March 2011

March 2011

Journal TEXAS DENTAL

Bond Strength Comparison 2010 American Heart Association Guidelines for Basic Life Support (CPR) 2010 TDA Financial Report and 2012 Proposed Budget

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Texas Dental Association 140th Annual Session 2010 TEXAS Meeting Photo Contest Award: Best of Show Photographer: Dr. Roy Tiemeyer Title: “Skimmers” For information on entering your photo in the 2011 TEXAS Meeting Photo Contest, please visit texasmeeting.com.

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To view courses online, visit www.txhealthsteps.com.

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Contents

TEXAS DENTAL JOURNAL n Established February 1883 n Vol. 128, Number 3, March 2011

TDA GOVERNANCE 260 Candidates Forum — TDA President-elect 2011-2012

Michael L. Stuart, D.D.S. 292 Texas Dental Association 2010 Financial Report,

2012 Proposed Budget, and 2012 Budget Explanation

ARTICLES 267 Bond Strength Comparison of Color Change Adhesives for

Orthodontic Bonding

Michael W. Duers, D.M.D., M.S.; Jeryl D. English, D.D.S., M.S.; Joe C. Ontiveros, D.D.S., M.S.; John M. Powers, Ph.D.; Harry I. Bussa, D.D.S.; Gary N. Frey, D.D.S.; Ronald L. Gallerano, D.D.S., M.S.D.; Sebastian Z. Paige, D.D.S.

The authors compare shear bond strengths of three different color change light-cured orthodontic bonding adhesives to a conventional light-cured orthodontic bonding adhesive.

279 Summary of the New 2010 American Heart Association

Guidelines for Basic Life Support (CPR)

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Roger E. Alexander, D.D.S.

The article summarizes the American Heart Association’s 2010 changes to the guidelines for basic and advanced life support procedures and how they apply to dental health care providers.

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MONTHLY FEATURES

256 257 262 264 308 310 314

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318 322 324 338

BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION

President’s Message Official Call to Delegates TDA 140th Annual Session 2010 TEXAS Meeting Photo Contest The View From Austin Oral and Maxillofacial Pathology Case of the Month TEXAS Meeting Preview Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management In Memoriam / TDA Smiles Foundation Memorial and Honorarium Donors Value for Your Profession Calendar of Events Advertising Briefs Index to Advertisers EDITORIAL STAFF

Texas Dental Journal (ISSN 0040-4284) is published monthly, one issue will be a directory issue, by the Stephen R. Matteson, D.D.S., Editor Texas Dental Association, 1946 S. IH-35, Austin, Texas, 78704-3698, (512) 443-3675. Periodicals Nicole Scott, Managing Editor Postage Paid at Austin, Texas and at additional mailBarbara S. Donovan, Art Director ing offices. POSTMASTER: Send address changes Paul H. Schlesinger, Consultant to TEXAS DENTAL JOURNAL, 1946 S. Interregional Highway, Austin, TX 78704.

EDITORIAL Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, ADVISORY BOARD Out-of-state ADA Affiliated $49.50. In-state NonRonald C. Auvenshine, D.D.S., Ph.D. ADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA AffiliBarry K. Bartee, D.D.S., M.D. ated, $17 Non-ADA Affiliated, September issue $17 Patricia L. Blanton, D.D.S., Ph.D. ADA Affiliated, $65 Non-ADA Affiliated. For in-state William C. Bone, D.D.S. orders, add 8.25% sales tax.

Phillip M. Campbell, D.D.S., M.S.D. Contributions: Manuscripts and news items of interest to the membership of the society are solicited. The Tommy W. Gage, D.D.S., Ph.D. Editor prefers electronic submissions although paper Arthur H. Jeske, D.M.D., Ph.D. manuscripts are acceptable. Manuscripts should be Larry D. Jones, D.D.S. typewritten, double spaced, and the original copy Paul A. Kennedy, Jr., D.D.S., M.S. should be submitted. For more information, please refer to the Instructions for Contributors statement Scott R. Makins, D.D.S. printed in the September Annual Membership DirecRobert V. Walker, D.D.S. tory or on the TDA website: www.tda.org. All statements of opinion and of supposed facts are published William F. Wathen, D.M.D. on authority of the writer under whose name they Robert C. White, D.D.S. appear and are not to be regarded as the views of the Leighton A. Wier, D.D.S. Texas Dental Association, unless such statements Douglas B. Willingham, D.D.S. have been adopted by the Association. Articles are accepted with the understanding that they have not The Texas Dental Journal is a been published previously. Authors must disclose any financial or other interests they may have in products peer-reviewed publication. or services described in their articles.

Advertisements: Publication of advertisements Texas Dental Association in this journal does not constitute a guarantee or 1946 South IH-35, Suite 400 endorsement by the Association of the quality of Austin, TX 78704-3698 value of such product or of the claims made of it by Phone: (512) 443-3675 its manufacturer.

FAX: (512) 443-3031 E-Mail: tda@tda.org Texas Dental Journal is a member of the Website: www.tda.org American Association of Dental Editors.

Member Publication

PRESIDENT Ronald L. Rhea, D.D.S. (713) 467-3458, rrhea@tda.org PRESIDENT-ELECT J. Preston Coleman, D.D.S. (210) 656-3301, drjpc@sbcglobal.net IMMEDIATE PAST PRESIDENT Matthew B. Roberts, D.D.S. (936) 544-3790, crockettdental@gmail.com VICE PRESIDENT, SOUTHEAST R. Lee Clitheroe, D.D.S. (281) 265-9393, rlcdds@windstream.net VICE PRESIDENT, SOUTHWEST John W. Baucum III, D.D.S. (361) 855-3900, jbaucum3@msn.com VICE PRESIDENT, NORTHWEST Kathleen M. Nichols, D.D.S. (806) 698-6684, toothmom@kathleennicholsdds.com VICE PRESIDENT, NORTHEAST Donna G. Miller, D.D.S. (254) 772-3632, dmiller.2thdoc@grandecom.net SENIOR DIRECTOR, SOUTHEAST Karen E. Frazer, D.D.S. (512) 442-2295, drkefrazer@att.net SENIOR DIRECTOR, SOUTHWEST Lisa B. Masters, D.D.S. (210) 349-4424, mastersdds@mdgteam.com SENIOR DIRECTOR, NORTHWEST Robert E. Wiggins, D.D.S. (325) 677-1041, robwigg@suddenlink.net SENIOR DIRECTOR, NORTHEAST Larry D. Herwig, D.D.S. (214) 361-1845, ldherwig@sbcglobal.net DIRECTOR, SOUTHEAST Rita M. Cammarata, D.D.S. (713) 666-7884, rmcdds@sbcglobal.net DIRECTOR, SOUTHWEST T. Beth Vance, D.D.S. (956) 968-9762, tbeth55@yahoo.com DIRECTOR, NORTHWEST Michael J. Goulding, D.D.S. (817) 737-3536, mjgdds@sbcglobal.net DIRECTOR, NORTHEAST Arthur C. Morchat, D.D.S. (903) 983-1919, amorchat@suddenlink.net SECRETARY-TREASURER Ron Collins, D.D.S. (281) 983-5677, roncollinsdds@hotmail.com SPEAKER OF THE HOUSE Glen D. Hall, D.D.S. (325) 698-7560, abdent78@sbcglobal.net PARLIAMENTARIAN Michael L. Stuart, D.D.S. (972) 226-6655, mstuartdds@sbcglobal.net EDITOR Stephen R. Matteson, D.D.S. (210) 215-1515, texdented@gmail.com EXECUTIVE DIRECTOR Ms. Mary Kay Linn (512) 443-3675, marykay@tda.org LEGAL COUNSEL Mr. William H. Bingham (512) 495-6000, bbingham@mcginnislaw.com

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141st ANNUAL SESSION OF THE TEXAS DENTAL ASSOCIATION

TEXAS MEETING May 5-8, 2011 - San Antonio, Texas

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Wait & Save!!! Take Advantage Of Exhibitor Specials

www.texasmeeting.com 254

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Component Peer Review Committee and Judicial Committee 2011 Training Dates

Friday, May 6, 2011 The TEXAS Meeting San Antonio, Texas

Please contact Cassidy Neal at 512-443-3675 ext. 152 for meeting details including meeting times and meeting rooms.

President’s Message Ronald L. Rhea, D.D.S., TDA President

In this issue you will see a presentation of the 2012 Budget of the Texas Dental Association.

The officers, directors, and staff of the TDA take the responsibility of using your money very seriously. The process for preparation of this budget is a long and arduous task. Initially, the TDA secretary-treasurer and staff prepare a preliminary budget to run the Association and its programs for the year. Estimates of the income are made. This income comes from your dues, profit from the TDA’s TEXAS Meeting, our forprofit subsidiary (TDA Financial Services, Inc., also known as TDA Perks), advertising in the TDA publications and website, and so on. Each department proposes its expenditures to carry out the programs assigned to it, which arise from the strategic plan.

This preliminary budget is then sent to the Budget Committee of the Board under guidance of TDA secretary-treasurer Dr. Ron Collins. Each line is reexamined for appropriateness and its variation from previous budgets and known changes that can be expected in 2012. A very small percentage is set aside in a “Contingency fund” for times when even the best estimates

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prove to be inaccurate. For 2012, this is 0.5 percent.

Then the budget is examined at the February Board of Directors meeting. The Board is initially responsible for setting the policies of the Association and assuring that its activities are in line with the strategic plan. Alterations in the budget may be made in this process.

Finally the completed budget is sent to the House of Delegates in May for final approval and modification for resolutions that the House passes.

When we complete the lengthy detailed process, what do we have? We have a financial battle plan for a future year, the events of which we cannot totally predict. Like all battle plans, the budget is good until the first shot is fired, or in this case, the first penny is spent. Leadership continually refers to the budget, and at each Board of Directors meeting the actual expenditures and income are evaluated to note variations from the budgeted amounts. Tough policy decisions are often made with the question, “Where did we budget for this and can we afford it?”

Official Call to the 2011 Texas Dental Association House of Delegates HOUSE OF DELEGATES: In accordance with Chapter IV, Section 70, paragraph A of the Texas Dental Association (TDA) Bylaws, this is the official call for the 141st meeting of the Texas Dental Association House of Delegates. The opening session of the House will convene at 8:00 a.m. on Thursday, May 5, 2011, in Ballroom B on the street level of the San Antonio Convention Center in San Antonio, Texas. The second meeting of the House will be at 8:30 a.m. on Saturday, May 7, 2011, in Ballroom B. The Sunday, May 8, 2011, meeting will be in the Marriott Rivercenter Hotel, starting at 8:30 a.m.

REFERENCE COMMITTEE HEARINGS: Reference Committees will meet on Thursday, May 5, 2011, in the Convention Center (please see the on-site program for specific room assignments). Reference Committee A will start at 11:00 a.m. or 15 minutes after the adjournment of the House of Delegates, whichever is later. Reference Committee E will start at 12:00 noon.

Reference Committee B will start at 1:00 p.m. Reference Committee C will start at 1:30 p.m. Reference Committee D will start at 2:00 p.m. The agendas for these meetings will be sent to the Delegates and Alternate Delegates prior to the meetings.

REFERENCE COMMITTEE REPORTS: Reference Committee Reports will be e-mailed in PDF format to all participants and these reports may be downloaded from any location with Internet access. Printed reports will be available on Friday, May 6, 2011 at 9:00 a.m. outside Rooms 1066 and 1067, the TDA Convention Offices in Exhibit Hall C, and may be downloaded at this location.

CANDIDATES FORUM: As a reminder, the TDA / ADA Candidates Forum will be held on Friday, May 6, 2011, from 2:00 p.m. to 4:00 p.m. in the Convention Center (please see the on-site program for specific room assignment).

DIVISIONAL CAUCUSES: Divisional Caucuses (Northwest, Northeast, Southwest, Southeast) will be held at 5:15 p.m. on Friday, May 6, 2011 (please see the on-site program for specific room assignments).

DELEGATE BOOK: In accordance with TDA Bylaws, the Delegate Book will be sent 30 days prior to the Annual Session. The supplement to the Delegate Handbook, containing the agenda and subsequent reports, will be sent after the spring TDA Board of Directors meeting, April 1-2, 2011. Delegates and alternates will receive their House book in a searchable PDF format.

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Candidates Forum Texas Dental Association President-elect, 2011-2012 Michael L. Stuart, D.D.S.

I

appreciate this opportunity to tell you a little about myself and also to let you know the reasons I am running for president-elect of the Texas Dental Association. Very soon after completing my dental degree at Baylor College of Dentistry, I became involved in organized dentistry. Joining the American Dental Association (ADA), TDA, and Dallas County Dental Society was never a question for me — I thought you had to be a member to practice dentistry!

It was a couple of years later that I found out membership was not mandatory, but, by then, I was hooked. I had the opportunity to see the value of organized dentistry early in my career and to foster friendships that I continue to enjoy today. As a general dentist, I recognized the need to continue to learn, so naturally I joined the Academy of General Dentistry (AGD).

Those early years in practice were critical in the formation of the values I still hold dear. I wanted to be the best dentist I could be and treat my patients as I would want to be treated. “Golden Rule” dentistry is a good philosophy for practitioners of any age, and I have been fortunate to have great mentors throughout the years to emulate. As I began to serve on the state level with the Texas AGD, two Texas leaders had a profound impact on my leadership style. Drs. Sam Rogers and Rene Rosas exhibited leadership with humility, always doing what was best for the members of the organization. They had great talent but never had the attitude that it was all about them. I wanted to be like that and have attempted to lead with that servant-leadership style.

Serving as parliamentarian of the TDA for the past 7 years has given me the opportunity to assist seven TDA presidents. While their styles and personalities were all different, each person always strived to leave the TDA better at the end of their term than at the beginning. As president, that would be my goal. The TDA and our profession have faced challenges, but I believe the next few years will be our most critical. The current state budget crisis, the continuing faltering economy, and the recently passed healthcare overhaul are only a few of the “outside” factors that will impact dentistry. The TDA must continue to position itself to be the chief influence in Texas when decisions are being made affecting dentists. We are “The Voice of Dentistry in Texas!” That is more than just a simple phrase. It describes the vision of who we are. It is vitally important that we maintain and even expand our membership numbers in the future. It is only together that we have the strength and resources to adequately counter the forces intent on changing the best healthcare delivery system in existence.

I recently had the opportunity to sit at a table with a diverse group of dentists and TDA staff members discussing how the TDA could best present our great message to the public, non-member dentists, and TDA members. Following a full day of brainstorming, the result was that the TDA has something to offer everyone. The resources this Association possesses can assist dentists in every career stage with valuable tools to meet the challenges of dental practice. The value of being a TDA member should be apparent to every dentist in this state. We have a great message, and we will be telling it even louder in the future.

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A few years ago, I had the privilege to represent Texas as a member of the ADA Council on Dental Practice and serve as chair of the council my final year. Listening to fellow council members from all across this nation convinced me that we are blessed beyond measure to be dentists in Texas.

While we share common challenges with other states, the TDA has been incredibly successful protecting dentistry from outside forces. As president, I would be serving during the legislative session in 2013. I pledge to you that I will do my utmost to continue that successful legacy. Our legislative council and lobbyists are second to none in effectiveness. That must and will continue. Dentists must continue to have the responsibility to provide quality care, and the dentist must be the only provider doing irreversible procedures. I believe that with all of my being.

If elected, my term will also see a change in the executive director for the TDA, due to the upcoming retirement of Ms. Mary Kay Linn. She has served this Association with incredible dedication and effectiveness, and the challenge will be to select a qualified person to replace her and have a smooth transition in 2012. I look forward to leading that process.

It is a privilege indeed to be a candidate for president-elect of the Texas Dental Association.

I pledge to you my best effort and to listen to you more than talk to you. The strength of our Association is found in its members. While I do not have all of the answers, together we can find those answers and formulate the solutions to solve the challenges ahead. I look forward to serving with you.

Curriculum Vitae: Michael L. Stuart, D.D.S. Practice Information: Full-time solo private practitioner of dentistry since 1986 Stone Canyon Dental, 192 S. Collins Rd., Ste. 100, Sunnyvale, TX 75182 Office Phone: (972) 226-6655 E-mail: mstuartdds@sbcglobal.net Education: Dallas Baptist College, Bachelor of Science, 1974 Southwestern Baptist Theological Seminary, Master of Church Music, 1978 Baylor College of Dentistry, Doctor of Dental Surgery, 1986 Professional Memberships: Member of the American Dental Association, Texas Dental Association, and Dallas County Dental Society since 1985 Member of the Academy of General Dentistry since 1986 Fellow, Academy of General Dentistry, 1997 Fellow, American College of Dentists, 1999 Fellow, International College of Dentists, 2002 Fellow, Pierre Fauchard Academy, 2010 Service to Dentistry President, Dallas County Dental Society, 2007-2008 President, Dallas Academy of General Dentistry, 1991-1992 President, Texas Academy of General Dentistry, 1997-1998 Trustee from Texas to the Board of Trustees, Academy of General Dentistry, 1998-2004 Member of the Council on Dental Practice of the American Dental Association, 2001-2005 Chair, Council on Dental Practice, ADA, 2004-2005 Editor, Texas Academy of General Dentistry GP, 1994-1996 Editor, Dallas County Dental Society, 1999-2002 Delegate, Academy of General Dentistry, 1993-2000 Delegate, Texas Dental Association, 1996-2004 Alternate Delegate to the American Dental Association, 1999-2002 Delegate to the American Dental Association, 2004-2013 (Currently) Secretary-Treasurer, Dallas County Dental Society, 2004-2006 Member of the Communications Committee, Texas Dental Association, 2003-2004, 2005-2006 Parliamentarian, Texas Dental Association, 2004-Current Parliamentarian, Academy of General Dentistry House of Delegates, 2006-2008 Secretary-Treasurer, Texas Section of the International College of Dentists, 2004-2011 Chair, Academy of General Dentistry’s Council on Dental Care, 2005-2006 Board of Directors, Southwestern Medical Foundation, 2007-2008 Chairman, John Findley for ADA President-elect Campaign Committee, 2006-2008 Member, Steering Committee for Pat Blanton’s candidacy for ADA Vice-President, 2010 Mentor, Great Expectations Program for First Year Dental Students, Baylor College of Dentistry, 2007-Current Service to Community and Church Member, Board of Directors, Mesquite Independent School District Education Foundation, 2010 Member, Deacon and Elder, Sunnyvale First Baptist Church Chair, Deacon Fellowship, Sunnyvale First Baptist Church, 2010-Current Member of Golf and Grounds Committee, Dallas Athletic Club, 2009-2011 Awards Nominated for Texas Dentist of the Year, 2002 Named Distinguished Alumnus of the Year, Dallas Baptist University, 2005 Personal Information Married 38 years to Kathy, a retired educator and principal, Mesquite ISD Two daughters: Laura, a 1999 graduate of Texas A&M University; Maryanne, a 2001 graduate of Baylor College of Nursing Five grandchildren: Grace Renee, age 8; Abigail Katherine, age 7; Anna Kaylynn, age 6; William Aaron, age 3; Clayton Stuart, age 1 Hobbies include golf, running, fishing, skiing, and church music.

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Texas Dental Association 140th Annual Session 2010 TEXAS Meeting Photo Contest Category: Natural Wonders Award: 1st Place Photographer: Ms. Tessa Kolodny, RDH, of Arlington, Texas Title: “Feeling Blue�

For information on entering your photo in the 2011 TEXAS Meeting Photo Contest, please visit texasmeeting.com.

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The View From Austin Stephen R. Matteson, D.D.S., FICD, Editor

“I’m Sorry” A dentist friend of mine told me about an “Oh my!” moment in his practice when he discovered that a clerical error in the his office had He had intended to refer a patient to an oral surgeon for the extraction of tooth #19 but his referral letter errantly listed tooth #30 as the tooth to be removed. Tooth #19 was badly broken down but could have been used as a bridge abutment. The “Oh my!” moment occurred when the patient returned to begin restoration of tooth #19 and the error was seen. Breaking out in a sweat and with abdominal distress sinking in, he had to tell the patient of the problem, refer the patient back to the oral surgeon to remove unrestorable tooth #19; and that the original treatment plan had to be changed.

The Texas Law provides that a communication which “expresses sympathy or a general sense of benevolence relating to the pain, suffering or death of an individual involved in an accident” is inadmissible (1). The Texas law has an additional limitation that prevents admissibility only of statements made to the patient or one related to the patient in the second degree (any relative who is two meioses away from a particular individual in a pedigree; a relative with whom one quarter of an individual’s genes is shared (i.e., grandparent, grandchild, uncle, aunt, nephew, niece, half sibling). Therefore, statements made to non-related parties or office staff are not protected. These statutes illustrate the complexity and different approaches to apology legislation that apply to accidental injuries.

Being a forthright person, my friend informed the patient that he had insurance to cover errors like this one. The patient then replied, “No Doc, I do not want to sue you because if I did, you would not be my dentist anymore.” My friend reflected on this event as an encouraging one from the viewpoint of his patient’s loyalty when the chips are down.

Well, back to my friend. Just saying “I’m sorry” would not have been possible. When the patient chose to continue his treatment in that office, the dentist had to reveal the error, refer the patient back to the oral surgeon to extract the correct tooth, make it clear the oral surgeon was not responsible for the error, and confirm that the problem was due to a clerical error in his office. Fortunately, this patient was a long-term patient who wanted to continue receiving care by my friend. So, all ended well with the patient receiving an adjusted restorative plan.

The literature on apologies for errors in medicine indicates that when medical errors occur, the attitude of the physician has an impact on the behavior of patients and families.

When a sincere apology is made, lawsuits may be avoided or juries may find for less severe financial penalties if cases come to court. Hospitals have reported that losses to litigation are reduced when physicians are trained to provide these apologies. The literature on this subject in dentistry is sparse but similar results from such behavior by dentists would seem to parallel that in medicine.

Apology law varies from state to state. Two types of laws have been enacted across the country pertaining to the admissibility of evidence in court, “full disclosure,” or “sympathy only” versions. Full disclosure laws are in place in eight states and protect physician admissions of fault and error, as well as expressions of sympathy, regret, and condolence. The sympathy only law, such as the one found in 28 states including Texas, protects physician expressions of sympathy, regret, and condolence only. Specifically, the State of Texas statute states that it does not protect “a statement … concerning negligence or culpable conduct.”

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With all of this in mind, Texas dentists are encouraged to confer with their legal counsel about how to comply with the Texas Apology Law. Reference 1. TEX. CIV. PRAC. & REM. CODE ANN., § 18.061

(2004 & Supp. 2005).

Bibliography McDonnell, WM, Guenther E. Narrative review: Do state laws make it easier to say “I’m Sorry?” Ann Intern Med. 2008; 149:811-815.

Lazare A. “Apology in Medical Practice: An Emerging Clinical Skill,” Journal of the American Medical Association (Sept. 20, 2006), Vol. 296, No. 11, pp. 1401–04.

Leape LL. “Full Disclosure and Apology: An Idea Whose Time Has Come,” Physician Executive (March–April 2006), Vol. 32, No. 2, pp. 16–18.

