42 North Dental
Abano Group
Academy of Laser Dentistry
Academy of Osseointegration
Affordable Care
Allied Dental
Altima Dental
America's ToothFairy
American Academy of Periodontology
American Academy of Oral Maxillofacial Surgery
American Association of Orthodontists
American Dental Assistants Association
American Dental Hygienists Association
Aspen Dental
Beacon Dental Health
Behl Orthodontics
Benevis
Bluetree Dental
Bright Side Dental
California Dental Association
Canadian Ortho Partners
Childrens Dental Health
ClearChoice
Community Dental Partners
CorDental Group
D4C Dental
DECA Dental
Dentalcorp
Dental Support Foundation
DecisionOne Dental Partners
DentalAssociates
DentalCareAlliance
DentalWhale
Dental365
Diamond Braces
Elite Dental Partners
Elmhurst Dental
Emergency Dentists
Genesis Dental
Great Expressions Dental Centers
Heartland Dental
Hero Practice Services
High Five Dental
Midwest Dental
Monticciolo Family Dental
MCDC Dental
NADG Dental
OMFS of Chicago
Onsite Dental
OrthoDent
OSAP.ORG
Pacific Dental Services
Pacific Smiles Group
Platinum Dental
Primary Dental
Pure Orthodontics
Riccobene Associates
Risas Dental
RockDental
Samson Dental
Smile Brands
Smile Doctors
Snow Orthodontics
SohDental
Southern Dental Alliance
TruFamily Dental
United Dental Partners

2019 World Ranking Top 50 Dental Schools

QS World University Rankings by Subject 2019: Dentistry


1
Karolinska Institutet Sweden

2
Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam the Netherlands

3
King's College London United Kingdom

4
The University of Hong Kong Hong Kong SAR

5
University of Michigan United States

6
University of Gothenburg Sweden

7
Harvard University United States

8
University of Zurich Switzerland

9
University of Bern Switzerland

10
Tokyo Medical and Dental University (TMDU)  Japan

11
University of Washington United States

12
UCL United Kingdom

13
University of Birmingham United Kingdom

14
University of California, San Francisco United States

15
University of North Carolina, Chapel Hill United States

16
New York University (NYU) United States

17
KU Leuven Belgium

18
The University of Manchester United Kingdom

19
University of Pennsylvania United States

20
Universidade de São Paulo Logo Brazil

21
University of British Columbia Canada

22
University of Copenhagen Denmark

23
Peking University China (Mainland)

24
Complutense University of Madrid Spain

25
Malmo University Sweden

26
University of California, Los Angeles (UCLA) United States

27
Aarhus University Denmark

28
Wuhan University China (Mainland)

29
Seoul National University South Korea

30
The University of Melbourne Australia

31
The University of Adelaide Australia

32
Columbia University United States

33
University of Minnesota United States

34
Universidade Estadual de Campinas (Unicamp) Brazil

35
University of Otago New Zealand

36
University of Southern California United States

37
University of Toronto Canada

38
Newcastle University United Kingdom

39
University of Geneva Switzerland

40
University at Buffalo SUNY United States

41
Ludwig-Maximilians-Universität München Germany

42
UNESP Brazil

43
University of Helsinki Finland

44
National and Kapodistrian University of Athens Greece

45
Radboud University Netherlands

46
Alma Mater Studiorum - University of Bologna Italy

47
Boston University United States

48
Osaka University Japan

49
Yonsei University South Korea

50
Cardiff University United Kingdom

EBIDTA Multiples & Calculations

DENTISTRY: FROM ONE TO FIVE OFFICES- WHY? 

Pete Newcomb PART 1: WHY WOULD ANYONE WANT FIVE DENTAL PRACTICES?
NOVEMBER 2016 – DTSpade Q&A WITH PETE NEWCOMB, CEO of US TRANSITIONS

CEO at US Dental Transitions (Formerly Southeast Transitions)

1 article 

Is dentistry an art, science or business? At DTSpade, we’d argue that it is all three.

But every Client decides how much time they can allocate to each. Do you invest in getting better at your craft? Do you invest in the newest equipment or staff training? Do you invest in improving operations, speeding collections or negotiating with insurance?

