May 2011

May 2011

You worry patients’ smiles.

We’ll worry about yours ... especially if you’re ever injured or become too sick to work.

Our disability coverage* for professionals is like an ounce of prevention for both you and your practice. It’s some of the finest available -Own-Occupation, the best choice for a professional -- guaranteed-renewable to age 65 or 67 and non-cancellable, so you can’t lose your coverage when you need it most.

You’ll also want to look into our practice protection policies -Overhead Expense**, to reimburse you for many of the expenses of running your practice, Business Reducing Term,*** to fund financial obligations that require regular payments expiring at a given time, and Disability Buy-Out**** coverage.

Most association coverage can’t match it. Call today and we’ll show you why.

* Policy Form 1400 and 1500. ** Policy Form 4100; in Montana, Policy Form NC82. *** Policy Form AH55-A. **** Policy Form 3100; in Montana, Policy Form AH84.

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

Vol. 128, No. 5

1-800-677-8644 TDAmemberinsure.com

Products not available in all states. Product provisions and features may vary by state.

T T

Or

a

c

May 2011

Journal TEXAS DENTAL

Hookah Smoking: A Popular Alternative to Cigarettes The Role of the Human Papillomavirus in Oropharyngeal Cancer Treatment of Nicotine Dependence with Chantix® (varenicline)

For a complimentary examination of your disability income insurance needs, please contact us at:

Disability income products underwritten and issued by Berkshire Life Insurance Company of America, Pittsfield, MA, a wholly owned stocksubsidiary of The Guardian Life Insurance Company of America (Guardian), New York, NY, or provided by Guardian.

500

E

n a lC

Living in Limbo: Ethics and Experience in a Conversation about Persistent Oral Lesions

The Texas Dental Journal – Special Issue – Oral Cancer

about your

Do you know we offer a complete line of high-quality Disability Income insurance designed especially for professionals like you?

SP

A CI

UE S S er LI

/ rg ns o . o a td ati nic al sit blic ectro ourn i V pu el l J a e a td for th Dent

409

Texas Dental Journal l www.tda.org l May 2011 xas Te

Peer Review: Process Snapshot Peer review is organized dentistry’s dispute resolution process that generally handles complaints from patients against dentists regarding the quality or appropriateness of clinical dental treatment received.

Need a peer review sign for your office?

You may print a copy of the peer review sign from the Resources section of the members homepage on the TDA Website (tda.org).

For more information about peer review please contact the Council on Peer Review via Cassidy Neal at 512-443-3675 ext. 152.

Recently Retired?

As a retired member, you still receive the same amazing member benefits.

Please contact Rachael Daigle at (512) 443-3675 or rachael@tda.org to let us know if you have retired.

Recently Relocated?

Making an address, phone or e-mail change to your profile can be done online at your convenience. To update your information, log in at tda.org and click on “Update Profile� on the member homepage.

Questions? Contact Rachael Daigle, TDA Membership Coordinator at (512) 443-3675 or rachael@tda.org

Contents

TEXAS DENTAL JOURNAL n Established February 1883 n Vol. 128, Number 5, May 2011

ON THE COVER Oral cancer will affect 37,000 Americans this year, according to the Oral Cancer

Foundation. Whether a patient develops oral cancer through smoking or develops it through a virus, the disease will cause more than 8,000 deaths.

CLINICAL AND RESEARCH ETHICS 427

Living in Limbo: Ethics and Experience in a Conversation about Persistent Oral Lesions Catherine M. Flaitz, D.D.S., M.S. Nathan Carlin, Ph.D.

The authors present a case report on a patient suffering from oral lichen planus and oral

cancer. They explain the patient’s “limbo experience” as he waits for a diagnosis and the

importance of a dental professional’s empathy with a patient in such a situation.

CLINICAL DENTISTRY 441

Hookah Smoking: A Popular Alternative to Cigarettes K. Vendrell Rankin, D.D.S.

As hookah smoking becomes more popular, the author explains that dental healthcare providers should include discussion of its prevention and intervention with their patients.

CLINICAL REVIEW 447

Aparna Naidu, D.D.S., M.S. John M. Wright, D.D.S., M.S.

The authors review the biology and risk factors associated with the human papillomavirus and oropharyngeal carcinoma.

457

Treatment of Nicotine Dependence with Chantix® (varenicline)

412

The Role of the Human Papillomavirus in Oropharyngeal Cancer

K. Vendrell Rankin, D.D.S. Daniel L. Jones, Ph.D., D.D.S.

Varenicline is the generic name for Chantix®, the newest drug available for smoking cessation. The authors explain its efficacy, prescribing information, adverse events, and FDA post-market warning.

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

MONTHLY FEATURES

BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION

416 420 422 464 466 470

President’s Message

Honorarium Donors

472 474 478

Oral and Maxillofacial Pathology Case of the Month

Diagnosis and Management

480 498

Advertising Briefs

The View From Austin Guest Editorial — K. Vendrell Rankin, D.D.S. Guest Editorial — Larry J. Sangrik, D.D.S. Value for Your Profession In Memoriam / TDA Smiles Foundation Memorial and

Calendar of Events Oral and Maxillofacial Pathology Case of the Month

Index to Advertisers EDITORIAL STAFF

Stephen R. Matteson, D.D.S., Editor Harvey P. Kessler, D.D.S., M.S., Associate Editor Nicole Scott, Managing Editor Barbara S. Donovan, Art Director Paul H. Schlesinger, Consultant

EDITORIAL ADVISORY BOARD Ronald C. Auvenshine, D.D.S., Ph.D. Barry K. Bartee, D.D.S., M.D. Patricia L. Blanton, D.D.S., Ph.D. William C. Bone, D.D.S. Phillip M. Campbell, D.D.S., M.S.D. Tommy W. Gage, D.D.S., Ph.D. Arthur H. Jeske, D.M.D., Ph.D. Larry D. Jones, D.D.S. Paul A. Kennedy, Jr., D.D.S., M.S. Scott R. Makins, D.D.S. William F. Wathen, D.M.D. Robert C. White, D.D.S. Leighton A. Wier, D.D.S. Douglas B. Willingham, D.D.S. The Texas Dental Journal is a peer-reviewed publication.

Texas Dental Association 1946 South IH-35, Suite 400 Austin, TX 78704-3698 Phone: (512) 443-3675 FAX: (512) 443-3031 E-Mail: tda@tda.org Website: www.tda.org

Texas Dental Journal (ISSN 0040-4284) is published monthly, one issue will be a directory issue, by the Texas Dental Association, 1946 S. IH-35, Austin, Texas, 78704-3698, (512) 443-3675. Periodicals Postage Paid at Austin, Texas and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S. Interregional Highway, Austin, TX 78704.

Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, Out-of-state ADA Affiliated $49.50. In-state NonADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA Affiliated, $17 Non-ADA Affiliated, September issue $17 ADA Affiliated, $65 Non-ADA Affiliated. For in-state orders, add 8.25% sales tax.

Contributions: Manuscripts and news items of interest to the membership of the society are solicited. The Editor prefers electronic submissions although paper manuscripts are acceptable. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. For more information, please refer to the Instructions for Contributors statement printed in the September Annual Membership Directory or on the TDA website: www.tda.org. All statements of opinion and of supposed facts are published on authority of the writer under whose name they appear and are not to be regarded as the views of the Texas Dental Association, unless such statements have been adopted by the Association. Articles are accepted with the understanding that they have not been published previously. Authors must disclose any financial or other interests they may have in products or services described in their articles.

Advertisements: Publication of advertisements in this journal does not constitute a guarantee or endorsement by the Association of the quality of value of such product or of the claims made of it by its manufacturer.

Member Publication

Texas Dental Journal is a member of the American Association of Dental Editors.

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

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

413

28694_Knight_Elements_Layout 1 12/29/10 5:21 PM Page 1

KNIGHT

D E N TA L

GROUP

Helping You Keep Your Promise

lements

By Knight Dental Group

Consistency is a key element of your practice…

Value & Consistency are key elements in our restorations.

E-Ceram PFM + metal E-Crown Full Gold Crown + metal BruxZir® Elements Empress Anterior Crown Elements e.Max Posterior Crown Elements Captek Crown

As low as $59.00 $59.00 $79.00 $89.00 $84.00 $94.00

3659 Tampa Road • Oldsmar, FL 34677

www.knightdentalgroup.com © 2011 Knight Dental Group.

39 Years of Exceptional Restorations • OnLine™ Case Services • Award Winning Restorations

414

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

W 20 in a 11 h C Te ote al xa l l f s st or M ay de ee at ta tin th ils g e ! !

800.359.2043

practice

. this ...

No Cap on Earning Potential $

Enter your income goal and give us a call

• Full-time opportunities available in: -Brownsville and Laredo, TX -Shreveport and New Orleans, LA • Part-time opportunities available in all locations For more information: Office of Doctor Recruitment 405-707-6110 www.oceandental.net Equal Opportunity Employer

ARKANSAS • INDIANA • IOWA • KENTUCKY • LOUISIANA • OHIO • OKLAHOMA • TEXAS Texas Dental Journal l www.tda.org l May 2011 439 Paul Apilado, DDS (General Dentist); Chad Hoecker, DDS (General Dentist & Owner)

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

Primum non nocere. “First, do no harm,” from which derives “nonmaleficence,” one of the principal precepts of medical ethics, must be unfailingly considered as we treatment plan and render care to those who entrust themselves to our ministrations.

With every procedure that we perform, there are associated risks. It is part of the informed consent process that we discuss these known risks with our patients and come to an acceptable treatment plan with a benefit:risk ratio that the patient understands and is willing to accept. With elective procedures, such as cosmetic dental care, it is doubly important that the patient understand this ratio. In all cases, if the patient is unwilling to accept any risk of adverse consequences, then no procedure can be performed.

Most of these decisions are fairly easy and straight forward. The small risk of a broken file during a root canal procedure versus a dental abscess and loss of a tooth can be accepted by most patients. Other decisions are harder. The risk of pulpal death and even tooth loss following an esthetic procedure may be harder to weigh against the improved esthetics and self esteem.

416

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

But we must all remember: harm to a patient can come not only from commission but also from omission. While loss of a tooth from inadvertent complications during preparation for a crown is sad for all of us, how much more serious is the failure to detect and diagnose those life-threatening conditions such as oropharyngeal cancers?

This special issue of the Texas Dental Journal is focused on oral cancers, their etiology, prevention, detection, and treatment. With the decrease in use of tobacco products, we might expect to see a decline in oral cancers. However, with our aging population and increasing prevalence of other associated diseases and infections such as human papillomavirus, the expected sharp decline in incidence has not appeared.

I hope that each of you will use this issue to refresh your knowledge on the extremely important subject of oropharyngeal malignancies. Each of us should be recommitted to counseling our patients on the prevention of these egregious diseases and to the early detection of lesions in our examinations.

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

417

J.D. Power and Associates | Highest in business customer satisfaction with retail electric service in 2009.

With TDA Perks Energy Program, You Have the Power to Choose.

10%

5%

Renewable

100%

Renewable

Renewable

The PUC requires 5% renewable energy to avoid penalty payments.

Standard

Green-Mountain System Mix

Clean

Pollution FreeSM Electricity at lowest group pricing in Texas.

Take Advantage of Money-Saving Group Buying Power from Perks!

TDA Perks Program has partnered with JLT Energy Consultants, a company that develops master programs with multiple energy providers to provide special rates for large groups of individuals. This means that through TDA Perks Program, TDA members living in deregulated areas now have access to lower-tier energy prices.

•OR Choose standard electricity at combined-usage group pricing.

Some of the features of the TDA Perks Program contract:

To Qualify for TDA Perks Group Electricity Program:

•Choose 100% renewable energy at the lowest published professional-group pricing in Texas.

1. You must be a TDA member.

•The Contract is for a FIXED rate per kilowatt, regardless of usage.

•The contract can be for one year up to three years; each dentist office has a choice, and is only responsible for his/her own contract.

2. Your area must be deregulated to permit competition.

(682) 224-1385 418

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

Brokered exclusively by JLT for TDA Perks

Contact: Jerry Trickel E: jtrickel@jltenergyconsultants.com Learn more at: tdaperks.com

3. Your current contract must be expired or expiring. When your contract expires, you can join other TDA members who qualify for a lower-tier rate, and have substantial savings per year. If your office uses up to 250,000 kilowatt hours (kW-h) per year, it can sign a new contract to pay the same rate as those using 1 million kW-h per year, OR choose 100% renewable energy at the lowest group pricing in Texas. Your new rate should effectively give you a savings equal to free electricity for the last two months of every year or more.

747 419

Journal l www.tda.org August TexasTexas DentalDental Journal l www.tda.org l Mayl 2011

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

New Associate Editor — Dr. Harvey Kessler Dr. Harvey P. Kessler has been appointed as associate editor of the Texas Dental Journal. Dr. Kessler is responsible for providing the “Oral and Maxillofacial Pathology Case of the Month” for the Texas Dental Journal. He has coordinated the submission of cases by Texas oral pathologists since 2001 and provided cases himself.

Kessler

He is professor of diagnostic sciences and director of the Division of Pathology at the Baylor College of Dentistry. A 1974 graduate of the University of Maryland School of Dentistry, Dr. Kessler earned a master’s degree in oral biology from George Washington University. He completed training in oral and maxillofacial pathology at the U.S. Army Institute of Dental Research and the Armed Forces Institute of Pathology. Kessler’s career in the U.S. Army spanned 24 years before he retired with the rank of colonel in 1998. At that time he was serving as chairman of the Department of Oral and Maxillofacial Pathology and deputy director of the Armed Forces Institute of Pathology. Kessler joined Baylor College of Dentistry in 2001 after spending 3 years on the faculty at the University of Florida College of Dentistry. He served on the American Board of Oral and Maxillofacial Pathology for 7 years and was president of that organization in 2007.

As per the TDA Bylaws, this appointment will be concurrent with the term of the current Editor. The Editor welcomes Dr. Kessler to the publications work group and looks forward to his continued participation.

420

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

We’ve howdied but we ain’t shook yet!

It’s time we got to know one another. Wherever you practice dentistry in Texas, you carry the risk of a claim or lawsuit. Is your dental liability coverage strong enough to protect you?

Texas Medical Insurance Company is a new name to Texas dentists, but TMIC was established in 1995 as a wholly owned subsidiary of the leading medical liability carrier for Texas physicians. Headquartered in Austin, TMIC is an Exclusively Texas dental liability provider for Texas dentists offering:

Secure your career now with strong protection from claims and lawsuits. Put our experience to work for you.

• Strong dental liability protection • Claims-made, occurrence, tail, prior acts coverages • Proven, successful claims management • Very competitive pricing • Outstanding personalized service

We look forward to working with you.

For a quote, please contact us online at www.tmicdental.biz; by email at sales@tmic.biz; or call 800-580-8658.

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

421

Guest Editorial “Comment on Oral Cancer” K. Vendrell Rankin, D.D.S.

This issue of the Texas Dental Journal

has been traditionally referred to as the “oral cancer issue” and has focused on a central theme. This year’s topics are

disparate, but have in common the prin-

ciples of professional ethics and continu-

ing education, in order to provide the best care possible for our patients.

Drs. Flaitz and Carlin describe the bioethics of living in the distressing state of limbo through the narrative of an oral cancer patient. The patient’s experience is specific to his journey from a diagnosis of lichen planus through malignant transformation and ultimately as a participant in an experimental treatment for oral cancer. However, the application of the principles illustrated are pertinent to a host of clinical situations we confront daily in the ethical practice of dentistry. Whether we are discussing restoration, replacement, or extraction of teeth, treatment of periodontal disease, implementation of smoking cessation, etc., it is our ethical obligation to be empathic, to respect the individual’s autonomy, to evoke the patient’s values, fears, expectations and hopes, and to collaborate with the patient through a frank and complete discussion of alternatives and possible consequences of treatment.

In an effort to provide the most current information to practitioners regarding oral cancer, this issue offers a review of the literature on the role of the Human Papillomavirus (HPV) in oral cancer and its impact on the prognosis of HPV positive or negative oral cancers. Additionally, a brief discussion of the controversy surrounding use of the newest drug in the armamentarium for smoking cessation, Chantix (varencline), is provided to address practitioners’ knowledge and comfort level with the use of this drug. The principle of full disclosure is a basic requirement for ethical and effective treatment. A brief discussion on the use of the hookah pipe, a popular alternative to cigarette smoking, is included to ensure that practitioners encourage full disclosure when asked to provide tobacco cessation therapy.

As clinicians, unless we stay abreast of the latest information, we miss the opportunity to intervene, educate, and offer treatment to patients and communities on the risks associated with the use of tobacco in all forms. Thus, the unifying theme of this issue might be considered the principles and knowledge necessary to exercise our ethical responsibilities.

422

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

Introducing a Full-Service IT Company with a Team of Foremost Experts in Dental Computing.

