Early Caries Intervention: A Collaborative Approach

Earn 2 CE credits Early Caries Intervention: A Collaborative Approach A Peer-Reviewed Publication Written by Kimberly M. Parsons, EdD, CDA, EFDA, RDH, and Jennifer K. Bartek, LDH, MS, CDA, EFDA Theseamuss Dreamstime.com This course was written for dentists, dental hygienists, and assistants. Abstract Educational Objectives: Author Profiles The incidence of dental caries is increasing globally. It is essential that the dental team work together with the patient to manage dental caries throughout the various stages of the patient s life. Using a risk assessment can assist the dental professional in addressing the disease process with the patient and in planning treatment. It is advantageous to use a completed risk assessment, along with various caries identification methods, to help guide the patient and dental team in management of early carious lesions. The use of minimal-intervention dentistry to address early carious lesions is an integral part of the caries management process and should be considered when devising a caries management plan. At the conclusion of this course, participants should be able to: 1. Recognize visual and radiographic methods used for caries identification 2. Describe how CAMBRA can assist with caries management 3. Identify seven methods used in minimalintervention dentistry that may aid in caries management Kimberly M. Parsons, EdD, CDA, EFDA, RDH, is the Program Chair of the Dental Assisting and Dental Hygiene Programs and an Assistant Professor of Dental Assisting/Dental Hygiene at the University of Southern Indiana. Her scholarly activities include research in the areas of educational technology, treatment of special needs patients, and allied dental education. Dr. Parsons has been a dental hygienist for 15 years, practicing in Arizona, Indiana, Kentucky, and Michigan. She has also worked as a dental educator in Arizona and Indiana. Jennifer K. Bartek, LDH, MS, CDA, EFDA, is the Dental Clinic Coordinator and a Clinical Assistant Professor of Dental Hygiene at the University of Southern Indiana. Her scholarly activities center on dental hygiene education, particularly methodology and peer assessment in the clinical setting. Mrs. Bartek has been a dental hygienist for 30 years, practicing in New Jersey, New York, Pennsylvania, and Indiana. Mrs. Bartek currently serves as a representative for the Indiana State Board of Dentistry. Author Disclosures Kimberly M. Parsons, EdD, CDA, EFDA, RDH, and Jennifer K. Bartek, LDH, MS, CDA, EFDA, have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. Go Green, Go Online to take your course Publication date: Apr. 2016 Expiration date: Mar. 2019 Supplement to PennWell Publications PennWell designates this activity for 2 Continuing Educational Credits Dental Board of California: Provider 4527, course registration number CA# 02-4527-15075 This course meets the Dental Board of California s requirements for 2 units of continuing education. The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to (10/31/2019) Provider ID# 320452. 1607DE_73 73 This educational activity was made possible through an unrestricted educational grant by Dentsply. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 2 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at hhodges@pennwell.com Educational Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. Image Authenticity Statement: The images in this educational activity have not been altered. Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents the most current information available from evidence based dentistry. Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient and improvements in oral health. Registration: The cost of this CE course is $49.00 for 2 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. 6/28/16 11:22 AM

Educational Objectives At the conclusion of this course, participants should be able to: 1. Recognize visual and radiographic methods used for caries identification 2. Describe how CAMBRA can assist with caries management 3. Identify seven methods used in minimal-intervention dentistry that may aid in caries management Abstract The incidence of dental caries is increasing globally. It is essential that the dental team work together with the patient to manage dental caries throughout the various stages of the patient s life. Using a risk assessment can assist the dental professional in addressing the disease process with the patient and in planning treatment. It is advantageous to use a completed risk assessment, along with various caries identification methods, to help guide the patient and dental team in management of early carious lesions. The use of minimal-intervention dentistry to address early carious lesions is an integral part of the caries management process and should be considered when devising a caries management plan. Introduction Caries rates are rapidly increasing on a global level 1 and dental health professionals should be mindful of this disease process in their patients. In addition, this should be an essential part of the process of care for practicing dental hygienists. 2 Dental caries should be managed through a partnership between the patient and dental team throughout the stages of the patient s life. 3 Using evidence-based research, appropriate actions for caries assessment and treatment is necessary to ensure successful outcomes with incipient carious lesions. 