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Award-Winning Journal of the Arkansas State Dental Association Volume 90, Number 1 | Spring 2018
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CONTENTS
Management of Odontogenic Infections
Award-Winning Journal of the Arkansas State Dental Association
Volume 90, Number 1 | Spring 2018
15 FEATURES
Scientific Article
By Chad S. Adams, DDS
Prevention/Treatment for Musculoskeletal
Disorders in Oral Health Professionals 22
Scientific Article
By Rachel R. Freyaldenhoven, Kayla E. Pruitt, Andrew D. Seymour, and Ragan B. Snyder and Melissa Efurd, RDH, Ed.D. (Faculty Mentor)
Smiles Program Q & A 26
Delta Dental
By Robert A. Mason, DMD
Fraudulent Claims 28
ASDA Journal Coding Corner
By Jim Phillips, MS, DDS, FICD
Comorbidities and Quality of Life
of Head and Neck Cancer Patients 30
Scientific Article
By William Wilson, DDS
The Rednick Chronicles 36
Chapter 6, Johnny’s First Deer
Southeast Program Director’s Meeting 37 PHOTO: ISTOCKPHOTO.COM
UAMS General Practice Residency Program
By Niki C. Carter, DMD
38
Dr. Carter Elected ICD Regent
UAMS and ACH Join Forces 38
Volunteer with Dental Lifeline Network • Arkansas! 39
DEPARTMENTS
9 M essage Past P resident : D avid Vammen , DDS
from the
11 From the E ditor : B y Terry Fiddler , DDS
14 Volunteer O pportunities
40 D ental S chools
43 D istrict D ental S ociet y N ews
48 A ssociate N ews
39 C lassified A ds
Page 48 50 O bituaries
COURTESY OFFICE OF THE GOVERNOR / RANDALL LEE
Arkansas Dentistry | Spring 2018 7
Practice Care is Our Priority
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FROM THE PAST
ASDA OFFICERS
PRESIDENT
PRESIDENT
John Pitts, DDS
Little Rock, Central
PRESIDENT-ELECT
David Vammen, DDS
Kim Kosmitis, DDS
Pine Bluff, Southeast
A Pleasure and an Honor
VICE PRESIDENT
Pierce Osborne, DDS
Fayetteville, Northwest
SECRETARY/TREASURER It has been my pleasure and honor to serve you as president of the Arkansas State
Larkin Wilson, DDS
El Dorado, Southwest Dental Association this past year. I have become better acquainted with old colleagues
EDITOR
and have enjoyed making new friendships along the way. We all have more traits in
Terry Fiddler, DDS common than differences that separate us. I can say without hesitation that the den-
Conway, Central District
tists within the realm of ASDA are focused on ethical and sensible dental care. I look
ASDA EXECUTIVE COUNCIL forward to continued successes for our Association as we move forward in organized
Werner Schneider, DDS Jamey Tinnin, DDS dentistry.
Little Rock, C (2020) Fayetteville, NW (2019)
Bob Carlisle, DDS Keith Jones, DDS I want to give credit to whom it is due. We have a core membership who is dedicated to
Benton, C (2022) Pine Bluff, SE (2023) the dental profession to make our mission of promoting health for our citizens a true
Cindy Landry, DDS Stacey Swilling, DDS reality. Included in our member roster is a splendid set of new dentists who have joined
Lepanto, NE (2019) Sheridan, SE (2020)
ASDA for the same reasons the rest of us have retained our membership. ADA
Brad Erney, DDS Ryan Hanry, DDS
Jonesboro, NE (2022) El Dorado, SW (2020)
President Joe Crowley has said that the young dentists (or “new talent” as he likes to
call them) are idealistic in their hopes for creating a better world for us all. And we
Charles Liggett, DDS Trevor Coffee, DDS
Fort Smith, NW (2021) Hope, SW (2021) should all strive for an idealistic outlook to keep our doors open to all who seek dental
care. Even though many dental patients underutilize the entire scope of dental treat-
ASDA STAFF ment, dentists strive to promote greater dental health to match their individual needs.
EXECUTIVE DIRECTOR
Billy Tarpley
billy@arkansasdentistry.org
Arkansas Mission of Mercy
MEMBERSHIP SERVICES We gather again as an honorable profession to give forward to our fellow citizens our
Cheryl Ball
cheryl@arkansasdentistry.org gifts and talents at the 2018 ArMoM to be held in Conway at the Conway Expo &
Convention Center on April 26–28. Registration for dental professionals needs to occur
ARKANSAS STATE BOARD OF
DENTAL EXAMINERS very soon if you have not already done so. You can sign up through arkansasdentistry.
PRESIDENT
org. This year for the first time we might have out of state dentists among us who have
Drew Toole, DDS applied to our Board of Dental Examiners for a four-day charitable license, so if you see
Pine Bluff (2018)
one of those “out-siders,” make them feel welcome and thank them for sacrificing their
VICE-PRESIDENT
Bill Dill, III, DDS
free time to give to our needy citizens. I have participated with Texas Mission of Mercy
Fayetteville (2019) a few times, and I greatly prefer our scenario over theirs. We expect a large population
SECRETARY/TREASURER of patients seeking care, and we do not want to turn anybody away because of not hav-
Fred Church, DDS ing enough workers. Please see to it that you become involved in 2018 ArMoM, and I
Little Rock (2020)
promise you will be blessed in so many ways.
Matt McDonough, DDS Carl Plyler, DDS
Jonesboro (2022) Glenwood (2021)
James Moore, DDS Erika Thomas, RDH Helping Hands
Hampton (2019) Conway (2021)
The Helping Hands committee was formed by ASDA Executive Council in 2016 with
the purpose of offering our members a temporary avenue for supplying volunteer den-
PUBLIC MEMBERS
Donna White
tists to substitute their presence in times of need to keep a dental practice opened dur-
Little Rock (2018) ing an emergency medical crisis. This concept was conceived arising from the medical
Nancy Dunlap emergency experienced by our colleague, the late Dr. Tim Chase, whereby his family
North Little Rock (2019) and staff coordinated with several ASDA members to provide substitute dentists to
care for patients in his office setting. The committee consists of Drs. Terry Fiddler(C),
Continues on page 13
Arkansas Dentistry | Spring 2018 9
FROM THE
Arkansas Dentistry is owned and
published by the Arkansas State Dental
Association three times a year. For
EDITOR
subscription information, please contact
ASDA at 501-834-7650.
