Journa

October 2016
Nonalcoholic
Fatty Liver Disease
Type 2 Diabetes Risk
Soda Taxes
Warning Labels
C A L I F O R N I A D E N TA L A S S O C I AT I O N

SUGAR IN THE SPOTLIGHT

Cristin E. Kearns, DDS, MBA
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Oct. 2016 C D A J O U R N A L , V O L 4 4 , N 1 0

D E PA R T M E N T S
601 The Editor/When the Universe Gets Really Small
603 Impressions
643 RM Matters/Understanding the Role of the
Better Business Bureau

647 Regulatory Compliance/Nitrous Oxide

Safe Practices

651 Ethics/Timely Referrals Our Ethical Obligations

to Our Colleagues

654 Tech Trends 603

F E AT U R E S

611 Sugar in the Spotlight

An introduction to the issue.
Cristin E. Kearns, DDS, MBA

613 Fructose and Nonalcoholic Fatty Liver Disease

This article details how the increase in sugar consumption in the United States has led to a
new disease, nonalcoholic fatty liver disease, which has become epidemic, even in children.
Robert H. Lustig, MD, MSL

619 Understanding the Impact of Added Sugar Consumption on Risk for Type 2 Diabetes
This review discusses the physiological mechanisms by which consumption of added
sugars may increase risk for type 2 diabetes, the research evidence that suggests it
does and the reason why there is conflicting evidence to suggest that it does not.
Candice Allister Price, PhD, and Kimber L. Stanhope, BS, MS, PhD

627 Advocating for Soda Taxes: How Oral Health Professionals Fit In
This article provides strategies that oral health professionals can use to increase their
visibility in the media to make the case for soda taxes.
Alisha Somji, MPH; Laura Nixon, MPH; Leeza Arbatman, BA; Pamela Mejia, MS, MPH;
Alysha Aziz, RN; Karen Sokal-Gutierrez, MD, MPH; and Lori Dorfman, DrPH, MPH

633 Sugar-Sweetened Beverage Warning Labels: Lessons Learned From the Tobacco Industry
This article shows how health warnings, such as those on tobacco products, could be an
effective tool for educating consumers about the health risks of sugar-sweetened beverages.
Lucy Popova, PhD

O C T O B E R 2 0 1 6 599
 C D A J O U R N A L , V O L 4 4 , N 1 0

CDA Classifieds.
JournaC A L I F O R N I A D E N TA L A S S O C I AT I O N
Volume 44, Number 10
October 2016

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600O C T O B E R 2 01 6
 Editor
When the Universe Gets Really Small
Kerry K. Carney, DDS, CDE
F
rom my mothers living room,
you can see the Lick Observatory
way off in the distance. It is
a group of tiny white domes
east of San Jose, settled on the
palomino ridge of the Diablo Range at
the summit of Mount Hamilton. It is
an icon of the San Francisco Bay Area.
The Lick Observatory saw its first
light on Jan. 3, 1888. For nine years,
it was the largest refracting telescope
in the world. It was a gift from James
Lick, piano maker, entrepreneur,
chocolate speculator, landholder and
wealthiest man in California. Lick, like
many others, was drawn to California
by the Gold Rush. He brought with
him a modest fortune from his piano
making company in South America
and 600 pounds of Ghirardelli
chocolates from Peru. After successfully
converting the chocolate to cash,
he convinced his friend Domenico
Ghirardelli to come to San Francisco
to establish his chocolate company.
Lick made his fortune not through
the mining of gold but through the
careful mining of the burgeoning
golden economy of California.
He bought property throughout
California, including the island of
Santa Catalina. He held large and
important parcels of land in San
Francisco and the Santa Clara Valley.
Lick opened a flour mill in San Jose
and a grand hotel in San Francisco.
After accumulating his great
wealth, he considered building statues
and grand architectural tributes to
himself and his accomplishments.
However, after George Madeira
introduced him to the wonders of
astronomy with a guided telescopic
tour of the night sky, Lick decided to
The birth of stars and their violent
deaths in supernovae have little
relevance today. My observations
are focused on my mothers breathing.
bequest the modern-day equivalent
of $1.2 billion to the building of an
observatory on Mount Hamilton.
The Lick Observatory has
figured prominently in astronomical
discoveries. The distance to the
moon was precisely measured at the
Lick Observatory by bouncing a
laser off the moon in 1969. The Lick
revolutionized astronomy by replacing
photographic plates with digital
detectors in 1971. Its newest telescope
is the Automated Planet Finder
(APF). It is constantly searching
nearby stars for earth-sized planets.
The Licks list of contributions
to astronomy is long but the one
that has the greatest visual impact
is the deep-space photography that
was perfected on Licks Crossley
telescope in the 1900s. It revealed
the myriad galaxies beyond our Milky
Way. It was the forerunner of the
Hubble Space Telescopes beautiful
eXtreme Deep Field photos that show
innumerable galaxies, unimaginably
far away. These photos prove the
universe is beautiful and vast.
Way up there at the Lick
Observatory, the researchers in those
tiny white domes are studying all the
wonders of the universe. But today,
for me, that universe has become very
small. It has shrunk to the distance
between my mother and me. The
C D A J O U R N A L , V O L 4 4 , N 1 0
center of my universe lies inches away
on her hospital bed in her living room.
The Lick Observatory is a distant
backdrop. The birth of stars and their
violent deaths in supernovae have
little relevance today. My observations
are focused on my mothers breathing.
Her comfort and security are my
purpose as she nears the completion
of her 97th revolution around the sun.
Astronomers speculate about
wormholes, alternate universes and time
travel. But I can sit here in my tiny
universe containing just two people and
travel through time by reviewing the 10
decades of my mothers life. I can see
her as a young girl in rough-and-tumble
Oklahoma when cars were beginning
to replace horses as the common means
of transportation. I can see her as a
teenager living through the Dust Bowl
and Depression. I can see her witnessing
her father destroying his bankbook
because their savings were lost.
I can see her as a newlywed when
she and my father listened to the radio
to learn that Pearl Harbor had been
bombed. I can see her when our family
settled in Pennsylvania. I can see her
enjoying all the opportunities that
life and a happy family can present.
I can see her traveling the world and
enjoying great friendships. I can see
all the lives she touched and enriched
over her 28 years as a teacher. I can
O C T O B E R 2 0 1 6 601
 O C T . 2 0 16 EDITOR
C D A J O U R N A L , V O L 4 4 , N 1 0

see her living out her happy retirement

here in California surrounded by her
family. I can time travel back and
forth through her life in this tiny

Our archive is
universe. She is my universal constant.
No matter what your profession or
vocation, no matter how fast-paced

available 24/7.
CDAs archive is online for your research. Access every issue
of the Journal from the past 17 years at cda.org/journal.
your life seems, your whole universe
can contract in an instant and time
can slow to a standstill when a debt
of devotion and love comes due. I am
grateful for many, many things but I
am most grateful for having the good
fortune to have had the mother I did.
In loving memory, B.B. Carney
19192016.

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602O C T O B E R 2 01 6
Impressions
The nub:
1. We like those who have the
capacity and interest to do us good.
2. We ignore those who cannot
help us and defend against those
who are capable of doing things
contrary to our interests.
3. If we only walk with those
who are there to help us, we will
generally be behind or in front of
the crowd but not with it.
David W. Chambers, EdM, MBA, PhD, is professor
of dental education at the University of the Pacific, Arthur
A. Dugoni School of Dentistry, San Francisco, and editor
of the Journal of the American College of Dentists.
C D A J O U R N A L , V O L 4 4 , N 1 0
Friends in High Places
and Others
David W. Chambers, EdM, MBA, PhD
Who do we want for patients, for friends, as allies for the
organizations we invest our time in?
Imagine a 2-by-2-foot table with good/bad for me on
one dimension and influential/benign on the other. It
should be obvious that we cultivate the powerful and friendly,
avoid those who can potentially harm us, smile on nice little
people and ignore the rest.
What a joy to have a few friends who are in a position to
do us some good.
Those with little prospect of mattering receive little
thought. We save a lot of time and energy that way. Those
with small influence but presumed positive attitudes are our
context. We like them on Facebook. We acknowledge
their compliments and ignore their requests if inconvenient.
They are frequently the objects of charity. We count on
them, often in the aggregate. They are ideal patients. They
have financial resources, time and availability, billable
needs, networks of friends for referrals and capacity to show
appreciation. In fact, that is the very definition of a patient:
one who agrees to the conditions of treatment.
We do not have a name for individuals who need dental
care but have not agreed to the terms of treatment. These
should be classified in the influential, but not very supporting
quadrant. They include the patient who insists on care that the
dentist knows is less than optimal, insurance companies, those
who post negative ratings, young dentists who want to change
what it means to be professional and owners of corporate
chains that place commercial interests above professional ones.
This is the troubling cell the one where interests
that do not align with our own are advanced by people who
matter. It says a lot about our character how we respond. The
philosopher Isaiah Berlin suggested that there are two common
patterns. The hedgehog curls up in a ball, leaving nothing
but hard bristles to ward off attack. This defensive posture is
favored by those who perceive that they hold a better hand
than they are likely to get if the cards are shuffled and redealt.
The fox, the other approach mentioned by Berlin, fusses
around looking for a rational perspective on the matter. The
great American advocate of pragmatism, William James, makes
much the same distinctions, but he places the elements on a
time continuum. First, we ignore the powerful and unfriendly
and then we push back. The third phase in this process is to
claim that the change was our idea in the first place.
O C T O B E R 2 0 1 6 603
 O C T . 2 0 16 IMPRESSIONS
Patients With Two Prescription
Drug Refills Likely to Become
Long-Term Users
New research has pinpointed the
number of prescription refills it can
take to tip the scales and push a patient
to become a long-term opioid user. A
study done at the Oregon Health and
Science University found that patients
who received two refills were likely to
become long-time users. The study was
completed by using data from Oregons
prescription monitoring program as well
as data from Oregon vital records and
a hospital discharge registry. In total,
3.6 million opioid prescriptions were
examined and it was found that The
odds ratio of becoming a long-term
opioid user was 2.25 higher among
patients who received two prescription
fills compared to one. It was also 2.96
higher for those initially receiving
between 400 and 799 cumulative
morphine milligram equivalent
dosages within 30 days, compared
to patients on lower doses. Long-
acting opioids were associated with a
higher risk than short-acting drugs.
Richard Deyo is with the Oregon
Health and Science University
and was the lead researcher for the
study, which was published in the
Journal of General Internal Medicine.
Our data suggest the value of
attention to high-risk prescribing, over
604O C T O B E R 2 01 6
C D A J O U R N A L , V O L 4 4 , N 1 0
Children With Dental Sealants 80 Percent Less
Prone to Caries
Further evidence has been presented that shows dental sealants are
more eective than other treatments in the fight against childhood caries.
The American Dental Association and American Academy of Pediatric
Dentistry (AAPD) have published two systematic reviews that evaluated the
eectiveness of dental sealants. The literature breaks down the outcomes
such as caries incidence, sealants retention and adverse side eects. The
reports are titled Sealants for Preventing and Arresting Pit-and-Fissure
Occlusal Caries in Primary and Permanent Molars and Evidence-Based
Clinical Practice Guideline for the Use of Pit-and-Fissure Sealants.
Timothy Wright, DDS, MS, is the lead author.
Sealants are a proven and eective therapy for preventing cavities in
children and teens. Oral disease can greatly impact ones concentration and
self-esteem and contributes to more than 51 million hours of missed school
each year, Wright said in a press release. The joint report rearms that
sealants should be a routine part of cavity prevention, as children with sealants
are up to 80 percent less prone to cavities compared to those without them.
The reports, which are accompanied with updated clinical practice
guidelines, were published in the August issue of the Journal of the American
Dental Association, as well as the July/August issue of AAPDs Pediatric
Dentistry journal.
The new guideline gives clear direction for dentists to best use
sealants to improve the oral health of their patients, Wright said.
To read the systematic review and
download the guideline, visit jada.ada.org.
For patient-friendly information to help
your practice, download the JADA
patient page at jada.ada.org or visit
MouthHealthy.org and mychildrensteeth.org.
which clinicians have greater control, dosage units of hydrocodone
he said in a press release. This in part combination products were
reflects concern that we are dealing dispensed in the 201314 fiscal year.
with risky drugs, not risky patients. Opioid use and deaths attributed
Prescribers in the United States to abuse are sharply on the rise,
write nearly 100 percent of opioid sending government agencies and
prescriptions worldwide, and in public health advocates looking
California alone more than 1 billion for tools to turn the tide.
 C D A J O U R N A L , V O L 4 4 , N 1 0

Undiagnosed Sleep Apnea Costing Billions

The cost of undiagnosed sleep apnea economic burden of it going undiagnosed
in the U.S. is in the billions, according to is around $149 billion. This amount is
two new reports released by the American calculated by lost productivity, vehicle
Academy of Sleep Medicine (AASM). accidents and workplace accidents.
The reports, titled Hidden health crisis The high-quality, patient-centered care
costing America billions and In an provided by board-certified sleep medicine
age of constant activity, the solution to physicians can significantly reduce the
improving the nations health may lie in health and economic burdens of sleep
helping it sleep better, includes results apnea, said AASM President Ronald
from of an online survey of obstructive Chervin, MD, MS, in a press release.
sleep apnea patients. The reports conclude While dentists can play a key role in scope of the practice of dentistry. Proper
that diagnosing and treating every patient recognizing potential sleep-disordered SDB diagnosis requires monitoring of
in the U.S. who has sleep apnea would breathing (SBD) and managing some the patient during sleep and evaluation
produce an annual economic savings of aspects of treatment, SBD is a medical of the events during the sleep cycle by
$100.1 billion. The reports state that the condition and its diagnosis is outside the a qualified physician. Collaboration
between the physician and the dentist in
identifying and diagnosing patients who
are suffering from SDB and determining
the best mode of treatment ensures
Gene Variant Found in Esophageal Cancer Study patients receive comprehensive and
appropriate care. Additionally, as SDB
A genetic mutation could be related to familial Barretts esophagus (FBE) and
is progressive, continued monitoring
esophageal cancer. New research published in the July issue of JAMA Oncology
and managing of this chronic condition
found a rare mutation (S631G) in FBE in the uncharacterized gene VSIG10L is best handled through continued
that segregated with disease in aected family members. Functional studies dentist-physician collaboration.
revealed that this mutation disrupts maturation of the normal esophageal lining. CDAs policy on SBD (25RC-
Amitabh Chak, MD, is with the University Hospitals Case Medical Centers 2011-H) is the following:
Seidman Cancer Center and Case Western Reserve University School of Medicine. It is appropriate for dentists to screen
Instances of esophageal cancer are on the rise, and the disease patients for signs and symptoms of
has a poor five-year survival rate of less than 15 percent, Chak said. SBD and to work with physicians
However, early detection through screening can prevent the development to diagnose and treat SBD.
of esophageal cancer. Further research assessing this gene variant may CDA supports increased awareness
reveal pathways important for the pathogenesis of BE and esophageal and the education of dental and
medical professionals on appropriate
adenocarcinoma, leading to earlier detection and better treatment options.
involvement in the screening,
There have been little advancements in finding treatment and gaining
diagnosis and treatment of SBD.
an understanding of this disease and this study aims to CDA supports efforts at the federal
change that. The discovery by the University Hospitals and state levels to ensure dentists
Case Medical Center lays out the biology in disease are recognized members of the
pathogenesis and could help enhance detection early health care team managing SBD
with close monitoring of those with the variant. and to ensure that patients health
This is a step forward in combating this deadly care benefits are maintained
disease as we discovered a new way to categorize those regardless of whether a dentist or
at risk for esophageal adenocarcinoma, Chak said. physician provides patient care.
For more information, visit
the Sleep Disordered Breathing Issue
Summary resource at cda.org.
O C T O B E R 2 0 1 6 605
 Practice Support

Employment Practices

If youre a practice owner in California, new Fair

Labor Standards Act rules may have a big impact
on how you classify your employees. First, review a
duties test to determine if team members should be
exempt. Then, either increase employees salaries to
be compliant with the new regulations or reclassify
them as hourly employees. The experts at CDA
Practice Support are here to help you navigate
the new overtime regulations and minimum salary
thresholds so you can get your office ready by
the Dec. 1 deadline. Explore online employment
practices resources or ask an expert today.

800.232.7645 or cda.org/practicesupport
 O C T . 2 0 16 IMPRESSIONS
Embryonic Mouth Formation
Explained
Researchers at Whitehead Institute
have tested frogs to help explain
mouth formation during embryonic
development. Xenopus frogs were
studied over many years and it was
discovered that the mouth starts
as a square with eight cells wide
and eight cells high and then later
becomes two cells wide and 20 cells
high. Later in the development,
the two rows of cells unzip to
create the mouth as we know it.
Hazel Sive, is a professor of biology
at MIT and part of the Whitehead
research team that made the discovery.
Mouth formation involves
many steps that ensure the opening
happens at the right time and at the
right place when the cells are
connected with the correct junctions
to be exposed to the outside and
where the opening connects to a
prepared region, in the case of the
mouth to the digestive system. But
I was so surprised when we found
that this process is initiated in frogs
several days before the mouth actually
opens, Sive said in a press release.
The results of the research were
published in the Aug. 2 issue of Cell
Reports. The Whitehead research team
propose that the premouth formation
occurs as neural crest cells come to lie
on either side of the extreme anterior
domain (EAD) and that these cells
then signal to the EAD cells to begin
608O C T O B E R 2 01 6
C D A J O U R N A L , V O L 4 4 , N 1 0
Dental Sealants Expose Children to Less BPA
Than Many Household Items
The amount of BPA in dental sealants is safe for young children, according
to research recently published by the ADA Science Institute. Specifically,
the research shows that dental sealants in a 6-year-old child has less BPA in
them than food, drinks, sunscreen, shampoo, body wash and other cosmetics
and air and thermal paper. The report, published in the ADA Professional
Product Review, lays out details on how the BPA released from dental
sealants is .09 nanograms far lower than the limit for a 6-year-old child.
David Sarrett, DDS, is the editor of the ADA Professional Product Review.
This issue of the PPR provides a much-needed perspective on the amount
of BPA in dental materials compared with other sources of exposure, Sarrett
said in a press release. Dental sealants oer a tremendous oral health
benefit to children and should continue to be a routine preventive service.
Sealants are most eective in reducing cavities in children with newly
formed permanent teeth. In fact, all children should have their molars
evaluated for sealants soon after they erupt. For most children, this occurs
approximately at ages 6 and 12. Dentists can remind their patients that
sealants can also be useful in cutting down formation of decay in adult
teeth, as well. An application of sealants is a
preventative measure to keep teeth healthy.
It is an eective way to reduce the need for
fillings and more expensive treatments that
may be required to repair the damage from
cavities, so sealants can save patients money.
forming the premouth. Therefore, the earlier point to avoid years of surgery
study claims to have revealed a precise and orthodontics, we need to obtain
cellular mechanism that positions and a better handle on whats going on.
contributes to the future mouth. Recognizing what is required to form
Laura Jacox is another researcher a mouth and the face and how its
on the project and said there is regulated is a step toward understanding
still a lot of work to be done. how these processes can be disrupted.
Theres a lot of craniofacial The work of this study was
development that we dont understand, supported by the National Institute
Jacox said. If we hope to understand of Dental and Craniofacial Research
why craniofacial anomalies happen in and Harvard Universitys Herschel
humans and how to treat them at an Smith Graduate Fellowship.
 C D A J O U R N A L , V O L 4 4 , N 1 0

Virtual Dental Home Model of Care Proven to Be Eective

The virtual dental home model
of dental care has been proven to
be effective at keeping people out of
pain and kids in school, according to
a recently released study. The results
from a six-year study by the Pacific
Center for Special Care, a program of
The term virtual dental home
describes a dental care model in which a
dentist utilizes teledentistry by connecting
electronically to specially trained allied
dental team members to deliver dental
care to underserved populations.
Through the virtual dental home Image courtesy of University of the Pacific.