Texas-Based, with 15 Years of Experience Exclusively Servicing the Dental Industry If you’re enrolled in Perks-endorsed data backup service, Managed Backup Solutions (MBS), you know about MBS’ reliable, cost-effective (starting at $10/month), automated and secure electronic data-backup and file-recovery solution. Now, Perks has added MBS’ entire range of services to bring you full-service IT!

“MBS keeps our practice running like a well-oiled machine...with proactive, scheduled maintenance and rapid emergency-response time...

MBS makes it seem like we have a dedicated IT person on our staff that cares about our business.”

Dr. James Condrey, D.D.S. Dr. Brian Machart, D.D.S. Dr. Randal M. Glenn D.D.S.

Seamless access to all your data from every computer in the office is an important part of proper network design. MBS’ highlytrained team of technicians will design, plan and install the network for any size office. Its years of experience in integrating software, hardware, intraoral cameras, patient entertainment/education screens, and all the technology components in a dental office, ensure that your technology implementation will be done right the first time.

Through Perks, TDA members have access to reduced rates on all IT services! For more information, contact MBS at:

(877) MBS-0787 Learn about other TDA Perks Programs at: tdaperks.com, or call: (512) 443-3675.

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

423

While you’re at tda.org, be sure to check out the following:

. . . . . .

Update your Profile Pay your Dues Read current/past issues of TDA Today Review TDA References Check out the Calendar of Events Look up peers in the Directory

New Topics have been added to the Third Party web tool (member homepage) Members can also sign up for a Personal Web Page or link to an existing website.

PRACTICES ARE SELLING FOR CASH NOW! INCREASE PRACTICE VALUE ANALYZE KEY AREAS OF YOUR PRACTICE

LOCATION

DEMOGRAPHICS STUDY

APPEARANCE OF YOUR OFFICE

TAKE PHOTOS OF EVERY AREA

SIZE OF PATIENT BASE

3 YEARS OF GROWTH TRENDS

NEW PATIENT FLOW

EXPLORE INTERNET MARKETING

ACTIVE RECALL

20% – 30% OF GROSS

“OPERATING PROFITS”

HYGIENE PROFITS MOST IMPORTANT

As an Appraiser/Consultant, I must know the practice in order to educate the Buyer concerning the practice future potential. A bunch of numbers/proformas do not give necessary information about your practice. My appraisals provide all the data above and more. Numbers alone rarely sell a practice. My appraisal is a 75 – 100 page Management Study with the Goodwill/Intangibles based upon comparable area practice sales (plus Tangibles). Routinely, our Practice Sales will bring 97% – 100% of the Appraised Value.

FOR OVER 37 YEARS YOU HAVE SEEN THE NAME… CEFTIFIED PRACTICE APPRAISALS

(Over 2,200 Dental Practice Sales for Comparison) OUR FEES LOW AS 3.75% – 5.75% IF YOU HAVE ASSOCIATE/BUYER • PMA MARKETING NETWORKS • 100% FUNDING AVAILABLE • NO DUAL REPRESENTATION • NEGOTIATE FAIR PRICE • PROCESS COMPLETE CLOSING • TAX STRATEGY • TRANSITION PLANNING • PARTNERSHIPS

NOT JUST A PRACTICE BROKER SELLING PRACTICES CONSULTING DENTISTS “37 YEARS”

“I PERSONALLY HANDLE EVERY TRANSITION”

GARY CLINTON Senior Appraiser

Member of The Institue of Business Appraisers, Inc. CALL 1-800-583-7765 OR DFW AREA 214-503-9696

Read Before You Sign Use ADA’s Contract Analysis Service!!

The ADA offers the Contract Analysis Service which analyzes dental provider contracts between dentists and insurance carriers. This service is free when submitted through state dental societies.

To submit a contract for analysis or ask questions regarding the contract analysis service, please contact Cassidy Neal at 512-443-3675 ext. 152.

CLINICAL AND RESEARCH ETHICS

Living in Limbo: Ethics and Experience in a Conversation about Persistent Oral Lesions Catherine M. Flaitz, D.D.S., M.S. Nathan Carlin, Ph.D.

Introduction In “Living in Limbo: Life in the Midst of Uncertainty,�

Donald Capps and Nathan Carlin write about “limbo situationsâ€? in everyday life. An example of a limbo situation LQFOXGHV WKH H[SHULHQFH RI Ă€QGLQJ RQHVHOI RXW RI ZRUN RU EHLQJ ODLG RII DQG QRW NQRZLQJ ZKHQ RU LI RQH ZLOO Ă€QG D QHZ MRE Âł WKH\ FDOO WKLV ZRUN UHODWHG OLPER $QRWKHU example of a limbo situation involves waiting to get married. Some couples, for example, do not have parental approval to proceed with their wedding plans, and, be-

Flaitz

Carlin

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à DLW]#XWK WPF HGX 7KH DXWKRUV GHFODUH SRWHQWLDO FRQà LFWV RI ÀQDQFLDO LQWHUHVW UHODWLRQVKLSV DQG RU DIÀOLDWLRQV UHOHYDQW WR WKH VXEMHFW PDWWHU RU PDWHULDOV GLVFXVVHG LQ WKH PDQXVFULSW 'U 1DWKDQ &DUOLQ UHFHLYHV UR\DOWLHV IRU FRSLHV RI ´/LYLQJ LQ /LPER /LIH LQ WKH 0LGVW RI 8QFHUWDLQW\ ¾ 'U &DWKHULQH )ODLW] UHFHLYHV JUDQW IXQGLQJ DQG VSHDNLQJ VSRQVRUVKLS IURP 7ULPLUD IRU WKH ,GHQWDÀŠ

Abstract This case report presents a conversation that the authors had with a patient who is suffering from oral lichen planus and oral cancer. The reason that the authors approached the patient for an interYLHZ ZDV WR Ă€QG RXW ZK\ he decided to enroll in an H[SHULPHQWDO VWXG\ UHODWed to his oral cancer. The patient reported that it was “the waitingâ€? that led KLP WR HQUROO LQ WKLV VWXG\ — that is, the pressure of waiting for oral cancer WR UH HPHUJH ZDV VLPSO\ unbearable, and enrolling LQ WKLV H[SHULPHQWDO VWXG\ enabled him to take a more proactive approach to his illness. The authors view this “waitingâ€? as a “limbo experienceâ€? and UHĂ HFW RQ WKH LPSOLFDWLRQV of this limbo experience for dental ethics and research ethics.

KEY WORDS: Oral cancer, oral lichen planus, dental ethics, research ethics, limbo H[SHULHQFHV DXWRQRP\ patient preferences Tex Dent J 2011;128(5): 427-437.

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

427

Living in Limbo cause they do not want to alienate themselves from their families and because they also do not want to give up on their relationship, they find themselves in relational limbo. Going through a divorce is another example of relational limbo (2). These authors also include a chapter on illness-related limbo, such as waiting while healthcare professionals try to determine one’s diagnosis and prognosis (3). Their book is filled with real life stories of people living in limbo, and they write about how these persons have made the best of these states, situations that seem to be more or less universal to all stages and walks of life (4).

In their book, Capps and Carlin wrote about limbo situations from a theological perspective for a religious audience (5). In this article, we draw on their ideas, but we do not write from a theological perspective, and we write for a clinical audience. And while these authors did apply the idea of limbo to illness, they did not think about illness-related limbo in terms of bioethics. Here we apply the idea of limbo to dental ethics, a subfield of bioethics, and we do so by interpreting a conversation that we had with a patient who has oral cancer. We begin by reviewing the clinical details of this patient because these details will help orient readers to the case. We then view the case in terms of Capps and Carlin’s notion of limbo so as to bring certain ethical issues to light that otherwise usually go unnoticed because there is not a vocabulary in dental ethics, or in bioethics, to talk about such situations. We argue that the notion of limbo can help healthcare professionals understand autonomy and patient preferences more fully. The tone of this essay, we also want to point out, is conversational, because this, we felt, would reflect the tone of our conversation with the patient.

Background Information When one of the authors (CF) mentioned to the patient that she would be interested in telling his story, he immediately agreed. We later followed up with the patient, and explained that we would like to interview him and to write about his experience in a journal article. The patient remained enthusiastic and gave verbal consent for this case report.

In order to maintain the privacy of the patient, he will be referred to as Mr. OC. His story is a long and complicated one because it is dealing with two different oral diseases, which may or may not be related.

This patient is in his 60s, and he reported that, throughout his life, he would only go to the dentist primarily when he had a problem. He also noted that he smoked two packs of cigarettes a day, and that he began smoking around the age of 14 and continued for 30 years.

He also reported that he drank beer periodically. Encouraged by his family because he was having breathing problems at work, he discontinued cigarette smoking on his own in the mid-1980’s.

In 2000, he developed periodontal disease with severe gingival recession that resulted in a referral to the periodontist. At that time, the periodontist recommended a gingival graft for the management of the receding gums. Mr. OC was also informed that there were unusual white patches in the roof of his mouth, close to the donor graft site. Following patient consent, a biopsy was performed at the time of the periodontal surgery. At the return visit, Mr. OC was

428

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

informed that he had lichen planus and that it was a chronic condition caused by stress and aggravated by certain foods and beverages. He understood that there was no treatment to cure this mouth disease.

After the follow up visit, he did not return to the periodontist because the grafting procedure did not seem to be successful. To control the symptoms of lichen planus, he learned to avoid certain foods by trial and error. He never mentioned the oral condition to other healthcare providers, and none of them questioned him about having an oral problem. Up to this point he did not recall any healthcare provider, including the dentist, performing an oral cancer examination.

Clinical Disease Progression The symptoms in the mouth worsened in 2007, when he noticed a red patch covering the side of the tongue, along with the typical white patches in his mouth caused by lichen planus. For more than 6 months, he avoided spicy foods, but eating became more problematic as the pain became constant.

At the encouragement of his wife, the patient recalls that he went to see an otolaryngologist, who diagnosed the lesions as leukoplakia and recommended that all of the white and red patches on the tongue be removed by laser treatment. After

Figure 1. White plaque on the anterior tongue with fresh surgical biopsy site. Note the small size of the tongue and the large depression on the left lateral border where the oral cancer was excised twice.

observing the laser treatment results and the lack of healing on one side of the tongue, a decision was made to refer Mr. OC to a head and neck oncologic surgeon. A wide excision of the lesion on the tongue was performed by the surgeon, who submitted the tissue for microscopic examination. At the follow up appointment, Mr. OC and his wife were informed that a diagnosis of oral squamous cell carcinoma with clear margins had been made.

Approximately 2 years later, the lesion on the tongue recurred and a second surgery was performed, along with removal of the nodes in the neck. After the second surgery, Mr. OC was given the diagnosis of oral squamous cell carcinoma with the good news that the lymph nodes in the neck were free of tumor. He was also informed that the cancer may recur and, if it did, chemoradiotherapy would be the next treatment approach. After the family researched its options, a decision was made to seek experimental chemoprevention at an academic cancer center.

Once arriving at the academic cancer center, a multidisciplinary approach to care was advised that included a head and neck oncologic surgeon, who supervised the entry into an experimental chemoprevention study, and referral to an oral and maxillofacial pathologist for evaluation and management of the lichen planus. The tender oral lesions were widespread and ranged from thick verrucoid-appearing plaques on the tongue (Figure 1) to white lacy striations and plaques with and without focal areas Texas Dental Journal l www.tda.org l May 2011

429

Living in Limbo of ulceration and erythema on the buccal and labial mucosa and attached gingiva (Figure 2).

Targeted laser ablation, repeat biopsies, multiple laboratory tests, periodic examinations that include screening with autofluorescence light devices, and appropriate topical and systemic medications have become the standard protocol for managing these two oral diseases. The patient is aware that lichen planus rarely undergoes spontaneous remission and has a reported annual malignant transformation rate of about 0.5 percent (7). Further, he knows the average 5-year survival rate for his type of oral cancer is about 80 percent (8).

For these reasons, long-term annual follow up of these oral diseases will be a necessary part of his routine to beat the odds.

as limbo situations in early life, relational limbo, work-related limbo, illness-related limbo, and limbo situations involving dislocation and doubt. They suggest that there are different durations of limbo situations — that is, limbo situations can be acute or chronic, and, moreover, some acute limbo situations last longer than others.

They suggest that there can be different kinds of distress in limbo situations, such as anxiety and worry or dread and despair, and that there can be different intensities or degrees of any given type of distress in an acute limbo situation. The longer one finds oneself in an acute limbo situation, the more likely it is that one will experience various kinds and higher degrees of distress. It is one thing, for example, to be out of work for a month, but it is quite another to be out of work for 2 years and, because of finances, foreclosing on one’s home. This framework, we found, proved to be useful in interpreting our conversation with Mr. OC, as one can observe Mr. OC’s kinds and intensities of distress changed when the type of his limbo situation changed.

What is a Limbo Situation?

We now want to move to a discussion of limbo situations.

Capps and Carlin define limbo situations as intermediate and indeterminate states and/or places of neglect, confinement, or oblivion (5). They also offer a framework for identifying and understanding such situations, which they derived from their conversations with people living in limbo as well as from psychological literature (5, 6). They suggest that there are different types of limbo situations, such

430

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

Figure 2. White striations and plaques with superficial areas of ulcerations and erythema of the buccal mucosa.

Oral Lichen Planus as a Limbo Situation: Living with Irritation A significant confounder to this patient’s oral malignancy is the original diagnosis of lichen planus that was made about 7 years prior to the occurrence of oral cancer. Although the patient was aware that he had lichen planus, a diagnosis which was biopsy-confirmed, he did not understand the cause or potential complications of this chronic disease. In part, this may have been due to the fact that he sought treatment for periodontal disease and gingival recession. It was only during the periodontal surgery, which included a palatal grafting procedure, that a biopsy of the adjacent mucosa was excised for evaluation of a white patch. The patient noted that he did not follow up for routine periodontal maintenance because he did not feel that the surgery had been successful.

It is normal for patients who have oral lichen planus to fluctuate between periods of disease exacerbation and remission for years. This, in itself, is a kind of limbo situation. Although many patients with lichen planus control the symptoms by meticulous oral hygiene, monitoring their diets, and the periodic use of topical steroids, there are the inevitable flare-ups that can create a prolonged state of uncertainty along with a loss of control and a compromise in the quality of life. To complicate matters, the

drugs most commonly used to control the signs and the symptoms of lichen planus are dermatologic agents that are adapted for oral use. Pharmacists are often unaware of this off-label use of the drug, and so, when they question this application inside the mouth, patients are often confused and unnerved. It is further disconcerting to patients when the drug label clearly states in bold letters, “For external use only — call Poison Control if ingested.” Not unexpectedly, some individuals fear the potential complication of long-term topical steroid use as much as the disease itself, thus creating another layer of unease, as patients wonder, “Am I doing more harm than good by using these agents?” (9, 10).

The patient did comment on how lichen planus affected his daily life. He noted that he lived with a chronic state of oral discomfort, and that he coped with his discomfort by avoiding certain foods. In this sense, he lived in a chronic state of confinement. He reported that he did not seek additional care for the lichen planus because he was informed that there was no cure — only that it was aggravated by stress and certain foods. Furthermore, he never mentioned the oral problem to other healthcare providers because he tended to seek care intermittently and for specific reasons—he did not want to bother anyone with an unrelated concern. In terms of Capps and Carlin’s framework (5), although he was experiencing an acute limbo situation that lasted for many years, he did not experience significant levels of anxiety because he

knew that his condition was not curable and because lichen planus was not life threatening.

Oral lichen planus, understood here as a case of illness-related limbo, was characterized more by irritation and frustration than by any other emotions.

When reflecting on his diagnosis of lichen planus, the patient stated that he wished that he would have known more about the disease and that rare cases may undergo malignant transformation. On this detail, we pointed out to the patient that the association of the oral malignancy with this persistent inflammatory disease was controversial, and we also emphasized that it was uncertain if managing the lichen planus would have had any impact on disease progression (7). Both of these facts are all part of the limbo of living with this common oral disorder. In any case, what is striking about this observation from the patient is that, in retrospect, he would have preferred to have had lived with the uncertainty of the possibility that rare cases of lichen planus undergo malignant transformation then than to living with the uncertainty that he lives with now. Why? Because the uncertainty that he lives with now has a tinge of regret: “If I would have acted sooner, could my oral cancer have been prevented?”

An important problem with lichen planus is that it can mask more serious oral diseases because it is red, white, or ulcerated—similar to oral cancer.

Although semiannual or annual periodic evaluations are emphasized for early detection of suspicious lesions, a healthcare provider cannot prevent a maTexas Dental Journal l www.tda.org l May 2011

431

Living in Limbo lignancy from developing. The healthcare provider faces some uncertainty because of the lack of disease predictability and the overlapping clinical features with more serious diseases, and so healthcare professionals often live in their own kind of lim-

bo, creating, as it were, a kind of double patient-dentist limbo.

The uncertainty of healthcare professionals, we suggest, should be openly discussed so that realistic expectations and management approaches are decided jointly. With this partic-

ular patient, the persistent oral lesions and constant tenderness allowed him to rationalize that the painful tongue lesions were a part of the lichen planus, which significantly delayed the seeking of care and the diagnosis of the oral cancer.