Terry Fiddler, DDS
EDITOR
Terry Fiddler, DDS
ART DIRECTOR Helping Others—ARMOM and HELPING HANDS
Jon D. Kennedy
The Freelance Co. That is what dentists do. I think after DDS or DMD behind your title, we could add HO (help-
freelanceco@comcast.net ing others). That certainly is part of our credentials even if was earned as on the job training
and not in school. Many have heard me say over the years that I truly believe that God put
MANAGING EDITOR
Billy Tarpley each of us on this earth to help others. Jesus gave the example of the ultimate servant.
COPY EDITOR
We wake up every day to earn a great living but invariably during that day we get sidelined
Joyce Fiddler
to go above your planned schedule. Perhaps you do a little extra to aid a patient when you
know they can’t afford it and it becomes free of charge; perhaps you get a phone call to carry
ADVERTISING QUESTIONS?
you away for a few minutes from your busy schedule to help in a community matter; per-
For advertising information,
haps you get called on to go to a nursing home or a free clinic for your expertise and not for
please contact Billy Tarpley at
income. Perhaps, that is why on nationwide polls are taken concerning professions, dentists
501.834.7650
are always at the top. As people from my generation once heard actor Walter Brennan say in
a popular role, “no brag, just fact.” We don’t do these things to beat our chest to be heard or
THE FINE PRINT: seen. We just do them. Others can beat your drum, not you.
The Arkansas State Dental Association
and Arkansas Dentistry disclaim and are So we come to the ARKANSAS MISSION of MERCY to be held April 26–28 in Conway. We
wholly free from responsibility for the
need 160 dentists. We have 60. Positions other than dental assistants are being quickly filled.
opinions, statements of alleged facts, or
views therein expressed by contributors WE NEED YOU. You have always come through for us and I feel certain that you will again.
to the publication unless such statements Please go online and register as soon as possible. We are in dire need of restorative dentists. I
have been adopted by the Association. promise you that it will be one of the most rewarding experiences of your life. The under-
Manuscripts and news items of interest served citizenry of Arkansas and surrounding states will love you! Like in other parts of your
to ASDA are invited. All communications
intended for publication should be practice, we just need your expertise. We provide everything else plus 8 hours of CE credit.
electronically mailed to Billy Tarpley at
billy@arkansasdentistry.org. We prefer that HELPING HANDS is a program that has been founded in the last few years by Dr. Chuck
the article be an attachment in Microsoft Wood, Dr. Cindy Landry, and others. This program helps out when a dentist and their fami-
Word, rich text format.The editor reserves
ly are suffering because of illness or other family crisis that has prevented the doctor from
the right to edit all contributions and to
reject or delete material which may be practicing. ASDA has for years, helped those struggling for so many reasons but now we are
deemed unsuitable for publication. organized in a manner to better serve. Dr. Tim Chase and his family, Dr. Tom Smith and his
family, and Dr. Cindy Landry and her family were helped in some manner because of other
HOW TO CONTACT US: caring dentists who helped by substituting in their offices while they were away, or by help-
Arkansas Dentistry ing family members in practice sales, or just by explaining what was going on. Sometimes
c/o Arkansas State Dental Association arms around the suffering means so much. I invite each of your reading this article to join
7480 Highway 107 our numbers. Our President, Dr. David Vammen, has been heavily involved in both pro-
Sherwood, AR 72120
grams. Granted both programs are physically tiring, but they are a labor of love.
Telephone: 501-834-7650
Facsimile: 501-834-7657
Dentistry may not be solution to all the problems in
the world, but to those it reaches out to help for
either program, it is a godsend. Terry Fiddler, DDS
Editor, Arkansas Dentistry
fiddler@conwaycorp.net
Arkansas Dentistry | Spring 2018 11Dr. Jackie Smith DDS, PLLC
Providing portable dentistry to the residents of nursing facilities
Now Hiring Dentists, Hygienists and Assistants!
(Positions available statewide from one day a week to supplement your income up to full-time.)
Call toll free 855-821-2214 or 501-821-2214 today
to speak with Kimberlee Brooks, Vice President,
or visit seniorworks.com
for your next career opportunity.
Senior Dental Care, LLC
110 West Colonel Glenn
Little Rock, Arkansas 72210
www.seniorworks.comPAST PRESIDENT concerns, organizes our state meetings,
ADVERTISER Continued from page 9 manages our award winning journal pub-
lications, represents organized dentistry
RESOURCE INDEX
chairman, David Cole (SW), Trevor Coffee at the legislature and agencies of our
AFTCO..................................................33 (SW), David Vammen (SW), Alisa Hopper state, coordinates our efforts with other
(SE), Stacey Swilling (SE), Chuck Wood state organizations at the ADA level, and
(NE), Cindy Landry (NE), Mike Williams performs all these tasks and much more
AXPM....................................................34
(NE), Tom Spivey (NW), and Mrs. Paige with the greatest smile our state has ever
Chase of Monticello. During our commit- seen. With his leadership, the Arkansas
Arkansas Dentistry...............................42 tee meeting Mrs. Chase related her expe- State Dental Association is well represent-
riences with handling the coordinated ed and respected in our professional deal-
Delta Dental Plan of Arkansas effort to keep the doors open at Tim’s ings. He coordinates our legislative agen-
.................................................Back cover practice during his medical leave of da with our lobbyist, Don Tilton. Our
absence. The Helping Hands committee coordinator of membership services is
Dental International Lab...................4-5 members ask you, the heart and soul of Cheryl Ball at the ASDA office. Our comp-
ASDA, to commit your willingness to troller is Gorma McBride who keeps tabs
serve our colleagues as a volunteer dentist on the financial dealings of our associa-
Duncan, Messersmith
should a crisis occur. In the bible verse tion. We have the finest dental associa-
& Associates.........................................19
from Ecclesiastes 4:10, we learn “If one tion staff in the nation, and they are
man falls down, his friend can help him renowned among their professional col-
Edmonds Dental Prosthetics, Inc........ 6 up; but pity the man who falls and has no leagues. We are certainly grateful for the
one to help him up.” Please search your cheerful manner our ASDA staff presents
Green Dental Lab heart and conscience and offer your name on our behalf.