the University of Pacific, Arthur A. model of dental care, specially trained

Dugoni School of Dentistry, show that dental hygienists and assistants collect send that information electronically via a
virtual dental homes prevent suffering dental diagnostic records, including secure web-based system (called store-
for millions of Californians who have X-rays and intraoral photos, from patients and-forward telehealth) to the supervising
no access to a dentist and, as a result, in community settings such as schools, dentist at a clinic or dental office. The
reduces school absenteeism. Head Start sites and nursing homes. They dentist uses that information to establish
a diagnosis and create a dental treatment
plan for the hygienist or assistant to carry
out. The hygienists and assistants provide
basic care at the community site and refer
Digital Dental Glossary of Terms Released patients to dental offices for procedures
that require the skills of a dentist.
Dentists looking for a complete list of dental terms will be pleased to The study, published in ScienceDaily,
know that the American Academy of Implant Dentistry (AAID) has released followed more than 3,000 patients in
the JOI Glossary of Terms, 2016 Edition. The glossary, published by the California since 2010. It found that
Journal of Oral Implantology (JOI), features more than 1,500 terms, two-thirds of children and nearly half
including words, phrases and definitions that are commonly found in general of the elderly with disabilities can
dentistry, implantology and oral surgery. James Rutkowski, DMD, PhD, is the gain proper treatment through virtual
editor-in-chief of the JOI. dental homes and the costs were
The goal of the JOI Glossary of Terms has always been to educate. lower per patient than Denti-Cal.
Paul Glassman, DDS, MBA, is a
Whether you are a first-year dental student or have been practicing dental
professor of dental practice, director of
implantology for 20 years, the Glossary is a wonderful professional resource
community oral health and director of
tool, Rutkowski said in a press release. It is our hope that the expanded the Pacific Center for Special Care at the
2016 edition of the Glossary reaches new audiences and continues to drive University of the Pacific, Arthur A. Dugoni
professional growth for both AAID and the dental community. School of Dentistry. Glassman developed
This will be the first time the glossary has the virtual dental home approach.
been published digitally. Previous editions were Our six-year demonstration project
in print. The new digital flipbook format was 2016 EDITION
confirms that this is a safe, effective way
developed with the goal of enhancing the to bring care to people who need it,
Glossarys audience as well as improving content Glassman said in a press release. Basing a
dissemination and ease of use. The tools and virtual dental home in a school, a nursing
features of the digital edition allow readers to home or other community setting allows
dental hygienists to prevent or treat the
more easily find the terms and definitions they need
majority of oral health problems on site,
in an online, searchable format.
and also brings prevention information
The glossary can be accessed at joionline.org.
to patients, families and caregivers.
Finally, it connects on-site care in the
community to dentists in dental offices.
O C T O B E R 2 0 1 6 609
introduction
GUEST EDITOR
Cristin E. Kearns, DDS,
MBA, is a postdoctoral
fellow at the University of
California, San Francisco,
and is aliated with the
Philip R. Lee Institute for
Health Policy Studies and
the department of oral
and craniofacial sciences
in the School of Dentistry.
Her research examines
the influence of food
industry public relations
practices on the scientific
evidence informing public
health policy.
Sugar in the Spotlight
Cristin E. Kearns, DDS, MBA
S
ugar is having a public
health moment. In 2015, the
World Health Organization
(WHO) called on countries
to decrease added sugars
intake among adults and children to
reduce the risk of being overweight,
obesity and dental caries.1 The WHO
recommended that added sugars intake
be limited to less than 10 percent
of daily calories and that a further
reduction below 5 percent would
provide additional health benefits.
Seventy percent of Americans
consume added sugars above the
WHOs recommended 10 percent
limit.2 As any dentist can attest,
motivating individuals to reduce
their added sugars intake will
require an armamentarium of
interventions targeting a wide range
of socioecological influences. Health
care professionals can play an essential
role in supporting health behavior
change at the policy, community and
individual levels. This collection of
articles in the Journal of the California
Dental Association is designed to
C D A J O U R N A L , V O L 4 4 , N 1 0
encourage dentists to consider their
part in the latest movement to curb
nutrition-related chronic disease.
The federal government is off to
an encouraging start. On the heels of
the WHO call, the 2015-2020 Dietary
Guidelines recommended that Americans
limit added sugars intake to less than
10 percent of daily calories,2 ending
decades of vague recommendations to
eat less sugar. The Food and Drug
Administration has already moved
to apply the new added sugars limit
to food labeling. As of July 26, 2018,
manufacturers with $10 million or more
in annual food sales will be required
to disclose added sugars content and
what percentage of the daily-added
sugars limit it represents on packaged
food nutrition labels.3 Consumers may
reconsider their food choices when
they learn that a 20-ounce bottle of
Coke contains 65 grams of sugars or
130 percent of the daily limit (based
on a 2,000 calorie diet). These new
requirements will end labeling practices
that have allowed manufactures to
hide added sugars content behind more
O C T O B E R 2 0 1 6 611
 introduction
than 60 names for sugars, such as barley
malt, dextrose and maltose. They will
also make clear the amount of sugars
that are added to savory foods, such
as bread, pasta sauce and ketchup.
At the state and local policy level,
a number of initiatives are focusing on
reducing added sugars consumption
through economic incentives, health
promotion programs and health risk
disclosure.4 In 2014 Berkeley, Calif.,
became the first city in the nation
to adopt a tax on the distribution
of sugar-sweetened beverages and in
2015 the city of Philadelphia became
the first large American city to do so.
Also notable in these efforts, though
occurring too late for inclusion in
this issue, are current initiatives on
the November 2016 ballot in the
cities of Oakland and San Francisco,
which would enact one-cent per
ounce taxes on the distribution
of sugar-sweetened beverages.
A set of articles presents unique
perspectives on recent efforts to curb
sugary beverage intake. Alisha Somji,
MPH, and colleagues present an
analysis of media coverage of sugary
beverage tax debates, which highlights
a shortfall of dental professional
voices. Lucy Popova, PhD, reviews
evidence supporting the effectiveness
of tobacco warning labels and
provides lessons that can be applied
to sugary beverage warning labels
initiatives. She highlights industry
efforts to counter warning labels and
the important role dentists can play
in policymaking by speaking to the
strength of evidence linking added
sugars consumption to dental caries.
On the subject of the strength
of evidence linking added sugars to
chronic disease, the second set of
articles review emerging evidence of
612O C T O B E R 2 01 6
C D A J O U R N A L , V O L 4 4 , N 1 0
the metabolic effects of fructose. This time period in San Francisco, where
evidence suggests that the health a similar measure was defeated,
risks of added sugars consumption sugary beverage consumption in
extend beyond overweight, obesity low-income neighborhoods increased
and dental caries. These reviews are by 4 percent. These results are a
important for dentists to consider testament to what can be achieved
when communicating with patients when we move beyond individual-
or policymakers might Americans level interventions to address the
attitudes toward added sugars many layers of influence that intersect
consumption change if they perceived to shape a persons food choice.
the risks of consumption to be greater?
REFERENCES
Robert Lustig, MD, who has been 1. World Health Organization. Guideline: Sugars intake for
credited with launching the modern adults and children. Geneva: World Health Organization; 2015.
antisugar movement, reviews research 2. U.S. Department of Health and Human Services and U.S.
Department of Agriculture. 20152020 Dietary Guidelines for
linking fructose consumption with Americans, 8th ed. Washington, D.C.: U.S. Government Printing
a new disease: nonalcoholic fatty Oce; 2016.
liver disease (NAFLD). NAFLD 3. U.S. Food and Drug Administration. Food Labeling: Revision
of the Nutrition and Supplement Facts Labels. www.regulations.
has become another chronic disease gov/document?D=FDA-2012-N-1210-0875. 2016. Accessed
epidemic, with an alarming prevalence Aug. 24, 2016.
rate in children. Candice Allister 4. California Center for Public Health Advocacy. Kick the can,
giving the boot to sugary drinks: SSB Campaign Map 2016.
Price, PhD, and her colleague www.kickthecan.info/ssb-campaign-map-2016. 2016. Accessed
Kimber Stanhope, PhD, a leading Aug. 24, 2016.
researcher who conducts clinical 5. Falbe J, Thompson HR, Becker CM, Rojas N, McCulloch
CE and Madsen KA. Impact of the Berkeley Excise Tax on
studies on the effects of diet on the Sugar-Sweetened Beverage Consumption. Am J Public Health
development of metabolic disease, 2016:e1-e7.
review research linking added sugars
consumption to type 2 diabetes risk.
Their review highlights conflicting
evidence and new experimental
techniques that hold promise for
unraveling the true relationship of
added sugars to type 2 diabetes.
While dentists have long-
discouraged added sugars consumption
to improve dental health, sugars
moment in the spotlight offers renewed
opportunities for us to engage with
diverse stakeholders developing policy
and community-level interventions.
An August 2016 study,5 which
evaluated Berkeley, Calif.s, sugary
beverage excise tax, passed in March
2015, found a 21 percent drop in
sugary beverage consumption in
low-income neighborhoods after
the tax took effect. During the same
liver disease
AUTHOR
Robert H. Lustig, MD,
MSL, is a professor of
pediatrics in the division
of endocrinology at the
University of California,
San Francisco, School of
Medicine and the director
of the Weight Assessment
for Teen and Child Health
(WATCH) program at
UCSF. He is also aliated
faculty at the Philip R. Lee
Institute for Health Policy
Studies at UCSF.
Conflict of Interest
Disclosure: Dr. Lustig has
never accepted money from
the food industry and has
no disclosures with respect
to this article. However, he
has authored three popular
books as a public health
service. He is also the
president of the nonprofit
Institute for Responsible
Nutrition.
Fructose and Nonalcoholic
Fatty Liver Disease
Robert H. Lustig, MD, MSL
I
n 1977, the first Dietary Goals for
Americans were issued by the U.S.
Senate, which targeted dietary
saturated fat as the primary driver
of heart disease.1 In response, the
food industry reduced the fat content
in processed food.2 However, to make
it palatable, dietary sugar replaced
the fat, so that by 2000, added sugar
had increased by 32 percent of total
calories.3 This dietary paradigm
continues to this day. More than 55
percent of all American adults consume
more than 50 grams of added sugars per
day, which is thought to be the cut-
off value for added risk of metabolic
derangement and the new guideline for
added sugar from the USDA and more
than the advised maximum according
to the American Heart Association
(2537.5 gram/day).4 Furthermore,
U.S. adolescents average 94 grams per
day.5 Over the past 40 years, coincident
with this change in dietary pattern,
the diseases of metabolic syndrome
(type 2 diabetes, dyslipidemia, heart
disease) have increased in prevalence.6
In addition, a brand new disease
nonalcoholic fatty liver disease
(NAFLD) has become epidemic,
even within the pediatric age group.7,8
C D A J O U R N A L , V O L 4 4 , N 1 0
What Is NAFLD?
NAFLD is defined by the presence
of liver fat in absence of primary causes
such as alcohol and hepatitis C.9 NAFLD
exists in three pathologic stages. Hepatic
steatosis, or fatty liver, occurs when up
to 5.5 percent of the liver parenchyma
is occupied by fat. Steatosis is now
found in up to 33 percent of adults,10 16
percent of all children and 38 percent of
obese children.8 Of those with steatosis,
approximately 5 percent will develop
nonalcoholic steatohepatitis (NASH),
in which steatosis is accompanied by
necroinflammation and fibrosis. Finally,
up to 25 percent of NASH patients
will progress to cirrhosis9 and cirrhosis
can further progress to hepatocellular
carcinoma. NASH is projected to become
the leading cause of liver transplantation
in the U.S. by 2020.11 Thirty to 40 percent
of NASH-cirrhotic patients succumb to
a liver-related death within 10 years.
Who Gets NAFLD?
Considering NAFLD was first
reported in adults in 198012 and in
children in 1983,13 the secular trend
of NAFLD prevalence is staggering.14
NAFLD is prevalent in 45 percent of
Latino, 33 percent of Caucasian and 24
O C T O B E R 2 0 1 6 613
 liver disease
percent of African-American adults.10
NAFLD is now the primary cause of liver
transplantation in adults, outstripping
hepatitis C.15 NAFLD is strongly
associated with insulin resistance16 and is
a primary predictor of type 2 diabetes.17
What Is the Pathogenesis of NAFLD?
Prior to 1980, fatty liver disease meant
one thing: alcohol. But children dont
drink alcohol. Therefore, understanding
the pathogenesis of NAFLD to support
prevention and control strategies is of
utmost importance.18 Fatty liver occurs
when the rate of the hepatic lipid influx
pathways (either fatty acid import or de
novo synthesis of fatty acids) exceeds the
rate of hepatic lipid clearance (either fatty
acid catabolism or lipoprotein export).19,20
Evidence suggests the following mechanisms
could promote the development of
fat accumulation in the liver:
Increased ingestion of dietary fat.
Unrestricted high-fat liquid feeding
to rats generates hepatic steatosis,21
whereas voluntary high-fat feeding
with chow does not.22 In humans,
although dietary fat ingestion
influences the accumulation of
fat in the liver,23 only 15 percent
of liver fat can be explained by
this mechanism.24 Furthermore,
dietary fat makes up a smaller
percentage of total calories
due to the low-fat directive.
Increased free fatty acid (FFA) influx.
FFA from lipolysis of adipose tissue
from either the subcutaneous or
visceral depot may contribute to fatty
liver in type 2 diabetes.25,26 However,
other conditions of lipolysis do not
result in steatosis. For instance,
patients with poorly controlled type
1 diabetes manifest both lipolysis and
insulin resistance, yet demonstrate
low liver fat.27 This is presumably
due to enhanced fatty acid
614O C T O B E R 2 01 6
-oxidation to ketones, accelerating
hepatic lipid clearance for energy
usage by the rest of the body.
Increased de novo lipogenesis (DNL).
DNL is driven by excessive dietary
carbohydrates,28 increasing the
transcription of three enzymes,
ATP citrate lyase, acetyl-CoA
carboxylase-1 and fatty acid
synthase, to convert carbohydrate
to fat, as in kwashiorkor. For
example, if carbohydrate intake
exceeds energy expenditure, hepatic
DNL is incremented tenfold.29
NAFLD is strongly
associated with insulin
resistance and is a
primary predictor of
type 2 diabetes.
Obese insulin-resistant subjects
show markedly increased DNL.30
Impaired hepatic fatty acid
-oxidation. Abrupt and massive
hepatic failure with steatosis
is noted in patients with Reye
syndrome.31 However, lipid
oxidation appears to exert only a
minor influence in the development
of NAFLD in humans.32
Impaired triglyceride export. The
liver esterifies excess fatty acids
into triglycerides, which are then
exported out as very low-density
lipoproteins (VLDL). Small numbers
of patients with the autosomal
recessive abetalipoproteinemia
demonstrate severe fatty liver,
although their serum triglyceride
levels are markedly diminished.33
C D A J O U R N A L , V O L 4 4 , N 1 0
Genetics. The increased risk of fatty
liver in some racial/ethnic groups
may be partially explained by
sociocultural differences in dietary
intake. However, genetic factors
may also play a role. Latinos are
at highest risk, Caucasians have
intermediate risk, while African-
Americans have lower-than-
expected prevalence for the degree
of obesity and insulin resistance.34
Specific genetic polymorphisms
predispose to NAFLD, most
notably patatin-like phospholipase
3 (PNPLA3), which may be
particularly important in Latinos.35
What About Diet Drives NAFLD?
While each of the processes described
above can be perturbed sufficiently in
humans to increase liver fat, none of these
explains the rise of the current NAFLD
epidemic, especially in children. There
are likely multiple factors driving NAFLD
in any individual. Weight gain predicts
incident NAFLD.36 Visceral adiposity and
insulin resistance are major risk factors,
as these increase hepatic lipid processing.
The increased risk in some racial/ethnic
groups may be partially explained by
sociocultural differences in dietary intake.
However, as NAFLD has exploded with
the export of the Western diet around
the world, specific macronutrient and/
or micronutrient component(s) of
the diet have been implicated. There
are four consumables that specifically
promote the development of fatty liver
disease unrelated to their calories.37
Trans fats. Trans fats cant be
completely metabolized by
mitochondria due to the trans-
double bond and generate increased
reactive oxygen species (ROS).
Trans fats have long been assumed
to contribute to chronic metabolic
disease, especially atherosclerosis.
 C D A J O U R N A L , V O L 4 4 , N 1 0

Visceral
adiposity Fructose
Insulin resistance
Adipose tissue
lipolysis
De novo Alcohol. Cross-sectional and
lipogenesis prospective studies implicate a
Beta-oxidation in dose-dependent effect of alcohol
mitochondria
in metabolic syndrome and
Circulating
FFA alcoholic steatohepatitis. Alcohol is
Hepatic metabolized to acetyl-CoA, which
FFA
Triglycerides steatosis
preferentially undergoes DNL,
Lipotoxic FFA metabolites ApoB100 driving fatty liver disease. While
Reactive oxygen species clearly a concern in adults, it is
unlikely that alcohol contributes
Dietary intake VLDL significantly to NAFLD in children.
of fats Inflammation Fructose. On average, American
Apoptosis NASH
Fibrosis children consume 362 calories or the
equivalent of 22 teaspoons of sugar
daily.44 Fructose metabolism (FIGURE )
generates lipogenic substrates (e.g.,
glyceraldehyde-3-phosphate and
acetyl-CoA) in an unregulated
FIGURE . This diagram illustrates nonalcoholic fatty liver disease development, highlighting the role of dietary
fashion, which are delivered
fructose and trans fats. In this model, free fatty acids (FFA) and their metabolites are thought to drive the steatosis,
inflammation and fibrosis that are hallmarks of nonalcoholic steatohepatitis (NASH). Sequestering of fatty acids straight to the mitochondria, but
in triglyceride droplets (hepatic steatosis) may actually protect against the inflammation and fibrosis that drive also simultaneously driving hepatic
progressive NASH. NASH develops when lipid influx into the liver exceeds lipid clearance from the liver. This can DNL, which will either be exported
occur through increased fat consumption, of which trans fat intake may be a particularly important component; as triglycerides or overwhelm the
increased liver FFA availability from lipolysis of adipose tissue or intrahepatic triglyceride, which is exacerbated by livers lipid export capacity, leading
insulin resistance; increased de novo lipogenesis, in which new FFA are synthesized using carbohydrates or amino to intrahepatic lipid deposition and
acids as substrate; impaired hepatic beta-oxidation of FFA within mitochondria, which can lead to accumulation
hepatic steatosis. In case-controlled
of FFA; and impaired, very low-density lipoprotein (VLDL) secretion. VLDL secretion from the liver is the major
mechanism for triglyceride export. From Perito ER, Rodriguez LA, Lustig RH. Dietary treatment of nonalcoholic studies, sugar-sweetened beverage
steatohepatitis. Curr Opin Gastroenterol 2013;29: 170176. (SSB) consumption is associated
with hepatic steatosis, independent
of the degree of obesity.45 In other
case-controlled studies, total fructose
The high trans fat content in fried percent of the amino acids in consumption was associated with
and highly processed foods appear the typical Western diet. In the NAFLD.46,47 In adults on high-
to specifically cause NAFLD.38,39 anabolic state, they build muscle. carbohydrate diets over 10 weeks,
Conversely, monounsaturated lipids However, when provided in excess reduced fat oxidation and increased
such as olive oil (oleic acid)40 and beyond anabolic requirements, DNL were seen in those randomized
linoleic acid41 (the dietary ligands these classic ketogenic amino to high-fructose but not high-glucose
for hepatic PPAR- ) or -3 fatty acids must be deaminated in diets.48 In adults, high-fructose diets
acids42 decrease accumulation of fat the liver to be diverted toward exacerbate dyslipidemia and insulin
in the liver. However, trans fats are energy utilization. This supplies resistance more than isocaloric
now being removed from our diet too much acetyl-CoA to liver high-glucose diets with effects
because the FDA declared them not mitochondria, leading to liver most pronounced in adults who
generally recognized as safe (GRAS). fat formation. BCAA serum already have metabolic syndrome.49
Branched-chain amino acids concentrations correlate with Trans fats, BCAAs, alcohol and fructose
(BCAAs). Valine, leucine and metabolic syndrome.43 High all share four biochemical properties:
isoleucine are essential amino BCAA concentrations are found They are metabolized for energy
acids that account for > 20 in corn-fed beef, chicken and fish. primarily within the liver.
O C T O B E R 2 0 1 6 615
 liver disease
They are not insulin regulated.
They do not have a pop-
off mechanism to form
glycogen for storage.
They overwhelm mitochondrial
-oxidative capacity, leading to
excessive DNL, which drives
hepatic insulin resistance
and fatty liver disease.50
How Is NAFLD Treated?
Treatment of the necroinflammation
associated with NASH can be achieved
with pioglitazone,51 which increases the
peroxisomal capacity within hepatocytes,
thus allowing for increased antioxidant
capacity. Other treatments that may hold
promise include liraglutide and vitamin
E, although long-term data are not
available.52 However, these treatments
do not reduce the hepatic steatosis.
Can Fructose Restriction Specifically
Reverse NAFLD?
Our group has demonstrated the effects
of fructose on DNL and liver fat in two
studies. First, in a crossover trial adults
consumed an isocaloric diet consisting
of either high-fructose or high-complex
carbohydrates for two weeks each.
Compared to the complex carb diet, the
high-fructose diet increased DNL and liver
fat by 38 percent.53 Second, our recent
paper in the journal Obesity54 documents
the effects of isocaloric substitution
of sugar with starch in 43 Latino and
African-American children with metabolic
syndrome over a 10-day period. On Day 0,
we assessed their metabolic health on their
home diet using baseline lab tests, including
lipids and lactate, oral glucose tolerance
testing, dual-emission X-ray absorptiometry
scanning for body composition and
magnetic resonance spectroscopy for liver,
visceral and subcutaneous fat. For the next
nine days, we catered their meals to provide
the same caloric content, the same fat,
616O C T O B E R 2 01 6
protein and fiber content, and the same
amount of total carbohydrate. However,
we reduced the percent of calories from
dietary sugar from a mean of 28 percent to
10 percent, while substituting isocalorically
with starch. If their weight was declining,
we made them eat more. Then we studied
them again 10 days later. Every aspect of
their metabolic health improved, with
essentially no change in weight. Blood
pressure reduced by 5 mmHg, triglycerides
by 33 mg/dL, LDL by 10 mg/dL and lactate
all improved markedly. Baseline glucose
levels reduced by 5 mg/dL, glucose area
under the curve dropped by 8 percent,
fasting insulin dropped by 10 mU/L,
insulin area under the curve dropped 25
percent all improved on the same
number of calories and without weight
loss, just by removing the added sugar
and in just 10 days. Furthermore, liver
fat as measured by magnetic resonance
spectroscopy dropped by 22 percent despite
no changes in calories or weight, and the
reduction in liver fat correlated with the
improvement in metabolic health.55
These data strongly argue that NAFLD
is a potent, if not the primary driver
of metabolic dysfunction, especially in
children. These two studies argue that
fructose consumption drives development
of NAFLD apart from its caloric content.
Thus, the mechanisms of alcoholic and
nonalcoholic fatty liver disease are quite
similar, even if the substrate is different,
as fructose and ethanol are metabolized
virtually identically in the liver.56
Conclusion
Evolutionarily, sugar was a rare
component of the human diet until the
Industrial Revolution brought refined
sugar to the masses, and with it, a host
of chronic noncommunicable diseases,
including tooth decay. Furthermore, the
ostensibly well-meaning dietary directive
of low fat led to the unregulated
C D A J O U R N A L , V O L 4 4 , N 1 0
substitution of sugar for fat, the unleashing
of a tsunami of metabolic syndrome and
the emergence of NAFLD as a primary
concern. Indeed, NAFLD is the hepatic
manifestation of metabolic syndrome57
and fructose consumption drives each of
the components of metabolic syndrome.58
While added sugar in the diet may not be
the sole perpetrator of chronic disease, it is
the easiest to identify.59 By speaking with
one voice, doctors and dentists can argue
for public health measures to stem the tide
of noncommunicable disease nationwide.
ACKNOWLEDGMENT
The author acknowledges the assistance of Cristin Kearns, MBA,
DDS; Laura Schmidt, PhD, MSW, MPH; Stan Glantz, PhD;
Claire Brindis, DrPH; Jean-Marc Schwarz, PhD; and Kathleen
Mulligan, PhD, in discussions that made this article possible.
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30. Schwarz JM, Linfoot P, Dare D, Aghajanian K. Hepatic de
novo lipogenesis in normoinsulinemic and hyperinsulinemic
subjects consuming high-fat, low-carbohydrate and low-fat,
high-carbohydrate isoenergetic diets. Am J Clin Nutr 2003;77:
4350.
31. Barr R, Glass IH, Chawla GS. Reyes syndrome: Massive
fatty metamorphosis of the liver with acute encephalopathy.
Can Med Assoc J 1968;98: 10381044.
32. Kotronen A, Seppl-Lindroos A, Vehkavaara S, Bergholm
R, Frayn KN, Fielding BA, et al. Liver fat and lipid oxidation in
humans. Liver Int 2009;29: 14391446.
33. Berriot-Varoqueaux N, Aggerbeck LP, Samson-Bouma M,
Wetterau JR. The role of the microsomal triglygeride transfer
protein in abetalipoproteinemia. Annu Rev Nutr 2000;20:
663697.
34. Bambha K, Belt P, Abraham M, Wilson LA, Pabst M,
Ferrell L, et al. Ethnicity and nonalcoholic fatty liver disease.
Hepatology 2012;55: 769780.
35. Davis JN, L KA, Walker RW, Vikman S, Spruijt-Metz D,
Weigensberg MJ, et al. Increased hepatic fat in overweight
Hispanic youth influenced by interaction between genetic
variation in PNPLA3 and high dietary carbohydrate and sugar
consumption. Am J Clin Nutr 2010;92: 15221527.
36. Zelber-Sagi S, Lotan R, Shlomai A, Webb M, Harrari G,
Buch A, et al. Predictors for incidence and remission of NAFLD
in the general population during a seven-year prospective
follow-up. J Hepatol 2012;56: 11451151.
37. Perito ER, Rodriguez LA, Lustig RH. Dietary treatment
of nonalcoholic steatohepatitis. Curr Opin Gastroenterol
2013;29: 170176.
38. Alkouri N, Dixon LJ, Feldstein AE. Lipotoxicity in
nonalcoholic fatty liver disease: Not all lipids are created
equal. Expert Rev Gastroenterol Hepatol 2009;3: 445451.
39. Tetri LH, Basaranoglu M, Brunt EM, Yerian LM,
Neuschwander-Tetri BA. Severe NAFLD with hepatic
necroinflammatory changes in mice fed trans fats and a high-
fructose corn syrup equivalent. Am J Physiol Gastrointest Liver
Physiol 2008;295: G987G995.
40. Nagao K, Inoue N, Wang YM, Shirouchi B, Yanagita T.
Dietary conjugated linoleic acid alleviates nonalcoholic fatty
liver disease in Zucker (fa/fa) rats. J Nutr 2005;135: 913.
41. Assy N, Nassar F, Nasser G, Grosovski M. Olive oil
consumption and nonalcoholic fatty liver disease. World J
Gastroenterol 2009;15: 18091815.
42. Cussons AJ, Watts GF, Mori TA, Stuckey BG. Omega-3
fatty acid supplementation decreases liver fat content in
polycystic ovary syndrome: A randomized controlled trial
employing proton magnetic resonance spectroscopy. J Clin
Endocrinol Metab 2009;94: 38423848.
43. Newgard CB, An J, Bain JR MM, Stevens RD, Lien LF, Haqq
AM, Shah SH, Arlotto M, Slentz CA, Rochon J, Gallup D,
Ilkayeva O, Wenner BR, Yancy WS Jr., Eisenson H, Musante G,
Surwit RS, Millington DS, Butler MD, Svetkey LP. A branched-
chain amino acid-related metabolic signature that dierentiates
obese and lean humans and contributes to insulin resistance.
Cell Metab 2009;9: 311326.
44. Ervin RB, Kit BK, Carroll MD, Ogden CL. Consumption
of added sugar among U.S. children and adolescents,
20052008. In: Statistics NCfH (ed). Centers for Disease
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Control, 2012.
45. Abid A, Taha O, Nseir W, Farah R, Grosovski M, Assy N.
Soft drink consumption is associated with fatty liver disease
independent of metabolic syndrome J Hepatol 2009;51:
918924.
46. Ouyang X, Cirillo P, Sautin Y, McCall S, Bruchette
JL, Diehl AM, et al. Fructose consumption as a risk factor
for nonalcoholic fatty liver disease. J Hepatol 2008;48:
993999.
47. Thuy S, Ladurner R, Volynets V, Wagner S, Strahl S,
Knigsrainer A, et al. Nonalcoholic fatty liver disease in
humans is associated with increased plasma endotoxin and
plasminogen activator inhibitor 1 concentrations and with
fructose intake. J Nutr 2008;138: 14521455.
48. Stanhope KL, Schwarz JM, Keim NL, Grien SC, Bremer
AA, Graham JL, et al. Consuming fructose-sweetened, not
glucose-sweetened, beverages increases visceral adiposity and
lipids and decreases insulin sensitivity in overweight/obese
humans. J Clin Invest 2009;119: 13221334.
49. Cox CL, Stanhope KL, Schwarz JM, Graham JL, Hatcher
B, Grien SC, et al. Consumption of fructose-sweetened
beverages for 10 weeks reduces net fat oxidation and energy
expenditure in overweight/obese men and women. Eur J Clin
Nutr 2012;66: 201208.
50. Bremer AA, Mietus-Snyder ML, Lustig RH. Toward
a unifying hypothesis of metabolic syndrome. Pediatrics
2012;129: 557570.
51. Cusi K, Orsak B, Bril F, Lomonaco R, Hecht J, Ortiz-Lopez
C, et al. Long-Term Pioglitazone Treatment for Patients With
Nonalcoholic Steatohepatitis and Prediabetes or Type 2
Diabetes Mellitus: A Randomized, Controlled Trial. Ann Int
Med 2016.
52. Barb D, Portillo-Sanchez P, Cusi K. Pharmacological
management of nonalcoholic fatty liver disease. Metabolism
2016.
53. Schwarz JM, Noworolski SM, Wen MJ, Dyachenko A,
Prior JL, Weinberg ME, et al. Eect of a high-fructose weight-
maintaining diet on lipogenesis and liver fat. J Clin Endocrinol
Metab 2015;100: 24342442.
54. Lustig RH, Mulligan K, Noworolski SM, Gugliucci A, Erkin-
Cakmak A, Wen MJ, et al. Isocaloric fructose restriction and
metabolic improvement in children with obesity and metabolic
syndrome. Obesity 2015;24: 453460.
55. Lustig RH, Wen M, Pan K, Tai V, Erkin-Cakmak A, Gugliucci
A, et al. Reduction of fatty liver after short-term isocaloric
fructose restriction in children with metabolic syndrome
correlates with improvement in insulin dynamics. Obesity
Society: Los Angeles, 2015.
56. Lustig RH. Fructose: Its alcohol without the buzz. Adv
Nutr 2013;4: 226235.
57. Yki-Jrvinen H. Nonalcoholic fatty liver disease as a cause
and a consequence of metabolic syndrome. Lancet Diabetes
Endocrinol 2014;2: 901910.
58. Lim JS, Mietus-Snyder M, Valente A, Schwarz JM, Lustig
RH. The role of fructose in the pathogenesis of NAFLD and the
metabolic syndrome. Nat Rev Gastroenterol Hepatol 2010;7:
251264.
59. Lustig RH, Schmidt LA, Brindis CD. The toxic truth about
sugar. Nature 2012;487: 2729.
THE AUTHOR, Robert H. Lustig, MD, MSL, can be reached at
rlustig@peds.ucsf.edu.
O C T O B E R 2 0 1 6 617
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 diabetes risk
C D A J O U R N A L , V O L 4 4 , N 1 0