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Bond Strength Comparison of Color Change Adhesives for Orthodontic Bonding Michael W. Duers, D.M.D., M.S. Jeryl D. English, D.D.S., M.S. Joe C. Ontiveros, D.D.S., M.S. John M. Powers, Ph.D. Harry I. Bussa, D.D.S. Gary N. Frey, D.D.S. Ronald L. Gallerano, D.D.S., M.S.D. Sebastian Z. Paige, D.D.S.

Introduction The introduction of the acid-etch bonding technique by Buonocore in 1955 has led to dramatic changes in the practice of orthodontics (1-3). By the late 1970’s, the bonding of orthodontic brackets became an accepted clinical technique (4-6).

English

Bussa

Gallerano

Paige

Dr. Duers, currently a Major, US Air Force; previously a resident, Department of Orthodontics, the University of Texas Dental Branch at Houston; michael.duers@lakenheath.af.mil.

Dr. English, chair and program director, Department of Orthodontics, the University of Texas Dental Branch at Houston; jeryl.d.english@uth.tmc.edu.

Dr. Ontiveros, associate professor of restorative dentistry and biomaterials, Department of Orthodontics, the University of Texas Dental Branch at Houston; joe.c.ontiveros@uth.tmc.edu.

Dr. Powers, professor of restorative dentistry and biomaterials, Department of Orthodontics, the University of Texas Dental Branch at Houston; john.m.powers@uth.tmc.edu.

Dr. Bussa, associate professor of orthodontics, Department of Orthodontics, the University of Texas Dental Branch at Houston; harry.i.bussa@uth.tmc.edu.

Dr. Frey, associate professor of restorative dentistry and biomaterials, Department of Orthodontics, the University of Texas Dental Branch at Houston; gary.n.frey@uth.tmc.edu.

Dr. Gallerano, associate professor of orthodontics, Department of Orthodontics, the University of Texas Dental Branch at Houston; ronald.l.gallerano@uth.tmc.edu.

Dr. Paige, 2nd year orthodontic resident, Department of Orthodontics, the University of Texas Dental Branch at Houston; sebastian.z.paige@uth.tmc.edu.

Corresponding Author: Dr. Jeryl D. English, D.D.S., M.S. 6516 M.D. Anderson Blvd., Ste. 473, Houston, TX 77030-3402. Phone: (713) 500-4470; FAX: (713) 500-4372. E-mail: jeryl.d.english@uth.tmc.edu.

Reprints will not be available.

The authors have declared no potential conflict of financial interest, relationship and/or affiliations relevant to the subject matter or materials discussed in the manuscript. This article has been peer reviewed.

Abstract This study investigated whether three different color change light-cured orthodontic bonding adhesives have comparable shear bond strengths to a conventional light-cured orthodontic bonding adhesive. The sample of 240 bovine incisors was divided into four groups of 60 each. Each group tested one of four orthodontic bonding adhesives: 3M Unitek Transbond PLUS, Ormco Gréngloo, Ormco Blúgloo, and 3M Unitek Transbond XT (control). The four groups were further divided into two subgroups of 30 with shear bond strength tested at two different times (15 minutes and 24 hours) post-bond.

The shear bond strength was measured on a universal testing machine.

The data were analyzed by two-way analysis of variance and post-hoc comparisons (Fisher’s PLSD) at the 0.05 level of significance. The average shear bond strength was greater at 24 hours than at 15 minutes for Transbond PLUS, Blúgloo, and Transbond XT. For Gréngloo, the average shear bond strength was greater at 15 minutes than at 24 hours. Gréngloo tested at 15 minutes had the highest average shear bond strength. Gréngloo tested at 24 hours had the lowest average shear bond strength. All four orthodontic bonding adhesives demonstrated bond strengths considered to be clinically acceptable for orthodontic purposes.

KEy WORDS: shear, bond, transbond,

gréngloo, blúgloo

Tex Dent J 2011;128(3):267-275.

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Bond Strength Comparison The ability to bond orthodontic brackets to enamel can dramatically reduce clinical chair time, eliminate band space and its subsequent closure, and circumvent the poor esthetics, difficult hygiene and gingival irritation resulting from orthodontic bands (7).

Two concerns that come with the bonding of orthodontic brackets are the remnants of excess orthodontic bonding adhesive, or flash, and its potential effect on the health of the enamel surface throughout treatment; and the return to a sound, unblemished enamel surface after the removal of the orthodontic brackets.

Despite the advances in dental care and the reduced prevalence of dental caries in children, the formation of white spot lesions is not uncommon around orthodontic brackets (8). Gorelick et al. found that half of the patients treated with fixed appliances had at least one white spot lesion after treatment, and there were no differences in incidence between banding and bonding (9). It has been noted that the development of white spot lesions can occur as quickly as 1 month into treatment, and even though they may regress, they still may present an esthetic problem 5 years after removal of the appliances (10-13). Poor brushing, sugary liquids, and acidic liquids also play a role. During the bonding procedure it is not uncommon to leave excess bonding adhesive around the margin of the bracket. The attribution of this excess bonding adhesive to the formation of white spot lesions has been investigated. It is thought that if the excess adhesive is not removed, it can act as a mechanical irritant to the gingiva and as a site for bacterial colonization, which can potentially increase the incidence of white spot lesions (14-16). It has also been recognized that if the excess bonding adhesive is not removed, it can increase the amount of plaque and, therefore, potentially increase the occurrence of white spot lesions during orthodontic treatment (17-20).

After the completion of orthodontic treatment, the objective of debonding is to restore

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the enamel surface as closely as possible to its pretreatment condition by removing the attachment and all the adhesive resin from the tooth. The sites of potential failure within the bracket-adhesive-enamel complex during debonding are within the bracket, between the bracket and the adhesive, within the adhesive, and between the tooth surface and the adhesive. Various debonding techniques have been suggested with failure usually occurring within the adhesive, leaving behind adhesive resin on the tooth surface that must be removed. This is preferable to a situation where the enamel becomes the weakest link and fractures during debonding (21). Due to most adhesives having a strong color resemblance to the teeth, removing the residual bonding material can be a difficult task and adhesive remnants may easily remain undetected (22,23). It has been reported in the literature that the removal of the remaining adhesive following debonding may also remove up to 150 Îźm of surface enamel (23-26).

Recently, orthodontic bonding adhesives with color change capability have been developed to help locate excess adhesive during bracket placement and detect any remaining adhesive after bracket removal. Transbond PLUS is a color change orthodontic bonding adhesive manufactured by 3M Unitek.

It incorporates a pink dye that becomes photobleached when it is exposed to light, both ambi-

ent and curing. The bleaching of the dye is not an indication of polymerization, it just renders suitable esthetics throughout treatment. The intended benefit of the dye is to facilitate the removal of excess adhesive during bracket placement that will potentially cause the buildup of plaque (16). Blúgloo is a two-way color change adhesive developed by Ormco Corporation. It possesses the property of color change with temperature; at cooler temperatures the adhesive possesses a blue color, which changes to a translucent color when the adhesive increases to body temperature.

This allows for removal of excess adhesive during bracket placement and identifiable cleanup of the remaining adhesive after debonding when the adhesive is cooled with air or water. The company claims that Blúgloo has 150 percent greater bond strength when used with their own esthetic bracket (27).

A similar two-way color change adhesive manufactured by Ormco Corporation is Gréngloo.

According to the manufacturer’s website, Gréngloo polymerizes faster than other light-cured orthodontic bonding adhesives providing a higher percent of total bond strength at initial force loading (28). It is also designed with a patented ingredient which increases impact resistance by 118 percent and has a chemical affinity for metal brackets which can ensure reliable bond strength. The green color contrast at lower temperatures during bonding facilitates accurate bracket placement and makes it easy to remove excess adhesive. As the adhesive warms to body temperature, the color disappears, remaining

clear throughout treatment. After debonding, simply introduce a short blast of cool air or water to lower the surface temperature, and the adhesive turns green again for easy and thorough cleanup.

The purpose of this study was to compare the shear bond strengths attained when using these three color change light-cured orthodontic bonding adhesives and a conventional light-cured orthodontic bonding adhesive. These conditions were studied at two different debond times: 15 minutes and 24 hours.

Materials and Methods On the basis of previous studies indicating that bovine enamel and human enamel were similar in their physical properties, composition, and bond strength, it was decided to use bovine teeth for this investigation (2932). These teeth have been used in various studies for comparison of bonding characteristics and bond strengths (33-39). Two hundred and forty extracted bovine incisors (Animal Technologies, Inc., Tyler, TX, USA) were collected and stored in a disinfecting solution of 0.25 percent sodium azide solution in saline for no more than 2 months.

The roots of the incisors were shortened with a diamond disk to allow for mounting in acrylic resin cylinders (SAMPL-KWICK® fast cure acrylic resin, Buehler Ltd., Lake Bluff, IL, USA). The facial surfaces of the incisors were left exposed to be used as the bonding surfaces. The enamel surface was ground

(Ecomet 6® variable speed grinder-polisher, Buehler Ltd., Lake Bluff, IL, USA) to obtain a suitable surface area for the bonding of orthodontic brackets.

The specimens were randomly divided into four groups of 60 specimens each.

Each of the four groups was to represent one of four light-cured orthodontic bonding adhesives [(Transbond PLUS, 3M Unitek, Monrova, CA, USA), (Gréngloo, Ormco Corporation, Glendora, CA, USA), (Blúgloo, Ormco Corporation, Glendora, CA, USA), (Transbond XT, 3M Unitek, Monrova, CA, USA)]. Each of the four orthodontic bonding adhesive groups was further divided into two subgroups to be debonded at two different time periods (15 minutes and 24 hours), giving a total of eight groups of 30 specimens each. Transbond PLUS, Gréngloo, and Blúgloo are color change light-cured orthodontic bonding adhesives, and Transbond XT is a conventional light-cured orthodontic bonding adhesive used as the control.

Before bonding, each specimen was rinsed and then thoroughly air dried. The enamel surface was etched for 15 seconds with 35 percent phosphoric acid (Transbond etching gel, 3M Unitek, Monrova, CA, USA), rinsed, and thoroughly air dried.

A thin coat of primer (Transbond primer, 3M Unitek, Monrova, CA, USA) was applied to the enamel.

The orthodontic adhesive was placed on the base of the orthodontic bracket (LP Twin Mini Master Series 0.022 mandibular incisor brackets, American Orthodontics, Sheboygan, WI, USA). The bracket was seated and positioned on the specimen,

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Bond Strength Comparison and the excess orthodontic adhesive was removed (Illustration 1). The orthodontic adhesive was light cured for 20 seconds (5 seconds on each of the four sides) with a curing light (Ortholux LED curing light, 3M Unitek, Monrova, CA, USA). The curing light was tested on a photometer and demonstrated the proper intensity and wavelength of light. All of the specimens were bonded by the same operator.

The specimens in the group to be debonded at 24 hours were placed in distilled water in an incubator at 37° Celsius to simulate the oral environment prior to testing. The 15-minute specimens and the 24-hour specimens were then tested under shear load utilizing a universal testing machine (Model 4465, Instron Corporation, Canton, MA, USA) at a crosshead rate of 1.0 mm/minute (Illustration 2a and 2b).

Illustration 1. Bracket placed on tooth.

Mean values and standard deviations of bond strengths were calculated. The data were analyzed by two-way analysis of variance and post-hoc comparisons (Fisher’s PLSD) at the 0.05 level of significance. Fisher’s PLSD intervals for comparisons of means between two times and within four orthodontic bonding adhesives were 0.8 and 1.2 MPa, respectively.

The debonding characteristics for each specimen were determined with the Adhesive Remnant Index (ARI) developed by Artun and Bergland in 198440. This is a four-point scale used to assess the amount of orthodontic bonding adhesive remaining on the tooth surface after debonding. ARI 0 signifies 0 percent of the adhesive remaining on the tooth, ARI 1 signifies less than or equal to 50 percent of the adhesive remaining on the tooth, ARI 2 signifies greater than 50 percent of the adhesive remaining on the tooth, and ARI 3 signifies 100 percent of the adhesive remaining on the tooth with a distinct impression of the bracket mesh. Each specimen was examined by one operator under 3.5x magnification.

Illustration 2a. Instron set up before exerting force.

Results Sixty teeth were bonded using each orthodontic bonding adhesive for a total sample size of 240. Each orthodontic bonding adhesive group was divided into two

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Illustration 2b. Instron set up while exerting force.

Figure 1. Bond Strength (MPa) of Four Adhesives at Two Times.

subgroups to test the two debond times (15 minutes and 24 hours). Gréngloo tested at 15 minutes had the highest average shear bond strength at 9.91 MPa (Figure 1 and 2). Gréngloo tested at 24 hours had the lowest average shear bond strength at 6.44 MPa (Figure 3). The average shear bond strengths for the remaining six groups had a range of 6.59 MPa to 8.18 MPa. The average shear bond strength for all groups was 7.69 MPa.

Figure 2. Bond Strength Comparisons at 15 Minutes.

Transbond PLUS, Blúgloo, and Transbond XT (control) showed no significant difference in average shear Texas Dental Journal l www.tda.org l March 2011

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Bond Strength Comparison bond strengths when compared at 15 minutes and at 24 hours (Table 1). Gréngloo demonstrated average shear bond strengths that were significantly higher than those of the control group at 15 minutes and significantly lower than those of the control group at 24 hours.

When comparing the average shear bond strengths of each orthodontic adhesive across the two different time points (15 minutes and 24 hours), only Transbond XT showed no significant difference.

Figure 3. Bond Strength Comparisons at 24 Hours.

Table 1. Means Table for Bond Strength, MPa. Testing Time Orthodontic Bonding Adhesive

15 Minutes Mean

Std. Dev.

24 Hours Mean

Std. Dev.

Transbond PLUS (Plus)

6.59b 3.05 7.69c 3.71

Gréngloo (GG)

9.91 4.69 6.44 3.04

Blégloo (BG)

7.31b 2.71 8.18c 1.82

Transbond XT (XT)

7.56ab 2.88 7.82ac 3.97

*Means with the same superscripted letters are not different statistically (P>0.05).

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Figure 4. Adhesive Remnant Index

When examining the amount of orthodontic bonding adhesive remaining on the specimens following debonding, Gréngloo tested at 15 minutes and at 24 hours had the lowest average ARI score at 0.97 (Figure 4). Transbond PLUS tested at 24 hours had the highest average ARI score at 2.23. The average ARI score for all groups was 1.57.

Discussion Ever since Buonocore revolutionized clinical orthodontics in 1955 by introducing the acidetch technique, there have been numerous attempts to further

improve the protocol. Products have been marketed to improve bond strength, reduce bonding steps, decrease chair time, and reduce unwanted effects to the enamel surface. Orthodontic bonding adhesives with color change capability have been developed to facilitate the removal of excess adhesive during bracket placement and identify remaining adhesive after bracket removal. This targets two concerns that come with the bonding of orthodontic brackets — enamel decalcification, or white spot lesions, and unnecessary removal of enamel surface during debonding.

This study compared shear bond strengths using a conventional light-cured orthodontic bonding adhesive (Transbond XT) and three color change light-cured orthodontic bonding adhesives (Transbond PLUS, Gréngloo, and Blúgloo). The shear bond strengths were measured at 15 minutes and 24 hours after bonding. For Transbond PLUS, Blúgloo, and Transbond XT (control), the average shear bond strengths measured at 24 hours were greater than those measured at 15 minutes (Figure 1).

For Gréngloo the average shear bond strength measured at 15 minutes was greater than that measured at 24 hours. The highTexas Dental Journal l www.tda.org l March 2011

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Bond Strength Comparison est average shear bond strength was Gréngloo at initial testing, which is in agreement with the manufacturer’s claim that Gréngloo provides a higher percent of total bond strength at initial force loading.

The amount of orthodontic bonding adhesive remaining on the specimen after debonding was greater at 24 hours than at 15 minutes for Transbond PLUS and Blúgloo (Figure 4). Gréngloo demonstrated the same average ARI score at 15 minutes and 24 hours, which was also the lowest average ARI score. This finding is in agreement with the manufacturer’s claim that Gréngloo has a chemical affinity for metal orthodontic brackets. Only Transbond XT had a higher average ARI score at 15 minutes than at 24 hours. Of particular note was Transbond PLUS resulting in a higher average ARI score at 15 minutes and at 24 hours when compared with the results of Transbond XT, which conflicts with the findings from the studies of Vicente and Bravo in 2006 and 2007 (41,42).

Transbond PLUS, Gréngloo, and Blúgloo demonstrated adequate bond strengths for use in clinical orthodontics. The major difference in the three products is the conditions under which the color change takes place.

Transbond PLUS changes from a pink tint to translucent after exposure to light. Gréngloo and Blúgloo change from a green tint and blue tint, respectively, to translucent after an increase in

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temperature; and their respective color tints return with a decrease in temperature. Each can be advantageous for various reasons depending on the clinician’s preference.

The combinations of orthodontic bonding adhesives and techniques used in this study have not been tested in this manner under the same testing conditions. Bond strengths are technique sensitive, and the same orthodontic bonding adhesives can yield different results in varying experimental conditions. Furthermore, remnants of adhesive remaining on the tooth surface after laboratory shear testing may be different than those after clinical debonding.

This study has clinical interest because it evaluated the shear bond strengths of four commercially available orthodontic bonding adhesives and assessed the amount of residual adhesive remaining on the tooth surface after debonding. However, laboratory results cannot be extrapolated to the clinical environment, hence, clinical studies need to be performed to yield clinically meaningful results (43). It may also be of interest to repeat this study using longer time periods to evaluate the trends of the shear bond strengths and adhesive remnants after 24 hours, with particular interest in the shear bond strength trend of Gréngloo.

Conclusions Both Transbond PLUS and Blúgloo produced average shear bond strengths similar to those of the control group (Transbond XT) when compared at 15 minutes and 24 hours. Gréngloo demonstrated average shear bond strengths that were significantly higher than those of the control group at 15 minutes and significantly lower than those of the control group at 24 hours. It is not clear why the three products demonstrated different bond strengths, but it may be due to differences in their chemical make up. Although the average shear bond strengths varied among the different orthodontic adhesives at two different time points, the measurements were still within the recommended bond strength range for orthodontic bonding. Therefore, Transbond PLUS, Blúgloo, and Gréngloo are practical options for orthodontic bonding.

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9. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation after banding and bonding.

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10. O’Reilly MM, Featherstone JD. De- and remineralization around orthodontic appliances: An in vivo study. Am J Orthod Dentofac Orthop 1987;92:33-40.

11. Øgaard B, Rolla G, Arends J. Orthodontic appliances and enamel demineralization. Part 1.

Lesion development. Am J Orthod Dentofac Orthop 1988;94:68-73.

12. Artun J, Thylstrup A. A 3-year clinical and SEM study of surface changes of carious enamel lesions after inactivation. Am J Orthod Dentofac Orthop 1989;95:327333.

13. Øgaard B. Prevalence of white spot lesions in 19 year olds. A study on untreated and orthodontically treated persons 5 years after treatment. Am J Orthod Dentofac Orthop 1989;96:423-427.

14. Zachrisson BU. A posttreatment evaluation of direct bonding in orthodontics. Am J Orthod 1977;71:173-189.

15. Eliades T, Eliades G, Brantley WA. Microbial attachment on orthodontic appliances: I. Wettability and early pellicle formation on bracket materials. Am J Orthod Dentofac Orthop 1995;108:351360.

16. Brennan JV, James D, Soo PP, Tzou S. The APC Plus adhesive coated appliance system: Features and technical review. Orthodontic Perspectives 2004;XI. 17. Oh K, Choo S, Kim KM, Kim KN. A stainless steel bracket for orthodontic application. Eur J Orthod 2005;27:237-244.

18. Vorhies AB, Donly KJ, Staley RN, Wefel JS. Enamel demineralization adjacent to orthodontic brackets bonded with hybrid glass ionomer cements: An in vitro study.

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19. Alexander SA, Ripa LW. Effects of self applied topical fluoride preparations in orthodontic patients.

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20. Øgaard B, Rolla G, Arends J, ten Cate JM. Orthodontic appliances and enamel demineralization.

Part 2. Prevention and treatment of lesions. Am J Orthod Dentofac Orthop 1988;94:123-128.

21. Retief DH. Failure at the dental adhesive-etched enamel interface.

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22. Caspersen, I. Residual acrylic adhesive after removal of plastic orthodontic brackets: A scanning electron microscopic study. Am J Orthod 1977;72:671-681.

23. Zachrisson BU, Arthun J. Enamel surface appearance after various debonding techniques. Am J Orthod 1979;7 (2):121-127.

24. Fitzpatrick DA, Way DC. The effects of wear, acid etching, and bond removal on human enamel.

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25. Pus MD, Way DC. Enamel loss due to orthodontic bonding with filled and unfilled resins using various clean-up techniques. Am J Orthod 1980;77(3):269-283.

26. Krell KV, Courey JM, Bishara SE. Orthodontic bracket removal using conventional and ultrasonic debonding techniques, enamel loss, and time requirements.

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27. Northrup RG, Berzins DW, Bradley TG, Schuckit W. Shear bond strength comparison between two orthodontic adhesives and self-ligating and conventional brackets.

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28. http://www.ormco.com/index/ ormco-products-grengloo.

29. Nakamichi I, Iwaku M, Fusayama T. Bovine teeth as possible substitutes in the adhesion test. J Dent Res 1983;62(10):1076-1081.

30. Osterle LJ, Shellhart WC, Belanger GK. The use of bovine enamel in bonding studies. Am Journal Orthod Dentofac Orthop 1998;113:514-519.

31. Saleh F, Taymour N. Validity of using bovine teeth as a substitute for human counterparts in adhesive tests. East Mediterr Health J 2003;9(1-2):201-207.

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33. Sinha PK, Nanda RS, Duncanson MG, Hosier MJ. Bond strengths and remnant adhesive resin on debonding for orthodontic bonding techniques. Am Journal Orthod Dentofac Orthop 1995;108:302307.

34. Almeida KG, Scheibe KG, Oliveira AE, Alves CM, Costa JF. Influence of human and bovine substrate on the microleakage of two adhesive systems. J Appl Oral Sci 2009;17(2):92-96.

35. Krifka S, Borzsonyi A, Koch A, Hiller KA, Schmalz G, Friedl KH. Bond strength of adhesive systems to dentin and enamel: Human vs. bovine primary teeth in vitro. Dent Mater 2008;24(7):888-894.

36. Titley KC, Childers S, Kulkarni G. An in vitro comparison of short and long term bond strengths of polyacid modified composite resins to primary human and bovine enamel and dentine. Eur Arch Paediatr Dent 2006;7(4):246-252.

37. Cozza P, Martucci L, De Toffol L, Penco SI. Shear bond strength of metal brackets on enamel. Angle Orthod 2006;76(5):851-856.

38. Dias WR, Pereira PN, Swift EJ Jr. Effect of surface preparation on microtensile bond strength of three adhesive systems to bovine enamel. J Adhes Dent 2004;6(4):279-285.

39. Hara AT, Amaral CM, Pimenta LA, Sinhoreti MA. Shear bond strength of hydrophilic adhesive systems to enamel. Am J Dent 1999;12(4):181-184.

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42. Vicente A, Bravo LA. Shear bond strength of precoated and uncoated brackets using a selfetching primer. Angle Orthod 2007;77(3):524-527.

43. Hajrassie MK, Khier SE. In-vivo and in-vitro comparison of bond strengths of orthodontic brackets bonded to enamel and debonded at various times. Am J Orthod Dentofac Orthop 2007;131(3):384390.