.....Inside front cover, inside back cover as a willing colleague to join a network as
a Helping Hands volunteer. Contact a
Hayes Handpiece.................................17 friend on the Helping Hands committee In Conclusion
to express your willingness to serve. I am grateful to all of you who have
Henry Schein.......................................... 8 offered to me your kind words of encour-
agement during my term as president of
Paragon Dental Practice Transitions...29 ADA—Honolulu ASDA. I really appreciate your involve-
It is time to make your plans to come to ment in our professional activities to per-
beautiful Hawaii for the 2018 ADA petuate organized dentistry. We are able
Patterson Dental Supply, Inc.............10 Convention. The dates of the meeting are to provide care for God’s children through
October 18-22. What a fabulous destina- His hands in the great profession of den-
Prosites.................................................25 tion to convene with colleagues from all tistry. May God bless each and every one
over the USA and the world! Earn valu- of you in the coming days.
Regions Insurance................................. 3 able CE hours and bask in one of the
Sincerely,
world's loveliest island retreat. Make your
plans now to attend the convention and
Regions Mortgage...............................27
book your lodging early at one of the
many hotels so you can stay at your pre-
David Vammen
David Vammen, DDS
Senior Dental Care, LLC.....................12 ferred resort. And once you have regis- President, ASDA
tered with the ADA, please notify the
This publication was made possible with the ASDA of your intentions to attend,
support of these advertisers. They support P.S. If you just can’t find me, I’m probably
the dental industry by enabling ASDA to because we want to know who’s going to relaxing in a chair in the cool waters of
provide this publication to its members, join the fun at America’s Dental Meeting! the Little Missouri River…
prospective members, elected officials and
the business community at large. They
deserve your consideration and patronage
when making your corporate purchasing
ASDA Staff
decisions. I want to draw special attention to our
Please visit arkansasdentristy.org to see the outstanding staff at the ASDA office. Billy
digital version of Arkansas Dentistry with Tarpley, executive director, coordinates
live links to advertisers’ websites. the many aspects of ASDA and represents
our cause with enthusiasm to the entire
state. He deals with member needs and
Arkansas Dentistry | Spring 2018 13VOLUNTEER
OPPORTUNITIES
Volunteer Opportunities – A Chance to Give Back
Why not volunteer your dental services once or twice a year in the community that provides your livelihood? Volunteer
dentists, hygienists, assistants and staff are needed.
Some of the volunteer dental clinics in central Arkansas and their times of operation are listed below. A contact person
is included to answer questions and set up a time to volunteer.
Harmony Health Clinic Shepherd’s Hope Clinic
201 East Roosevelt Road 2404 S. Tyler
Little Rock, AR 72206 Little Rock, AR 72204
Contact: Eddie Pannell Contact: Pam Ferguson
501-375-4400 501-614-9523
Hours: day and evening clinics, Hours: 6:00 p.m. – 9:00 p.m. every Tuesday
Monday – Saturday www.shepherdshopelr.org
www.hamonyclinicar.org
River City Ministries
Interfaith Health Clinic 1321 East Washington Ave.
514 West Faulkner No. Little Rock, AR
El Dorado, AR 71730 Contact: Carol Ezell
Contact: Charlotte Ellen, 501-376-6694
870-864-8010 Hours: 8:30 a.m. – 4:30 p.m.,
Hours: 8:00 a.m. – 5:00 p.m., seven days a week
Monday through Friday www.rivercityministries.org
Northwest Arkansas Free Christian Community Care Clinic
Health Center 2200 W. South St., Benton, AR 72015
10 South College Avenue Contact: Kae Wissler at Dr. Richard Phelan 501-778-7129
Fayetteville, AR 72701 Hours: The 2nd and 4th Tuesday of every month
Contact: Monika Fischer-Massie, 6:00 p.m. – 8:00 p.m.
479-444-7548 or www.bentoncareclinic.com
mfischerm@arkansasusa.com
Hours: Thursdays start between 4:00 and 5:30 p.m. for about Arkansas Health Care Access
2.5 hours; Little Rock, AR
Fridays start between 8:30 and
9:00 a.m. for about 2.5 hours Arkansas Donated Dental Services
Clinic makes accommodations for the volunteer dentists’ Little Rock, AR
schedules. Eureka Christian Health Outreach, Inc. (ECHO Clinic)
Jonesboro Church Health Center Dental Clinic 4004 East Van Buren
200 West Matthews Ave. Eureka Springs, AR 72632
Jonesboro, AR 72401 Contact: Janet Arnett
870-972-4777 479-253-5547
Clinic offers free dental extractions and other medical
Charitable Christian Medical Clinic services.
133 Arbor St.
Hot Springs, AR 71901
Contact: Millie Lopez, 501-318-1153
The Harmony Health Clinic is a free medical and dental clinic that strives to meet the
needs of the homeless and less fortunate in the greater Pulaski County area.
We are currently in need of dentists to volunteer on Fridays, hours ranging from
8:00 a.m. to 12:00 p.m. and can be adjusted to meet volunteers’ schedules.
An experienced dental assistant is on staff and available to assist all volunteers. If you have
four hours a year to give back or more please contact Tiffany Sikes at 501-375-4400.
14 Spring 2018 | Arkansas DentistryScientific Article
MANAGEMENT OF ODONTOGENIC
INFECTIONS
CHAD S. ADAMS, D.D.S.
University of Arkansas For Medical Sciences
General Practice Residency
One of the hallmarks of being a
healthcare provider in a hospital system is
treating patients who have entered into a
more advanced stage of the disease
process. In the case of dentistry, this
usually implies a severe odontogenic
infection. Patients are overwhelmingly
unaware of how serious a “cavity” can
become, both locally and systemically. As
a practitioner, part of our commission is
to treat these individuals with the best
care that can be provided. Ultimately,
prevention and diligence on the part of
the patient and the provider will largely
preclude a severe odontogenic infection PHOTO: ISTOCKPHOTO.COM
from arising; however, when a case
inevitably presents, it is our responsibility
to be equipped with the skills and the
knowledge to produce a successful
outcome. The intention of this paper is to The intention of this paper is to educate
educate and to offer guidance in the
treatment planning options for patients and to offer guidance in the treatment
with severe odontogenic infections.
Before discussing treatment options
planning options for patients with severe
for patients presenting with odontogenic odontogenic infections.
infections, it is important to first under-
stand the source of infection as well as to
fully understand the disease process.