Understanding the Impact of

Added Sugar Consumption
on Risk for Type 2 Diabetes
Candice Allister Price, PhD, and Kimber L. Stanhope, BS, MS, PhD

A B S T R A C T The association between dietary sugar and type 2 diabetes (T2D) is

likely mediated by the unregulated hepatic metabolism of fructose, which promotes
hepatic and whole-body insulin resistance. Experimental evidence from clinical
studies that utilize sensitive methods to test the effects of added sugar on insulin
sensitivity is required. Establishing a causal link between added sugar and insulin
resistance will help to stimulate health policies that target the reduction of added
sugar consumption and T2D prevention.

AUTHO RS

Candice Allister Price,
PhD, received her
doctorate in endocrinology
from the University of
California, Berkeley. As
a scientist, she conducts
research to improve obesity
and type 2 diabetes
prevention eorts. the eects of sugar
Conflict of Interest
Disclosure: None reported.
Kimber L. Stanhope,
BS, MS, PhD, is an
associate research
nutritional biologist at the
University of California,
Davis. She specializes in
well-controlled, clinical
diet studies investigating
consumption on the
development of metabolic
disease.
Conflict of Interest
Disclosure: None reported.
C
onsiderable epidemiological
evidence over the past
decade suggests that
consumption of dietary
added sugars is linked to
the prevalence or risk for obesity, type
2 diabetes (T2D) and cardiovascular
disease in adults and adolescents.1-9
Clinical dietary intervention studies
provide strong evidence to suggest that
the link between added sugar intake and
cardiovascular disease risk is causal.10-15
However, direct experimental evidence
illustrating a causal relationship between
added sugar intake and risk for T2D
in humans is not as compelling. This
review will discuss the physiological
mechanisms by which consumption of
added sugars may increase risk for T2D,
the research evidence that suggests it does
and the reason why there is conflicting
evidence to suggest that it does not.
HFCS and sucrose are the most
commonly consumed added sugars
in the American diet.
The term added sugar refers to
sugars that are not naturally occurring
in foods. Naturally occurring sugars, also
known as simple carbohydrates, come
in the form of monosaccharides (one
sugar) or disaccharides (two sugars).
Monosaccharides include glucose,
fructose and galactose. Disaccharides
include sucrose (glucose-fructose),
maltose (glucose-glucose) and lactose
(glucose-galactose). Examples of sources
of naturally occurring sugars include
honey, sugar beets, sugar cane, fruit
and milk. The two most commonly
consumed added sugars are sucrose and
high-fructose corn syrup (HFCS). Both
sugars contain fructose and glucose, but
differ as to chemical structure. Sucrose is a
disaccharide composed of one fructose and
O C T O B E R 2 0 1 6 619
 diabetes risk
Sucrose
CH2OH
O CH2OH
OH
O HO
HO
OH
FIGURE . Chemical composition of sucrose versus high-fructose corn syrup.
one glucose as a single molecule, whereas
HFCS is composed of both fructose and
glucose as separate monosaccharides
(FIGURE ). Sucrose is extracted and
purified from sugar cane and sugar beets.
HFCS is derived from the hydrolysis of
cornstarch, which produces glucose syrup
and then isomerization of glucose syrup
to produce syrup containing 42 percent
fructose. The fructose in this syrup can
be extracted to produce syrup that is 90
percent fructose. The proportion of the
fructose to glucose in the final HFCS
product is variable depending on how
much of the 90 percent fructose syrup is
added to the 42 percent fructose syrup.
As described by the Code of Regulation,26
the proportion of fructose in HFCS is
either approximately 42 percent or 55
percent. However, when analyzed for
fructose content, sodas sweetened with
HFCS contained 47 percent to 65 percent
fructose.27 Unfortunately, food and
beverage nutrition labels do not provide
information stating the percentage of
fructose in the HFCS that is contained in
the product, and thus consumers are not
able to determine how much fructose is
present in the HFCS they are consuming.
Sugar consumption in the U.S.
exceeds dietary guidelines for
cardiovascular health.
The total amount of energy consumed
from naturally occurring sugars in fruit,
vegetables and milk in the American
diet is only about 5 percent of total daily
energy intake.28,29 However, according
620O C T O B E R 2 01 6
Glucose
CH2OH
O O
HO OH
CH2OH HO
OH
OH
to self-reported data from the National
Health and Nutrition Examination Survey
(NHANES), U.S. adults consume an
average of approximately 15 percent of
daily calories as added sugar.30 Results
from this study30 also demonstrated
that added sugar consumption at this
level was associated with an increased
risk for cardiovascular disease mortality
of 18 percent over 15 years.
Of the added sugars consumed in
the U.S., approximately 42 percent are
consumed as SSBs31 and the remainder as
solid food. Added sugars from beverages
may affect metabolic function differently
than added sugar from solid food due
to their more rapid absorption from
the intestine. However, the only report
comparing the chronic effects of solid
versus liquid sugar focused mainly on
body weight.32 Adults gained significant
amounts of weight after four weeks of
consuming sucrose in a beverage, but
not after consuming sucrose in jelly
beans; the difference between diets was
not significant.32 Studies comparing
the effects of added sugars in solid
foods versus beverages on risk factors
for type 2 diabetes and cardiovascular
disease are currently lacking, so it
cannot be assumed that consumption
of added sugars between these two
sources have similar metabolic effects.
Some improvement in added sugar
intake has been observed over the last 13
years, mainly due to a large decrease in
SSB consumption.33 SSB consumption
was shown to have decreased between
C D A J O U R N A L , V O L 4 4 , N 1 0
High-fructose corn syrup
Fructose
CH2OH O
HO
OH CH2OH
OH
1999 and 2010,33 coinciding with declines
in obesity.34 This is marked progress from
the increase of SSB consumption, 11.8
percent to 21 percent of daily energy
intake, which occurred between 1965
and 2002.33 Nevertheless, fewer than
1.5 percent of U.S. adults and children
meet the American Heart Association
(AHA) criteria for a healthy diet pattern
for positive cardiovascular health.33
The criteria include a target that limits
the consumption of sweets and bakery
desserts to 2.5 50-gram servings/week
and SSBs to 4.5 8-ounce servings/week.
In 2013, the average consumption of
sweets and bakery desserts ranged from
a low of 3.9 servings/week for Mexican
American men to a high of 7.3 servings/
week for white women. The average
consumption of SSBs ranged from a low
of 6.8 servings/week for white women to
a high of 11.7 servings/week for Mexican
American men. Consumption of added
sugar from as little as one SSB per day
has been shown to be associated with an
increased risk for T2D between 26 and
83 percent, with the highest risk seen
amongst young and middle-aged women.35
Metabolic eects of fructose versus
glucose: Is a calorie really just a calorie?
Much speculation and press has been
devoted to the adverse health effects
of consuming HFCS versus sucrose.
However, both are fructose-containing
sugars and fructose is the principal
reason why added sugar consumption is
associated with metabolic disease. Studies

comparing the consumption of fructose
and glucose (mainly in beverages) in
humans have demonstrated that fructose
induces markedly greater metabolic
dysregulation than glucose. Compared
with glucose, fructose has been shown to
increase de novo lipogenesis (DNL) (the
synthesis of new fatty acids),36 inhibit
fat oxidation (the conversion of fat to
energy),37 increase liver fat content,38
increase blood lipids20,36,39,40 and uric
acid41 and decrease liver39 and whole-
body insulin sensitivity.36 However, all
of these studies utilized overfeeding
or ad libitum (unrestricted eating)
dietary protocols, making it difficult
to separate the effects of fructose from
the effects of positive energy balance/
weight gain. Therefore, Schwarz and
colleagues42 recently investigated the
effects of fructose compared with starch
using a crossover, energy-balanced
dietary protocol. They found, even in
the absence of positive energy balance
and weight gain, subjects exhibited
increased DNL, decreased fat oxidation,
increased liver fat and blood lipids
and decreased hepatic (liver) insulin
sensitivity when consuming the fructose
diet. This study challenges the notion
that a calorie is a calorie and clearly
demonstrates that the adverse metabolic
effects of fructose overconsumption
are not dependent on positive energy
balance and body weight gain.
Regulation of glucose and fructose
metabolism in the liver is not identical.
Although fructose and glucose
are both monosaccharides and have
identical chemical composition
(C6H12O 6), their metabolisms are
not identical. Both sugars exit the
intestine via the portal vein and are
delivered directly to the liver. Glucose
metabolism in the liver is regulated by
an enzyme called phosphofructokinase.
This enzyme is inhibited when hepatic
energy status is elevated and there
is no need for more glucose. As a
result, the energy-replete liver will
stop taking up glucose, and instead,
the glucose will bypass the liver to
the peripheral circulation and be
distributed to other tissues. The
metabolism of fructose in the liver,
on the other hand, is not regulated
because its rate-limiting enzyme,
fructokinase, is not inhibited in
response to increased hepatic energy
status. Instead, fructokinase remains
The uninhibited uptake of
fructose causes a substrate
overload that leads to increased
DNL and inhibited fat oxidation
compared to the ingestion of
equal amounts of glucose.
active at all times, regardless of the
livers need for energy. As a result, the
ingested fructose will be rapidly taken
up and metabolized almost exclusively
by the liver43,44 and very little will
reach the peripheral circulation45
to be utilized by other tissues.
The uninhibited uptake of fructose
by the liver leads to metabolic
dysregulation.
The rapid absorption and metabolism
of fructose within the liver triggers a
cascade of metabolic consequences. The
liver can synthesize both glucose and
fructose into fatty acids by the process
of DNL. However, the uninhibited
uptake of fructose causes a substrate
overload that leads to increased DNL46
and inhibited fat oxidation37 compared
C D A J O U R N A L , V O L 4 4 , N 1 0
to the ingestion of equal amounts of
glucose. The fatty acids are turned into
triglycerides (TG), which increases
liver fat content and upregulates the
packaging of TG into large, TG-
rich, very-low density lipoprotein-1
(VLDL-1) particles.47 The VLDL-1
is sent into the circulation leading to
increased levels of postprandial TG,
one of the first and most consistent
effects of fructose consumption.45,48,49
With continued fructose consumption,
the increased TG production may
also lead to increased fat stores in the
liver.42 Increasing levels of hepatic
lipids, particularly diacylglycerol
(DAG), prevents proper activation
of the insulin receptor50 and may lead
to hepatic insulin resistance.39,42
Insulin resistance, a risk factor
for T2D, cardiovascular disease and
metabolic syndrome, is the state when
insulins ability to do its many jobs is
impaired. In the liver, one of these jobs
is to suppress hepatic glucose production,
and thus, hepatic insulin resistance is
measured by upregulation of hepatic
glucose production. Another role of
insulin in the liver is to suppress the
production and secretion of VLDL.
Therefore, when fructose consumption
leads to hepatic insulin resistance, hepatic
glucose production is upregulated,51
and VLDL production and secretion,
which was already upregulated by the
increased liver fat content,47 is further
upregulated.52 DNL in the normal liver
is activated by insulin, but ironically, the
insulin-resistant liver remains sensitive
to insulins stimulation of hepatic lipid
production.53 This is called selective
insulin resistance. Thus, when insulin
binds to the receptor, the downstream
signaling that inhibits glucose and VLDL
production in the liver is impaired, while
the signaling that upregulates DNL
remains intact. This continued activation
O C T O B E R 2 0 1 6 621
 diabetes risk
of DNL in the insulin-resistant liver very
likely exacerbates the effects of sustained
fructose consumption, resulting in even
higher increases of liver TG production,
liver fat accumulation, insulin resistance
and VLDL production.54,55 Increased
and sustained VLDL production leads
to dyslipidemia consisting of not just
higher levels of postprandial TG, but
also increases in other risk factors for
cardiovascular disease. These include
low-density lipoprotein cholesterol
(LDL-C), apolipoprotein B,56 small dense
LDL-C57 and apolipoprotein CIII.58
Continued exposure to high levels of
postprandial TG in the blood may lead
to lipid accumulation within the muscle
cell.22 Intramyocellular lipid content is
negatively correlated with whole-body
insulin sensitivity,59 possibly because,
as in the liver, DAG prevents proper
activation of the insulin receptor.60,61
Results from studies in which men
consumed fructose-sweetened beverages
for nine days42 and three weeks39 suggest
that the development of hepatic insulin
resistance precedes the development
of whole-body insulin resistance.
Uric acid levels increase in response to
fructose.
The association of fructose
consumption with the development and
prevalence of T2D and cardiovascular
disease may also be related to the effect
of fructose to increase circulating uric
acid levels.25,41,62 The rapid absorption
and unregulated metabolism of fructose
leads to upregulation of the purine
degradation pathway,44 of which uric
acid is an end product. While uric acids
role in gout has been established for
years, more recent evidence suggests
that circulating uric acid is strongly
associated and predictive of metabolic
syndrome, fatty liver and cardiovascular
disease.63-66 Furthermore, Johnson and
622O C T O B E R 2 01 6
colleagues have suggested that circulating
uric acid has a contributory causal role
in the development of T2D due to its
adverse effects on insulin sensitivity
and on the pancreatic beta cell.67,68
Sucrose and high-fructose corn syrup
impair lipid metabolism.
It is evident that glucose and fructose
are metabolically different; however,
these monosaccharides are not typically
consumed as added sugars. Therefore,
studies investigating the effects of
consuming sucrose and HFCS are more
Recent evidence suggests that
circulating uric acid is strongly
associated and predictive of
metabolic syndrome, fatty liver
and cardiovascular disease.
relevant to understanding the metabolic
and health consequences of added sugar
consumption. There are old and recent
studies that provide strong evidence that
the consumption of sucrose or HFCS
increase risk factors for cardiovascular
disease. More than 30 years ago, Reiser
and colleagues provided insulin-resistant
subjects standardized, energy-balanced
diets containing 5, 18 or 33 percent of
energy as sucrose, each for six weeks.
Compared with the 5 percent sucrose
diet, total, VLDL- and LDL-cholesterol
plasma concentrations increased by 17
percent on the 18 percent sucrose diet
and by 22 percent on the 33 percent
sucrose diet.69 In more recent crossover
studies comparing glucose-, sucrose- and
fructose-sweetened beverages, Aeberli
and colleagues observed similar increases
C D A J O U R N A L , V O L 4 4 , N 1 0
in small dense LDL-C and LDL-C
during consumption of fructose and
sucrose that were higher than those
during consumption of glucose.20,39
Total cholesterol, fasting TG and liver
fat content were increased in subjects
consuming sucrose-sweetened cola
compared to subjects consuming diet
cola, water or isocaloric amounts of
low-fat milk for six months.22 Similarly,
a recent study demonstrated dose-
dependent elevations in body weight,
plasma levels of postprandial TG, fasting
and postprandial LDL-C, apolipoprotein
B, apolipoprotein CIII and uric acid
following two weeks consumption of
beverages containing 0, 10, 17.5 and 25
percent energy requirement as HFCS.25
These studies suggest that consumption
of both sucrose and HFCS increase risk
factors for cardiovascular disease.
Reducing added sugar consumption
improves metabolism health.
Three recent dietary intervention
studies provide direct evidence that
reducing consumption of added sugar
results in beneficial health effects.
Fasting glucose concentrations decreased
in overweight/obese adults who were
provided with four servings of water/day as
replacements for caloric beverages for six
months.70 In healthy, overweight subjects,
replacing SSBs with artificially sweetened
beverages for 12 weeks reduced hepatic
fat content by 74 percent.71 Another
study in Hispanic and African-American
adolescents with metabolic syndrome
demonstrated beneficial results in just nine
days. Reducing added sugar intake from
27 percent to 12 percent of daily calories,
with starch replacing the removed added
sugar, lowered blood pressure, body weight,
total triglycerides (TG), low-density and
small-density lipoprotein (sdLDL-C and
LDL-C), apolipoprotein B and CIII, small
and improved glucose tolerance.72,73

