Diagnostic approach used by US general dental practitioners following discovery of oral lesions suspicious for malignancy/premalignancy: findings from the National Dental Practice-Based Research Network.

OBJECTIVE: Oral cancer examinations seek to clinically identify early oral cancers and discover premalignancies prior to their progression to invasive cancer. METHOD AND MATERIALS: A cross-sectional study was conducted between April and August 2017 to explore and quantify the diagnostic approach used by United States (US) general dental practitioners following discovery of an oral lesion suspicious for malignancy/premalignancy. US licensed general dental practitioners who were clinically active members of the US National Dental Practice-Based Research Network were eligible to participate. Data for analysis were obtained via two questionnaires. RESULTS: The majority of participants were males, practiced full-time, had a suburban primary practice, were born during the 1950s, and graduated dental school in the 1980s or 2000s. After identifying an oral lesion suspicious for premalignancy/malignancy, the next action of most general dental practitioner respondents (65.4%) was to refer the patient for consultation/biopsy. Most general dental practitioners (87.2%) referred to an oral and maxillofacial surgeon; 22% of general dental practitioners reported personally biopsying suspicious lesions. There was a relatively weak association between completing an Advanced Education in General Dentistry or General Practice Residency and subsequently personally performing biopsies on patients with oral lesions suspicious for malignancy/premalignancy (OR 1.33, P = .06). Most written referrals took place electronically and often included information, including lesion location (87.0%), lesion sign/symptoms (85.3%), lesion history (83.9%), radiographs (59.3%), medical history (50.6%), dental history (48.8%), and photographs (42.4%). When a referral biopsy was performed, referring clinicians were most frequently informed of the findings via a written report (96.7%, when positive for malignancy/premalignancy, and 95.4% when negative). CONCLUSION: A snapshot is presented of current actions taken by US general dental practitioners following the discovery of oral abnormalities suspicious for premalignancy/malignancy.

Cues used by dentists in the early detection of oral cancer and oral potentially malignant lesions: findings from the National Dental Practice-Based Research Network.

OBJECTIVE: The aim of this study was to assess the influence of clinical cues on risk assessment of cancer-associated mucosal abnormalities. STUDY DESIGN: We differentiated lesions with a low risk from those with a high risk for premalignancy or malignancy by using 4 cues: (1) color, (2) location, (3) induration, and (4) pain on exploration. Combinations of color and location were presented through 8 photographs, with induration and pain status variably presented in the standardized history and physical findings. This created 16 clinical scenarios (vignettes) that were permutations of the 4 cues. Three questions assessed the extent to which each cue was used in obtaining a clinical impression as to whether a lesion was benign, premalignant, or malignant. RESULTS: Completed vignette questionnaires were obtained from 130 of 228 invited dentists, (two-thirds males; 79% white; mean age 52 years; average weekly hours of practice 33 hours). Only 40% of the responding dentists had statistically significant decision policies to assign a clinical diagnosis of a lesion as benign, premalignant, or malignant. Lesion location and color were the 2 dominant cues. As a cue, induration was used as a cue by more of the respondents in determining a clinical diagnosis of malignancy, and pain was infrequently used as a cue. CONCLUSIONS: Many dentists do not to have a decision strategy for the clinical diagnosis and risk stratification of oral potentially malignant lesions.

Some Cancer Chemotherapy (CH) Agents May Be Associated With Tooth Agenesis, Though CH Dose, Age of CH Exposure, and Dental Development at the Time of Treatment May Be Critical Determinants.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Adverse effects of chemotherapy on the teeth and surrounding tissues of children with cancer: A systematic review with meta-analysis. Busenhart DM, Erb J, Rigakos G, Eliades T, Papageorgiou SN. Oral Oncol 2018;83: 64-72. SOURCE OF FUNDING: None. TYPE OF STUDY/DESIGN: Systematic review with meta-analysis of data.

Re: "Commentary: Oral cancer examinations and lesion discovery as reported by U.S. general dentists".

This is a letter to the Editor of Preventive Medicine responding to Drs. Al-Soneidara, Madathilb, and Nicolaub's "Commentary: Oral cancer examinations and lesion discovery as reported by U.S. general dentists." (Al-Soneidar WA, Madathil SA, Nicolau B. Commentary: Oral cancer examinations and lesion discovery as reported by U.S. general dentists. Preventive medicine 2019;124:124-5).