Odontogenic infections are bacterial- to severe odontogenic infection was caries of bacteria can be present at any given
mediated. They occur when bacteria gain (65%), followed by pericoronitis (22%), moment in the oral cavity, it is the specif-
entrance into the periapical space of a and periodontal disease (22%) ( 2006). ic compilation as well as location, which
tooth by way of the pulp, pericoronal tis- The severity of the infection is multi-fac- can permit such an infection to propa-
sue, or the periodontium. In terms of fre- torial, but is largely dependent upon the gate (Mougeot, et al., 2015). Odontogenic
quency, author Flynn, et al., explains that microflora present. Though it has been infections are polymicrobial in nature and
“the most frequent dental disease leading shown that roughly 700 different species ➥
Arkansas Dentistry | Spring 2018 15are predominately anaerobic gram-posi- as a virulence factor by stimulating the ness will soften, and the underlying tissue
tive cocci and gram-negative rods. It is the production of inflammatory cytokines” will form a necrotic mass of granulation
virulence factors of these bacterial species (Stefanopoulos & Kolokotronis, 2004). tissue, sequestered bacteria, and immuno-
that allow them to be so effective. Endotoxin, hydrogen sulfide, and other logically-active cells. Abscess formation
Stefanopoulos and Kolokotronis state proteolytic enzymes are inherently cyto- helps by walling off the infection allowing
that, “pathogenicity [of bacteria] include toxic. This accounts for tissue degrada- the immune system of the host to effec-
aerotolerance, a variety of bacterial tion resulting in the continuing spread of tively kill the invading bacteria and to
enzymes, toxins, and metabolites detri- the infection. The addition of the beta- stop further spread (Flynn, 2000).
mental to the host, possession of a cap- lactamases family of enzymes to some of Without removing the source of infec-
sule with antiphagocytic and abscesso- these bacterial species increases their tion by way of endodontic therapy or
genic properties, and bacterial synergism” pathogenicity by inactivating two of the exodontic therapy, this process can repeat
(2004). Because odontogenic infections most commonly used antibiotic classes of over and over again in a patient with an
are mixed infections, the bacteria are able drugs. odontogenic infection. At this point, the
patient will ultimately have a chronically
abscessed tooth. The necrotic tissue in
the periapical area will eventually pene-
Without removing the source of infection trate through the cortical plate of the
alveolar bone in the path of least resis-
by way of endodontic therapy or tance. “Changes in the cortical plates were
exodontic therapy, this process can repeat observed more frequently in the labial
and buccal side than in the palatal side,”
over and over again in a patient with an according to Obayashi, et al., when dis-
cussing maxillary abscesses (2004). Once
odontogenic infection. through the bone and soft tissue, a fistula
with draining exudate is the common pre-
sentation that practitioners are all too
familiar with. It is quite common for
to behave synergistically; this allows bac- This brief introduction into the micro- patients to be unaware of the severity of
teria to survive alongside one another flora of odontogenic infections has shown complications that an odontogenic infec-
when impossible on their own. An exam- how these bacteria are able to be so effec- tion can produce. They will often admit to
ple of the effectiveness of this synergism tive in their pathogenicity. Now it is having a draining abscess present over
can be witnessed in the presence of oxy- important to understand the staging of the course of months to even years. In
gen. As stated, the major bacteria the infection and what practitioners many cases, no life-threatening infection
involved in these infections are typically should look for when a patient presents will occur.
anaerobic; this implies that in the pres- with symptoms of infection. Now that staging of a typical odonto-
ence of oxygen they are unable to survive. The inoculation of invading bacterial genic infection has been fully appreciated,
In a mixed infection, there are facultative species into the tissue is the first stage of it is imperative to understand how an
anaerobes present that decrease the oxy- the infection process. There is an early odontogenic infection becomes severe.
gen tension in the living tissue, which can inflammatory period at this time, due to The classic example is that of Ludwig’s
allow for obligate anaerobes to survive. the presence of the invading bacterial; angina. “Ludwig’s angina is a bilateral
On a related note, moderate anaerobes this inflammation will ultimately cause infection of the submandibular space that
are able to combat the oxygen presence by edema. Clinically, this is significant consists of two compartments in the floor
an enzyme called superoxide dismutase. because clinicians are able to objectively of the mouth, the sublingual space and
An assortment of enzymes and toxins see signs of the infection. Two to five days the sub mylohyoid space” (Chow, 2015).
that these bacteria possess or metaboli- into the infection, the edema will have The hallmark of this disease process is
cally produce further accounts for the progressed and cellulitis develops. The airway obstruction. This occurs by the
severity of these infections. The capsular softer swelling of the initial stage will bilateral spread of the cellulitis.
polysaccharide found surrounding some begin hardening. This infected area will Mandibular second and third molars are
bacteria gives them antiphagocytic quali- be hot to the touch, quite tender, and will most likely to be the source of infection
ties as well as the ability to stimulate rapidly enlarge. From this stage to the resulting in Ludwig’s angina. This is due
inflammation. “Lipid polysaccharide plays next stage the cellulitis begins transition- to the location of the roots of these teeth
an important role in the initiation and ing into an abscess formation. Four to in relation to the fascial planes necessary
magnification of abscess formation acting seven days into the infection, the hard- ➥
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• Serving Arkansas and Texarkana, Texas, Since 2001to be crossed, notably beyond the attach- of choice” at this time (Chow, 2015). In fact, 60%-70% of cases of descending nec-
ments of the mylohyoid muscles, in order many cases magnetic resonance imaging rotizing mediastinitis have been implicat-
to infect the submandibular space. It can offer a superior image to that of a CT ed in resulting from unresolved odonto-
should be noted “fascial layers prevent in regards to the initial evaluation of a genic infections (Sakamoto, et al., 2000).
inflammatory spread, once the infection patient with deep space infections; how- Another potential danger of odonto-
spreads into the muscle beyond the fascia, ever, the authors Bali, et al., explain that genic infections lies in the bacteria’s abili-
the muscle itself can transfer inflamma- this is not a practical option for many ty to gain entrance to the blood stream.
tion to the adjacent tissues” (Obayashi, et emergency cases (2015). This bacteremia can produce numerous
al., 2004). A severe odontogenic infection does distant site infections. Infective endocar-
The symmetrical presentation of the not only present itself in the form of ditis is one such infection.