Oral Cancer as a Limbo Situation: The Decision to Participate in an Experimental Study We now want to move to a discussion of oral cancer as a limbo situation, the situation in which the patient is currently experiencing. In our conversation with the patient, our initial interest was to find out why he had volunteered to take part in an experimental study at the academic cancer center. We also wanted to view his decision in context. We wanted, in other words, something more than a one sentence answer such as, “Because I want to live,” or “Because I want to help other people.” We, therefore, asked the patient a series of questions so as to encourage him to tell his story. Much of the conversation focused on the clinical disease progression. At various points during the conversation, we asked the patient how he felt during different stages of the progression of his illness. The most striking part of the interview was when we asked the patient to comment on the worst part of his disease. He did not identify pain as the worst part, and he did not identify the financial hardships, though considerable, as the worst part. The worst part, he said, was “the waiting.” This comment from the patient is what led us to use the category of limbo to understand this patient’s experience.

When the patient was diagnosed with oral squamous cell carcinoma, he remembers feeling frightened, especially because he was told that there was nothing that could cure his condition. He remembers that he was given several options. One was to do nothing, but this would lead to death. Another was to have surgery. He was reluctant to have surgery, however, because he remembered that his neighbor developed cancer of the neck and that he had multiple surgeries and yet he ended up dying anyway. He did not want to end up like his neighbor. A third option was to have some combination of chemotherapy and radiation, but he was advised that this should only be “a last resort.” At first, he elected to do nothing, because he did not want to end up like his neighbor. His wife, however, persuaded him to have surgery. This decision — Which option do I take? — is a kind of limbo situation, and his wife helped him through this one as he elected to have surgery.

After he had the surgery, he thought — or hoped — that it was all over, and he felt a sense of relief. But when the cancer came back, he felt a renewed sense of

432

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

In contrast to the waiting involved with lichen planus, the waiting involved with oral squamous cell carcinoma produced high levels of dread and anxiety in the patient because his life, not simply his quality of life, was at stake. Surgery, then, became no longer an adequate option for him, because “the waiting” literally became a place of oblivion.

dread, for he recalled the fate of his neighbor. The first surgery, then, provided a sense of closure for him — he was moving from being ill to being well — but, after the cancer returned, it became obvious that he would have to return to limbo after each surgery to see if the cancer would return. It is this waiting for the cancer to return — a cancer that would slowly take away his tongue, that would slowly take away his speaking abilities, and that would slowly take away his life — that proved too much for him to bear. In contrast to the waiting involved with lichen planus, the waiting involved with oral squamous cell carcinoma produced high levels of dread and anxiety in the patient because his life, not simply his quality of life, was at

stake. Surgery, then, became no longer an adequate option for him, because “the waiting” literally became a place of oblivion. He needed another way, something other than doing nothing or having surgery, and preferably something other than “the last resort.” This other way was enrolling in an experimental study.

Enrolling in an experimental study, the patient told us, gave him a way of being proactive.

He was on the offense now — he was no longer just waiting for the cancer to return. When he enrolled in the study, he was troubled by the fact that he could receive a placebo instead of the experimental drug, because this would directly challenge his sense of agency.

His reason for enrolling in

the study, after all, was to be proactive, but, if he received a placebo, he would be confined back in the limbo of waiting for the cancer to return. We do not know if he is receiving the drug — it is a randomized, double-blind, controlled study — but the patient believes he is receiving the experimental drug because he thinks that he has developed some of the side effects associated with the experimental drug. When he developed these side effects, both he and his wife jumped for joy, because now, he believes, he is no longer just waiting for the cancer to return, but, rather, he is waiting for a cure — waiting for life, not waiting for death. These side effects, whether real or perceived, became an occasion for hope.

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

433

Living in Limbo Implications for Dental Ethics In the closing questions of our interview, we asked the patient if he had any advice for other patients. He said, “Don’t put it off.” By this he meant that, when a person begins to notice something wrong in his or her mouth, they should go to a healthcare professional right away. He said that he was afraid that there might be something wrong, and that this fear prevented him from seeking help. He knew that something was seriously wrong for about 6 months or more before he sought help. This advice from the patient has implications for educational initiatives about both lichen planus and oral cancer. Honest and open discussions about the risk factors, clinical features, management options, prognosis, and the advantages and disadvantages of oral cancer screening devices and adjunctive tests are important so that patients are armed with adequate information to make an informed decision about their health. The patient’s advice is well grounded in dental ethics (11).

“I would have liked to have known that my first condition could have led to something cancerous.” That is, he would have liked fulldisclosure, and, as he put it, no “sugar-coating.”

434

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

We also asked the patient if he had any advice for health care professionals. He said, “I would have liked to have known that my first condition could have led to something cancerous.” That is, he would have liked full-disclosure, and, as he put it, no “sugarcoating.” The principle of veracity in the American Dental Association Code of Ethics supports the patient’s advice here — he wants to know the truth of his situation so that he can make decisions based on the best available evidence (12). This advice from the patient is also well grounded in dental ethics (13). The patient’s advice also suggests the importance of ethics education for healthcare professionals, and that students need to know not only basic knowledge of their profession’s codes of ethics, but also, how to apply this knowledge in daily clinical practice. The advice from the patient is straightforward and, as noted, well supported

in dental ethics. Viewing this case report in light of limbo underscores other issues in dental ethics, as well — specifically, ethical issues related to autonomy and patient preferences. A few words about key sources in bioethics are needed to put our reflections in context.

A key document in the founding and establishing the field of bioethics is the Belmont Report, which stresses the importance of autonomy, which literally means “self-rule,” and respect for persons, as well as other principles (14). Thomas Beauchamp and James Childress later came to refer to autonomy/respect for persons as “respect for autonomy” (15).

The basic approach of Beauchamp and Childress in bioethics came to be called the “principlist approach,” which involves weighing and balancing, as well as specifying, the principles of respect for autonomy, beneficence, nonmaleficence, and justice in a given bioethical dilemma (16). Some bioethicists have criticized the principlist approach for being simplistic and mechanistic, leading to a kind of listing of principles related to an ethical dilemma rather than a sophisticated application of the principles (17). This oversimplification of the principlist approach is, perhaps, related to a pedagogical strategy for teaching medical ethics in medical schools, which is sometimes called the “four boxes” (18).

The four boxes that students use to analyze an ethical dilemma include medical indications, patient preferences, quality of life, and contextual

issues. While Beauchamp and Childress never intended their approach to be reduced to a listing of facts and observations, others have argued that the way to rectify such oversimplification is by turning to story and narrative (15, 19).

We support this turn to story and narrative, as intimated by our telling of the patient’s story here, as a way of strengthening the principlist approach.

Why? This turn invites the application of various tools from the humanities to understand human experience, such as Capps and Carlin’s framework for understanding limbo situations, in bioethics (5).

What issues in bioethics does the category of limbo bring to light in this case report? We argue that the framework of limbo provides a deeper understanding of his autonomy as expressed in his preference to participate in an experimental study. In terms of bioethics, what is relevant here is not only that he wants to participate in this study, but also, why he wants to do so, and the category of limbo provides an explanation of why he wants to participate in this experimental study. Mr. OC wants to be proactive rather than reactive and, therefore, to do something other than simply wait because the quality of the waiting in the limbo of oral cancer, in contrast to the limbo of lichen planus, was characterized not by irritation and confinement, but, rather, by anxiety and dread as oblivion lay in the horizon.

Viewing Mr. OC’s decision to participate in an experimental study in light of his comments about “the waiting,” one might wonder about the relationship between his need to find a way out his illness-related limbo related to oral cancer and his understanding of the nature of the experimental drug. Some bioethicists might be pessimistic about the likelihood that the experimental drug, if the patient is actually receiving it and not a placebo, would add any quantity or quality to his life, and that such studies, some worry, exploit false hope for the sake of science and research (20). These are valid concerns.

Perhaps one way to begin to think about them, based on our conversation with this patient, is to weigh the likelihood of harm that will come to the patient on account of the experimental drug against the distress of this patient’s experience of living in limbo. For this patient, the side effects are minor and they are an occasion for celebration, symbolizing to him that he — not cancer — is on the offense. Viewing the issue in this way means that the risk-benefit analysis is not only a biomedical matter, but also, a personal and individual matter, and that this analysis is more a matter of art than science, more a matter of reflection than calculation.

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

435

Living in Limbo Concluding Comments When one is living in limbo, one needs to find a way to pass the time. Mr. OC continues to work and much, if not all, of his time is spent battling his illness. He has found that he is much closer to his family than before, and that, together, they are fighting oral cancer in ways that, without the study, they could not. Perhaps, in time, he will feel differently. But, for now, this experimental research study offers a ray of hope into the darkness of the limbo of oral cancer.

Practice Points The lessons learned so far from the experiences of this patient are straightforward and outlined below.

1. It is not uncommon for patients to delay seeking care when they feel that they are experiencing a serious disease. Empathy for the fears of the patient, as well as an honest discussion about the oral problem, is critical for motivating the patient to receive appropriate care.

2. Detailed disclosure about a disease is important so that the patient can understand the full impact of the condition. At times, referral to a more experienced specialist may be necessary to provide the patient with the most current and accurate information.

3. Sometimes patients are not aware that their dentist is evaluating them for oral abnormalities, such as cancer, during a routine examination. For this reason, it is important to inform the patient what the oral examination entails and why it is being performed.

4. Communication styles of patients vary, and reserved conversation should not be interpreted as lack of interest. Furthermore, respect for an authority figure, such as the dentist, may significantly inhibit the asking of life-saving questions, unless the patient is encouraged to do so. The patient in this case report did not want to bother healthcare professionals with his questions about lichen planus.

5. Oral potentially malignant disorders, such as lichen planus, are challenging because of the persistence of the disease, variable malignant transformation rate, unpredictable behavior, and debate over the best treatment approaches. These uncertainties induce not only illness-related limbo for the patient, but also stressful ambiguity for healthcare providers.

6. Not all limbo situations are the same. For this patient, lichen planus produced one kind of limbo experience — one that was relatively free of dread and anxiety — but oral cancer produced

436

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

a different kind of limbo experience — one that was characterized by dread and anxiety. The difference between the two situations is on account of the fact that the latter is life-threatening and, therefore, produced higher levels of distress.

7. Enrolling in experimental research protocols may be one way that patients attempt to propel themselves out of illness-related limbo.

Acknowledgements The authors wish to express gratitude to Thomas Cole, director of the McGovern Center for Humanities and Ethics, Jeffrey Spike, director of the Campus-Wide Ethics Program at UTHealth, and to the faculty of the Campus-Wide Ethics Program. The authors would also like to thank Laurence McCullough for suggesting the application of the idea of limbo to bioethics.

References 1. Capps, D, Carlin, N. Workrelated limbo. In Living in limbo: life in the midst of uncertainty. Eugene, OR: Cascade Books. 2010, 4563.

2. Capps, D, Carlin, N. Relational limbo. In Living in limbo: life in the midst of uncertainty. Eugene, OR: Cascade Books. 2010, 27-43.

3. Capps, D, Carlin, N. Illnessrelated limbo. In Living in limbo: life in the midst of uncertainty. Eugene, OR: Cascade Books. 2010, 6590.

4. Carlin, N, Capps, N. Matters of life and death—and limbo: and other mundane issues in bioethics. Hous-

ton Medical Journal 2011, In Press.

5. Capps, D, Carlin, N. Introduction. In Living in limbo: life in the midst of uncertainty. Eugene, OR: Cascade Books, 2010, 1-10.

6. Scott, W. Depression, confusion and multivalence. Int J Psychoanal 1960;41:497503.

7. Van der Waal I. Potentially malignant disorders of the oral and oropharyngeal mucosa; present concepts of management. Oral Oncol 2010;46:423-25.

8. Altekruse SF, Kosary CL, Krapcho M, Neyman N, Aminou R, Waldron W, et al (eds). SEER Cancer Statistics Review, 1975-2007, National Cancer Institute.

Bethesda, MD, http:// seer.cancer.gov/csr/1975 2007/, based on November 2009 SEER data submission, posted to the SEER web site, 2010.

9. Al-Hashimi I, Schifter M, Lockhart PB, Brennan M, Bruce AJ, Epstein JB, et al.

Oral lichen planus and oral lichenoid lesions: diagnostic and therapeutic considerations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103(suppl 1):S25. e1-S25.e12.

10. Gonzalez-Moles MA, Scully C. Vesiculo-erosive oral mucosal disease management with topical corticosteroids: (2) Protocols, monitoring of effects and adverse reactions, and the future. J Dent Res 2005;84:302-8.

11. Odom, J, Bowers, D. Informed consent and refusal.

In Weinstein, B (ed.), Dental ethics. Philadelphia: Lea & Febiger, 1993, 65-80.

12. American Dental Asso-

ciation. Principles of ethics and code of professional conduct, January 2011: www.ada.org/sections/ about/pdfs/ada_code.pdf.

13. Kahn, J, Hasegawa, T. The dentist-patient relationship.

In Weinstein, B (ed.), Dental ethics. Philadelphia: Lea & Febiger, 1993, 53-64.

14. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont report, April 18, 1979: http://ohsr.od.nih. gov/guidelines/belmont. html.

15. Beauchamp, T, Childress, J. The principles of biomedical ethics (5th ed.).

New York: Oxford University Press, 2001: ix.

16. Beauchamp, T. Principlism and its alleged competitors. Kennedy Inst Ethics J 1995;5(3):181-98.

17. Clouser, K., Gert, B. A critique of principlism. J Med Philos 1990;15:219-36.

18. Jonsen, A., Siegler, M, Winslade, W. Clinical ethics: a practical approach to ethics decisions in clinical medicine (4th ed). New York: McGraw Hill, 1998: http:// depts.washington.edu/bioethx/tools/4boxes.html.

19. Charon, R. Narrative medicine: form, function, and ethics. Ann Intern Med 2001;134:83-7.

20. Appelbaum, P, et al. False hopes and best data: consent to research and the therapeutic misconception.

In Emanuel, E et al. (eds.), Ethical and regulatory aspects of clinical research: readings and commentaries. Baltimore: The Johns Hopkins University Press, 2003: 216-221.

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

437

A Bright Idea.

member benefits to protect your lifestyle We’re pleased to announce that we’ve teamed up with Mutual of Omaha Insurance Company and its affiliates to offer you a variety of products and services to meet your individual needs. And, as a member of the Texas Dental Association, you’re eligible for preferential rates or no-cost benefit enhancements not available to the general public.

To learn more, please contact TDA Financial Services Insurance Program, 800-677-8644, marketing@TDAmemberinsure.com.

Mutual of Omaha Insurance Company, Mutual of Omaha Plaza, Omaha, NE 68175. Mutual of Omaha Insurance Company is licensed nationwide. Affiliates: United of Omaha Life Insurance Company, Mutual of Omaha Plaza, Omaha, NE 68175. United of Omaha Life Insurance Company is licensed nationwide except in New York. Companion Life Insurance Company, Hauppauge, NY 11788-2934.

Companion Life Insurance Company is licensed in New York. Insurance products and services are offered by Mutual of Omaha Insurance Company or one of its affiliates. Each underwriting company is solely responsible for its contractual obligation. These policies have exclusions and limitations. Products are not available in all states. For costs and complete product detail, contact your licensed Mutual of Omaha insurance agent.

An insurance agent (In WA: Producer) will contact you.

AFN42652

438

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

AGD 2011 San DieGO! Annual Meeting & Exhibits July 28 to 31, 2011

Register Today!

Visit www.agd.org/sandieGO and click on “Register Now.”

Get Ready for Cool Courses!

An entire year’s worth of quality courses will be offered at the meeting and dentist registrants will receive access to up to 80 hours of recorded continuing education sessions—FREE with registration.

Get Set for Sun-sational Speakers and Participation Courses!

• Gordon J. Christensen, DDS, MSD, PhD (“The Christensen Bottom Line”) • David S. Hornbrook, DDS, FAACD (“Hot Topics in Restorative and Esthetic Dentistry”) • Pascal Magne, PhD, DrMedDent (“Biomimetic Restorative Dentistry”) • Harold L. Crossley, DDS, PhD (“What’s the Real Deal About Street and Prescription Drug Abuse?” and “The 30 Most PhysicianPrescribed Medications”) • Louis Malcmacher, DDS, MAGD (“Total Facial Esthetics for Every Dental Practice”)

GO! to Hear from the Leading Scientist in Genomic Research!

The pioneer researcher who uncovered the sequence of the human genome, Dr. J. Craig Venter, is the 2011 AGD Keynote Speaker!

GO

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

439

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 “Texas Dental Association�

CLINICAL DENTISTRY

Hookah Smoking: A Popular Alternative to Cigarettes K. Vendrell Rankin, D.D.S.