More evidence is needed to determine
the direct eect of added sugar
consumption on insulin resistance.
Evidence to support a causal
relationship between consumption of
added sugar and insulin resistance, also
called reduced insulin sensitivity, is
not as strong as that for consumption
of added sugar and lipid risk factors of
cardiovascular disease. Insulin resistance
is a major risk factor for T2D and is
defined as a reduction in tissue insulin
response and signaling.74 This results in
impaired insulin function, which in the
liver, as already stated, leads to increased
hepatic glucose production and VLDL
production/secretion. With whole-body
insulin resistance, the major impairments
in insulin function lead to reduced
uptake of glucose from the blood by
muscle and other tissue cells and reduced
removal of lipids from the circulation.
Use of the gold standard method
directly assesses the eects of added
sugar on insulin resistance.
Population data show strong
associations between added sugar
consumption and insulin resistance
and T2D.4-8,75,76 In contrast, direct
experimental evidence demonstrating
that added sugar consumption leads
to a reduction in insulin sensitivity in
humans is sparse. This is partly due to the
variable validity and sensitivity of current
methods for assessing insulin sensitivity.
The hyperinsulinemic euglycemic clamp
is considered to be the gold standard for
determining both whole-body insulin
sensitivity, via insulin-mediated glucose
disposal and hepatic insulin sensitivity,
via liver glucose production.77 It is also
the most difficult and expensive of the
methods to conduct. The least expensive
and easiest method is homeostatic
model assessment of insulin resistance
(HOMA-IR), which is calculated from
fasting insulin and glucose levels. Its main
advantage is its utility for large population
studies,78 however, it is frequently used in
intervention studies with limited samples
sizes. Several diet intervention studies that
have utilized HOMA-IR to index insulin
sensitivity have failed to detect effects of
dietary sugar manipulations.22,24,71,79,80
Only a few studies have used the
hyperinsulinemic euglycemic clamp
to determine the effects of fructose
consumption on insulin sensitivity. In
2013, researchers in Switzerland reported
significantly reduced hepatic insulin
These two studies
support the idea that
hepatic insulin resistance
precedes whole-body
insulin resistance.
sensitivity, indexed by liver glucose
production, in subjects consuming 80 g of
fructose per day for three weeks compared
to when they consumed 80 g of glucose/
day.39 They did not, however, observe
any differences in whole-body insulin
sensitivity, fasting glucose, fasting insulin
and, presumably, HOMA-IR. Schwarz
and colleagues reported similar results for
their nine-day crossover study comparing
a fructose diet to a complex carbohydrate
diet.42 Again, even though changes in
fasting glucose, fasting insulin, HOMA-IR
and whole-body insulin sensitivity were
not detected following either diet, liver
glucose production was less suppressed
when the subjects consumed the fructose
compared with the complex carbohydrate
diet. Importantly, body weight gain was
clearly not the mediator for the increase in
C D A J O U R N A L , V O L 4 4 , N 1 0
hepatic insulin resistance in either study.
In the study by Aeberli and colleagues,
body weight and BMI were significantly
higher after the glucose intervention
compared to the fructose intervention,39
and in the Schwarz study, diet was
specifically designed to maintain energy
balance and body weight throughout both
interventions.42 As already stated, these
two studies support the idea that hepatic
insulin resistance precedes whole-body
insulin resistance. They also demonstrate
that HOMA-IR, based on the changes
of fasting glucose and insulin, does not
have the sensitivity to detect changes in
hepatic insulin sensitivity. Furthermore,
Shaibi and colleagues have reported that
HOMA-IR lacked the sensitivity to detect
changes of whole-body insulin sensitivity
that were detected by more laborious
methods.81 More sensitive measures than
HOMA-IR are necessary to directly
assess the impact of consuming sugar on
the development of insulin resistance.
A few studies that have used oral glucose
tolerance tests (OGTT),72,82 or variations
of,46,83,84 have detected effects of dietary
sugar manipulations on glucose tolerance.
OGTTs are easier and less expensive
to conduct than the hyperinsulinemic
euglycemic clamp. Impaired glucose
tolerance, indexed as a two-hour glucose
concentration between 140199 mg/dl
during OGTT, is indicative of whole-body
insulin resistance and is a strong predictor
of future T2D.85 Several investigators
have proposed methods for utilizing
OGTT outcomes to calculate an index for
whole-body insulin sensitivity,86-89 and a
couple of these have been utilized to show
detrimental effects of fructose24,88 or fructose
and glucose82,86 consumption on whole-body
insulin sensitivity. The sensitivity of these
methods compared to hyperinsulinemic
euglycemic clamp in detecting a change in
whole-body insulin sensitivity following a
dietary sugar intervention is unknown.
O C T O B E R 2 0 1 6 623
 diabetes risk
Fructose induces metabolic dysfunction
by two pathways.
Obesity is one of the major risk
factors for insulin resistance, T2D
and cardiovascular disease,90 and
both population studies91-95 and direct
experimental evidence25,36,96-98 suggest
that sugar consumption induces weight
gain. This evidence, along with the
evidence that sugar consumption
increases risk factors even in the absence
of weight gain,21,42,69,83,84,99 suggests that
added sugar consumption promotes the
development of metabolic disease by
promoting weight gain and through
the direct adverse effects of fructose.
Furthermore, it is possible that when
added sugar consumption promotes
weight gain, the direct adverse effects
of fructose (i.e., increased DNL,
hepatic fat content and hepatic insulin
resistance) are exacerbated. This is
an important possibility to consider
given that the average American diet
contains 50 percent more added sugar30
than that recommended by the newly
revised 2015-2020 Dietary Guideline
for Americans100 and has resulted in
weight gain and obesity in two-thirds
of the U.S. adult population.101
Conclusion
Substantial evidence from
epidemiological studies supports a
positive association between the
consumption of added sugars and
metabolic dysfunction that increases
risks for T2D and cardiovascular
disease. The evidence from clinical
diet intervention studies testing the
effects of sucrose or HFCS on risk
factors for cardiovascular disease suggest
that sugar consumption can increase
risk for cardiovascular disease. Recent
dietary intervention studies also show
improvement in risk factors for metabolic
disease when intake of added sugar
624O C T O B E R 2 01 6
is reduced. However, stronger direct
experimental evidence from studies that
utilize methods more sensitive than
HOMA-IR to test the effects of sucrose
and HFCS to promote insulin resistance
is required to establish a causal link
between added sugar intake and insulin
resistance. Establishing this link will
help to stimulate the implementation
of policy changes targeting T2D and
obesity prevention. Policies that help to
change the food environment into one
that does not promote the development
of obesity and metabolic disease may lead
to behavioral changes in a population
that is not meeting dietary guidelines.
Similarly, clinical interventions
investigating the effects of dental caries
and periodontitis on metabolic disease
risk are needed to establish potential
mechanisms of contribution and direct
causation. Such evidence may lead
to improved dental care and reduced
incidence of periodontal disease. The
health community, including physicians
and dentists, can have a significant role
in attenuating the obesity and T2D crisis
by educating their patients about clinical
research findings and dietary guidelines
that limit add sugar consumption.
AC K N O W L E D G M E N T
Research conducted by Kimber L. Stanhope, BS, MS, PhD,
et al. is funded from NIH grants R01 HL-075675, 1R01 HL-
091333, 1R01 HL-107256 and a University of California,
Davis, multicampus award. Dr. Stanhope is supported by an
NIH K12 HD051958.
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 soda ta xes
C D A J O U R N A L , V O L 4 4 , N 1 0

Advocating for Soda Taxes:

How Oral Health
Professionals Fit In
Alisha Somji, MPH; Laura Nixon, MPH; Leeza Arbatman, BA; Pamela Mejia, MS, MPH;
Alysha Aziz, RN; Karen Sokal-Gutierrez, MD, MPH; and Lori Dorfman, DrPH, MPH

A B S T R A C T Our recent analysis of how soda tax debates appear in the news
revealed that oral health professionals seldom appear. By elevating their expert voices,
oral health practitioners can contribute new and salient arguments for soda taxes
to the public discourse and help advance public policy that improves oral health
outcomes. We propose media advocacy strategies that oral health professionals can
use to increase their visibility in the news to make the case for soda taxes.

AUTHO RS

Alisha Somji, MPH, is
a research consultant for
Berkeley Media Studies
Group. She holds a
masters degree in public
health from the University of
Toronto.
Conflict of Interest
Disclosure: None reported.
Laura Nixon, MPH,
conducts qualitative and
quantitative media research
at Berkeley Media Studies
Group. She holds a
masters degree in public
health from the University of
California, Berkeley.
Conflict of Interest
Disclosure: None reported.
Leeza Arbatman, BA,
conducts qualitative
and quantitative media
research at Berkeley
Media Studies Group.
She holds a bachelors
degree in sociology from
the University of California,
Santa Cruz.
Conflict of Interest
Disclosure: None reported.
Pamela Mejia, MS, MPH,
directs qualitative and
quantitative media research
at Berkeley Media Studies
Group. She holds masters
degrees in nutrition science
and public health from the
University of California,
Berkeley.
Conflict of Interest
Disclosure: None reported.
Alysha Aziz, RN, is
a registered nurse and
public health researcher
passionate about
integrating scholarship and
clinical knowledge. She
is a former Fulbright and
currently interns for Doctors
Without Borders.
Conflict of Interest
Disclosure: None reported.
Karen Sokal-Gutierrez,
MD, MPH, is a physician
trained in pediatrics,
preventive medicine
and public health, and
clinical professor at the
UC Berkeley-UCSF Joint
Medical Program and UC
Berkeley School of Public
Health.
Conflict of Interest
Disclosure: None reported.
R
Lori Dorfman, DrPH, educing the consumption of sugary
MPH, directs Berkeley drinks is a key public health goal, as
Media Studies Group. She
sugary drinks are the largest source
oversees BMSGs research,
media advocacy training,
of added sugar in the American
strategic consultation and diet1 and are associated with a
education for journalists. range of chronic diseases, including obesity,
She has publications on type 2 diabetes, cardiovascular disease and
bmsg.org.
dental caries.2,3 From the landmark 1954
Conflict of Interest
Disclosure: None reported.
Vipeholm Study to national surveys and
recent epidemiologic studies, evidence
suggests there is a direct link between
sugar consumption and the risk of dental
caries.4-9 Sucrose has specifically been
highlighted in the literature as cariogenic,
contributing to increased metabolic
activity and acid production from bacterial
plaque and demineralization of tooth
enamel.5,8,9 Recent studies confirm that
consuming sugary drinks increases the risk
of caries among children.10,11 Wilder and
colleagues found, for example, that among
elementary school children in Georgia,
each additional serving of sugary drinks
consumed per day increased the risk of
experiencing cavities by 22 percent.10
O C T O B E R 2 0 1 6 627
 soda ta xes
Oral health professionals see the effects
of sugar and sugary drink consumption
on their patients every day, particularly
in low-income and ethnic minority
communities.12 Though preventable,
dental caries is the most prevalent
chronic disease worldwide13 and the most
common chronic childhood disease in the
U.S.14 In California and across the U.S.,
children from low-income households and
communities of color are at highest risk for
acquiring dental caries and being unable
to get treatment for them.15-17 Untreated
tooth decay can lead to substantial mouth
pain and is a leading cause of childrens
school absences in the U.S., compromising
their educational potential as well.18,19
Because consumption of sugar and
sugary drinks is a strong risk factor for
dental erosion and caries across the
lifecourse,3,13 oral health professionals
recognize the need for limiting the
consumption of sugary drinks.20 Together
with other public health professionals, oral
health leaders are increasingly exploring
the potential of soda taxes as a policy
lever.21-28 Indeed, one of the California
Dental Associations current policy
priorities is reducing consumption of sugary
drinks by supporting taxes and warning
label policies.29,30 These taxes can reduce
consumption of sugary drinks and fund
health promotion programs.21,22,24,28 In 2013,
Mexico became the first country to pass
a substantial excise tax on sugary drinks,
and within the first year of implementation
soda sales decreased by 12 percent, with
the sharpest decline among vulnerable low-
income residents.31 However, the sugary
drink industry has fought aggressively
against these policies, spending tens of
millions of dollars against state and local
soda tax proposals in recent years.32
Dentists and other oral health
professionals can take the lead in making
the case for soda taxes and framing
overconsumption of sugar as a significant
628O C T O B E R 2 01 6
public health and health equity issue
with oral health consequences. Too often,
however, their voices are absent from the
dialogue about these policy strategies.
News coverage, which sets and reflects the
public debate about public policy, offers a
window through which we can understand
that dialogue. Based on our recent analysis
of how soda tax debates were portrayed
in news coverage and specifically, how
oral health and oral health professionals
appeared we identify possible strategies
for the oral health community to support
soda tax efforts, particularly using media
Together with other public
health professionals, oral
health leaders are increasingly
exploring the potential of
soda taxes as a policy lever.
advocacy. By raising their voices, dentists,
hygienists and other oral health experts
can contribute new arguments in favor
of soda taxes to the public dialogue
and help advance public health policy
to improve oral health outcomes.
Berkeley and San Franciscos Soda
Tax Debates
In 2014, Berkeley and San Francisco
voters both considered sugary drink tax
proposals. Berkeley became the first city
in U.S. history to pass a sugary drink
tax. More than half of voters supported
San Franciscos proposal, but it lacked
the two-thirds majority of votes needed
for it to pass. In a previous analysis, we
examined news coverage, social media and
campaign materials to gauge what types
of discourse surrounded the initiatives.33
C D A J O U R N A L , V O L 4 4 , N 1 0
We found that tax proponents
regularly made the case for soda taxes
using health-related arguments. In the
news, journalists, tax advocates and
others most often connected sugary
drinks to obesity (38 percent of articles)
and diabetes (34 percent). However, tax
proponents rarely discussed the negative
oral health implications of sugary drink
intake or the oral health benefits of
sugary drink taxes. Indeed, oral health
was mentioned in only 2 percent of
articles about sugary drink taxes. Though
dental caries are the most prevalent
chronic disease worldwide,13 diabetes
was discussed 17 times more frequently
and obesity 19 times more frequently
than were the oral health consequences
of sugary drink consumption.
Even when oral health did appear
in the news, it was rarely discussed
substantively. Instead, oral health issues
were typically mentioned in passing or
listed among other chronic diseases. For
example, one San Francisco Chronicle
letter to the editor referred to
diabetes, tooth decay, obesity and the
myriad other problems that result from
the consumption of sugary drinks
Dental caries and oral health
may have been left out of the public
debate in part because of the absence
of dentists and other oral health
professionals in media coverage. The
soda tax debates in Berkeley and San
Francisco featured a range of speakers
promoting the taxes, including campaign
representatives, city officials, public
health advocates, clinicians, researchers
and community residents. However,
though the Berkeley Dental Society
was a major supporter of Berkeleys
proposal and a local dentist is part of
the citys new panel of experts to advise
how to allocate the funds collected,34
oral health experts were almost entirely
absent from the media we examined.

Why Oral Health Needs to Be Part of
the Conversation
Dental health professionals have a
long history of advancing community
dental health through advocacy.
The Centers for Disease Control and
Prevention listed community water
fluoridation as one of the top 10 greatest
public health achievements of the
20th century an achievement that
likely would not have been possible
without oral health professionals
promoting institutional change.35
Oral health practitioners have also
led advocacy efforts specifically targeting
sugary drinks. In Illinois, for example,
dentists and the Illinois State Dental
Society urged policymakers to impose a
sugary drink tax. In 2009, 200 dentists
converged on the State Capitol to show
support and generate media attention.29
Using these and other media advocacy
strategies,36 these oral health advocates
made the case for a soda tax, arguing
that the funds generated could help open
dental clinics and assist people in need.37
The voices of dentists, hygienists
and other oral health experts, then,
can help shift the public conversation
around sugary drink regulation a
conversation that is often influenced by
forces concerned with profits over health.
Policies to limit sugary drink consumption
face stiff opposition from the soda and
sugar industry. Led by the American
Beverage Association, the nonalcoholic
beverage industry has spent tens of
millions of dollars since 2009 defeating
the more than two dozen municipal
and state sugary drink taxes proposed
across the country.32,38,39 During the most
recent soda tax battles in California, the
soda industry spent $9.1 million in San
Francisco40 and $2.4 million in Berkeley.41
Oral health professionals also need
to be vigilant and vocal in their own
backyards, because the sugar industry
has gone as far as influencing scientific
research to downplay the implications
of sugar consumption. Historically, the
industry interfered with the agenda
of the National Institute of Dental
Research, forcing it to shift priorities
toward vaccines against tooth decay
and enzymes to remove dental plaque
and away from studying how to restrict
sugar consumption to prevent tooth
decay.42 More recently, Coca-Cola was
criticized for providing millions of dollars
to fund misleading research that shifted
the blame for obesity to lack of physical
Oral health advocates made
the case for a soda tax, arguing
that the funds generated could
help open dental clinics and
assist people in need.
activity and away from the consumption
of sugary drinks.43 Dental practitioners
should be alert to industry influence that
can distract from their health goals.
Recommendations
What can oral health professionals
do to build the capacity of the field
to advocate for policies to combat
the adverse effects of sugar? Among
other strategies, the field can:
Make advocacy a part of dental
education. While dentists provide clinical
care to individual patients, their advocacy
for dental public health policies at the
community, state and federal levels can
improve the health of whole populations
and shape the future of dental practice.
However, dental training largely ignores
the role of policy in shaping oral health
C D A J O U R N A L , V O L 4 4 , N 1 0
and does not develop future dentists
advocacy skills. A study examining the
participation of American Academy of
Pediatric Dentistry members in advocacy
found that while 90 percent of respondents
supported advocacy as a role for dentists,
less than half reported taking action
and only 22 percent were specifically
trained in advocacy during residency.44
But dental students are eager to be
more involved in shaping policy. At Texas
A&M Universitys Baylor College of
Dentistry, for example, students created
an Advocacy Academy and planned a
lobby day where they gained experience
interacting and building relationships
with state representatives.45 Indiana
University School of Dentistry also
introduces students to the policy process
through an annual Health Policy Forum,
an evaluation of which showed half of
students who participated in the 2009
forum were more likely to get involved in
political advocacy afterward.46 A recent
study from the Journal of Dental Education
found that dental hygiene students benefit
from leadership courses that include
training on legislative advocacy, and that
ongoing mentorship after graduation
is necessary so that practitioners can
continue to develop these skills.47 The
American Student Dental Association
recognizes advocacy as an important
aspect of leadership development for
dental students and provides opportunities
for members to develop advocacy skills,
including national lobby days.48 There
are also postgraduate programs that
incorporate policy advocacy. Dental public
health residencies, such as the one at the
University of California, San Francisco,
provide training to dentists in planning,
evaluating and advocating for policies.49,50
In short, the field needs comprehensive
and organized efforts to teach dental
students core competencies about oral
health policy issues and how to lobby
O C T O B E R 2 0 1 6 629
 soda ta xes
their local and state governments.
Integration of these skills into dental
training can help create a new generation
of professionals who are equipped with
the tools to advocate for policies that
guarantee oral health for everyone.
Build coalitions with other stakeholders
and assume a seat at the table. Oral health
is part of overall health, and risk factors
for oral disease coincide with risk factors
for other chronic noncommunicable
diseases associated with sugary drink
consumption, including obesity, diabetes
and cardiovascular disease. Established
dental societies and organizations, such
as the California Dental Association and
the American Dental Association, can use
their existing leverage and broad reach to
bring oral health professionals together to
participate in advocacy efforts. Oral health
professionals can also form alliances and
coalitions with those in public health and
health care. These coalitions will be poised
to make a stronger and more cohesive
case for policies that limit soda intake,
such as sugary drink taxes, restrictions
on sugary drink marketing (company
sponsorships for health organizations,
schools and sports events) and sugary
drink-free health facilities, public buildings,
schools, childcare centers and sports
facilities. As part of these coalitions, dental
professionals can bring an oral health
lens to advocacy efforts, for example by
pushing for the money garnered from
soda taxes to go toward funding oral
health prevention efforts along with
other health promotion programs.
Incorporate media advocacy into broader
advocacy efforts. Media advocacy, the
strategic use of mass media to support
community organizing to advance a social
or public policy initiative,36 is a tool that
can amplify and accelerate larger strategic
efforts by dentists to advance policies to
promote oral health. A range of resources
exist to support oral health advocates
630O C T O B E R 2 01 6
in learning about and successfully using
media advocacy51,52 we highlight
here a few key tactics, including:
Identify policy goals and targets. As
mentioned above, there is a range
of policies with the potential to
limit sugary drink intake. A first
step for creating an effective media
advocacy strategy is to consider
what specific policy change you
are trying to achieve, who has
the power to create that change
and who the allies are that can
work with you to achieve it.
Oral health professionals see
the eects of sugary drink
consumption every day and
can speak to the impact of
sugary drinks on the lives and
health of their patients.
Put oral health on the agenda using
news and opinion space. To increase
the visibility of dentists and other
oral health professionals in public
dialogue about health policy and
related issues, submit blog posts and
opinion pieces that provide an oral
health perspective. Some examples
of effective springboards for opinion
pieces include breaking news, the
release of new research/data about
sugary drinks, controversial behavior
from the soda industry, local events
or holidays connected in the publics
mind with the policy process or with
sugar consumption, like Election
Day or Halloween, respectively.
Also, reach out to and develop
relationships with journalists
to ensure that the news stories
C D A J O U R N A L , V O L 4 4 , N 1 0
they write on public health issues
incorporate oral health perspectives.
Contact journalists over social media,
send them emails and be proactive
in putting stories on their radar.
Become visible and vocal spokespeople.
Oral health professionals see the
effects of sugary drink consumption
every day and can speak to the
impact of sugary drinks on the lives
and health of their patients. As
experts, they can use the media to
educate the public and build support
for soda taxes. They can also recruit
community members who have
experienced oral health problems
themselves or whose children have
been affected. These authentic
voices36 can speak powerfully and
effectively about the consequences
of tooth decay and the importance
of policies to reduce sugary drink
consumption in guaranteeing that
every child has a healthy smile.
Conclusion
Media coverage of Berkeley and San
Franciscos soda tax debates offers insight
into the public dialogue around these
high-profile issues. We found that oral
health was largely absent from discussions
of health around these policies, but that
there are many opportunities for oral
health professionals to become part of the
conversation. By identifying specific policy
goals, inserting oral health perspectives
into news and opinion coverage and
becoming visible spokespeople, oral health
professionals can position themselves
to provide new and powerful health
arguments to both policymakers and
the public. In other words, oral health
professionals are well poised to build
their capacity as media advocates and
advocate for policies that reduce sugary
drink consumption and improve the
oral health of whole populations.

