Cannabidiol, commonly known as CBD, is getting significant attention in new advances of pain management for its non-psychoactive therapeutic properties. Topical CBD oil has been suggested as a way to non-invasively treat pain caused by temporomandibular disorders. But does the science currently support CBD oil or even prove its efficacy versus a placebo?
CBD smoothies, CBD cream, CBD bath bombs… the consumer market is flooded with a variety of premium products touting everything from anxiety reduction to chronic pain treatment. If you haven’t been asked for your medical opinion about CBD yet, you may be soon.

Topical CBD oil is expensive and trendy. Roll-on applicators are often combined with other active ingredients like menthol and arnica to soothe the symptoms of pain. Roll-on CBD may be infused with essential oils, so it even has a therapeutic aroma. With attractive green packaging and clever names to boot, the purchase can be a no-brainer for those suffering from aches and tension in their jaw.

Evidence-based dentistry demands a suspicious eye. Is all this external dressing, pleasant smells, and clever marketing covering up a dearth of clinical evidence? Let’s take a dive into the science:

What CBD Is and What CBD Isn’t

Cannabidiol has come to prominence as the safer alternative to tetrahydrocannabinol (THC). Evidence has shown it may be effective in the treatment of childhood epilepsy.¹ There is even an FDA-approved CBD-based treatment, Epidiolex, for two severe forms of epilepsy.²

Besides this specific use in the management of epileptic seizures, CBD is sold as a supplement.¹ The number one issue here is the lack of regulation over supplements. You can’t be certain that the amount of CBD stated on the label corresponds to the actual levels in the formulation.¹ Even more concerning, there is no widely accepted, clinical trial approved therapeutic topical or oral dose of CBD designated for the management of chronic pain.¹ Can a treatment be ethically recommended when there is no consensus on effective, safe dose?

Unlike THC, CBD does not cause a high. But it can have side effects such as nausea or even impact the level of medications in the blood.¹ We know very little about the effects of cannabidiol in the context of large sample size human clinical trials. How long should a patient apply CBD for? At what dose should they apply it? How regularly? The answers to these questions are not currently known.

CBD and TMD: Friend, Foe, or Placebo?

A 2020 systematic review with meta-analysis of topical intervention efficacy for temporomandibular disorders compared the current data on treatments such as nonsteroidal anti-inflammatories (NSAIDs), cannabidiol, capsaicin, bee venom, and more.³ Topical therapies are especially attractive because of the serious consequences to long-term oral NSAID use for TMDs.³

Topical doses of a drug or therapeutic can bypass the debilitating side-effects of systemic treatment.³ Topical NSAIDs include diclofenac sodium and methyl salicylate.3 Therapies like bee venom and CBD are called “nutraceuticals,” which refers broadly to food-derived alternatives to pharmaceuticals, usually sold as supplements.³

The 2020 review was only able to find 9 studies regarding topical treatment of TMDs that met rigorous criteria for quality of evidence while also qualifying as randomized controlled trials.³ For topical NSAIDs, the review found no clinically significant difference compared to a placebo.³ Interestingly, ultrasound therapy was found to reduce pain, but applying an NSAID gel with ultrasound had no statistically significant difference compared to ultrasound without the gel.³

The effect of bee venom and capsaicin was similarly inscrutable, with few relevant studies including the proper data values or standard deviations to conduct a meta-analysis.³ The evidence in general was low quality or showed little effect.³

CBD also suffered from a lack of high-quality evidence in the form of studies in humans.³ Animal models have shown that “transdermal cannabinoids” may reduce pain and inflammation, but there is currently no clear evidence for long-term benefits in humans.³

Why is the research for topical treatment of TMD-associated pain so poor? The answer is small sample sizes, poor blinding, and unreported funding sources.³ Because of this, we don’t know whether demonstrated effects, if any, apply to a larger population.

Statistics have less meaning in small sample sizes. Poor blinding means that bias cannot be controlled. Lack of clear funding disclosures may also influence blinding and make it difficult to trust whether research was conducted in good faith.

The Future of CBD in Dentistry

Though data regarding CBD for TMDs is severely lacking, the future may offer some hope. If motivated researchers feel passionately about reducing the burden of chronic pain for sufferers of temporomandibular disorders, they may be able to put forward the time, money, and effort necessary to distinguish the minimum safe yet therapeutic dose of CBD.

