NDA Journal Summer 2023

NDA JOURNAL Summer 23 Volume 25, Issue 2 Official Magazine of the Nevada Dental Association and Component Societies A Peer Reviewed Journal

SUMMER 23 NDA JOURNAL Editor’s Message Daniel L. Orr II, DDS, MS (anesth), PhD, JD, MD 2 News Dental-Legal, Removable Orthodontic Devices 8 Featured Articles The DAT’s Lost Art Daniel L. Orr II, DDS, MS (anesth), PhD, JD, MD 6 Masks Cause Headaches, Itching, and Lower Oxygen Intake: Study 9 More Confirmation of Covid Experimental Formulation Ophthalmological Complications 11 A Historical Perspective on Informed Consent 12 Reports NDA President and Executive Director 16 Jason R. Doucette, DMD; Michele M. Reeder SNDS President Richard Schoen, DDS 18 SNDS Executive Director Esther Johnson 19 NNDS Executive Director Lori Benvin 20 NNDS President Chris Galea 22 Sections Event Calendars 23 Administrative Offices & NDA Committees 24 On the Cover Alexander King’s advice on DAT Carving, Conquer Carving for the Dental Aptitude Test (ISBN 9780981349237) was published in 2011. If it isn’t too late to try again, it can be found used for about $100.00. Nevada Dental Association 600 E. William Street, Ste 202 Carson City, NV 89701 PH 702-255-4211 FAX 702-255-3302 EMAIL [email protected] WEB www.nvda.org NDA Journal is published four times each year by the Nevada Dental Association and state component societies. All views expressed herein are published on the authority of the writer under whose name they appear and are not to be regarded as views of the publishers. We reserve the right to reduce, revise, or reject any manuscript submitted for publication. Materials: All articles, letters to the editor, photos, etc. should be sent to Daniel L. Orr II, DDS, via email to [email protected]. All chapter and committee reports and business communications should be sent to Michele Reeder, Executive Director, Nevada Dental Association, 600 E. William Street, #202, Carson City, NV 89701. Ph: 702-255-4211. Materials may be reproduced with written permission. Subscription: Members receive each publication as a membership benefit paid by membership dues. Non-members may subscribe to the Nevada Dental Association Journal for $50 annually. Advertising Policy: All advertising appearing in the NDA Journal and other Nevada dental publications must comply with the advertising standards of the Nevada Dental Association and its component societies. The publication of an advertisement is not to be construed as an endorsement or approval by the publishers of the product or service being offered in the advertisement unless the advertisement specifically includes an authorized statement that such approval or endorsement has been granted. The publishers further reserve the right to cancel any and all contractual advertising agreements should an advertiser be engaged in litigation concerning their product or service, or should the product or service be in conflict with the standards of the NDA or its component societies. Advertising rates and specifications are available upon request. Contact Grandt Mansfield, LLM Publications, at 800-647-1511 ext 2226 or email [email protected]. Mailing: Send address changes to: 600 E. William Street, #202, Carson City, NV 89701. © 2023 Nevada Dental Association Editor Daniel L. Orr II, DDS, MS (anesth), PhD, JD, MD [email protected] Publisher LLM Publications 800-647-1511 www.llmpubs.com Design: Shelby Bigelow NDA JOURNAL

NDA Journal 2 Dr. Orr practices Anesthesiology and OMS in Las Vegas, is an Adjunct Professor (Surgery) at UNLV SM and Touro University SM (Jurisprudence), Professor Emeritus at UNLV SDM, and a member of the CA Bar and Ninth Circuit Court of Appeals. Editor’s Message Daniel L. Orr II, DDS, MS (anesth), PhD, JD, MD [email protected] NDAJ Exclusive The Tyranny of Testing The dentist readership of the NDAJ have all been through a highly competitive and quantitatively and qualitatively rigorous academic course on the road to a dental degree. Congratulations on making the grade; not everyone did. It is safe to say that many pre- professionals have wondered if they would make the cut. For the last 100 years or so,1 achieving academic goals has been determined by success with multiple-choice testing, wherein the alleged “best” answer must be picked, but without allowing the tested the option of explaining the reasoning behind the chosen answer. The Scholastic Aptitude Test (SAT) became the standard in 1926. What serious university, or even high school, student, has not accurately determined that a multiple-choice question was ridiculous? Who hasn’t wondered if the test developer wasn’t even as qualified to pose the question as the student? With regards to nonsensical questions, were they intentionally or unintentionally bad? Lives are actually seriously affected by such testing issues, so they matter, a lot. Evaluating multiple-choice tests occasionally includes listening to the tested, for instance when one or more are challenging the “right answer” with incisive reasoning. We’ve been in classes where it is announced that a question or two has been “thrown out” for some defect, which is fine unless you already happened to stumble upon the “right answer.” Intentionally making the test question more difficult than the actual subject being evaluated is a real phenomenon. Two examples come to mind: Advanced Trauma Life Support (ATLS) and the California State Bar examination. The population taking these tests are either trauma surgeons or attorneys, so theoretically an erudite crowd that probably knows most of the answers in a practical sense. In order to somewhat artificially obtain a more typical bell curve, or perhaps to limit Figure 1, Chalk Dust

