CO M M EN TA RY A N D C A S E ST U DY

Minimizing Aerosols with
Non-Surgical Approaches toCaries Management
By Brian B. Nový, DDS; Erinne N. Kennedy, DMD, MPH, MMSc;
Janice Donahoe; and Susan FournierC

linical caries manageto eliminate foci of infection,
ment has changed sigthere is little emphasis paid
Abstract
nificantly over theto and for bidirectionallypast decade. With the startlinking oral health and sysClinical caries management has improvedof a new decade, the world
temic health. Until dentists
significantly during the past decade by way ofis facing a new challenge,
are reimbursed to treat the
COVID-19. More than ever,underlying disease of dental
detection, treatment, and prevention. Now,
we are relying on a diseasecaries, our clinical system
COVID-19 has brought about even more impetus
management model of carwill remain stuck in the trato alter the practice of dentistry. Providers wereies, and a non-surgical apditional dogma of “drill anddirected to deploy caries treatment modalities thatproach to treatment of denfill,” a dogma that is domital caries disease.
nated by aerosol generating
do not generate aerosols and yet still control
The American Dental Asprocedures (AGP).6 Patientscaries disease. Never before has there been moresociation created a new Cardeserve and demand better.
reason to use remineralization agents and novel
ies Classification System,
Every dentist has access totreatment models including salivary diagnostics
and systematic reviews rechemistries and processes
garding sealants as well asthat have the potential toand creating dentists who are prodependent
non-surgical interventions
revolutionize the model ofcariologists. By walking through a patient case,have led to the creation ofcare. Is the profession willincluding traditional radiographs, salivary data,
new clinical guidelines1–4
ing to tap into these technoland patient photographs, we can see the benefit
that are more appropriate
ogies in an effort to effecthan ever before due to thetively
fight
the
most
of organizations that are “revolutionizing oral
inherent lack of aerosol genprevalent disease on Earth?
health.”eration. Patients of dentists
If not, they risk remaining
who are early adopters areentrenched in archaic modbeing introduced to the conels of prevention that seem
cept of remineralization rather than restoration, andto foster the delayed arrival of better evidence and im“patient-centered care” has been transformed into “perproved outcomes. More importantly, is there a payment
son-centered care.”system designed to encourage the adoption of better
All these changes may be viewed as “disruptive inscience and therapies without creating an environment
novation” or merely the natural evolution of our profesof fearful “co-dependent cariologists”?
sion based on improved science.5 Yet, without the coDespite fluoridation campaigns and public service
evolution of a business model that incentivizes diseaseprograms encouraging proper oral hygiene, our tradimanagement, this progress toward creating improved
tional therapeutics seem impotent and appear to be no
health for our patients will either adapt and affirm thematch for a population addicted to sugar, armed naively
medical management of dental caries or encounter conwith nylon bristles and string. Aciduric and acidogenic
tinued resistance through the reliance upon traditional
bacteria continue to evolve and adapt to an oral envioperative dentistry.
ronment. Salivary secretions continually modify that
There is a dental caries disease management-shaped
environment with the potential to buffer plaque acids
void in the payment system. Aside from patients withand confer a state of health.7 We must accept that we
co-morbidities such as cancer, where a dentist is asked(Continued on Page 50)
48

JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JULY 2020

Oral

Cleanliness

Gum healthTooth health

Figure 1 — SiLL-Ha salivary screening data from a patient before consuming arginine bicarbonate taffy (BasicBites).
Cariogenic
bacteria

31

Average
Ave.: 37

Every mouth contains a few of the bacteria that causes cavities. We want tohelp you keep this level from increasing, or decrease it.

Acidity70

High
Ave.: 43

Your saliva is too acidic and is encouraging the growth of bacteria. We will
help you find a way to change this, and lower your risk for cavities.

Buffercapacity

35

Average
Ave.: 36

The chemistry of your saliva is considered normal, but you may be able toimprove it by eating more protein (especially the amino acid arginine).

Blood

13

Low
Ave.: 22Congratulations! There is very little blood in your saliva, which indicatesyour gums are healthy.

Leukocyte

7

Low
Ave.: 49

Your saliva contains a low level of white blood cells indicating very little
inflammation in your mouth.