The Hookah Pipe According to the World Health Organization the hookah, also known as water pipe, shisha, nargile, and hubblebubble, has been used to smoke tobacco and other substances by the indigenous people of Africa and Asia for at least four centuries (1). The hookah consists of a KHDG LQ ZKLFK VZHHWHQHG DQG Ă DYRUHG WREDFFR is placed. Approximately 30 percent of the mixture placed in the pipe is tobacco. Charcoal, separated from the tobacco by a piece of perforated aluminum foil, is used to heat the

Abstract Hookah smoking has recently emerged as a popular alternative to cigarette smoking, particularly among young adults.

The perception that hookah smoking is cleaner and less harmful than cigarette smoking appears to be key to its increased use, although this is not the case. Hookah tobacco smoking delivers the powerful addictive drug nicotine, higher levels of carbon monoxide than a cigarette as well as many of the carcinogens in cigarette smoke.

7KHUH LV DOVR VLJQLĂ€FDQWO\ increased risk associated with secondhand smoke from hookah smoke. Communal hookah use increases the risk of transmission of infectious diseases. Transition from social to individual hookah use is a critical step toward nicotine dependence as well as progression to cigarette use.

Prevention and intervention in patients’ tobacco use should include discussion of cigarette alternatives including hookah smoking.

KEY WORDS: Rankin

Dr. Rankin is a professor and associate chair, Department of Public Health Sciences, Baylor College of Dentistry – Texas A&M Health Science Center, Dallas, Texas.

7KH DXWKRU KDV QR GHFODUHG SRWHQWLDO FRQà LFWV RI ÀQDQFLDO LQWHUHVW UHODWLRQVKLSV DQG RU DIÀOLDtions relevant to the subject matter or materials discussed in the manuscript.

Hookah, water pipe, tobacco smoking Tex Dent J 2011;128(5): 441445.

This article has been peer reviewed.

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

441

Hookhah Smoking tobacco. A stem connects the head to the bowl, which is half filled with water. Smoke passes through the stem into the water. A hose located just above the waterline connects the mouthpiece to the bowl. Some models have multiple mouthpieces.

When the user draws on the mouthpiece, tobacco and charcoal smoke pass through the stem, into the water and out through the hose into the user’s mouth and lungs (Figure 1). The smoother texture and the use of added flavoring and oils may promote extended use.

Figure 1.

Risks The shared social experience and the perception that hookah smoking is cleaner and less harmful than cigarette smoking appear to be associated with increased use (2). The delivery of smoke cooled by passage through water leads users to believe that the carcinogens, carbon monoxide, and toxins have been removed, when they are in fact still present. On average, carbon monoxide is increased by 21.2 ppm for hookah smoking when compared to cigarette smoking (3). A significant portion of the carbon monoxide in hookah smoke originates from the charcoal (4). Hookah-related emergency room admissions due to acute carbon monoxide poisoning have been reported (5).

The delivery of the addictive drug nicotine is of concern in hookah smoking. In a single hookah session, lasting approximately 45 minutes, plasma nicotine levels increase from 0.79 ng/ml to a maximum of 51.95 ng/ml 3 hours after the end of a hookah session (6). In a direct comparison of hookah smoking to cigarette smoking, investigators reported similar nicotine expo-

442

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

per hour, during a typical 1-hour waterpipe use session, a smoker likely generates ambient carcinogens and toxicants equivalent to two to 10 cigarette smokers, depending on the compound in question (10).

The World Health Organization recently issued a warning about the link between hookah smoking and the serious risk of transmission of communicable disease. A definite association between tuberculosis and hookah smoking has now been established (1). Studies also show that communal smoking increased the rate of infection with Helicobacter pylori, the bacteria associated with gastric ulcers. Transmission of other pathogens including hepatitis A, hepatitis C, herpes simplex and Epstein-Barr virus have also been associated with hookah use, although additional research is required to substantiate the strength of evidence regarding potential transmission of these pathogens (1).

Figure 2. Photo courtesy of the Texas A&M University System Health Science Center.

sure (7). Abstinent hookah tobacco smokers report symptoms similar to those reported by abstinent cigarette smokers. The amount of nicotine delivered over the course of a session is sufficient to create nicotine dependence (8).

Although the quality of evidence for the different outcomes varies, the results of a systematic review of the available evidence on hookah smoking found a significantly increased risk for lung cancer, respiratory illness, low birth-weight, and periodontal disease (9).

At the environmental level, side stream (secondhand) smoke from a single hookah session contains approximately four times the carcinogenic polycyclic aromatic hydrocarbons, four times the volatile aldehydes, and 30 times the carbon monoxide of a single cigarette.

Exhaled mainstream smoke from a typical 1-hour hookah session generates ambient carcinogens and toxicants equivalent to two to 10 cigarette smokers. Accounting for exhaled mainstream smoke, and given a habitual smoker smoking rate of two cigarettes

Prevalence Although cigarette smoking in the US is either stable or declining, other forms of tobacco use show a rising trend, particularly among young adults.

Several studies indicate that this is the case with hookah smoking. A survey of athletes on eight college campuses (8,075 participants) found that hookah smoking existed at all levels of collegiate sports, although the percentage was higher in athletes participating in club sports (34.8 percent) as opposed to varsity sports (27.6 Texas Dental Journal l www.tda.org l May 2011

443

Hookhah Smoking

percent) (11). The authors postulate that the attraction of tobacco smoking using the hookah was high in this population, traditionally considered at low risk for tobacco use, due to the perception that hookah smoking was either not harmful or less harmful than cigarette smoking. The spread of hookah smoking among US college students is also reflected in the dramatic rise (400 percent since 1999) of hookah lounges near US campuses (12) (Figure 2). A cross-sectional sample of 3,770 college students from eight universities in North Carolina completed a web-based survey in fall 2008. Forty percent reported ever having smoked tobacco from a hookah, and 17 percent reported current (past 30-day) hookah smoking (13). Use was more common in individuals who also smoked cigarettes. Users in this group also perceived hookah use as less harmful, more socially acceptable and less addictive than cigarette smoking.

It is a matter of concern that hookah smoking may be the first contact with tobacco for youth.

Evidence suggests that hookah smoking may serve as a gateway to cigarette use (14). A study of 762 Danish youth (14-16 years of age) provides the first prospective evidence that hookah use predicts progression to regular cigarette smoking (15). The 2007 Florida Youth Tobacco Survey found that 11 percent of high school students reported ever having used a hookah (16). In 2008 a representative sample of 3,010 students responded to the New Jersey Youth Tobacco Survey. Four percent of middle school students and 11 percent of high school students reported ever having smoked hookah (17). Those students reporting hookah use were more likely to have smoked cigarettes. The preliminary evidence suggests that the transition from social to individual hookah use is a critical step toward nicotine dependence.

444

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

Conclusion The informed clinician should be mindful of the increase in the use of alternative forms of tobacco use, including the hookah. The traditional tobacco history should be modified to identify users of alternative forms of tobacco use. The first step in prevention is the identification of tobacco use in all forms. Intervention should address the particular risks associated with the method of tobacco use.

References 1. www.who.int/tobacco/global_interaction/ tobreg/Waterpipe%20recommendatin_Final. pdf 2. Primack BA, Aronson JD, Agarwal AA. An old custom, a new threat to tobacco control.

Am J Public Health. 2006; 96:1339.

3. Eissenberg T, Shihadeh A. Waterpipe tobacco and cigarette smoking: direct comparison of toxicant exposure. Am J Prev Med. 2009; Dec;37(6):518-23.

4. Monzer B, Sepetdjian E, Saliba N, Shihadeh A. (2008). Charcoal emissions as a source of CO and carcinogenic PAH in mainstream narghile waterpipe smoke. Food Chem Toxicol. 2008; 46(9), 2991-2995.

5. Lim B, Lim G, Seow E. (2009). Case of carbon monoxide poisoning after smoking shisha. Int J of Emerg Med. 2009; 2(2), 121122.

6. Shafagoj YA, Mohammed FI, Hadidi KA. Hubble-bubble (water pipe) smoking: levels of nicotine and cotinine in plasma, saliva and urine. Int J Clin Pharmacol Ther.2002;40(6):249-255.

7. Cobb CO, Shihadeh A, Weaver MF, Eissenberg T. Waterpipe tobacco smoking and cigarette smoking: a direct comparison of toxicant exposure and subjective effects.

Nicotine Tob Res. 2011 Feb;13(2):78-87.

8. Maziak W, Rastam S, Ibrahim I, Ward K, Shihadeh A, Eissenberg T. CO exposure, puff topography, and subjective effects in waterpipe tobacco smokers. Nicotine Tob Res. 2009;11(7) 806-811.

9. Akl EA, Gaddam SK, Honeine R, Jaoude PA, Iran J. The effects of waterpipe tobacco smoking on health outcomes: a systematic review. Int Journal of Epidemiol.

2010;39:834-857.

10. Daher N, Saleh R, Jaroudi E, Sheheitli H, Sepetdjian E, Al Rashidi M, Saliba N, Shihadeh A, Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from narghile waterpipe and cigarette smoking: Sidestream smoke measurements and assessment of second-hand smoke emission factors. Atmos Environ. 2010;44: 8-14.

11. Primack BA, Fertman CI, Rice KR, AdachiMejia AM, Fine MJ. Waterpipe and Cigarette Smoking Among College Athletes in the United States. J Adolesc Health. 2010; 46(1):4551.

12. Eissenberg T, Ward KD, Smith-Simone S, Maziak SW. Waterpipe Tobacco Smoking on a U.S. College Campus: Prevalence and Correlates. J Adolesc Health. 2008; 42 (5):526-52.

13. Sutfin EL, McCoy TP, Reboussin BA, Wagoner KG, Spangler J, Wolfson M. Prevalence and correlates of waterpipe tobacco smoking by college students in North Carolina. Drug Alcohol Depend. 2011; Feb 24. (Epub ahead of print).

14. Knishkowy, B., Amitai, Y. Water-Pipe (Narghile) Smoking: An Emerging Health Risk Behavior. Pediatrics. 2005;116:113-9.

15. Jensen P, Cortes R, Engholm G, Kremers S, & Gislum M. Waterpipe use predicts progression to regular cigarette smoking among Danish youth. Subst Use Misuse. 2010;45(7– 8):1245-1261.

16. Barnett T, Curbow B, Weitz J, Johnson T, & Smith-Simone S. Water pipe tobacco smoking among middle and high school students. Am J Public Health. 2009;99(11):2014-2019.

17. Jordan HM & Delnevo C D. Emerging tobacco products: Hookah use among New Jersey youth. Prev Med. 2010;51(5):394-396.

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

445

EXPRESS

The Texas Dental Association has integrated the existing TDA website (www.tda.org) into the “TDA Express” Internet portal. The TDA Express portal allows members to customize their homepage to show only the content in which they're interested.

Members can choose from existing links or add their own. TDA Express now includes a video library showcasing TDA videos and podcasts. Be sure to view the “Welcome” video by Mary Kay Linn, TDA Executive Director.

EXPRESS

Google

More News...

Cargo plane crashes in Uganda's Lake Victoria (AP) Yahoo News Dental News & Videos

Stefanie’s Desktop My Account

Sign-Out

Set as Home

RSS News Center Calculators

News & Publications

Dental

Personal

My Links

•

How to Reduce Stress Dr. Ben Bernstein has created a stress reduction m...

11/14/2008 10:00:00 AM

•

Understanding, Planning and Funding My Retirement This podcast addresses topics related to retiremen...

11/14/2008 10:00:00 AM

•

Revive, Refresh, Renew — Creating Balance for the Dental Has your get up and go, got up and left? This uniq...

11/14/2008 10:00:00 AM

•

Dental Professional Liability 101 This podcast addresses topics related to professio...

11/14/2008 10:00:00 AM

•

More Headlines...

Announcement Click HERE - TDA Express Feedback TDA Express has been enhanced! Along with a new look, TDA Express now has its very own TDA video library.

Events Calendar 2009 2007

Su

M

T

W

Th

F

Sa

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

1

2

3

4

Welcome to the TDA Video Library Introduction to the new TDA video library

by Mary Kay Linn, TDA Executive Director

Endodontics

TDA News TDA Committee on the New Dentist Podcast: Starting a New Practice The second installment of the TDA Committe on the New Dentist podacst series, conducted by Dr, Josh Austin.

TDA Perks Program TDA Members Website TDA Public Website DENPAC Website TDA Smiles Website

ADA News

Dental Plans Website

Pediatric Dentistry

TDA Perks Program Website TEXAS Meeting Website

7278.38

-122.42

S&P 500

768.54

-15.50

NASDAQ

457.27

-26.21

S&P/TSX

8506.35

-184.14

•

Five-year follow-up of a root canal filling material in the Oral Surgery, Oral Medicine, Oral Pathology, Oral ...

3/20/2009 10:21:05 AM

•

A longitudinal study of dental caries risk among very Community Dentistry and Oral Epidemiology 3/20/2009 10:21:05 AM

•

Putative signaling action of amelogenin utilizes the Journal of Periodontal Research 3/19/2009 10:25:15 AM

•

Silver Diamine Fluoride: A Caries Silver-Fluoride Bullet Journal of Dental Research 3/19/2009 10:25:15 AM

Orofacial Pain/TMJ News •

Patient Image Selection Criteria for Cone Beam Computed Seminars in Orthodontics 3/19/2009 10:25:14 AM

•

Current Diagnostic Tests to Assess Pulp Vitality Journal of the Canadian Dental Association 3/19/2009 10:25:15 AM

•

Likelihood ratio methodology to identify predictors of Oral Surgery, Oral Medicine, Oral Pathology, Oral ...

3/18/2009 11:15:34 AM

•

More Headlines...

•

Effects of a Liquid Diet on Temporomandibular Joint Journal of Dental Research

World Indices DOW JONES

Tools

ADA Podcast Network

Meetings/Planners Weather Center

March

Austin Weather: Overcast 70

Finance

TDA Videos

GO

Implantology

Top Section: Google search box (top-right corner), Helpful Tips, Contact Info (top-left), News scroll of top headlines, Local weather update Left-hand margin: RSS News Center, Calculators, Meetings/Planners, Weather Center, Announcements from TDA, Events Calendar, TDA News and TDA Perks Program highlights, List of TDA and affiliate websites, and World Indices Middle section (portlets) - Content divided into 7 sections: • Dental News & Videos: TDA video library, ADA Podcast Network, and dental specialty news.

• News & Publications: Business and personal news, magazines, television, and Internet links.

• Dental: Links related to the profession and dental office needs.

• Personal: Links to travel, weather, people, sports, and other leisure interests.

• Finance: Banking and finance related links, including investment, retirement, and bankruptcy.

• Tools: Variety of helpful links such as office and tech tools, research, demographic, and people searches.

• My Links: Links and categories created by the user.

Contact: Stefanie Clegg (512) 443-3675 or stefanie@tda.org

CLINICAL REVIEW

The Role of the Human Papillomavirus in Oropharyngeal Cancer Aparna Naidu, D.D.S., M.S. John M. Wright, D.D.S., M.S.

Introduction In 2010, an estimated 36,540 cases of oral and oropharyngeal cancer were diagnosed in the United States, with approximately 7,880 people expected to die of the disease (1). The combined effects of smoking tobacco and alcohol use result in a 30 times higher risk for oral cancer (1). When all stages of disease are considered, the overall 5-year survival rate is 61 percent, dropping to 50 percent after 10 years. There is a considerable difference in 5-year survival rates if an individual is diagnosed at an early stage. When the cancer is limited to localized disease, 83 percent of individuals survive 5 years, while only 32 percent of individuals survive if they are diagnosed after distant spread or metastasis has occurred (Stage IV).

Abstract In recent years there has been an overall decrease in cancers of the oral cavity, and a concurrent increase in cancers in specific sites of the posterior oral cavity and oropharynx in the United States. There is increasing evidence that the human papillomavirus (HPV) may play a role in the development of oropharyngeal squamous cell carcinoma.

In this article we review the biology and risk factors associated with HPV and oropharyngeal carcinoma, and recent data suggesting that this type of cancer may be unique in its response to treatment and prognosis.

Key words: Human papillomavirus, oral cancer, oropharyngeal cancer Naidu

Wright

Dr. Naidu is an assistant professor, Department of Diagnostic Sciences, Baylor College of Dentistry–Texas A&M Health Science Center, Dallas, Texas.

Tex Dent J 2011;128(5): 447-454.

Dr. Wright is regent’s professor and chair, Department of Diagnostic Sciences, Baylor College of Dentistry–Texas A&M Health Science Center, Dallas, Texas.

The authors have no potential conflicts of financial interest, relationships and/or affiliations relevant to the subject matter or materials discussed in the manuscript.

This article has been peer reviewed.