swelling in Ludwig’s angina is due to the Ludwig’s angina, the spread of infection Infective endocarditis (IE) is inflamma-
aforementioned spread of infection. If the can follow many fascial layers. According tion that occurs in the endocardium of
infection were instead spread through to Jose, et al., “maxillofacial infections the heart. Artificial heart valves are more
lymphatic involvement, one would note are known to spread intracranially by commonly associated with cases of IE
that the swelling and infection would be direct extension along the fascial planes than native heart valves. The species of
unilateral. This is an important finding or by hematogenous route into the cav- bacteria that are present in the oral cavity
that would rule out a diagnosis of ernous sinus” (2014). are associated with the same infecting
Ludwig’s (Chow, 2015). This route of infection is typically seen bacterial species as with IE. Though
An established infection in the sub- when the infraorbital space has become extracting infected teeth can help remove
mandibular space will cause the tongue to involved. There are angular veins that a source of the bacteria associated with
swell and be pushed in a posterior direc- run through this space, and when a septic IE, it has been shown that extractions in
tion towards the hypopharynx and supe- thrombophlebitis enters these veins it can and of themselves can cause bacteremias,
riorly against the palate. These factors, then ascend into the cavernous sinus which have the potentiality to cause IE.
along with infection spread to the retro- through valveless veins. Once present in This discovery has prompted many to
pharyngeal and parapharyngeal spaces, the cavernous sinus, a thickening of the prophylactically medicate high-risk
patients with antibiotics prior to extrac-
tion of diseased or even virgin teeth. Such
conditions deemed high-risk include: arti-
Though extracting infected teeth can help ficial heart valves, orthopaedic joint pros-
remove a source of the bacteria associated theses, immunosuppressed patients, as
well as patients with catheters or shunts
with IE, it has been shown that extractions for hemodialysis (Lockhart et al., 1999).
The use of prophylactic antibiotics for the
in and of themselves can cause bacteremias, purpose of preventing distant site infec-
which have the potentiality to cause IE. tions (DSI) has many opponents. Some
argue that organisms that cause IE and
other DSI can be found in the upper and
lower digestive tract, skin, as well as the
accounts for the airway occlusion. Airway meningeal walls can produce compression upper respiratory tract. These extraoral
obstruction can be slightly relieved by of cranial nerves III-VI resulting in signs sites could also be the source of IE and
having patients assume the “sniffing posi- of neuropathy. DSI. Mougeot et al. explains “although
tion.” This position helps to straighten Though Ludwig’s angina and cavernous [antibiotic prophylaxis] decreases the fre-
the upper airway allowing for a more pat- sinus involvement are two of the more quency of all oral bacterial species, both
ent airway (Flynn, 2000). It should be severe complications associated with tooth brushing and single tooth extrac-
noted that due to the swelling of the odontogenic infections, many other head tions disrupt similar bacterial species in
tongue, occlusion of the airway, and pala- and neck spaces can become involved. The similar proportions” (2015). This finding
tal involvement the patient would have a following other spaces can be involved: suggests that, regardless of antibiotic pro-
difficult time communicating verbally. buccal, infraorbital, subperiosteal, vestib- phylaxis, bacteremias are present in simi-
This can further complicate getting neces- ular, submental, masticatory, submasse- lar microbial-content as well as quantity
sary information from the patient for teric, pterygomandibular, temporal, later- following a common task such as brush-
proper treatment. For a definitive diagno- al pharyngeal, and retropharyngeal. ing one’s teeth. Though the literature cur-
sis of Ludwig’s angina, “a computed There have been cases of mediastinitis rently asserts that this bacteremia is
tomography scan is the imaging modality resulting from odontogenic infections. In ➥
18 Spring 2018 | Arkansas DentistryPHOTO: ISTOCKPHOTO.COM
caused on a daily basis through normal more severe cases, “the establishment of products and a greater influx of defensive
activities, it should be left to the discre- gravity-dependent surgical drainage of cells and antibodies” (Bahl et al., 2014).
tion of the practitioner whether or not deep space odontogenic infections is the As indicated in the previous passage,
prophylactic antibiotics are prescribed. primary treatment” (Flynn, 2000). By antibiotic therapy is typically used in con-
Consider the patient’s systemic condi- opening up the infected space, a junction with surgical drainage or remov-
tions, history with IE, as well as other significant portion of the microbial load al of the offending tooth, but not as the
extenuating circumstances when formu- will be removed allowing leukocytes to sole treatment. The most accurate meth-
lating a decision. Despite acting against gain better access to the remaining od for choosing an antibiotic class,
the literature, the litigious society in infection. Not only is the infected space assuming no drug allergies, is culturing
which one lives makes this decision more more accessible, but also by collapsing the for the purpose of determining antibiotic
difficult. avascular abscess cavity, blood is able to efficacy. Though, a more pragmatic choice
A clear understanding of the cause and more effectively flow near and into the would be to place the patient on an antibi-
the process of complications resulting infected space increasing local leukocyte otic class that is statistically likely to be
from severe odontogenic infections has numbers. efficacious against bacteria that are com-
been provided. Understanding how to Following incision and drainage, most monly the cause of odontogenic infec-
manage these patients surgically is the surgical sites will stop producing exudate tions. At this time, “penicillin remains
next phase. in two to three days. Complete resolution the drug of choice in the management of
As one would imagine, removal of the is often seen five to twelve days post- most odontogenic infections” (Bahl et al.,
source of infection is the primary goal for operatively. To further increase healing 2014).
treatment of odontogenic infections. This response time, patients are often placed Due to an increase in penicillin-resis-
can take many forms. Less severe on antibiotics as well as instructed to tant bacteria, it has become common
infections can be primarily treated by place moist heat on the infected tissue. practice to additionally place the patient
extraction of the infected tooth and This will trigger vasodilation in the on clavulanic acid to counter the beta lac-
curettage of the socket. Antibiotics can be associated area resulting in a more tamase enzyme. In addition, many practi-
a good supplement to primary treatment; prompt resolution of the infection by a tioners will add metronidazole to the
however, this is not always necessary. In “rapid removal of tissue breakdown antibiotic combination to aide in the reso-
20 Spring 2018 | Arkansas DentistryReferences:
Bahl, R., Sandhu, S., Singh, K., Sahai, N., & Gupta, M.,
As one would imagine, removal of the (2014). Odontogenic infections: Microbiology and man-
agement. Contemporary Clinical Dentistry. 5(3): 307-311.
source of infection is the primary goal for Bali, R. K., Sharma, P., Gaba, S., Kaur, A., & Ghanghas, P.,
(2015). A review of complications of odontogenic infec-
tions. National Journal of Maxillofacial Surgery. 6(2):
treatment of odontogenic infections. This 136-143.