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Summary of the New 2010 American Heart Association Guidelines for Basic Life Support (CPR) Roger E. Alexander, D.D.S.

Introduction Each year an estimated 350,000 people suffer a cardiac arrest in the United States and Canada and receive an attempted resuscitation (1). This number does not include victims who suffer an out-of-hospital cardiac arrest where resuscitation is not attempted. The concept of chest compressions and rescue breathing to save victims of cardiac arrest was first introduced to doctors at a meeting of the Maryland Medical Society 50 years ago (2). The first guidelines were issued by the American Heart Association (AHA) in 1966. Since that epic moment, Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) have become the centerpieces for emergency responses to life-threatening cardiopulmonary emergencies in medical and dental offices, and in everyday life.

Abstract Approximately every 5 years, American Heart Association (AHA) experts review emerging scientific evidence and recent clinical experiences and update the AHA guidelines for basic and advanced life support procedures for in-hospital and out-of-hospital victims of life-threatening cardiac events. This article summarizes many of the 2010 changes in those guidelines as they apply to dental healthcare providers (HCP). More detailed information will be available in the near future as these guidelines are fully implemented and instructional materials are released by the AHA. Until they are trained in future AHA or American Red Cross (ARC) basic or advanced cardiac life support (BLS, ACLS) courses in 2011, dentists, dental assistants, dental hygienists, and office staff should continue to rely on the training and information they received in their most recent basic (and/or advanced cardiac) life support training course.

KEy WORDS: Basic Life Sup-

Alexander Dr. Alexander is professor emeritus, Department of Oral and Maxillofacial Surgery, Baylor College of Dentistry — Texas A&M Health Science Center, Dallas.

Contact Information: Department of Oral & Maxillofacial Surgery, Baylor College of Dentistry – TAMHSC, 3302 Gaston Ave., A Dallas, TX 75246. Telephone: T (972) 240-7718, Fax: (214) 828-8382.

E-mail: reausn@verizon.net, Alternate E-mail: ralexander@bcd.tamhsc.edu.

Reprints of this article will not be available.

The author has no declared financial interests in any product mentioned in this article.

This article has been peer reviewed.

port (BLS), 2010 American Heart Association Guidelines, Cardiopulmonary Resuscitation (CPR), 2010 CPR Guidelines, 2010 BLS Guidelines, medical emergency management, dental office emergencies Tex Dent J 2011; 128(3):279-288.

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Guidelines for Basic Life On November 2, 2010, the AHA marked that 50-year milestone by publishing the newest (2010) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care in Circulation.

(3) The guidelines were last revised in 2005 and were summarized in a previous article in this journal (4).

Publication of new BLS guidelines (which include recommended CPR protocols) are often received with concern by healthcare providers (HCPs), not only because they often introduce changes to long-held dogma and learned skills, but also because of the perception that the skills learned in the most recent recertification classes may now be obsolete. This should not be a concern, however. The AHA emphasizes that the 2005 guidelines are still considered safe and effective, and that there is no problem with rescuers continuing to follow them until such time as they have been updated with the newer guidelines.

The 2010 guidelines are simply the latest refinements of previous knowledge and techniques, based on published evidence and experience since the 2005 guidelines were published. They represent the collective opinions of 356 resuscitation experts from 29 countries who have analyzed current data over the past 3 years and believe the new modi-

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fications of skills and knowledge will result in better compliance and improved outcomes when resuscitations are performed by both lay and professional rescuers. Dental HCPs will be taught these new concepts in future AHA and American Red Cross (ARC) training courses.

The new guidelines will be incorporated into AHA and ARC training classes as new instructional materials are released by the AHA over the next few months and new textbooks and training aids are developed. The “2010 Handbook of Emergency Cardiovascular Care for Healthcare Providers” is scheduled to become one of the first new training books to be released, and will be available by the time this article is published. The cost will be $25. As training materials are released, future ACLS courses will introduce the changes in the new ACLS guidelines.

This article will only preview the new BLS guidelines. Interested readers who wish more information can obtain a complete set of the 2010 guidelines from any of the American Heart Association’s publication sources for $20. The sources can be found on the AHA website (www.heart. org/HEARTORG/CPRAndECC/ CPR_UCM_001118_SubHomePage.jsp). Based on past trends, it is anticipated that the Journal of the American Dental Association will publish a more comprehensive summary of the changes sometime in early or mid-2011.

What’s New or Changed in the 2010 Guidelines?

This article will summarize only the most significant changes to guidelines that relate to healthcare providers. Some of the more significant changes for lay bystanders will also be briefly discussed, because healthcare providers may become involved in rescues away from the office, where a professional team approach is not applicable.

Lay rescuers and HCPs will continue to be taught two substantially different BLS protocols.

This approach was begun several years ago, and an even wider departure from HCP guidelines was implemented with the introduction of “hands-only (compressiononly)” CPR in 2008 (5). Anecdotally, the author has heard that this change has caused confusion in some dental offices, who are under the impression that the lay guidelines now also apply to HCPs, but the HCP guidelines have not substantially changed, when applied in a professional environment. Dental HCPs need to be aware of the scope of lay providers’ training, however, because they may become involved in out-of-office rescue situations, involving lay persons rather than trained HCPs. In those situations HCPs may need to follow lay protocols rather than those used when they are functioning with a trained office team.

Emphasis on Compressions, Compression-only CPR, and “C-A-B”. The most dramatic recent changes in CPR for lay rescuers has been the introduction of “compressions-only” (“hands only”) CPR, and the other significant change occurred in the adult and pediatric CPR algorithms changing the sequence from “A-B-C” to “C-A-B”. Lay rescuers are taught to assume cardiac arrest if an adult suddenly collapses, does not respond to verbal stimulation, and is not breathing (or is breathing abnormally). They are also taught to avoid opening the airway, listening for breathing, or searching for a pulse. The long pauses that have been caused by lay rescuers awkwardly trying to open the airway, deliver two adequate ventilations, and find a pulse during the performance of CPR are thus avoided. The experts believe there will be enough residual oxygen in the victim’s blood stream and lungs to briefly sustain life during the performance of CPR. Lay rescuers are instructed to initiate chest compressions immediately, to compress the chest continuously (at a rate of at least 100 per minute), and to minimize any interruptions of chest compressions until advance emergency care (EMS) and/or an automatic external defibrillator (AED) arrives at the scene. To highlight the need for adequate chest compressions, the emphasis is on “push hard, and push fast.”

Limiting Pulse Checks to 10 Seconds (HCP). Both lay rescuers and HCPs have demonstrated difficulty in detecting the presence or absence of a pulse, especially in victims who are hypotensive or have bradycardia.

The 2010 guidelines stipulate that professional rescuers should not check any longer than 10 seconds for a pulse, and if a definitive pulse is not felt within that time period, cardiac arrest should be assumed and chest compressions should be immediately started. This includes minimizing interruptions of chest compressions to perform periodic pulse checks during CPR. The emphasis should be on performing continuous chest compressions, with a minimal number of brief pulse checks.

Lay rescuers are instructed to initiate chest compressions immediately, to compress the chest continuously (at a rate of at least 100 per minute), and to minimize any interruptions of chest compressions until advance emergency care (EMS) and/or an automatic external defibrillator (AED) arrives at the scene.

Eliminating Delays and Interruptions. Since the introduction of the 2005 guidelines, the AHA has made a concerted effort to reduce wasted time during the performance of CPR, and to reduce the number of instances where bystanders are reluctant to perform CPR, or are unable to perform CPR correctly. Studies show that less than 50 percent of adult cardiac arrest victims receive bystander CPR. One of the impediments has been the difficulty in teaching how to open an airway, diagnose the lack of pulse, and deliver adequate rescue breaths using a mask or other barrier device (2). Even HCPs occasionally demonstrated difficulties accomplishing those skill-related tasks. This translated to delays in beginning chest compressions which, in turn, resulted in a low percentage of successful outcomes to CPR (averaging a mere 6 percent worldwide). When victims are shocked with an automatic external defibrillator (AED), shortening the intervals between the cardiac event, initiating CPR, and delivering the first shock substantially improves the victim’s chance for survival and recovTexas Dental Journal l www.tda.org l March 2011

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Guidelines for Basic Life ery (2). Ironically, surveys have failed to validate the belief that rescuers do not get involved in CPR because of a reluctance to perform mouth-to-mouth ventilation, as widely stated in the media. They cite fear, uncertainty, or panic as the primary causes for delay or non-involvement (6). Studies show that delays in initiating CPR are most often due to confusion, uncertainty and/ or panic, and it is hoped that by simplifying the procedures, and removing those elements that most lay rescuers found difficult or confusing to perform will increase lay bystander willingness to become involved and yield improved outcomes.

Pediatric Differences. Only 5-15 percent of pediatric (child/ infant) cardiac arrests are true cardiac arrests due to ventricular fibrillation or other arrhythmias (2). Many pediatric cardiac arrest cases are due to trauma or are secondary, due to breathing failure (termed “asphyxial”). The AHA continues to recommend a combination of ventilations and chest compressions for most child and infant scenarios, except for certain situations, such as a collapse during an athletic event that may call for CPR and defibrillation. Ventilations are recommended because studies have shown that children who received compressions-only CPR for management of non-cardiac (asphyxial) arrests (e.g. SIDS, disease, drowning) had poor results, comparable to those children who received no CPR at all (2). It is unknown whether

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administering compressions prior to ventilations (“C-A-B” instead of “A-B-C”) in infants and children has any significant positive or negative effect, but initiating compressions first only delays the administration of ventilations for about 18 seconds (7).

For that reason, the guidelines recommend CPR with ventilations (using the “C-A-B” algorithm) for infants and children in order to standardize training and the telephone guidance given by emergency dispatchers. The recommendation for the depths of compressions has been increased and it is now recommended that the depths should be approximately 1/3rd of the anterior-posterior dimension of most childrens’ chests (2). This corresponds to approximately 1 1/2 inches in infants and 2 inches for most children. The pulse assessment has been deemphasized in children as it has been in adults, due to the difficulty in reliably and consistently detecting the pulse. Lay rescuers are taught to not assess the presence or absence of a pediatric pulse, and HCPs should not spend more than 10 seconds attempting to palpate a Brachial pulse.

No “Look, Listen, Feel.” Studies have suggested that the previous “look, listen, feel” protocol significantly delayed the start of chest compressions, so it has been deleted from the guidelines.

Immediate recognition of sudden cardiac arrest is based on noting unresponsiveness (previously “shake and shout;” now, “tap on the shoulder and shout”) and

the absence of normal breathing (i.e. the victim is not breathing, or is showing periodic gasping breaths). If no signs of responsiveness and normal breathing are noted, CPR should be immediately started.

Emphasis on Deeper, Full-Relaxation Chest Compressions.

The quality of chest compressions is emphasized, and the new mantra is “Push Hard, and Push Fast.” Rescuers are advised to compress the chest of an adult victim at a rate of at least 100 compressions per minute, and push the chest deeper than previously recommended. The 2010 guidelines recommend compressing the chest of an adult victim at least 2 inches (not 1 1/2-2” as previously taught), and allowing the chest to fully recoil (expand) after each compression to allow the heart to refill completely before the next compression. The compressions: ventilations ratio for HCP rescuers remains 30 compressions: two ventilations for adult victims that have not been intubated or had some other advanced airway device implemented. This c:v ratio is arbitrary and based on expert consensus and limited evidence. Additional data are needed in the future to confirm whether this is the most ideal combination of compressions and ventilations (6).

More Frequent Compressing Rescuer Changes (Rescuer Fatigue). Numerous studies show that rescuer fatigue significantly compromises CPR outcomes, even when rescuers do not per-

ceive they are fatigued. Even after performing CPR for more than 5 minutes, some rescuers claim not to be fatigued but studies show that fatigue begins to adversely affect chest compressions after as little as 1 minute of CPR, resulting in shallower and less effective chest compressions (6). The 2010 guidelines recommend that whenever there are a sufficient number of rescuers, those performing chest compressions should switch approximately every 2 minutes, interrupting compressions for less than 5 seconds during the changes. For two rescuers this can be best accomplished by positioning one rescuer on each side of the victim’s chest, so they can quickly switch roles.

Continued Emphasis on Defibrillation. Several studies have documented that survival rates from cardiac arrest decrease 7 – 10 percent for every minute that passes from the time of arrest to the administration of the first defibrillating shock, if no CPR is provided (8). When bystander CPR is provided the reduction in survival is only decreased 3 – 4 percent per minute. Prompt bystander CPR coupled with early use of an AED (<10 minutes) can significantly increase survival rates and improve neurologic outcomes. Survival rates of up to 74 percent have been documented in out-of-hospital arrests when CPR and defibrillation occurred in less than 3-5 minutes (7). CPR alone, however, generally does not terminate ventricular arrhythmias nor restore a perfusing rhythm. The 2010 guidelines state: “To give the victim the best chance of survival, three actions must occur within the first moments of a cardiac arrest: activation of the … EMS system,

provision of CPR and operation of an AED” (7). It is noted that there continues to be ongoing discussion on two AED issues: 1) whether providing CPR before shocking the patient should be routinely recommended (versus administering a shock immediately), and 2) the ideal number of shocks to be delivered in sequence before CPR is resumed.

The AHA expresses concern that the currently marketed AED units cause delays of up to 37 seconds between shock delivery and CPR compressions, and they urge manufacturers to seek new methods to decrease the amount of time chest compressions are interrupted for AED rhythm analysis.

New Link Added to the AHA “Chain of Survival.” The 2010 guidelines have an increased emphasis on the post-resuscitation period, which has resulted in the addition of a new link in the AHA’s previously-four links “Chain of Survival” for optimum success in the management of cardiac emergencies. In addition to the previous four links (Early recognition and activation of the EMS system, early bystander CPR, rapid use of an AED if indicated, and arrival of advanced medical care) a new link of “Integrated post-cardiac arrest care” has been added.

Elimination of Cricoid Pressure Technique. Randomized studies show that the technique recommended for HCP rescuers over the years, to apply twofinger pressure over the cricoid cartilage (to allegedly reduce the risk for aspiration and gastric inflation), really does not work reliably. The procedure was difficult for rescuers to perform properly and generally not help-

ful, so routine use in adult CPR is no longer recommended (2).

Aspirin Concerns. One interesting section of the new guidelines, actually found in the First Aid section, brings up the question of whether first responders should administer aspirin to victims experiencing chest pain?

Although the literature is clear that there is an ultimate benefit for patients experiencing a heart attack, concern is noted regarding whether on-scene rescuers can properly diagnose an acute coronary event and recognize contraindications to aspirin administration, such as aspirin allergy, bleeding disorders, and potential medication interactions (6). There is limited discussion about whether delaying aspirin administration until the victim arrives at an advanced medical facility would compromise the effect, but no definitive recommendation is made one way or another. This appears to leave this important issue for future guidelines to clarify.

CPR Devices. There is an entire section that reviews the evidence regarding the use of various devices to assist rescuers in providing compressions and ventilations. The majority of these devices are not of interest to dental HCPs, and overall the majority of the devices appear to potentially delay chest compressions and/or AED shocks, and therefore are not recommended. The 2010 guidelines summarize this by stating: “To date, no adjunct has consistently been shown to be superior to …conventional (manual) CPR for out-of-hospital basic life support …”(9)

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Guidelines for Basic Life Summary of Healthcare Provider Actions All CPR Cards Are Not Equal.

As noted previously, the new 2010 guidelines present only minor refinements to the HCP actions for managing adult and pediatric cardiopulmonary arrest. Because of the dramatic differences between HCP and lay rescuer protocols, many dental emergency response experts believe, as the author does, that it is extremely important that all dental office personnel be trained in healthcare providerlevel classes (called “Professional Rescuer” in the ARC system) (10). Lay-oriented CPR classes are cheaper and shorter in duration, but offer minimal skills and knowledge training. If dental auxiliaries are allowed to attend lay CPR training classes, they may be able to attest that they have a “valid CPR card,” which meets the most-minimal state standards, but they will not be equipped with the knowledge and skills required of a healthcare team member working on a dental office rescue team. When someone is having an emergency in the dental office is not the time to find that your auxiliaries only know how to perform “hands-only” chest compressions as a single rescuer, and have had no introduction to the AED. Train Your Team. Dental offices should respond to a life-threat-

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ening emergency by working as a team, whose available members can perform any of several actions, and multiple actions can be carried out simultaneously by the team members (e.g. one rescuer activates the emergency response system and retrieves the AED or emergency oxygen, while another begins chest compressions and a third provides ventilations) (6,10). In the author’s opinion, mock emergency drills should ideally be practiced by the office team monthly, or at least every 6 months, at minimum. These need not be disruptive and generally take less than 15-20 minutes. These recommendations are consistent with other published recommendations for dental offices (11).

•

• HCP Algorithm for Adult Victims. In the following summary, the person having the emergency has been intentionally identified as the “victim” rather than the “patient,” because dental office emergencies don’t always involve patients under treatment. They can involve visitors who have accompanied a patient to the office, passers-by in an adjacent hallway or parking lot, or may involve one of the dentists or staff members in the office. The most obvious change in the sequence is that chest compressions are begun before ventilations are administered.

• •

The doctor (or first responder) in the room should check for responsiveness by grasping or tapping the victim’s shoulder and loudly asking

“Are You OK?” (or a similar phrase). Simultaneously the rescuer should assure the victim’s airway is open (head tilt, chin lift or other appropriate technique) and look for signs of breathing — e.g. rise and fall of the chest, or exhalation noise. (Some arrest victims may have occasional gasping during the initial moments of the arrest, but this is not considered adequate breathing.)

If the victim is unresponsive and not breathing normally, an emergency should be called out. The EMS system (9-1-1) should be activated immediately and office emergency equipment brought to the scene.

The doctor/first responder should check for a Carotid pulse, taking no more than 10 seconds. If a definitive pulse is detected, but the victim is not breathing, then rescue breathing should be administered (one breath every 5 seconds) via mouthto-mouth breathing, or using a barrier, pocket mask, or bag-valve-mask device.

Oxygen can be added, if indicated, upon equipment arrival. Assessment for some other cause of the breathing loss should begin (e.g. airway obstruction), and appropriate treatment initiated.

Compressions. If no pulse is detected within 10 seconds, or there is uncertainty regarding the presence or absence of a pulse, then cardiac arrest is presumed and

•

chest compressions started compressions and ventilainflation of the victim’s lungs immediately. No initial ventions until the AED prompts and prevents the rescuer from tilations are administered begetting lightheaded (6). Oxythem to stop for the next gen can be added upon equipfore compressions begin (6). rhythm analysis (and addiment arrival at the scene.

(Compressions are more adtional shocks if indicated). equate when performed on a • AED. As soon as the AED • Upon arrival of the EMS firm surface, so I recommend arrives on scene, one resresponders, the rescue scene that several team members cuer should apply the pads is turned over to the arriving work together to quickly and to the victim’s exposed, bare paramedics for continuation carefully remove the victim chest, and the AED should of the rescue and transportafrom the soft upholstered be turned on. Compressions tion to a hospital. dental chair onto the floor. are stopped and the AED This also generally provides verbal prompts are followed.

Figure 1 attempts to create a better access to the victim’s If a shock is delivered but simplified algorithm for HCPs side during CPR, as well as an acceptable rhythm is not (adult victim) in a dental office improved compression qualdetected, rescuers will be situation, based on the 2010 prompted to resume CPR AHA guidelines. ity.) Compressions are performed at a rate of at least 100 per minute; interrupFigure 1. 2010 Algorithm for Dental Healthcare Providers; Adult Victim* Figure 2010 Algorithm for Dental Healthcare Providers; Adult Victim* tions should be1:minimized.

If possible, two HCPs should perform chest compresUnresponsive Patient with No Breathing or Periodic (“Gasping”) Breathing sions, positioned on opposite sides of the chest and ideally change roles approximately Activate EMS (9-1-1) every 2 minutes (five cycles), Bring AED to Scene to prevent rescuer fatigue (Send other personnel, if available) and resulting shallower compressions (6). Chest compressor changes should not Check Pulse (<10 Seconds) Pulse Detected take longer than 5 seconds.

Each compression should be at least 2 inches deep and No Pulse Detected Give 1 breath the chest must be allowed to every 5-6 seconds; completely relax after each recheck pulse every 2 minutes; compression, to allow the Begin CPR (30c:2v) assess cause heart to refill with blood be(Start Compressions First) fore the next compression.

Ventilations. After 30 compressions have been adminAED Arrives; Apply Pads istered, the airway should To Patientʼs Bare Chest be opened and two rescue breaths should be administered by mouth-to-mouth (with barrier), mask, or Follow AED Verbal Prompts; Clear and Shock as Prompted bag-valve-mask. Each breath (If rhythm is not shockable, continue CPR) should be delivered over 1 second time and produce visible chest rise. The rescuer should take a regular breath EMS Arrives & Takes Over rather than a deep breath before delivering each rescue *Based prevents on concepts overpresented in Figure 2, Reference 6 * Based on concepts presented in Figure 2, Reference 6. breath, which Texas Dental Journal l www.tda.org l March 2011

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Figure 2. Dental students at Baylor College of Dentistry also learn how to hold mock emergency drills in their future offices as they practice medical emergency management in classes.

Pediatric variations in HCP Resuscitations. The 2010 guidelines have not changed dramatically for children (and infants), but some minor refinements have been introduced for HCPs. CPR should be performed if a child’s pulse is less than 60/ minute, and rescuers are reminded not to spend more than 10 seconds attempting to locate a pulse. Single rescuers who perform chest compressions on infants should use the two-finger technique; In two-rescuer infant CPR, the compressor uses two

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thumbs on the lower third of the sternum, with both hands encircling the infant’s chest, squeezing the infant’s thorax simultaneously with chest compressions (termed “circumferential squeeze”) (7). Some evidence suggests this variation provides higher coronary artery perfusion pressures. Like the 2005 recommendations, the compressions: ventilations ratio in infants is 30:2 for single rescuers and 15:2 for two-person rescues. There should be minimal interruptions of compressions for delivery of

the ventilations (7). Studies show that HCPs often deliver excessive ventilations during CPR, which can be harmful. Each breath should be given slowly, over 1 second in time, while watching for chest rise. Once chest rise is noted, the lungs are full. Foreign Body Airway Obstruction protocols are largely unchanged, except that the “C-A-B” protocols apply for unresponsive victims, rather than the previously recommended “A-B-C” protocol (compressions before ventilations). The Foreign Body Airway

Obstruction guidelines remain largely unchanged from the 2005 guidelines.

Pediatric hyperoxemia concerns. The guidelines note that there is some evidence in animal studies that high oxygen exposure may be harmful in children once spontaneous circulation is restored following cardiac arrest (2). It is recommended that 100 percent oxygen be used during resuscitation, but once circulation is restored, if appropriate equipment is available the inspired oxygen should be titrated to maintain oxyhemoglobin saturation >94 percent, pending arrival of EMS personnel, to reduce the risk of hyperoxemia (7).

Discussion This article alerts dentists to the upcoming changes because it is important that all dental healthcare providers are aware of the changes. The changes forwarded in the 2010 AHA guidelines are not as extensive as they were in the 2005 guidelines, and mostly represent refinements of the techniques and knowledge we have already learned, based on new evidence that has been published since 2005. The greatest change is the new emphasis on high-quality chest compressions, with minimal interruptions, delivered in a new “C-A-B” algorithm (compressions before ventilations). Additional information will be provided in upcoming AHA or ARC training classes and office teams will be able to get hands-on practice, incorporating these changes.