They will also have to determine its ideal application parameters and any necessary or helpful active ingredients. They’ll need large numbers of study participants, including hundreds of individuals for control and experimental groups, and a well-considered experimental design.
That outcome may take many years. In the meantime, topical CBD will remain the equivalent of a high-end massage oil.

References:

1. MD PG. Cannabidiol (CBD) — what we know and what we don’t. Harvard Health Blog. Published August 24, 2018. https://www.health.harvard.edu/blog/cannabidiol-cbd-what-we-know-and-what-we-dont-2018082414476
2. FDA Approves First Drug Comprised of an Active Ingredient Derived from Marijuana to Treat Rare, Severe Forms of Epilepsy. FDA. Published March 27, 2020. https://www.fda.gov/news-events/press-announcements/fda-approves-first-drug-comprised-active-ingredient-derived-marijuana-treat-rare-severe-forms
3. Mena M, Dalbah L, Levi L, Padilla M, Enciso R. Efficacy of topical interventions for temporomandibular disorders compared to placebo or control therapy: a systematic review with meta-analysis. J Dent Anesth Pain Med. 2020;20(6):337-356. doi:17245/jdapm.2020.20.6.337

Key Points:
• Platelet-Rich Plasma (PRP) is not FDA approved. It is an “off-label” therapy.
• PRP is considered safe.
• There is no standardization of PRP treatments, making it difficult to determine how it heals or encourages healing.

If you regularly work with an oral surgeon, you’ve probably heard the term Platelet-Rich Plasma or “PRP.” Put simply, PRP is a technique where blood is drawn from a patient and spun in a centrifuge to produce a clot composed of the patient’s own platelets. This clot is then placed into a wound or surgical site to stem the flow of blood and promote healing. In short, a clinician removes the red blood cells from whole blood.

PRP is an autologous cell therapy. This just means that cells are used on the same patient they came from.

What is PRP and How is it Regulated?

PRP is a relatively simple procedure that is favored in clinical practice due to its safety and perceived efficacy. Because it is drawn from a patient’s own blood and is similar to a previously cleared therapeutic, it has so far bypassed the lengthy and expensive process of FDA approval for biologics.¹ PRP is not FDA approved, though it is cleared legally for specific therapeutic uses, and therefore guidelines must be followed to adhere to FDA regulations.¹

A 2018 review of the economics and regulatory outcomes for PRP describes the treatment’s 5-to-10-year outlook as enormous, citing “between 380 million and 4.5 billion (USD)” in growth.¹ Procedures may start at a minimum of $500 and can be thousands of dollars.¹

What this means in short is that PRP is an expensive treatment lacking in proven clinical trial data and is not paid for by insurance.¹ This may not sound like a promising description, but it doesn’t mean the treatment is ineffective or not worth the money depending on its application.

PRP is regulated based on certain qualities of how it is collected from the patient and the number of platelets per volume.¹ It often contains a unique combination of leukocytes (immune cells/white blood cells), platelets (cell fragments without a nucleus), and fibrin (fibrous protein necessary for clotting).¹

Why Clinical Trial Data is Limited for PRP

The large variation in techniques used for the collection of PRP, as well as inherent differences in composition that can be attributed to individual patient differences, make it supremely difficult to study the efficacy of the treatment.¹ It also makes it very challenging to compare different treatment styles. It is complicated to design a study with the necessary “statistical power” to draw a valid conclusion from the data. This is true of many biologics or stem-cell based therapies. How do you determine that the effect you are witnessing is truly a result of the cell-based therapy? Moreover, what part of the therapy is generating the effect? Cells are unpredictable.

In order to study the effect of PRP therapeutically, it would be necessary for multiple studies with large sample sizes to use the exact same materials and experimental conditions, all the way down to the exact collecting tube and centrifugation speed.¹ Clear and replicable methodology (the exact steps taken, in what order, with what materials, and for what duration) is often missing in scientific literature due to fears over proprietary information or lack of thorough reporting.