Oral cancer examinations and lesion discovery as reported by U.S. general dentists: Findings from the National Dental Practice-Based Research Network.

General dentists (GDs) have the opportunity to examine their patients for oral premalignancy/malignancy. We estimated the annualized per dentist number of oral lesions suspicious for premalignancy/malignancy discovered by United States (U.S.) general dentists and the annualized per dentist number of histologically-confirmed cancers subsequently diagnosed. Eligible participants were licensed, clinically-active U.S. GDs who were members of the U.S. National Dental Practice-Based Research Network. An a priori sample size of 900 was determined; 2000 GDs were invited to participate; 1,073 completed the study. Self-reported, cross-sectional data were obtained via an online questionnaire during 4/12/2017-8/31/2017 and analyzed. The reported numbers of suspicious oral lesions and histologically-confirmed oral cancer cases diagnosed over the previous six months were quantified. Potential outcome predictors were evaluated as covariates in multivariable analyses. Crude and adjusted statistics were produced by regressing each outcome on each independent variable while assuming a Poisson distribution, log link and utilizing robust standard errors. Eighty-seven percent of dentists reported discovering 1+ lesion suspicious for oral premalignancy/malignancy during the preceding six months. The mean number of suspicious lesions/dentist/year was 9.5; adjusted mean: 9.6. Fifteen percent of participants reported discovering 1+ lesion confirmed as cancer during the same period, 213 confirmed cancer cases/6 months or 426/year. Crude and adjusted mean numbers of histologically-confirmed oral cancers were both 0.4 cancers/dentist/year. Our findings suggest that many U.S. general dentists are actively identifying oral lesions suspicious for premalignancy/malignancy, thereby aiding in the discovery of oral malignancies and representing an important component in the frontline against cancer.

The Head and Neck Cancer Patient Concern Inventory© : Patient Concerns' Prevalence, Dental Concerns' Impact, and Relationships of Concerns with Quality of Life Measures.

PURPOSE: The Patient Concern Inventory© (PCI) is a clinical tool of self-reported patient concerns to be used by the clinician to structure the patient-oncologist visit. It was developed in the United Kingdom to address the issues of quality of life (QOL) in head and neck cancer (HNC) patients. The purpose of the study reported here was to determine the prevalence of PCI© items, the associations between PCI© items and QOL, and to explore the importance of oral/dental issues in the patient's well-being. METHODS: The PCI© and the University of Washington (UW-QOLv4) instruments were self-administered by an HNC population in a cross-sectional study. Following an a priori sample size estimate, consecutive HNC patients attending at the University of Florida's Oral Medicine and the ENT Clinics had the study described, eligibility assessed, and if eligible, were invited to participate in the study. Participants completed the PCI© and UW-QOL. PCI© issues prevalence was determined, and for those with a ≥10% prevalence: 1) Fisher's exact test was used to test for statistical differences between treatments, and 2) multivariable regression was used to test each of the prevalent PCI© issues across four QOL measures, health in the last 7 days, overall QOL in the last 7 days, and the physical and social domain scores. RESULTS: Twenty of 45 PCI© issues had a prevalence ≥10%. Of the 15 prevalent items statistically associated with a QOL measure, four issues are the clinical responsibility of the dental profession: 1) chewing/eating, 2) dental health/teeth, 3) mouth opening, and 4) salivation. An additional four (eight total, 50%) are of clinical concern for dental clinicians: 5) pain in head/neck, 6) swallowing, 7) speech/voice/being understood, and 8) taste. CONCLUSIONS: Dental concerns represent almost half of all PCI© concerns observed in 10% or more of the sample patients. Prosthodontists should support our maxillofacial prosthodontics specialists in joining other oral oncologists and advocate for comprehensive, integrated dental support for HNC patients by assuring dental involvement/inclusion with the multidisciplinary oncology team and a research agenda to established best patient-centered outcomes.

Delayed tooth emergence in children infected with human immunodeficiency virus.