At best, a single physician can do one or two well. Larger practices can invest in talent to delegate, but that brings another set of challenges. Single physician practices that maintain high standards of customer care are not at any more of a disadvantage than multiple practice operations that sacrifice personal attention.

But we believe this along with some changes in the way that practices are valued (that Pete alludes to below) has caused a sea of change toward dentists wanting to own and operate multiple offices.

In this “1 to 5 series”, we talk with industry experts about whether there is value in growth and how they’ve seen it best accomplished.

To kick off the series, we spoke with Pete Newcomb, CEO of Southeast Transitions, who has worked with over 400 dentists in transitioning their practices.

Q: Before we get started, what’s going on here? What’s so magical about the number 5 as it pertains to practices and is it worth the trouble to press toward it as a goal? Couldn’t a dentist be as profitable running a single office better?

A: A dentist can certainly be profitable running a single practice or even a couple practices. But there’s been a lot of talk about getting to an EBITDA valuation that comes with a portfolio sale. With one or two offices, your value will be based on a percentage of collections—say 80%. But when you get to three or more practices the valuation method changes to an EBITDA valuation. With this change in valuation methods your offices together could be worth more than 100% of collections or 3-7 times EBIDTA depending on the number of locations (5 or more is optimum), profitability, location, and types of dentistry performed. When a large DSO adds your practices to their portfolio the value of your practice to a DSO could be 2-3 times what they paid you for it. When they aggregate the EBIDTA numbers the practices become much more valuable as a larger group. Unfortunately, a dentist who owns 3-5 practices will be unable to get 2-3 times their value prior to being a part of a larger group.

Q: As a dental practice consultant, what pieces do you see that a dentist needs to have in place, to make the growth from 1 to 5 offices?

A: There are a lot of pieces. Management is probably the biggest piece for me. You can buy 5 independent practices and run them in silos but you don’t really gain anything when you do that. The challenge is deciding when to get a full time manager for your multiple locations. Is it when you go from 2 to 3 locations, or is it when you get to 4 or 5? Somebody has to oversee all of these practices. And, at what point do you need a Clinical Director? When do you have to get someone who acts as the HR Manager? When do you aggregate resources between locations?

And there’s Marketing…are you marketing under one brand or are you marketing under individual brands? If you can figure that out and drive 50-100 new patients at every location per month, it’s Game Over! But that’s a really tall order.

Q: What would you say are the most common pitfalls?

A: Buying the wrong doctor’s practice. This seems so obvious, but it happens all the time. I have seen many transitions fail when the purchaser buys the wrong practice, different management or treatment philosophy etc. This difference in philosophy can add more stress on a transition. I see dentists who buy a super star’s practice, which makes a great profit every month. But what they don’t understand is that Dr. X has excellent chairside manners. They are an outgoing person, a very good salesperson and their clinical skills are excellent. Finding someone to “replace” them is a tall order.

So they buy that practice, the seller stays on as an associate for a grace period, and then they go on their way and they put somebody else in his place. But some of these dentists are 30 plus year, excellent providers. Once the patients find out they are no longer the provider, they’re not going back. If you’re going to buy a superstar’s practice, you better make sure you have a superstar in your arsenal to replace them.

You have to really understand what you’re buying. You have to really understand the practice. I think too many people get excited about the opportunity to have multiple practices. There’s an emotional enthusiasm so they lose sight of the due diligence to know what they’re really getting themselves into sometimes.

Q: What’s different about dentists who succeed in this growth? Why are THEY able to be successful?

A: This may sound crazy, but introverts, who have figured out a way to compensate by being very personable, make excellent clinicians. It’s very difficult to get through dental school… it’s extremely challenging. But then to be able to “relate” to patients and have great chairside, too… that’s a gift. So they have to have both.

So, on the other hand you can buy the right doctor’s practice maybe because they are very successful at surrounding themselves with a very outgoing staff, although they may not have an outgoing personality. Or maybe they don’t like to do some of the treatments that you offer, so there would be a lot of opportunity in that practice.

Q: What do you think is different today, versus ten years ago, that affects a dentist’s ability to be successful in growing to five locations?

A: I think competition has become really stiff. You’ve got close to $300 million out there, earmarked for practice acquisitions in 2016. There are 1-3 DSOs out there with acquisition budgets in excess of $50 million annually and hundreds of others with annual budgets of $10 million . It’s a seller’s market right now, so if you want to buy anything, you’re going to have to pay top dollar for it if it’s anything worth buying.