Publication of the 2010 AHA guidelines for CPR and emergency cardiac care do not render

the 2005 guidelines obsolete.

The knowledge and skills learned

by HCPs in their last AHA or ARC class remain safe and effective, but the AHA resuscitation experts feel the refinements will further enhance the older skills, result in greater bystander involvement, and result in more successful outcomes. These new aspects will be incorporated in future AHA and ARC CPR classes as soon as training materials can be developed and instructors can be updated.

As noted above, most dental emergency response experts recommend that all dental HCPs (dentists, assistants, hygienists, office staff) renew their CPR cards annually, even if they are provided with a 2-year expiration date by the issuing organization.

Studies have shown that reaction times, and the quality of resuscitation skills erode quickly when not used. After 6 –12 months the typical dental rescuer may not be able to react and perform to the highest level if called upon to do so during an actual emergency.

By renewing their skills each year, and regularly participating in mock emergency drills with the office team, dental offices will ensure the highest probability that any patient who experiences an unexpected life-threatening emergency problem will have a successful outcome. It is also beneficial if the entire office staff undergoes CPR renewal as a group, rather than each taking an individual class. Many AHA and ARC CPR instructors are willing to come into a dental office and hold a HCP class for the entire staff on site, and some will even incorporate mock patient emergency drills as part of the session, using the office’s own emergency equipment for familiarity.

BLS guidelines for HCPs now includes defibrillation efforts, by definition (12). It is highly recommended that each dental office purchase a good quality AED (Automated External cardiac Defibrillator) and arrange for the office staff to participate in an initial AED provider course to learn how to incorporate this important piece of equipment into the office’s emergency plan (10-14).

Once trained, in future renewal courses dentists and their staffs can be updated in one integrated session of a combined CPR and AED course. Further information on AED purchasing can be found in the literature (10).

References 1. Travers AH, Rea TD, Bobrow BJ et al. Part 4: CPR overview: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122 (Suppl3):S676-84.

2. Field JM, Hazinski MF, Sayre MR et al. Part I: Executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122 (Suppl3):S640-56.

3. Field JM, Hazinski MF, Sayre MR et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Circulation 2010; 122 (Suppl3):S639-933.

4. Alexander RE. The new 2005 American Heart Association Guidelines for Basic Life Support: A Preview. Texas Dent J 2006; 123:200-9.

5. Sayre MR, Berg RA, Cave DM et al. Hands-only (compression-only) cardiopulmonary Texas Dental Journal l www.tda.org l March 2011

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Guidelines for Basic Life resuscitation: a call to action for bystander response to adults who experience outof-hospital sudden cardiac arrest. Circulation 2008; 117:2161-67.

6. Berg RA, Hemphill R, Abella BS et al. Part 5: Adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122 (Suppl3):S685-705.

7. Berg MD, Schexnayder SM, Chameides L et al. Part 13: Pediatric Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and

Emergency Cardiovascular Care. Circulation 2010; 122 (Suppl3):S862-75.

8. Link MS, Atkins DL, Passman RS et al. Part 6: Electrical therapies: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122 (Suppl3):S706-19.

9. Cave DM, Gasmuri RJ, Otto CW et al. Part 7: CPR techniques and devices: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122 (Suppl3):S720-28.

10. Alexander RE. Selecting an

automated external defibrillator (AED) for the dental office: Which is â&#x20AC;&#x153;best?â&#x20AC;?. Texas Dent J 2004; 121:1168-79.

11. Malamed SF. Medical emergencies in the dental office, 6th Ed. St. Louis; MosbyElsevier, 2007: 500.

12. Malamed SF. Automated external defibrillators, Part 2. Dentistry Today 2003; 22:109-14.

13. Lazar RA. AEDs in dental offices. Dental Econ 2007; 97:116-21.

14. Kandray DP, Pieren JA, Benner RW. Attitudes of Ohio dentists and dental hygienists on the use of automated external defibrillators. J Dent Educ 2007; 71:480-6.

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2010 Financial Report Texas Dental Association Prepared by Ron Collins, D.D.S., TDA Secretary-Treasurer I feel optimistic that 2010 was the turning point in the economic downturn and Texas will be a leader in the national recovery. Although unemployment remains relatively high by past standards, most indicators suggest that we have reached a bottom and are now headed in a positive direction. Our membership numbers have had a slight increase and these factors bode well for TDA’s financial future.

The year 2010 showed a modest recovery in our investments in the Reserve Division of our General Fund. The year showed a gain of $129,250 (6.61 percent). However, the interest made in other accounts in the Operating Division suffered significantly in that rates have remained historically low, barely above any inflation we may have had in costs of goods and services we purchase to run the business of the TDA. The Relief Fund, our philanthropic trust, showed a gain of $16,241 (2.98 percent). A total distribution of $12,951 was made among five different charitable organizations in 2010.

As your new secretary-treasurer, I have set a number of objectives that I feel will strengthen the Association.

My overall financial vision for the TDA is to work toward implementing changes that will institute and maintain audit recommendations, consolidate accounts, review insurance risks and any gaps to determine the necessary monies to have for any unintended “rainy day” contingencies, and to maximize a return on our assets with an acceptable level of risk.

The 2010 unaudited year-end analysis showed we had income of $6,246,692 at 4.5 percent below budget and expenses of $5,607,360 at 16.6 percent below budget.

This realized surplus of $639,332 has been placed into a TDA savings account for use in future years.

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Similar surpluses from the early 2000’s had been placed into an interest bearing account labeled “Operating Reserve Account,” ostensibly to be used for cash demands presented during future years operations. This account grew to more than $950,000 by 2010; however, no demands were made upon it. The TDA Board of Directors decided that funds from this account would be used to pay the $900,000 National Labor Relations Board (NLRB) settlement costs we incurred in 2010. The remainder has been consolidated with other TDA savings accounts for clarity and to maximize potential return on investment.

The annual TEXAS Meeting, our publications/website, and TDA Financial Services, Inc. (TDA Perks) and MBL Partnership (our “for-profit” affiliates) continue to provide significant income streams for the Association that help maintain dues levels at a minimum. Based on our best projections of income and expenses for the fiscal year 2012, there appears to be no need for a dues increase. Of course, if the House of Delegates (HOD) passes significant projects, a decision will have to be made on either a dues increase or to take additional monies from savings.

The Board has approved a consolidation of Operation’s bank accounts. We have eliminated several bank accounts leaving only those mandated by HOD resolutions or those that must remain segregated by regulatory agencies or generally accepted accounting principals. A monthly cash flow analysis for 2010 was completed. From that we were able to see the seasonal fluctuations in our Operation’s Division accounts. It is my intention to maintain funds for day-to-day operations at an adequate minimum, moving un-needed funds into a higher interest bearing saving’s account; or from that account, back into checking if cash flow is needed for seasonal adjustments.

As the budget is a priority item, it is presented early in the HOD. At the end of the session, any additional added projects or programs with a financial implication would raise the estimated expenses to pay for them. The HOD will then be empowered to decide if additional monies should be taken from the savings account or by a dues increase which would be one of the last items of business.

The building extension adjacent to the TDA main building will be paid for by 2012 and the assessment for it will cease after the 2012 dues year. The new facility will house the Board of Directors meetings as well as some for-rental offices. In addition it has been designed to accommodate 100-120 people to be used by outside organizations as a conference center for additional rental, thus producing a new source of revenue.

Two of the more challenging areas in estimating income and expenses 18 months in advance were travel and a search for a new executive director. Travel associated with Board, councils, committees, the ADA delegation, and staff is always difficult to predict for a number of reasons. The different cities involved where members reside changes every year due to elections and presidential appointments and the costs of hotel space can change dramatically in 18 months from city to city. The expenses for 2012 will include a search committee and an outside vendor to consult with the search committee.

The vendor’s expertise will be used in narrowing the field for a suitable list of candidates for the search committee to interview for finalists. The Board will make its final decision from those finalists. The 2012 budget includes an estimate of 1 month’s overlap sal-

ary for transition from our present executive director to the new executive director at the end of 2012 and all associated costs for this search are included in a separate line item of $100,000.

With the help of a special Financial Task Force, an analysis of possible risks to the association was made in concert with an outside insurance broker. As a result of this analysis, newly recommended coverages for exposures were proposed and are included in this budget. One particular benefit to the membership at the local level is that TDA will pay the premiums of all components for their Directors and Officers liability insurance.

This budget continues to support the TDA Smiles Foundation, the Association’s philanthropic foundation, at a level of $100,000. There are philosophical opinions as to the amount that the TDA membership should support our foundation. However, this is the greatest area that can positively affect the public image of the TDA — a concern that consistently rates as the number one priority in past surveys. The foundation, along with our legislative activity, are two of the best weapons in our battle in the Texas Legislature to preserve the dental profession as we practice it today.

This also helps fulfill the financial goal of the TDA strategic plan on public image.

As your secretary-treasurer, I will continue to pursue my objectives to strengthen the financial position of the TDA, to make the reporting as clearly understandable and accurate as possible, and to remain watchful so that systems and procedures are carefully followed.

I remain optimistic about the financial outlook of the TDA in the next 2 years.

Texas Dental Journal l www.tda.org l March 2011

293

2012 Proposed Budget Texas Dental Association

Revenues Annual Session PUBLICATIONS/WEBSITE

BUILDING

OPERATIONS

Expenses

Annual SESSION PUBLICATIONS/WEBSITE

BUILDING

CAPITAL IMPROVEMENTS CONTINGENCY CENTRAL OFFICE BOARD OF DIRECTORS COMMITTEES COUNCILS ADA/NATIONAL ORGANIZATIONS HOUSE OF DELEGATES FEDERAL INCOME TAX

294

2010 Actual

2010 Budget

2011 Budget

2012 Proposed

1. Annual Session 1,805,872 1,869,850 1,908,650 1,908,700

2. Journal 414,180 457,301 475,527 442,646 3. TDA Today 39,455 39,265 39,655 39,690 4. TDA Website 21,140 24,950 20,400 18,990

Total Publications/Website 474,774 521,516 535,582 501,326

5. Building

a. Building Leases 165,327 219,873 186,327 191,917 b. Building Extension Leases 2,802 23,352 4,500 11,000

Total Buildings 168,129 243,225 190,827 202,917

6. Operating

a. Dues 2,707,766 2,651,113 2,626,912 2,660,078

b. Interest & Dividends 492 132,500 12,000 30,000 c. Miscellaneous 3,421 7,500 7,500 5,000

d. Contributions — Grants — AAPD 6,600 0 0 0 e. Dental Assistant Training 43,156 8,000 47,042 36,580

f. Seminars 0 0 0 0 g. Affiliates Administration 90,588 86,502 96,534 92,690

h. MBL Partnership 340,449 415,000 415,000 340,449 i. Cash Carry Over 605,445 605,445 469,008 577,774

Total Operating 3,797,917 3,906,060 3,673,996 3,742,571

TOTAL REVENUES 6,246,692 6,540,651 6,309,055 6,355,514

7. Annual Session 1,327,971 1,374,700 1,376,796 1,388,455

8. Journal 302,848 331,500 347,845 327,100 9. TDA Today 45,189 60,100 61,100 49,100 10. TDA Website 18,347 20,685 20,510 18,870

Total Publications/Website 366,384 412,285 429,455 395,070

11a. Building Leases 224,055 252,122 241,560 233,800 11b. Building Extension Leases 70,879 84,700 57,425 63,435

Total Buildings 294,934 336,822 298,985 297,235

12. Capital Improvements 30,166 35,000 35,000 30,000

13. Non Budgeted Contingency 5,948 40,000 40,000 30,000

14. Central Office Departments 2,792,179 3,233,209 3,155,213 3,237,053

15. Board of Directors 207,175 254,195 250,220 219,595

16. Committees 67,048 93,600 71,231 81,585

17. Councils 273,542 330,610 356,475 318,465

18. ADA/National Organizations 193,358 279,640 190,990 259,545

19. House of Delegates 48,655 65,590 54,690 48,510

20. Federal Income Tax 0 85,000 50,000 50,000

TOTAL EXPENSES 5,607,360 6,540,651 6,309,055 6,355,514

REVENUE OVER EXPENSE

BEFORE OTHER EXPENSE 639,332 0 0 0

21. NLRB SETTLEMENT

(from Operating Reserve account) 900,000 0 0 0

REVENUE OVER EXPENSE (260,668) 0 0 0

Texas Dental Journal l www.tda.org l March 2011

Central Office Departments PERSONNEL

EXECUTIVE DIRECTOR

OFFICE OPERATIONS

SERVICES

OTHER EXPENSES

2012 Proposed Budget Texas Dental Association 2010 Actual

2010 Budget

2011 Budget

2012 Proposed

14. Central Office Departments Personnel

a. Regular Salaries 1,295,578 1,622,583 1,556,409 1,600,000

b. Salaries — Temporary 25,060 1,000 1,000 1,000

c. Payroll Taxes 117,723 145,974 140,879 140,460

d. Dental Reimbursement — Employee 11,290 13,639 16,537 13,869 e. Health Insurance 133,951 187,890 204,803 162,981

f. Retirement 134,595 168,825 162,981 155,031

Total Personnel 1,718,196 2,139,911 2,082,609 2,073,341

Executive Director:

g. Salary 145,401 146,799 151,217 155,754

h. Auto Allowance 7,200 7,200 7,200 7,200

i. Health Insurance 7,366 8,169 8,687 8,878

Total Executive Director 159,967 162,168 167,104 171,832

Office Operations:

j. Insurance — Directors/Officers 35,202 35,226 50,000 55,800 k. Maintenance 30,481 42,330 36,328 34,000

l. Postage & Couriers 29,630 34,384 35,804 31,700 m. Printing 12,377 11,200 12,100 12,100

n. Supplies — Office 18,581 22,475 16,700 18,400

o. Taxes — State & Local 2,754 2,432 2,675 3,288 p. Telephone 29,072 32,200 32,225 30,100

Total Office Operations 158,097 180,247 185,833 185,388

Services:

q. Accounting Services — Payroll 3,941 3,951 4,346 4,200

r. Accounting & Auditing Services 32,131 32,985 34,634 35,000 s. Bank Charges 15,825 11,618 15,104 15,000

t. Consultants 0 0 0 0

u. ED Search Expenses 0 0 0 100,000 v. Human Resources 84,445 40,000 0 0

w. Legal Services 123,357 123,000 123,000 135,000 x. Lobbying 268,500 275,100 297,600 269,500

y. Gifts and Memorials 2,808 2,200 2,200 2,000

Total Services 531,007 488,853 476,883 560,700

Other Expenses:

z. Contributions 100,000 100,000 100,000 100,000 aa. Dues Processing 68,827 70,255 65,000 70,000

bb. Education & Organizational Development 5,721 16,750 16,000 13,300

cc. Meetings 10,516 11,528 12,651 10,100

dd. Professional Dues & Memberships 3,384 5,660 4,160 5,050

ee. Subscriptions-Publications 4,221 3,155 3,473 3,707 f f. Recruiting 458 1,500 1,500 500

gg. Travel 31,785 53,182 40,000 43,135

Total Other Expenses 224,912 262,030 242,784 245,792

Total Central Office 2,792,179 3,233,209 3,155,213 3,237,053

Texas Dental Journal l www.tda.org l March 2011

295

2012 Proposed Budget Texas Dental Association

Board of Directors, Councils, Committees, ADA, HOD BOARD OF DIRECTORS

2010 Actual

2010 Budget

2011 Budget

2012 Proposed

15. Board of Directors:

a. President 28,410 33,230 33,230 29,000

b. President — Stipend 30,000 30,000 30,000 30,000 c. President Elect 10,644 11,915 13,915 13,320

d. President Elect — Stipend 8,400 8,400 8,400 8,400

e. Past President 9,152 8,450 10,200 7,990

f. Secretary Treasurer 6,612 7,185 7,185 7,225

g. Secretary Treasurer — Stipend 8,400 8,400 8,400 8,400 h. Editor 5,612 11,950 13,225 11,830

i. Editor-Stipend 8,400 8,400 8,400 8,400

j. Vice Presidents 20,816 29,660 29,660 24,760

k. Senior Directors 17,770 25,700 25,700 18,800

l. Directors 17,313 24,700 25,200 18,800 m. Other Officers 14,404 12,250 12,250 12,075

n. Board Meetings 21,241 23,955 24,455 20,595

o. Board Docs 0 10,000 0 0

Total Board of Directors 207,175 254,195 250,220 219,595

COMMITTEES

COUNCILS

ADA/NATIONAL ORGANIZATIONS

HOUSE OF DELEGATES

FEDERAL INCOME TAX

296

16. Committees:

a. Access to Care 8,496 8,640 8,640 17,100 b. Assets Management 39 2,410 1,410 200

c. Awards 24,529 26,450 20,500 19,000

d. Budget 5,805 5,526 5,026 5,360 e. Building 173 524 425 650

f. Communications 2,761 8,185 2,000 4,000 g. Finance and Audit 2,397 2,100 3,830 3,310

h. New Dentist 8,351 15,420 13,915 18,120

i. Personnel 72 200 200 200 j. Future Focus Committee 14,425 24,145 15,285 13,645

Total Committees 67,048 93,600 71,231 81,585

17. Councils:

a. Annual Session Council 18,136 23,725 27,425 24,530

b. Legislative and Regulatory Affairs 119,122 124,276 166,311 116,171 c. Constitution and By — Laws Council 6,915 4,311 4,311 6,330

d. DENPAC 52,630 65,000 50,000 50,000 e. Dental Economics Council 5,077 13,350 10,350 10,000

f .

Dental Education, Trade and Ancillaries Council 39,663 26,515 44,690 48,424

g. Ethics and Judicial Affairs Council 7,866 11,590 8,590 13,255 h. Membership Council 11,805 45,503 28,458 33,415

i. Peer Review Council 12,327 16,340 16,340 16,340

Total Councils 273,542 330,610 356,475 318,465

18. ADA /National Organizations:

a. ADA Delegates 151,819 225,390 134,740 213,345 b. ADA 15th Trustee Headquarters 10,071 17,600 17,600 14,350

c. ADA Texas Reception 31,469 36,650 38,650 31,850 d. National Museum of Dentistry 0 0 0 0

Total ADA /National 193,358 279,640 190,990 259,545

19. House of Delegates:

a. HOD 50 Year and Life Luncheon 3,900 4,000 4,100 4,000 b. HOD Headquarters 42,686 59,390 48,390 42,310

c. HOD Past President’s Breakfast 2,069 2,200 2,200 2,200

Total House of Delegates 48,655 65,590 54,690 48,510

20. Federal Income Tax 0 85,000 50,000 50,000

Total Miscellaneous 0 85,000 50,000 50,000

Texas Dental Journal l www.tda.org l March 2011

2012 Proposed Budget Texas Dental Association 2010 Actual

2010 Budget

2011 Budget

2012 Proposed

Annual Session ANNUAL SESSION REVENUE

ANNUAL SESSION EXPENSE

1. Annual Session Revenue

a. Advertising 7,700 9,500 6,500 9,000 b. Clinics for Continuing Education 943,856 900,000 941,000 961,000

c. Classes 3,165 4,500 4,500 2,500

d. Contests — Photo 222 350 350 200

e. Exhibits 627,913 700,000 700,000 690,000

f. Merchandise Sales — Logo Shop 1,731 6,000 3,000 0 g. Miscellaneous 0 1,500 300 0

h. Other Groups 85,273 100,000 100,000 100,000

i. Registration 56,678 60,000 65,000 61,000

j. Sponsorships 79,334 88,000 88,000 85,000

Total Annual Session Revenue 1,805,872 1,869,850 1,908,650 1,908,700

7. Annual Session Expense

a. Audio-Visual 189,006 148,000 155,000 160,000

b. Bank Charges 41,917 40,000 40,000 40,000

c. Classes 4,195 4,500 4,500 2,500 d. Clinician Handouts 196 15,000 10,000 200

e. Clinician Honorariums 262,200 300,000 300,000 300,000 f. Clinician Support 173,815 175,000 175,000 175,000

g. Clinics — Other 0 0 500 500

h. Council/Board Dinner 3,334 4,500 4,500 4,500 i. Education 0 0 0 0

j. Exhibits 184,185 160,000 160,000 170,000 k. Hospitality Suite 34,051 40,000 40,000 40,000

l. Insurance 0 0 0 5,000

m. Logo Shop 2,488 6,000 1,500 0 n. Meetings 0 0 0 0

o. Miscellaneous 9,201 4,000 4,000 4,500

p. Onsite Program 29,967 35,000 35,000 35,000

q. Other Groups 48,466 70,000 70,000 70,000

r. Photo Contest 3,667 4,000 4,000 4,000 s. Postage 13,633 15,000 18,000 17,000

t. President’s Reception 1,335 2,000 2,000 2,000 u. Printing 0 0 0 0

v. Promotion 49,292 50,000 50,000 48,000

w. Red Coats’ Breakfast 431 450 450 450

x. Registration 119,363 135,000 135,000 128,000

y. Shuttle Services 6,741 8,500 8,500 11,000 z. Stipends 19,250 19,250 19,750 22,750

aa. Supplies — Office 2,984 5,000 3,000 4,000

bb. Temporary Salaries 0 500 500 0

cc. Texas Party 50,609 45,000 45,000 45,000

dd. Tours 0 0 0 0 ee. Travel 45,584 60,000 60,596 69,055

f f. VIP Reception 32,063 28,000 30,000 30,000

Total Annual Session Expense 1,327,971 1,374,700 1,376,796 1,388,455

Annual Session Net Revenue 477,900 495,150 531,854 520,245

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297

2012 Proposed Budget Texas Dental Association 2010 Actual

Publications/Website JOURNAL REVENUE

JOURNAL EXPENSE

TDA TODAY REVENUE

TDA TODAY EXPENSE

WEBSITE REVENUE

WEBSITE EXPENSE

298

2010 Budget

2011 Budget

2012 Proposed

2. TDA Journal Revenue

a. Advertising 291,150 336,000 354,400 319,000 b. Single Issue Purchases 54 500 500 200

c. Subscriptions — Membership Dues 122,976 120,801 120,627 123,446

d. Miscellaneous 0 0 0 0

Total TDA Journal Revenue 414,180 457,301 475,527 442,646

8. TDA Journal Expense

a. Meetings 90 100 100 100

b. Postage & Couriers 44,734 50,000 57,000 50,000

c. Printing & Production 257,902 280,800 290,345 276,600 d. Supplies — Office 25 500 300 200

e. Travel 97 100 100 200

Total TDA Journal Expense 302,848 331,500 347,845 327,100

3. TDA Today Revenue

a. Advertising 4,675 5,000 5,500 5,000

b. Subscriptions — Membership Dues 34,780 34,265 34,155 34,690

Total TDA Today Revenue 39,455 39,265 39,655 39,690

9. TDA Today Expense

a. Postage 20,138 24,000 24,500 22,000

b. Printing & Production 25,051 36,000 36,500 27,000 c. Supplies — Office 0 100 100 100

Total TDA Today Expense 45,189 60,100 61,100 49,100

4. TDA Website Revenue

a. Advertising and Merchandise Sales 19,640 16,950 17,400 15,990

b. Sponsorships 0 5,000 0 0 c. TDA Affiliates Support 1,500 3,000 3,000 3,000

Total TDA Website Revenue 21,140 24,950 20,400 18,990

10. TDA Website Expense

a. Education & Organization Development 175 600 600 600

b. Postage 0 25 25 25

c. Promotion 779 1,000 1,000 500 d. Repairs and Maintenance 0 0 0 0

e. Software and Software Support 6 350 200 500 f. Subscriptions — Publications 0 50 25 25

g. Supplies — Office 116 150 150 150

h. Travel 897 1,510 1,510 970

i. Website Engineering 0 1,000 1,000 100

j. Website Hosting 5,574 5,000 5,000 5,000 k. Website Services — TDA Express 10,800 11,000 11,000 11,000

Total TDA Website Expense 18,347 20,685 20,510 18,870

2-4 Total Public/Web Revenues 474,774 521,516 535,582 501,326 8-10 Total Public/Web Expense 366,384 412,285 429,455 395,070

Communications Net Revenue 108,391 109,231 106,127 106,256

Texas Dental Journal l www.tda.org l March 2011

2012 Proposed Budget Texas Dental Association Buildings BUILDING REVENUE

BUILDING EXPENSE

2010 Actual

2010 Budget

2011 Budget

2012 Proposed

5.