ACKNOWLEDGMENTS
Research reported in this publication was partially supported
by the Global Obesity Prevention Center (GOPC) at Johns
Hopkins and the Eunice Kennedy Shriver National Institute of
Child Health and Human Development (NICHD) and the Oce
of the Director, National Institutes of Health (OD) under award
number U54HD070725. The content is solely the responsibility
of the authors and does not necessarily represent the ocial
views of the National Institutes of Health. This work was also
funded in part by the Voices for Healthy Kids program, a joint
initiative of the Robert Wood Johnson Foundation and the
American Heart Association, and the UC Berkeley Food Institute.
Thanks to Susan Hoang for assistance with translation and
Clancey Bateman and Aron Egelko for research assistance.
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THE CORRESPONDING AUTHOR, Lauren Nixon, MPH, can be
reached at nixon@bmsg.org.
O C T O B E R 2 0 1 6 631
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warning labels
C D A J O U R N A L , V O L 4 4 , N 1 0

Sugar-Sweetened Beverage
Warning Labels:
Lessons Learned From
the Tobacco Industry
Lucy Popova, PhD

A B S T R A C T Tobacco warning labels effectively educate consumers about the harms

of tobacco and reduce smoking behavior. Lessons from tobacco warning labels can
be applied to developing and implementing warning labels for sugar-sweetened
beverages (SSBs). Large pictorial rotating warnings are particularly effective. Dental
professionals can be an important voice in countering the industrys efforts to create
controversy around the effects of SSBs and in advocating for effective warning labels
based on the evidence from the tobacco warning labels.

AUTHOR

Lucy Popova, PhD, is a
tobacco control researcher
at The Center for Tobacco
Control Research and
Education at the University
of California, San Francisco.
Sugar, rum and tobacco are commodities health and medical communities have
which are nowhere necessaries of life, which been calling for regulating added sugars
are become objects of almost universal in a similar way.2 Consumption of added
consumption and which are therefore sugars has been linked to the development
extremely proper subjects of taxation.1 of dental caries,3-5 obesity,6-8 diabetes,9

T
She is studying how we can fatty liver disease10 and cardiovascular
better communicate about he similarities between sugar, disease.11,12 Sugar-sweetened beverages
the harms of tobacco and
rum and tobacco do not end (SSBs) are the leading source of added
other products.
Conflict of Interest with them being unneeded yet sugars in the diet.13 SSBs are beverages
Disclosure: None reported. ubiquitous consumer products to which sugar or other caloric sweetener
and good candidates for taxes, has been added. Examples of SSBs are
as Adam Smith pointed out almost two soft drinks, fruit drinks, sports drinks, tea
and a half centuries ago. Since then, we and coffee drinks and energy drinks.14
learned that sugar, alcohol and tobacco Sometimes sweetened milk products
are also detrimental to health. Alcohol, are included in the SSB category as
and particularly tobacco, have become well, but with the caveat that unlike
subjects of additional regulations, such as other SSBs, milk contains protein and
restrictions on advertisements and sales and other nutrients.14 SSBs typically do
health warnings. More recently, the public not comprise 100 percent fruit juice.
O C T O B E R 2 0 1 6 633
 warning labels
Consumption of SSBs is greater
among African-Americans and Mexican-
Americans than among Caucasians
for both men and women and across
most age groups.15-17 Consumption is
also greater among low-income and
low-education groups.18 These are the
same groups that have higher rates of
obesity, diabetes and other diseases.19-22
Lessons learned from tobacco
control are applicable to developing
and promoting policies around added
sugars. Public health advocates, including
dental professionals, could use the
tools, strategies and policies of tobacco
control to reduce the negative impact
of added sugars on population health.
One such policy is warning labels on
sugar-sweetened beverages. This article
provides an overview of what we know
about tobacco warning labels, what
types of labels are particularly effective
and how these lessons can be translated
to SSB warning labels policymaking.
History of Tobacco Warning Labels
The U.S. was the first country in the
world to require a health warning on
cigarette packages. This earliest warning
label appeared in 1966 on the side of
cigarette packs and read, Caution:
Cigarette Smoking May Be Hazardous to
Your Health. U.S. labels were updated
slightly over the years to change the
copy, but remained in the same place
the side of the package. Although
Congress authorized the U.S. Food and
Drug Administration (FDA) in 2009 to
develop and implement new pictorial
warning labels, the first set of warning
labels was struck down in court and today
cigarette packs still carry the same four
labels first introduced in 1985 (FIGURE 1 ).
The rest of the world moved on.
Driven by the motivation to make
warnings more effective, written
warnings became more specific, explicitly
634O C T O B E R 2 01 6
mentioning diseases caused by smoking,
such as lung cancer and heart attack,
as Iceland first did in 1969.23 Warnings
moved from the side of the packs to the
front and the back of the pack (first in
Saudi Arabia in 1987) and grew larger
covering 30 percent, 50 percent,
80 percent and even 90 percent of the
pack, as Nepal did in 2015. Pictures
illustrating the health effects of smoking
appeared in Iceland first in 1985.23
Finally, the brand colors and logos were
removed from the packs and replaced
with a drab olive color, pioneered
by Australia in 2012 (FIGURE 1 ).
Previously secret internal tobacco
industry documents chronicle the history
of the tobacco industrys resistance to the
implementation of warning labels and
reveal that tobacco companies made it
their policy to avoid health warnings
on all tobacco products for just as long
as we can24 because of their potential
effectiveness. These internal tobacco
industry documents are housed in the
University of California, San Francisco,
Truth (formerly Legacy) Tobacco Industry
Documents Library. This library contains
more than 80 million documents and
is available as a free online resource,
industrydocuments.library.ucsf.edu/
tobacco, to researchers all over the world.
Sen. Wallace Bennett (R-Utah) put
forth the first proposal for a warning
label on cigarettes in 1957.25 It read,
Warning, prolonged use of this product
may result in cancer, in lung, heart
and circulatory ailments and in other
diseases.26 However, the legislation
didnt pass until eight years later, and
then in a much weaker form, as described
above. The first pictorial warning label
was proposed to be on state cigarette tax
stamps in South Dakota in 1959 by Sen.
Donald Stransky, who was a heavy smoker
himself.27 The picture would feature skull
and crossbones with the words The use of
C D A J O U R N A L , V O L 4 4 , N 1 0
F I G U R E 1. Examples of cigarette warning labels in
the U.S. (left) and Australia (right).
this product is not recommended by the
State of South Dakota. The use thereof
may result in cancer or heart disease.28
The bill passed in the South Dakota
Senate by a small majority. The tobacco
industry mobilized tobacco distributors,
agricultural and business groups and
others.29 A governor of North Carolina,
a tobacco-growing state, threatened to
retaliate by labeling the farm products
from South Dakota as coming from
the soil with the highest content in
the nation of selenium, a well-known
poison.27 Newspapers in other tobacco-
growing states, such as West Virginia,
asked whether bread, butter and meat
produced in South Dakota and linked
to obesity and heart disease should be
labeled with skull and crossbones as well.30
The bill was defeated in the House.31
Following South Dakota, between
1959 and 1961, Utah and New York
proposed skull and crossbones labels,
while Massachusetts and Missouri
proposed textual health warnings.31 None
of these legislative proposals passed.
As the momentum of the legislative
proposals demanding warnings on
cigarettes and continued accumulation of
scientific evidence linking smoking and
disease made warnings inevitable, tobacco
companies were determined to influence
the content of these warnings to minimize
their effectiveness, saying, it has been
our policy to resist any mention of specific

diseases.24 The first U.S. cigarette warning
label, Caution: Cigarette Smoking
May Be Hazardous to Your Health
was originally proposed by the Federal
Trade Commission (FTC) as, Caution:
Cigarette Smoking Is Dangerous to
Health. It May Cause Death From Cancer
and Other Diseases.32 The tobacco
industry succeeded not only in curtailing
the wording of this health warning but
also in postponing its implementation
date and in prohibiting (preempting)
any local or state governments from
passing any laws related to warnings on
cigarette packaging or advertising.33 The
passage of this law (Federal Cigarette
Labeling and Advertising Act of 1965)
was called by The Atlantic, The Quiet
Victory of the Cigarette Lobby: How It
Found the Best Filter Yet Congress.34
Tobacco companies also worked
to always to have warning clauses
attributed to an appropriate government
authority.24 This allowed tobacco
companies to continue to dispute the
claims about the harmful effects of
tobacco. Because the government was
the source of the warnings, the tobacco
companies could disassociate themselves
from these warnings and continue to
argue that tobacco was not that harmful
and continue to confuse smokers, despite
conclusive scientific evidence.24
The warning created by this act and
later weak warnings were successfully
used by the tobacco companies to seek
immunity from litigation in state and
federal jurisdictions35,36 and then in the
Supreme Court.37 They argued that
the federally mandated warning label
was sufficient for consumers to be fully
informed about the risks of smoking.
Most recently, tobacco companies
sued the FDA when it required nine new
pictorial warning labels to cover 50 percent
of the front and back of cigarette packs
and 20 percent of advertisements.38 The
tobacco companies claimed that these
labels unjustifiably and inappropriately
violated their First Amendment rights by
compelling them to disseminate anti-
tobacco messages for the government.
Two different challenges were brought up
and the courts used somewhat different
standards for constitutional review resulting
in different outcomes, but ultimately, the
divided United States Court of Appeals for
the District of Columbia Circuit ruled the
proposed pictorial warning labels as written
to be in violation of the tobacco companies
constitutional right to freedom of speech.39
Tobacco companies could
disassociate themselves from
personally relevant.46 Warning labels,
these warnings and continue
to argue that tobacco was
not that harmful and continue
to confuse smokers.
A detailed discussion of the different
levels of scrutiny and the courts decision
making is available elsewhere.40,41 In brief,
the court ruled that the government did
not provide sufficient evidence that the
proposed warning labels would lower
smoking rates. The FDA chose not to
appeal to the Supreme Court; instead, it
revoked its pictorial warning regulation
but promised to continue research and
develop new warning labels.42 As of June
2016, the FDA had not announced any
further regulatory developments regarding
pictorial warning labels on cigarettes.
While tobacco companies oppose
warning labels, consumers actually
support them. A national survey in
Brazil showed that 76 percent approved
of pictorial warning labels, including
73 percent of smokers.43 In the U.S.,
C D A J O U R N A L , V O L 4 4 , N 1 0
the majority of residents supported the
introduction of pictorial warning labels
between 2007 and 2012, although after
the specific labels were introduced by the
FDA in 2011 the support among current
smokers (those who reported smoking
cigarettes in past 30 days) declined from
62 percent in 2011 to 40 percent in 2012.44
People consider warning labels effective in
dissuading themselves or other smokers from
smoking and pictorial warning labels were
perceived as more effective than text.45
Research on Tobacco Warning Labels
After the implementation of the
first warning labels in 1966, the FTCs
1981 report concluded that the original
warning labels were not novel, overexposed
and too abstract to remember and be
like advertisements, wear out over time.47
Written warning labels wear out faster than
graphic ones.48,49 In response, Congress
passed a law mandating four rotating
warnings. Studies on them began appearing
in the late 1980s, demonstrating that
several years after the implementation,
those written labels on cigarette packs were
also not noticed and not remembered by
smokers and adolescents.50-53 Since then,
the diffusion and evolution of tobacco
warning labels have been propelled by
observational and experimental studies
showing the effectiveness of large graphic
warning labels in informing consumers
about the health harms of smoking and
reducing their smoking behavior.45,54
Warning labels are noticed, read and
remembered. Both smokers and nonsmokers
notice warning labels on cigarettes and
recall their content.54 For example, in an
Australian study, among the new written
warning labels, the most frequently recalled
were Smoking kills and Smoking in
pregnancy harms your baby.55 A meta-
analysis of experimental studies showed that
pictorial warning labels attract attention
O C T O B E R 2 0 1 6 635
 warning labels
and keep it longer than written warning
labels, but that the differences in recalling
the content of the warning labels were
not significant between written and
pictorial labels.45 Another study showed
that graphic warning labels on tobacco
advertisements, compared to small
copy-only warnings capture attention
quicker and hold it longer, resulting in
better recall of the warnings message.56
Warning labels increase knowledge
of the risks of smoking. Noticing
warning labels is related to a greater
knowledge of health risks of smoking.57
In countries where a specific disease
(such as stroke) was mentioned on
health warnings, more people had the
knowledge that smoking causes this
particular disease than in countries
without health warnings concerning this
disease.57,58 After new written warning
labels were introduced in Australia,
smokers increased their knowledge of
the harmful constituents of smoke.55
Warning labels make smokers think about
quitting. In countries with pictorial or large
(50 percent of the pack) written warning
labels, more smokers report that labels led
them to think about stopping smoking.59
For example, 57 percent of Australian
smokers said that warning labels motivated
them to think about quitting smoking.60
Warning labels make smokers quit smoking
and prevent nonsmokers from starting to
smoke. Evidence from countries after the
introduction or changes in warning labels
indicate that these changes are related
to reduced numbers of cigarettes smoked
and fewer smokers.54 A recent systematic
review found that implementation of
strengthened warnings (i.e., a switch
from copy-only to graphic warning) was
associated with increased quit attempts
and short-term smoking cessation and
decreased smoking prevalence in those
countries.61 However, in observational
population-level studies it is difficult to
636O C T O B E R 2 01 6
determine unique causal effects of warning
labels when they are implemented along
with other policies, such as smoke-free
laws. Nonetheless, a quasi-experimental
study parsing out the effects of other
policies estimated that implementation of
graphic warning labels in Canada reduced
smoking rates by 2.87 to 4.68 percentage
points.62 In addition, a recent randomized
clinical trial demonstrated that smokers
whose packs had large graphic warning
labels were more likely to attempt to quit
smoking during the four-week clinical trial
than smokers with copy-only warnings
(40 percent versus 34 percent, or 1.29).63
History of Warning Labels on
Sugar-Sweetened Beverages
As of April 2016, no health warnings
on SSBs have been implemented.
However, there is support for this
measure. In California, 78 percent
of registered voters support requiring
text warning labels on soda or other
sugary drinks.64 There have been some
attempts to pass laws requiring warning
labels on SSBs. In February 2012, a
bill was introduced in California that
would require SSBs to carry a warning:
STATE OF CALIFORNIA SAFETY
WARNING: Drinking beverages with
added sugar(s) contributes to obesity,
diabetes and tooth decay65 (FIGURE 2 ).
However, this bill was held in
committee and did not advance. Another
attempt to implement this warning label
was undertaken in 2015, but likewise did
not pass the committee.66 The beverage
industry opposed these bills and lobbied
the legislators to make sure they did
not advance.67,68 The California Dental
Association lent its support to both
bills.69,70 Similar bills have been proposed
in New York state,71 Hawaii, Vermont and
Washington,72 but as of July 2016 these
bills had not yet been passed into laws.
San Francisco passed a law in 2015
C D A J O U R N A L , V O L 4 4 , N 1 0
F I G U R E 2 . California proposed warning
labels on sugar-sweetened beverages. (Source:
California Center for Public Health Advocacy www.
publichealthadvocacy.org/resources/warninglabel/
sodawarninglabel.html.)
requiring advertisements for SSBs
displayed on billboards, buses, transit
shelters, posters and stadiums within the
city to carry a warning: WARNING:
Drinking beverages with added sugar(s)
contributes to obesity, diabetes and tooth
decay. This is a message from the City and
County of San Francisco.73 Baltimore
City Council has been considering
requiring warning signs in businesses
that sell sugar-sweetened beverages.74
Just as tobacco companies resisted
warning labels on cigarettes, the food
and beverage industry is fighting the
implementation of warning labels on
SSBs. Newly discovered sugar industry
documents reveal that the cane and beet
sugar industries have actually been working
to resist regulation of sugars, including
warning labels, since the 1970s.75,76 Their
main tactic was to influence research
agenda of the national agencies (such as
the National Caries Program) and produce
their own research that would point at
causes other than sugar for health issues
such as dental caries.77 More recently,
the American Beverage Association
argued that warning labels on SSBs are
misleading, that SSBs are not uniquely

harmful to health and that singling them
out is unfair and will not improve public
health.78 They claim that the solution to
the obesity and diabetes crises lies not in
demonizing the SSBs but in educating
people on balancing calories consumed
and calories spent through exercise.79
During the hearing on the warning labels
ordinance in San Francisco, the American
Beverage Association brought in a dietician
from Washington, D.C.,80 to repeat this
argument.81 After the San Francisco Board
of Supervisors unanimously passed the
ordinance requiring warning labels on
advertisements for SSBs, the American
Beverage Association, the California
Retailers Association and the California
State Outdoor Advertising Association
sued the city of San Francisco.82 Their
motion for preliminary injunction that
would have prevented the ordinance
from taking effect was denied by the U.S.
district judge on May 17, 2016. Expert
testimony countering industry claims,
including the evidence linking SSBs to
health effects (such as dental caries) as well
as evidence of the effectiveness of tobacco
warning labels, played an important
role in the judges decision.83 On June 8,
2016, however, the same judge granted
a shorter-term injunction that would
prevent the ordinance from going into
effect until his previous ruling is reviewed
in the U.S. Circuit Court of Appeals.84
Research on SSB Warning Labels
Some research is emerging evaluating
reactions to and short-term effects of textual
warnings on SSBs. A study evaluated the
effects of different versions of a California
warning label (SAFETY WARNING:
Drinking beverages with added sugar(s)
contributes to obesity, diabetes and tooth
decay) on parents of 6- to 11-year-old
children in an online experiment.85
Labels differed in that one used weight
gain instead of obesity, another added of the SSB warning labels according
F I G U R E 3 . Examples of potentially ineective and eective warning labels for soda.
(Source: flickr.com/photos/figgenhoer/3661358131.)
preventable diseases in front of the
disease names and another added type
2 diabetes to the list of diseases. Parents
who saw any of these labels (compared
to parents who saw a beverage with no
label or with the American Beverage
Associations Clear on Calories label that
depicted the number of calories) believed
that SSBs were less healthy for their child
and were significantly less likely to select
an SSB for their child from an online
vending machine. The variations in the
wording of the warning label (e.g., weight
gain versus obesity) did not have a
significant effect on the parents perceptions
or hypothetical purchasing behavior.
What Should Warning Labels on
Soda Look Like?
Lessons from tobacco warning labels
can be applied to SSBs to make these
labels more effective. The World Health
Organization (WHO) Framework
Convention on Tobacco Control
(FCTC)86 provides specific guidance.
Adopted in 2003, the FCTC was the
worlds first global public health treaty, and
it was signed by 168 countries (the U.S.
was not one of them). Article 11 of the
FCTC could be used to guide the design
C D A J O U R N A L , V O L 4 4 , N 1 0
to the recommendations for tobacco
warning labels that were developed based
on empirical evidence. For example, a
warning label should cover no less than
30 percent (preferably 50 percent) of the
primary display area of a package. Warning
labels should be rotated frequently to keep
them novel. They should appear on the
package and on advertisements. Ideally,
a picture should accompany the written
warning to make the message more salient
and to communicate the message for those
with low literacy. All of the currently
proposed warning labels for SSBs fall
short of the FCTC recommendations.
Two examples of SSB warning labels are
presented in FIGURE 3 . The soda can on the
left features a warning label similar to the
current U.S. alcohol and tobacco warning
labels. The label is positioned vertically,
while the main product copy is horizontal.
The use of all capital letters and a text
color that blends in with the background
may also make this label less effective.87
In contrast, the soda can on the right
has a prominent pictorial warning label
that could be more effective. The image
covers 50 percent of the front surface,
which makes it easier to see and attract
attention.45,86 The copy and the picture
focus on one specific disease (tooth
O C T O B E R 2 0 1 6 637
 warning labels
decay), but this would be part of the set
of rotating pictorial warnings with other
labels focusing on obesity and diabetes.
Tobacco companies extensively researched
visual elements for cigarette packs to
make them more eye-catching.87,88 They
found that a white background, high-
color saturation and high contrast made
the design elements stand out. Yellow
was the most noticeable and memorable
color, but consumers did not perceive
it as pleasant, associating it with stress
and anxiety. Based on the findings from
tobacco industry research, to increase
visible prominence of labels, black copy
on a yellow background could be used.
The warning does not contain attribution
to the government source. Attribution
to a government authority allows the
industry to continue to dispute the
science about the harms of the products.
Knowing the history of the resistance
of tobacco companies to warning labels
and the incipient resistance from the
beverage and sugar industries, putting
warning labels on sugar-sweetened
beverages will not be an easy public health
task. It would be helpful for advocates to
review the arguments the tobacco industry
used to avoid, delay and curtail warning
labels,24 as well as other strategies of
tobacco companies35 and other industries.2
There are useful summaries available for
the arguments that are commonly used by
the tobacco industry to combat warning
labels and the ways to counter them.89
Similar resources are now available for
advocates promoting regulation and
labeling for SSBs.90 For example, the
slippery slope argument might have
contributed to the defeat of the early
warning labels in the U.S. In Australia,
when the ominous predictions of tobacco
companies failed to materialize, this
argument seemed to have lost its appeal.24
Tobacco control advocates should point
out the fallacy in this argument that
638O C T O B E R 2 01 6
there is no evidence that putting warning
labels on one product automatically leads
to labeling other undesirable products.
When proposing warning labels
for SSBs, whether textual or graphic,
localities should work with legal counsel
in order to pass judicial review. Among
other things, advocates of warning labels
on SSBs might need to demonstrate
that the current advertising for SSBs
is deceptive and needs to be corrected,
propose labels that are based on facts
and are not unjustifiably burdensome
or too broad and convince the court
Attribution to a government
authority allows the industry
to continue to dispute
the science about harms
of the products.
that warning labels would advance a
governments substantial goal (such
as reduce the rates of obesity, diabetes
and other diseases or inform consumers
about the harmful effects of SSBs).
When choosing whether to pursue
warnings on products, advertisements or
other locations (such as point of sale),
advocates should consider several issues.
It might be easier politically to require
warning labels on advertisements because
making separate packages for different
localities or states might be seen as
too burdensome to the manufacturers
or distributors. Legally, they should
consider if their proposed warning labels
might be preempted by the federal
Nutrition Labeling and Education Act
(NLEA), which gives the FDA the
authority to regulate food labeling.91
C D A J O U R N A L , V O L 4 4 , N 1 0
Conclusion
Health warnings on tobacco products
have been an effective tool for educating
consumers about the health risks of
tobacco. Warning labels are just one
of the tobacco control policies that
are applicable to SSBs. Other policies
include mass media campaigns, taxes
and restrictions on marketing and sales,
among others.2,92,93 Dental professionals
are already educating their patients about
this and other health issues, such as
smokeless tobacco. The California Dental
Association94 and the American Dental
Association95 provide online, printable
handouts that dental professionals can
use to educate their patients about a
variety of dental issues, including the
role of sugar. But dental professionals
should not only educate their patients.
Health advocates, including dentists,
should familiarize themselves with the
history of the tobacco warning labels,
the industrys tactics to resist warning
label regulations and the research on
the effectiveness of warning labels. The
industry will continue to challenge the
science on health effects of SSBs and any
efforts to put warning labels, including
challenging the content and design of
the labels. Dentists can lend support to
policymakers to resist these challenges.
Testifying in front of local city councils
and writing or calling state representatives
or writing editorials to local newspapers96
are just some of the ways to do this.
Future proposals for SSB warning
labels should base the design, content,
size and copy versus graphics on the
evidence from tobacco research.
More research on the effectiveness of
SSB warning labels with the stronger
design (such as the one suggested in
this paper) should be conducted to
preempt further industry challenges.
Lessons from the tobacco warning
labels indicate SSB warning labels
 C D A J O U R N A L , V O L 4 4 , N 1 0