Candamourty, R., Venkatachalam, S., Babu, M. R. R., &
can take many forms. Kumar, G. S., (2012). Ludwig’s Angina—An emergency: A
case report with literature review.
Journal of Natural Science, Biology, and Medicine. 3(2):
206-208.
Cho, A. W. (2015) Submandibular space infections
(Ludwig’s Angina). In A. Bloom (Ed.), UpToDate.
Retrieved June 9, 2017, from https://www.uptodate.com/
lution of more serious anaerobic bacterial Both trismus and airway management contents/submandibular-space-infections-
species. Regardless of the concoction of issues are objective signs that a practitio- ludwigs-angina/print
antibiotics that has been chosen, it is ner can look for when determining Dhandrajani, P.J., and Jonaidel, O., (2002). Trismus:
Aetiology, Differential Diagnosis and Treatment. Dental
imperative to monitor the efficacy. If whether or not a patient requires admit- Update. 29:88-94.
infection is not responding, one must cul- tance into an in-patient hospital setting. Flynn, T. R., (2000). The Swollen Face – Severe
ture and choose a more effective drug Other objective signs that should alert Odontogenic Infections. Emergency Medicine Clinics of
North America. 18(3):481-519.
class. Tomas, et al. conclude that the physician include: fever over 101°F Flynn, T. R., Levi, M. H., and Kraut, R. A., (2006). Severe
“clindamycin should be considered as a (38.3°C), dehydration requiring intrave- Odontogenic Infections, Part 1: Prospective Report.
Journal of Oral and Maxillofacial Surgery. 64: 1093-
first-line antibiotic in the field of dentist- nous fluid therapy, need for incision and 1103.
ry” (2006). drainage, possible need for general anes- Flynn, T. R., Shanti, R. M., and Hayes, C., (2006). Severe
One must be aware of and consider thesia, patients with significant systemic Odontogenic Infections, Part 1: Prospective Outcomes
Study. Journal of Oral and Maxillofacial Surgery. 64: 104-
some common complications that can health conditions, as well as immuno- 1113.
arise in patients with severe odontogenic compromised patients (Flynn, 2000). Gams, K., Shewale, J., Demian, N., Khalil, K., and Banki,
F., (2017). Characteristics, length of stay, and hospital
infections. As mentioned earlier, airway Early recognition of these symptoms and bills associated with severe odontogenic infections in
obstruction as seen with Ludwig’s angina proper diagnosing of pathology are two Houston, TX. The Journal of the American Dental
Association. 148(4): 221-229.
can be one of the more serious complica- important tasks a physician can perform
Jose, A., Nagori, S. A., Ongkila, B., and Roychoudhury, A.,
tions. Ensuring that the patient has a pat- for their patient. Prevention of the initial (2014). Odontogenic infection and pachymeningitis of the
ent airway is of upmost importance, spread of infection can spare the patient, cavernous sinus. British Journal of Oral and Maxillofacial
Surgery. 52: e27-e29.
achieving an open airway however, can be physician, as well as the healthcare sys- Lockhart, P. B., Durack, D. T., (1999). Oral microflora as a
quite a challenge for the medical team. tem the unwanted burdens of the afore- cause of endocarditis and other distant site infections.
Infectious Disease Clinics of North America. 13(4):
Candamourty et al. advise that a blind mentioned complications and treatments 833-850.
nasotracheal intubation can be quite dan- necessary for patients with severe odon- Mougeot, F. K. B., Saunders, S. E., Brennan, M. T., and
gerous in Ludwig’s angina patients togenic infections. Gams et al., demon- Lockhart, P. B., (2015). Associations between bacteremia
from oral sources and distant-site infections: tooth brush-
because there is potential for significant strated that the pathosis described in the ing versus single tooth extractions. Oral Surgery, Oral
bleeding and abscess rupture. Options to above paragraphs “were associated with Medicine, Oral Pathology and Oral Radiology. 119: 430-
435.
consider can include fiberoptic intubation substantial morbidity and cost in a largely Obayashi, N., Ariji, Y., Goto, M., Izumi, M., Naitoh, M.,
via nasal route, or the “gold standard” unsponsored patient population.” They Kurita, K., Shimozato, K., Ariji, E., (2004). Spread of odon-
togenic infection originating in the maxillary teeth:
elective tracheostomy under local anes- went on to communicate to their peers Computerized tomographic assessment. Oral Surgery,
thesia (2012). that early treatment of odontogenic infec- Oral Medicine, Oral Pathology and Oral Radiology. 98:
223-231.
Another common complication result- tions could spare unnecessary hospital
Sakamoto, H., Aoki, T., Kise, Y., Watanabe, D., and Sasaki,
ing from an odontogenic infection is tris- admittances (2017). J., (2000). Descending necrotizing mediastinitis due to
mus which occurs when the infection The task of treating patients with odontogenic infections. Oral Surgery, Oral Medicine, Oral
Pathology, and Oral Radiology. 89: 412-419.
infiltrates the masticatory space resulting severe odontogenic infections can be a Stefanopoulos, P. K., and Kolokotronis, A. E., (2004). The
in inability to open the mouth to a nor- daunting one; however, it is important to clinical significance of anaerobic bacteria in acute orofacial
odontogenic infections. Oral Surgery, Oral Medicine, Oral
mal range of 40 - 60 mm. This makes think logically when treatment planning, Pathology, and Oral Radiology. 98: 398-408.
extractions or access to the site of infec- and to fully consider what has been dem- Tomas, I., Alvarez, M., Limeres, J., and Diz, P., (2006).
tion more difficult, or even impossible. onstrated in this paper. Evidence-based Clindamycin in dentistry: Is it an effective prophylaxis for
endocarditis? Oral Surgery, Oral Medicine, Oral Pathology,
Trismus is yet another contributing factor treatment planning and problem solving and Oral Radiology. 1(6): 698-700.
which can make an odontogenic infection that can be verified in literature will lead
more difficult for the practitioner to both the patient as well as the practitio-
effectively treat. ner down a successful path. AD
Arkansas Dentistry | Spring 2018 21Scientific Article
PREVENTION/TREATMENT FOR
MUSCULOSKELETAL DISORDERS IN
ORAL HEALTH PROFESSIONALS
quality of life and financial well-being
(Kott & Lemaster, 2014). Since the 1980s,
MSD, or other injuries related to repeti-
tive motions, have increased substantially
among dental professionals, with neck
and shoulders being the most common
areas affected. As high as 93% of hygien-
ists have reported that their daily work
activities have either caused or worsened
their musculoskeletal pain (Chismark,
Asher, Stein, Tavoc, & Curran, 2011).