Protein9

Low
Ave.: 43

Congratulations! You have very little gingival crevicular fluid in your saliva.
This is an indication your gums are healthy.

Ammonia100

High
Ave.: 53

Your saliva contains an abundance of ammonia, which usually indicates thegrowth of commensal (healthy) bacteria. Sometimes this is linked to halitosis.

Overall comment

The findings above reflect the physiology of your mouth based on saliva and bacteria. These results help
us develop a highly personalized plan to prevent cavities, gingivitis, and gum disease. Our goal is toensure your optimal oral health for years to come.

Oral

Cleanliness

Gum healthTooth health

Figure 2 — SiLL-Ha salivary screening data from a patient after consuming arginine bicarbonate taffy (BasicBites).
Cariogenic
bacteria

55

High
Ave.: 37

Your mouth appears to have elevated levels of the bacteria that causes
cavities. We will provide you with some strategies to decrease this level.

Acidity

38

Average
Ave.: 43

Your saliva appears to be healthy today, but with some changes to your dietwe can ensure it stays healthy in the future.

Buffercapacity60

High
Ave.: 36

Congratulations! Your saliva contains all the chemistry necessary to help
your teeth and gums stay healthy.

Blood

10

Low
Ave.: 22Congratulations! There is very little blood in your saliva, which indicatesyour gums are healthy.

Leukocyte

18

Low
Ave.: 49

Your saliva contains a low level of white blood cells, indicating very little
inflammation in your mouth.

Protein

60

High
Ave.: 43

Your protein levels are elevated, which usually indicates some type of
infection. However, this may also be caused by recently eating healthy protein.

Ammonia92

High
Ave.: 53

Your saliva contains an abundance of ammonia, which usually indicates thegrowth of commensal (healthy) bacteria. Sometimes this is linked to halitosis.

JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JULY 202049

cannot fluoridate our way out of oral disease, we mustovercome the stale dogma that dental caries is simply
the result of bacteria metabolizing sugar and secretingacid. There are biochemical systems utilized by commensal (“good”) bacteria that result in the release ofammonia and generate a basic (capable of remineralization) biofilm. We as a profession are equipped, but not
well-positioned, to fully embrace disease managementin practice and pave the way for an era of truly efficacious oral health care while also decreasing aerosolgenerating procedures.
The health and disease of the mouth is highly dependent upon the physiology and chemistry provided bysaliva, yet few clinicians utilize salivary screening. It’s
often noted that a clinical treatment plan of restorations
and calculus removal is largely unaffected by the findings of a saliva analysis; however, the information obtained from basic salivary testing offers objective measurements upon which we can evaluate the success of
our therapeutic interventions. The data can act as a mo-tivating conversation-starter for patient engagement,
and the objective findings help clinicians prescribe customized interventions that address the individual needsof patients rather than continuing the traditional mindset of applying stronger fluoride with increased frequency8 (Figures 1 and 2, see Page 49).
Technology such as SiLL-Ha and Boka Flow alreadyoffer the potential to collect and analyze salivary datathat may ultimately improve the evidence base anddrive the future of oral health care.9 The SiLL-Ha Oral
Wellness System offers the ability to measure sevenmarkers for oral wellness (cariogenic bacteria, acidity,
buffer capacity, blood, leukocytes, protein, and ammonia). Boka Flow measures resting salivary flow with theaccuracy of three significant figures. Imagine a clinicalsystem wherein a patient’s intraoral physiology is understood on a chemical level so the prognosis for treatment is improved with tailored therapeutic interventions based on objective data, and dentists receive
financial compensation for improving and maintaining

Oral

Cleanliness

Gum healthTooth health

Figure 3 — SiLL-Ha salivary screening data from a patient before initiating sodium bicarbonate rinse.

Cariogenic
bacteria

44

Average
Ave.: 37

Every mouth contains a few of the bacteria that causes cavities. We want tohelp you keep this level from increasing, or decrease it.

Acidity89

High
Ave.: 43

Your saliva is too acidic and is encouraging the growth of bacteria. We will
help you find a way to change this, and lower your risk for cavities.

Buffercapacity

16

Low
Ave.: 36Your saliva seems to be lacking some critical chemistry. You would benefit
from using baking soda toothpaste and/or using MI Paste at bedtime.