DSOs are able to offer services below the going rate because they have more volume. They can open a 16 operatory facility on any street corner and take a loss on it for as long as they need to become profitable. They have 100-400 other practices that are profitable, so they can afford to take a loss on ten while they’re setting them up. Any dentist wanting to set up 5 locations probably needs to be profitable in each location they acquire. So a lack of necessary capital also makes it more challenging to compete with that.

The problem today is most Americans probably don’t understand the difference between dentists. They think they can all do the same job. When I ask my neighbors why they go to a certain dentist, do you know what their #1 answer is? “He’s a nice guy”. You know what never comes up? “He does great work”, because they don’t know. Patients don’t see the quality in work that is performed. So it becomes nearly impossible to compete in an environment where everyone thinks dentists are all the same, and some of the largest DSOs use billboard advertising and are opening offices within a few miles of each other. It makes it hard to compete with that.

Q: As a dentist wanting to open multiple locations, would you want to expand in more rural areas, where you’re not going to have as much competition with DSOs?

A: Sure, and that’s a great plan. You would set up on the perimeter of growth, so that the growth comes to you. But if you go outside the edge of the metro area, I think your ability to attract great talent goes down. If I said I had an associateship in Buckhead, I’m pretty sure I’ll be able to fill that associateship. But if I said I had one in Rome, GA it’ll probably be a lot tougher.

Q: Do you feel this is a timing market or is this a sustainable model?

A: That’s one of the questions I think everyone should be asking, but nobody seems to care. Everybody’s throwing money at this thing like, “you can’t lose, anybody can do it.” But is that really true?

I don’t think it’s sustainable at this level forever. I don’t think everybody can make money as multiple practice owners forever. There has to be losers in this game.

You’ve got to know somebody who knows where a lot of practices are, and you’ve got to network. I can think of providers out there who have done pretty well, secretly, just buying a little bit here and there. I think getting too aggressive is the wrong move. You look at a lot and you buy the ones you think you can make work. Like anything, you’ve got to get as educated as you can possibly be.

I think the number one thing is to be ultra selective about what you’re acquiring. You’ve really got to know what you’re buying. You really have to have a good relationship with the seller, and you have to understand the ups and downs of the practice entirely. But yet, there’s still a ton of risk out there.

And second, you need to make sure you are willing to own those practices, not just build it to sell. The window will close on this valuation cycle in the market and you’ve got to have a business that you can run into the next cycle if you happen to miss it.

There exists a very real opportunity to acquire and sell practices today. How long will this model last?

Pete Newcomb is the CEO of US Transitions, the largest dental M&A firm on the eastern seaboard. Pete graduated from the University of Rhode Island in 1991 and enjoyed a career in telecom for 15 years prior to becoming a dental broker. Over the last twelve years, Pete has managed over 400 sale/acquisition transactions. 

How Much is My Dental Practice for Sale Worth?

March 7, 2019/in Selling a Dental Practice /

When it comes to valuing a dental practice for sale, there are a lot of different methods and theories. In all honesty, there are so many variable factors that there is no one formula where you plug in numbers on one end and get an objectively correct answer out the other. But there are a couple of rules of thumb that can give you a good idea of a ballpark range. Realistically, you’ll need to work closely with your accountant, your dental practice broker, and, ideally, a certified valuation analyst (here at ddsmatch Southwest, we partner with Blue & Co. for our client’s valuation needs).

The two most common methods for valuing a dental practice dental practice for sale are to use a multiple of collections or a formula relying on your earnings before interest, tax, depreciation, and amortization (EBITDA). We’ll discuss each in turn and then discuss why these numbers will only tell part of the story.

Multiple of Collections

The multiples of collections method is fairly simple, until its not. The simple part is that it’s just a multiplication equation. You take your total collections (or gross revenue from the practice) and multiply it by a percentage. This, however, is where it gets less clear: what percentage do you use? Historically, the average answer has been about 67%, although you will also hear this should be 70-80% of the average of your last three years collections. Another way to consider this approach is the price to gross revenue. That is, what will the buyer be willing to pay for each dollar of collections? $.67, $.70, $.75, or $.80?