The main cause for the rise in MSD is
due to poor ergonomics, longer workdays,
and outdated dental equipment.
According to Dimensions of Dental
Hygiene, two out of three dental hygien-
ists have experienced general MSD at
some point in their career (Kott &
Lemaster, 2014). Taking this statistic into
consideration, imagine 20 or more years
of chronic pain, which could lead to an
early retirement or require a career
change.
How important is career longevity
among dental professionals? Many people
endure prolonged pain without being
ART: ISTOCKPHOTO.COM
aware of alternative treatments that are
unique to a person’s injury, interests, and
BY RACHEL R. FREYALDENHOVEN, (MSD) is one of the most common prob- financial standing. These alternatives
KAYLA E. PRUITT, ANDREW D. SEYMOUR, lems dental hygienists may encounter include physical therapy, yoga/Pilates,
AND RAGAN B. SNYDER during their career (Gehrig, Sroda, & chiropractic’s/acupuncture, and home
MELISSA EFURD, RDH, ED.D. (FACULTY Saccuzzo, 2017). MSD is a combination of exercises (Brenman, 2007). Proactive pre-
MENTOR) disorders that affect the body’s natural vention and alternative treatments are
University of Arkansas for Medical Sciences range of motion, including injuries to por- essential for quality of practice. The pur-
tions of the muscular, nervous, and skele- pose of this paper is to educate dental
tal systems. hygienists regarding overall health, in
Introduction MSD may lead to diminished produc- order to prolong careers in this field.
With a prevalence rate ranging from tivity and patient care, while increasing MSD is a major factor connected with
64% to 93%, musculoskeletal disease medical costs, which in turn impacts injury-related retirement that affects
22 Spring 2018 | Arkansas Dentistry15-50% of the dental profession (Waddell,
2006). Treatment for this disease is not
difficult to find; the confusion is what
treatment will offer the most benefit
Massage therapy also provides benefits for
regarding the injury. The prevalence of both prevention and treatment of MSD and
musculoskeletal disease among dental
hygienists has in part been linked to poor may target the areas of the body that affect
ergonomics in the workplace (Chismark et
al., 2011).
dental hygienists greatly.
In one study, participants who reported
experiencing a higher level of pain also
reported that they practiced correct pos- for the clinician, not the other way nificant amount of stress is also concen-
ture less than 50% of the time (Humann around (Gehrig et al., 2017, p. 21). trated on the hands of a hygienist while
& Rowe, 2015). By teaching ergonomics as Additionally, loupes can be used to scaling, probing, and polishing through-
part of the dental hygiene curriculum and potentially reduce MSD pain in the head, out the day. This constant straining of the
enforcing this during clinical dental neck, and back. However, wearing loupes hand can lead to carpal tunnel syndrome
hygiene instruction, the likelihood of does not assure that the hygienist will use (Chismark et al., 2011). The stretches
future work-related pain could be proper posture (Humann & Rowe, 2015). found on the “Ergo-Break Poster,” ( http://
reduced. Continuing education courses As a single factor, loupes cannot be used www2.tulane.edu/oehs/upload/Ergo-
regarding proper ergonomics will advance to guarantee a reduction in work-related Break-Poster.pdf) demonstrate step-by-
the hygienist’s knowledge, especially for pain. They must be used in conjunction step finger and wrist flexor/extensor
those who did not receive ergonomics as with optimal patient-operator position- stretches to help prevent muscle tension
part of their dental hygiene curriculum ing. Consequently, an emphasis on prop- that can lead to carpal tunnel (The Back
(Humann & Rowe, 2015). er ergonomics continues to be a leading School, n.d.). Allowing 30 to 45 minutes
prevention in lowering the risk of devel- each day to practice these yoga poses and
Proper Ergonomics oping musculoskeletal disease. stretches may be the difference between a
Proper operator positioning includes long career of comfort or early retirement.
maintaining a “neutral body position” Prevention and Treatment Massage therapy also provides benefits
(Gehrig et al., 2017, p. 11). The hygienist’s Yoga and specialized stretches may also for both prevention and treatment of
neck should be tilted no more than 20 help in the prevention and reduction of MSD and may target the areas of the body
degrees downward, and the head should MSD in dental hygienists. The continuous that affect dental hygienists greatly. This
never be angled to one side. The back practice of poor posture can lead to therapy is one of the six most commonly
should not be overly curved, but it should chronic discomfort in multiple parts of used complementary and alternative
be flexed forward from the hips no more the body. The neck, shoulders, upper and medicine (CAM) therapies along with
than 20 degrees. The hygienist’s torso lower back, hips, arms, wrists, and yoga and chiropractic care. Massaging the
should be kept straight, without leaning thumbs are some of the main areas in muscles in the needed areas will relax the
to one side. The shoulders should be in a which hygienists experience aches and tissue. Spasms and painful contractions
straight line, not raised or rounded for- pains (Gupta, Ankola, & Hebbal, 2013). are reduced from the lessened compres-
ward. The upper arms should be kept par- Along with poor posture, lack of flexibili- sion of nerves and the proper nutrients
allel to the body, no more than 20 degrees ty can also lead to musculoskeletal pain in reaching the tissues. This results in effi-
away from the torso, while the forearms the practice of dentistry (Chismark et al., cient operation of the muscles. Studies
should be parallel to the floor, optimally 2011). with the general population have shown
angled at 90 degrees. Both yoga and certain stretching exer- massage therapy is an effective manipula-
The hygienist should take care to avoid cises have shown to improve posture, tive and body-based medicine to manage
bending the wrists up or down, as they increase flexibility, and combat the pain musculoskeletal pain. This therapy can
should stay in line with the forearms that stems from MSD. Some yoga poses lead to reductions in chronic low back
(Gehrig et al., 2017, p. 12-13). such as Bhujangasana, Salabhasana, pain and short-term benefits for treat-
Other ergonomic principles to be Namaskar, Surya, Ardha, Bidalasana, ment of chronic neck pain.