Summer 23 www.nvda.org 3 Editor’s Message the competition, the exam questions for these entities are routinely peppered with, for instance, unnecessary and confusing double-negative queries or long-precursor sentences in which a correct “mm” is replaced by a “cm” even though 5–6 other factoids are 100% correct. For 100 years, there has been a group of dentists that think graduation from an accredited dental school should qualify one for a license. (And if it does not, why in the world are candidates allowed to test/experiment on real, live patients?) In the 1970’s most clinical board examinations were state specific, now most are qualifiers for large regional areas. But even after a professional license is obtained, we are required to submit to the highly profitable MOC (maintenance of certification) industry under the apparent assumption that age and experience produces a dumber professional. MOC in reality helps drive highly qualified individuals out of professions prematurely, not because of a MOC failure but because many decide MOC isn’t worth the time and expense as they enter other fields.2 While taking tests is challenging, as a test administrator for multiple entities now, (UNLV SDM, CODA, NSBDE, AAAHC, etc.) it is my opinion that creating a test that validly evaluates and ranks the test takers is at least as difficult as sitting for one. However, while test takers are painfully stressed on multiple levels, test creators are not as very little, if anything, about the test affects them personally. In contract law, this is an unequal bargaining position, and dooms the purported agreement. We all developed various levels of testmanship in order to position ourselves to achieve our goals. Testmanship has nothing to do with the subject matter of the test, but rather how to significantly optimize one’s chances for a better score. It is important in everything from driver’s Psychological testing is an area that has a singular testmanship learning curve. An acquaintance who was applying for a higher-level law-enforcement position “failed” the Minnesota Multiphasic Personality Inventory (MMPI) when answering “feeling” questions. A successful result was obtained when he learned to balance his answers, sometimes liking, for instance, flowers, and sometimes not, but never hating innocent rhododendrons or not being able to live without a special floral arrangement. Same person the second time around, but one who recognized the necessity of proffering different feelings. In dental school at USC, our faculty channeled the highly correlative DAT chalk carving exercise3 (Figure 1) with…oh, never mind. Anyway, we were required to carve, out of wax, each tooth in the mouth. I spent 5–6 hours on my first one, a maxillary central incisor. My instructor gave me a B and I gave him the benefit of the doubt for an, in my inexperienced opinion, obvious A tooth. But just in case, I almost doubled down on hours, 8 of them dedicated to the maxillary lateral incisor. The extra hours were rewarded, with another B. Admittedly, my dental school attitude was devolving rapidly. For the cuspid caution was thrown to the wind and #6 was knocked out in two hours. Shockingly I was rewarded, along with salvaging many extra hours, with another subjective B effort. Taking the valuable lesson that the enemy of good is better, 11 months before graduation I was the first student to finish all the clinical requirements, contentedly collecting my Bs along the way. There is a trend now in some areas to not seek the most talented candidate for a position, but the most mediocre,4 intentionally rating applicants on traits other than intellect or abilities especially suited for the position. license strategies to Ph.D. dissertations. Techniques such as determining how much average time one has for each question and then making sure time is allowed at the end of the period in order to randomly guess at all unanswered questions predicably increases a score (unless there is an enhanced penalty for a wrong answer that changes this testmanship approach). » Figure 2, Not tooth carving, but the real teeth in the USC cariology project, another A effort that was misgraded with a B What serious university, or even high school, student, has not accurately determined that a multiple-choice question was ridiculous? Who hasn’t wondered if the test developer wasn’t even as qualified to pose the question as the student?

NDA Journal 4 Editor’s Message This has resulted in unqualified candidates gaining positions of serious responsibility, particularly in government sectors.5 Everyone lives with testing to one degree or another. I have 9 kids that have been taught testmanship principles with varying degrees of success. We have not been particularly efficient in obtaining our 7, so far, driver’s licenses. Holly (Figure 3) successfully prepped enough to navigate the DMV waters the first time. Kaitlin (Figure 4) passed the first day she went to the DMV. In terms of full disclosure, Katie actually failed initially and was told to come back in a few weeks to try again. Someone said we should just go to another DMV before » References Ramirez A, The Dark history of the Multiple-Choice Test, Edutopia The George Lucas Educational Foundation, May 20, 2013. Kempen P, The Curse and Corporate Cult of Certification in America, J Am Assoc Phys and Surg, 26:2, 39–42, 2001. Orr D, The DAT’s Lost Art, NDAJ 17:1, 4–5, 2015. Hoffmann, B, The Tyranny of Testing, Crowell-Collier, NY, 1962. Ngcukana L, Many government employees not qualified for the positions they hold, City Press, April 12, 2021, https://www.news24.com/citypress/ news/many-government-employees-not-qualified-for-the-positions- they-hold-minister-discloses-in-parliament-20210412, accessed March 25 2023. 1 2 3 4 5 the failure was entered into the computer, which we did immediately, where Katie passed, learning about creative DMV testmanship along the way. After learning, as the number of kids grew, how important testmanship is, our efforts were also rewarded by #5 Andrew’s 4.0 summa cum laude university recognition. Poor #6 Ivy didn’t fare so well with just magna cum laude, secondary to an A- in a dance class (Figure 5). By the way, Andrew and Ivy both lowered the driver’s license curve by initially failing at the DMV. One younger child, Luke, figured out the keys for a stress-free educational experience, kind of, at his all-online Covid-non-crisis-era school. It was a full semester before he and multiple junior high school coconspirators were discovered to have pushed the “submit” button without actually attaching any work. These outside- the-box creative thinkers were ultimately rewarded with self-funded mandatory summer school classes if they wanted to matriculate into high school. But, with a possible silver lining discovery, during the pre-high school intelligence testing at summer school, my temporarily wayward son tested 3–4 years above his grade level…aye. Fight On! 0 Figure 4, Katie had near immediate DMV success Figure 3, Holly in early DMV preparation at Chuck-E-Cheese It is my opinion that creating a test that validly evaluates and ranks the test takers is at least as difficult as sitting for one. However, while test takers are painfully stressed on multiple levels, test creators are not as very little, if anything, about the test affects them personally. Figure 5, Ivy, center, trying to keep up with beautiful Polynesian ladies