Our use of the word “historically” should be telling. This method of valuation is become less common as the business side of the dental industry changes (more on this in the next section). However, before you get too excited about the simplicity of this method, consider the following hypothetical: if you have a practice will $1m in collections, using a multiple of collections method, the practice could be valued reasonably within the $670,000-$800,000 range, depending on other variables. The problem here is you are only looking at one number, the total collections. You don’t have any information yet about overhead and other costs. This hypothetical dental practice for sale could actually be worth much less.

EBITDA

The earnings before interest, tax, depreciation, and amortization (EBITDA) is becoming increasingly popular as the business side of the dental industry has experienced a shift towards a greater number of group practices being driven by entrepreneurial dentists and outside investors. With group practices being more and more focused on investor returns, there is a shift to an investor perspective of owning and operating dental practices. Typically, investors consider the actual debt-free cash flow, rather than gross collections, as the most reliable indicator of the likelihood of a return on their investment. The EBITDA method can be considered a price to earnings method. The question here is how much is the buyer willing to pay for each dollar of free-and-clear net earnings?

This method is trickier because determining your debt-free earnings is not as simple. Also, the range for the multiplier for EBITDA is much wider (you can see anywhere between two and 18 as the correct multiplier) and more variable by practice type. For a solo practice, a reasonable multiplier might be three-to-four times. For a multi-doctor practice, in might be four-to-five times. For a multi-location practice, it might be five-to-six times. And for a group practice with infrastructure and scalability, it could be six times and up from there.

When we apply the EBITDA method to our above hypothetical, you can see both the difference and the advantage of this method. If a dental practice for sale has $1m in collections and 60% overhead (which is about average for a dental practice), its EBITDA is $400,000. But, what if a practice has an above average amount of overhead? If a practice has $1m in collections but 75% overhead (if, say, the practice has more employees than it needs or the doctor pays themselves a hefty salary), the EBITDA is only $250,000. The multiplier of collections would place both practices at the same value, however, the second practice is clearly worth less than the first.

The Rest of the Story

There are two major factors that are not accounted for in either of these models. First, as mentioned previously, there are all kinds of variables that impact value outside of the information used in either of these valuation methods, including:

• Location
• Product mix
• Payer mix
• Fee schedules
• Referral rates
• New patient acquisition
• Fixed assets
• Whether office is leased or owned
• Cosmetic appearance of the office
• How modern or well-maintained is the equipment
• Availability of financing and current interest rates
• Transition plan (whether seller will stay on for a period)
• Community goodwill and how well that will translate to the buyer

All of these things will impact the value that both the buyer and seller will place on the dental practice for sale. Which brings us to the second factor: market value. At the end of the day, a practice is worth whatever it can bring from an open market. All of the valuation methods are simply ways to try and reach an agreed upon range from which negotiations can start.

Oral Path Slides by Dr. Jerry Bouquot

A really great powerpoint presentation.

https://www.dropbox.com/sh/umu7o3jce1p5vz6/AABhfYreRJu165xBU1yKUdzta?dl=0&fbclid=IwAR0kgyyyj_owOYnV4wjnYerOyiY-WuTEWPrKZ4a88pRA_U4-tpael6ogTqY&preview=53_Most_Common_Oral_Lesions.pptx

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SWELLCX

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Favorite composite for large posterior fills

ACTIVA

c.)

Good site to review rewards for travel

the points guy

d.)

Hall crowns

good for smaller teeth
place seps for a day or two
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Good dental supply company.
SAFCO

Infant Oral Health

Chapter 1: INFANT ORAL HEALTH AAPD GUIDELINE:
http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf http://www.aapd.org/media/Policies_ InfantOralHealthCare.pdf Guidelines/G_ http://www.aapd.org/media/Policies_Guidelines/P_CariesRiskAssess.pdf