PRP is a Mixture of Many Different Therapeutic Substances

When trying to understand or tease out how PRP effects the surrounding tissue, it’s helpful to think of the clot as an intentionally overcooked minestrone. This soupy, gelatinous mixture was made by a brilliant chef with a few screws loose. We know there are tomatoes and carrots and potatoes, with some vegetable broth and a bit of salt, but some of the ingredients are difficult to identify. Did she throw in a dash of dill? Is it the pepper that’s leaving such a strong aftertaste? Does the minestrone taste good mainly because of the tomato? The tomato is everywhere, so it’s easy to differentiate. But that can’t possibly be the entire picture contributing to such a delicious soup du jour.

PRP is infinitely more complicated than a well-made minestrone. It contains growth factors, AKA a protein or hormone that regulates cell behavior, such as proliferation or healing.¹ But it also contains the immune cells mentioned earlier. And ions. And many other molecules and proteins with diverse purposes in the body. It’s hard to offer a therapy to someone if you don’t fully understand why it works. You know the soup is tasty, but what about this exact combination of ingredients is making it better than the one you make at home from a can?

So far, PRP has been deemed relatively safe.¹ It is considered an “off-label” treatment that was cleared, but not approved, by the FDA under the 510(k) substantial equivalency pathway.¹ This pathway allows transplanted human tissue or other medical devices to be cleared if it similar enough to a prior cleared device.¹ There are pros and cons to off-label use of drugs and biologics.¹ One major con is that there is a dearth of scientific evidence in humans explaining why and how the biologic works.¹

PRP in Oral Surgery

PRP is used for a variety of orthopedic purposes. Oral surgery is just one of the many ways in which this therapy is leveraged. A 2013 study of PRP in dental surgery found mixed results in the literature.² The goal of PRP for tooth extraction is to manage the bleeding and pain of extraction sockets while encouraging bone formation.² Some studies found improved benefits to post-operative pain, bleeding, and bone healing, whereas other studies found no significant effects of PRP, especially long-term for bone growth.² Overall, the review indicates that there is evidence of PRP being effective for soft tissue but not for bone regeneration.²

The body of knowledge regarding Platelet-Rich Plasma will continue to grow in the next decade. Over this period of time, perhaps the FDA approval process will be fruitful and standardized treatments will make their way onto the market.

References:

1. Jones IA, Togashi RC, Thomas Vangsness C. The Economics and Regulation of PRP in the Evolving Field of Orthopedic Biologics. Curr Rev Musculoskelet Med. 2018;11(4):558-565. doi:1007/s12178-018-9514-z
2. Albanese A, Licata ME, Polizzi B, Campisi G. Platelet-rich plasma (PRP) in dental and oral surgery: from the wound healing to bone regeneration. Immunity & ageing. 2013;10(1):23-23. doi:1186/1742-4933-10-23

It is with the greatest sadness that we announce the loss of Pankey legend and founding member, Dr. Bill Lockard. As one of the original Pankey faculty, we’d like to give tribute to his legacy and impact on dentistry, specifically the Pankey mission and what it has meant to decades of dentists since its inception.

Dr. Myers William Lockard, Jr., who went by “Bill,” meant many things to the Institute and to the people who knew and loved him. Born in Oklahoma City and a child during the Depression, he was pointed toward dentistry by a high school instructor who suggested the career path after learning Dr. Lockard was interested in music.

He met the love of his life, Sue, while attending Northwestern University Dental School in Chicago. After an initial chance encounter, the two were set up on a blind date that signaled the start of a lifetime of romance and joy with their three children and now many grandchildren.

Dr. Lockard was a founding member of The Pankey Institute, serving as Associate Faculty, Advisory Faculty, and on the Board of Trustees. He developed Pankey’s first course for dental assistants and was an active part of the Pankey community for nearly 50 years. In 1984, he lectured in Japan, thereby creating a formative relationship with those dentists. After retiring from practice in 1991, he and Sue provided dental services to nursing homes for many years. As part of his commitment to dentistry, he authored a 2007 book titled, “The Exceptional Dental Practice: Why Good Enough is not Good Enough.”

There are no words that can truly describe the loss of a man who lived such an extraordinary life. He will be missed by the Pankey faculty and alumni who attended his study clubs and dental groups, benefited from his mentorship and advice, or met him during Pankey’s Annual Meeting or other dental meetings. Dr. Lockard was an excellent clinician, educator, and writer for the duration of his career. We have the utmost gratitude for his contribution to the history of dental education and innovation.