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that the UPI wire carried a story on the introduction... from four countries over five years. Tob Control October
diseases mortality among U.S. adults. JAMA Intern Med
1959; industrydocuments.library.ucsf.edu/tobacco/docs/ - 2009;18(5):358-364. 10.1136/tc.2008.028043
2014;174(4):516524.
id=hhgc0086. Accessed April 4, 2016. 49. Yong H-H, Fong GT, Driezen P, et al. Adult smokers
13. Reedy J, Krebs-Smith SM. Dietary sources of
29. Hill F, Knowlton C. Hill and Knowltons Recommendations reactions to pictorial health warning labels on cigarette
energy, solid fats and added sugars among children
to the Tobacco Institute. 1959; industrydocuments.library. packs in Thailand and moderating eects of type of cigarette
and adolescents in the United States. J Am Diet Assoc
ucsf.edu/tobacco/docs/ - id=xyxp0146. Accessed April 4, smoked: Findings from the International Tobacco Control
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14. Centers for Disease Control and Prevention. The
30. Williamson News. Skull and crossbones. 1959; 50. Richardson P. Review of the Research Literature on the
CDC guide to strategies for reducing the consumption
industrydocuments.library.ucsf.edu/tobacco/docs/ - Eects of Health Warning Labels: A Report to the United
of sugar-sweetened beverages. 2010. www.cdph.
id=lrgm0137. Accessed April 4, 2016. States Congress, Silver Spring, Md., Macro Systems, Inc.
ca.gov/SiteCollectionDocuments/StratstoReduce_Sugar_
31. Summary of state labelling legislation. 1959; ADM. 1987;281:860003.
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tobacco advertisements. JAMA 1989;261(1):8489.
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in Outdoor Cigarette Advertising: Are They Readable?
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cigarette packages are ineective. JAMA 1989;261(1):4545.
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Graphic warning labels in cigarette advertisements: Recall
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57. Hammond D, Fong GT, McNeill A, Borland R, Cummings
KM. Eectiveness of cigarette warning labels in informing
smokers about the risks of smoking: Findings from the
International Tobacco Control (ITC) Four Country Survey.
Tob Control Jun 2006;15 Suppl 3:iii19-25. 10.1136/
tc.2005.012294.
58. Thrasher JF, Hammond D, Fong GT, Arillo-Santilln
E. Smokers reactions to cigarette package warnings
with graphic imagery and with only text: A comparison
between Mexico and Canada. Salud publica de Mexico.
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59. Hammond D, Fong GT, Borland R, Cummings KM,
McNeill A, Driezen P. Text and graphic warnings on cigarette
packages: Findings from the international tobacco control
four country study. Am J Prev Med 2007;32(3):202209.
60. Shanahan P, Elliott D. Evaluation of the eectiveness of
the graphic health warnings on tobacco product packaging
2008. Canberra: Australian Government Department of
Health and Ageing. 2009.
61. Noar SM, Francis DB, Bridges C, Sontag J, Ribisl
KM, Brewer NT. The impact of strengthening cigarette
pack warnings: Systematic review of longitudinal
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socscimed.2016.06.011.
62. Huang J, Chaloupka FJ, Fong GT. Cigarette graphic
warning labels and smoking prevalence in Canada: A critical
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63. Brewer NT, Hall MG, Noar SM, et al. Eect of Pictorial
Cigarette Pack Warnings on Changes in Smoking Behavior:
A Randomized Clinical Trial. JAMA Intern Med 2016.
64. Field Research Corporation. Voters see a close linkage
between kids regularly drinking sugary beverages and their
developing serious health conditions, like type 2 diabetes.
Broad-based support for both government and beverage
company actions to address the problem. 2016; www.field.
com/fieldpollonline/subscribers/Rls2529.pdf. Accessed
March 23, 2016.
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billHistoryClient.xhtml?bill_id=201320140SB1000.
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id=201520160SB203. Accessed April 4, 2016.
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Accessed June 8, 2016.
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THE CORRESPONDING AUTHOR, Lucy Popova, PhD, can be
reached at lyudmila.popova@ucsf.edu.
 Specialists in the Sale and Appraisal of Dental Practices
Serving California Dentists since 1966
How much is your practice worth??
Selling or Buying, Call PPS today!
NORTHERN CALIFORNIA
(415) 899-8580 (800) 422-2818
Raymond and Edna Irving
Ray@PPSsellsDDS.com
www.PPSsellsDDS.com
California DRE License 1422122
6112 HEALDSBURG
LDSBUR URGG Ideal
Ide
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DDS
DS sseeking
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eeking
ng ppart-time
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highly desirable locale or as foundation to grow. 100% out-of-
network. Trending $200,000 in collections with Profits of $105,000.
6111 SANTA ROSA Perfectly positioned for next Owner. Best
equipment, networked and digital including Pano. 3-days of Hygiene.
2016 trending $520,000+ with profits exceeding $250,000.
Conservative Owner. Best location.
6110 CONCORD Well cared for practice. 2015 collected $260,000 in
2015. 3-ops. 580 patients. Great curb appeal. Little done in marketing.
Great merger opportunity for nearby practice.
6109 CALIFORNIA'S NORTH LAKE TAHOE Best-of-the-best!
Solid foundation anchored by 8.5 days of Hygiene. Consistent $1
Million per year performer. Beautiful office with unsurpassed views.
Enjoy great Alpine lifestyle.
6107 EUREKA 100% out-of-network with insurance industry.
Produced $918,000 and collected $895,000 on 20-hour week.
ooked 3-months out. 7+ days of Hygiene. Highly
respected. Full price $250,000.
6106 SACRAMENTO'S EL DORADO HILLS No rush and no
chaos here. Staff is Dream Team. Beautiful facility. 2015 collected
$640,000. UCR Fees. Very special opportunity. Median household
income in 2013 was $104,500. Great schools, growing business parks
and very upscale community.
6105 MODESTO Collected $430,000+ on 3-day week. 3-days of
Hygiene. 5-ops. Central location. Successor should open 4th day.
6104 SANTA CLARA CUPERTINO AREA Restorative practice.
2015 collected $1.55 Million with Profits of $694,000. Paperless and
digital. Beautiful office. UCR Fees! Extremely attractive selling
features available to retain the goodwill.
6103 SAN FRANCISCOS UNION SQUARE Opportunity to
acquire highly regarded practice with condo. Beautiful 5-ops, digital
and paperless. 6th op available. 2015 collected $658,000.
6100 SANTA CLARA Phenomenal launching pad for next Owner.
Fantastic location, 5-op facility. Management not taking advantage of
what is possible even though 2015 collected $758,000 with Profits of
$323,000. Perfectly positioned to be a $1 Million+ year performer
immediately! Needs young DDS.
6098 WEST PETALUMA Petaluma is THE business center of the
North Bay! Business parks are growing and young families are drawn
to this great family community per the unique amenities of this
historic river city. Collected $468,000 with Profits of $199,000. 3-days
of Hygiene and starting a 4th day in September.
6089 MOUNT SHASTA Small town living renowned for outdoor
lifestyle. Best air and water! Escape Rat Race and corporate intrusion.
3-day week collected $881,000. Available Profits totaled $485,000.
Digital radiography including Pano. Full price $350,000.
Practices
Wanted
SOUTHERN CALIFORNIA
(714) 832-0230 (888) 440-5957
Thomas Fitterer and Dean George
PPSincnet@aol.com
www.PPSDental.com
California DRE License 346937
in ANTELOPE VALLEY Has grossed $1.8 Million. Fantastic location.
60,000 autos pass by per day. 8 ops. Partnership for $250,000 or buy all.
ARCADIA Facility only. 3-ops equipped. $65,000 or $95,000 with Ortho.
BAKERSFIELD AREA 5-ops, next to McDonalds. 1,800 sq.ft. includes
building. Grosses $40,000/month. Full Price with building $350,000.
BAKERSFIELD Established 55 years. 5-ops in 3,000 sq. ft. Will do
$1 Million. Full Price $300,000. Building available for $350,000.
BELLFLOWER Established 60-years. Grossing $350,000. Full Price
$240,000.
EAST LOS ANGELES One million Latinos in service area. PPS sold
to Seller in 1985. Will do $1 Million in 18 months. Full Price $300,000.
EAST SAN FERNANDO VALLEY Absentee Owner. $8,000/month
Cap Check. 4-ops. Do a Million within a year.
INDIO 4,000 sq.ft. dental building. Full Price $650,000.
LADERA RANCH Grossing $650,000. Shopping center location.
LAGUNA NIGUEL Location, location, location! 4-ops with Panorex.
Full Price $185,000.
LA JOLLA Established 20-years. 3-ops. Grossed $150,000. Super
opportunity with immediate growth. Full Price $150,000.
LAWNDALE Hi identity. 2 ops . Full price $125,000.
LOS ANGELES HMO Grossing $1.2 Million. 5-ops. Full Price $1.2 Million.
LOS ANGELES HMO Does $4 Million. OLD
S
NORCO CORONA Will do $1.5 Million. 8-ops. Exquisite. Full
Price $1.2 Million.
SOLD
NORWALK Fantastic high identity location. 5 ops. Full Price
$250,000.
ORAL SURGERY PRACTICE LOS ANGELES Established 40 years.
ORANGE Beautiful 10 operatory office ready for merger.
PASADENA Established 60 years. 7-ops. Always $1+ Million. Full
Price $600,000.
REDLANDS Shopping center. Grosses $350,000. Full Price $250,000.
RIVERSIDE Facility only. 4 ops. Full Price $50,000.
SOUTH ORANGE COUNTY BEACH CITY Grosses $650,000.
4 ops. Beautiful!
PERIO PRACTICE - PRESTIGIOUS BEACH CITY Established
40 years.
TORRANCE Established 12 years. 5 star building. 3-ops. Grossing
$250,000. Full Price $195,000.
TUSTIN Dental building. Full Price $1.5 Million.
VENTURA - OXNARD 5-ops. Grossing $850,000. High identity. Full
Price $685,000.
YUCCA VALLEY 8/10th of an acre. Great highway visibility. Full
Price $250,000.
Seeking Senior Dentists wishing to have more time to enjoy life, be free
of management & overhead to join a Dental Cooperative. Call Tom
Fitterer at 714-832-0230 or cell 714-345-9659.
**FOUNDERS OF PRACTICE SALES**
120+ years of combined expertise and experience!
3,000+ Sales - - 10,000+ Appraisals
**CONFIDENTIAL**
PPS Representatives do not give our business name when returning your calls.
 RM Matters C D A J O U R N A L , V O L 4 4 , N 1 0

Understanding the Role of the Better Business Bureau

TDIC Risk Management Sta

A
s recently as a century ago, When a complaint is filed, the BBB will to respond due to patient privacy concerns.
unscrupulous companies automatically send it to the business owner The dentist can then attempt to contact
peddled an assortment of for a response. However, responding can put the patient and resolve the matter directly.
questionable products to a dentist at risk because HIPAA prohibits The Better Business Bureau is
relieve common medical any disclosure of confidential patient not a regulatory agency and responses
ailments. Persuasive salesmen and information, regardless of whether the are not mandatory, Davis said.
deceptive advertising touted these magic patient disclosed his or her information first. Dentists who are accredited members of
tonics as miracle cures. Unfortunately, Even acknowledging that the complainant the BBB are required by the terms of their
many of these so-called medicines were was a patient of record is a violation of law accreditation to respond. However, they are
ineffective at best and deadly at worst. and can set dentists up for liability claims. still required to follow patient privacy laws.
Fed up with shady opportunists making For dentists who are not accredited TDIC recommends they submit a generic
false claims that tarnished the public members of the BBB, TDIC recommends response, refraining from identifying the
perception of their profession, a group of not responding to complaints at all. Dentists patient or disclosing anything that could
advertising executives came together to can send a letter stating that they decline be considered private patient information.
boost consumer trust. Promoting self-
regulation, ethical business practices and
truth in advertising, the group is now
known as the Better Business Bureau.
While the mission of the BBB has stayed
the same, its role has changed significantly.
Like other consumer protection entities,
it can be either a blessing or a curse for You are not a sales goal.
business owners, including dentists. Positive
ratings through the BBB can help a business
grow, but the opposite can happen should
a dissatisfied customer file a complaint.
The Dentists Insurance Company,
TDIC, reports a case in which a patient
was unhappy with a stayplate. He showed
up to the dental practice unannounced,
threw the stayplate, cursed and demanded
a refund. The dentist declined the You are a dentist deserving of an insurance company relentless
refund, so the patient filed a complaint in its pursuit to keep you protected. At least thats how we see
with the BBB. In another case, a patient it at The Dentists Insurance Company, TDIC. Take our Risk
demanded a partial refund of a dentists
Management program. Be it seminars, online resources or our
consultation fee. When the dentist
Advice Line, were in your corner every day. With TDIC,
declined, the patient filed a complaint.
We have been getting an increase in you are not a sales goal or a statistic. You are a dentist.
calls to the Risk Management Advice Line
about complaints to the Better Business
Bureau, said Sheila Davis, assistant vice
Protecting dentists. Its all we do.

president, claims and risk management,

800.733.0633 | tdicinsurance.com | CA Insurance Lic. #0652783
TDIC. It is important for dentists to
know how to protect themselves should
they be the subject of a complaint.
O C T O B E R 2 0 1 6 643
 O C T . 2 0 16 RM MAT TERS
In another case reported to TDIC,
the BBB contacted an accredited member
dentist after reading a negative review
of the dentist on a popular review site.
The BBB asked whether the accusations
outlined in the review were true,
questioned the dentists practices and
requested she provide copies of treatment
records. The dentist was advised not
to disclose any patient records and to
withdraw membership from the BBB.
Dentists who fail to protect
patient information can be subject
to disciplinary action, Davis said.
It is their responsibility to ensure
644O C T O B E R 2 01 6
patient information is only accessible
to those authorized to have access.
TDIC recommends that dentists
address complaints to the BBB the same
way they would address any patient
complaint: with professionalism and
compassion. Upset or angry patients
often lodge complaints when they
feel they have no other option for a
resolution. Dentists should schedule
a consultation, at no charge, to listen
to the patients concerns and offer
mutually agreed upon solutions.
Patients sometimes file complaints
because they feel their issues are not
C D A J O U R N A L , V O L 4 4 , N 1 0
being addressed, Davis said. Often,
they just want to be heard.
Finding the right balance between
consumer protection and patient
privacy can be tricky, but it is a crucial
responsibility of all dentists. By arming
yourself with accurate information
and understanding the role the BBB
plays, it is possible to protect yourself
and your practice from risk.
TDICs Risk Management Advice Line
at 800.733.0634 is staffed with trained
analysts who can answer consumer and
other questions related to dental practice.
t Lee Skarin and Associates has been serving the dental profession since 1959.
t Kurt Skarin has over 30 years experience in dental practice sales.
t We have sold more practices than any broker in the state within
the last 12 months.
t Our experienced practice appraisals are backed with
credentials unequaled among dental practice brokers.
t We provide in-house legal counsel to advise you in all
aspects of the sale and purchase, including the tax
consequences of the sale.
t Excellent financing is available, in most cases for 100%
of the purchase price.
t With a reputation for experienced, concientious,
and ethical performance, we give our clients
personal attention in all aspects of the purchase.

With scores of Buyers, profiles of their

practice interests and financial ability,
is able to
find the right buyer for your practice.