1. DEFINITION
   
2. RATIONALE
   
3. GOALS
   
4. STEPS INVOLVED IN INFANT ORAL HEALTH
   
5. ANTICIPATORY GUIDANCE (T)
   
6. ORAL HEALTH RISK ASSESSMENT (T)
   
7. CARIES RISK ASSESSMENT (T)
   
8. RESPONSIBILITY OF NON-DENTAL PROFESSIONALS REGARDING INFANT ORAL HEALTH
   
9. ADDITIONAL READINGS
   

J. Lee, K. Weber Gasparoni

Chapter 1: INFANT ORAL HEALTH

I. DEFINITION
Professional intervention within six months after the eruption of the first primary tooth or no later than 12 months of age directed at factors affecting the oral cavity, counseling on oral disease risks, and delivery of anticipatory guidance

II.
III.

• • •
• •
•
• •
•
• • •
•

Early intervention aimed at preventing or mitigating common pediatric oral diseases and conditions while initiating a relationship between infant, child, family and the pediatric dental caregiver
Primary prevention of dental disease based on timely family education, instruction and motivation for behavioral changes, appropriate fluoride management, early identification of risks and tailored preventive programs
Foundation upon which prevention of oral injuries, management of oral habits, assessment of oral development, and consideration of other individual and special needs enhance a child’s opportunity for a lifetime free from preventable oral disease
RATIONALE
Early oral exam, along with oral health risk assessment and anticipatory guidance are effective means of true primary prevention
Early identification and intervention of oral health problems are cost effective and lead to satisfactory outcomes
GOALS
Timely delivery of family education on caries etiology/process, appropriate oral hygiene and feeding/dietary habits for caries prevention with ultimate goal of avoiding future surgical intervention (if possible, initiate educational process during pregnancy)
Timely consideration of fluoride management and preventive strategies as the primary dentition erupts based on individualized risk assessment
Provide anticipatory guidance and identify high-risk children for Early Childhood Caries (ECC) at an early age (if possible, identify high-risk mothers during pregnancy)
Establish a dental home by 12 months of age (Refer to “Policy on the Dental Home” at http://www.aapd.org/media/Policies_Guidelines/P_DentalHome.pdf)
STEPS INVOLVED IN INFANT ORAL HEALTH CARE
Record detailed medical and dental histories
Clinical examination of oral structures in parent-assisted (knee-to-knee) position
Counsel about caries risk factors and provide anticipatory guidance in the areas of dental and oral development, fluoride adequacy, teething, non-nutritive habits, injury prevention, dietary and oral hygiene instructions (Refer to Section V)
Counsel about bacteria transmissibility and provide anticipatory guidance directed to the mother or other intimate caregiver in order to avoid or delay colonization

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The Handbook of Pediatric Dentistry

IV.

V.

• •
•

Assess the infant’s caries risk using AAPD Caries-Risk Assessment Tool (CAT) in order to address current problems, and determine individual preventive strategies and follow-up intervals (Refer to Section VII)
Decide on supplemental procedures which may include caries risk testing, such as assay of salivary mutans streptococci (MS) levels by culture, selected radiographic examination, water fluoride analysis, consultation with other dental and medical providers and other interventions deemed necessary by a child’s individual needs
Follow-up procedures are those indicated in the “Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for Children”
ANTICIPATORY GUIDANCE

Chapter 1: INFANT ORAL HEALTH

In dental anticipatory guidance, parents are given counseling in infant oral hygiene, home and office-based fluoride therapies, dietary counseling, and information relative
to oral habits and dental injury prevention. Counseling of parents by providers about dental developmental changes expected to occur between their children’s dental visits is an important part of preventive care. Like well-child medical visits, one of the cornerstones of the infant dental visit is to prepare parents and caregivers for future age-specific needs and dental milestones.

ANTICIPATORY GUIDANCE: SUGGESTED CONTENT GUIDE – BIRTH TO THREE YEARS
Topic	6-12 months	12-24 months	24-36 months
Dental and oral development	milestones patterns of eruption environmental and genetic influences teething infant oral cavity	• occlusion • spacing issues • speech and teeth • tooth calcification	last primary tooth erupted exfoliation future orthodontic needs radiographs
Fluoride supplementation	F mechanisms sources of F choice of F vehicles F and vitamins toxicity issues/ storage formula and F	• F dentifrice use • F in food sources • avoiding excessive ingestion	• F use revisited at every interval • daily access
Non-nutritive habits	• pacifier use and types/safety • mouthing/oral stimulators	• digit habit issues • effect on occlusion	• revisit habit issues