At the request of Bill’s children and in memory of his dedication to dental care, donations may be made to the William Lockard Development Fund at the Pankey Institute to further promote excellence in dental faculty. There are three ways to donate:
(1) Call 1-305-428-5500
(2) Mail check payments to: The Pankey Institute, 1 Crandon Blvd., Key Biscayne, FL, 33149
(3) Donate at online.pankey.org. Register for free and select the “Make a Donation” tab. Dr. Lockard’s Fund is listed on the next page.

On day one of the 2019 Annual Pankey Meeting, Dr. Gary Severance and Angela Severance will explore how digital technology continues to expand the opportunities dental professionals have to know their work and to provide better dentistry and ultimately better care.  Preliminary to this presentation, we share this quote with you.

“Be not the first to try the new or the last to leave the old aside.”

This is a statement from Dr. L.D. Pankey in his 1985 interview with the International College of Dentists. As a well-read and literary man, Dr. Pankey was familiar with Alexander Pope, an 18th-century English poet who is best known for his satirical verse and translation of Homer. Because Pope is the second-most frequently quoted writer in The Oxford Dictionary of Quotations (after Shakespeare), it is highly likely Dr. Pankey was inspired by the following famous couplet from Pope’s Essay on Criticism.

Be not the first by whom the new are tried,
Nor yet the last to lay the old aside.

We offer this conjecture, because Pope’s couplet is often used across the professions in the context of evaluating and adapting to technological change.

Pushing Forward Mindfully

Dr. Pankey was on the forefront of the technological and methodological changes that rapidly occurred in dentistry during the 1950s and onward. He was internally driven to be and do his best for his patients and profession. He urged dentists to “know your work” to provide better dentistry and ultimately better care.

Digital technology in dentistry has advanced to address special needs, just as Dr. Pankey advanced in his systems of thought and practice to address special needs. He did this mindfully.

His genius, in concert with those of Dr. Arvin Mann and Dr. Clyde Schuyler, had produced the “P.M.S. Technic.” They had selected the best of the procedures that had been developed by outstanding practitioners in their special fields and assembled them into a system that functioned well for addressing full mouth rehabilitation. They applied their intelligence to “try” new techniques and new materials. They gained knowledge through carefully doing their best for patient, after patient. They then stepped out to share what worked successfully for them. Along the way, Dr. Pankey was mindfully developing his philosophy of practice. He intentionally set out to learn from many great minds, and the composite of principles he lived by and generously shared through his lectures, publications, and ceaseless conversations with other dentists have rippled into our lives today.

Learn, Converse, Lead with Confidence

As a community, you can share your knowledge, immerse in conversation, and lead with confidence. The L.D. Pankey Institute from its beginning was a radical departure from dental school settings of the day. The Institute pioneered a training clinic with overhead cameras and closed-circuit TV, anatomical simulators (which had heretofore only been developed for training in medical schools), and it’s characteristic “hands on” learning process. The Institute’s founding leaders conceived of novel ways to fulfill their goals. But—building the unique learning environment and learning process involved tens of thousands of hours of research, thought, and conversation. A group of “top” minds in dentistry worked together to close the gap between what was known (the science) and what was practiced.  Adaptation to emerging digital technology is no different.

The Pankey Institute’s 50th Anniversary celebrates the thousands of dentists who have learned and advanced their practice of dentistry through relationship-driven education principles pioneered by Dr. L. D. Pankey. We’re kicking off a year long celebration to honor half a century of transformative professional growth. 

Here’s how you can get in on the fun:

50 Years of Dental Continuing Education Excellence

The Pankey Institute was opened in honor of Dr. L.D. Pankey, a dental visionary who supported patient care designed to ensure oral health longevity while inspiring dentists to greater career satisfaction. Throughout 2019, we will celebrate the organization’s history, as well as its impact on dental professional across the US and internationally.

The celebration will culminate in the Pankey Annual Meeting, which will be held on September 13-14 at the Ritz Carlton, Key Biscayne.  Our theme is “The Future Starts Now, and are hosting some of dentistry’s top speakers. During the event plan to join us for the Triple Plus Club dinner, do yoga with Sheri Kay, get out and stretch your legs for the Fun Run/Walk and tour the newly renovated Institute at 1 Crandon Blvd. 