enforced include proper patient position- Matsyendrasan, and Adho Mukha are Relaxation of the mind and body over-
ing, so that the hygienist may see all nec- helpful in preventing neck, shoulder, and all is also a benefit for patients. As a treat-
essary areas without forcing an awkward back pain (Gupta et al., 2013). ment, massage therapy may help with
working position. The patient should be Along with the accumulated physical pain that causes work interruptions. As a
adjusted accordingly to what works best stress for several parts of the body, a sig- ➥
Arkansas Dentistry | Spring 2018 23es that require the patient to use their
own body weight and strength to generate Senior students at the University of Arkansas
their own forces and facilitate self-care for Medical Sciences, Department of Dental
(Cherkin, Deyo, Battie, Street, & Barlow, Hygiene work in groups to investigate topics
1998). Minor injuries may require fewer of interest to dentistry. The result is a written
sessions compared to a detrimental injury paper and a free two hour CE offering
that could require months of sessions. which will occur April 12, 2017. Please see
Prices vary from state to state, but based the department website for details; http://
on this specific example, the lack of MSD healthprofessions.uams.edu/programs/
preventative practices can lead to costly dentalhygiene/
treatment that may otherwise have been
avoided. References
Brenman, E.K. (Ed.). (2007). Pain management:
PHOTO: ISTOCKPHOTO.COM Another form of treatment for muscu- Musculoskeletal pain. Retrieved 12 March, 2017, from
loskeletal disease is the performance of http://www.medicinenet.com/pain_management_muscu-
loskeletal_pain/article.htm
chiropractic treatment. Common treat-
Burgan, B. (2016). How does massage work? University of
Both yoga and ments included stretching and strength-
ening exercises performed via quick, com-
Minnesota. Minneapolis, MN: Regents of the University of
Minnesota. Retrieved from https://www.takingcharge.csh.
certain stretching pact thrusts. In the same study, partici-
umn.edu/explore-healing-practices/massage-therapy/
how-does-massage-work
pants who underwent chiropractic care
exercises have
Ceas, C. G. (2002). Ergonomics in Dentistry, Part 1.
Retrieved from http://www.dentistrytoday.com/ergonom-
showed improvement, although it was ics/1113
shown to improve also determined that not all people with
MSD related pain should be referred to a
Cherkin, D.C., Deyo, R.A., Battie, M., Street, J., & Barlow,
W. (1998). A comparison of physical therapy, chiropractic
posture, increase chiropractor (Cherkin et al., 1998).
manipulation, and provision of an educational booklet for
the treatment of patients with low back pain. The New
flexibility, and Acupuncture is an alternative to MSD England Journal of Medicine, 339, 1021-1029.
Cherkin, D.C., Sherman, K.J., Deyo, R.A., & Shekelle, P.G.
that may benefit from a different method (2003). A review of evidence for the effectiveness, safety,
combat the pain of care. Acupuncture is a method of care
using needles placed specifically on the
and cost of acupuncture, massage therapy, and spinal
manipulation for back pain. Annals of Internal Medicine,
that stems from body based on the patient’s pain. The nee-
138(11).
Chismark, A., Asher, G., Stein, M., Tavoc, T., & Curran, A.
MSD. dles puncture the spinal cord and stimu-
late hormonal reactions that mediate pain
(2011). Use of complementary and alternative medicine
for work-related pain correlates with career satisfaction
among dental hygienists. The Journal of Dental Hygiene,
by increasing pain tolerance and/or lessen 85(4), 273-284.
Fried, J.L. (2017). Antidotes for musculoskeletal disorders:
cost effective alternative, compared to the feeling of pain (Vickers & Zollman, Maintaining fitness and sticking to a regular exercise rou-
more extensive treatments, dental 1999). tine may help oral health professionals prevent work-relat-
ed injury. Dimensions of Dental Hygiene 15, 18-21.
hygienists are more likely to favor these
Gehrig, J. S., Sroda, R., & Saccuzzo, D. (2017).
therapies (Chismark et al., 2011). The Conclusion Fundamentals of periodontal instrumentation & advanced
price for a one hour massage is approxi- Non-surgical medication free treat- root instrumentation (p. 3-22). Philadelphia: Wolters
Kluwer.
mately $60.00 depending on where you ments are available. Consultations are Gupta, A., Ankola, A. V., & Hebbal, M. (2013). Optimizing
live and the type of treatment received necessary to determine which treatment human factors in dentistry. Dental Research Journal,
10(2), 254–259.
(Burgan, 2016). Massage Envy, a popular would be most beneficial based on the
Humann, P., & Rowe, D. J. (2015). Relationship of muscu-
massage therapy chain, offers an hour type of injury the cost incurred. Some loskeletal disorder pain to patterns of clinical care in
massage for $50 and 90 minutes for $75; may benefit from a combination of treat- California dental hygienists. The Journal of Dental
Hygiene, 89(5), 305-312.
however, the businesses are independent- ments, while others may only need one Jefferson, J. (2018). Personal communication.
ly owned so the prices vary with location type of intervention to obtain relief from Kott, K., & Lemaster, M.F. (2014). Injury prevention with
(https://locations.massageenvy.com/ar/ MSD. Prevention of MSD is preferred over physical therapy. Retrieved from http://www.dimension-
sofdentalhygiene.com/2014/04_April/Features/Injury_
little-rock/17200-chenal-parkway- injury and treatment. Hopefully, by prac- Prevention_with_Physical_Therapy.aspx
ste-270.html). Some insurance companies ticing prevention early, less extensive The Back School. (n.d). Ergo Break. Retrieved from https://
www2.tulane.edu/oehs/upload/Ergo-Break-Poster.pdf
provide coverage for massage therapy treatment will be required. It is important
Vickers, A., & Zollman, C. (1999). Acupuncture. British
with a doctor’s prescription (Burgan, to act early to seek help to prevent pro- Medical Journal, 319, 973-976.
2016). longed pain and chronic damage to the Retrieved from http://www.bmj.com/con-
tent/319/7215/973
Because it is a common treatment, body. It is vital to maintain proper ergo- Waddell, G. (2006). Preventing incapacity in people with
many people use physical therapy as an nomics which continues to be a leading musculoskeletal disorders. British Medical Bulletin, 1-15.
‘umbrella’ term for injury-related treat- prevention in lowering the risk of devel-
ments. Physical therapists utilize exercis- oping musculoskeletal disease. AD
24 Spring 2018 | Arkansas DentistryYou can also read