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

447

HPV Role in Oropharyngeal Cancer

Researchers currently propose that there are two distinct pathways for the development of

Squamous cell carcinoma accounts for over 90 percent of all head and neck oropharyngeal cancer: one initiated by the cancers (2). There is clear evidence that squamous cell carcinoma develops from carcinogenic effects of tobacco and/or alspecific gene mutations which occur in cohol use, and a second pathway caused by the upper aerodigestive tract epithelium after exposure to carcinogens such as tobacco and alcohol (3). Multiple gegenetic mutations due to HPV. netic alterations which affect cell cycle regulation, proliferation, and angiogenesis cause abnormal maturation of the mutated cells, ultimately leading to invasion and metastasis. The overall incidence of cancer of the oral cavity has steadily declined by 1-9 percent annually since 1973 in the U.S (4). This has been attributed to the decrease in tobacco use over the past few decades. From 1965 to 2006, rates of smoking in the United States declined from 42 percent to 20.8 percent (5). This trend has been similar in most developed countries (6).

By contrast, base of tongue and tonsillar cancers in the U.S. have increased annually by 1-3 percent and 0-6 percent, respectively, since 1973 (4). An increase in oropharyngeal cancer has been seen both in the United States and Europe. In 1973, 18 percent of head and neck carcinomas in the United States were located in the oropharynx, and in 2004 this number increased to 31 percent (7).

In other countries this increase is even greater, with the incidence

448

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

of tonsillar cancer in Sweden increasing by 45 percent from 1970 to 2006 (8). The increase in carcinoma occurring in this anatomic site seems to be more pronounced in young adults.

In the U.S. and Europe, studies have demonstrated an increased incidence of squamous cell carcinoma of the tongue in adults under the age of 45 over the past 10 years (9-11). European studies have shown a five- to six-fold increase in the incidence of tongue squamous cell carcinoma in young adults under the age of 39, compared with a two-fold increase in older age groups (12).

In recent years, several molecular studies have indicated a link between the human papillomavirus (HPV) and the development of squamous cell carcinoma of the head and neck (13-15). As early as 1983, the role of HPV in oral squamous cell carcinogenesis had begun to be studied (16). Researchers currently propose that there are two distinct pathways for the development of oropharyngeal cancer: one initiated by the carcinogenic effects of tobacco and/or alcohol use, and a second pathway caused by genetic mutations due to HPV (8,17,18). While there are more than 100 types of HPV, 90 percent of all HPV-associated oropharyngeal cancer in the United States has been linked to HPV 16 (13,19). Other types that have been correlated with squamous cell carcinoma of the head and neck are HPV 6, 11, 18, 33, 35, 38, 52, and 59 (20).

In a retrospective study that was conducted in Sweden, researchers used the polymerasechain-reaction technique to

extract DNA from stored tissue specimens. They demonstrated an increase in HPV-positivity in tonsillar squamous cell carcinoma from 23 percent in the 1970’s to 79 percent from 2000 to 2007 (8). Concurrently, they have seen a significant decrease in HPV negative tonsillar cancer since 1980. Their most recent data from 20062007 shows that 93 percent of all tonsillar cancer was HPV positive, which has led them to suggest that almost all tonsillar squamous cell carcinoma will soon be linked to HPV. There also appears to be a difference between oral tongue and base of tongue cancer. An analysis of 110 cases of squamous cell carcinoma of the oral tongue and base of tongue in Sweden showed that HPV was detected in 40 percent of base of tongue cases but in only 2.3 percent of oral tongue cases (21). Researchers attribute the dramatic increase in base of tongue and tonsillar carcinoma to an increased rate of HPV infection (22).

Several large case control studies have been initiated in the U.S. to study the epidemiology and incidence of HPV in oropharyngeal cancer (18, 23). A meta-analysis of several studies of individuals with oropharyngeal cancer showed that 40-80 percent of cases were associated with HPV in the U.S. (24).

In a study of specimens taken from 100 patients diagnosed with oropharyngeal cancer at Johns Hopkins University, HPV 16 DNA was detected in 72 percent of patients using a technique called in-situhybridization, which detects viral DNA in a tissue specimen (18). Most of the tumors

occurred on the mucosa of the palatine tonsils or base of the tongue. The researchers found that exposure to HPV increased the likelihood of oropharyngeal cancer, regardless of tobacco or alcohol use. E6 and E7 are circulating oncogenic proteins encoded by HPV 16 which can be detected in the serum and are known to alter the activity of several tumor suppressor genes found in mucosal epithelial cells (25, 26). Sixty-four percent of patients diagnosed with oropharyngeal cancer showed seropositivity for E6 and E7 compared to 8 percent of the control group (18).

HPV-associated oropharyngeal carcinoma appears to follow a unique clinical course. There is increasing evidence that it carries a better prognosis than HPV-negative oropharyngeal carcinoma (13, 27-29). In a study of 52 individuals with tonsillar squamous cell carcinoma, researchers found that tumors containing detectable HPV DNA were associated with a 5-year survival rate of 71 percent, compared to 36 percent in HPV negative tumors (30).

Almost all HPV positive cases were associated with HPV 16.

HPV positive tumors appear to be more sensitive to chemotherapy and radiation. The higher response rates to induction chemotherapy and chemoradiation seen in HPV positive tumors may account for the greater survival rates (31). This has led researchers to search for markers that could be used routinely to indicate whether a tumor is HPV positive or not.

There are specific molecular markers that differentiate HPVpositive carcinoma from HPVTexas Dental Journal l www.tda.org l May 2011

449

HPV Role in Oropharyngeal Cancer

negative carcinoma, and have been shown to correlate with tumor prognosis. Two common genetic changes that occur in squamous cell carcinoma associated with the carcinogenic effects of tobacco and alcohol are the mutation of p53 and inactivation of p16, which are both tumor suppressor genes (3234). In contrast, HPV associated head and neck squamous cell carcinoma seems to have a different molecular profile, and is usually not associated with p16 inactivation (35, 36).

Because p16 is still activated in HPV positive carcinoma, it has begun to be utilized as an indicator of whether a squamous cell carcinoma is HPV associated or not. In a longitudinal study following 107 individuals with diagnosed oropharyngeal carcinoma, one group of researchers found that p16 expression was associated with a 79 percent 5-year survival rate, compared with an 18-20 percent 5-year survival rate in individuals with HPV-negative tumors or tumors not expressing p16 (28).

There is increasing evidence that chemotherapy and radiation are more effective in treating p16 positive HPV associated oropharyngeal carcinoma and preventing regional spread and local recurrence. A large phase 3 clinical trial of chemoradiation included over 400 cases of oropharyngeal carcinoma from North America, South America, Australia, Europe, and New

450

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

Zealand (37). Individuals with tumors showing p16 positivity were found to have a 91 percent 2-year survival rate, compared to 77 percent in individuals with p16 negative tumors. Individuals with p16 negative tumors were much more likely to be smokers (45 percent versus 15 percent). The authors concluded that while this data is still preliminary, the combined results from several ongoing clinical trials confirm HPV status as an important prognostic variable in the treatment of oropharyngeal cancer (31, 37).

HPV is known to preferentially infect squamous epithelial cells and a significant association between HPV and squamous cell carcinoma has been documented in the anogenital tract, conjunctiva, and oropharynx (38). The role of HPV in cervical cancer is well known. HPV 16 was first isolated in cervical cancer specimens in 1983 (39).

Following this initial study, various types of HPV have been isolated in almost all cases of cervical intraepithelial neoplasia and invasive cervical cancer.

A large review of cervical cancer estimates that the worldwide prevalence of HPV in cervical carcinoma is 99.7 percent (40).

While HPV 16 is the type that is most commonly detected, the high risk subtypes 18, 31, 33, 39, 45, 52, and 58 are also found in cervical cancer (40).

The lower risk subtypes 6 and 11 are associated with prema-

lignant lesions and contribute to the overall burden of HPV infection through development of anogenital condylomas, cervical intraepithelial neoplasia, and respiratory papillomatosis (41).

Two vaccines have been approved by the U.S. Food and Drug Administration (FDA) for use in protection against specific strains of HPV. Gardasil® (HPV4; Merck and Co.) is a quadrivalent vaccine against HPV types 6,11,16, and 18 approved for use in the U.S. in 2006 for females aged 9 to 26 (42). HPV 16 and 18 are high risk oncogenic types that are thought to cause 70 percent of cervical cancers. HPV 6 and 11 are the cause of 90 percent of genital condylomas (“warts”) which can occasionally progress to cervical cancer (42, 43). In 2009, the FDA licensed Gardasil® for use in males aged 9 to 26 to prevent genital warts caused by HPV 6 and 11.

Cervarix® (HPV2; Glaxo Smith Kline) is a bivalent vaccine which protects against HPV 16 and 18 and was approved by the FDA in 2009 for females aged 10 to 25. Both of the vaccines have been highly effective against cervical intraepithelial neoplasia and invasive cervical carcinomas (44, 45). They are both most effective when administered as an intramuscular injection in a three-dose schedule over a period of 6-8 months (42).

In 2010, the U.S. Centers for Disease Control and Prevention (CDC) published the recommendations of the Advisory Committee on Immunization Practices (ACIP) (42). The recommendations included routine vaccination of females aged 11 or 12 years with three doses of either Gardasil® or Cervarix®. The vaccination series can be started beginning at the age of 9. They recommend vaccination for females aged 13 through 26 years who have not been vaccinated previously or who have not completed the three-dose series, and indicate the vaccines should be administered before potential exposure to HPV through sexual contact. The ACIP recommends vaccination with Gardasil® or Cervarix® for prevention of cervical cancers and premalignancy, as well as vulvar and vaginal cancer. They recognize that, in addition to cervical cancer, “both vaccines might provide protection against some other HPV-related cancers in addition to cervical cancer.”

The estimated annual incidence of HPV associated head and neck cancer is only secIt remains to be seen whether ond to cervical cancer when compared to all anatomic sites, and men seem to be affected vaccination against certain subtypes much more commonly than women (Figures 1 and 2). There is some evidence of a correlaof HPV will have any effect on the tion between sexual activity and incidence of oropharyngeal cancer. A study of 284 cases development of oropharyngeal cancer. of oropharyngeal cancer conducted in the western U.S. showed that after adjustment for The possibility that this subset of cancer alcohol consumption and tobacco exposure, the total number of lifetime sexual partners, may actually be preventable will young age at first intercourse, and history of genital warts are all factors associated with continue to be a public health challenge a higher risk of oropharyngeal cancer (46).

The researchers at Johns Hopkins University worthy of future debate and effort. studied the past sexual history in the subset of cases that showed HPV 16 positivity. They found that the incidence of HPV associated oropharyngeal cancer significantly increased as the number of sexual partners increased (18). The authors suggest that the increased rate of base of tongue and tonsillar cancer in young adults over the past few decades may be due to an increase in oral sexual practices in adolescents and young adults. They propose that if the HPV vaccines are as successful preventing oropharyngeal cancer as they are in preventing cervical cancer, vaccination is indicated in both males and females, since oropharyngeal cancer occurs in both groups.

HPV associated oropharyngeal squamous cell carcinoma appears to be unique in its epidemiology, biology, associated risk factors, response to treatment, and prognosis. As more is learned about this subtype of head and neck cancer and the role of HPV in carcinogenesis, it may affect management of the disease and alter treatment protocols. It remains to be seen whether vaccination against certain subtypes of HPV will have any effect on the development of oropharyngeal cancer. The possibility that this subset of cancer may actually be preventable will continue to be a public health challenge worthy of future debate and effort.

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

451

HPV Role in Oropharyngeal Cancer Figure 1. HPV Associated Cancer by Anatomic Site Cervical: 10,800 cases (43.4%) Other anogenital tract sites: 6,700 cases (26.9%) Head and Neck: 7,400 cases (29.7%)

Figure 2. HPV Associated Head and Neck Cancer by Sex

Males: 5,700 cases (77.0%) Females: 1,700 cases (22.9%)

Figures 1 & 2: Average Annual Incidence Rates of Cancers Associated With HPV in the United States from 1998-2003. (Charts adapted from: Watson M, Saraiya M, Ahmed F, Cardinez CJ, Reichman ME, Weir HK, Richards TB. Using population-based cancer registry data to assess the burden of human papillomavirus-associated cancers in the United States: Overview of methods. Cancer 2008;113(S10): 2841–2854.)

Data was derived from population-based cancer registries that participate in the National Program of Cancer Registries and/or the Surveillance, Epidemiology, and End Results (SEER) Program, which cover approximately 83 percent of the population for the period studied.

452

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

References

1. Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin.

2010 Sep-Oct;60(5):277-300.

2. Barnes L, Eveson JW, Reichart P, Sidransky D (Eds.): World Health Organization Classification of Tumours.

Pathology and Genetics of Head and Neck Tumours .

IARCPress: Lyon 2005.

3. Choi S, Myers JN. Molecular pathogenesis of oral squamous cell carcinoma: implications for therapy. J Dent Res. 2008 Jan;87(1):14-32.

Review.

4. Chaturvedi AK, Engels EA, Anderson WF, Gillison ML. Incidence trends for human papillomavirus-related and -unrelated oral squamous cell carcinomas in the United States. J Clin Oncol 2008;26: 612–19.

5. Rock VJ, Malarcher A, Kahende JW, Asman K, Husten C, Caraballo R. “Cigarette Smoking Among Adults --- United States, 2006”.

United States Centers for Disease Control and Prevention. (November 9, 2007 / 56(44);1157-1161). http:// www.cdc.gov/mmwr/preview/mmwrhtml/mm5644a2. htm. Retrieved 2/02/2011.

6. World Health Organization Regional Office for the Western Pacific. “WHO/ WPRO-Smoking Statistics.”

5/28/2002. http://www. wpro.who.int/media_centre/ fact_sheets/fs_20020528. htm. Retrieved 2/2/2011.

7. Shiboski CH, Schmidt BL, Jordan RC. Tongue and tonsil carcinoma: increasing trends in the U.S. population ages 20-44 years. Cancer 2005;103(9):1843-9.

8. Nasman A,Attner P,Hammarstedt L et al. Incidence of human papillomavirus (HPV) positive tonsillar carcinoma in Stockholm,

Sweden: An epidemic of viralinduced carcinoma? Int. J. Cancer 2009;125:362–366.

9. Shemen L, Klotz J, Schottenfeld D, Strong E. Increase of tongue cancer in young men.

JAMA 1984;252:1857.

10. Depue R. Rising mortality from cancer of the tongue in young white males. N Engl J Med 1986;315:647.

11. Davis S, Severson R. Increasing incidence of cancer of the tongue in the United States among young adults. Lancet 1987;2:910 –911.

12. Annertz K, Anderson H, Biorklund A, et al. Incidence and survival of squamous cell carcinoma of the tongue in Scandinavia, with special reference to young adults. Int J Cancer 2002;101:95–99.

13. Gillison ML, Koch WM, Capone RB, et al. Evidence for a causal association between human papillomavirus and a subset of head and neck cancers. J Natl Cancer Inst 2000;92:709-20.

14. Kreimer AR, Clifford GM, Boyle P,Franceschi S. Human papillomavirus types in head and neck squamous cell carcinomas worldwide: a systematic review. Cancer Epidemiol Biomarkers Prev 2005;14:467-75.

15. Gillison ML. Human papillomavirus associated head and neck cancer is a distinct epidemiologic, clinical, and molecular entity. Semin Oncol 2004;31:744-54.

16. Syrjanen K, Syrjanen S, Lamberg M, Pyrhonen S, Nuutinen J. Morphological and immunohistochemical evidence suggesting human papillomavirus (HPV) involvement in oral squamous cell carcinogenesis. Int J Oral Surg 1983;12:418–24.

17. Allen CT, Lewis JS, El-Mofty SK, et al. Human papillomavirus and oropharynx cancer: biology, detection, and clini-

cal implications. The Laryngoscope 2010;120:17561772.

18. D’Souza G, Kreimer AR, Viscidi R. Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med 2007;356:1944-56.

19. Herrero R, Castellsague X, Pawlita M,et al. Human papillomavirus and oral cancer: the International Agency for Research on Cancer multicenter study. J Natl Cancer Inst 2003;95:1772-83.

20. Lajer CB, von Buchwald C. The role of human papillomavirus in head and neck cancer. APMIS 2010; 118: 510–519.

21. Dahlgren L, Dahlstrand H, Lindquist D, et al. Human papillomavirus is more common in base of tongue than in mobile tongue cancer and is a favorable prognostic factor in base of tongue cancer patients. Int J Cancer 2004;112:1015–1019.

22. Syrjanen S. The role of human papilloma virus infection in head and neck cancers. Ann Oncol 2010;21 Suppl 7:vii243-vii245.

23. Dahlstrom KR, Adler-Storthz K, Etzel CJ, et al. Human papillomavirus type 16 infection and squamous cell carcinoma of the head and neck in never-smokers: a matched pair analysis. Clin Cancer Res 2003;9:2620-2626.

24. Marur S, D’Souza G, Westra WH, et al. HPV-associated head and neck cancer: a virus-related cancer epidemic.

Lancet Oncol 2010;11:78189.

25. Klingelhutz AJ, Foster SA, McDougall JK. Telomerase activation by the gene E6 gene product of human papillomavirus type 16. Nature 1996;380:79-82.

26. Dyson N, Howley PM, Munger K, Harlow E. The human papilloma virus-16 E7 onco-

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

453

HPV Role in Oropharyngeal Cancer

protein is able to bind to the retinoblastoma gene product.