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NDA Journal 6 Dr. Orr practices Anesthesiology and OMS in Las Vegas, is an Adjunct Professor (Surgery) at UNLV SM and Touro University SM (Jurisprudence), Professor Emeritus at UNLV SDM, and a member of the CA Bar and Ninth Circuit Court of Appeals. Featured Article Daniel L. Orr II, DDS, MS (anesth), PhD, JD, MD [email protected] From the NDAJ 17:1, 2015 The DAT’s Lost Art At a recent Eagle Scout Court of Honor, one of the speakers talked about “rites of passage,” in which young people participate in a culture’s ceremony in order to progress to adulthood. His example was that of the Mandan Indians’ Okipa—wherein young men refrained from food, water, and sleep for four days before incisions were made over their pectoral and trapezius musculature. Wooden skewers were then placed beneath the muscles and the initiates were hung from the ceiling via ropes attached to the skewers. After that, the little finger of one hand was cut off. The last Okipa ceremony was in 1889, but it was revisited in the 1970 movie “A Man Called Horse.” Another rite of passage, the Dental Admission Testing (DAT) Dental Aptitude Chalk Carving was last practiced in 1972, after having been an integral part of the DAT since its inception in 1945. Fortunately, I entered dental school in 1971, thus earning the title of a true chalk carving (CC) dentist, unlike later post-modern pretenders who probably have no comprehension of the gold foil restorative ideal either. Carving, albeit with soap, has been revisited recently with a study published in JAMA.1 Shockingly, the soap carving exercise some ENT programs require during residency interviews appears to have no correlation with surgical skills. Maybe that’s because soap gets slippery when handled and chalk is designed to keep hands dry—just ask Mary Lou Retton or Olga Korbut. Imagine what would have happened to them if they’d tried soaping up instead of chalking up at the Olympics. Silly ENTs… Another problem with the ENT paradigm is the object carved…a hollowed out shark fin…are you kidding? Why would they want to carve a functional curved shape when they could demand the imaginative ‘whatever it was’ that the DAT used to require? True chalk carving dentists, who have not repressed the event, will joyfully recognize the figures shown in the sidebar (page 7); younger dental aspirants can only envy those upon whose shoulders they stand. (See Steps 1–4) So, since chalk carving is obviously superior to soap carving, why did the DAT discontinue this valuable exercise (was it simple coincidence it was right after receiving my most excellent carving?)? (Figure 1) Offcially, the ADA states that they found pencil-and- paper test scores were as valid as the Chalk Carving Test in predicting performance.2 Humbug, I say.

Summer 23 www.nvda.org 7 Figure 1, The Editor’s “Corrected” DAT. Inconceivably, Carving Dexterity was downgraded from an 8 to a 7. Even more astounding, the Academic Average morphed from a 4 to a 6 Figure 2, Dr. Tom’s elephant in the UNLV SDM applicant’s boat At present, the DAT’s Perceptual Ability Test currently contains questions which include “problems in block counting” (my four year-old, Brighton, does that), “angle size” (the bigger the angle’s tackle, the bigger the fish, duh), “form development” (don’t we have enough forms being developed already?), “orthographic projections” (what does orthographics, orthodontics, ortho-whatever have to do with it?), “comparison of shapes of object with apertures” (what, square peg, round hole problem? Get a bigger hammer, problem solved), and “paper folding” (ah, origami). The only realistically meaningful one of these less ideal than chalk carving ADA options is paper folding. For instance, I interviewed a dental student applicant a couple of years ago and his chart mentioned he did origami. Since I needed a boat for the elephant Dr. Fransom Tom made for me, I said “show me.” He did, with my own dollar bill (Figure 2). Perhaps the ADA changed the DAT model because of the known complications of chalk carving. Tragically, as happened in my chalk carving session, at times masterpieces are accidently dropped to the floor, or thrown against the wall prn, necessitating career change considerations on the spot either way. As with the Mandans, occasionally fingers were cut, albeit not amputated, an advantage of the DAT over Okipa. But, then again, the Mandans, like post-1972 DAT examinees, have never dared to renegotiate the rite of chalk carving!0 References Tang CG, Hilsinger RL, et al, Manual dexterity aptitude testing: a soap carving study, JAMA 140:3, March 2014. ADA, History of the Dental Admission Testing Program, 2009, http://www.ada. org/~/media/ADA/Education%20and%20Careers/Files/dat_users_manual. ashx, accessed 06 November 2014. 1 2 DAT Dental Aptitude Chalk Carving Image by Louisiana State University Health Sciences Center School of Dentistry. Step 1: Get stuff and look at picture. 1 Step 4: Viola! Pick dental school. 4 Step 3: Measure dust pile. 3 Step 2: Stare at chalk. If nothing happens, begin carving. 2 Featured Article