Blood

17

Average
Ave.: 22Your saliva contains a small amount of blood, which usually indicatesgingivitis, although it could also be due to recent brushing or flossing.

Leukocyte

36

Low
Ave.: 49

Your saliva contains a low level of white blood cells, which indicates there isvery little inflammation.

Protein32

Low
Ave.: 43

Congratulations! You have very little gingival crevicular fluid in your mouth.
This is an indication your gums are healthy.

Ammonia

47

Average
Ave.: 53

Your saliva contains an abundance of ammonia. You may want to try andincrease this level by consuming more protein, especially when you snack.

Overall comment

50

The findings above reflect the physiology of your mouth based on saliva and bacteria. These results help
us develop a highly personalized plan to prevent cavities, gingivitis, and gum disease. Our goal is toensure your optimal oral health for years to come.

JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JULY 2020

health. That is the epitome of value-based care.
In 2019, the Massachusetts Public Employees Fundcreated a clinical practice (the Alliance Dental Center
LLC) to serve as an incubator for improving oral healthcare processes and systems while also providing traditional restorative dental treatment. Before COVID-19,
novel therapeutics were offered to patients along withevidence-based treatments based on clinical salivary
data in an effort to decrease disease incidence. During
the global pandemic the ADC was able to keep employees working and treating patients using teledentistry.
For example, patients at high risk for tooth decay were
contacted by phone to review oral health goals and proactively apply preventive strategies using motivational
interviewing. After the initial patient contact, patientspecific kits were assembled containing resources, educational materials, and preventive agents or therapies
that could balance risk factors.
Current theories in behavior change indicate patientengagement is paramount to successful use of preventive agents, and consequently the clinical staff at the Alliance Dental Center received intensive training in moti-

vational interviewing prior to beginning to offer clinicalservices.10 Rather than prescribing a preventive product, patients are encouraged to select their preferredcaries management strategy and create their own oral
health goal. A matrix was created for the clinical team to
identify preventive products that would “fit” into the patient’s lifestyle and preferences. For example, some patients prefer to simply use a different toothpaste, whileothers may choose to change their diet or begin chewing gum in between meals (Figure 5, see Page 52).
The therapeutics and preventive products used at
the Alliance Dental Center reflect the tremendous
strides in the past decade within the field of clinicalcariology. Although fluoride will continue to be the mostevidence-based preventive and therapeutic agent for
the time being, the body of research in novel therapies
has been the subject of three separate International
Conferences on Novel Anticaries and Remineralization
Agents (ICNARA 1, 2 and 3).11–13 These conferences haveresulted in entire publications focused on the future of
improving the clinical success of treating dental caries(Continued on Page 52)

Oral

Cleanliness

Gum healthTooth health

Figure 4 — SiLL-Ha salivary screening data from a patient after initiating sodium bicarbonate rinse.
Cariogenic
bacteria

61

High
Ave.: 37

Your mouth appears to have elevated levels of the bacteria that causes
cavities. We will provide you some strategies to decrease this level.

Acidity2

Low
Ave.: 43

Congratulations! The pH of your saliva is considered “Very Good.” While
this helps prevent cavities, you may notice more tartar forming on your teeth.

Buffercapacity100

High
Ave.: 36

Congratulations! Your saliva contains all the chemistry necessary to help
your teeth and gums stay healthy.

Blood

11

Low
Ave.: 22Congratulations! There is very little blood in your saliva, which indicatesyour gums are healthy.

Leukocyte

38

Average
Ave.: 49

The level of white blood cells in your saliva is elevated, probably due togingivitis or other sores in your mouth.

Protein

24

Low
Ave.: 43

Congratulations! You have very little gingival crevicular fluid in your mouth.
This is an indication your gums are healthy.

Ammonia1

Low
Ave.: 53

Your saliva has decreased ammonia content, which indicates an elevatedrisk for tooth decay. Consuming more protein can help raise this level.

Overall comment

The findings above reflect the physiology of your mouth based on saliva and bacteria. These results help
us develop a highly personalized plan to prevent cavities, gingivitis, and gum disease. Our goal is toensure your optimal oral health for years to come.

JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JULY 202051

around the world, with many of the therapies being
non-aerosol-generating procedures. As we move forward and treat patients in light of infectious diseases
like COVID-19, we all are called to look to innovative andless invasive means of offensively preventing and treating oral disease.
The Alliance Dental Center strives to deliver innovative care that is developed based on recognition of theevidence and the application of synergistic therapies
that many would consider novel. Rather than continuing what the clinical team felt was an ineffective strategy of disinfecting the mouth with broad spectrum antimicrobials and creating fluorapatite, chitosan

technology was identified as offering a new mechanism
for biofilm removal and control. Originally created formilitary purposes of wound management on the battlefield, chitosan rinses are now available over the counterand specifically designed for oral use. This remarkabletechnology appears to have all the characteristics of an
ideal mouthwash with a positive charge, basic pH, andthe ability to attract moisture, while also disrupting bacterial cell membranes. Peer-reviewed clinical studies
have already demonstrated utility in treating even themost severe hyposalivation (for example, patients undergoing chemotherapy, or those who suffer from medication induced xerostomia) with a minimal quantity.14

Figure 5 — The clinical matrix used at the Alliance Dental Center to identify preventive modalities that are customized
to patient’s preference and desired therapeutic outcome.
Desired treatment effectAntibacterial		

Neutralize acidic pH/
promote salivary flow

Improve the Oral
Microbiome

Remineralize or
Improve Enamel

Toothpaste

Baking soda
toothpaste

Xylitol toothpaste
Arginine toothpaste

5000 ppm F w/TCP
MI Paste One

MI Paste One

Livionex
Carbamide peroxide Xylitol gel
Carbamide peroxide		
Carbamide peroxide
Stannous fluoride gel			
				
				

Stannous fluoride
MI Paste Plus
Enamelon
Curodont
ReminProMI Paste
MI Paste Plus
ReminPro

Rinse

Synedent/Moisyn
ClosysCTx4 rinse
Listerine
Chlorhexidine

Baking soda water Xylitol water
Synedent/Moisyn
Xylitol rinse
CTx3/4 treatment		rinse
Xylitol		Synedent FLX
ACT mouthwash
Fluoride mouthwash

Salivamax

Spray

MoisynXylitol spray

Moisyn spray
CTx2 spray

Closys5000 ppm F
toothpaste

Patient preference for delivery

Gel

Lozenge/
Mint/Gum

Dentiva
SaleseLoloz				

Xylitol spray		CTx2 spray

Dentiva
Probiora		
SaleseXylitol candies/mints		
Xylitol gum
Loloz
Sugar-free gum
Pilocarpine lollipops

Food
Cranberry extract
Basic Bites
Xylitol granules
Product
Licorice root extract		
Erythritol granules
				

Improve Salivary		
Chemistry

CTx2 spray
Dentiva
SaleseSpinachIncrease protein inTea
the diet especially
Fluoridated tap water with arginine-rich foods

The table is meant to identify caries management strategies that can be easily implemented by individual patients based on
their personal preferences. Only one product should be recommended to the patient at each appointment and subsequent
recare visits should be used to inquire into the successful use of the recommended product. All patients should be
encouraged to increase contact time of toothpaste with their teeth by “leaving the foam alone.”52

JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JULY 2020

Probiotics, prebiotics, and protein scaffold remineralization strategies like P11-4 (also known as Curodont)take clinical interventions to new levels that haven’t
been appreciated by randomized controlled trials, but
outcomes measurement can better inform their strategic use. Progressive clinicians can provide probiotic
lozenges to a patient in an attempt to “seed” a healthy
biofilm, and dispense lozenges for patients to use daily
at bedtime.15 The commensal biofilm can be nurtured
further by adding a prebiotic such as dietary proteinrich in arginine, which serves as metabolic substratecreating the generation of basic plaque so that pathogen growth is suppressed.16 And, if a lesion does happen
to form, the application of P11-4 can create a biomimetic
precipitation of peptide chains that penetrate into early
demineralized surfaces, unlike any remineralization
chemistry we’ve seen before.17 In our practice, we areable to treat an initial carious lesion with a liquidsoaked sponge rather than a drill, a mode of treatmentthat can be safely delivered in the time of a pandemic.
All of these disruptive innovations require a value-