4 Methods for caries identification Various methods are available for the identification of carious lesions. The clinician should inspect the dentition for areas on the tooth surface that appear gray in color, often described as a shadow or halo on the tooth. The clinician can also use visual inspection to assess the dentition for dark stain in deep pits and/or fissures on the tooth surface. Assessments such as the International Caries Detection Assessment System (ICDAS) are available to guide clinicians and provide universal interpretation. 5 Radiographs may be used in caries identification with advancements in digital imaging and technology-based assessment methods showing great promise. 4 6 Bitewing radiographs specifically aid in the identification of carious lesions on the interproximal tooth surface (figure 1). In addition, radiographs provide value for the dental team as an assessment tool, as past radiographs can be used as a baseline to compare changes in the patient s dentition over time. 6 Lasers and fluorescence based technologies are additional assessment methods used in the identification of carious lesions. 4 Research has demonstrated a high sensitivity for caries detection with the use of lasers. 4,7 However, it is currently recommended that dental professionals not use lasers as a sole diagnostic methodology but rather in conjunction with good visual and radiographic techniques for caries detection. 4 Figure 1: Bitewing radiograph showing incipient lesion Risk assessment A proficient dental health professional must serve as an investigator to uncover those daily factors in the patient s life that allow for control of disease. Utilization of risk assessment for dental caries allows the dental professional to focus on the disease process instead of disease treatment. 2 There are various tools commonly used to identify caries risk, such as Caries Management by Risk Assessment (CAMBRA). 2,8 CAMBRA is an evidence-based approach to caries management that helps with assessment of the patient s level of risk and aids the dental health professional in care-planning strategies. 8 This tool places emphasis on the whole disease process, provides ways to identify problems early, and uses evidence-based strategies to provide the best oral health outcomes for patients. 1,8 CAMBRA can guide early intervention for carious lesions, instead of traditional restorative treatment. Consideration for disease indicators and pathogenic factors are weighed against competing protective factors for each individual patient. 8 Understanding nutrition, products, and oral health educational goals are imperative once the risk is identified for individual patients. The dental hygienist should be actively involved in using the evidence gathered through a risk assessment to determine an intervention plan unique to the patient s caries risk 8 that includes treatment and products. 74 07.2016 DENTALECONOMICS.COM

Minimal-intervention dentistry By using evidence from a completed caries risk assessment, the dental health team can guide the management of lesions diagnosed early in their development. Strategies include products that improve salivary flow, correct ph balance, antimicrobials, sealants, xylitol, fluoride, and minimally invasive restorative work. 8 While some strategies may be used alone, various minimal-intervention strategies can be used together for optimal prevention and/or treatment of incipient carious lesions. Saliva-stimulating products and ph-balancing products: Saliva-stimulating products and those that help balance the ph of the oral cavity can be useful in the management of early carious lesions. Neutralizing products, such as antacid tablets, may raise a low intraoral ph to combat the progression of incipient caries. 9 ph-balancing products include desensitizing toothpastes that contain calcium phosphate, sodium bicarbonate rinses, and over-the-counter rinses aimed specifically at neutralizing ph. 8 Recent research has described dental caries as a ph-specific disease, with a low ph level being directly related to the demineralization of teeth. 1 Saliva-stimulating products, such as sorbitol-containing gum, can also reduce the development of dental caries. 10 Antimicrobials: Prescription-based antimicrobial products may aid in caries management. Chlorhexidine gluoconate, a broad-spectrum agent proven effective against Streptococcus mutans and Lactobacilli is a second-generation product with considerable substantivity. 11 This agent will reduce the bacterial count but should be used in conjunction with fluoride remineralization therapy. Essential-oil mouth rinses have also been shown to be effective in reducing bacterial plaque and the bacterial count in the mouth as well as aiding in the arrest of incipient lesions. 11 An additional benefit of rinsing with an antimicrobial agent is that the rinse can reach areas of the mouth that are rarely targeted, inaccessible, and often missed by mechanical means. Sealants: Glass-ionomer sealants have fluoridereleasing properties to aid in the remineralization of incipient lesions. 12 Research has shown that placing a glass-ionomer sealant over an incipient carious lesion reduces the level of bacteria in the carious lesion. 