Dr. Pankey’s philosophy has changed the lives of over 25,000 dentists since the Institute was founded 50 years ago. Celebrating this legacy is about every one of the clinicians in our community and all that they themselves have done to transform their practice of dentistry for the benefit of patients.

We encourage you to connect with us on Facebook, Twitter, and Instagram as we make 2019 a year to never forget! Thank you for all your support of the Pankey family. Learn more about our upcoming programs here and read more about the Pankey experience here!

When you visit Miami, don’t just check out the common sights. A short drive from Key Biscayne is the big city, with plenty to do, see, and explore. One of our favorite lesser-known spots is the Miami River. Beloved by locals, it’s worth visiting for some water-oriented fun.

Miami River: Why Go?

A course at Pankey is an opportunity to learn and experience something unique. That extends to what you do in your free time as well.

The Miami River is a six-mile waterway with boating and views of the impressive Miami shoreline. It is entertaining a fabulous rebirth that provides ample attractions to the curious tourist.

Multi-million dollar developments going up in the area have inspired growth and some of the hottest Miami restaurants. It’s also just plain old beautiful looking at the high rises, gorgeous homes, and marinas dotting the view.

Best Sightseeing, Food, and Fun

The best way to appreciate the Miami River is by getting out on the water, instead of observing it from afar. Interestingly, the river is still a cargo passageway, with many container ships easily navigating the booming trade path. Get a look at the river up close by chartering a small, private cruise along the river. This company also has an option for chartering.

Our favorite place to eat overlooking the Miami River has to be Seaspice, a brasserie and lounge with a garden. Watch the sunset over the river after a long day out in the warmth. Cool down with a handcrafted Blossom Martini and sample their delightful wagyu dumplings.

Walk off your amazing meal along the riverfront to take in more of the lush, green blend of cityscape and natural environment. If you’re beat from the long day, you could also take a segway.

If you visit the Miami River, let us know below! We’d also love your tips on what else the Pankey community should do in Miami …

Time is a major priority in the thriving dental practice. Balancing the need for comprehensive care with the efficiency necessary to get everything done in a day is a serious challenge. When it comes to periodontal assessments, the numbers today shockingly still show that a majority of offices are not routinely completing a perio exam.

It doesn’t have to be that way!

Implement a Quick Perio Screening

Consider making your life a lot easier while still improving patient care by offering periodontal screenings. An efficient screening that divides the mouth into scored sextants shouldn’t take more than a minute or two.

Your hygienists will appreciate the opportunity to show off their probing skills. They will be able to help patients recognize the signs of gingivitis and periodontal inflammation that may have gone unnoticed otherwise. If the patient scores high enough, then that will necessitate a full-mouth periodontal exam that includes full mouth probing furcation scoring and measuring muco-gingival attachment loss and recession.

This simple addition can lead to more dentistry in your practice and therefore higher production. That’s a boon for both patients and dentists, as the former improves their health and the latter is able to offer more complex treatment.

Periodontal disease is a sneaky, pervasive issue that can be detrimental to a patient’s entire health. Systemic diseases like atherosclerosis and diabetes have been associated with periodontitis. Gingivitis, while reversible, can still be exceedingly unpleasant and eventually lead to worsening periodontal health.

The way your hygienist educates patients about periodontal disease contributes to how patients understand the screening’s purpose. The hygienist must make it clear that you are checking for gingivitis and periodontitis because they can lead to pain and tooth loss. This would require much more invasive care in the long run.

Get our take on dental esthetics by reading this awesome Pankey blog here. Do you carry out perio screenings in your practice? We’re dying to know more, don’t be a stranger!

There are many reasons to continually think about how you can add more value to patient appointments. First and foremost, though returning patients want to feel comfortable, they will also appreciate small beneficial changes when they visit.

Value is the number one motivator that will keep patients coming in regularly on time without missing appointments. If being at your practice is particularly enjoyable, they’ll be excited to keep their commitment to regular recall appointments. Additionally, if you provide expanded health services, you’ll be elevating your hygiene appointments to another level.

Here’s a value add that’s easy to implement and good for patients:

Hygiene Boost: Taking Blood Pressure

Many patients may see their hygienist more often than their regular physician. That’s why taking their blood pressure at the start of an appointment is so beneficial. Blood pressure can tell you a lot about the state of their general health.