OBJECTIVE: There is limited evidence that early deficits in growth might be reflected in tooth emergence in children infected with human immunodeficiency virus (HIV). The purpose of this study was to prospectively evaluate tooth emergence timing between children positive and negative for HIV in the exposed and unexposed groups, respectively. STUDY DESIGN: A longitudinal study of children positive for HIV and HIV-negative household peers, aged 2 to 15 years was conducted between 1993 and 1996. Emergence status was determined for the maxillary and the mandibular permanent first molars and the central and lateral incisors. A multivariable, discrete time, proportional hazards model was fitted to the data. Median age of emergence for each of the six pairs of teeth was calculated using the parameter estimates from the regression model. RESULTS: A total of 116 participants (62 HIV positive, 54 HIV negative) completed six examinations over the 36-month study period. Statistical differences in tooth emergence timing were observed for five of the six tooth pairs, with children positive for HIV being less likely to have emergence of the corresponding tooth compared with the children negative for HIV. Age differences for each tooth pair ranged from 0.7 to 1.5 years, with a median emergence age difference of 1.03 years. CONCLUSIONS: Delayed tooth emergence of the permanent dentition was observed in children with HIV.

Association of Radiographically Diagnosed Apical Periodontitis and Cardiovascular Disease: A Hospital Records-based Study.

INTRODUCTION: Numerous studies have demonstrated an association between oral health status and systemic diseases. However, reports examining apical periodontitis (AP) and cardiovascular disease (CVD) are few. This study investigates whether an association exists between AP and CVD. METHODS: The present study was a pair-matched, cross-sectional design that used medical and dental chart review. The AP group (n = 182) was defined as subjects with radiographic AP, and the non-AP group (n = 182) was defined as subjects without any radiographic AP. Samples for both groups were pair-matched by age and gender. Diagnosis for CVD, hypercholesterolemia, hypertension, and diabetes were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification and collected from electronic medical records. Documentation of alcohol use, smoking, race, and body mass index within the electronic medical records was also collected. Presence or absence of AP, missing teeth, teeth with root canal treatment, caries experience, and history of periodontal disease were collected from the electronic dental records. Analysis was performed by using Pearson χ(2), the paired t test, and conditional multivariate logistic regression. RESULTS: AP was significantly associated with CVD, hypercholesterolemia, race, missing teeth, caries experience, and number of root canal treatments in our bivariate analysis. Our final adjusted conditional logistic regression model showed statistically significant positive associations between AP and CVD (odds ratio, 5.3; 95% confidence interval, 1.5-18.4). CONCLUSIONS: Subjects with AP were more likely to have CVD than subjects without AP by 5.3-fold. However, further research is needed to elucidate temporality and reinforce association between CVD and AP.

Head and neck cancer radiation therapy with and without chemotherapy may result in decreased health-related quality of life followed by a return to baseline over a 1-year period.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Health related quality of life in head and neck cancer treated with radiation therapy with or without chemotherapy: a systematic review. Klein J, Livergant, J, Ringash J.Oral Oncol 2014;50(4):254-62. REVIEWERS: Walter J. Psoter, DDS, PhD, Maria Lucia Aguilar, DDS, MSD, MSc PURPOSE/QUESTION: The authors conducted a systematic review to evaluate health-related quality of life (HRQoL) outcomes in head and neck squamous cell carcinoma (HNSSC) in non-surgical patients whose treatment consisted of radiotherapy with and without chemotherapy. SOURCE OF FUNDING: Information not available TYPE OF STUDY/DESIGN: Systematic review LEVEL OF EVIDENCE: Level 2: Limited-quality patient-oriented evidence STRENGTH OF RECOMMENDATION GRADE: B Limited-quality patient-orientated evidence.

Increasing opportunistic oral cancer screening examinations: findings from focus groups with general dentists in Puerto Rico.

This study aims to identify educational and training modalities that dentists in Puerto Rico (PR) believe will increase the quality and quantity of opportunistic oral cancer screening examinations (OCS) in dental offices on the island. The study was conducted in three phases: a systematic search of relevant literature, an expert review and consensus panel, and focus groups (FG) involving PR general dentists. To increase OCS by dentists in PR, the FG participants proposed a small group, hands-on OCS training, an integrated oral cancer course, and readily available videos, photographs, and computer simulations to further demonstrate OCS performance and facilitate differential diagnosis. OCS training requirements for licensure and re-licensure, improving OCS dentist-patient communication skills, and establishment of an oral lesion referral center were also viewed favorably. In conclusion, general dentists in our FGs believed the quality and quantity of OCS in Puerto Rico can be increased through the application of specific continuing education and training modalities.