NDA Journal 8 News Dental-Legal, Removable Orthodontic Devices Federal prosecutors have launched a criminal investigation into the Anterior Growth Guidance Appliance, or “AGGA” dental device, following a recent CBS News-KFF Health News investigation, according to a motion filed in federal court. Multiple lawsuits allege the device has caused grievous harm to at least 20 patients and the FDA is now investigating its safety, CBS News and KFF Health News have reported. The AGGA is a retainer-like device promoted by dentists as an option for expanding adult patients’ jawbones, beautifying their faces, and curing common ailments like sleep apnea. The lawsuits have alleged patients suffered damaged gums, eroded bone, and, in some cases, lost teeth. The criminal investigation of the use of the AGGA was revealed in a court motion that seeks to delay the largest of the lawsuits until the investigation is complete. The motion was filed this month by attorneys for AGGA inventor Dr. Steve Galella, his company, the Facial Beauty Institute, and AGGA manufacturer Johns Dental Laboratories, all of whom said the investigation is being conducted “for the purpose of potentially bringing criminal charges” against their clients. The attorneys said in their court filing that there is “no doubt” the investigation arose from the investigations by CBS News and KFF Health News. “The U.S. Attorney’s Office for the Western District of Tennessee and the U.S. Department of Justice is currently conducting a criminal investigation which, it is anticipated, will ultimately result in the presentation of evidence to a grand jury relating to the facts in this case,” the attorneys state in a court filing in support of the motion. None of the court records identifies what criminal charges could result from the investigation. The U.S. Attorney’s Office in Memphis, which generally does not discuss ongoing investigations, declined to comment. Scott Charnas, an attorney representing many AGGA patients, also declined to comment. Attorneys for Galella, the Facial Beauty Institute, and Johns Dental did not respond to requests for comment on Tuesday. The AGGA, which was recently rebranded as the Osseo-Restoration Appliance, uses springs to apply pressure to the front teeth and upper palate, according to a patent application filed in 2021. Galella has said pressure from the device causes an adult’s jaw to “remodel” forward, which he described, in training footage produced in discovery in an AGGA lawsuit, as the key to “curing” patients and making them more beautiful. “You can sell good health. You can help people and at the same time you’re going to make a wheelbarrow full of money,” Galella tells dentists in the video footage. “And it’s all OK, and it’s all fair. We’re not cheating anybody and we’re not being greedy, but that just comes with the territory.” The CBS News-KFF Health News investigation of the AGGA involved interviews with 11 patients who said they were hurt by the device—plus attorneys who said they represent or have represented at least 23 others— and dental specialists who said they’d examined patients who had experienced severe complications using the AGGA. The investigation also found no record of the AGGA being registered with the FDA, despite the agency’s role in regulating medical and dental devices. Galella has said in a sworn court deposition that the device was never submitted to the FDA, which he believes wouldn’t have jurisdiction over it. The FDA announced late last month that it is “evaluating safety concerns” about the AGGA and other similar devices. Galella has declined to be interviewed by CBS News and KFF Health News. His attorney, Alan Fumuso, previously said in a written statement that the AGGA, “when properly used, is safe and can achieve beneficial results.” All the AGGA lawsuits are ongoing. Galella and the other defendants have denied liability in court filings. The plaintiffs do not allege in their lawsuits that Galella treated them but allege he or his company consulted with each of their dentists about their AGGA treatment.0 Editor’s Note: The NDAJ would be interested in the other side of this story or further information on the use of removable orthodontic devices in general. Several Dentists have been interviewed and opined negatively about AGGA. Is AGGA realistically defensible? Thank you.

Summer 23 www.nvda.org 9 Featured Article » Masks Cause Headaches, Itching, and Lower Oxygen Intake: Study by: Naveen Athrappull A systematic review of 2,168 studies that looked into the adverse effects of wearing masks during the COVID-19 pandemic has found that the practice led to negative health consequences, including itching, headaches, and restriction of oxygen. “We found significant effects in both medical surgical and N95 masks, with a greater impact of the second,” states the review, published in the “Frontiers in Public Health” on April 5. A meta-analysis of multiple studies found that headache was the “most frequent symptom” among mask wearers, with a prevalence of 62 percent for general mask use and up to 70 percent when using N95 masks. Shortness of breath was observed at 33 percent for general mask use and 37 percent among N95 users. While 17 percent of surgical mask wearers experienced itching, this number was at 51 percent among users of N95. Acne prevalence among mask users was at 38 percent and skin irritation was at 36 percent. Dizziness was found to be prevalent among 5 percent of subjects. “Masks interfered with O2-uptake and CO2-release and compromised respiratory compensation,” the review states. “Though evaluated wearing durations are shorter than daily /prolonged use, outcomes independently validate mask-induced exhaustion-syndrome (MIES) and down-stream physio-metabolic disfunctions. MIES can have long-term clinical consequences, especially for vulnerable groups.” The restriction of oxygen uptake and hindrance in carbon-dioxide release was identified as more significant among users of N95 masks. Continuous rebreathing of carbon dioxide results in the “right-shift of hemoglobin-O2 saturation curve.” “Since O2 and CO2 homeostasis influences diverse down-stream metabolic processes, corresponding changes toward clinically concerning directions may lead to unfavorable consequences such as transient hypoxemia and hypercarbia, increased breath humidity, and body temperature along with compromised physiological compensations,” the review states. The review also said that several mask-related symptoms may have been misinterpreted as symptoms of long COVID. “In any case, the possible MIES contrasts with the WHO definition of health,” it states, referring to The World Health Organization. It suggested that the side effects of face masks be assessed based on risk-benefit analysis after taking into consideration their effectiveness against viral transmissions. If “strong empirical evidence” showing the effectiveness of masks is absent, the study recommended that wearing masks should not be mandated, “let alone enforced by law.” Prior to the COVID-19 pandemic, existing data on respiratory viruses had shown that there was no basis for wearing masks to prevent their spread. “All the studies done in the world until 2020 showed that there is no justification for this,” Yoav Yehezkelli, a specialist in internal medicine and a lieutenant colonel in the Israel Defense Forces, said in an interview with The Epoch Times in January. The U.S. Centers for Disease Control and Prevention as well as the WHO issued guidelines that there was no need for wearing masks in the general public, he pointed out. But in 2020 following the COVID19 outbreak, recommendations on mask-wearing around the world suddenly changed “without having any new professional support to confirm that it does indeed have effectiveness against respiratory infection.” A December letter that he co-wrote and sent to the Israel Medical Association Journal pointed to multiple