TDA Building Revenue

a. Lease Income 165,327 219,873 186,327 191,917

Total TDA Building Revenue 165,327 219,873 186,327 191,917

11. TDA Building Expense

a. Building Tenants 1,733 1,400 1,400 1,300

b. Gifts & Memorials 60 500 500 300

c. Insurance — Operating 17,413 24,000 22,000 20,000

d. Meetings 0 0 0 0

e. Postage 23 0 0 0 f. Repairs & Maintenance — Equipment 12,211 2,000 3,500 3,000

g. Service Contracts 79,434 88,000 89,760 88,000

h. Supplies — Office 3,260 9,000 5,000 5,000

i. Taxes — State & Local 53,277 57,200 59,000 53,000 j. Telephone 0 750 400 200

k. Utilities 56,645 69,272 60,000 63,000

Total TDA Building Expense 224,055 252,122 241,560 233,800

EXTENSION REVENUE

5.

TDA Extension Revenue

b. Lease Income 2,802 23,352 4,500 11,000

Total TDA Extension Income 2,802 23,352 4,500 11,000

EXTENSION EXPENSE

11. TDA Extension Expense

l. Capital Expenditures 0 0 0 0

m. Insurance — Operating 0 2,500 2,500 2,500 n. Interest Expense 25,689 29,500 11,525 4,500

o. Legal Fees 0 0 0 0 p. Repairs & Maintenance — Equipment 0 8,500 4,000 3,000

q. Service Contracts 9,722 7,800 5,000 8,800

r. Taxes — State & Local 16,390 19,000 21,000 24,835 s. Telephone 7,718 4,400 5,000 7,800

t. Utilities 11,360 13,000 8,400 12,000

Total TDA Extension Expense 70,879 84,700 57,425 63,435

TDA Building Maintenance Fund

Building Maintenance & Repair 10,313 17,473 2,493 59

(1) By House Resolution 132-1997-H, building repairs are funded from the interest generated from the Building

Maintenance Fund from 2 years previous to the current year. The 2012 budgeted amount for these lines is the

interest earned in the year 2010 by the Building Maintenance Fund

BUILDING MAINTENANCE FUND

Texas Dental Journal l www.tda.org l March 2011

299

Texas Dental Association 2012 Budget Explanation 1a.

Income from vendor advertising in the Annual Session program brochures.

1b. Income from ticketed clinician classes and events.

1c. Income from classes such as cooking and painting.

1d. Fees from Photo Contest.

1e. Income from exhibit booth spaces.

1f. Income from sale of TDA logo items.

1g. Other income associated with the TDA Annual Session.

1h. Fees from alumni lunches and other professional groups’ events.

1i. Pre-registration and on-site registration fees.

1j. Income from corporate sponsorships.

2a. Income from sale of classified and display advertising in Texas Dental Journal.

2b. Sale of single issues.

2c. Income from sale of Journal subscriptions, including

allocations of dues of $17 per dues-paying member.

2d. Fees from continuing

education offering.

3a. Income from advertising in TDA Today.

3b. Member subscriptions

allocated from dues at $5 per dues-paying member.

4a. Income from advertising on the TDA Website.

4b. Vendor support for web related promotion.

4c. Payment from affiliates for portion of website development and maintenance costs.

5a. Income from leased space in the TDA building.

5b. Income from leased space in the TDA building extension.

6a. Dues income available for

operations after allocation of $22 per member for Texas Dental Journal and TDA Today.

6b. Money earned from various short-term investments of dues collected and any interest income from current revenue.

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Texas Dental Journal l www.tda.org l March 2011

6c. Legislative Day and other income associated with the operating fund.

6d. American Academy of Pediatric

Dentistry DHI Grant.

6e. Income from dental assistant training program.

6f. Income from sponsored seminars.

6g. Payment from the for-profit affiliate, FSI, for administrative support of staff and equipment provided by the TDA. 6h. Distribution of 90 percent of the partnership income from TDA Member Benefits, Ltd, in which TDA is the limited partner.

6i. Surplus carried over from 2009.

7a. Audio-visual for clinicians.

7b. Charges in connection with the Annual Session bank accounts and credit card charges.

7c. Costs of classes, such as

cooking and painting.

7d. Printing of clinicians’ handouts.

7e. Cost of honoraria, hotel, and travel.

7f. Course supplies, electrical, and gifts for clinicians; convention center meeting rooms; and signs.

7g. Other costs associated with clinics.

7h. Costs of Council/Board Dinner.

7i. Costs associated with education.

7j. Exhibit hall costs, printing of exhibitors’ prospectus,

refreshments, electric/

decorating for exhibitors and security.

7k. Cost of catering for speakers, staff and A/S Council during Annual Session.

7l. Insurance premiums paid to cover meeting cancellation.

7m. Cost of merchandise sold at the Annual Session.

7n. Staff meetings associated with

Annual Session 7o. Charges for other costs

associated with the Annual Session.

7p. Cost of printing on-site program.

7q. Alumni luncheons and CPR classes.

7r. Costs associated with the Photo Contest.

7s. Postage used for Annual Session.

7t. Costs associated with the President’s Reception.

7u. Costs associated with printing materials.

7v. Mass mailings, promotional items, and advertising.

7w. Cost of A/S Council and A/S staff breakfast during meeting.

7x. Cost for registration firm for the Annual Session, as well as on-site setup cost, electrical, and staffing.

7y. Cost of shuttle transportation around downtown for attendees.

7z. Stipends paid to the San Antonio Dental Society, TDA Alliance, and the Dental

Assistants Association.

7aa. Supplies purchased for use at the Annual Session.

7bb. Temporary help hired

specifically for the Annual Session.

7cc. Catering, music and space rental for The Texas Party.

7dd. Tours.

7ee. Annual Session staff travel and Annual Session Council travel to scout other dental meetings.

7ff. Catering, music and space rental for the VIP Reception.

8a. Cost of meetings held in

connection with Journal business.

8b. Cost of mailing the Texas

Dental Journal to all members.

8c. Cost of printing, typesetting and artwork for the Texas

Dental Journal.

8d. Supplies used for the Texas Dental Journal.

8e. Staff travel in connection with Journal business.

9a. Cost of mailing newsletter, TDA Today.

9b. Cost of printing newsletter, TDA Today.

9c. Supply costs associated with TDA Today.

10a. Educational programs for

website staff.

10b. Cost of postage for mailing to potential website advertisers.

10c. Costs on site at the Annual Session to promote the website.

10d. Maintenance costs for website specific software.

10e. Costs associated with

software and support for the website.

10f. Professional publications

related to the website.

10g. Supply costs for the website.

10h. Travel costs for staff to

promote the website to the membership at the Annual Session.

10i. Costs for maintaining updates and enhancements to the website.

10j. Costs to design, implement and host website.

10k. Software service costs to

maintain TDA Express.

11a. Expenses allotted to maintain the tenant relations.

11b. Gifts of appreciation for service vendors and memorials for building display.

11c. Premiums paid for insurance associated with the TDA Building.

11d. Staff meetings associated with the building.

11e. Postage used for mailing

building information.

11f. Cost of equipment maintenance for the building.

11g. Service contracts associated with building such as the elevator service, security, HVAC, landscaping, etc.

11h. Supplies used to maintain the building.

11i. Property taxes paid on building.

11j. Telephone expense allocated to the building.

11k. Gas, water and electricity expenses.

11l. Capital Improvement needs

are reviewed and prioritized, and estimated costs are projected.

11m. Premiums paid for insurance associated with the TDA Extension.

11n. Interest paid for building

extension term note.

11o. Legal Fees associated with the building extension.

11p. Repairs and maintenance required above and beyond the service contracts.

11q. Service contracts associated with building such as the

janitorial service, security, HVAC, landscaping, etc.

11r. Property taxes paid on the TDA Extension.

11s. Telephone expense allocation to the TDA extension.

11t. Gas, water and electricity expenses.

Building Maintenance Fund uses interest earnings for remodeling and major repair costs. The budgeted expense amount is based on the

interest earnings for the year ended 2 years prior to the

budget year.

12. Capital improvement needs are reviewed and prioritized, and estimated costs are projected.

13. Contingency for approved expenditures by the Board of Directors.

14a. Full- and part-time salaries and year-end bonus (one week’s salary). The amount for 2012 reflects maintaining

current staffing levels with

annual salary adjustments.

14b. Temporary help for the TDA Central Office.

14c. Employer’s portion of FICA and Medicare based on 7.65 percent plus state and federal unemployment tax.

14d. Direct Reimbursement Dental Plan for employees.

14e. Medical insurance for employees.

14f. Payments to retirement plan for all eligible employees.

14g. Salary for the Executive Director.

14h. Car allowance for the Executive Director.

14i. Health insurance for the

Executive Director.

14j. Liability coverage for TDA

Officers and Component

Society Officers, personal

property coverage and

workers’ compensation insurance.

14k. Maintenance contracts for office and computer equipment and general office operations.

14l. Postage, metering equipment and maintenance, and UPS and Federal Express charges.

14m. All printing jobs done outside office such as stationery,

business forms, office forms, and dues statements.

14n. General office, printing and copy machine supplies.

14o. Personal property taxes of the Central Office furniture and equipment.

14p. Eight incoming WATS and business lines for Central Office using XO Communications, facsimile charges, and cellular phones.

14q. Cost of payroll service used by TDA. 14r. Accountant fees for annual audit, consulting services, and tax return preparation.

14s. Charges for transaction fees and returned checks.

14t. Expenses associated with

outside consulting firms.

14u. Expenses related to search for new Executive Director.

14v. Cost of out-sourced human resource service.

14w. Retainer for legal counsel and related legal expenses.

14x. Expenses associated with consulting firms engaged for legislative lobbying services.

14y. Flowers for funerals, special gifts to VIP’s, members, and their families.

14z. Funding for the operating costs of the Texas Dental Association Smiles Foundation.

14aa. Credit card processing fees and other bank charges for

processing dues payments.

14bb. Continuing education and

organizational development costs for TDA staff members.

14cc. Meals and supplies not directly related to a specific council, committee, or board meeting Texas Dental Journal l www.tda.org l March 2011

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that occurs at the TDA Central Office.

14dd. Memberships to the Austin Club, TSAE, ASAE and other licensing requirements for TDA staff.

14ee. Press clippings and other

subscriptions used in the

Central Office.

14ff. Advertising cost for open staff positions.

14gg. Travel expenses for Executive Director and TDA staff not

related to a council or committee.

15a. Travel reimbursement for the President while on TDA business.

15b. Stipend paid to the President.

15c. Travel and per diem

reimbursement for the

President-Elect while on TDA business.

15d. Stipend paid to the PresidentElect.

15e. Travel and per diem

reimbursement for the Past President, previously included in the Other Officers line.

15f. Travel and per diem

reimbursement for the

Secretary-Treasurer while on TDA business.

15g. Stipend paid to the SecretaryTreasurer.

15h. Travel expenses for the Editor.

15i. Stipend paid to the Editor.

15j. Travel and per diem

reimbursement for the four Vice Presidents while on TDA business.

15k. Travel and per diem

reimbursement for the four Senior Directors while on TDA business.

15l. Travel and per diem reimbursement for the four Directors while on TDA business.

15m. Travel and per diem

reimbursement for the Speaker of the House and Parliamentarian while on TDA business.

15n. Costs associated with conducting Board meetings such as coffee, soft drinks, lunches, Board dinners (the cost of the Board lunch and dinner is deducted from BOD per diem), mailing and printing of Board-approved communications and

conference calls.

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15o. Costs for board.docs, an

electronic governance software.

16a. Meeting and travel costs for the Committee on Access to Care Medicaid and CHIP which monitors access to care and state funding issues.

16b. Meeting costs and travel

reimbursement for committee that oversees the investments of the Reserve Fund and the TDA Relief Fund.

16c. Cost of awards presented by the TDA, including meeting and travel reimbursement costs for committee.

16d. Meeting costs and travel

reimbursement for committee that formulates initial

budget recommendations for the Board of Directors.

16e. Meeting costs and travel

reimbursement for committee that administers Building Fund and is responsible for oversight of the building.

16f. Meeting costs, travel

reimbursement, and projects of the Communications Committee.

16g. Meeting costs and travel

reimbursement for committee that monitors the TDA

financial functions.

16h. Meeting costs, travel

reimbursement, G.O.L.D.

Reception, and projects of the New Dentist Committee.

16i. Meeting costs to discuss

personnel issues. Minimal costs are budgeted as this committee meets in conjunction with Board Meetings or by telephone conference.

16j. Oversight of the strategic plan is accomplished through the Future Focus Committee.

17a. Reimbursement for travel, meeting costs, and council projects for the Council on

Annual Session.

17b. Reimbursement for travel, meeting costs, and council projects for the Council on

Legislative and Regulatory Affairs.

17c. Reimbursement for travel, meeting costs, and council projects for the Council on Constitution and Bylaws.

17d. Administrative support for DENPAC. 17e. Reimbursement for travel, meeting costs, and council projects for the Council on Dental Economics.

17f. Reimbursement for travel, meeting costs, and council projects for the Council on Dental Education, Trade, and Ancillaries.

17g. Reimbursement for travel, meeting costs, and council projects for the Council on Ethics and Judicial Affairs.

17h. Reimbursement for travel, meeting costs, and council projects for the Council on Member Services.

17i. Reimbursement for travel, meeting costs, and council projects for the Council on Peer Review plus training sessions for component officers.

18a. Reimbursement for travel and hotel for 44 Delegates and

Alternates to attend the ADA Annual Session and Pre-Caucus, and meeting costs of printing, postage and supplies.

18b. Printing, supplies, meeting rooms and general expenses associated with the 15th Trustee District Headquarters at the ADA Annual Session.

18c. Reception given by the TDA at the ADA Annual Session.

19a. Costs of luncheon for 50 Year and Life Members at the TDA Annual Session.

19b. Costs associated with meetings of the TDA House of Delegates, including reference committees.

19c. Costs for breakfast for Past Presidents and Past Vice

Presidents at Annual Session.

20. Estimated costs for federal income taxes for non-related business income.

21. Settlement paid for the

National Labor Relations

Board claim.

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While youâ&#x20AC;&#x2122;re at tda.org, be sure to check out the following:

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Oral and Maxillofacial Pathology Case of the Month Case History A 14-year-old female was referred by her general dentist to the oral surgeon for evaluation and management of a large expansile lesion associated with the left buccal cortex of the mandible. The area demonstrated recent growth by report. The patientâ&#x20AC;&#x2122;s medical history was non-contributory. Clinically, tooth #21 was missing and teeth #20 and #22 were converging onto each other. Firm, mild expansion of the mandibular buccal cortex in the area of #21 was appreciated. Intermittent neurosensory changes were reported but not reproducible. No lymphadenopothay or overlying mucosal changes were appreciated. Teeth #20 and #22 responded normally to electric pulp testing (E.P.T.) and cold testing. Radiographically, there was a large, well circumscribed, unilocular radiolucency associated with unerupted tooth #21, and it appeared as if the lesion extended almost to the apex of the tooth (Figures 1a and 1b). Significant displacement of the roots of teeth #20 and #22 were observed. The CT scan showed that the inferior alveolar canal had been displaced as well. It also revealed a thinning of the inferior border of the mandible and all cortices were intact. Aspiration of the lesion revealed serosanguinous fluid.

Juliana Robledo, D.D.S., South Texas Oral Pathology, San Antonio, Texas; and James B. Mazock, D.D.S., private practice of oral and maxillofacial surgery, San Antonio, Texas

Robledo

Mazock

Figure 1a. Panoramic radiograph showing a large radiolucent lesion associated with unerupted tooth #21

The tooth and associated cystic lesion was removed by the oral surgeon and submitted for histologic examination.

Histologic sections showed a well defined tumor surrounded by a thick fibrous capsule (Figure 2).

The tumor was arising from a thin epithelial lining and it consisted of a proliferation of polyhedral to spindle cells organized in sheets and lobules (Figure 3). Within this cellular proliferation there were rosettes and duct-like structures composed of columnar epithelial cells (Figure 4). Some foci of pink, somewhat calcified material was present associated with the tumor cells.

What is your differential diagnosis?

See page 314 for the diagnosis.

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Figure 1b. Reformatted three dimensional image from cone-beam.

Figure 2. Thick fibrous capsule surrounding the tumor (2.5x magnification).

Figure 4a. Duct-like structure in the tumor (40x magnification).

Figure 3a. Tumor consists of sheets and lobules composed of polyhedral to spindle cells (4x magnification).

Figure 4b. Rosette in the tumor (40x magnification).

Figure 3b. Small pseudoducts and pink calcifying material seen within the tumor (20x magnification).

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r P

w e i v e

Improved Temporization with Modern Materials

Mark Kleive, D.D.S.

Kleive

Mark Kleive, D.D.S., and Richard Hunt, III, D.D.S. “Yes Marge, These Are Just the Temporaries!”: A Hands-on Workshop Thursday, May 5, 2011 8:00 AM – 4:00 PM Mark Kleive, D.D.S., and Sheri Kay, R.D.H., M.S. You’re Hired! And We’d Like the Rest of You to Stay Friday, May 6, 2011 8:30 AM – 11:30 AM 1:30 PM – 4:30 PM (repeat)

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The placement of temporary restorations is common in all dental practices because it allows patients to use their teeth during the manufacturing phase of their restorative treatment. While the dental profession has not placed much emphasis on the importance of well-fabricated temporaries because their service is usually short in duration, the opportunity to improve patient comfort, practice efficiency and communication with the laboratory technician exists if we utilize modern materials and techniques.

Temporary Materials For many years, polymethyl methacrylate (PMMA), polyethyl methacrylate (PEMA), and various types of preformed crowns were the industry standard materials for temporary restorations. While many of their properties were acceptable for use by the patient and in communication with the dental technician, these products were not as efficient or effective to use (in the hands of the average dental team member, including the dentist) as modern materials. In particular, the modern, widely-used chemical cured composite resins (bis-acrylates) facilitate fabrication more efficiently and in ways that enhance the many functions of temporaries.

The most popular temporary materials on the market today are the chemical cure composite resins, which include products such as ProTemp™ (3M ESPE US), Luxatemp® (DMG America), and Integrity (DENTSPLY International).

The Advantages of Bis-acrylate Materials:

They are widely available in many shades. They dispense easily. Minimum heat is required for setting. There is very little shrinkage. They have excellent biocompatibil-

Texas Dental Journal l www.tda.org l March 2011

ity. They can be polished with existing armamentarium. They lack objectionable smell or taste. They can be repaired easily. Their color is stable.

They resist wear.

Functions of Temporaries A well-fabricated temporary provides the opportunity to influence the final restorative outcome by demonstrating appropriate tooth form, establishing a consistent color, supporting gingival health, providing occlusal support, maintaining arch space, and improving communication among the dentist, patient, and dental technician. Communicating Tooth Form: The temporaries offer an important guide for fabrication of the definitive restoration. The most efficient way to communicate the desired final tooth form to the dental technician is to provide a sample of this form by including a model of the temporary in the arch (1). While the laboratory technician’s ability to accurately “copy” the exact contours of a temporary restoration may be limited, the goal is to closely follow the accepted contours to maintain the length, form, tooth position, and phonetics for the patient. The goal is to leave as little to interpretation as possible. An accurate guide with temporaries will allow the dental technician to use his or her artistry within the parameters of what the patient has already experienced as acceptable (2). A written description of the desired changes wanted, even an average likeness of the desired outcome such as a photograph and/or an impression of the temporary, will do more to improve the communication process between the dentist and dental technician. Communicating Tooth Color: Most temporary materials have industry-standard tooth shades (A1, A2, B1, and so on) that can be used to communicate the desired color outcome to both the patient and the dental technician. The additional translucency and charac-

terization of porcelain will add further aesthetic value for the patient. Supporting Gingival Health: Well-fabricated temporaries help support gingival health for the final restoration. The patient can brush and floss normally and keep the tissues in excellent health. There is significant gratification for the dentist and benefit for the patient when, after removing a temporary restoration, the gingival is healthy and ready to support an optimal cementation or bonding environment. Temporaries also have the additional benefit of sculpting the soft tissue contours adjacent to natural teeth, implants and pontic sites (3). Providing Occlusal Support and Maintaining Arch Space: It is widely known that teeth can move or shift without appropriate support from the adjacent and opposing teeth. The goal for the dental team is to minimize this risk as much as possible as it may have a significant effect on the efficiency of seating the final restoration. Trial Phase Communication: While the dentist and patient can compare study models or wax-ups of the intended definitive treatment, nothing will provide as much information to both parties as well-fabricated temporaries that have been tried in the mouth during a trial phase. Most importantly, this trial phase allows the patient to experience changes in contour, texture, bite, and color and offer valuable feedback (4).

This builds additional trust and rapport between the patient and dentist. With this information, the dentist, patient, and dental technician can move confidently forward with the permanent treatment phase and expect excellent results.

Using Chemical Cure Composite Resins (Bis-Acrylates) While bis-acrylates are the most widely used temporary materials in dentistry and their handling characteristics are well known, many dentists are inexperienced when it comes to proper technique from dispensing to insertion. Below is a simple, yet efficient outline for fabrication that yields superior results: Fabricate matrix of intended tooth form using either a clear acrylic sheet or silicone laboratory putty. Fill matrix with bis-acrylate material. Place matrix over prepared teeth based upon the manufacturer’s recommendations and then remove.

Evaluate temporary for voids and add flowable composite if necessary. Place

Figure 1. The patient wants to improve his smile with restorations on the maxillary incisors.

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Improved Temporization temporary in heat environment â&#x20AC;&#x201D; under curing light or in hot water, to increase the density of the bis-acrylate. Place temporary in rubbing alcohol solution for 30 seconds to dissolve air-inhibited layer. Trim any gross excess with acrylic bur. Polish in successive stages with silicone point, bristle brush, and rag wheels. Evaluate for fit intra-orally and adjust as necessary. Cement in place with appropriate temporary material. The individual clinical situation (for example, a single crown, multiple anterior crowns, or veneers) may require additional steps, such as placement of characterizing tints or stains. The goal is to achieve temporaries that most closely match the desired final restorations. Most clinicians find it easier to practice the outlined fabrication on posterior temporaries and later move with confidence to anterior temporaries.