A preliminary study on the relationships between global health/quality of life and specific head and neck cancer quality of life domains in Puerto Rico.

PURPOSE: Health-related quality of life (HRQOL) is an important treatment outcome for head and neck cancer (HNC) patients. By ascertaining the most important HNC HRQOL issues, research and practice can be directed toward enhancing patient QOL. MATERIALS AND METHODS: A cross-sectional study of 46 ENT clinic HNC patients in Puerto Rico (PR) was completed. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 (general QOL), and the QLQ-H&N35 (HNC QOL) instruments were administered. Correlations and multivariable regressions were separately conducted for QLQ-H&N35 variables on the three QLQ-C30 outcome variables: overall health, overall QOL, and the global health/QOL domain. RESULTS: Correlation findings included statistically significant negative correlations between the three QLQ-C30 outcome variables and the QLQ-H&N35 variables pain, swallowing, social eating, social contact, and sexuality. Multivariable linear regression identified statistically significant inverse indicators of the outcomes: (1) "lessening of sexuality" with "overall health" (p= 0.02), (2) "problem with social eating" (p= 0.023), "taking pain killers" (p= 0.025), and "problem with social contact" (p= 0.035) with "overall QOL," and (3) "problems with social eating" (p < 0.009) and "taking pain killers" (p= 0.016) with the "global health/QOL" domain. CONCLUSIONS: We conclude that problems with pain, social eating, social interactions, and loss of sexuality are critical indicators of degraded HRQOL in HNC patients living in Puerto Rico. Our results add to the overall knowledge base regarding QOL among HNC patients. The promise of improved QOL for the HNC patient is attainable through additional research in conjunction with advances in clinical treatments and patient management protocols.

Smoking and drinking in relation to oral potentially malignant disorders in Puerto Rico: a case-control study.

BACKGROUND: Oral cancer incidence is high on the Island of Puerto Rico (PR), particularly among males. As part of a larger study conducted in PR, we evaluated smoking and drinking as risk factors for oral potentially malignant disorders (OPMDs). METHODS: Persons diagnosed with either an OPMD (n = 86) [oral epithelial dysplasia (OED), oral hyperkeratosis/epithelial hyperplasia without OED] or a benign oral tissue condition (n = 155) were identified through PR pathology laboratories. Subjects were interviewed using a standardized, structured questionnaire that obtained information, including detailed histories of smoking and drinking. Odds ratios (ORs) for smoking and drinking in relation to having an OPMD, relative to persons with a benign oral tissue condition, were obtained using logistic regression and adjusted for age, gender, education, fruit/vegetable intake and smoking or drinking. RESULTS: For persons with an OPMD and relative to individuals with a benign oral tissue condition, the adjusted OR for current smoking was 4.32 (95% CI: 1.99-9.38), while for former smokers, the ORadj was 1.47 (95% CI: 0.67-3.21), each ORadj relative to never smokers. With regard to drinking, no adjusted ORs approached statistical significance, and few point estimates exceeded 1.0, whether consumption was defined in terms of ever, current, level (drinks/week), or beverage type. CONCLUSIONS: In this study, conducted in Puerto Rico, current smoking was a substantial risk factor for OPMDs while former smokers had a considerably reduced risk compared to current smokers. There was little evidence suggesting that alcohol consumption was positively associated with OPMD risk.

Perspectives of San Juan healthcare practitioners on the detection deficit in oral premalignant and early cancers in Puerto Rico: a qualitative research study.

BACKGROUND: In Puerto Rico, relative to the United States, a disparity exists in detecting oral precancers and early cancers. To identify factors leading to the deficit in early detection, we obtained the perspectives of San Juan healthcare practitioners whose practice could be involved in the detection of such oral lesions. METHODS: Key informant (KI) interviews were conducted with ten clinicians practicing in or around San Juan, Puerto Rico. We then triangulated our KI interview findings with other data sources, including recent literature on oral cancer detection from various geographic areas, current curricula at the University of Puerto Rico Schools of Medicine and Dental Medicine, as well as local health insurance regulations. RESULTS: Key informant-identified factors that likely contribute to the detection deficit include: many practitioners are deficient in knowledge regarding oral cancer and precancer; oral cancer screening examinations are limited regarding which patients receive them and the elements included. In Puerto Rico, specialists generally perform oral biopsies, and patient referral can be delayed by various factors, including government-subsidized health insurance, often referred to as Reforma. Reforma-based issues include often inadequate clinician knowledge regarding Reforma requirements/provisions, diagnostic delays related to Reforma bureaucracy, and among primary physicians, a perceived financial disincentive in referring Reforma patients. CONCLUSIONS: Addressing these issues may be useful in reducing the deficit in detecting oral precancers and early oral cancer in Puerto Rico.