Experience the difference. Call Lee Skarin and Associates

for responses to all of your questions - No obligation!
Visit our website for current listings: www.LeeSkarinandAssociates.com
Dental Practice Brokers CA DRE #00863149
800.752.7461
C CARROLL
& C O M P A N Y
Complete Evaluation of Dental Practices & All Aspects of Buying and Selling Transactions
4103 SAN FRANCISCO GP
Vibrant downtown location in historic high-rise bldg. Retiring doctor
o ering 30+ years of goodwill. 4.5 days of hygiene, 1,500+ active
patients, 20-25 new patients/mo. Gorgeous, spacious facility in
approx. 2,500 sq. ft. 2015 GR $796K. 2014 GR $768K. Average
adjusted net income $274K+ Asking $599K.
4129 PETALUMA GP
GP located in stunning 1,856 sq. ft. seller owned facility. State-of-the-
art o ce includes 6 ops, sta lounge, reception area, private o ce,
business o ce, lab area, sterilization area, consult room, separate
storage area, bathroom plus private bathroom. Asking $525K.
4126 HONOLULU GP
4 ops in 942 sq. foot o ce located in popular local mall. Practice est.
over 35 years ago, 7 years in current location. Equipment includes
digital x-ray, pano & laser. Seller transitioning to retirement. Avg. GR
$433K. Asking $279K.
4108 HUMBOLDT COUNTY GP
Well-established, high performing general practice boasts 6 fully
equipped ops. in 2,900 sq. ft. free standing o ce w/Digital X- ray, 2
platinum Dexis sensors, & Cerec Omnicam & MCXL units. Loyal &
stable pt. base in charming community, w/ a small town feel. Perfect
for a dentist who wants to escape the grind and live along the
coastline. Avg. GR $1.4M+, 2016 on schedule for $1.5M+. Seller
willing to help for smooth transition. Asking $1,041K.
4091 HOLLISTER GP & PEDIATRIC
Country living at its best ~ small town feel with a ordable housing, in
quaint bedroom community to Silicon Valley. Fully equipped 1,600 sq.
ft. o ce with 2 enclosed adult ops and 3 open pedo ops, near Hazel
Hawkins Hospital. Turn-key practice, great opportunity for a pediatric
dentist. Approx. 565 active patients. 2015 GR $219K. Seller is
relocating but will help for a smooth transition. Asking price $125K.
4114 CONCORD GP
Well-established practice o ering 30+ yrs of goodwill. Concord is on
the verge of redevelopment of the old Naval Weapons Base later this
year, which will cover 2,300 acres and include 12,000 housing units.
The project will include Residential/Commercial/Recreational and Open
Space. This practice opportunity is strategically located for growth
potential due the slotted re-development. O ce has 3 fully equipped
ops in 836 sq. Average GR $360K+ on 2 doctor days. Asking $224K.
4114 WALNUT CREEK GP
Walnut Creek practice in gorgeous facility with recent leasehold
improvements plus new and upgraded equipment. Practice has 30+
years of goodwill. Looking for a mature, experienced practitioner for a
loyal and mature patient base. Located in commercial center with
several amenities and marketing opportunities. Doctor works 2 days
per week. Owner available for a smooth transition. Asking $432K.
4120 SF GP
Well est. downtown family practice grossing over $1M with an avg.
overhead of 61%. 5 fully equipped ops.,
NG in remodeled o ce. Retiring
DISeasoned, dedicated sta & loyal
seller works 3.5 Dr. days/week.
N Mike Carroll
Asking $806K.
PE
www.carrollandco.info dental@carrollandco.info
Matching the Right Dentist
to the Right Practice
4104 SAN JOSE GP
Seller retiring and ready to transition a 29 year practice located
close to Westgate Center with close proximity to several amenities,
in a well travelled, commercial and residential neighborhood. 2015
GR $354K+. Asking $244K.
4121 NAPA GP
Gorgeous, state-of-the-art o ce available in beautiful wine
country! Incredible location with super high visibility on the corner
of two major cross streets near Queen of the Valley Hospital. 7
ops in 3,250 sq. ft. facility. Seller retiring but would like to transition
with buyer after the sale. 2,100+ active patients, 9 days of
hygiene, 15-20 new patients/mo. 2015 GR $1.56M, 2014 GR
$1.62M. Average Adjusted net income of $513K. Asking
$1,151K.
4096 MENDOCINO COUNTY GP
Seller o ering well est. 48 year practice. Located in outdoorsman's
paradise. Just 2 hours North of SF surrounded by redwood forest,
vineyards and mountains. 950 sq. ft. o ce in single level building w/ 4
fully equipped ops. 2014 GR $565. Asking $300K.
4099 MT VIEW DENTAL FACILITY
Dental facility o ered in a desirable location in the heart of silicon valley.
Great patient population including Google, Apple, and many local
startups. Excellent for a starter o ce to build a patient base or grow
your existing patient base here. Approx 1,164 sq feet with 5 plumbed
ops. Asking price for facility only $105K.
4093 SAN JOAQUIN VALLEY ORTHO
Established over 35 years with a solid reputation, near several referral
sources in seller owned building. 2,500 sq. ft. o ce with 7 chair open
bay in professional center on a well-travelled street with many retailers.
Avg. Gross Receipts $763K. Seller retiring and willing to help for
smooth transition. Asking $561K. The building is available to purchase
as well for $608K.
4105 STANISLAUS COUNTY GP
Get away to a less demanding commuter friendly town. Seller retiring
from practice est. over 30 years ago with loyal patient base in
charming community with historic small town feel. 3 fully-equipped
ops. in 1,200 sq. ft. o ce. Approx. 1,400 active pts. w/4 doctor days/
week. 5 year avg. GR $647K+ w/approx. 50% overhead. Seller willing
to help for smooth transition. Asking $375K.
Carroll & Company
2055 Woodside Road, Ste 160
Redwood City, CA 94061
P (650) 362-7004
F (650) 362-7007
dental@carrollandco.info
www.carrollandco.info
BRE #00777682
Pamela Carroll-Gardiner
P (650) 362-7004 F (650) 362-7007
 Regulatory Compliance C D A J O U R N A L , V O L 4 4 , N 1 0

Nitrous Oxide Safe Practices

CDA Practice Support Sta

Nitrous oxide (N2O) is a clear,
colorless, oxidizing liquefied gas with a
slightly sweet odor that, when mixed with
oxygen, is used for dental anesthesia. It is
considered a nonflammable gas. Inhaling
pure nitrous oxide can lead to asphyxiation.
Dental practices using nitrous oxide
should utilize scavenging equipment to
minimize employee exposure to the gas.
Cal/OSHA has established a time-
weighted average permissible exposure level
(PEL) of 50 ppm for nitrous oxide over an
eight-hour day. An employer must monitor
the work environment if the employer
or any employee believes individual staff
may be exposed to concentrations in
excess of the PEL. Monitoring should be
performed until such time that the work
environment is within the PEL. Title 8
of the California Code of Regulations,
Section 5155 Airborne Contaminants
establishes the PEL for nitrous oxide. The
appendix to section 5155 explains how
to compute exposure levels and includes
a link to the table of permissible exposure
Systems Using Infrared
Thermography to Visualize and
Control Emissions. J Am Dent Assoc
February 2009 140(2): 190-199.
Nitrous oxide in the dental office.
ADA Council on Scientific
Affairs; ADA Council on Dental
Practice. J Am Dent Assoc March
1, 1997 128(3): 364-365.
The U.S. National Institute for
Occupational Safety and Health
(NIOSH) has online resources for
controlling nitrous oxide exposure:
Control of Nitrous Oxide in
Dental Operatories, 1996.
NIOSH Alert: Controlling
When Looking To Invest In Professional
Dental Space Dental Professionals Choose
Exposures to Nitrous Oxide During
Anesthetic Administration, 1994.
Waste Anesthetic Gases, 2008.
Anesthetic Gases: Guidelines
for Workplace Exposure, 2000.
Pregnant Employees
Once an employer is notified of a
pregnancy, the first obligation is to assess
the risks within the workplace for the
pregnant employee. We recommend:
Assessing the risks to which a
pregnant woman, a woman who has
recently given birth or a woman
who is breastfeeding is exposed
and the length of the exposure.

Linda Brown
limits for all identified air contaminants.
Vendors that provide monitors
for assessing employee exposure
levels are listed in Glutaraldehyde,
Formaldehyde and Nitrous Oxide 30 Years of Experience Serving
Monitors on cda.org/practicesupport. the Dental Community Proven
Effective scavenging equipment and
periodic inspection of equipment should Record of Performance
keep nitrous oxide exposures to within
acceptable limits. Recommendations Dental Office Leasing and Sales
for the safe use of nitrous oxide in the
dental office are included in articles For your next move, Investment Properties
published in the Journal of the American contact: LINDA BROWN Owner/User Properties
Dental Association. These articles may
be accessed online at jada.ada.org.
Locations Throughout
Donaldson M, et al. Nitrous Direct: (818) 466-0221 Southern California
oxide-oxygen administration: Office: (818) 593-3800
When safety features no longer Email: LindaB@TOLD.COM
are safe. J Am Dent Assoc February Web: www.TOLD.com
2012 143(2): 134143. Cal BRE: 01465757
Rademaker A, et al. Evaluation
of Two Nitrous Oxide Scavenging
O C T O B E R 2 0 1 6 647
 O C T. 2 016 R E G U L ATO RY C O M P L I A N C E
Informing any employee concerned
with identified risks with information
on the control/protective measures
that will be put in place.
Determining the practical measures
to be implemented in the workplace
to protect against the risks.
To be cautious, it is best to have
a pregnant staff member, or one who
is trying to conceive, refrain from
being in the same operatory when
nitrous oxide is being administered,
unless the employees physician states
otherwise. Even the best scavenger
system does not prevent exposure to
nitrous oxide gas as patients can have
their mouths open during procedures
allowing the gas to escape.
Integrity.
Relationships.
Peace of Mind.
Thats the PARAGON way.
PA RA GON has guided t housands of buyers and sellers w it h
superior dent al t ransit ion services and support . Our client s are
Your local PARAGON
dental transition consultant
Trish Farrell
86 6 .89 8.186 7
648O C T O B E R 2 01 6
Other Regulations
The Dental Board does not require
a permit to administer nitrous oxide to
patients.
Dental practices that use nitrous
oxide and have 10 or more employees
should post a Proposition 65 notice. The
notice, an FAQ and patient fact sheet are
available on cda.org/practicesupport.
Piped systems for compressed gases
must comply with local fire code. Portable
cylinders of compressed gas must be stored
and handled according to Cal/OSHA
regulation, 8 CCR 4650. Dental practices
with compressed gas cylinders must:
a) Store the cylinders in areas where
they are protected from external
heat sources.
f)
Approved PACE Program Provider
FAGD/MAGD Credit
Approval does not imply acceptance
by a state or provincial board of
dentistry or AGD endorsement
4/1/2016 to 3/31/2020
Provider ID# 302387.
C D A J O U R N A L , V O L 4 4 , N 1 0
b) Inside of buildings, store cylinders
in a well-protected, well-ventilated,
dry location at least 20 feet from
highly combustible materials. The
storage space must be located where
cylinders will not be damaged by
passing or falling objects or subject to
tampering by unauthorized persons.
Store cylinders in places away from
elevators or stairs.
c) Not keep cylinders in unventi-
lated enclosures such as lockers and
cupboards (with the exception of fire
extinguishers).
d) Store oxygen cylinders separate from
fuel gas cylinders or combustible
materials (especially oil or grease) a
minimum distance of 20 feet or by
a noncombustible barrier at least 5
feet high or a minimum of 18 inches
(46 centimeters) above the tallest
cylinder and having a fire-resistance
rating of at least one hour.
e) Transport and store compressed gas
cylinders in a manner that prevents
them from creating a hazard by tip-
ping, falling or rolling.
Ensure all cylinders that are designed
to accept valve protection devices
are equipped with such devices when
the cylinders are not in use or con-
nected for use.
g) Unless cylinders are secured on a
special truck or rack, regulators shall
be removed and valve-protection de-
vices, when provided for, shall be put
in place before cylinders are moved.
h) Securely fasten and transport
compressed gas cylinders in suitable
trucks. All gas cylinders in service
must be secured to other rigid struc-
tures so that they will not fall or be
knocked over. For short distances,
cylinders may be moved by tilting and
rolling them on their bottom edges.

Dr. Lee Dr. Thomas
Maddox Wagner
LIC #01801165 LIC #01418359
(949) 675-5578 (916) 812-3255
25 Years in Business 40 Years in Business
PRACTICE SALES PARTNERSHIPS MERGERS VALUATIONS/APPRAISALS ASSOCIATESHIPS CONTINUING EDUCATION
NORTHERN CALIFORNIA
BAY AREA: New Listing! 2,120 sq. ft.
Perio practice, 6 Ops, Digital X-rays,
Pulse Oximeter, Endoscope, Piezosurgery,
Dentrix software. 2015 GR $1M. #CA373
BENICIA:
GR $305K 2 day/week. Sister practice-
#CA322, sale combined or separate. #CA321
CAMPBELL: New Listing! 2050 sq. ft.,
5 ops, CAD/CAM, Digital Pan, MacPractice
software. 2015 GR $1,000,007, 100% fee for
service. #CA374
CASTRO VALLEY: New Listing!
$530,000. Eaglesoft PMS, Digital X-Ray,
Fiber Optics & Laser. Owner retiring. #CA368
CITRUS HEIGHTS: Prosthodontic practice
& stand-alone building for sale. 3 Ops, 2015
GR of $601,617. #CA326
EL DORADO COUNTY: 960 sq. ft. w/4
Ops, intraoral camera, digital x-ray, Practice
Works software. 2015 GR $466K. #CA339
GREATER EL DORADO HILLS:
Sensors, Eaglesoft software. 2015 GR $737K.
#CA343
GREATER ROSEVILLE/AUBURN:
Practice & Bldg, 1,600+ sq. ft. w/5 Ops.
2015 GR $850,000. #CA338
GREATER ROSEVILLE/ROCKLIN:
1,300 sq. ft., 4 Ops, IO camera, digital x-rays,
digital Pano, 3M Scanner, Dentrix software.
2015 GR$697K. #CA350
GREATER ROSEVILLE/ROCKLIN:
4 Ops w/IO, Digital X-ray, Laser, Dentrix
software. Established 20+ years, 2015 GR
$945K. #CA331
GREATER SACRAMENTO: 7 Ops,
3,079 Sq. Ft. (Shared w/2nd DDS Separate
Practices), 2013 GR $974K. #CA140
HAYWARD: 2 Fully-Equipped ops, 2
addl Plumbed. 2014 GR $186K. 3100 sq. ft.
building w/rental income for sale. #CA316
MARIN COUNTY: 1250 sq. ft. 3
operatories. Fee for service 2014 GR $370K,
on pace for same in 2015. #CA302
MTN. VIEW:
location w/4 ops, Dentrix software, digital
x-rays. 2015 GR $371,000. #CA335
OAKLAND: 12 ops in 5000 sq. ft. modern
and FFS patients. #CA360
OAKLAND: Appx. 1,500 sq. ft. w/4 Ops,
Dentrix software, Dexis Digital X-ray. 2014
GR $869K, adj. net $370K. #CA293
OROVILLE: 1,000 sq. ft.. Dentrix &
Dentrix software, Digital Pan & X-rays,
Laser, Intra-Oral. 2014 GR $512K. #CA287
OROVILLE: 3 Ops, recently remodeled.
Great satellite or startup practice. Owner
retiring. #CA288
PASO ROBLES AREA: $2.25M GR,
52% overhead. Buyer needs to be skilled
in restorative, surgical procedures, implant
placement. #CA355
1.800.519.3458
Dr. Dennis Dr. Russell Jim
Hoover Okihara Engel
LIC #0123804 LIC #01886221 LIC #01898522
(209) 605-9039 (619) 694-7077 (925) 330-2207
36 Years in Business 33 Years in Business 42 Years in Business
ROSEVILLE: 4 Equipped Ops, 1 addl
plumbed, 1,650 sq. ft. w/Digital X-ray,
Laser, Dentrix software. 2015 GR $564K+.
#CA3233
SACRAMENTO:
Equip. Ops, 2 addl Plumbed. DentalMate
software. 2015 GR $110,427 #CA332
SACRAMENTO: 8 Ops w/Schick digital
x-ray, Pano, Laser, and Eaglesoft software.
2015 GR $1.9M. #CA337
SAN FRANCISCO: Periodontal Practice &
Condo Unit. 1,160 sq. ft. w/4 Op, 2014 GR
$714K w/$363K Adj. Net. #CA274
SAN FRANCISCO:
5 Ops, room for 6th, 1760 sq. ft. 2015 GR
$1.2 mil, Adj. Net. $480,000. #CA357
SAN JOSE: CANT RENEW LEASE!
2015 GR $568K on 2 day week. 4
Equipped ops, 2 addl Plumbed, 2,200 Sq.
#CA330
SAN RAFAEL: New Listing! General &
$796,000, 3 day week, 55% overhead.
#CA358
SAN RAMON-FACILITY: New Listing!
4 op facility w/high-end Pelton & Crane
Equipment, Digital X-Ray, Digital Pan, I.O.
Cameras, 1654 sq. ft. corner suite. #CA370
SANTA ROSA: General Dentistry &
Building. 3 Ops. 2013 GR $542K w/Adj.
Net $182K. #CA200
STOCKTON: 7 Ops, 2052 sq. ft., great
lease and options to renew. GR $750,000
VACAVILLE:
2015 GR $519K 3 day/week. Sister practice-
#CA321, sale combined or separate. #CA322
YOLO COUNTY: Pediatric practice, 2
equip. Op, approx. 1,000 sq. ft., Intra-oral,
Open Dental software. 2014 GR $245K.
#CA301
CENTRAL CALIFORNIA
FRESNO:
4 Ops, 1480 sq. ft., great lease. 2015 GR
$237,000 and priced to sell. #CA349
HANFORD: 4 days hygiene, 1,345 active
patients. 2015 GR $509K. Digital x-rays,
Intra-oral cameras, and Imaging System.
#CA336
MODESTO: Dental Air Space
Condominium. 1,511 sq. ft. dental condo unit.
Sale price $286,000. #CA333
SOUTHERN CALIFORNIA
ALISO VIEJO: New Listing! Turnkey
Leaseholds Sale-5 Ops, 3 Equipped, Retail
Plaza. Great Signage, move-in ready.
Includes computers, x-rays & instruments.
#CA365
BELL: 3 Ops, Dentrix, Digital in a Free-
standing Building. PPO/Denti-Cal. 2015 GR
$453K with $259K Adj. Net. #CA317
BEVERLY HILLS: Perio practice.
Beautifully designed, 4 Ops, Desirable prof.
bldg. Dentrix, 24 years of Goodwill. 2015
GR of $382K.
www.henryscheinppt.com
DENTAL PRACTICE BROKERAGE
Making your transition a reality.
Kerri Mario
McCullough Molina
LIC #01382259 LIC #01423762
(949) 566-3056 (949) 675-5578
35 Years in Business 35 Years in Business 26 Years in Business
BEVERLY HILLS: 5 Ops, EagleSoft,
Digital, CEREC. Long-term staff, newer
equipment. 2015 GR 1.2M+, #CA210
BURBANK: New Listing! General/Prosth/
Implant practice. 15 years of goodwill,retail
center. 5 Ops, 3 equipped, EasyDental,
Digital. 2015 GR $291K, $118K Adj. Net.
#CA348
CARSON: 3 Ops Paperless, EagleSoft,
Digital, Pano. All Equip. <3 yrs. old. 2014
GR $143K. #CA280
CENTRAL ORANGE COUNTY: 3 Ops,
Paperless, digital, busy retail center. 2015 GR
of 381K with 156K Adj. Net. #CA328
COASTAL ORANGE COUNTY: New
Listing!
ENCINO: New Listing! 4 Ops, Est.
40+years, EagleSoft, Digital, intra-oral
camera. 2015 GR of $450K and $182K
Adjusted Net. #CA372
FULLERTON: 6 Ops, 4 Equipped, 13 years
of Goodwill, Dentrix, Digital, Paperless.
Great location. 2015 GR of $410K. #CA352
GREATER LOS ANGELES: Perio
Practice. 5 Ops, 34 Yrs. of Goodwill. Dentrix,
Digital, Laser, great referral base, 2015 GR
$728K, Adj. Net $307K. #CA173
INLAND EMPIRE: 7 Ops, Dentrix, Digital,
#CA283
INLAND SOUTH BAY, LOS ANGELES:
6 Ops, 5 Equipped, 35+ years Goodwill.
Paperless, Digital, Dentrix, Pano. 2015 GR of
$833K and $368K Adj. Net. #CA346
LAGUNA BEACH: General Dentistry.
5 Ops, 3 Equipped. Great Location. 2014
GR $503K. #CA303
LAKEWOOD: 4 Ops, 3 Equipped, retail
center location on busy corner. 38 years of
Goodwill, Dentrix, Digital. 2015 GR $264K.
#CA341
LONG BEACH: New Listing! 5 Ops,
4 Equipped, Est. for 50+ years, 1,850 sq. ft.,
digital. 2015 GR $359K. #CA363
LOS ANGELES: 3 Ops and 50+ years of
Goodwill. Pano, Digital, Laser, and Intra-oral
camera. 2015 GR $241K and Adj.Net of
$121K on 2 days/wk. #CA345
NEWPORT BEACH:New Listing! 5 Ops,
3 Equipped, EagleSoft, Digital, Paperless,
Pano, Intra-Oral Camera. 2015 GR
$550K+.#CA366
NEWPORT BEACH: New Listing! 4 Ops,
3 Equipped, Dentrix, Digital, and all high-end
equipment that is less than 10 years old. Est.
21+ years. #CA375
ORANGE COUNTY: Endo practice with
6 Ops, Digital and Paperless, 5 year old
equipment. Strong referral base for 25+ years.
#CA327
PALM SPRINGS: New Listing! 4 Ops, 30
years of goodwill. Good location, Doctor
wants to remain and work part time if
possible, 2015 GR $549K. #CA351
Jaci Steve Thinh
Hardison Caudill Tran
LIC #01927713 LIC #00411157 LIC #01863784
(949) 675-5578 (951) 314-5542 (949) 675-5578
25 Years in Business 11 Years in Business
PASADENA AREA: Practice & Building -
3 Ops, Dentrix, Dexis, CEREC, established
for 50+ yrs. #CA282
S. ORANGE COUNTY: Pedo Practice with
4 Ops, 1 year new Equipment, Digital, Pano.
2015 GR $363K with room to grow. #CA222
SANTA BARBARA: 4 Ops, est. for 40+
FFS. GR of $827K. #CA291
TEMECULA: New Listing! 5 Ops, 4
Equipped, Newer equipment, Digital, Pano, 3
day work week w/1 day of hygiene. 2015 GR
of $561K #CA
VICTORVILLE: 3 Ops, 3 Plumbed,
2,150 Sq. Ft. Est. 34 yrs., SoftDent. 2015 GR
$277K. #CA149 Price Reduced!
WHITTIER: 4 Ops, 3 Equipped. Dentrix,
Dexis. Est for 50+ yrs. on Main Street. 2015
GR $195K. #CA276
SAN DIEGO
CHULA VISTA EAST: 3 Ops. Est. 19
years. Professional Bldg. 2015 GR $421K.
#CA304
LA JOLLA: 3 Ops, FFS and Delta Premier.
2015 GR of $558K. Owner retiring. #CA278
OWNER RETIRING!
NORTH COUNTY, SAN DIEGO:
New Listing! 5 Ops, 26 years of Goodwill,
with low overhead. #CA354
NORTH COUNTY, INLAND:
3 Ops, Digital X-Rays, EagleSoft, Excellent
Location, Bright and Modern Facility. 2015
GR of $397K. #CA376
SAN DIEGO: New Listing!
practice, 44 years of Goodwill. Shopping
center location. #CA
SAN DIEGO: Modern Restorative/Implant
Practice. State of the art, Digital, i-CAT, Lab,
#CA334
SAN DIEGO: New Listing! 6 Ops,
3 Equipped, FFS/PPO, Dentrix, Digital,
Curbside Exposure. Excellent opportunity.
#CA359
SAN DIEGO: 3 Ops, EagleSoft, Excellent
Strip Mall Location. Priced to sell. #CA340
SOUTH BAY AREA: 4 Ops, PPO/FFS,
EagleSoft, Digital, Modern and Spacious.
Practice & Building for Sale. #CA313
OUT OF CALIFORNIA
MAUI, HAWAII: 7 Ops, 5 Equipped,
Modern Design, CEREC. 2014 GR
CENTRAL OAHU, HAWAII:
3 Ops in Central Oahu. Dentrix, Dexis, Pano.
HONOLULU, HAWAII: New Listing!
6 Ops, 5 Equipped, Dentrix, Digital
CEREC Blue Cam, Est. 37 years. 2015 GR
HONOLULU, HAWAII: 3 Ops,
Dentrix, Digital, FFS/PPO. 2014 GR $356K.
1.888.685.8100
 O C T. 2 016 R E G U L ATO RY C O M P L I A N C E
C D A J O U R N A L , V O L 4 4 , N 1 0

i) Not use valve protection devices to

lift cylinders, except when a device
is designed for allowing manual lift-
ing of the cylinder. Do not use bars
under valves or valve protection
caps to pry cylinders loose when
frozen to the ground or otherwise
fixed; the use of warm (not boiling)
water is recommended.