NDA Journal 10 studies suggesting that wearing masks can end up causing harm. Potential negative effects include headaches, shortness of breath, a dip in blood oxygen levels, a rise in carbon dioxide levels, concentration difficulties, and bacterial contamination. The accumulation of CO2 can end up causing tiredness, blurriness, and sleepiness, he noted. There have also been attempts to subdue studies that expose the ineffectiveness of masks. A 2023 study published in the Cochrane Database of Systematic Reviews stated that wearing masks made “little or no difference” when it came to the transmission of COVID-19. A columnist at The New York Times published an opinion piece titled “Here’s Why the Science Is Clear That Masks Work” and reached out to Cochrane for its view. The editorin-chief at Cochrane then issued a statement saying that it’s an “inaccurate and misleading interpretation” to say the study shows that masks do not work, adding that the publication was “engaging” with the authors on updating the article’s abstract. However, the authors refused to do so, with the lead author insisting that “there is just no evidence that [masks] make any difference…full stop.”0 Editor’s Note: As with nearly all the recent studies on complications of the Covid injectable experimental therapies, there are no surprises here. See Orr D, Unmasking Masks, or Vectors Trump Barriers, NDAJ, 22:4, 2020. » References Epoch Health, https://www.theepochtimes.com/health/maskscause-headaches-itching-and-lower-oxygen-intake-study_5181866. html?utm_source=healthnoe&src_src=healthnoe&utm_campaign=health2023-04-19&src_cmp=health-2023-04-19&utm_medium=email&est= gxwnV2I7PRVTna1hdRVdXbKiacLOuL1rWMdQCJ1t1%2FHjM46EP0 OHehMH0VLBf%2FM%3D, accessed 11 May 2023. 1 Featured Article

Summer 23 www.nvda.org 11 Featured Article More Confirmation of Covid Experimental Formulation Ophthalmological Complications by: Jing-Xing Li, Yu-Hsun Wang, Henry Bair, Shu-Bai Hsu, Connie Chen, James Cheng-Chung Wei & Chun-Ju Lin Risk assessment of retinal vascular occlusion after COVID-19 vaccination Vaccines volume 8, Article number: 64 (2023) Coronavirus disease 2019 (COVID-19) vaccines are associated with several ocular manifestations. Emerging evidence has been reported; however, the causality between the two is debatable. We aimed to investigate the risk of retinal vascular occlusion after COVID-19 vaccination. This retrospective cohort study used the TriNetX global network and included individuals vaccinated with COVID-19 vaccines between January 2020 and December 2022. We excluded individuals with a history of retinal vascular occlusion or those who used any systemic medication that could potentially affect blood coagulation prior to vaccination. To compare the risk of retinal vascular occlusion, we employed multivariable-adjusted Cox proportional hazards models after performing a 1:1 propensity score matching between the vaccinated and unvaccinated cohorts. Individuals with COVID-19 vaccination had a higher risk of all forms of retinal vascular occlusion in two years after vaccination, with an overall hazard ratio of 2.19 (95 percent confidence interval 2.00–2.39). The cumulative incidence of retinal vascular occlusion was significantly higher in the vaccinated cohort compared to the unvaccinated cohort, two years and 12 weeks after vaccination. The risk of retinal vascular occlusion significantly increased during the first two weeks after vaccination and persisted for 12 weeks. Additionally, individuals with first and second dose of BNT162b2 and mRNA-1273 had significantly increased risk of retinal vascular occlusion two years following vaccination, while no disparity was detected between brand and dose of vaccines. This large multicenter study strengthens the findings of previous cases. Retinal vascular occlusion may not be a coincidental finding after COVID-19 vaccination.0