8,12 Sealants can prevent caries progression by blocking fermentable substrates that cause carious lesions to advance; when the bacteria are not nourished due to the placement of a sealant, the bacterial count of a carious lesion may decrease, thus inhibiting further growth of the lesion. 12 Reduction in bacterial count of sealed lesions increases over time with sealant retention. 12 Xylitol: Studies suggest that xylitol, a five-carbon sugar alcohol, reduces the incidence of caries and may lead to anticariogenic results. 13 Xylitol reduces plaque formation and adherence of bacteria, inhibits enamel demineralization, and has a direct inhibitory effect on Streptococcus mutans, a decay-causing bacteria by preventing adhesion to the tooth. 11,13 There are numerous forms available, including gum, mints, chewable tablets, lozenges, toothpastes, mouthwashes, and oral wipes. 13 The American Academy of Pediatric Dentistry supports the use of xylitol as part of a strategy for long-term caries pathogen suppression. 13 Fluoride: Using fluoride for the prevention and control of caries is proven to be both safe and highly effective. 14,16 Fluoride has three main mechanisms of action: (1) to promote remineralization; (2) to reduce demineralization; and (3) to inhibit bacterial metabolism and acid production. 16 In particular, stannous fluoride is proven to have both antimicrobial and anti-caries properties and may be an effective choice in certain cases. 15 The use of regular, low-dose fluoride is a good home-care strategy for suppressing dental caries. Forms of home fluoride delivery include fluoridated toothpastes and mouth rinses (both of which are available over the counter and in prescription strength), fluoridated water and dietary fluoride supplements (Table 1). 14,16 A high-dosage, in-office treatment is an additional option for patients with a moderate or high risk of caries who may benefit from professional topical fluoride application. 17 In-office fluoride delivery options for patients include fluoride rinses, gels, foams, and varnishes (table 1). 17 Minimally invasive restorations- The philosophy of minimally invasive restorative care centers on not preparing access cavities in the tooth, thus protecting and preserving the tissues surrounding the carious lesion. 3 This technique is virtually painless and is gaining ground, particularly in pediatric dentistry. 18 One example of a minimally invasive restorative procedure uses a chemical etchant, (instead of a mechanical high-speed handpiece), to access carious tissue vis-a-vis penetration into the pores of the lesion. A glass-ionomer sealant is then placed on the lesion, allowing for the slow release of fluoride onto the carious surface, halting progression of the lesion. 18 This technique is increasing in popularity, as it preserves healthy tissues and restores incipient lesions without discomfort. Table 1: Types of fluoride treatments Home fluoride treatments Toothpastes Mouth rinses Fluoridated drinking water Dietary supplements In-office fluoride treatments Rinses Gels Foams Varnishes DENTALECONOMICS.COM 07.2016 75

Conclusion In conclusion, as the incidence of caries rises in the United States, it is increasingly important that the dental team be knowledgeable of the best practices in the early diagnosis and treatment of incipient lesions. 3,16 The dental team should work with the patient to devise an action plan for assessment, prevention, and treatment of dental caries. This may include a thorough assessment of caries risk and current patient status, staying abreast of the most recent evidence-based recommendations for effective treatment of lesions, and continual assessment of lesions over time. 2 Whether caries intervention includes assessment of the lesion at regular intervals while providing oral health education, non-restorative intervention (fluoride, saliva enhancers, antimicrobials, etc.), or minimally invasive restorative procedures, the dental team and patient must work together to achieve optimal outcomes. The relationship should be considered a lifelong process, with reassessment and continual change so that the care provided is optimal for the individual patient s oral health needs. References 1. Malterud MI, Kutsch VK. The evolution of dental caries treatment. Gen Dent. 2012;60(5):386 389. 2. Fransisco EM, Johnson TL, Freudenthal JJ, Louis G. Dental hygienists knowledge, attitudes and practice behaviors regarding caries risk assessment and management. J Dent Hyg. 2013;87(6):353 361. 3. Pitts NB. Are we ready to move from operative to non-operative/preventive treatment of dental caries in clinical practice? Caries Res. 2004;38:294 304. doi: 10.1159/000077769 4. Rochlen GK, Wolff MS. Technological advances in caries. Dent Clin N Am. 2011;55:441 452. doi: 10.1016/j.cden.2011.02.018 5. Braga MM, Mendes FM, Ekstrand KR. Detection activity assessment and diagnosis of dental caries lesions. Dent Clin A Am. 2010;54:479 493. doi: 10.1016/j.cden.2010.03.006 6. Shah N, Bansal N, Logani A. Recent advances in imaging technologies in dentistry. World J Radiol. 2014;6(10):794 807. doi: 10.4329/wjr.v6.i10.794 7. Zero DT, Fontana M, Martinez-Mier EA, et al. The biology, prevention, diagnosis and treatment of dental caries. JADA. 2009;140:25S 33S. 8. Young DA, Lyon L, Azevado S. The role of dental hygiene in caries management: A new paradigm. J Dent Hyg. 2010;84(3):121 129. 