Science 1989;243:934-937.

27. Li W, Thompson CH, O’Brien CJ, et al. Human papillomavirus positivity predicts favourable outcome for squamous carcinoma of the tonsil.

Int J Cancer 2003;106:553558.

28. Weinberger PM, Yu Z, Haffty BG, et al. Molecular classification identifies a subset of human papillomavirus-associated oropharyngeal cancers with favorable prognosis. J Clin Oncol 2006;24:736-747.

29. Hennessey PT, Westra WH, Califano JA. Human papillomavirus and head and neck squamous cell carcinoma: recent evidence and clinical implications. J Dent Res 2009;88(4):300-306.

30. Charfi L, Jouffroy T, de Cremoux P, et al. Two types of squamous cell carcinoma of the palatine tonsil characterized by distinct etiology, molecular features and outcome. Cancer Lett 2008;260:72-78.

31. Fakhry C, Westra WH, Li S, Cmelak A, Ridge JA, Pinto H, et al. Improved survival of patients with human papillomavirus-positive head and neck squamous cell carcinoma in a prospective clinical trial. J Natl Cancer Inst 2008;100:261-269.

32. Herman JG, Merlo A, Mao L, et al. Inactivation of the CDKN2/p16/MTS1 gene is frequently associated with aberrant DNA methylation in all common human cancers.

Cancer Res 1995;55:45254530.

33. Reed AL, Califano J, Cairns

454

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

P, et al. High frequency of p16 (CDKN2/MTS-1/INK4A) inactivation in head and neck squamous cell carcinoma.

Cancer Res 1996;56:36303633.

34. Braakhuis BJM, Leemans CR, Brakenhoff RH. A genetic progression model of oral cancer: current evidence and clinical implications. J Oral Pathol Med (2004) 33: 317–22.

35. Perrone F, Suardi S, Pastore E, et al. Molecular and cytogenetic subgroups of oropharyngeal squamous cell carcinoma. Clin Cancer Res 2006;12:6643-6651.

36. Ragin CC, Taioli E, Weissfeld JL, et al. 11q13 amplification status and human papillomavirus in relation to p16 expression defines two distinct etiologies of head and neck tumours. Br J Cancer 2006;95:1432-1438.

37. Rischin D, Young RJ, Fisher R, et al. Prognostic significance of p16INK4A and human papillomavirus in patients with oropharyngeal cancer treated on TROG 02.02 phase III trial. J Clin Oncol 2010;28(27):4142-8.

38. Gillison ML, Shah KV. Chapter 9: Role of mucosal human papillomavirus in nongenital cancers. J Natl Cancer Inst Monogr. 2003;(31):57-65.

Review.

39. Durst M, Gissmann L, Ikenberg H, zur Hausen H. A papillomavirus DNA from a cervical carcinoma and its prevalence in cancer biopsy samples from different geographic regions. Proc Natl Acad Sci U S A 1983;80: 3812–5.

40. Walboomers J, Jacobs M, Manos M, Bosch F, Kummer J, Shah K, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol 1999;189:1–3.

41. Paavonen J. Human papillomavirus infection and the development of cervical cancer and related genital neoplasias. Int J Infect Dis. 2007 Nov;11 Suppl 2:S3-9.

42. Centers for Disease Control and Prevention (CDC). FDA licensure of quadrivalent human papillomavirus vaccine (HPV4, Gardasil) for use in males and guidance from the Advisory Committee on Immunization Practices (ACIP).

MMWR Morb Mortal Wkly Rep 2010;59(20):630-2.

43. Bosch FX, de Sanjose S. Chapter 1 :Human Papillomavirus and Cervical Cancer—Burden and Assessment of Causality. J Natl Cancer Inst Monogr 2003;31;3–13.

44. Schwarz TF. Clinical update of the AS04-adjuvanted human papillomavirus-16 ⁄ 18 cervical cancer vaccine, cervarix. Adv Ther 2009;26:983– 98.

45. Majewski S, Bosch FX, Dillner J, et al. The impact of a quadrivalent human papillomavirus (types 6, 11, 16,18) virus-like particle vaccine in European women aged 16 to 24. J Eur Acad Dermatol Venereol 2009;23:1147–55.

46. Schwartz SM, Daling JR, Doody DR, et al. Oral cancer risk in relation to sexual history and evidence of human papillomavirus infection. J Natl Cancer Inst 1998;90:1626–36.

w w w . P o r t a b l e i v. c o m In-office Dental I.V. Sedation Services for your patient.

Sedation customized to your patients psychological & physical requirements Travel to your practice along with all necessary equipment and supplies.

Sign up for our newsletter or ask for more information.

Catharine Quartapella Goodson DDS. UT Houston 1985 General Dentist providing In-office Dental I.V. Moderate Sedation Services for your patient.

(office) 281.332.6964 (cell) 713.417.9924 Website:

www.portableiv.com

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

455

DDR Dental Trust

Serving Texas Dentists for more than 40 Years

• Practice Appraisals • Practice Sales • Associate Agreements

800-930-8017

James L. Dunn, Trustee

• Inexpensive • Disposable • Non-Toxic

PROTECT YOUR PATIENT FROM PAINFUL TISSUE PLUGS PROTECT YOUR EQUIPMENT FROM COSTLY REPAIRS PACKAGED 100/ZIPLOCK BAG CALL/FAX: 1-509-448-2602 • EMAIL: kenevac@hotmail.com E-VAC INC.© 4528 South Helena Street, Spokane, WA 99223

CONTACT YOUR LOCAL DENTAL SUPPLY PURCHASED BY: General Practitioners • Pediatric Dentists • Periodontists • Prosthodontists Dental Assistants • Hygienists • Hospitals • Universities Made in U.S.A. - FDA Registered

456

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

CLINICAL REVIEW

Treatment of Nicotine Dependence with ChantixÂŽ (varenicline) K. Vendrell Rankin, D.D.S. Daniel L. Jones, Ph.D., D.D.S.

Introduction :KLOH VPRNLQJ SUHYDOHQFH KDV GHFOLQHG VLJQLÀFDQWO\ VLQFH WKH ÀUVW 86 6XUJHRQ *HQHUDO¡V UHSRUW RQ WKH FRQVHTXHQFHV RI VPRNLQJ LQ WKH GHFOLQH RI DGXOW DQG \RXWK VPRNLQJ KDV VORZHG LQ UHFHQW \HDUV

$SSUR[LPDWHO\ PLOOLRQ 86 DGXOWV DQG RQH LQ ÀYH KLJK VFKRRO VWXGHQWV FXUUHQWO\ VPRNH 6PRNLQJ UHPDLQV WKH OHDGLQJ FDXVH RI SUHYHQWDEOH GHDWK LQ WKH 8QLWHG 6WDWHV NLOOLQJ PRUH WKDQ $PHULFDQV DQQXDOO\ $GGLWLRQDOO\ PLOOLRQ SHRSOH LQ WKH 8 6 FXUUHQWO\ VXIIHU IURP D VPRNLQJ UHODWHG LOOQHVV

Rankin

Jones

Dr. Rankin is a professor and associate chair, Department of Public Health Sciences, Baylor College of Dentistry – Texas A&M Health Science Center, Dallas, Texas.

Dr. Jones is a professor and chair, Department of Public Health Sciences, Baylor College of Dentistry – Texas A&M Health Science Center, Dallas, Texas.

7KH DXWKRUV KDYH QR GHFODUHG SRWHQWLDO FRQà LFWV RI ÀQDQFLDO LQWHUHVW UHODWLRQVKLSV DQG RU DIÀOLDWLRQV UHOHYDQW WR WKH VXEMHFW PDWWHU RU PDWHULDOV GLVFXVVHG LQ WKH PDQXVFULSW

Abstract Varenicline is the generic name for ChantixÂŽ, the newest drug available for the treatment of tobacco dependence. In a randomized controlled clinical trial, the abstinence rate at 1 year for patients using varencline was superior to that of patients in the group using bupropion SR (ZybanÂŽ) and in the placebo group (11).

Varenicline reduces nicotine withdrawal symptoms, cigarette craving and nicotine satisfaction. Post-market reports prompted a warning of serious adverse neuropsychiatric events in patients taking varenicline. As is the case with any surgical procedure and/or prescription medication, full disclosure of the risks and beneÀWV VKRXOG EH GLVFXVVHG ZLWK WKH SDWLHQW 7KH VLJQLÀFDQW KHDOWK EHQHÀWV RI TXLWWLQJ smoking should be weighed against the individual’s risk of adverse events associated with the use of varenicline for smoking cessation.

KEY WORDS: Tobacco cessation, varenicline, nicotine dependence Tex Dent J 2011;128(5): 457-461.

This article has been peer reviewed.

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

457

Treatment of Nicotine Dependence with Chantix®

The effects of tobacco use are clearly evident in the oral cavity, which provides dentists an ideal opportunity to initiate the discussion of tobacco cessation with patients. Poor wound healing, dental implant failure, oral cancer, and a host of reactive changes are attributable to smoking. Estimates indicate that smoking is responsible for over half of periodontitis cases among adults in the United States (5).

Randomized clinical trials have shown that even brief dental office-based interventions can be effective in motivating and assisting tobacco users to quit. Furthermore, adults ages 20-44 rarely visit their physicians for preventive care (6). In contrast, more than half of adult smokers see a dentist each year for prevention-oriented care (7). This positions dentists in an ideal situation to provide tobacco cessation intervention (8). Although dentists may fear that the discussion of cessation may alienate patients, research indicates that most dental patients want their dentists to offer tobacco cessation advice and are comfortable receiving such advice (9).

Advice and assistance from a dental professional can have a significant positive impact on patients’ success in quitting tobacco use. Brief counseling in conjunction with appropriate medication has been demonstrated to increase the odds of successful and sustained abstinence (10). Seven medications are currently available to assist patients ready to quit smoking, including five nicotine replacement medications (nicotine gum, nicotine inhaler, nicotine lozenges, nicotine nasal spray and nicotine patches) and two non-nicotine medications, Zyban® (bupropion SR) and Chantix® (varenicline) (10).

Varenicline Action and Efficacy Varenicline was approved by the U.S. Food and Drug Administration (FDA) in May 2006 for smoking cessation. The drug partially binds to a subtype of nicotine receptors in the brain, which prevents nicotine from occupying these receptors. This action relieves nicotine withdrawal symptoms and cravings. Varencline also acts as an antagonist, blocking the reinforcing effects of nicotine, which decreases smoking satisfaction. The efficacy of varenicline has been compared with placebo and bupropion SR for tobacco abstinence. In a randomized controlled clinical trial, the abstinence rate at 1 year for patients using varencline was 23 percent in contrast with 14.6 percent in the group using bupropion SR (Zyban®)

458

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

and 10.3 percent in the placebo group 11. Varenicline has not been approved by the FDA for treatment of tobacco use for forms of tobacco other than cigarette smoking.

Prescribing Information Varenicline should only be prescribed for patients ready to set a quit date within 2 weeks. Drug titration should begin 1 week prior to the quit date. For the first 3 days the patient should be instructed to take one 0.5 mg tablet per day. On the fourth day the dose should be increased to one 0.5 mg tablet in the morning and one 0.5 mg tablet in the evening. At 1 week the dose is increased to one 1 mg tablet in the morning and one 1 mg tablet in the evening for the duration of treatment. When the first month of therapy is prescribed as a starter pack the dosing schedule is detailed on the packaging. Each tablet should be taken after meals and with a full glass of water.

Treatment should continue for 11 weeks, but may be extended beyond the initial treatment period to prevent relapse in susceptible patients. Patients who are treated with varenicline for 6 months are more likely to be abstinent at 1 year than those who receive only 3 months of therapy (12). The medication need not be tapered when discontinued. At present the efficacy of varenicline in combination with other smoking cessation drugs is under investigation.

Adverse Events The most common adverse event associated with varenicline treatment is nausea (30 percent) compared with 11 percent for placebo (11). Nausea was generally described as mild or moderate and often transient. If patients treated with the maximum recommended dose of 1 mg twice per day are unable to tolerate nausea, the dose may be reduced to 0.5 mg twice per day. The incidence of nausea at the reduced dose was 16 percent compared with 11 percent for placebo. Patients also reported sleep disturbance, constipation, flatulence, and, to a lesser degree, vomiting. Drug interaction studies performed with varenicline in combination with digoxin, warfarin, transdermal nicotine, bupropion, cimetidine and metformin showed no clinically meaningful pharmacokinetic drug to drug interactions. There are no studies on the safety and efficacy of varenilcine in patients under 18 years of age. The effects of varenicline on pregnant females and their offspring have not been adequately studied. It is unknown whether varenicline is excreted in the milk of nursing mothers (12). Prescription of varenicline for these groups is not recommended.

The warnings and precautions section in the prescribing information for varenicline includes adverse reactions that are expected to occur, but have not yet been observed. The warning information for varencline describes the possibility of serious skin reactions, with swelling of the face, mouth, and neck that can lead to life-threatening

respiratory compromise. If patients experience this reaction they should be instructed to discontinue the drug and immediately seek medical care.

FDA Post-market Warning In 2008, the FDA required the manufacturers of varenicline to add a boxed warning to the product labeling, based on continued review of post-marketing adverse event reports. A boxed warning is used to highlight adverse reactions so serious in proportion to the potential benefit from the drug that it is essential that it be considered in assessing the risks and benefits of using a drug. The boxed warning states that there is a risk of serious neuropsychiatric symptoms in patients using varencline, including changes in behavior, hostility, agitation, depressed mood, suicidal thoughts and behavior, and attempted suicide. This warning was also added to the prescribing instructions for bupropion SR (Zyban速).

Symptoms of nicotine withdrawal are also associated with adverse neuropsychiatric symptoms, including dysphoric or depressed mood, insomnia, irritability, frustration, anger, and anxiety. It is not unusual to have these symptoms associated with nicotine withdrawal, independent of treatment with varenicline or bupropion SR. The possible risks of serious adverse events occurring while using varenicline or bupropion SR should be weighed against the significant health benefits of quitting smoking (13).

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

459

Treatment of Nicotine Dependence with Chantix®

In a recent publication, researchers conducted an assessment of the risks of varenicline compared with similar patients trying to quit smoking using alternative pharmacotherapy (14). Researchers identified all adult patients who were prescribed a smoking cessation medication between September 2006 and May 2008. Of the 80,660 patients included in the study, 63,265 were using some form of nicotine replacement therapy (NRT), 6,422 were taking bupropion SR, and 10,973 were taking varenicline. In the population using some form of smoking cessation medication, there were 166 episodes of selfharm, 37 episodes of suicidal thinking, and two suicides during the follow-up period. Both the suicides were in patients who had used NRT. There were no suicides among the patients using varenicline, and no statistically significant increased risk of suicide, self-harm, suicidal thoughts or subsequent use of antidepressants in patients using varenicline or bupropion SR as compared with NRT. Overall, this large study found only 18 episodes of selfharm in the 10,973 smokers taking varenicline. This proportion is not significantly different from patients using NRT or bupropion SR. Additionally, significantly fewer vareniclinetreated patients had a subsequent need for antidepressants.

These results should be interpreted with some reservation, as patients with serious mental

460

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

health or medical problems were largely excluded from this study.

However, the sample did include patients who had a history of a previous suicide event (11 percent), a history of alcohol misuse (10 percent), patients taking antipsychotic medication (5 percent), antianxiety medication (13 percent) and antidepressants (24 percent).

In an attempt to conduct a more rigorous assessment of the safety profile of varenicline, a pooled analysis of psychiatric adverse events from 10 randomized, controlled trials treating a total of 3091 participants with varenicline was performed. The analysis reported no significant increase in overall psychiatric disorders due to varenicline other than sleep disorders and disturbances (15).

Patient Information Prior to initiating varenicline therapy the patient should be (13): • • • • •

•

•

•

•

•

Provided with educational materials and counseling.

Encouraged to reveal any history of psychiatric illness prior to initiating treatment.

Informed that nausea is a common side effect, but that a dose reduction may address this.

Informed that they may experience vivid, unusual, or strange dreams during treatment.

Informed that quitting smoking may be associated with nicotine withdrawal symptoms, including depression, agitation, or exacerbation of pre-existing psychiatric illness.

Informed that some patients have experienced changes in mood including depression, mania, psychosis, hallucinations, paranoia, delusions, homicidal ideation, aggression, anxiety and panic, as well as suicidal ideation and suicide when attempting to quit smoking while taking varenicline.

Informed that if they experience serious changes in mood, they should discontinue varenicline and contact the prescribing clinician immediately.

Advised to use caution driving or operating machinery until they know how quitting smoking with varenicline may affect them.

Informed that while rare, if swelling of the face, mouth, and neck occurs, they should discontinue varenicline and immediately seek emergency medical care.

Encouraged to continue to attempt to quit if they have early lapses after quit day.