NDA Journal 12 Featured Article A Historical Perspective on Informed Consent The idea of informed consent stems from the principle that every adult human being has a right to determine what is to be done with their own body. If a dentist performs treatment without the patient’s consent, he may be liable for damages against that person. Under the doctrine of informed consent, even though a particular treatment has been successful, the dentist still may be liable irrespective of whether the dentist has exercised the care required. Also, the doctrine of informed consent provides that a dentist may be liable for damages to a patient who assented to a particular treatment if the dentist failed to render an adequate disclosure in regard to the diagnosis, the procedure to be followed, the risks of the procedure, and the alternative treatments. In regard to the patient, informed consent is the only legal control over the communication component of the dentist-patient relationship. Dentists have a fiduciary obligation to their patients because of the inherent relationship between the “submissive” patient and the authoritarian control of the doctor. Informed consent acts as an instrument to assist the patients in neutralizing this imbalance in status and knowledge. As such, this increased involvement in their own well-being increases a person’s dignity and self-worth. The mechanism itself in informed consent provides a unique tool in creating an opportunity for the patient’s involvement in the decision-making process. It gives the individual the right to the ultimate judgment about a course of dental treatment which helps create a “patient partner” as opposed to a submissive patient. This does not mean that a dentist must inform the patient of every conceivable risk possible. It is the dentist’s responsibility to make a “reasonable disclosure” to their patient concerning the nature and probable consequences of the proposed treatment. As such: • The dentist does not need to disclose relatively minor risks which are inherent in the procedures and where there is common knowledge of those risks. • A dentist does not need to give the patient information concerning the proposed treatment if the patient requests that they not be informed. The vast majority of courts use a term called an “objective” test which means that a “prudent” person in the patient’s position would have decided if they were suitably informed of “all perils bearing significance.” This measure’s “materiality” from the position of what the dentist “reasonably” believes would be material to the reasonable patient’s decision. It is the dentist’s duty to place the welfare of their patient above all else. A dentist must give his patient sufficient information so that consent given by the patient is informed, but the dentist may withhold information if that disclosure would be harmful to their patient. It may be alarming to a patient, making them unduly apprehensive, if a dentist were to give their patient every risk, no matter how remote, concerning the treatment. Likewise, a dentist may not minimize the known dangers of treatment in order to induce the patient’s consent. Quinn Dufrene, DDS, JD

Summer 23 www.nvda.org 13 Featured Article They must weigh various factors and use a certain amount of discretion when deciding on how much information to give the patient. In certain situations, the patient may be unable to give informed consent. If an emergency situation arises whereby the patient is unable to communicate, yet treatment must be rendered, implied consent may be necessary. The most common situation where implied consent is utilized is where the patient is unconscious in a medical emergency and rapid treatment is necessary to save the patient’s life. An interesting yet difficult concept deals with children under the age of eighteen. At what point do they have the ability to consent to treatment? The legal standard used to determine whether children can consent to treatment depends on whether they are considered “mature” or “emancipated” and varies from state to state. The standard of care today states the duty of a dentist to disclose is limited to those disclosures which a “reasonable” dental practitioner would make under the same or similar circumstances. This full disclosure of facts is necessary to assure informed consent by the dentist’s patient. The necessary information to be disclosed consists of the following: • Diagnosis. The patient must be informed of the tests required in making a diagnosis. They must also be informed of the alternatives to the tests and the possible consequences of not having the tests completed. • Nature and purpose of the proposed treatment. The dentist must provide the patient with enough “reasonable” information concerning the proposed treatment and the nature of the procedure so that the patient is informed. » It is the dentist’s duty to place the welfare of their patient above all else. A dentist must give his patient sufficient information so that consent given by the patient is informed, but the dentist may withhold information if that disclosure would be harmful to their patient.

NDA Journal 14 • Risks of the treatment. It is important that the patient receives enough information concerning the risks that a reasonable person in the patient’s position would be “likely to attach significance” as to the risk. However, remote risks do not need to be discussed. • Treatment alternatives. Dentists need to discuss with their patients’ alternatives to the proposed treatment and also the risks and consequences of the alternative treatment. The alternative treatment needs to be discussed even if they are more dangerous than the proposed treatment. • The option of doing nothing. There is always the option of doing nothing. As such, an outgrowth of informed consent is the concept of informed refusal. The patient must be informed of the possible consequences of refusing treatment or diagnostic procedures. • A consent form needs to be signed by the patient. A consent form is a simple document which confirms that the patient has knowingly consented to a particular treatment. This indicates that a discussion between the dentist and patient has taken place in which the treatment, its risks and benefits and alternatives have been discussed. This informed consent form is merely evidence that this discussion took place. Either the dentist or the staff must ensure that it is signed and dated by the patient. A copy should be placed in the patient’s chart and a copy given to the patient. Also, it is a guide to use so that the dentist fully and clearly explains the risks, benefits, and treatment alternatives to their patients. • A consent form preferably should be signed by the dentist. Signing the consent form adds another layer to managing risk. The ritual of signing consummates a communication relationship between the patient and their dentist. This should give the dentist a moment of pause before delegating this important duty. Conclusion Informing your patients of the risks, benefits and alternatives for their proposed treatment is not only helpful but a necessary element in modern dentist-patient relationships. By increasing the role of the patient in deciding what treatment is more appropriate, the patient benefits. The dentist also benefits by allowing and encouraging the patient to accept more autonomous responsibility for themselves and therefore reducing the dentist’s liability risk.0 Featured Article »