Figure 2. Close-up image demonstrates the existence of two PFM crowns and rotated lateral incisors.

Improved Efficiency and Results Frank Spear writes that three things facilitate the fabrication of excellent temporaries: time, proper materials, and proper technique (5). Experience has demonstrated that when proper materials are used with proper techniques, the results are improved, and although it takes a bit more time to fabricate the temporaries, the efficiency gained in communication and delivery of the final restorations saves more time and increases profitability. The patientâ&#x20AC;&#x2122;s experience is more satisfactory, supporting happy relations, doctor-patient trust, and referrals. The dentist and lab technician experience improved relations and satisfaction with their partnered results.

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Figure 3. A silicone matrix is fabricated from a wax-up of the desired final contours.

Figure 4. The tooth preparations are completed and an impression is made.

References 1. Fondriest JF. Using provisionals to improve results in complex esthetic restorative cases. Pract Proced Aesthet Dent 2006;18(4):217-224.

2. Magne M, Magne P, Cascione D, Munck I. Optimized laboratory-fabricated provisionals. Dental Dialogue 2006; April.

3. Magne P, Magne M, Belser U. The diagnostic template: a key element to the comprehensive esthetic treatment concept. Int J Periodontics Restorative Dent 1996;16(6):560-9.

4. Donovan TE, Cho GC. Diagnostic provisional restorations in restorative dentistry: the blueprint for success. J Can Dent Assoc 1999;65(5):260-2.

5. Spear FM. The art of temporization.

Spear Perspective; 1(1). Great Lakes Orthodontics, Ltd.

Figure 5. The bis-acrylate material is placed into the matrix, applied to the teeth, and then removed.

Figure 6. A simple armamentarium is used to trim the temporaries.

Figure 7. The temporaries demonstrate a preview of the final restorations for the patient, dentist, and technician.

Figure 8. The final restorations follow the design of the temporaries and provide a pleasing aesthetic result.

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Oral and Maxillofacial Pathology Diagnosis and Management

Adenomatoid Odontogenic Tumor Oral and Maxillofacial Pathology Case of the Month (from page 308)

Discussion Adenomatoid odontogenic tumor (AOT) is classified as a benign odontogenic tumor. The tumor cells are derived from enamel organ epithelium and it is characterized by the presence of unusual ductlike or gland-like structures. AOT is a relatively uncommon neoplasm, representing 2 percent to 7 percent of all odontogenic tumors (1-3). This tumor is seen more often in young patients between the ages of 10 to 19 and females are affected more than males. The anterior portion of the jaws are affected more frequently than the posterior regions and the maxilla is involved twice as often as the mandible. The most common clinical presentation of AOT is in association with an unerupted maxillary canine, presenting as a slow-growing, symptom free lesion which is frequently discovered during a routine radiographic examination. Larger lesions may cause some bony expansion (1-4).

There are various types of adenomatoid odontogenic tumors.

They can occur intraosseously and extraosseously. The intraosseous

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AOT may be radiographically divided into two types: follicular or dentigerous type and extracoronal type.

The follicular or dentigerous type is associated with the crown of an unerupted tooth. The extrafollicular, or extracoronal type, is not associated with an impacted tooth but may occur in the interradicular areas of erupted teeth. The follicular type appears as a unilocular radiolucency involving the crown of an unerupted tooth and sometimes extends apically along the root, past the cementoenamel junction. The extracoronal type is also a well defined unilocular radiolucency located between or superimposed upon the root of an erupted tooth, likely a result of trapped enamel epithelium during development. The extraosseous or peripheral type of AOT occurs on the gingival tissues; it is rarely detected radiographically but may develop slight erosion of the underlying alveolar bony cortex. This type is often clinically diagnosed as a gingival fibroma. Adenomatoid odontogenic tumors may appear completely radiolucent, however in some cases; small fine calcifications are present and may be helpful in differentiating them from a dentigerous cyst (3-6).

Histologically, the AOT is a well defined lesion, which is usually surrounded by a thick fibrous capsule.

The lesion itself has very distinctive features; however it may demonstrate proliferation into the lumen mimicking a solid tumor or show varying degrees of cystic change (1-3). The tumor consists of sheets, strands, or whorled masses of spindle-shaped cells in a scant fibrous stroma (1-3).These cells are positive for cytokeratyns (7). The cells may form rosette-like structures about a central space which may or may not contain an eosinophilic material. This material stains positive for amyloid.

The characteristic duct-like structures in the AOT may be prominent, scant or even absent. These structures consist of a central â&#x20AC;&#x153;lumenâ&#x20AC;? surrounded by a layer of columnar or cuboidal epithelial cells. The nuclei of these cells are polarized away from the center. These structures are not true ductal elements. Small calcified foci can be seen throughout the tumor and it is believed to represent abortive enamel formation.

Large areas of a pink matrix material has also been reported to occur in AOT and may represent dentinoid or cementum. The number, size, and

degree of calcifications in this tumor determines how the lesion presents radiographically (1-7).

A well defined radiolucent lesion surrounding an impacted tooth is highly suggestive of an odontogenic cyst or neoplasm. The clinical and radiographic presentation of this patient favored various developmental and neoplastic conditions over some kind of inflammatory process (2,3,6). The first consideration was a dentigerous cyst, it is the most common developmental odontogenic cyst and it arises in association with an impacted tooth. The dentigerous cyst is usually detected on a routine radiographic examination and presents as a well defined unilocular radiolucency. An odontogenic keratocyst (OKC) can be radiographically identical to a dentigerous cyst. Aspiration of an OKC may be creamy, thick, or keratinatious, however in this case there was serosanguinous, straw-colored fluid upon aspiration (3).

Another consideration was unicystic ameloblastoma. The radiographic features, age of the patient and site of the lesion were supportive of this diagnosis. Ameloblastic fibroma, a benign odontogenic tumor which occurs mostly in the posterior mandible of young patients as a unilocular radiolucency associated with an impacted tooth, also had to be considered. Finally, the adenomatoid odontogenic tumor typically affects teenagers, presents as an asymptomatic well defined unilocular radiolucency involving the crown of an unerupted tooth, and sometimes extends apically along the root, past

the cementoenamel junction. This characteristic may help differentiate this lesion from a dentigerous cyst.

The AOT is more likely to occur in the anterior maxilla, different from this case which is located in the posterior mandible (2,3).

The treatment of choice is conservative surgical enucleation. The thick capsule usually surrounding this tumor makes enucleation favorable to remove the lesion in its entirety.

Aggressive behavior has not been reported, however large tumors have had more aggressive approaches to treatment such as large resections with iliac bone grafts. No recurrences of AOT have been reported and therefore the prognosis is excellent.

In our case the inferior border was intact but compromised and additional support was achieved via a lingual splint wired to the mandibular dentition. The patient is an otherwise healthy teenager and will likely have spontaneous bone growth in the defect, therefore grafting procedures were deferred. The patient is healing without incident for a followup period of 6 months (1-3,6).

Pathol Oral Radiol Endod 2004; 98: 511-515.

4. Philipsen HP, Reichart PA, Zhang KH, Nikai H, Yu QX. Adenomatoid odontogenic tumor: biologic profile based on 499 cases. J Oral Pathol Med 1991; 20: 149-58 5. Swasdison S, Dhanuthai K, Jainkittivong A, Philipsen HP Adenomatoid odontogenic tumors: an analysis of 67 cases in a Thai population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105: 210-215.

6. Philipsen HP, Reichart PA, Adenomatoid odontogenic tumor: facts and figures. Oral Oncol 1999; 35: 125-31 7. Martinez A, Mosqueda-Taylor A, Marchesani F, Brethauer U, Spencer ML Adenomatoid odontogenic tumor concomitant with cystic complex odontoma: Case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 108: e25-e29.

References 1. ORAL PATHOLOGY: Clinical Pathologic Correlations. Regezi JA, Sciubba JJ, Jordan RC. 4th Edition. Saunders 2003.

2. Oral and Maxillofacial PATHOLOGY. Neville BW, Damm DD, Allen CM, Bouquot JE. Third Edition. Saunders Elsevier 2009.

3. Litonjua LA, Aguirre A, Estrada MC. Radiolucency in the mandible. Oral Surg Oral Med Oral

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In Memoriam Those in the dental community who have recently passed Alexander, Kenneth Vaughn Vidor, Texas August 27, 1939 – December 23, 2010 Good Fellow, 1991 • Life, 2004 Crabtree, Leonard Eugene Houston, Texas March 16, 1934 – January 4, 2011 Good Fellow, 1989 • Life, 2000 Inman, Thomas Carroll Houston, Texas October 31, 1931 – December 25, 2010 Good Fellow, 1985 • Life, 1997 • Fifty Year, 2010 Richardson, James Matthew Hallsville, Texas June 6, 1945 – January 2, 2011 Good Fellow, 1998 • Life, 2010

Memorial and Honorarium Donors to the Texas Dental Association Smiles Foundation

In Honor of: Dr. Dan Macauley

By Bobby M. Boaz

Dr. & Mrs. Thomas Randers

By Dr. Barry Currey

In Memory of: Margie Springfield

By Dr. & Mrs. Russell & Paula Owens Kenneth Naylor, Sr.

By Dr. Charles Robertson Shigemi Glenn Seno

By Charles Robertson Eleanor Blaschke

By Beverly Zinser Sylvia Lankford

By Beverly Zinser

Dr. Lewis Gilcrease

By Dr. Robert Tocker Robert Huelskamp

By Beverly Zinser James Hyman

By Beverly Zinser Marie King Drs. Jamie and Jennifer Bone Mr. & Mrs. Noel Bryant Drs. Jamie and Jennifer Bone

Your memorial contribution supports: • educating the public and profession about oral health; and • improving access to dental care for the people of Texas.

Please make your check payable to:

TDA Smiles Foundation, 1946 S IH 35, Austin, TX 78704

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Provided by TDA Perks Program

value for your

profession Critical Terms to Negotiate When Leasing Office Space Evan Reynolds, The Reynolds Company As a dental professional, you’ll probably lease office space at

least once during your career. The

process can be daunting, as you’re

introduced to a number of new concepts and terms. Obviously, there are legal and real estate experts

that can assist you in the process however it’s extremely beneficial if you also possess some basic

knowledge. The following is a brief overview of the critical items that

should be addressed in the leasing process.

It’s important to first establish how much square footage you’ll be leasing, and exactly how it will be calculated. There’s a standard methodology for measuring space, and you’ll want to make sure that both parties are on the same page. You may also want to have a mechanism in the lease that allows for a re-measurement

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once you occupy the space, to be certain you have an accurate number.

Assuming your lease space will require the construction of interior improvements, you’ll need to negotiate a period of time to complete these improvements without incurring rental cost. I recommend you get at least 120 days for interior construction before any rental payments are due. It will likely take you 75 to 100 days to complete construction.

The key related economic items to be negotiated include: the lease term, rental rate, and tenantimprovement allowance. The tenant-improvement allowance is the amount of money the landlord gives you to help construct your interior improvements. Each of these items affects the others in most negotiations. For example, the longer the lease term, the higher the tenant improvement allowance you can get. The longer the lease term, the lower the rental rent will be in most cases. The vast majority of dental leases are at least 7 years in length; most being 10 years. Leasing a dental office is an expensive, long-term commitment and the terms negotiated need to be consistent with that fact, i.e. a longer lease term will provide more allowance money and greater cost certainty for a longer period. The obvious primary objective is to negotiate for the lowest rental rate and highest tenant improvement allowance. The overall economics of the transaction can also be enhanced by negotiating for free rent to start the lease term.

Another key economic item in an office lease is establishing how the landlord will charge you for the cost of operating the building. You will pay your proportionate share of these costs in a building where there are multiple tenants. You will pay all of these costs in a building where you are the only tenant. There are some standard definitions for establishing legitimate operating expenses that can be charged to a tenant.

You will need to make sure that these items are well defined, as well as the process for annual operatingexpense reconciliation.

Negotiating for renewal options beyond the original term is very important for a dental tenant because of the disruptions and expenses related to moving. You want make sure you have the option to stay for an extended period if you choose. It’s typical to negotiate the right to extend your lease for two or three 5-year periods after the initial term expires. I prefer that the

rent during these renewal terms be at market rates.

Some would argue that it is better to pre-negotiate these rates far in advance to ensure there won’t be a significant increase at the time of renewal. In my opinion, the market rate at the time of renewal is almost always lower than a rate that is pre-negotiated for far into the future. You will have to negotiate the market terms each time you renew the lease, but I believe that the savings will be well worth it.

You must also understand the existing condition of the space, including all mechanical, electrical, and plumbing systems. A dental office requires above-standard electricity and extensive plumbing. The landlord will often have little knowledge of these systems, so it’s important to have an experienced dental contractor tour the space to make sure there are no problems. Not having enough power or plumbing capacity can be disastrous if you find out after you have already signed your lease.

It is critical to negotiate for the right to assign or sublease your space, particularly in a situation where you sell your practice. It’s standard in most leases to allow you to sublease or assign the lease, but it also typically mandates that you remain a guarantor on the lease if you sell your practice. You’ll want to make sure you’ll be relieved of the entire lease obligation once you sell your practice to another dentist.

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Another critical item to negotiate is the right to be the exclusive provider of dental services in the real estate project. This is typically more important if you are in a retail project; not as much if you are in a multi-tenant office building or professional office park. Usually, you’ll want this exclusive to be as broad as possible, to eliminate the possibility of competitors leasing space in the same project. You’ll also want to make sure you understand any exclusives that may already be in place. For example, there may be an orthodontist in a project that has an exclusive to provide orthodontic services. This would obviously prevent a general dentist from doing the same if he or she were to lease space in the same project.

In almost all cases, the landlord will want you to personally guarantee the lease for the entire lease term. You want to try to limit the guarantee to only a few years, or possibly limit the guarantee to only the amount paid by the landlord for the tenant improvement allowance and leasing commissions.

Other items that need to be addressed include: parking, signage, and the non-disturbance agreement.

You may want to negotiate for reserved parking in some cases, particularly in a busy retail project. It is important to get as much signage as you can get.

This may include building, pylon, monument, and suite signage. You’ll want to try to get the landlord to agree to provide a non-disturbance agreement, which will ensure that your lease will not be affected, should the landlord default on its loan and the project enters foreclosure. Most landlords don’t want to provide this document for smaller tenants but it’s important to secure if you can, particularly given the number of foreclosures that occur in the current economic climate.

Negotiating a dental office lease can be an intimidating process; however, with the help of experienced professionals and a basic understanding of the key lease concepts, you can secure a quality lease that will protect your interests for many years to come.

The author, Evan Reynolds, is president of TDA Perks Partner The Reynolds Company, a healthcare real estate services firm that specializes in helping Texas dental professionals with their office space needs. The company is headquartered in Dallas, and has offices in Austin and Houston. For more information regarding The Reynolds Company, visit thereynoldscompany.com, or call (972) 231-8900.

For information regarding other TDA Perks Programs, visit tdaperks.com, or call (512) 443-3675.

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April 2011 11 – 13 The American Association of Public Health Dentistry will hold its National Oral Health Conference at the Hilton Pittsburgh in Pittsburgh, PA. For more information, please contact Ms. Pamela J. Tolson, CAE, 3085 Stevenson Dr., Springfield, IL 62703. Phone: (217) 529-6941; FAX: (217) 529-9120; E-mail: natoff@aaphd.org; Web: aaphd.org.

13 – 16 The American Association of Endodontists will hold its annual session at the San Antonio Convention Center in San Antonio, TX. For more information, please contact Mr. James M. Drinan, AAE, 211 E. Chicago Ave., Ste. 1100, Chicago, IL 60611-2616. Phone: (312) 266-7255; FAX: (312) 266-9867; E-mail: jdrinan@aae.org; Web: aae.org.

15 & 16 The TDA Smiles Foundation (TDASF) will hold a Texas Mission of Mercy event in Dallas, TX. For more information, please contact TDASF, 1946 S. IH 35, Ste. 300, Austin, TX 78704; Phone: (512) 448-2441; Web: tdasf.org.

28 – 30 The American Dental Society of Anesthesiology will hold its annual meeting at the Westin Keirland Resort & Spa in Scottsdale, AZ. For more information, please contact Ms. Barbra Josephson, ADSA, 211 E. Chicago Ave., Ste. 780, Chicago, IL 60611. Phone: (312) 664-8270; FAX: (312) 642-9713; E-mail: barbra.josephson@ mac.com; Web: adsahome.org.

May 2011 5–8 The Texas Dental Association will hold its 141st annual session, The TEXAS Meeting, at the Henry B. Gonzalez Convention Center in San Antonio, TX. For more information, please contact TDA, 1946 S. IH 35, Ste. 400, Austin, TX 78704. Phone: (512) 443-3675; FAX: (512) 443-3031; Web: texasmeeting.com.

6 The TDA Smiles Foundation (TDASF) will hold its Healthy Smiles Golf Classic in San Antonio, TX. For more information, please contact TDASF, 1946 S. IH 35, Ste. 300, Austin, TX 78704; Phone: (512) 448-2441; Web: tdasf.org.

9 – 11 The ADA will hold its Washington Leadership Conference in Washington, D.C. For more information, please contact Mr. Brian Sodergren, ADA, 1111 14th St., NW, Ste. 1100, Washington, DC 20005. Phone: (202) 7895168; FAX: (202) 789-2258; E-mail: sodergrenb@ada.org; Web: ada.org.

17 – 21 The American Academy of Cosmetic Dentistry will hold its annual scientific session at the Hynes Convention Center in Boston, MA. For more information, please contact Ms. Kelly Radcliff, AACD, 5401 World Dairy Dr., Madison, WI 53718. Phone: (800) 543-9220; FAX: (608) 222-9540; E-mail: kelly@aacd.com; Web: aacd.com.

26 – 29 The American Academy of Pediatric Dentistry will hold its 64th annual session at the Marriott Marquis New York in New York, NY. For more information, please contact Dr. John S. Rutkauskas, CAE, AAPD, 211 E. Chicago Ave., Ste. 1700, Chicago, IL 60611-2663. Phone: (312) 337-2169; FAX: (312) 337-6329; E-mail: jrutkauskas@aapd.org; Web: aapd.org.

June 2011 11 The TDA Smiles Foundation (TDASF) will hold a Smiles on Wheels mission in Mineral Wells, TX. For more information, please contact TDASF, 1946 S. IH 35, Ste. 300, Austin, TX 78704; Phone: (512) 448-2441; Web: tdasf.org.

15 – 18 The ADA will hold its 25th New Dentist Conference in Chicago, IL. For more information, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org.

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23 – 25 The ADA Council on Access, Prevention and Interprofessional Relations (CAPIR) will meet in Chicago, IL. For more information, please contact Ms. Carrie Campbell, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-2500; FAX: (312) 440-7494; E-mail: campbellc@ada.org; Web: ada.org.

July 2011 15-17 ADPAC, the American Dental Political Action Committee, will meet. For more information, please contact Ms. Cynthia Taylor, ADA, 1111 14th St., N.W., Ste. 1200, Washington, D.C. Phone: (202) 789-5172; FAX: (202) 898-2437; E-mail: taylorc@ada.org.

28 – 31 The Academy of General Dentistry will have its annual meeting and exhibition at the Ernest Morial Convention Center in New Orleans, LA. For more information, please contact Ms. Rebecca Murray, AGD, 211 E. Chicago Ave., Ste. 900, Chicago, IL 60611. Phone: (312) 440-3368; FAX: (312) 440-0559; E-mail: agd@agd.org; Web: agd.org.

28 – 30 The International Association of Comprehensive Aesthetics will meet at the Manchester Grand Hyatt in San Diego, CA. For more information, please contact Ms. Mary Williams, IACA, 1401 Hillshire Dr., Ste. 200, Las Vegas, NV 89134. Phone: (888) NOW-IACA; FAX: (702) 341-8510; E-mail: info@theiaca.com; Web: theiaca.com.

August 2011 5&6 The TDA Smiles Foundation (TDASF) will hold a Texas Mission of Mercy event in Texarkana, TX. For more information, please contact TDASF, 1946 S. IH 35, Ste. 300, Austin, TX 78704; Phone: (512) 448-2441; Web: tdasf.org.

18 & 19 National Conference on Dentist Health and Wellness will be in Chicago, IL. For more information, please contact Ms. Mary Gilliam, ADA, 211 E. Chicago Ave., Chicago, IL 60611-2678. Phone: (312) 440-2500. FAX: (312) 440-7494; E-mail: online@ada.org; Web: ada.org.

September 2011 12 – 17 The American Association of Oral and Maxillofacial Surgeons will meet at the Pennsylvania Convention Center in Philadelphia, PA. For more information, please contact Dr. Robert C. Rinaldi, AAOMS, 9700 W. Bryn Mawr, Rosemont, IL 60018. Phone: (847) 678-6200; FAX: (847) 678-6286; Web: aaoms.org.

14 – 17 The FDI Annual World Dental Congress will meet at the Banamex Convention & Exhibition Centre in Mexico City, Mexico. For more information, please contact Mr. John Hern, FDI/USA Section, ADA, 211 E. Chicago Ave., Chicago, IL 60611; Phone: (800) 621-8099 ext. 2727; FAX: (312) 440-2707; E-mail: hernj@ada.org.

22 – 27 The ADA Kellogg Executive Management Program will be in Chicago, IL. For more information, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Ave., Chicago, IL 60611; Phone: (312) 440-2599; FAX: (312) 4402883; E-mail: polanieckir@ada.org; Web: ada.org.

The Texas Dental Journal’s Calendar will include only meetings, symposia, etc., of statewide, national, and international interest to Texas dentists. Because of space limitations, individual continuing education courses will not be listed. Readers are directed to the monthly advertisements of courses that appear elsewhere in the Journal.

Calendar of Events

17 – 18 The Southwestern Society of Oral Medicine will hold its 62nd annual meeting, “Diabetes, Inflammatory Periodontal Disease and the Relationship to Systemic Health,” at the Marriott Plaza San Antonio Hotel in San Antonio, TX. For more information, please contact Dr. Ron Trowbridge, 2943 Thousand Oaks, Ste. 4, San Antonio, TX 78247. Phone (210) 653-7174; FAX (210) 653-8204.

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e v Ad IMPORTANT: Ad briefs must be in the TDA office by the 20th of two months prior to the issue for processing.

For example, for an ad brief to be included in the January issue, it must be received no later than November 20th. Remittance must accompany classified ads. Ads cannot be accepted by phone or fax. * Advertising brief rates are as follows: 30 words or less — per insertion…$40. Additional words 10¢ each.

The JOURNAL reserves the right to edit copy of classified advertisements.

Any dentist advertising in the Texas Dental Journal must be a member of the American Dental Association.

All checks submitted by non-ADA members will be returned less a $20 handling fee. * Advertisements must not quote revenues, gross or net incomes. Only generic language referencing income will be accepted. Ads must be typed.

Briefs

Practice Opportunities MCLERRAN AND ASSOCIATES: AUSTIN: Associate to purchase. High grossing, family practice located in retail center with seven operatories was recently remodeled. Near major freeway. High growth area. Practice boasts solid, well-established patient base. ID #108.