The Handbook of Pediatric Dentistry 3

Chapter 1: INFANT ORAL HEALTH

Injury prevention	signs of trauma child abuse oral signs emergency access instructions implications for permanent teeth car seats	daycare instructions electric cord safety replantation warning Re: primary teeth child proofing	• helmet safety • seat belts • safety network
Diet	nutrition and dental health bottle use and weaning sippy-cup use and content breast feeding caries process	role of carbohydrates (juice) exposures retention of food review caries process revisit sippy-cup issues	snacks frequency issues review caries process role of carbohydrates (juice) exposures revisit sippy-cup issues
Oral hygiene	oral as part of general hygiene acquisition of S. mutans positioning baby for oral hygiene special techniques	• child participation • dentifrice use • Fl dentifrice for high risk	electric brushes/ toddler techniques use of floss continued parental participation

VI. ORAL HEALTH RISK ASSESSMENT
Systemic evaluation of the presence and intensity of etiologic and contributory caries risk factors designed to provide a disease estimation susceptibility and help in determining preventive and treatment strategies

What to address	What to ask
Medical history: pre-/perinatal history (hypoplasia), general health (healthy vs. special needs), medications (some high in sucrose)	Nutritional deficiencies in pregnancy Prematurity (~ < 36 weeks gestational period) Birth weight (~ < 2.5 kg) Medical problems/special health care needs (i.e. compromised salivary flow, compromised oral hygiene due to behavior problems, high- caloric diets, etc.) History of hospitalization and past/current medications
Oral hygiene: visible plaque on maxillary anterior teeth is one of the best predictors of future caries	Age brushing began? Are the child’s teeth brushed daily, once in while or not yet? Who brushes the child’s teeth? When are the child’s teeth brushed: morning, before bedtime, morning and before bedtime and/or after meals? Any problems with positioning, child’s cooperation, etc.?

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The Handbook of Pediatric Dentistry

Chapter 1: INFANT ORAL HEALTH

Infant Feeding: only formulas, breastmilk or water in infant bottles; milk is not cariogenic, but a vehicle for cariogenic substances (i.e. chocolate powder); breastmilk alone is not cariogenic, prolonged on-demand nighttime feeding associated with increased risk for caries; weaning from the bottle/sippy-cup at age 1 and from the breast as long as the mother and the child desires; breastfeeding in the 1st year of life found to be protective of future obesity	Breastfed/Bottle-fed? Breastfed/Bottle-fed to sleep and/or in the middle of the night? If yes, duration and frequency for each If bottle-fed, content of bottle: formula, milk, milk and sugary substances, juice/sugary drinks and/or water?
Dietary Habits: early introduction of unhealthy foods (i.e. sugary drinks and snacks) can alter taste preferences for foods and beverages and predispose to obesity; high frequency of sugary drinks and snacks between meals (≥ 3 times) increases caries risk; limit juice and sugary drinks daily intake to 4-6 oz and best given in open cups; best to limit sweet foods/drinks at mealtimes	Does the child regularly eat sweets more than 2× a day? What does the child like to snack on and how frequently? What type of container does the child usually use for drinks? Daily amount in oz during meals and/or throughout the day for the following drinks: 100% juice, juice drinks, regular/diet soda and sugary drinks (i.e. Kool-Aid)
Fluoride Adequacy: daily fluoride exposure through water or supplementation, and monitored use of fluoridated toothpaste (no more than a lateral smear) can be effective primary preventive procedures	Main water source from which the child is drinking: city water (unfiltered, Brita/Pur filter), city water (filtered, reverse osmosis), well water or bottle water? Fluoride level in the child’s drinking water? Does the child take fluoride supplements? If yes, dosage and frequency Does the child use fluoridated toothpaste daily, once in a while or not yet? If yes, amount placed on toothbrush
Bacteria Transmission: Mutans streptococci (MS) transmission can be direct or indirect, vertical (usually from mother) or horizontal (within or outside of the family)	Does the child’s mother (intimate caregiver) have any untreated decay? Does the child and mother (intimate caregiver) share the same utensils, foods and cups? Does the mother (intimate caregiver) pre-chew the child’s food or kiss the child on the mouth?
Demographic data: low SES, low maternal educational level, and minority groups are at higher risk for ECC
Teeth characteristics: white spot lesions considered severe ECC in children younger than 3 years of age; inspect for enamel hypoplasia, enamel defects, retentive pits/fissures; stained pits/fissures not common in primary dentition (possible higher risk for future cavitation?)
Iatrogenic factors: use of braces or orthodontic/oral appliances provide hard, non-desquamating surfaces and serve as plaque traps