Protein-energy malnutrition during early childhood and periodontal disease in the permanent dentition of Haitian adolescents aged 12-19 years: a retrospective cohort study.

OBJECTIVES: The aim of this retrospective cohort study was to examine whether exposure to early childhood protein-energy malnutrition (ECPEM) is related to worsened periodontal status in the permanent dentition during adolescence. DESIGN: A trained clinician/researcher examined the periodontal status of 96 persons aged 12-19 living in rural Haiti using WHO diagnostic criteria (Community Periodontal Index, WHO 1997). Malnutrition data of the study participants had been collected during the years 1988-1993 by a nongovernmental organization. We compared those who had been malnourished in early childhood, based on z-scores for anthropomorphic data collected during the first 5 years of life, with those who had not been malnourished, regarding mean Community Periodontal Index (CPI) score, controlling for age, sex, socioeconomic status, and smoking. RESULTS: Overall, 57.3% of the participants demonstrated a CPI score of 3 or greater in at least one sextant. ECPEM was independently and positively related to mean CPI score, when controlling for sex and smoking. CONCLUSIONS: More than half of these young Haitians demonstrated CPI scores of 3 or greater, and ECPEM was related to poorer periodontal status, as measured by CPI, in the permanent dentition.

Smoking and drinking in relation to depressive symptoms among persons with oral cancer or oral epithelial dysplasia.

BACKGROUND: We examined whether smoking or drinking during or before the diagnosis-year of oral cancer or oral epithelial dysplasia (OED) was related to "subsequent depression" measured months after the oral diagnosis. METHODS: Incident cases of oral cancer or OED were identified via 3 oral pathology laboratories. A telephone-administered questionnaire included questions on smoking/drinking history through the diagnosis-year and measured depressive symptoms using the Center for Epidemiologic Studies-Depression Scale (CES-D); scores of 16+ indicated clinical depression. "Subsequent depression" was defined as a CES-D score of 16+, measured at the time of assessment several months after the diagnosis of oral cancer or OED. RESULTS: Patients who smoked during their diagnosis-year had twice the odds of subsequent depression relative to former/never smokers. Diagnosis-year (vs never/former) drinking was not associated with depression; however, average alcohol consumption of >1.5 drinks/week was negatively associated with subsequent depression for both diagnosis-year and ex-drinkers (past reported drinking) even among heavy drinkers. CONCLUSION: Our findings suggest that subsequent depression is positively associated with diagnosis-year smoking and negatively associated with alcohol consumption of >1.5 drinks/week among both diagnosis-year and ex-drinkers.

A deficit in biopsying potentially premalignant oral lesions in Puerto Rico.

BACKGROUND: Intraoral lesions clinically suspicious for cancer/precancer should be biopsied and diagnosed histopathologically. We evaluated whether the frequency of oral cancer (OC) cases diagnosed in Puerto Rico (PR) is disproportionately high relative to the frequency of persons with histopathologic diagnoses that would have appeared clinically suspicious for OC/precancer at biopsy. METHODS: All pathology reports for oral (ICD-O-3 C01-C06) soft tissue biopsies generated during 1/2004-5/2005 by seven PR and two New York City (NYC) pathology laboratories were reviewed. The analysis was restricted to persons diagnosed with invasive oral squamous cell carcinoma (OSCC), epithelial dysplasia, or hyperkeratosis/epithelial hyperplasia (HK/EH), i.e., diagnoses associated with lesions clinically suspicious for OC/precancer. The OC relative frequency measured the percentage of persons diagnosed with OSCC among persons with OSCC, dysplasia, or HK/EH. OC relative frequencies for PR and NYC laboratories were compared. RESULTS: Overall, the OC relative frequency was 67% in PR and 40% and 4% in the NYC general and oral pathology laboratories, respectively (each p<0.001). In PR, the OC relative frequency was highest for males (80%). When OC relative frequencies were stratified by pathology laboratory type (general/oral) and compared across PR and NYC, age/gender-specific OC relative frequencies were always higher in PR; however, differences were consistently statistically significant for males only. CONCLUSION: A disparity in the OC relative frequency exists in PR vs. NYC indicating a shortfall in biopsying potentially precancerous oral lesions in PR. PR residents with intraoral lesions suspicious for oral cancer/precancer are most likely to be biopsied only after developing an invasive OC.