9. Lindquist B, Lingstrom P, Fandriks L, Birkhed D. Influence of five neutralizing products on intra-oral ph after rinsing with simulated gastric acid. Eur J Oral Sci. 2011;119(4):301 304. doi: 10.1111/j.1600-0722.2011.00841.x 10. Stookey GK. The effect of saliva on dental caries. JADA. 2008;139:11S 17S. 11. Darby JL, Walsh M. Dental Hygiene Theory and Practice. 4th ed. St. Louis, MO: Elsevier; 2015. 12. Oong EM, Griffin SO, Kohn WG, Gooch BF, Caufield PW. The effect of dental sealants on bacteria levels in caries lesions: A review of the evidence. JADA. 2008;139:271 278. 13. Council on Clinical Affairs. Policy on the use of xylitol. Reference Manual: American Academy of Pediatric Dentistry. 2015;37(6):45 47. 14. Council on Clinical Affairs. Guideline for fluoride therapy. Reference Manual: American Academy of Pediatric Dentistry. 2015;37(6):176 179. 15. Sensabaugh C, Sagel ME. Stannous fluoride dentifrice with sodium hexametaphosphate: Review of laboratory, clinical and practice-based data. J Dent Hyg. 2009;83(2):70 78. 16. Clark MB, Slayton RL. Fluoride use in caries prevention in the primary care setting. Pediatr. 2014;134(3):626 633. 17. American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. J Dent Ed. 2007;71(3):393 402. 18. Soviero VM, Sellos MC, Santos MG. Micro-invasive treatment of caries-expanding the therapy spectrum in modern pediatric dentistry. Int Dent SA. 2010;12(5):34 42. Author Profiles Kimberly M. Parsons, EdD, CDA, EFDA, RDH, is the Program Chair of the Dental Assisting and Dental Hygiene Programs and an Assistant Professor of Dental Assisting/ Dental Hygiene at the University of Southern Indiana. Her scholarly activities include research in the areas of educational technology, treatment of special needs patients, and allied dental education. Dr. Parsons has been a dental hygienist for 15 years, practicing in Arizona, Indiana, Kentucky, and Michigan. She has also worked as a dental educator in Arizona and Indiana. Jennifer K. Bartek, LDH, MS, CDA, EFDA, is the Dental Clinic Coordinator and a Clinical Assistant Professor of Dental Hygiene at the University of Southern Indiana. Her scholarly activities center on dental hygiene education, particularly methodology and peer assessment in the clinical setting. Mrs. Bartek has been a dental hygienist for 30 years, practicing in New Jersey, New York, Pennsylvania, and Indiana. Mrs. Bartek currently serves as a representative for the Indiana State Board of Dentistry. Author Disclosures Kimberly M. Parsons, EdD, CDA, EFDA, RDH, and Jennifer K. Bartek, LDH, MS, CDA, EFDA, have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. 76 07.2016 DENTALECONOMICS.COM

Online Completion Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the Online Courses listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the Take Exam link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your Verification Form will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page. Questions 1. Which of the following is not a delivery method for receiving a high-dose fluoride treatment in a dental office? a. Fluoridated toothpaste b. Gel/foam c. Rinse d. Varnish 2. Which method of inspection for dental caries includes the identification of halos and areas of distinct stain on the teeth? a. Radiographs b. Visual inspection c. Use of an explorer d. Fluorescence 3. Who should be involved in the planning process for caries assessment and treatment? a. Patient b. Dentist c. Dental hygienist 4. During minimally invasive restorative work, what type of material is placed on the carious lesion that allows the slow release of fluoride onto the carious surface? a. Amalgam b. Chlorhexidine gluconate c. Sodium bicarbonate d. Glass ionomer 5. Which of the following is not considered to be a ph-balancing product? a. Desensitizing toothpaste containing calcium phosphate b. Sodium bicarbonate rinse c. Sealant d. Over-the-counter mouth rinse 6. What type of radiographs aid in the identification of carious lesions on the interproximal tooth surface? a. Bitewings b. Panoramic c. Periapical d. Occlusal 7. Which of the following is true concerning Caries Management By Risk Assessment (CAMBRA)? a. Places emphasis on the whole disease process b. Provides ways to identify problems early c. Uses evidence-based strategies to provide best outcomes 8. A form of home fluoride delivery includes: a. Over-the-counter toothpaste b. Prescription toothpaste c. Gum with xylitol d. Both A and B 9. Which of the following can be described as a second-generation product with considerable substantivity that has been proven effective against Streptococcus mutans? a. Saliva stimulant b. Chlorhexidine gluconate c. Sealant d. Antacid tablet 10. What type of preventive agent reduces plaque formation and adherence of Streptococcus mutans to the tooth? a. Xylitol b. Minimally invasive restorations c. Rinsing with water 11. Which type of caries treatment protects and preserves tissue surrounding the carious lesion by not preparing access cavities? a. Xylitol-containing gum b. ph-balancing rinse c. Minimally invasive restorations d. Saliva-stimulating product 12. Fluoride, saliva enhancers, and antimicrobials are all