The Handbook of Pediatric Dentistry 5

VII. CARIES RISK ASSESSMENT

Chapter 1: INFANT ORAL HEALTH

Salivary assays for MS: Ivoclar Vivadent CRT system (www.ivoclarviva.com), MSKB agar plates

Perceived risk by dental professional is reliable

AMERICAN ACADEMY OF PEDIATRIC DENTISTRY CARIES-RISK ASSESSMENT*
RISK FACTORS TO CONSIDER (For each item below, circle the most accurate response found to the right under “Risk Indicators”.)	RISK INDICATORS
	HIGH	MODERATE	LOW
Part 1 – History (determined by interviewing the parent/primary caregiver)
Child has special health care needs	Yes		No
Child has condition that impairs salivary flow/composition	Yes		No
Child’s use of dental home	None	Irregular	Regular
Time lapsed since child’s last cavity	<12 months="" span="">	12 to 24 months	>24 months
Child wears braces or orthodontic/oral appliances	Yes		No
Child’s mother has active decay present	Yes		No
Socioeconomic status of child’s caregiver	Low	Mid-level	High
Frequency of exposure to between meal sugars/cariogenic foods (include ad lib use of bottle/sippy cup containing juice or carbonated beverage)	>3	1 to 2	Mealtime only
Child’s exposure to fluoride	Does not use fluoridated toothpaste; drinking water is not fluoridated; not taking fluoride supplement	Uses fluoridated toothpaste; usually does not drink fluoridated water and does not take fluoride supplement	Uses fluoridated toothpaste; drinks fluoridated water or takes fluoride supplement
Part 2 – Clinical evaluation (determined by examining the child’s mouth)
Visible plaque on anterior teeth	Present		Absent
Gingivitis		Present	Absent

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The Handbook of Pediatric Dentistry

VIII.

•
IX.
1. 2. 3. 4. 5.

RESPONSIBILITY OF NON-DENTAL PROFESSIONALS REGARDING INFANT ORAL HEALTH CARE
Since health care professionals (i.e. physicians, nurses) are more likely to serve new mothers and children in their first three years of life compared to dental professionals, it is important they understand their role in providing parent/ caregiver oral health education, and be aware of the infectious and transmissible nature of bacteria that cause ECC, associated ECC risk factors, methods of oral health risk assessment (CAT), anticipatory guidance, and appropriate decisions regarding timely and effective intervention, as well as appropriate referral
ADDITIONAL READINGS
O’Connor TM, Yang SJ and Nicklas TA. Beverage Intake Among Preschool Children and it’s effect on Weight Status. Pediatrics 118:e1010-e1018, 2006.
Nowak A J and Warren J J. Infant Oral Health and Oral Habits. Ped Clinics NA 47:1043-1066, 2000.
Nowak AJ. Rationale for the timing of the first oral evaluation. Pediatr Dent 19:8-11, 1997.
Nowak AJ and Casamassimo PS. Using anticipatory guidance to provide early dental intervention. JADA 126:1156-1163, 1995.
Nowak AJ and Casamassimo PS. The Dental Home: A primary oral health concept. JADA 133:93-98, 2002.

Chapter 1: INFANT ORAL HEALTH

Areas of demineralization (white spot lesions)	More than 1	1	None
Enamel characteristics; hypoplasia, defects, retentive pits/fissures	Present		Absent
Part 3 – Supplemental assessment (Optional)
Radiographic enamel caries	Present		Absent
Levels of mutans streptococci	High	Moderate	Low

* Based on AAPD Policy on Use of Caries-risk Assessment Tool (CAT) for Infants, Children, and Adolescents. Pediatr Dent 2004:26(7) 25
Each child’s overall assessed risk for developing decay is based on the highest level of risk indicator circled above (i.e. a single risk indicator in any area of the “high risk” category classifies a child as being “high risk”).

The Handbook of Pediatric Dentistry