based reimbursement system to incentivize their clinical utilization and widespread adoption. At the AllianceDental Center, caries susceptibility testing is reimbursed
in order to facilitate screening and intervention with appropriate therapeutics. The clinical team is held accountable for health outcomes measured via a decreasein caries risk. The forward-thinking board of directorsof the Massachusetts Public Employees Fund and staff
at the Alliance Dental Center are on the leading edge of
pursuing improved health unhindered by a lack of evidence for the clinical utility of improved diagnostics andtherapies. Yet often, the simplest modification of raising
the intraoral pH to a basic level using sodium bicarbonate rinse achieves results in a short period of time.(Figures 4, see Page 51, and Figure 5).
The rest of the dental ecosystem is at least one stepbehind. At the moment, most dental practices don’t assess the caries risk of patients at all visits. Worse still isthe fact that some payers reject claims containing a caries risk assessment, or refuse to reimburse for more(Continued on Page 54)

Figure 6 — Radiographic presentation of the patient’s dental caries disease secondary to medication-induced
xerostomia.

JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JULY 202053

than one risk assessment every three years. However,
without the use of caries risk assessment codes, clinical environments are unable to track the disease prevalence and incidence within their systems. Every practice should be able to calculate the health of the
population it treats using metrics within its practicemanagement software; however, our data systems
struggle to calculate outcomes. Instead, the majority ofelectronic dental records are designed to calculate financial gains and losses rather than the incidence oforal disease. Practice level metrics belong in every dental office, not just the meetings of the Dental Quality Alliance. The Dental Caries Management Virtual Practicum (available online for free) offers a comprehensive
experience for all members of the dental team to create
health measurement in any practice setting using any
computer-based practice management system.18
Dr. Bob Barkley wrote in 1972 in Successful Preventive
Dental Practices, “. . . disease management programs are
finally gaining respectability as bonafide tools of dentistry.”19 Yet, nearly 50 years later, our fee-for-service
reimbursement system continues to incentivize a surgi-

cal model that leads to more restorations rather thanless disease. It’s doubtful that G.V. Black thought itwould take more than a century for his famous statement, “The day is surely coming, and perhaps within the
lifetime of you [clinicians] before me when we will be
engaged in practicing preventive rather than reparative
dentistry” to come true.20
Perhaps value-based oral health care and our response to a global pandemic will usher in the practice oftrue preventive dentistry as G.V. Black envisioned. As optimistic as some of us are, something is holding us backfrom achieving the goal of an oral health care ecosystem.
The profession has never been better prepared to treat
oral disease and measure our success — the science,therapies, clinicians, and patients are all ready and eager. It is up to the profession to guide the new era of oral
health care, wherein patients stop developing disease
and payment is linked to the creation of health. The clinician who fears the pitfalls of co-dependent cariology may
find some solace in the realization that once value-based
reimbursement becomes a reality, every general dentist
is capable of becoming a prodependent cariologist.

Oral
54

Cleanliness

Gum healthTooth health

Figure 7 — Baseline SiLL-Ha salivary screening data demonstrating an oral environment highly prone to continued
demineralization and disease.

Cariogenic
bacteria

0

Low
Ave.: 37

Studies have shown that higher cariogenic bacteria count makes the teeth
more vulnerable to caries.

Acidity85

High
Ave.: 43

Studies have shown that higher salivary acidity makes the teeth more
vulnerable to caries.

Buffercapacity25

Low
Ave.: 36

Studies have shown that lower buffer capacity (resistance to acid) makes theteeth more vulnerable to caries.

Blood

55

High
Ave.: 22

Studies have shown that gingival inflammation, oral damage, and oral
mucosal ulcer increase blood in saliva.

Leukocyte

84

High
Ave.: 49

Studies have shown that gingival inflammation increases leukocytes insaliva.

Protein

78

High
Ave.: 43

Studies have shown that higher periodontal disease-causing bacteria countand gingival inflammation increase protein in saliva.

Ammonia7

Low
Ave.: 53

Studies have shown that higher bacteria count in the oral cavity increases
ammonia in saliva, causing bad breath, etc.

JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JULY 2020

Clinical case

Patients with medication-induced
xerostomia (also known as MIX disease) present a unique clinical challenge that requires aggressive caries
disease stabilization and intensive
home prevention prior to providing
long term restorations.
A 52-year-old female presented
with a two-year history of periapical
pathology on multiple teeth identified by her primary care physician
via MRI, resulting in chronic sinusitis
and hospitalization. Due to personal
circumstances and a complicatedmedical history consisting of lupus,
attention deficit hyperactivity disorder (ADHD), anxiety, depression, insomnia, fibromyalgia, anemia, gastroesophageal
refluxdisorder(GERD), and gastric bypass, she de-layed seeking dental care. Upon presenting for care she was identified as
an extreme dental caries risk secondary to medication-induced xerostomia, resulting in what would betraditionally referred to as “rampant
dental caries disease” with multiple
non-restorable teeth (Figure 6, see
Page 53).
The patient’s salivary assessment
via SiLL-Ha data verified her acidic
oral environment, lack of buffering
capacity, overgrowth of cariogenic
bacteria, and periodontal inflammatory markers, which became a baseline measurement to assess the patient’s progress toward health in the
future (Figure 7).
She was immediately treated witha full mouth application of silver diamine fluoride, and she selected to

Figure 8 — Clinical presentation of the patient’s dentition after restorative
treatment with resin modified glass ionomer and conventional glassionomer.

begin using a mouthwash (Moisyn)that would alleviate her constant xerostomia. A compounding pharmacy
was contacted to create pilocarpine
lollipops (5 mg pilocarpine in a 2g
sorbitol/xylitol base), which the patient was instructed to use as needed throughout the day. At her second
visit, she remarked that the mouthwash seemed to be helping because
she had noticed a decrease in oral
discomfort. Nonsurgical periodontal
therapy was provided along with asecond application of silver diamine
fluoride to all surfaces. She was referred to an endodontist for evaluation and treatment of her symptomatic teeth and she consented to an
initial treatment plan consisting of
the elimination of all active caries
disease and restoration of all surfaces with conventional and resin modified glass ionomer.
Over the course of her eightmonth treatment plans the patient
had three extractions, and five teeth
were treated with endodontics. Allexisting restorations were removed
and replaced with glass ionomer(and resin-modified glass ionomer)
restorations with the intention to
use the large restorations as buildups for full coverage restorations in
the future (Figure 8). She continues
to use the Moisyn rinse every night,
pilocarpine lollipops as needed, andtries to sip on xylitol water throughout the day (4 grams of xylitol in 16
ounces of water). She reports an improved quality of life and looks forward to her dental visits.
Although her salivary analysis
data does not show the creation ofan altogether stable and low caries
risk environment, the screening metrics allow for continued evaluationof the patient’s progress. Further useof her salivary data will hopefully
demonstrate continued stabilizationof her oral condition. (Continued on Page 56)

JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JULY 202055

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About the Authors
Brian B. Nový, DDS, is affiliated with
the Alliance Dental Center LLC in
Quincy, Massachusetts; the Harvard
School of Dental Medicine Departmentof Oral Health Policy andEpidemiology in Boston,
Massachusetts; Loma Linda University
School of Dentistry, Division of
Operative Dentistry, in Loma Linda,
California, and the College of Dental
KennedyNovýMedicine, Western University of Health
Sciences, Pomona, California.
Erinne N. Kennedy DMD, MPH,
MMSc, is affiliated with the AllianceDental Center LLC in Quincy,
Massachusetts, and the Harvard
School of Dental Medicine Departmentof Oral Health Policy andEpidemiology in Boston,
Massachusetts.
Janice Donahoe is affiliated with theFournier
Donahoe
Alliance Dental Center LLC in Quincy,
Massachusetts.
Susan Fournier is affiliated with the Alliance Dental Center LLC in Quincy,
Massachusetts, and the Massachusetts Public Employees Fund in Boston,
Massachusetts.

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Disclosure: Dr. Nový has received lecture honoraria in the past from GC
America, Air Techniques, Xlear, Ivoclar, SDI, Triodent, Shofu, CariFree, GSK,
Straumann, Church and Dwight, and has served as a consultant to Philips andMars-Wrigley. Dr. Kennedy is a consultant to ARKRAY USA. Donahoe and Fournier
have no potential conflicts to disclose.

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JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JULY 2020