Patients may be surprised at the result gathered from the blood pressure cuff. If it reveals seriously high blood pressure, a recommendation to a physician may be necessary. The hygienist should explain that your practice takes this additional measure so that you can truly provide comprehensive care. It’s part of your thorough screening process, including periodontal assessments and oral cancer screenings.

Your hygienists will also appreciate being able to provide this extra touch of healthcare. They could really be making a difference for someone who had no idea they were experiencing an issue. Most importantly, it’s another relatively inexpensive way to show patients they are cared for. The entire process should take less than two minutes.

For more Pankey fun, check out this blog on our favorite places to eat Cuban food here. The next time you’re in Key Biscayne, you won’t be able to resist.

What add-on services do you provide during hygiene appointments? We’d love to hear your good ideas!

Donuts have been making a come back for years now. Where once you might have stuck with the Krispy Kreme classic, now there are endless donut shops to choose from. Miami is no exception, so when you get that craving for a round pastry on your visit to Pankey, you have to know where to go.

We’re big on desserts while traveling because they are such a fun diversion from regular habits. And why not try a delightful concoction or baked good that you can’t get anywhere else?

Here are the best donuts in Miami:

Top 4 Miami Donut Spots

1. The Dandee Donut Factory

Dandee does it right, with old-fashioned favorites prepared fresh daily. They have over 50 varieties of handmade donuts complementing an all-day breakfast menu and delightful coffee. Getting there may be a little bit more of a drive if you’re staying on the Key, but take it as an opportunity to explore Miami with a pot of gold at the end of the journey.

2. Mojo Donuts

This place knows how to make an Instagram-worthy donut. Their fried goods are fluffy and luxurious, topped with sugary glaze and creamy icing. They have unique Miami treats such as guava ‘n’ cheese and key lime donuts.

3. Velvet Creme

Velvet Creme is a self-proclaimed donut and coffee company that has a long history in Miami. They’ve been around since 1947 and currently offer a variety of finger-licking good flavors. They are bound to put a smile on your face.

4. The Salty Donut

This establishment may be last on our list, but it is certainly not last in our donut-loving hearts. The Salty Donut attracts large crowds, so be prepared for a wait that is definitely worth it. They provide artisanal donuts in the trendy Wynwood area of Miami. Flavors like nutella and white chocolate tres leches will keep you dreaming of their donuts for months after.

What’s your favorite dessert to try when you visit Miami for a Pankey course? 

How you schedule in your dental practice can significantly impact productivity. If patients are arriving late, not showing up at all, or moving their appointments a lot, you may have a minor crisis on your hands.

There’s no reason to stress when efficiency is only a few simples changes away:

Efficient Practice Scheduling

Scheduling effectively is largely determined by how much patients value your services. Are you and your dental team doing your part to make patients feel respected, cared for, and treated with the highest level of attention possible? Do your patients understand what services are provided during a hygiene appointment? Do they value oral healthcare or know how it can affect the entire body? Do they understand their individual risk factors and how routine care supports managing and minimizing these risks?

All of these are questions you should ask before going out and searching for answers to a mysterious lack of practice growth. Also, you should consider how you set up the daily schedule. Are you moving more intensive cases to the beginning of the day when you and your team are fresh? Do you have enough energy, are you arriving late to the operatory, are you running behind? If patients feel like you aren’t respectful of their time they may not be respectful of yours.

The simple change is to engage your team more. Are your hygienists and dental assistants taking the reigns as much as they can for procedures and managing the schedule? Are they an integral part of developing patient relationships, creating ownership and building an atmosphere where patients want to keep their appointments? The team is also a key component of schedule flow. Are they being utilized effectively to complete clinical procedures? This can be a key to maximizing your productivity without chronically running behind.

Have your hygienists complete their assessments at the beginning of appointments so you can drop in whenever it’s most convenient. That way patients aren’t waiting for you if you get trapped in a complex situation. All of the above are ways in which your schedule could be improved.

How do you maintain steady growth and increased productivity on a yearly basis? Please let us know your favorite tips or recent changes! Also, we have a feeling you’ll love this blog on setting splint therapy fees …