examples of what? a. Non-restorative caries intervention b. Minimally invasive restorations c. Invasive restorations d. Cariogenic agents 13. What agent does the American Academy of Pediatric Dentistry support as part of a strategy for long-term caries pathogen suppression? a. Amalgam restorations b. Xylitol c. Dental crowns d. Dental implants 14. Demineralization of the tooth occurs with what type of ph level? a. Neutral b. High c. Low d. ph does not effect demineralization Notes 15. What effect does the placement of a glass-ionomer sealant have on an incipient carious lesion? a. Reduces bacteria level in the lesion b. Increases bacteria level in the lesion c. Has no effect on bacteria level in the lesion d. Effect depends on the brand of sealant used 16. Current recommendations for the use of lasers in caries detection include: a. Use of lasers as a sole diagnostic technique b. Use of lasers in conjunction with visual and radiographic techniques c. Use of lasers in conjunction with an explorer on the occlusal surface d. There are currently no recommendations for laser use 17. Which of the following can guide early intervention strategies for carious lesions? a. Saliva-stimulating products b. CAMBRA c. Antimicrobials d. Use of an explorer on the occlusal surface of the tooth 18. With what type of caries risk can patients benefit from professional fluoride application? a. Low caries risk b. Moderate caries risk c. High caries risk d. Both B and C 19. Xylitol is available in which of the following forms? a. Mints b. Chewable tablets c. Oral wipes 20. Which of the following statements is true regarding minimally invasive restorative work? a. This technique has not been well-received among dental professionals b. This technique includes making a smaller-thannormal access cavity in the tooth c. This technique is gaining popularity, particularly in pediatric dentistry d. This technique utilizes amalgam to cover carious lesions for prevention of further growth DENTALECONOMICS.COM 07.2016 77

ANSWER SHEET Early Caries Intervention: A Collaborative Approach Name: Title: Specialty: Address: E-mail: City: State: ZIP: Country: Telephone: Home (. Offce (. Lic. Renewal Date: AGD Member ID: Requirements for successful completion of the course and to obtain dental continuing education credits: 1. Read the entire course. 2. Complete all information above. 3. Complete answer sheets in either pen or pencil. 4. Mark only one answer for each question. 5. A score of 70% on this test will earn you 2 CE credits. 6. Complete the Course Evaluation below. 7. Make check payable to PennWell Corp. For Questions Call 800-633-1681 Educational Objectives 1. Recognize visual and radiographic methods used for caries identification 2. Describe how CAMBRA can assist with caries management 3. Identify seven methods used in minimal-intervention dentistry that may aid in caries management Course Evaluation 1. Were the individual course objectives met? Objective #1: Yes No Objective #2: Yes No Objective #3: Yes No Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. 2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 5. How do you rate the author s grasp of the topic? 5 4 3 2 1 0 6. Please rate the instructor s effectiveness. 5 4 3 2 1 0 If not taking online, mail completed answer sheet to PennWell Corp. Attn: Dental Division, 1421 S. Sheridan Rd., Tulsa, OK, 74112 or fax to: 918-831-9804 For IMMEDIATE results, go to www.ineedce.com to take tests online. Answer sheets can be faxed with credit card payment to 918-831-9804. Payment of $49.00 is enclosed. (Checks and credit cards are accepted.) If paying by credit card, please complete the following: MC Visa AmEx Discover Acct. Number: Exp. Date: Charges on your statement will show up as PennWell 7. Was the overall administration of the course effective? 5 4 3 2 1 0 8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0 10. Do you feel that the references were adequate? Yes No 11. Would you participate in a similar program on a different topic? Yes No 12. If any of the continuing education questions were unclear or ambiguous, please list them. 13. Was there any subject matter you found confusing? Please describe. 14. How long did it take you to complete this course? AGD Code 257 15. What additional continuing dental education topics would you like to see? PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: hhodges@pennwell.com. INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be mailed within two weeks after taking an examination. COURSE CREDITS/COST All participants scoring at least 70% on the examination will receive a verification form verifying 2 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/ Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00. PROVIDER INFORMATION PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP at www.ada. org/cotocerp/. The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to (10/31/2015) Provider ID# 320452. Customer Service 800-633-1681 RECORD KEEPING PennWell maintains records of your successful completion of any exam for a minimum of six years. Please contact our offces for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. CANCELLATION/REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. 2016 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell CARIES0716DE