NDA Journal 16 NDA President and Executive Director’s Summer Article Dear Valued Members of the Nevada Dental Association, As we enter the early summer months, we reflect on the past few months and want to express our deep appreciation for your dedication to our profession, patients, and community. We proudly report that the NDA has come into the year like a lion, with a successful Mid-Winter House of Delegates meeting in January and strong advocacy efforts during the 2023 Nevada Legislative Session. Thanks to the hard work of our TriStrategies lobby team, Council on Government Affairs, and NDA leadership, we are making progress on our legislative priorities, including our insurance reform bill, modernization of dentistry bill, and expanded function dental assistant bills. In March, the NDA represented Nevada at the ADA and Student Lobby Day in Washington, DC, advocating for the Resident Education and Deferred Interest Act, Dental and Optometric Care Access Act, and Ensuring Lasting Smiles Act. Then on April 6, in collaboration with the Dental Hygiene Association, the NDA stormed the Nevada State Capitol in Carson City for Oral Health Day. This was an effective opportunity to put our members in front of legislators to discuss the importance of our bills and share stories about the harmful impact of current insurance policies on our dental practices and patients. We are pleased to report that we have stemmed the year-over-year loss of members and are now refocusing our efforts on growing our membership. We encourage current members to educate their colleagues about the tangible and valuable benefits of NDA membership at the local, state, and national levels. We also want to remind you about the upcoming NDA Annual Summer Meeting, which will take place at Harvey’s in beautiful South Lake Tahoe! This event will include our semi-annual House of Delegates and a variety of guests from the ADA, including Dr. Linda Edgar, ADA President-Elect; Dr. Marko Vujicic, Director of the ADA’s Health Policy Institute; and Dr. Brett Kessler, our 14th Districts Trustee who is currently running for ADA President-Elect. This is a fantastic opportunity to network with fellow dentists and industry leaders while enjoying the stunning scenery of Lake Tahoe. We hope to see you there! As we continue to work hard and plant seeds for the future, we want to thank you for your ongoing support and dedication to Nevada’s NDA and the dental profession. Together, we can continue to make a difference for our patients and communities.0 NDA President and Executive Director’s Article Michele M. Reeder Jason R. Doucette, DMD

Summer 23 www.nvda.org 17 Contact us today! www.llmpubs.com | 800-647-1511 Advertise to Support Your Association! Make your company stand out while supporting your association so they can change your industry for the better! • Speak to your entire association’s member base • Complimentary graphic design services • Modify an existing ad or have a new one created • Multi-publication discounts

NDA Journal 18 SNDS President’s Spring Message Richard Schoen, DDS​ SNDS President’s Message When I lived in Chicago during dental school, springtime was always a time of renewal after a long hard winter. Springtime this year is also a time of renewal after a long hard three years of Covid. Dentistry and the Southern Nevada Dental Society took a big hit during those years. We were forced to curtail meetings or hold them on Zoom. We saw membership decline. SNDS lost its Executive Director. After several missteps in our search for a new E.D. we were lucky to find a diamond in the rough in Ms. Esther Johnson our new E.D. Esther has taken the reigns of SNDS and has done a remarkable job, along with Dr. Ron Laux, our past president, to right the ship. As the newly elected president of SNDS, I have a tough act to follow. My main emphasis during my tenure as president will be to continue our focus on membership. We have done an excellent job retaining our current membership, but we need to increase the number of dentists that belong to organized dentistry. The percentage of dentists that belong to the ADA and its components is approaching the 50 percent mark. If we can’t stay above the 50 percent mark then we have no claim to represent the majority of dentists in America. Last month, I had the opportunity, along with other members of SNDS, to represent our society at Oral Health Day at the state capitol. Along with members from the NDA and the NNDS, we met with state legislators to discuss proposed legislation supported by dentistry in the state of Nevada. One of the things that caught my eye while in the capital was the number of people roaming the halls of the legislature wearing badges that identified them as “paid lobbyists.” It made me realize that dentistry is only a small group battling an army of special interests out to get their way over us. To combat that army of lobbyists, dentistry must increase our membership numbers. We have a great group, Tri-Strategies, representing us in Carson City. As a California Legislator once said, “Money is the mother’s milk of politics.” We need to increase our donations to our PAC. Increased membership will help fill the coffers of our PAC. Money talks, as the expression goes. So I am looking forward to leading the SNDS for the next year!0

Summer 23 www.nvda.org 19 SNDS Executive Director’s Spring Message Esther Johnson SNDS Executive Director’s Message Hello Members, It has been such a pleasure getting to know so many of you and meeting you at SNDS functions. We’ve already had so much success seeing the attendance at our events and meeting grow this spring. In January we had a compelling Town Hall Meeting that educated us on what the Tripartite hopes to do on behalf of Nevada dentists during the current Legislative session. In February we heard from Dr. Mary Tabrizi on Geriatric Dentistry. She was so moved by the work the Tripartite was doing and the community she saw at our meeting that she decided to become a member herself! In March we welcomed over 90 dentists to complete their Opioids Continuing Education requirement with us and in April we supported both the UNLV and the Nellis Airforce Base Resident programs. We capped the spring off with a very successful Infection Control course that saw 75 dentists and staff at the Gold Coast Hotel. We are so excited to continue growing both our membership as well as our event attendance. I want to meet you and find out how I can be part of supporting you, a dentist of Southern Nevada! Please stay tuned for all of the incredible things we have planned for summer 2023 and the fall! Warm Regards, Esther Johnson!0