AUSTIN: North, high grossing, five operatory practice in free-standing building. Plenty of room to expand. Fee-for-service patient base, good equipment. Owner wishes to sell and continue part-time as an associate. ID #115.

NEW! AUSTIN: Unique, quality fee-for-service practice in five operatory free-standing building. Grossed near seven figures, boasts quality staff and well-established patient base. ID #123.

NEW! AUSTIN: Newly built out, seven operatory (four equipped) practice in high growth, affluent area in northwest. Practice grossed mid-six figures on limited schedule in second year, is equipped and priced like a startup. Excellent opportunity with tremendous upside. ID #124.

NEW! AUSTIN: Two operatory practice in free-standing building grossing low six figures on a part-time schedule. Practice and real estate available in transition. ID #125.

CORPUS CHRISTI: Doctor retiring, six op office with excellent visibility and access.

Good numbers, excellent patient base, good upside potential. Excellent practice for starting doctor. Priced to sell. ID #023.

CORPUS CHRISTI: Three operatory, fee-forservice/crown and bridge oriented family practice in great location. High grossing practice on 3-day week! Doctor ready to retire. Make an offer. ID #098.

RIO GRANDE VALLEY: Excellent four operatory, 20-year-old general practice. Modern, new finish out in retail location with digital

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radiography. Fee-for-service patient base and very good new patient count. Great numbers. Super upside potential. ID #093.

SAN ANTONIO: Prosthodontic practice with almost new equipment and build out. Doctor wants to sell and continue to work as associate. Beautiful office! Perfect for stand alone or satellite office. ID #060.

SAN ANTONIO, NORTH CENTRAL: Twoop practice just off major freeway; perfect starter office. Terrific pricing. ID #009.

SAN ANTONIO: Four operatory general family practice located in professional office building off of busy thoroughfare in affluent north central side of town. Very nice equipment and decor. Excellent opportunity. ID #003.

SAN ANTONIO: Well-established, endodontic specialty practice with solid referral base. Located in growing, upper middle income area. Contact for more information.

ID #074.

SAN ANTONIO: Oral surgery specialty practice. Very good referral base. Almost new build out, great location, and excellent equipment. Good gross and net. Transition available. ID #113.

SAN ANTONIO, NORTH CENTRAL: Six operatory general practice located in high growth area- All operatories have large windows with great views. Very nice equipment, solid patient base, great hygiene program.

Priced to sell. ID #112.

SAN ANTONIO, NORTH CENTRAL: Three operatory office in retail/office center with great visibility and access. New equipment and nice build out. Good solid numbers, very low overhead. ID #111.

SAN ANTONIO: Six operatory practice with three chair ortho bay located in 3,400 sq. ft. building. Modern office with newer equipment. Free-standing building on busy thoroughfare. Practice has grossed in seven figures for last 3 years. Great location with super upside potential. ID #055.

SAN ANTONIO, NORTH CENTRAL: Five operatory, state-of-the-art facility with new equipment. Located in a medical professional building in high growth, affluent area. Grossing seven figures with high net income. ID #106.

SAN ANTONIO NORTH WEST: Excellent, four-chair general family practice in high traffic retail center across from busy mall location. Solid gross income on 30 hours/ week. Ideal opportunity for doctor wanting a quick start in low overhead operation. ID #086.

SAN ANTONIO, SOUTHEAST: Three operatory, 30-year-old practice in high traffic retail center, good equipment, solid patient base, low overhead. Perfect location for a satellite office or high gross Medicaid office. ID #121.

NEW! SAN ANTONIO, SOUTHEAST: Three operatory satellite office located in highly visible retail center. Excellent location. Practice has tremendous upside potential. ID #121.

NEW! WEST OF SAN ANTONIO: Doctor retiring. Four operatories in modern, open, freestanding building. Excellent fee-for-service patient base. Newer equipment. Very nice decor. Very nice numbers with low overhead.

Low competition in mid-sized city. ID #122.

SEGUIN: Three operatory, 30+-year-old practice with condo is priced very aggressively as doctor must sell. Call now to learn more about this great deal. ID #118.

SOUTH TEXAS BORDER: General practitioner with 100 percent ortho practice. Very high numbers, incredible net. ID #021.

WACO AREA: Modern and high-tech, three op general family practice grossing in mid-six figures with high net income. Large, loyal patient base. Office is well equipped for doctor seeking a modern office. ID #107.

Contact McLerran Practice Transitions, Inc.: statewide, Paul McLerran, DDS, (210) 7370100 or (888) 656-0290; in Austin, David McLerran, (512) 750-6778; in Houston, Tom

Guglielmo and Patrick Johnston, (281) 362-1707. Practice sales, appraisals, buyer representation, and lease negotiations.

See www.dental-sales.com for pictures and more complete information.

GARY CLINTON / PMA WEST OF FORT WORTH PRACTICE FOR SALE: A little more than an hour west of Fort Worth, this is an excellent high six-figure grossing practice with high operating profits.

Excellent recall; six operatories; fee-for-service; no DMO or low fee PPO. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.”

I personally handle every appraisal/transition/sale. No real estate commission.

Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA NORTHWEST OF DALLAS CARROLLTON AREA PRACTICE FOR SALE: Well-established practice; exceptional recall; full general service practice with lots of crown and bridge.

Retiring dentist. Will continue to work as needed 1 day per week. We have the best source for 100 percent buyer funding.

Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No real estate commission. Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATS: (800) 583-7765.

WE NEED SELLERS! Some areas reduced fees. No real estate commission. Gary Clinton / PMA. Serving the dental profession since 1973: I have buyers! Sell your practice and travel while you have your health. In many cases, you can stay on to work 1-2 days per week if you wish. I need practices to sell/transition as follows: any practice in or near Austin, San Antonio,

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DFW and Houston areas, and other Texas locations. We have buyers for orthodontic, oral surgery, periodontic, pedodontic, and general dentistry practices. Values for practices have never been higher. Tax advantages high for present time. One hundred percent funding available, even those valued at more than seven figures. Call me confidentially with any questions. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No real estate commission. Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATS: (800) 583-7765.

ORTHODONTIC PRACTICES FOR SALE / TRANSITION — GARY CLINTON / PMA TEXAS: O-1 West Central Texas mid-sized to larger community — Ideal transition; professional referral based; traditional fee-for-service, referral, highly productive.

Gorgeous building with room for two in this planned 50/50 partnership; within 5 years complete buy-out with owner working 1-2 days as needed. O-2 South Texas — Retiring orthodontist. Initial associateship with high salary, transitional sale, or immediate buy-out; seller will stay 1-2 days per week as needed. Seven figure practice collections; 60 percent profits; lovely building. He is ready to spend time with his grandchildren.

Easy drive to San Antonio. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/ transition/sale. No real estate commission.

Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA ARLINGTON PRACTICE FOR SALE: The place to be for young families. Texas Rangers baseball. Cowboys football, and Six Flags for entertainment. Well-established practice.

Excellent recare program. Near seven figure gross, over 50 percent net. Garden style offices and operatories. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute

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of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No real estate commission. Every call is very confidential.

General and specialty practice certified appraisals. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA FORT WORTH AREA GENERAL PRACTICES FOR SALE: Fl — Excellent patient base; well-established recall. Bread and butter practice.

Very fast growing area near Texas Motor Speedway. Average gross with excellent net.

F-2 — Primarily fee-for-service 30+-yearold practice in southwest Fort Worth/ White Settlement/Lake Worth area. Associate buy-out or outright sale. Solid recall program. Above average gross. F-3 — Near Burleson. Excellent practice for sale We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No real estate commission. Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATS: (800) 583-7765.

ORAL SURGERY PRACTICES FOR SALE. GARY CLINTON / PMA: OS-1 West Houston / Sugar Land area — High growth area.

State-of-the-art practice. Many referring doctors for cosmetic and implant, and reconstructive surgery. Outright sale. Sevenfigure gross. Seller and family are relocating out of state; will transition on a limited basis. OS-2 Southwest Houston — Retiring surgeon. Bread and butter practice. Sevenfigure gross on 4 days; will transition. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No real estate commission. Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA PLANO / FRISCO AREA: Future rapid growth area where people will want to live. Practice in the

middle of the high growth area. Projected seven-figure gross. Newly equipped, gorgeous office. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/ transition/sale. No real estate commission.

Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA HOUSTON PRACTICES FOR SALE: H-l North Houston. Fast growing, most requested area; seven-figure gross, high net. Nine operatories, full recall.

Very attractive large building. H-2 Well-established practice, retiring dentist. Excellent recall in southwest Houston area. H-3 Clear Lake area practice. Well-established.

Average gross. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/ transition/sale. No real estate commission.

Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA BRYAN / COLLEGE STATION PRACTICE FOR SALE: Retiring dentist; excellent visible location ready to hand over the ball to a young motivated dentist. Will transition PRN. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No real estate commission. Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA WEST TEXAS AREA WELL-ESTABLISHED PRACTICES FOR SALE: W-1 North of Lubbock — Highly productive practice; large growing patient base. Doctor will work for purchaser as needed. Purchase building outright or lease/purchase. W-2 Abilene — Retiring dentist outright sale/PRN transition; great location south side of Abilene. W-3 San An-

gelo — Excellent well-established restorative practice. Very nice newer equipment. Dentist relocation. Purchase building or lease/ purchase. Transitional or outright sale. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No real estate commission. Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA AUSTIN PRACTICE FOR SALE: Excellent practice with gross over high six figures. Building may be purchased with practice or leased with later purchase options. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/ transition/sale. No real estate commission.

Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA GARLAND PRACTICE FOR SALE: North Garland area.

Doctor retiring for health reasons; 20+ year practice. Average gross. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No real estate commission. Every call is very confidential.

General and specialty practice certified appraisals. DFW: (214) 503-9696; WATS: (800) 583-7765.

DDR PRACTICE SALES — DUNN/ISENHART: SERVING TEXAS DENTISTS FOR OVER 40 YEARS. National direct (and fax): (800) 930-8017.

CORPUS CHRISTI: Laid back lifestyle with the benefits of the Gulf Coast. Lucrative revenues on 4 days per week. Denture focus could be expanded to a broader scope of restorative general treatment. In-house lab with experienced technician. Great location, great staff, and a great lifestyle. Motivated Texas Dental Journal l www.tda.org l March 2011

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seller. High six-figure gross provides owner six-figure income. Dentists will work as associate if desired. Call DDR Practice Sales at (800) 930-8017.

BRYAN/COLLEGE STATION AREA: Wellestablished practice serving rural community of 5,000 just 20 minutes from College Station. Providing seven-figure gross collections with substantial 40 percent net.

High quality implant practice. Four fully equipped operatories, private office, two full-time hygienists and a great staff. Ownership of free-standing 1,900 sq. ft. building is optional. Over 4,000 patient base with average age of 45. Call DDR Practice Sales at (800) 930-8017.

GALVESTON: Must sell for relocation.

Thriving practice in Galveston providing the best of both worlds ... the great outdoors and a laid back lifestyle, yet quick access to metropolitan Houston. This 15-year practice has three fully equipped operatories, private office, full-time hygienist, and a great staff. Half interest in free-standing building included in price. Generating mid six-figure gross collections on only 3 days per week. Owner currently splits time with out-of-town practice. Call DDR. Practice Sales at (800) 930-8017.

AUSTIN: Five operatory, two hygienists, one associate dentist, gross of seven figures in 2010. Mature practice; doctor wants to sell practice but is also willing to work contact for buying dentist; great location in beautiful Austin. Practice in the heart of most desired city in Texas. Substantial net income with four fully equipped operatories and two full-time hygienists. Current associate will remain at buyer’s discretion. Call DDR Practice Sales at (800) 930-8017.

DALLAS: Practice in high-traffic professional building, run very lean. Mid six-figure net. Need to add patient charts to your practice? Call DDR Practice Sales at (800) 930-8017.

CORPUS CHRISTI: General dentistry practice — location, location,, location; 25-yearold practice grossed more than seven figures last year with a single dentist and one hygienist. Updated office, very profitable practice, excellent staff. Call DDR Practice Sales at (800) 930-8017.

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HOUSTON: Motivated buyer seeking Galleria area practice. Willing to acquire office, staff, or charts only. Looking to expand his practice. Call DDR Practice Sales at (800) 930-8017.

SAN ANTONIO: Beautiful fast-growing area, exceptional practice with five operatories.

Ten-year-old practice, doctor motivated to sell. Earns a seven-figure gross on 4-day week. Excellent opportunity for younger dentist to make his or her mark. Call DDR Practice Sales at (800) 930-8017.

GOLDEN TRIANGLE GENERAL DENTAL PRACTICE — SALE: Outstanding practice for sale developed by published mentor.

Supported by outstanding staff and latest in dental equipment. Strong revenues and profit margin. Excellent new patient flow.

Given high level of FFS revenues, doctor to transition to comfort level of purchaser.

Come build your retirement in low competition community. Contact The Hindley Group at (800) 856-1955. Visit us at www. thehindleygroup.com.

SOUTH HOUSTON GENERAL DENTAL PRACTICE — SALE: Most attractive office located on busy thoroughfare in rapidly growing south Houston suburb. Six treatment rooms, five fully equipped. Two additional plumbed operatories such that practice has capacity to grow well in excess of seven figures. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www. thehindleygroup.com.

NORTH TEXAS GENERAL DENTAL PRACTICE — SALE: Small, well-established practice in mid-sized community in north Texas. Three fully-equipped operatories.

Experienced staff with excellent skills. Doctor will assist with transition. Contact The Hindley Group, LLC, at (800) 856-1955.

Visit us at www.thehindleygroup.com.

CORPUS CHRISTI GENERAL DENTAL — SALE: Moderate revenues with a very healthy profit margin. Experienced and loyal staff. Totally digital and highly efficient facility layout. If you need to practice to refund your retirement, but don’t want to fight the competitiveness of the city, come see this practice. Contact The Hindley Group at (800) 856-1955. Visit us at www. thehindleygroup.com.

DFW METROPLEX ORAL SURGERY PRACTICE — SALE: Well-established practice enjoying 2009 revenues exceeding seven figures from two locations. Extensive referral base, experienced staff, and highly qualified mentor to assist in transition.

Don’t miss this opportunity. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

NORTHWEST HOUSTON GENERAL DENTAL PRACTICE — SALE: New practice in growing area located near well-traveled Highway 290 and Jones Road. Two fully equipped treatment rooms with three others plumbed for expansion. Digital X-rays.

Moderate revenues on 3.5 days per week. If you want to be in the rapidly growing NW quadrant, this practice is for you. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

SOUTH OF HOUSTON GENERAL DENTAL PRACTICE — SALE: Established practice in mid-size town generating revenues approaching seven figures the last 3 years.

Associate in place providing orthodontic treatment. Building is also for sale. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

WEST HOUSTON GENERAL DENTAL PRACTICE — SALE: Wonderful opportunity in rapidly growing community west of Houston. Excellent revenues, steady new patient flow. Four operatories. Capable staff. Contact The Hindley Group at (800) 856-1955.

Visit us at www.thehindleygroup.com.

LAS VEGAS ORAL SURGERY PRACTICE — SALE: Excellent practice with revenues of seven figures with net profit margin over 48 percent. Strong professional referral base and new patient flow. Latest in 3D digital projection including CT scanner.

Highly skilled, experienced staff. Doctor will assist in transition. Contact The Hindley Group at (800) 856-1955. Visit us at www. thehindleygroup.com.

DALLAS / FORT WORTH: Area clinics seeking associates. Earn significantly above industry average income with paid health and malpractice insurance while working in a great environment. Fax (312) 944-9499 or e-mail cjpatterson@kosservices.com.

WACO PEDIATRIC DENTAL PRACTICE — SALE: Well-established practice with moderate revenues and high profit margin on 4 days per week. Limited competition and a large facility. Ample room to grow in this community that is home to Baylor University. This is a wonderful central Texas community in which to raise your family.

All ortho cases are being completed, unless purchaser would like to expand new cases.

No Medicaid being seen, but good opportunity with facility capacity. Experienced staff and steady new patient flow. Wonderful mentor. Building also available. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

BRYAN/COLLEGE STATION GENERAL DENTAL PRACTICE — SALE: Well-established practice in mid-size town. Four operatories. Healthy revenues, excellent profit margin, and strong new patient flow. Doctor must transition due to health reasons.

Building also for sale. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

EAST TEXAS GENERAL DENTAL PRACTICE — SALE: Well-established practice in small town in hills in East Texas. Moderate revenues on 4 days per week; three operatories; excellent staff. Room to expand in adjacent space. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www. thehindleygroup.com.

FORT WORTH ORTHODONTIC PRACTICE — SALE: Excellent opportunity for satellite office; general dentist wanting to add orthodontics to services offered; female dentist desiring part-time position while children in school; or older dentist wanting to utilize orthodontics as less physically taxing exit strategy. Doctor will mentor or assist with transition. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www. thehindleygroup.com.

WEST TEXAS GENERAL DENTAL PRACTICE — SALE: Spacious office with five fully-equipped operatories; two additional spaces plumbed for future use. Strong revenues and profit margin. Excellent new patient flow. Eight hygiene days per week.

Contact The Hindley Group. LLC, at (800) 856-1955. Visit us at www.thehindleygroup. com.

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ARLINGTON ORAL SURGERY PRACTICE — SALE: Highly successful practice with strong revenue history of more than seven figures. Selling doctor cut production in half due to back injury but will assist purchaser in rebuilding practice. Extensive referral pattern. Building also for sale. Contact The Hindley Group, LLC, at (800) 856-1955.

Visit us at www.thehindleygroup.com.

SOUTHEAST OF HOUSTON GENERAL DENTAL PRACTICE — SALE: Wonderful location on well-traveled street. Excellent revenues and profit margin. Four fullyequipped operatories. Contact The Hindley Group at (800) 856-1955. Visit us at www. thehindleygroup.com.

NORTH CENTRAL TEXAS GENERAL DENTAL PRACTICE — SALE: Wonderful opportunity in small town that is 1 hour north of DFW Metroplex. Four operatories. Good new patient flow. Excellent staff. Building also for sale. The Hindley Group, LLC, (800) 856-1955. Visit us at www.thehindleygroup. com.

ASSOCIATESHIPS: EAST TEXAS GENERAL DENTAL PRACTICE — Small but busy practice generating mid-range revenues on 4 days per week. Located in quaint small town with excellent access to forests and lakes for hunting, fishing, and boating.

Excellent opportunity for dentists looking ahead to separation from the military.

Pre-determined buy-in terms. SOUTH CENTRAL TEXAS PERIODONTAL —Wonderful practice completing periodontal treatment seeks long-term associate who desires to be a partner within 1-2 years.

Great location with strong new patient flow.

Pre-determined purchase and partnership terms. Wonderful mentor looking for an “equally-yoked” individual. Excellent staff.

SAN ANTONIO PERIODONTIST AND ENDODONTIST ASSOCIATESHIPS — Periodontist associateship with pre-determined buy-in for very active, multi-office periodontal practice. Endodontist associate also needed in this practice. Outstanding mentor and cohesive staff. If you are “equally yoked” and the right person, this is an outstanding opportunity. WEST TEXAS GENERAL DENTAL PRACTICE — Associateship with pre-determined buy-in and partnership terms. Nine operatories. Strong mentor and experienced staff. Excellent revenues and

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profit margin. Large Medicaid component.

EAST TEXAS GENERAL DENTAL PRACTICE —Associateship for busy practice in large facility. Strong mentor. Excellent revenues and profit margin. Predetermined buy-in and partnership terms. EAST OF HOUSTON GENERAL DENTAL PRACTICE Wellestablished practice in small town seeks associate desiring practice buy-in with predetermined terms. Steady new patient flow a] strong revenues. Contact The Hindley Group, LLC at (800) 856-1955. Visit us at www.thehindleygroup.com.

HOUSTON AREA PRACTICE FOR SALE: Profitable practice for sale. Well-established.

Call Jim Robertson at (713) 688-1749.

ADS WATSON, BROWN & ASSOCIATES: Excellent practice acquisition and merger opportunities available. DALLAS AREA — Six general dentistry practices available (Dallas, North Dallas, Highland Park, and Plano); five specialty practices available (two ortho, one perio, two pedo). FORT WORTH AREA — Two general dentistry practices (north Fort Worth and west of Fort Worth).

CORPUS CHRISTI AREA — One general dentistry practice. CENTRAL TEXAS — Two general dentistry practices (north of Austin and Bryan/College Station). NORTH TEXAS —One orthodontic practice. HOUSTON AREA — Three general dentistry practices.

EAST TEXAS AREA —Two general dentistry practices and one pedo practice. WEST TEXAS — Three general dentistry practices (El Paso and West Texas). NEW MEXICO — Two general dentistry practices (Sante Fe, Albuquerque). For more information and current listings, please visit our website at www.adstexas.com or call ADS Watson, Brown & Associates at (469) 222-3200.

FULLY EQUIPPED MODERN DENTAL OFFICE SPACE AVAILABLE FOR LEASE. Have four ops. Current doctor is only using 2 days a week. Great opportunity to start up new practice (i.e., endo, perio, oral surgery). Available days are Monday, Tuesday, Thursday per week. If you are wanting an associate, please inquire. Call (214) 3154584 or e-mail ycsongdds@yahoo.com.

TEXAS PANHANDLE: Well-established 100 percent fee-for-service dental practice for immediate transition or complete sale at below market price by retiring dentist.

Relaxed work schedule with community centrally located within 1 hour of three major cities. The office building can be leased or purchased separately and is spaciously designed with four operatories, doctorsâ&#x20AC;&#x2122; private office and separate office rental space.

This is an excellent and profitable opportunity for a new dentist, a dentist desiring to own a practice, or a satellite practice expansion. Contact C. Vandiver at (713) 205-2005 or clv@tauruscapitalcorp.com.

SUGAR CREEK / SUGAR LAND: General dentist looking for periodontist, endo, ortho specialist to lease or sell. Suite is 1,500 sq. ft. with four fully-equipped treatment rooms, lab, business office, telephone system, computers, reception and playroom; 5 days per week. If seriously interested, please call (281) 342-6565.

AUSTIN: Unique opportunity. Associateship and front-office position available for husband/wife team. Southwest Austin, Monday through Thursday. Option to purchase practice in the future. Send resume and questions to newsmile@onr.com.

GALVESTON ISLAND: Unique opportunity to live and practice on the Texas Gulf coast.

Well-established fee-for-service, 100 percent quality-oriented practice looking for a quality oriented associate. Ideal for a new graduate or for an experienced dentist wanting to relocate and become part of an established practice with a reputation for providing comprehensive, quality dental care with a personable approach. Practice references available from local specialists. Contact Dr. Richard Krumholz, (409) 762-4522.

ROUND ROCK GENERAL PRACTICE FOR SALE. High visibility location. I want to move to my satellite office full-time. Only one PPO (Delta). E-mail inquiries to buyaroundrockdentalpractice@yahoo.com or call (512) 965-6725.

HOUSTON: General dentist with pediatric experience needed. Full-time position available. Excellent compensation. Please send CV to cvanalfen@yahoo.com.

ASSOCIATE FOR TYLER GENERAL DENTISTRY PRACTICE: Well-established general dentist in Tyler with 30+ years experience seeks a caring and motivated associate

for his busy practice. This practice provides exceptional dental care for the entire family. The professional staff allows a doctor to focus on the needs of their patients. Our office is located in beautiful East Texas and provides all phases of quality dentistry in a friendly and compassionate atmosphere.