Detection of very early oral cancers in Puerto Rico.

We evaluated a possible disparity in the detection of very early oral cancers in Puerto Rico relative to the United States. The percentage of in situ (noninvasive) cases among all oral cancer cases was calculated separately for Puerto Rico and the United States using population-based cancer registry data (1992-2001). In situ cancers constituted 1.2% of oral cancer cases in Puerto Rico and 3.4% in the United States (P<.001). These findings suggest a disparity in very early oral cancer detection in Puerto Rico compared with the United States.

Smoking and drinking in relation to oral cancer and oral epithelial dysplasia.

OBJECTIVE: Risks associated with smoking and drinking are not necessarily constant over the multistage pathway to oral cancer. We investigated whether smoking and drinking patterns differ for persons with oral cancer (OC) relative to those with oral epithelial dysplasia (OED), a precancerous condition. METHODS: Incident cases of OC and OED were interviewed using a questionnaire containing questions on smoking and drinking. Odds ratios (ORs) compared the odds of smoking and drinking among persons with OC relative to OED. RESULTS: No adjusted ORs for smoking achieved statistical significance; however, most were <1.0. The odds of OC relative to OED increased with drinking level; the adjusted OR for 19+ drinks/week was 3.03 (1.56-5.87). Age drinking began and years of drinking were not notably different for OC and OED cases; a higher proportion of OC cases reported discontinuing alcohol for 9+ years before diagnosis. CONCLUSIONS: The relationship between smoking and OED was at least as strong as that for smoking and OC, suggesting that smoking may have its greatest impact on oral carcinogenesis prior to malignant transformation. Drinking was more strongly associated with OC than OED, particularly at elevated consumption levels; the role of alcohol does not appear limited to a late-stage effect.

Sociodemographic risk indicators for depressive symptoms among persons with oral cancer or oral epithelial dysplasia.

PURPOSE: We report findings from a study that measured associations between sociodemographic risk indicators and depressive symptoms among individuals diagnosed with either oral cancer or a premalignant lesion. MATERIALS AND METHODS: Incident cases of oral cancer and oral epithelial dysplasia (OED) were identified by reviewing pathology reports generated by 3 oral pathology laboratories serving primarily community-based oral and maxillofacial surgeons. Subjects were interviewed by telephone to collect information on sociodemographic characteristics, depressive symptoms using the Center for Epidemiologic Studies-Depression (CES-D) Scale, and social support using the Berkman Social Network Inventory. RESULTS: The analysis included 167 oral cancer and 234 OED cases. Nineteen percent of the subjects had a CES-D score indicative of clinical depression (CES-D > or =16). Forward and backward stepwise logistic regression identified diagnosis (cancer/OED), age, social support, employment status, and gender as sociodemographic indicators of CES-D scores of 16+. In the final model, which also controlled for smoking and drinking, the odds of having elevated CES-D scores (16+) were 79% higher among oral cancer relative to OED cases. The odds of high CES-D scores were significantly reduced in persons over the age of 50 compared with those aged 50 years and younger as well as in persons with higher, relative to low, levels of social support and in persons employed outside the home compared with those who were not. Although not statistically significant, men were more likely to have CES-D scores indicative of clinical depression. CONCLUSIONS: Knowledge of sociodemographic characteristics may assist the clinician in identifying those individuals with an elevated risk of concomitant depressive symptoms.

Preparing for a terrorist event: a scenario-driven approach.

Since September 11, 2001, government agencies on all levels have focused on planning and preparing to respond to another possible terrorist attack. In addition to emergency and medical issues, these agencies must be concerned about the public's behavior and psychological response when they plan the management of a bioterrorist event. We present readers with one such possible incident, a radiological bomb scenario, with the aim of educating dentists and communicating the risks involved.