NDA Journal 20 Lori Benvin [email protected] News from the Northern Nevada Dental Society NNDS Executive Director’s Message It’s warming up finally, what a winter it has been. I want to welcome a few elected changes to our Executive Board and Committee members. First and foremost, I must thank our outgoing President Dr. Hannah Beus for her outstanding presidential year and her exceptional dedication to the Executive Board for the past several years. Dr. Beus brought the FUN and togetherness back to the NNDS that we had been missing for many years. Our 2022 Holiday party was the perfect storm that she created, as we broke record attendance in over 10 years. Her ability to appreciate and embrace the room at our dinner meetings was beyond reproach and her ideas of an amazing Leadership Conference and bringing back the Mystery Bus Trip now scheduled for this October, will definitely jump start a new beginning for the future for the NNDS. You have been stellar Dr. Hannah, you will be missed greatly but we will count on you to continue to contribute to our amazing society, THANK YOU! As Dr. Beus becomes our Past President on June 1, please help us welcome Dr. Christopher Galea as our new NNDS President, Dr. K.C. Gilbert as Vice President, Dr. Garrett Swanson as Secretary/Treasurer, Dr. Ben Syndergaard as Member at Large, and newest Members at Large Dr. Megan Utter and Dr. Debra Peterson. Dr. Scott Sutter will remain our Chief Delegate and ADA Alt. Delegate. Dr. Whitney Bryant will become our new CE Chair with Dr. Beus as her co-chair and Dr. Amy Nygren takes over as our New Dentist Chair. A HUGE thank you goes out to Dr. John McLennan who is stepping down as Member at Large but his bigger and more significant role with the NNDS for these past years has been CE Chair. Thank you, Dr. Johnny, for your dedication and time committed to this role, and thank you for bringing an impressive lineup of amazing speakers to the north, you will be sorely missed. We once again are grateful to our committed Delegation from the north who represent YOU our valued members: Dr. Aimee Abittan, Dr. Troy Savant, Dr. Amy Nygren, Dr. Kellie McGinley, Dr. Justin Kiggins and Dr. Deaudre LeCato. We know you all are a huge asset to our society and its members, and we thank you for joining the ranks for 2023/24. On April 29 our non-profit program Healthy Smile Healthy Child (HSHC) a program of the Northern Nevada Dental Health Programs (NNDHP) held our first of 2023 Give Kids A Smile event at TMCC dental clinic. Last year we hosted three of these events at Truckee Meadows Community College and their gracious Dental Assisting Academic Program Director Julie Muhle offered up their amazing dental clinic on the TMCC campus. This state-of-theart facility is the home to the TMCC Dental Assisting program and the TMCC Dental Hygiene program. The students from both scholastic programs volunteer at our events alongside our volunteer dentists, UNR Pre-dent students, and staff volunteers. These events screen uninsured low-income children by appointment and children are then placed with one of our volunteer NNDHP providers for dental treatment. If a child is identified as only needing preventive care, the TMCC DH program students will take those children for follow-up after our event for needed prophies. Our HSHC program is a year-round program that has existed since 1985 Jesse Cardenas, DDS–General WELCOME BACK! Katharina Fung, DMD–Orthodontics Kaelie Reviglio, DMD–General WELCOME BACK! Jonny Winfield, DDS–Prosthodontics Welcome Newest NNDS Members

Summer 23 www.nvda.org 21 and places underserved children with our generous volunteer dentists and specialists. We THANK all the volunteers who come to these events, and we especially thank TMCC for this partnership and the volunteer dentists who treat these qualified children in their offices for needed dental care pro-bono. On April 29 we saw: • 82 chlldren seen for screening, x-rays, fluoride, sealants, and exams. • 29 children were referred to TMCC DH program. • One Endo referral. • 30 children will be referred to our HSHC program providers for further treatment. • 10 doctors of dentistry volunteering including one oral surgeon. • Four UNR pre-dent students. • TMCC DA, DH and staff and teaching volunteers. Please watch for more event information this summer and continuing education opportunities as we will kick off our 2023/24 year this October. You can go to our website at www.nndental.org and watch for our electronic newsletters and other e-communication. Lastly, I want to do a BIG SHOUT OUT and thank you to our new Director of Member Services, Marianna Kacyra at the NDA. How fortunate we are to have her and what Marianna has done to retain and recruit members this year has been off the charts! Thank you, Marianna, for joining the NDA team and for your unparalleled devotion to the success of membership. You truly are a superstar.0

NDA Journal 22 NNDS President’s Message Chris Galea NNDS President’s Spring Message Greetings from the NNDS! It has been a great Spring in Northern Nevada. Douglass Damm from the University of Kentucky gave an excellent presentation on Oral Pathology at our March NNDS dinner meeting. He also gave a full day CE program the following day. The dental society hosted a very successful Vendor Night for its members and their staff. Over twenty eight dental representatives participated in this year’s event. The event was truly beneficial for the society, it’s members and our vendors. The final NNDS spring event is our upcoming OSHA training. The yearly event is open to dental providers and their staff and also satisfies our Nevada State Board requirements for recertification. This summer, the NNDS is hosting two great events that will give our members the opportunity to mingle with each other and their families. Our first event is the NNDS Dentist Crawl on August 10. The second summer event is our yearly NNDS Open House Picnic. I’m looking forward to interacting with everyone this summer! On Saturday April 29, the Northern Nevada Dental Health Programs hosted Give Kids A Smile at the Truckee Meadows Community College Dental Clinic. The event was extremely successful as roughly 80 children from low income families were screened for any necessary dental treatment. Ten dental providers volunteered time on a Saturday to help provide their care. A special thank you as well to the TMCC dental clinic and its students for helping to host another successful event. At the state level in Northern Nevada, NDA representatives took valuable time away from their practices to participate in the 2023 Oral Health Day at the Capitol in Carson City. NDA member dentists from all over the state donated their time to talk to legislators on NDA’s bills and legislative priorities. Thank you to everyone who participated and helped support our profession. The NDA Annual Summer Meeting is right around the corner. This year’s meeting will be hosted in beautiful Lake Tahoe at Harvey’s in South Lake. There’s never a dull moment at the House of Delegates as dentists from all over the state discuss the latest topics in dental legislature. I’m anticipating an outstanding event with the opportunity for some of our state’s most active members to interact and share their dedication for organized dentistry. Chris Galea 0

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