Summary Varenicline is a useful tool in the pharmacologic armamentarium to treat tobacco use and dependence. Many patients are familiar with this drug and may request information and/or a prescription. Clinicians should be familiar with the information provided by the pharmaceutical company prior to prescribing varenicline. As is the case with any surgical procedure or use of any prescription medication patients should be provided with complete information, a description of the risks and benefits and possible adverse events. Clinicians may wish to have the patient sign an acknowledgment that they have been advised of the possible adverse events. Finally, clinicians should weigh the significant health benefits of quitting smoking against the individual’s risk of adverse events associated with the use of varenicline for smoking cessation.

References 1. Cigarette Smoking Among Adults and Trends in Smoking Cessation United States, 2008 MMWR November 13, 2009;58(44);1227-123.

2. Cigarette Use Among High School Students - United States, 1991-2007. MMWR June 27, 2008; 57(25);689691 3. McGinnis J, Foege WH. Actual Causes of Death in the United States.

JAMA.1993;270:2207–12.

4. Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses-United States, 2000–2004; MMWR November 14, 2008; 57(45) 12261228.

5. Tomar SL, Asma S. Smoking-attributable periodontitis in the United States: findings from NHANES III. National Health and Nutrition Examination Survey. J Periodontol. 2000 May;71(5):743-51.

6. Albert D, Ward A, Ahluwalia K, and Sadowsky D. Addressing tobacco in managed care: a survey of dentists’ knowledge, attitudes, and behaviors. Am J Public Health. 92(6), 997-1001.

6-2002.

7. Tomar SL. Dentistry’s role in tobacco control. 132 Suppl, 30S-35S. 11-2001.

8. Gordon JS and Severson HH. Tobacco cessation through dental office settings. J Dent Educ. 65(4), 354-363. 4-2001.

9. Campbell HS, Sletten M and Petty T. Patient perceptions of tobacco cessation services in dental offices.

JADA. 130(2), 219-226.

2-1999.

10. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services.

Public Health Service. May 2008.

11. Jorenby DE, Hays JT, Rigotti NA, et al; Varenicline Phase 3 Study Group.

Efficacy of varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial [published correction appears in JAMA. 2006; 296(11):1355].

JAMA. 2006;296(1):56-63.

12. Chantix® (varenicline) prescribing information.

Available at: http://media. pfizer.com/files/products/ uspi_chantix.pdf. Accessed Jun 3, 2010.

13. [7/1/2009]:http://www. fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ DrugSafetyInformationforHeathcareProfessionals/ ucm169986.htm 14. Gunnell D, Irvine D, Wise L, Davies C, Martin RM. Varenicline and suicidal behavior: a cohort study based on data from the General Practice Research database. BMJ. 2009 Oct 1;339:b3805.

15. Tonstad S, Davies S, Flammer M, Russ C, Hughes J. Psychiatric adverse events in randomized, doubleblind, placebo-controlled clinical trials of varenicline: a pooled analysis. Drug Saf. 2010;33(4):289–301.

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

461

EXPRESS Customize your homepage to show only the content you’re interested in. PLUS:

JKJ Pathology Oral Pathology Laboratory

John E Kacher, DDS • Available for consultation by phone or email • Color histology images on all reports • Expedited specimen shipping with tracking numbers • Reports available online through secure web interface

Professional, reliable service with hightechnology solutions so that you can better serve your patients.

Call or email for free kits or consultation. jkjpathology.com 713-598-9284 (T) 281-292-7372 (F) johnkacher@jkjpathology.com

-

Check out the NEW! TDA Video library Add your own links Hide links you’re not interested in Select text size Personalize your weather center Make TDA Express your homepage Choose news headlines to display Search TDA’s interactive calendar Check stocks Perform MedLine, Google, WebMD, or Answers.com searches Utilize tools such as conversion, business, time zone, and deadline calculators Access reference and meeting planner

Start your day with TDA Express!

Protecting your patients, limiting your liability Log in at tda.org to get started today!

462

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

Experienced Counsel for Texas Dentists Since 1994. legaldental.com 281.304.1000

Not Certified by the Texas Board of Legal Specialization

Boyd W. Shepherd, DDS, JD

  



Legal Forms for Dental Informed Consent

legaldental App for iPhone and iPad.



The information you require for your dental practice…Right Now. 

Available on iTunes





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

463

Guest Editorial The Six Links of Survival A Comprehensive Approach to Medical Emergency Preparedness For Dental Offices Larry J. Sangrik, D.D.S. I remember going to the dentist as a child growing up in a small Ohio town around 1960.

The office was located above the music store on Main Street. Two things were noteworthy. First, the reception room had a lava lamp. The other was the steep flight of stairs one needed to climb to reach the office.

The underlying cause of the crisis may or may not be directly caused by the dental care provided. Yet the dentist and the dental team are expected, both by the public and the legal system, to provide appropriate responses until additional care arrives.

464

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

As the dentist’s practice and the town grew, the dentist eventually acquired the services of a young associate, fresh out of dental school at Ohio State. According to folklore within the dental society, the young dentist wanted to institute the practice of taking medical histories on patients, much like he had been trained during dental school. The senior dentist, having already practiced without incident for many decades, feared his patient’s reluctance to give their neighborhood dentist such personal information. He reputedly told his young protégé, “That staircase is my medical history. If a patient is healthy enough to climb it, then they are healthy enough for me to treat.”

I am lucky enough to practice in my hometown. As I drive to my own office, I pass that building on Main Street. Both the music store and the dental office vacated many years ago.

My practice, like those of you reading this journal, shares little in common with that dental office of only 50 years ago. For that matter, my patients share little in common with those seen above the music store.

Dental patients are older. All dentists, as they progress through their years of practice, see a natural aging of their patient bases. I now see the children of the child patients I saw during my first week in practice. But more than practice maturity is occurring. Demographically, the population is aging. That fact impacts both the dental problems our patients face as well as the challenges we, as healthcare providers, face in meeting those needs.

Dental patients are sicker. Sicker? Really? Yes. The old dentist above the music store could rely on a flight of stairs to “weed out” high risk patients.

Today, advances in medicine have allowed those individuals that once were not part of the dental patient population (because they were dead or homebound) to not only have survived and have a high quality of life, but also be capable of receiving dental care.

Moreover, obesity, Type II diabetes, and coronary artery disease are reaching almost epidemic proportions as the pool of typical dental patient’s age. Finally, these patients now present with teeth. While a 1960’s era dentist might assume a 50-year-old patient would present needing complete denture replacement, today’s practitioner is restoring a mouthful of teeth.

Finally, patients expect a higher degree of comfort during dental care. While dentistry has always been at the forefront of pain control, today’s patient is also expecting adequate anxiety control for dental care. Hence, oral sedation and other sedation techniques are routine offerings in many dental continuing education venues.

Taken together, these factors combine into an environment where a medical emergency may occur at any time in a modern dental office. The underlying cause of the crisis may or may not be directly caused by the dental care provided. Yet the dentist and the dental team are expected, both by the public and the legal system, to provide appropriate responses until additional care arrives.

The Six Links of Survival was developed to provide dental providers and their staffs the comprehensive tools to assure that dental offices provide the patients they serve the highest quality response should a medical complication occur.

The following article provides you with an overview of the six links and details of each component. Assess your own office and determine in what areas you can improve.

Dr. Sangrik is in private practice in Chardon, Ohio.

He lectures nationally on medical emergency preparedness and is the medical consultant to the Raven Maria Blanco Foundation, a non-profit patient advocacy group that works toward helping dental offices be prepared for medical emergencies.

Dental care is increasingly complex. Today’s dental patient both expects and is entitled to receive a sophistication of care that seemed impossible only a few years ago. Implants, bone grafts, periodontal therapy, and molar root canals are no longer the exception, but rather the “bread and butter” of modern dentistry. Moreover, the profession for the first time is addressing a generation of geriatric patients with teeth. Assuming an elderly patient could climb the flight of stairs, the old dentist on Main Street probably was being called upon to service or replace a complete denture, hardly a medically challenging task. Today’s dentist offers far more complex care.

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

465

Provided by TDA Perks Program

value for your

profession BLS:

You Are the Very-First, First Responder Dr. John Roberson and Dr. Chris Rothman, Founders of Institute of Medical Emergency Preparedness Many dental professionals believe that a medical emergency will not occur in their offices. But statistics paint a different picture. As dentists, we’re offering more advanced and involved treatments to our patients, and regularly injecting local anesthesia for pain control, which alters patients physiologically. As medical advances continue, and the amounts and kinds of medications consumed increases, the population ages, and health-related issues rise. We cannot ignore the fact that these factors make an emergency in our offices more likely.

466

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

As a healthcare professional, a dentist needs to be prepared for a medical crisis in his or her office. After all, the dentist and his or her staff are considered the very-first first responder to a medical emergency. EMS’ response time averages in excess of 11 minutes in the city, and 15 minutes in rural areas. So calling 911 should only be part of a medical emergency-preparedness plan. Treatment needs to begin with you and your staff, prior to the arrival of EMS. Basic Life Support (BLS) training (training in life-saving techniques) is one of the fundamentals of good preparation for a medical emergency, and required in Texas for a dental license. The training you receive at a BLS course can mean the difference between life and death; lay persons have used BLS to save lives every day for years.

The C-A-Bs of BLS A–B–C (also known as Airway–Breathing–Circulation) has been the bedrock of BLS in the dental office for years. In October 2010 the American Heart Association (AHA) released its new Emergency Cardiovascular Care (ECC) Guidelines. AHA now recommends a C-A-B (Circulation–Airway–Breathing) sequence with compressions performed before ventilations if the patient is not breathing normally and has no obvious pulse. This is the new BLS; the same old letters, new sequence.

Basic Life Support emphasizes the C-A-Bs of emergency care: n Circulation/Compression: provides an adequate blood supply to the body, (especially to the heart and brain), by delivering oxygen to all cells and removing carbon dioxide via the perfusion of blood throughout the body. n Airway: the protection and maintenance of a clear passageway for oxygen and carbon dioxide to pass between the lungs and the outside of the body n Breathing: inflation and deflation of the lungs (respiration) via the airway

For breathing, BLS may include artificial respiration, (which is often assisted by emergency oxygen).

For circulation, it may include implementing bleeding control or cardiopulmonary resuscitation (CPR) techniques to manually stimulate the heart and assist its pumping action.

In an emergency, BLS ensures a patient undergoes the C-A-B sequence, or it assists in maintaining C-A-B for a patient who is unable to on his or her own. BLS includes positioning a patient so he or she can maintain optimal angles, or for possible insertion of oral or nasal adjuncts, to keep his airway unblocked. For breathing, BLS may include artificial respiration, (which is often assisted by emergency oxygen). For circulation, it may include implementing bleeding control or Cardiopulmonary Resuscitation (CPR) techniques to manually stimulate the heart and assist its pumping action. In each case, the BLS provider is trained to detect C-A-B problems and attempt to correct them.

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

467

BLS

The Six Links of Survival BLS is critical to managing a crisis in the office, but emergency-crisis management goes beyond that. It requires preparation to prevent and handle a medical emergency when it occurs.

Every insert in packages of local anesthetics clearly states that the dental practitioner should have the proper equipment and resuscitative drugs before administering any local anesthetic. But, do you? Many dental offices lack components to respond optimally to medical emergencies. Data from surveys we’ve conducted show that most dental offices don’t have a scripted emergency plan, and many don’t have an emergency drug kit, proper resuscitative equipment, or regularly perform mock drills. This is where the Six Links of Survival™ fits in.

The Six Links of Survival™, developed by Institute of Medical Emergency Preparedness, are: doctor training, staff training, a written medical-emergency plan with protocols, an emergency drug kit, proper resuscitative equipment, and mock drills. These “links” must be implemented or in place in the dental office, because they are the foundation for medical-emergency preparedness. We must be able to have confidence in our and our staff’s abilities to deliver basic medical emergency treatment to a patient when it’s needed. The “Six Links” is a comprehensive, team approach that builds on BLS, which is why the two combined provide a solid foundation for patient safety in the dental office.

The ADA’s Council on Scientific Affairs published a preparedness statement in 2002 that emphasizes these points. It reads: Preparedness to recognize and appropriately manage medical emergencies in the dental environment includes the following: Current basic life support certification for all office staff Didactic and clinical courses in emergency medicine Periodic office emergency drills Telephone numbers of EMS or other appropriately trained healthcare providers • Emergency Drug Kit and equipment and knowledge to properly use all items

• • • •

The ADA has also taken recent actions to expose dental offices to more medical-emergency information. In May 2010 the American Dental Association (ADA) released a supplement to The Journal of the American Dental Association (JADA), and upgraded its website to include more resources for dental offices seeking to increase their medical-emergency preparedness.

468

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

TDA Perks Program has made the “Six Links of Survival™ Reference Guide” available online and free-of-charge. You can download the Guide at www.tdaperks.com (click on the “Endorsed Partners” button and the “Institute of Medical Emergency Preparedness” logo).

The “Six Links of Survival Reference Guide” is a solid foundation for dental healthcare professional development in the area of medical emergency preparedness that should be an ongoing, continual program that is never interrupted or discontinued for the lifetime of your practice.

The CORE 16 In a dental office, the following medical emergencies can happen at any time. It’s for this reason a dentist and his or her team must be experts in these particular medical emergencies. They must know these from top to bottom, and side to side; anything less would be sub-standard. There should be no doubt regarding the proper responses for 16 Critical Office Resuscitation Emergencies (The CORE 16): 1. Syncope 2. Angina 3. Myocardial infarction 4. Cardiac arrest 5. Hypertension 6. Hypotension 7. Asthma 8. Anaphylaxis/allergic reactions 9. Hyperventilation 10. Emesis/aspiration

11. Diabetes 12. Seizures 13. Sudden Cardiac Arrest (SCA) 14. Cerebrovascular Accident (Stroke) 15. Foreign Body Obstruction (FBO) with airway management 16. Local Anesthetic Toxicity *If you practice any form of sedation, you need to be able to respond to overdose and airway emergencies, in addition to the CORE 16.

Patient Risk Factors = Potential Medical Emergencies Additionally, at any moment you’re treating patients with risk factors, a medical emergency could occur! The following is a very good list of risk factors to keep in mind when treating patients.

Risk factors are, but are not limited to: Patients that are: • Geriatric • Pediatric • Obese • Using medical advances to prolong their life • Medically-compromised, with either one or multiple diseases (e.g., diabetics, hypertensives, stroke victims, dialysis, hepatic, or immunecompromised patients) • Suffering from coronary artery or peripheral vascular diseases • Non-compliant, in regard to their pharmacological therapy • Suffering from obstructive sleep apnea Procedures involving: • • • • • •

Advanced surgical techniques Longer time spent on patients Increased use of local anesthetics Increased use of sedatives, narcotics, analgesics, antibiotics A greater number of drug combinations; such as local anesthetics, sedatives, narcotics Medications for one disease state (as in #13), or multiple medications for multiple disease states

How many of the different types of patients listed above do you treat daily in your office?

Conclusion The dentist and staff must NOT take the attitude of “this will never happen to me” regarding office medical emergencies. Medical emergencies happen everywhere, including in dental offices. Read about cases where patients died in dental offices, and you’ll recognize the state of medical-emergency preparedness in these offices at the time of the crisis. Much can be learned from them that can assist dental offices in preparing for that unthinkable event. Most importantly, preparation is the key to saving lives.

Medical emergencies are very stressful, chaotic events. Under heavy pressure, anxiety, confusion, and the inability to recall proper treatment protocols can occur.

Many facilities have an emergency drug kit, but have a staff that isn’t familiar with its contents. This is why mock-emergency drill preparedness is so very important!

The time to become familiar with the emergency drug kit is not during a crisis, but before one; during continuing education and mockemergency drills. You need to be proficient in handling emergency situations, and at how to handle them until EMS arrives. Though it’s true that adverse outcomes and death may result even if an emergency is treated correctly, education and preparation will optimize the chances of a favorable result.

Institute of Medical Emergency Preparedness (IMEP) is a TDA Perks Program partner. For more information regarding IMEP, please contact IMEP at: (866) 729-7333, visit tdaperks.com, or call TDA Perks Program at: (512) 443-3675.

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

469

In Memoriam

Those in the dental community who have recently passed Addison, James H. Dallas, Texas October 29, 1946 – February 15, 2011 Good Fellow, 2000

to the Texas Dental Association Smiles Foundation

In Honor of: Greater Houston Alliance By: Jill Kralicke

In Memory of:

Boswell, Vernon O. Lake Jackson, Texas November 6, 1946 – March 2, 2011 Good Fellow, 2010

Carol Isenhour By: Dr. Beverly Zinser

King, Stephen Charles Kempner, Texas November 7, 1920 – February 9, 2011 Good Fellow, 1979 Life, 1985

Curtis Rutledge By: Dr. Beverly Zinser

Sills, Ashley Harold, Jr. Hamilton, Texas September 18, 1924 – March 5, 2011 Good Fellow, 1972 • Life, 1989 • Fifty Year, 1997 Stansbury, Bruce Eugene San Antonio, Texas November 10, 1924 – March 6, 2011 Good Fellow, 1999 • Life, 1989

Are You Relying on Selling your Dental Practice for Retirement?