j) Close cylinder valves when work

is finished and before moving
cylinders.
Paul Maimone
It is a Great Time to Sell! Inventory & Broker/Owner
k) Close valves of empty cylinders.
Rates are Still Low & Buyer Demand is
High! Call for a Free in Office Valuation! l) Not allow cylinders to be dropped,
ARCADIA (4) op comput G.P. Located in a well known Prof. Bldg. on a main thoroughfare. struck or permitted to strike each
Cash/Ins/PPO pt base. Annual Gross Collect $300K+ on a (3) day week. PENDING other violently.
GROVER BEACH - (3) op Turnkey Office w included charts (not guaranteed). (2) ops eqtd w
newer eqt. 3rd plmbed. Digital Pano & x-ray. Dentrix. In a strip ctr. LL incentives. SOLD m) Ensure keys or handles on valve
HUNTINGTON BEACH - (5) op plumbed space for lease. Some eqt available. TIs too. NEW
OXNARD #9 - (3) op comput G.P. & a Prof Office Condo for sale. Located on a main spindles or stems are on cylinder
thoroughfare. (3) ops eqtd. Annual Gross Collect $200K+ p.t. Cash/Ins/PPO/HMO $4.5K/mos valves while cylinders are in service.
Cap Cks. Digital x-rays. Low overhead. Buy & Combine or open a satellite. NEW
PANORAMA CITY (5) op comput G.P. located in a free stand. bldg. w exposure /visibility. In multiple cylinder installations,
Cash/PPO/Denti-Cal. Was doing $600K+ f.t. Now doing $300K p.t. Needs new f.t. DDS. NEW only one key or handle is required
PORT HUENEME (3) op comput. G.P. located in a large strip ctr. with exposure, visibility, & for each manifold.
signage. 2.5 - 3.5 year old eqt. Mostly associate run. Gross Collect $200K p.t. w no adv. NEW
SANTA BARBARA COUNTY (3) op comput G.P. & a 1,900 sq ft Bldg. that houses the
practice & a residential unit that can be rented or lived in. Fee for Service. No PPO, HMO or n) Not use leaking regulators, cylinder
Denti-Cal. 2015 Gross Collections ~ $275K on a relaxed 3 day week. Seller refers all O.S., valves, hose, piping systems, ap-
Perio, Ortho, Endo & implant placement. Seller retiring but will assist w transition.
So. EAST KERN COUNTY - (5) op comput. G.P. located in a free stand bldg. w exposure/
paratus and fittings. Do not tamper
visibility & signage. VERY LIMITED COMPETITION. 2015 Collect $600K. Cash/Ins/PPO. or attempt to repair cylinder valves.
Digital x-rays & CT Scan. (6) sensors, Bldg. also available. Seller retiring. Report problem and the cylinders se-
SAN FERNANDO VALLEY #9 - (8) op comput. G.P. w modern eqt. In a prof. bldg. on a main
thoroughfare. Cash/Ins/PPO/HMO. Cap Ck approx $7K/mos. 2015 Collect $1.4M+ SOLD rial number to the supplier promptly.
SAN FERNANDO VALLEY #10 - Located in an exclusive area of the Valley. (5) op comput Suppliers instructions as to its
G.P. w high end buildout. Digital x-ray and CT Scan, Laser, Dentrix s/w & (5) year old eqt. Gross
Collect $1M+/yr. Cash/Ins/PPO pts. Reasonable overhead, high Net! NEW disposition must be followed. Avoid
SAN GABRIEL VALLEY - (4) op comput G.P. w newer P&C Chairs/Eqt, All the toys & complete removal of the stem from a
whistles. Paperless, Schick digital x-rays, Solaris Steril Ctr, Soprocare Intra Oral Camera, diaphragm-type cylinder valve.
Velscope Cancer Screen, The Wand, Air Abrasion, Electric Hand Pieces, Laser, etc. FFS, 2015
Gross Collect. $881K+ on a 3 day week. (4) days of Hygiene. Seller retiring. SOLD
SANTA ANA - absentee owned (6) op fully eqtd G.P. First floor street front location on a main o) Never use cylinders as rollers or sup-
thoroughfare. Exposure/visibility/signage. Cash/Ins/PPO. No HMO & No Denti-Cal. Pano eqtd ports, whether full or empty.
& Comput. Annual Gross Collect. $400K- $500K on a (3) to (4) day week. PENDING
THOUSAND OAKS (4) ops/(2) eqtd comput. Turnkey Office w included charts. Chart included
but not guaranteed. Sirona Eqt. Located in a condo in a Prof. Bldg. PENDING
p) Not place cylinders where they
WESTLAKE VILLAGE - Turnkey Office. (4) ops/(3) eqtd. Located in a smaller prof. bldg. might form part of an electric circuit.
Very reasonable Lease terms. Newer build out & some newer eqt. Comput. & digital. NEW
UPCOMING PRACTICES: Bakersfield, Beverly Hills, Central Coast, Covina, Downey, q) Not use a cylinders contents for
Duarte, Goleta, Oxnard, Pasadena, Pomona, San Gabriel, Torrance, Van Nuys, & West L.A..
purposes other than those intended
D&M SERVICES: by the supplier.
Practice Sales and Appraisals Practice Search & Matching Services
Practice and Equipment Financing Locate and Negotiate Dental Lease Space Regulatory Compliance appears monthly and
Expert Witness Court Testimony Medical/Dental Bldg. Sales & Leasing
Pre - Death and Disability Planning Pre - Sale Planning
features resources about laws that impact
P.O. Box #6681, WOODLAND HILLS, CA. 91365 dental practices. Visit cda.org/practicesup-
Toll Free 866.425.1877 Outside So. CA or 818.591.1401 www.dmpractice.com port for more than 600 practice support
Serving CA Since 1994 CA BRE Broker License # 01172430
resources, including practice management,
CA Representative for the National Association of Practice Brokers (NAPB) employment practices, dental benefits plans
and regulatory compliance.

650O C T O B E R 2 01 6
 Ethics
Timely Referrals Our Ethical Obligations to
Our Colleagues
Robert D. Stevenson, DDS
A
n important, but often
overlooked, element of
professionalism is conduct
between dental practitioners.1
Because dentists possess
specialized knowledge and skills that
are not readily available to the public,
we are obligated to work together for
the collective best interest of society.2
Although we may be competent in
many areas, occasionally situations arise
that demand a higher level of expertise
than we can provide. These cases are
best referred to a qualified specialist.
Management of the referral process may
be taken for granted, but it is an important
process nonetheless. A good relationship,
including appropriate communication
between the referring dentist and the
consulting dentist,3 helps to ensure
continuity of care for the patient and
benefits the individual practices as well.
Section 9 of the CDA Code of Ethics
informs us that, Whenever the delivery
of care to a patient requires diagnostic and
therapeutic modalities that are beyond a
dentists scope of services, the dentist has
the obligation to inform the patient of all
available treatment options and to refer
the patient to a provider who is qualified
to provide consultation or necessary care.4
What are the ethical obligations
that the referring dentist and the
consulting dentist owe to one another?
Competence is a significant value
in the referral process. The ability of
the referring dentist to assess his or her
own competence, as well as his or her
confidence in the consulting dentist are
both central to the referral process.
Another value involved in this
professional connection is veracity. The
relationship between the referring dentist
and the consulting dentist is obviously
founded on trust, which is based in
part on open, honest communication
and on perceived competence. The
patient must also be aware of this trust.
Professionalism is also notably
important. Among the many
courtesies that are extended among
collaborating professionals, clear and
effective communication is essential
in facilitating continuity of care.
The referring dentist should clearly
convey the requested treatment, the
reason for referral and, if possible, how
the procedure fits in with the overall
treatment plan. The consulting dentist
is obligated to discuss treatment results,
prognosis and needed follow-ups with
the referring dentist. If treatment is
extended, periodic updates should
be given. If complications arise, the
consulting dentist should discuss this
in a timely manner with the referring
dentist so that modifications can be
considered in the larger treatment plan.
If a treatment plan involves multiple
specialists, this communication becomes
exponentially more important. The
referring dentist should take the lead
in transmitting information among
the various consulting dentists. Each
consulting dentist should know how his
or her responsibility fits in the larger
picture, and the consulting dentists
should share their follow-up information
with all the dentists involved.
Another essential part of this
discussion is autonomy. Each patient
has the right to self-determination.
Respect for autonomy insists that
the patient be informed of the risks,
benefits and alternatives of the proposed
referred treatment. The patient has
the right to consider the available
options and make a decision.
C D A J O U R N A L , V O L 4 4 , N 1 0
In some instances, the patient may
exercise his or her autonomy by refusing
the referral.5 In other instances, the
patient may inform the consulting
dentist of his or her refusal to return to
the referring dentist. Consulting dentists
must carefully consider their response
when autonomy appears to conflict with
continuity of care. The guiding principle
is the consideration of the benefit of the
patient as [the] primary goal.6 Regardless
of the outcome, this refusal should be
communicated with the referring dentist.
By considering these and other
principles, dentists will protect the patients
right to competent, comprehensive
care from their dental providers.
Robert D. Stevenson, DDS, is clinical
managing partner and associate professor
at Western University of Health Sciences,
College of Dental Medicine. He is a
member of the CDA Judicial Council.
For further assistance with any additional
questions related to referrals, contact
your local ethics committee, or Britney
Ryan, CDA judicial council manager, at
800.232.7645.
REFERENCES
1. CDA Code of Ethics, 2012, Introduction, p. 1.
2. CDA Code of Ethics, 2012, p. 1.
3. American Dental Association, General Guidelines for
Referring Dental Patients, 2007, p. 2. Because referrals are not
limited to general dentist referring to specialists, the referring dentist
is defined here as the primary care provider and the consulting
dentist is the dentist who is not the primary care provider.
4. CDA Code of Ethics, 2012, Section 9.
5. It is not within the scope of this article to discuss
management of this scenario.
6. ADA Principles of Ethics, 2012, Preamble, p. 3.
O C T O B E R 2 0 1 6 651
 BAY AREA
AC-335 SAN FRANCISCO:
8ops in desirable location of SF. Call for Details
$475k
AC-566 SAN FRANCISCO: Spectacular views of
Washington Square. 3ops +2 addl plumbed in
1400sf office $225k
AG-564 SAN FRANCISCO: Over 25 yrs goodwill. Large
5,600+ sf w/ 9 ops near Lands End $2.225M
AG-576 SAN FRANCISCO: Part time practice w/
Amazing Growth Potential. Perfect for 1-3 DDS 4 ops
1.400 sf $550k
AG-615 SAN FRANCISCO: Move-In Ready Facility in
charming desirable neighborhood. 1400 sf w/ 4 ops
$125k
AN-514 SAN FRANCISCO Facility: Located in the bus-
$125k
AN-565 SAN FRANCISCO: This remarkable opportuni-
ops. $1.05M
AN-592 SAN FRANCISCO: Imagine accessibility, visi-
ops + 1 addl $100k
BC-361 OAKLAND:
2,200 sf w/ 7 ops. Seller is retiring. $330k
BC-432 PITTSBURG: Own this family-oriented Prac-
$350k
BC-520 HAYWARD Facility: Located in Downtown,
1500 sf, 4 equipped ops, X-Rays in 3 ops. Call for
Details $65k
BC-549 LAMORINDA AREA Facility: Excellent Loca-
$75k
BC-563 BERKELEY: Excellent, Well-established,
Family-oriented Practice, 4ops in 1382sf 10pts/
day, 35npts/mo $450k
BC-614 SAN LEANDRO Charts Only: Increase your
Production & continue TX to this stable patient
base $150k
BG-570 SAN LEANDRO: 30+ yrs goodwill w/focus
on C&B. 2100 sf w 5 ops. Room for 6th op. Over
$908k in 2015 $625k
BN-504 RICHMOND: Established Practice and Real
$100k /RE
$700k
BN-575 PLEASANT HILL: Do not pass up this re-
. $330k
BN-586 BRENTWOOD:
sf w/ 8 ops. $1.4M
BAY AREA CONTINUED
CC-552 SAN RAFAEL: 3ops in 800sf. Practice & Lease
Concession: $225,000 / Charts Only: $175,000 + an
addl amt for EQ
CC-567 ST. HELENA: Live and Practice in beautiful
Wine Country, 5ops in 1842sf, single-story bldg.
Price Reduced $790k
CC-599 SANTA ROSA: Wonderful & stable pts base in
well-respected Practice, 3ops in 1040sf. $250k
CC-611 SOUTHERN MARIN COUNTY: Desirable, well-
established neighborhood, 20npts/mo 3ops in
1100sf $650k
CG-537 MARIN COUNTY: Rare Opportunity in up-
scale, highly desirable area. State of the art office.
2400 sf w/ 7 ops $1.1M
CG-583 SEBASTOPOL: Practice & Real Estate. Seller
Willing to consider all reasonable offer. Health Forc-
es Sale $875K includes building
CG-607 FAIRFIELD:
$160k w/ Cerec
CG-616 NAPA: State of the Art Practice - Seller mov-
Call for Details
DC-480 SILICON VALLEY: Multi-Specialty Practice,
14+ ops in 7500sf, Owner Financing avail-Terms &
Priced to Sell $1.075M
DC-476 DUBLIN: Shared Facility. Great for Specialist -
Endo, Pedo or Ortho. 1100 sf w/ 2 ops+1 addl
$125k
DC-604 LIVERMORE Facility: Turn Key Facility in fast
growing city, 3ops +3 addl plumbed in 2380sf mod-
ern office, $110k
DN-497 PLEASANTON Facility:
w/ 3 ops + 1 addl. Owner Financing w/10% Down
Reduced $95k
DG-519 SANTA CLARA Facility:
sf w 6 fully equipped ops $225k
DG-530 SAN JOSE: Highly respected quality prac-
Priced at $899k
DG-581 SAN JOSE:
$496k
DG-582 SAN JOSE:
$550k
DN-542 FREMONT Facility:
equipped State-of-the-
addl. $295k
DN-557 SALINAS:
over $2.225M. Priced at only $1.4M
DG-619 SAN JOSE:
$1.1M
Timothy Giroux, DDS Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA Edmond P. Cahill, JD

NORTHERN CALIFORNIA NORTHERN CALIFORNIA CONTINUED

EC-525 SACRAMENTO GN-546 CHICO AREA: -known

10-15 new pts/mo $220k $350K
EC-531 GREATER SACRAMENTO: Prac ce and Real Estate for Sale 1,750sf GN-606 BUTTE COUNTY: Hesitate and you will miss out on this one
w/ 4ops + 1 addl, 8npts/mo $800k $295k
EN-464 ROCKLIN Facility: GN-605 CHICO Facility: Turn-
2,150 sf w/ 4 ops. Now Only: $100k $50k
EG-556 SACRAMENTO: Near CSUS Campus. Long-term 2nd generation HC-461 SONORA: In the beautiful Sierra Foothills, 4ops, 1350sf, free-
office. 935 sf w/ 4 ops $389k standing bldg.. Practice $700k & RE Also Available
EG-589 SACRAMENTO: HN-213 ALTURAS:
6 ops $475k $115k
EN-534 ROSEVILLE Facility: -keyjust HN-280 NO EAST CA: Only Practice in Town 900 sf w/ 2 ops REDUCED ONLY
$45k $60k
EG-560 CARMICHAEL:
$130k CENTRAL VALLEY
EN-573 SACRAMENTO:
$93.1k IC-468 SAN JOAQUIN VALLEY: High-End
EG-579 ROCKLIN Perio/Gen: A - the $425k
NOW ONLY IC-572 MODESTO: In desirable Dental/Medical Professional building of town,
$235k 3ops in 1300sf office. $160k
EN-588 SACRAMENTO: well- IN-506 TURLOCK:
skill 1,500 sf w/ 4ops. Now Only $295k 5ops + 1 addl. $425k
EN-603 ELK GROVE: Absolutely one of Californias most desirable com- IN-577 W. STANISLAUS CO: Offering that Main Street feel and quality of
$318k life. 1,800 sf w/ 4ops + 1 addl. $250k
EN-609 SACRAMENTO: Truly a cut above, this remarkable, well- JC-541 FRESNO Facility:
Call for Details
10 ops. $1.7M JN-551 COALINGA AREA: S
FC-415 FT. BRAGG: Dr. avgs 18+ pts/day & 20+ npts/mo, REDUCED $395k
1,800 sf w/ 5 ops + 1 hyg. Op $425k JN-593 FRESNO: Change smiles in this quality family-
FC-489 CLEARLAKE: Located on 4-Corners of Hwy 53, 4ops in shared 2,430 sf w/ 6ops. $375k
3600sf facility. $470k / 50% interest in RE Also Available
FN-527 TRINITY COUNTY: SPECIALTY PRACTICES
2350sf w/ 5 ops +1 addl. $250k
GC-472 ORLAND: Live & Practice in charming small town community. 1,000 sf AC-601 SAN FRANCISCO Perio: High quality practice, 30npts/mo, 3ops in
w/ 2ops. Seller Retiring. $160k shared 1963sf office, Seller workback for smooth transition $800k
GG-386 REDDING: BC-544 ALAMEDA COUNTY Pedo: 1,056sf w/ 4 chairs in growing, revital-
ONLY $260k ized community, Seller Retiring $225k
GG-453 CHICO: $325k BG-517 NORTH EAST BAY Endo: $500k
GG-454 PARADISE: BC-600 CONCORD PEDO & ORTHO Charts Only: Continue treatment to
$525k $400k
GG-574 SIERRA FOOTHILLS: Popular Professional Plaza. Spacious 3,000 sf CC-346 SO MARIN CO Perio: Beautiful 1,142 sf w/ 3 ops. No reasonable
w/ 7 ops $875k o er will be refused Reduced $150k
GG-617 YUBA CITY: Rare Opportunity to purchase Dental Facility with CG-424 NAPA Prostho: Office has Digital X-
Only $350k Ready for Experienced, high-
GN-244 OROVILLE: under $1m $690k
lections over $450k in 2013. Only $315k DC-459 SF PENINSULA Perio: $600k
GN-399 REDDING: Loyal patient base and relaxed workweek schedule. 1,440 EG-579 ROCKLIN Perio/Gen: A - the
sf w/3 ops. $150k $325k
GN-507 CHICO: FN-536 LAKE COUNTY Pedo: Focusing on Prevent dental problems
Practice $535k 1,750 sf w/ 3ops. Now Only: $225k

ASK THE BROKER CAN NOW BE FOUND AT WWW.WESTERNPRACTICESALES.COM

 Tech Trends
A look into the latest dental and
general technology on the market
ILIFE V5s Robot Vacuum Cleaner
($189, ILIFE)
Robot vacuum cleaners have become increasingly popular
with the Roomba among the most well-known. Roombas and
other top-of-the line robot vacuums, however, can be expensive
(anywhere from $300 to $900). New competitors have
sprouted up oering cheaper price tags and more features.
The ILIFE V5s Robot Vacuum Cleaner is less than $200 and it
vacuums and mops. It can vacuum up anything from fur to dust
and can be programmed to begin vacuuming at any time of
the day. The setup is relatively easy. Simply plug the charging
docking station into the wall, turn the device on and let it charge.
Push the Clean button either on the top of the device or on
the remote to get started. The remote control is handy and helps
users manually direct the device if it needs some help finding
its way. The V5s comes with a dustbin that is easy to clean
out and a water tank for the mopping feature. The vacuuming
is eective, as the device is able to sweep up a pile of coee
grounds with ease. It navigates around the house on its own and
can go easily from hard wood to carpet and is thin enough to
fit under couches. The bumper on the front detects obstructions
and quickly redirects the device. It isnt the sharpest tool in the
shed, however. It doesnt remember the layout of a home all
that well and can get stuck often. Users will need to have their
spaces clear of random chairs, kid or pet toys, etc., for it to
function completely. And it doesnt alert the user when it is stuck,
which can lead to a battery drain. In other words, it requires a
little babysitting. The mopping feature isnt terribly eective, but
it is better than nothing. Overall, the V5s gets the job done at a
decent price and will take some of the pressure o those who
must constantly vacuum.
Blake Ellington, Tech Trends editor
654O C T O B E R 2 01 6
C D A J O U R N A L , V O L 4 4 , N 1 0
Truebill (Free)
Every day, more users are shifting to the subscription model for many
online services that feed daily productivity and recreation. With
many of these accounts linked to credit cards and bank accounts,
spending money is now easier than ever. Keeping tabs of how much
is spent on these services is a daunting challenge. Without a means
to track these recurring expenditures, there is high potential that
some people do not even know they are paying for some services.
Truebill seeks to make users aware of these charges and helps them
save by canceling the things they no longer want or need. Once an
account is created, Truebill requires linking to credit card and bank
accounts in order to analyze statements and oer suggestions on
how users can save money. The company assures users that bank-
level security with read-only access to statements is used. The service
never asks the user for a credit card number in order to charge
them; it only requires the user to give login account information
for their bank accounts in order to work as advertised. This could
be a hard selling point because the user has to trust this company
in order for the service to work. After users link their accounts, the
service uses sophisticated algorithms to find and track bills and
subscriptions. Depending on the specific financial institutions and
number of accounts needed to link, it may take several hours or
days for the service to obtain all statements. When the analysis is
complete, users receive a dashboard of all their subscriptions, bills
and other recurring payments in a simple, yet comprehensive display
listing. Selecting a subscription from the dashboard reveals details
on how much money was spent on it in previous months. Users can
get detailed, step-by-step directions on how to cancel a subscription
directly from the app. In addition, the service looks for ways to save
money on other things like auto insurance, credit monitoring and
cellphone service. The dashboard for every user varies based on his
or her subscriptions and services. On average, users will be surprised
at what Truebill can find in order to save money. There may be
subscriptions that users dont realize they have. Users may be paying
too much for services and utilities they currently have. Users will find
this app and service useful in analyzing their spending habits and
taking action to reduce the amount of money wasted every month.
Hubert Chan, DDS
What will you discover?

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The Art
Anaheim, CA San Francisco, CA and Science
May 4 6, 2017 August 24 26, 2017 of Dentistry
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