The practice offers a tremendous opportunity to grow a solid foundation with-the doctor. The practice offers excellent production and earning potential with a possible future equity position available. Our knowledgeable staff will support and enhance your growth and earning potential while helping create a smooth transition. Interested candidates should call (903) 509-0505 and/or send an e-mail to steve.lebo@sbcglobal. net.

ASSOCIATE NEEDED FOR NURSING HOME DENTAL PRACTICE. This is a nontraditional practice dedicated to delivering care onsite to residents of long term care facilities. This practice is centered in Austin but visits homes in the central Texas area.

Portable and mobile equipment and facilities are used, as well as some fixed office visits.

Patient population presents unique technical, medical, and behavioral challenges, seasoned dentist preferred. Buy-in potential high for the right individual. Please toward CV to e-mail: renee@austindentalcares.com; FAX (512) 238-9250; or call (512) 238-9250 for additional information.

PEDIATRIC DENTIST: Pediatric Dental Wellness is growing and needs a dynamic dentist to work full time in our pediatric practice. The perfect complement to our dedicated staff would be someone who is compassionate, goal oriented, and has a genuine love for working with children.

If you are a motivated self-starter that is willing to give us a long-term commitment, please apply. Salary plus benefits. Looking to fill position immediately. Send resumes and cover letters to candice.n.moore@gmail. com.

GREAT OPPORTUNITY FOR A PEDIATRIC DENTIST OR GP to join our expanding practice. We are opening a new practice in the country (Paris, Texas), just 1 hour past the Dallas suburbs and our original location. The need for a pediatric dentist out there is tremendous, and we are the only pediatric office for 70 miles in any direcTexas Dental Journal l www.tda.org l March 2011

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tion. We are looking for someone that is personable, caring, energetic, and loves a fast-paced working environment in a busy pediatric practice. We are willing to train the right individual if working with children is your ambition. This position is part-time initially, and after a short training period will lead to full-time. If you join our team, you will be mentored by a Board certified pediatric dentist and will develop experience in all facets of pediatric dentistry including behavior management using oral conscious sedation as well as IV sedation. For more information, please visit our websites at www.wyliechildrensdentistry.com and www. parischildrensdentistry.com. Please e-mail CV to allenpl2345@yahoo.com.

ASSOCIATE SUGAR LAND AND CYPRESS: Large well-established practice with very strong revenues is seeking an associate.

Must have at least 2 years experience and be motivated to learn and succeed. FFS and PPO practice that ranks as one of the top practices in the nation. Great mentoring opportunity. Possible equity position in the future. Base salary guarantee with high income potential. Two days initially going to 4 days in the near future. E-mail CV to Dr. Mike Kesner, drkesner@madeyasmile.com.

SEEKING ASSOCIATE DENTISTS. Dental Republic is a well-established general dental practice with various successful locations throughout the Dallas Metroplex.

A brand new state-of-the-art facility in a bustling location will be opening soon. Join our outstanding and professional team in creating beautiful healthy smiles for all. Let us give you the opportunity to enhance your professional career with excellent hours, competitive salary/benefits, and by forming long-lasting friendships with our patients and staff members. Please contact Phong at (214) 960-3535 or e-mail CV to phong@ dentalrepublic.com.

CARE FOR KIDS, A PEDIATRIC FOCUSED PRACTICE, is opening new practices in the San Antonio and Houston area. We are looking for energetic full-time general dentists and pediatric dentists to join our team. We offer a comprehensive compensation and benefits package including medical, life, long- and short-term disability insurance, flexible spending, and 401(K) with employer contribution. New graduates and dentists

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with experience are welcome. Be a part of our outstanding team, providing care for Texasâ&#x20AC;&#x2122; kids. Please contact Anna Robinson at (913) 322-1447; e-mail: arobinson@ amdpi.com; FAX: (913) 322-1459.

SAN ANGELO, ABILENE: Associates â&#x20AC;&#x201D; outstanding earnings. Historically proven at over twice the national average for general dentists; future potential even greater. Thriving, established practice in great location.

Bright and spacious facility. Experienced, efficient, loyal staff. Best of all worlds; big city, earnings, small-town easy lifestyle, outstanding outdoor recreation. Contact Dr. John Goodman at john@goodman.net or (325) 277-7774.

ASSOCIATE DENTIST NEEDED IN EULESS: Well-established general practice seeking full-time associate/future partner.

Cosmetic and full family practice. Please send resume to wendy.tcd@sbcglobal.net.

ESTABLISHED, SUCCESSFUL GENERAL PRACTICE AVAILABLE FOR OWNERSHIP with no personal financial investment. Niche market limited to removable prosthetics and related services. Guaranteed minimum salary plus unlimited potential from net profits.

Full benefits package. Onsite lab. Monday through Friday, 8 a.m. to 5 p.m. Professional gratification, personal rewards. E-mail michele.cooke@affordablecare.com.

GREAT OPPORTUNITY FOR ORTHODONTISTS AND GENERAL DENTISTS to join our busy practices providing orthodontic care in the Rio Grande Valley area. We are looking for orthodontists to oversee all aspects of patient care and general dentists to work in coordination with our orthodontists to be able to provide the highest quality care for our patients. Be a part of our exceptional team helping the children of Texas get great smiles. Please contact Dr. Hal D. Lerman at (214) 789-4601 or e-mail to nflq21b@swbell.net.

KATY: Dr. Bui X. Dinh, D.D.S., M.S. is looking for a dentist right now with minimum 2 years experience. Please contact office manager Michelle, (832) 620-6982 or fax resume to (281) 579-6045.

FOR SALE — GREAT 41-YEAR SUCCESSFUL PRACTICE IN SOUTH CENTRAL TEXAS. Owner retiring but will stay through transition period. Five operatories in beautiful building, Pan-0, digital X-ray.

Experienced long-term dependable staff.

Room for multiple dentists. Please mail letter of interest to Box 1, TDA, 1946 S. IH 35, Ste. 400, Austin, TX 78704.

SEEKING ASSOCIATE: Established general dental office in Brownsville (30 minutes away from South Padre Island) is seeking a caring, energetic associate. We are a busy office providing dental care for mostly children. Our knowledgeable staff will support and enhance growth and earning potential allowing the associate to focus on patient dental care. Interested candidates should call (956) 546-8397.

NEW, TYLER: Excellent opportunity, location, and lifestyle. Join an established doctor and share a 2-year-old, free-standing, award-winning building on busy south Tyler Street. Five of 10 ops and private office available. Share reception, lab, and sterilization. Equity position in property available or lease. E-mail dburrow@suddenlinkmail.com.

TEMPLE DENTAL CENTER IN TEMPLE, TEXAS, IS FOR SALE: Doctor changing professions. Firesale! Four operatories, tons of equipment and instruments, three wall X-rays (film just needs sensors to convert), Panorex (also easily converted) Velopex processor. Call (254) 791-0977 and leave message. E-mail doctorbrown80@hotmail.com.

GREAT PRACTICE IN BEAUTIFUL EAST TEXAS. This fee-for-service practice was established by a prominent community-involved dentist with an excellent reputation for quality care. The office has 1,300 sq. ft. with four available treatment rooms and a large private office. Don’t miss the opportunity to become part of this stable economic town with an experienced staff and a growing patient base. Interested? Call (972) 5621072 or e-mail sherri@slhdentalsales.com.

EXPERIENCED DENTISTS ARE NEEDED FOR TWO PRIVATE GROUP PRACTICES LOCATED IN KATY AND SPRING. General dentistry practice with a comfortable and friendly atmosphere without administrative responsibilities. Full- or part-time position

with competitive compensation, benefits, and flexible schedule. Great opportunity for a quality oriented person. Please call Dr. Akerman at (832) 934-2044 or e-mail yourhappydentist@aol.com.

TEXAS — PEDIATRIC DENTAL ASSOCIATE NEEDED. Fast-growing pediatric dental practice is looking for a pediatric dentist to join our team. We are located north of San Antonio just 10 minutes from New Braunfels and 45 minutes from Austin.

We offer a generous compensation package including paid time off and holidays.

Experience is a plus, but new graduates are welcome. Please respond via e-mail to Sherri at velezluke@yahoo.com or by fax (210) 659-9436.

ENDODONTIST NEEDED TO JOIN WITH HOUSTON PERIODONTIST. Full- or parttime. Brand new state-of-the-art office. Associateship with possible partnership. Ideal for primary or second office. Please initiate contact by fax to (713) 795-5514.

AMARILLO: SEEKING FULL-TIME DENTIST TO WORK IN STATE CORRECTIONAL SETTING. We offer a flexible work schedule, excellent state benefits, retirement, and a very competitive salary without the financial challenges faced in private practice. Contact the dental director at (806) 381-7080 x 8301, e-mail at mack. hughes@ttuhsc.edu, or visit the job site at http://jobs.texastech.edu.

TEXAS — HOUSTON: A well-established pediatric dental practice is seeking a fulltime pediatric dentist to join our dental staff. Centrally located near the Texas Medical Center, West University Place, Rice University, and The Galleria, the office is easily accessible off the Southwest Freeway.

Our office’s neighbor is one of Texas Children’s Hospital’s largest outpatient medical groups with 12 pediatricians. Please send all inquiries either by fax (713) 522-1537 or e-mail drmickeymark@aol.com.

MATURE GULF COAST PRACTICE. Still growing, upscale retirement community.

Great visibility in retail strip center, great anchors. Three operatories, hygiene 3 days per week. Great numbers, small investment.

Call for appointment, (361) 205-4582.

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EAST TEXAS GENERAL PRACTICE NEEDS ASSOCIATE TO TRANSITION TO OWNER/PARTNER, buyout to fit situation.

Thirty-five-year-old practice in dynamic northeast Texas hub city, centrally located and easily accessible Dallas, Shreveport, and Arkansas. Great for fishing, hunting, and all outdoor activities. Practice is in a 2,300 sq. ft. office (owned) in a professional building across from the regional hospital.

Four ops, two hygienists provide 6 hygiene days/week. Softdent and Kodak digital Xrays including Pano. Good patient base and excellent staff to stay. Doctor moving closer to grandkids. Call (903) 572-4141.

LONESTAR ON-SITE CARE is seeking a caring dentist to join our group practice. We currently have a PT (2-3 days) opportunity available in the Houston, Texas, area. We offer a competitive salary. Paid malpractice insurance, a flexible schedule (no weekends), established patient base, equipment, supplies, and complete office support provided. If interested in this opportunity, please call Maria toll free at (877) 724-4410 or e-mail caring@healthdrive.com.

EXCITING OPPORTUNITY FOR TEXAS DENTISTS. We are seeking general dentists for our future locations in Lubbock, Abilene, Midland, and Odessa. Full- or part-time available. Exceptional salary plus bonus. Health insurance available. This is an immediate opportunity to perform quality dentistry with a helpful and energetic staff. Please e-mail your CV resume to erik. pierson@mydcdental.com and join our team today.

NEW MEXICO MOUNTAIN RESORT OPPORTUNITY. Tired of the fast pace? Join me and work 2-3 days/week. Great patient base with good attitudes because they love living in this beautiful place. Modern equipment/digital X-ray and Pano. Cool summers, mild winters, six golf courses, hunting, hiking, skiing, horse racing, arts, and culture theater. General or specialist.

Must be dedicated to good patient care and have outgoing personality. Send resume to Dr. John Bennett at 200 Sudderth Dr. #C, Ruidoso, NM 88345; FAX: (575) 257-5170; or e-mail: jnbennett@windstream.net.

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OFFICE SPACE SPACE AVAILABLE FOR SPECIALIST. New professional building located southwest of Fort Worth in Granbury between elementary and junior high schools off of a state highway with high visibility and traffic. Call (817) 326-4098.

ORTHODONTIST NEEDED NEXT TO DENTIST IN HIGH GROWTH, HIGH TRAFFIC AREA IN ROUND ROCK, north of Austin in one of the fastest-growing counties. Available at $155/sq. ft. For more information, e-mail john@herronpartners.com or call (512) 457-8206.

SHERMAN — 1,750 SQ. FT. DENTAL OFFICE. Building has established general dentist and perio/implant dentist. Plumbed and ready to go. High traffic and visibility with lots of parking. Sherman is beautiful and growing town 50 miles north of Dallas and near Lake Texoma, the second largest lake in Texas. It has great schools, a vibrant arts community, and is home to many, many Fortune 500 companies such as Texas Instruments and Tyson Foods. Call (760) 436-0446.

ALLEN: Prior dental, high end practice that relocated. Five plumbed and ready ops, reception, office, conference, two bath, some built-in cabinets, no equipment. High traffic visibility with lots of parking. Affluent residential, across the street from large grocer.

Offering 5-7 years lease plus extensions.

Levin Realty, (323) 954-1934, levinrealty@ sbcglobal.net.

ROUND ROCK — DENTAL SPACE AVAILABLE FOR LEASE: 323 Lake Creek, 2,032 sq. ft. Lease rate is $18 PSF + $6.50. PSF NNN. Existing air lines and plumbing. Call Darren Quick, (512) 255-3000.

ROUND ROCK — ORTHODONTIST SPACE FOR LEASE: On IH-35, between FM 620 and Hwy. 79. Call Darren Quick, (512) 2553000.

INGLESIDE DENTAL BUILDING FOR SALE! 1,700 sq. ft., two chairs plumbed. Rental side, near Corpus Christi!. Busy main street location. Vacant, no equipment. Landscaping, parking, owner/dentist, $115,900. Great

opportunity! Photographs available. E-mail mbtex@aol.com or call (702) 480-2236.

ARLINGTON DENTAL OFFICE FOR LEASE: Current doctor is only using 1 day a week. Has four up-to-date operatories with HD TVs in each op, assistant computer, doctor computer, Casey educational system, digital X-rays, digital panoramic machine, electric handpiece, sterilization room, laboratory, and Cerec CAD/CAM technology. Perfect for new practice start up. Visit our website to view our office.

Contact (817) 274-8667, info@docdds.com, www.docdds.com.

THE BEST FACILITY IN TOWN CAN BE YOURS. We build free-standing dental offices throughout the state of Texas. Onehundred percent financing is available.

Each facility is custom designed to your specifications by nationally acclaimed Fazio Architects.

THROUGHOUT TEXAS: Why lease when owning a building provides so many incredible advantages? Past clients tell us building a custom facility for their practice was easily the best decision of their career. I’d be happy to put you in touch with them to hear of their experiences directly. We’ve helped more than 800 of your fellow dentists achieve their dream during the past 20 years... And look forward to using that experience to assist you. Check us out at fazioarchitects. com. Then, give me a call at (512) 494-0643.

Or e-mail jim@fazioarchitects.com.

ROUND ROCK: Property site available for dental/medical facility on Gattis School Road near the area’s new high school. Excellent frontage with more than 25,000 cars passing by daily. Demographics for this area are through the roof. Call Jim at (512) 4940643 or e-mail jim@fazioarchitects.com.

ROUND ROCK — OLD SETTLERS DENTAL PARK: Three pad sites available.

Thriving two-doctor general practice already onsite. Good frontage and traffic on fourlane road. High growth area has shortage of specialty dentists. Call Jim at (512) 4940643 or e-mail jim@fazioarchitects.com.

AUSTIN — MCNEIL DRIVE DENTAL PARK: Successful general dentist with established

practice has two pad sites available. Beautiful wooded area with great traffic volumes.

Once you tour this office, you will want to build next door. Call Jim at (512) 494-0643 or e-mail jim@fazioarchitects.com.

WHITNEY: Free-standing vacant building for sale. Perfect location, 6 miles from the lake for any specialty start-up. Location near hospital complex, 2,600 sq. ft., no equipment, four bathrooms, private office, built 1978. Pictures are available. For more information call (972) 562-1072 or e-mail sherri@slhdentalsales.com PLAINVIEW, TEXAS, COULD USE TWO NEW DENTISTS. For sale — fully equipped free-standing, high visibility dental office. Excellent opportunity for right person. Contact Dr. J. Irvin Gaynor, jigaynor@suddenlink.net or (806) 292-3156.

ORTHODONTIST / ORAL SURGERY OPPORTUNITY AVAILABLE. Northwest Houston, 7700 Highway 6N, 77095, Copperfield; 2,039 sq. ft. space available for specialty practice. General build-out allowance, high income demographics, high traffic count.

Next to Straw Smiles, high volume family practice. Call John Torry, (713) 824-9608.

HIT THE GROUND RUNNING IN THRIVING CITY OF FLOWER MOUND. Beautiful adorned dental office, five operatories.

Plumbed chairs, state-of-the-art equipment.

Rent below market. A really great opportunity for a beginner or a seasoned practitioner. Landlord supported and onsite. This is a once-in-a-lifetime opportunity where you can move in immediately in a beautiful and well-appointed office sitting on the creek with windows abundance. Please contact Nick at (972) 899-9992 or (972) 899-6412.

FOR SALE LARGE INVENTORY OF QUALITY REFURBISHED AIR DRIVEN DENTAL HANDPIECES. All have been repaired and tested by a qualified technician. All have new ceramic bearing turbines and all are fiberoptic. For sale — Star 430 SWL, $269; Kavo 640B, $279; Kavo 642B, $299; Kavo 647B, $299; Midwest Tradition push button or lever, $239; new Kavo multi-flex coupler five-hole, $249; new Kavo coupler six-hole,

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$149; new Star coupler five-hole, $145.

Slow speed and implant handpieces available, too. Quality discounts are possible. I have been a TDA member for 25 years. If what you are looking for is not on this list, we stock a wide variety at wonderful prices, just inquire. Call (877) 863-4848 or visit our website, www.truespindental.com.

FOUR COMPLETE OPERATORIES INCLUDING cabinets, Pelton Crane chairs (recently re-upholstered), and chair mounted lights. Midwest fiber optics, two X-ray units, two Einstein inter-oral wireless cameras, and more. Call (512) 280-5114 or dquickdds@gmail.com.

INTERIM SERVICES TEMPORARY PROFESSIONAL COVERAGE (Locum Tenens): Let one of our distinguished docs keep your overhead covered, your revenue-flow open wide,

your staff busy, your patients treated and booked for recall, all for a flat daily rate not a percent of production. Nation’s largest, most distinguished team. Short-notice coverage, personal, maternity, and disability leaves our specialty. Free, no obligation quotes. Absolute confidentiality. Trusted integrity since 1996. Some of our team seek regular part-time, permanent, or buy-in opportunities. Always seeking new dentists to join the team. Bread and butter procedures.

No cost, strings, or obligations —ever! Work only when you wish. Name your fee. Join online at www.doctorsperdiem.com. Phone: (800) 600-0963; e-mail: docs@doctorsperdiem. com.

OFFICE COVERAGE for vacations, maternity leave, illness. Protect your practice and income. Forest Irons and Associates, (800) 433-2603 (EST). Web: www.forestirons.com.

“Dentists Helping Dentists Since 1983.”

PER DIEM INC

TEMPORARY

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MISCELLANEOUS LOOKING TO HIRE A TRAINED DENTAL ASSISTANT? We have dental assistants graduating every 3 months in Dallas and Houston. To hire or to host a 32-hour externship, please call the National School of Dental Assisting at (800) 383-3408; Web: www.schoolofdentalassisting-northdallas. com.

THE NATIONAL SCHOOL OF DENTAL ASSISTING â&#x20AC;&#x201D; NORTH DALLAS offers the Texas RDA course and exam. Call (800) 383-3408 for available dates.

DOCTORSCHOICEGOLDEXCHANGE.COM: Try our high prices for dental scrap. Check sent 24 hours after you approve our quote.

See why we have so many repeat customers. Visit www.DoctorsChoiceGoldExchange. com.

DENTAL OFFICE needed to lease 12 hours per week for Dental Assisting School. Class hours are during office downtime one weekend day and one weekday evening.

Lease payment to office is $500 to $1,500 per month, depending on enrollment. Seeking locations in Dallas, San Antonio, and Houston. Please call the National School of Dental Assisting at (800) 509-2864.

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ADS Watson, Brown & Accociates ......................276 AFTCO ....................................................................304 A.J. Riggins Co ......................................................337 Anesthesia Education and Safety Foundation ..........................................................278 Bright Now Dental .................................................254 Crown Dental Studio .............................................258 DDR Dental Trust ...................................................307 Dental Systems......................................................306 Doctors Per Diem ..................................................336 Fortress Insurance ................................................258 Gary Clinton, PMA .................................................303 Hanna, Mark — Attn. at Law .................................306 Henderson, Sherri L. & Associates......................265 Hindley Group........................................................316 JKJ Pathology........................................................290 JLT Energy Consultants .......................................266 Kennedy, Thomas John, D.D.S., P.L.L.C..............337 Knight Dental Group .............................................259 LVI Global/Dr. Reece..............................................305 Medical Protective .................................................289 Ocean Dental..........................................................277 OSHA Review............................... Inside Back Cover Paragon, Inc. ..........................................................321 Patterson Dental ..........................Inside Front Cover Portable Anesthesia Services ..............................321 Professional Recovery Network...........................338 Robertson, James M .............................................290 Sharp & Cobos.......................................................304 Sharps ....................................................................307 Southern Dental Associates.................................263 SPDDS ....................................................................316 TDA Express ..........................................................320 TDA Financial Services Insurance Program..........................................288/Back Cover TDA Perks Program...............................................251 Texas Health Steps................................................255 Texas Medical Insurance Company .....................291 TEXAS Meeting — Reminder Dates .....................254 TEXAS Meeting — Speakers ................................276 USA Civilian Dental Corps....................................257 UTHSCSA Oral & Maxillofacial Lab......................290 Waller, Joe..............................................................317

Join us on Facebook, Twitter and LinkedIn! The Texas Dental Association has created groups on Facebook, Twitter and LinkedIn. The goal of these groups is to provide updates on events and current issues.

If you do not have a Facebook or LinkedIn account, you can set one up in minutes!

Questions? Contact Stefanie Clegg, TDA web & new media manager at (512) 443-3675 or stefanie@tda.org

Join us on facebook.com/texasdental or groups.to/texasdental Follow us on twitter.com/theTDA Get LinkedIN at linkedin.com, search â&#x20AC;&#x153;Texas Dental Associationâ&#x20AC;?

Did you know that TDA members could save up to $327.96 or more a year on auto insurance?

You may already know that you can enjoy competitive auto insurance rates and special money-saving discounts through the Liberty Mutual Advantage® program.* But did you know that Liberty Mutual offers many other discounts on both auto and home insurance?* In fact, you could save hundreds of dollars a year on auto insurance alone. And you could save even more by insuring your home, as well.

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*Discounts and savings are available where state laws and regulations allow, and may vary by state. Certain discounts apply to specific coverages only. **Figure based on a February 2008 sample of auto policyholder savings when comparing their former premium with those of the Liberty Mutual Advantage program. Individual premiums and savings will vary. Coverage provided and underwritten by Liberty County Mutual Insurance Company and its affiliates, 2100 Walnut Hill Lane, Irving, TX. A consumer report from a consumer reporting agency and/or a motor vehicle report, on all drivers listed on your policy, Journal l www.tda.org may be obtained whereTexas stateDental laws and regulations allow. l March 2011 © 2009 Liberty Mutual Insurance Company. All Rights Reserved.

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