Did you know that 80 percent of practices with the doctors over age 50 couldn’t be sold with the selling doctor continuing to work in his old practice?

Let us help you protect your retirement and position yourself to work in your practice for as long as you wish.

Dental Practice Specialists is a Growth & Management Consulting Firm

Clyde Dollens, DDS cdollens@aftco.net 281-639-4703

Memorial and Honorarium Donors

We can help with: • Increased Schedule Production • Increased Hygiene Production • Staff Assessment and Coaching

Helen Bostock By: Dr. Beverly Zinser

Anna Lee Davis By: Dr. Robert Cody Robert Southard By: Dr. Robert Cody Vera Lange By: Dr. Robert Cody Robert Wheaton By: Dr. Stephen Hunsaker Mary Mason By: Dr. Stephen Hunsaker Leland Elwood Oneacre By: DFW Oral Surgeons Tonya Gonzales By: Russell & Paula Owens Harry Schmidt By: Drs. Jamie and Jen & your friends at Hill Country Dental Associates Ellen Macaulay Melinda Biggs Rene & Judith Gonzalez Missy Quintana David & Alicia Woodburn Don & Cathy Lutes

Beverly & Steele Zinser Paula & Kurt Loveless Dick & Jimmie Ruth Smith Jim & Linda Black John, Alex and Chi at Georgetown Perio Pat and Virginia Townsend Henry & Brenda Castillo & Family Jay & Dee Dee Adkins Austin Oral & Maxillofacial Surgery Associates, P.A. Brian & Linda Lott JC & Dorothy Byrd Mike & Diane Gielser Cedar Park Periodontics Rex & Jane Evans Julius & Susan Eickenhorst Mr. & Mrs. Hank Hester Drs. Joanna Davis and Brett Strong Jeff Murray Dr. Jon Williamson Charles & Linda Shirey Lorene Cotton Grill Dr. Ron Rhea Rita Cammarata Russell & Paula Owens Dr. Larry Spradley Don & Cathy Lutes Dr. Mike Giesler Rex & Jane Evans Dr. Craig Armstrong Rachael Daigle Michael Goulding Dr. Kent Macaulay Dick & Jimmie Ruth Dr. Jon Williamson Dr. Burt Kunik David & Alicia Woodburn Carol Woods Dr. Barry Currey

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

www.DentalPracticeSpecialists.com Free Practice Appraisal and Evaluation Dental Transitions & Sales through the AFTCO Network

470

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

Please make your check payable to:

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

TX-FEB-2011.pdf

1

2/2/11

5:28 PM

C

M

Y

CM

MY

CY

CMY

K

Dr. Brian Gurinsky, a Fortress Dentist.

When you choose Fortress Insurance

I live in Denver, Colorado. I skied here once in college and

liability coverage, you can be con-

that was it, I wanted to live near the mountains.

fident that your practice is protected.

I started my own practice in 2003. Our practice is focused

Company for your professional

We are owned and operated by

on implants and soft tissue grafting and we see patients

dentists and only insure dentists.

of all ages. They all call me by my first name.

Aggressive claims defense, valuable

I chose periodontics because I like the challenge of surgery

risk management and outstanding

and the ever-changing techniques and materials.

customer service are why dentists

I believe in creating a caring environment for my patients. Everyone gets specialized care.

I’m involved in the academic side of the

all over the country have selected Fortress. Our local agents are responsive and knowledgeable

profession. I teach surgery and do active

too. To get Fortress protection, call

clinical research.

Kyle Wallace at Bell Insurance Group,

I am a sports and music junkie. I enjoy skiing,

800-521-2355 X4871. Tell him

playing tennis, running and triathlons.

Dr. Gurinsky sent you.

I recommend Fortress professional liability coverage. My previous insurance company could settle a case without consent. That was the reason I switched to Fortress.

Protecting & Defending

Over 14,000 dentists trust Fortress with their professional liability insurance.

www.dds4dds.com

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

471

Oral and Maxillofacial Pathology Case of the Month Clinical History A 7-year-old Hispanic male presented with a mass of the anterior mandible which had rapidly developed over a period of several months (Figure 1). The lesion was bothersome but not painful. The lingual mandibular cortex was perforated and the lesion expanded into the floor of mouth.

The overlying mucosa was intact. The associated permanent incisor teeth were displaced and mobile. Radiographic examination revealed a circumscribed unilocular radiolucency of the mandibular symphysis region (Figures 2-3).

The borders of the lesion were somewhat ill-defined. The patient had no neurosensory deficits. Palpation of the neck revealed no associated cervical lymphadenopathy. The patient was taken to the operating room and under general anesthesia, a firm circumscribed tan-white soft tissue mass was curetted from the surrounding bone and submitted for pathologic examination.

Pathologic Findings

McGuff

Jones

Thornton

H. Stan McGuff, D.D.S., Department of Pathology, The University of Texas Health Science Center at San Antonio, Texas Anne Cale Jones, D.D.S., Department of Pathology, The University of Texas Health Science Center at San Antonio, Texas William E. Thornton, D.D.S., M.S.D., private practice – oral and maxillofacial surgery, San Antonio, Texas.

The gross surgical specimen consisted of a firm nodular pale tan to pink-grey-brown soft tissue mass measuring 2.3 x 2.0 x 2.0 cm. The lesion was serially sectioned revealing a gritty vaguely whorled grey-white cut surface. The specimen was entirely submitted following decalcification.

Histopathologic examination revealed a fibro-osseous lesion composed of a moderately cellular spindled fascicular fibrous connective tissue stroma containing scattered irregular trabeculae of woven bone (Figure 4). The stroma consisted of bland spindled fibroblasts with interspersed collagen fibers. Plump osteoblasts rimmed the bone matrix and focal associated osteoclasttype giant cells were also noted. Stromal mitotic activity was readily identified; however no abnormal forms were seen. There were no areas of necrosis (Figure 5).

What is the most likely diagnosis?

See page 478 for the diagnosis.

472

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

Figure 1. Expansile mass of anterior mandible extending into the floor of mouth.

Figure 2.

Panoramic radiograph showing a circumscribed unilocular radiolucent lesion of the anterior mandible.

Figure 3. Periapical radiograph showing a circumscribed radiolucency with somewhat poorly delineated borders and tooth displacement.

Figure 4. Fibro-osseous lesion composed of a moderately cellular spindled fibrous stroma with interspersed trabeculae of woven bone. Focal osteoclast-type giant cells are present. (Original magnification 10X).

Figure 5. Osseous trabeculae rimmed by osteoblasts with surrounding spindled fibrous stroma exhibiting focal mitotic activity.

(Original magnification 40X).

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

473

Calendar of Events 474

June 2011 10 - 11 The Southwest Prosthodontic Society will hold its annual meeting at Moody Gardens in Galveston, TX. For more information visit swprosthodonticsociety.com or contact Dr. G. Romero at (713) 664-1661, gromero1@sbcglobal.net; or Dr. Mark Connelly at (281) 481-8530, m.e.connelly1@comcast.net.

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.

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.

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.

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

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

October 2011 9 – 12 The Alliance of the American Dental Association will hold its convention in Las Vegas, NV. For more information, please contact Ms. Patricia Rubik-Rothstein, AADA, 211 E. Chicago Ave., Ste. 730, Chicago, IL 60611-2678. Phone: (312) 440-2865; FAX: (312) 440-2587; E-mail: manager@allianceada.org; Web: ada.org.

10 – 13 The American Dental Association will hold its 152nd annual session in Las Vegas, NV. For more information, please contact the ADA, 211 E. Chicago, Ave., Chicago, IL 60611-2678. Phone: (312) 440-2500; Web: ada.org.

13 – 16 The Southwestern Society of Orthodontists will hold its annual session at the Westin Galleria in Houston, Texas. For more information, please contact Ms. Judy Salisbury, Southwestern Society of Orthodontists, 10032 Wind Hill Dr., Greenville, IN 47124. Phone: (812) 923-2100; FAX: (812) 923-2900; E-mail: jsalisbury00@gmail.com; Web: flyingdentists.org.

19 – 22 The 35th Annual American Society for Dental Aesthetics International Conference will be held in Amelia Island, FL. For more information, please contact Dr. Dan Ward, ASDA, 635 Madison Ave., New York, NY 10022; Phone: (800) 454-2732; E-mail: dward@columbus.rr.com; Web: asdatoday.com.

28 & 29 The TDA Smiles Foundation will hold a Texas Mission of Mercy event in Amarillo, TX. For more information, please contact TDASF, 1946 S. IH35, Ste. 300, Austin, TX 78704. Phone: (512) 448-2441; Web: tdasf.org.

November 2011 6 – 12 The United States Dental Tennis Association will hold its 44th annual fall meeting at the Shadow Mountain Resort in Palm Desert, CA. For more information, please contact Ms. Cori Lee, United States Dental Tennis Association, 1096 Wilmington Ave., San Jose, CA 95129. Phone: (800) 445-2524; E-mail: dentaltennis@gmail.com; Web: dentaltennis.org.

10 – 15 The American Dental Association Kellogg Executive Management Program (ADAKEMP) will convene 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.

12 – 15 The 97th American Academy of Periodontology will hold its annual meeting at the Miami Beach Convention Center in Miami, FL. For more information, please contact Ms. Alice De Forest, CAE, AAP, 737 N. Michigan Ave., Ste. 800, Chicago, IL. Phone: (312) 787-5518; FAX: (312) 787-3670; E-mail: aap-info@perio.org; Web: perio.org.

17 – 20 The American Academy of Oral & Maxillofacial Radiology will hold its 61st annual session at the Kona Kai Resort in San Diego, CA. For more information, please contact Dr. Michael Shrout, AAOMR, PO Box 1010, Evans, GA 30809-1010. Phone: (706) 721-2881; FAX: (706) 721-8349; E-mail: mshrout@mail.mcg.edu; Web: aaomr.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

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) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org.

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

475

SPDDS

Employees Benefit Trust

Group Health Care Plans Designed for Dental Offices Health Care Coverage is our business ... we’ve been providing it exclusively to the dental industry since 1996!

Three distinct plans now available: Freedom Plan

PPO Plan

HSA High Deductible Health Plan

• Multiple deductibles available for all plans • May choose different plans and deductibles within the dental office • Employer determines the amount of employee contribution and waiting periods

To obtain rates or more information, please call 1-800-658-6810 or visit us on the Web at www.spddsebt.com SPPDS Employee Benefit Trust is a Texas licensed, multiple employer welfare arrangement, governed by ERISA, providing self-funded health coverage for dentists, their employees, and dependents.

476

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

AD-9

AFTCO is the oldest and largest dental practice transition consulting firm in the United States. AFTCO assists dentists with associateships, purchasing and selling of practices, and retirement plans. We are much more than a practice broker, we are there to serve you through all stages of your career.

Call 1-800-232-3826 for a free practice appraisal, a $2,500 value!

Ahmed El-Halaby, D.D.S. has acquired the practice of

Thomas M. Smith, D.D.S. Longview, Texas AFTCO is pleased to have represented both parties in this transaction.

Helping dentists buy & sell practices for over 40 years.

WWW.AFTCO.NET

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

477

Oral and Maxillofacial Pathology Diagnosis and Management

Trabecular Juvenile Ossifying Fibroma Oral and Maxillofacial Pathology Case of the Month (from page 472)

Discussion Trabecular juvenile ossifying fibroma (TJOF) is a rare benign though potentially aggressive fibroosseous neoplasm occurring in the jaws of children and adolescents (1-9). The mean age of occurrence for these tumors ranges from 8.5 to 12 years, with only 20 percent of cases involving patients older than 15 years of age (2). There appears to be no distinct gender predilection, though some studies have reported an increased incidence in males (1). The maxilla is involved slightly more frequently than the mandible. Origin within the extragnathic craniofacial bones may occur but is less common. Patients often present with a rapidly growing expansile mass lesion that may cause facial asymmetry. Patients rarely have associated pain or neurosensory deficits. Maxillary tumors extending into the sinonasal tract may cause nasal airway obstruction and epistaxsis.

Radiographically, TJOF presents as a circumscribed unilocular radiolucency with variable degrees of central radiopacity, depending on the amount of calcified extracellular matrix material produced by the

478

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

tumor. Less often the lesion may have an opaque “ground-glass� or multilocular appearance. The borders of the lesion may be well delineated or poorly defined.

The histopathologic features of TJOF include a moderately cellular fibrous connective tissue stroma containing spindled to stellate fibroblasts, relatively scant collagen and interspersed trabeculae of woven bone. The bone matrix is typically lined by plump active osteoblasts. Scattered osteoclasts are also present. The lesion is typically circumscribed but unencapsulated and may show infiltrative growth with erosion of bone and cortical perforation. Stromal mitotic activity may be present but is usually not brisk and abnormal mitoses are not seen. Necrosis should not be present.

There may be areas of myxoid/ pseudocystic stromal change.

Associated aneurysmal bone cyst formation has also been reported.

Local surgical excision/curettage is the treatment of choice for TJOF. These tumors do have the potential for rapid, progressive, and locally destructive growth with ex-

tension into contiguous structures and facial deformity. Large destructive lesions may require an en-bloc resection and reconstruction. Such aggressive lesions tend to occur in infants and young children. The recurrence rate is significant and has been reported to range from 30-58 percent (1). However, the overall prognosis for TJOF is generally good. There appears to be no tendency for malignant transformation.

Juvenile ossifying fibroma was separated from conventional ossifying fibroma based on differences in patient age, anatomic sites of occurrence, and clinical behavior. While originally considered to represent one entity, juvenile ossifying fibroma is now generally recognized to occur in trabecular and psammomatoid forms. The psammomatoid juvenile ossifying fibroma is more common than TJOF, occurs at an older age range (mean 22 years), tends to develop in the sinonasal tract, and is seen less often in the jaws (1,2, 8-9). Histologically, this tumor characteristically produces small spherical lamellated ossicles as opposed to the trabecular pattern seen in TJOF. The psammomatoid

variant may have a higher recurrence rate, invade the orbit and cranial cavity, cause significant morbidity and rarely result in the death of the patient.

References 1. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology, 3rd Ed. Saunders/Elsevier, St. Louis, 2009: 648-650.

2. Gnepp DR. Diagnostic Surgical Pathology of the Head and Neck, 2nd Ed. Saunders/ Elsevier, Philadelphia, 2009: 762-766.

3. Dominguete PR. Meyer TN. Alves FA. Bittencourt WS. Juvenile Ossifying Fibroma of the Jaw. British Journal of Oral & Maxillofacial Surgery. 46(6): 480-1, 2008 Sep. 4. Juneja M. Kamboj M. Juvenile Ossifying Fibroma of Maxilla: Report of a Case. Journal of Clinical Pediatric Dentistry.

33(1): 55-8, 2008.

5. Zama M. Gallo S. Santecchia L. Bertozzi E. De Stefano C. Juvenile Active Ossifying Fibroma with Massive Involvement of the Mandible. Plastic & Reconstructive Surgery.

113(3): 970-4, 2004 Mar.

6. Leimola-Virtanen R. Vahatalo K. Syrjanen S. Juvenile Active Ossifying Fibroma of the Mandible: a Report of 2 Cases.

Journal of Oral & Maxillofacial Surgery. 59(4): 439-44, 2001 Apr. 7. Wenig BM. Atlas of Head and Neck Pathology, 2nd Ed. Saunders/Elsevier, Philadelphia, 2008: 86-88.

8. Yang HY. Zheng LW. Luo J. Yin WH. Yang HJ. Zwahlen RA. Psammomatoid Juvenile Cemento-Ossifying Fibroma of the Maxilla. Journal of Craniofacial Surgery. 20(4): 1190-2, 2009 Jul.

Creating “treatment plans” for practice transitions for more than 23 years…

L. Norton Hindley III, A.S.A. Purchase/Sale of Practice • Negotiations and Closing Documents • Purchaser Representation Practice Mergers and Reformations • Associate Buy-in and Partnership Agreements Practice Valuations Leading to Merger and Acquisition • Banking: Loan Packages and Origination of Loans

The Hindley Group, L.L.C. 2202 Timberloch Place, Suite 218 • The Woodlands, Texas 77380 281-367-1955 • 800-856-1955 norton@thehindleygroup.com www.thehindleygroup.com

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

479

g n i rtis

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, wellestablished 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 NORTH: Modern five op office with four equipped. Seventeen-yearold practice in well located office complex.

Good visibility and access. Good gross with super upside potential. ID #128.

NEW! AUSTIN: Unique, quality fee-forservice practice in five operatory freestanding 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.

480

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

CORPUS CHRISTI: Three operatory, feefor-service/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 radiography. Fee-for-service patient base and very good new patient count. Great numbers. Super upside potential. ID #093.

NEW! NORTH CENTRAL SAN ANTONIO: Five operatory, 11-year-old practice in beautiful free-standing building. Great location! Excellent equipment and decor.

Fee-for-service practice. ID #126.

NEW! NORTHWEST SAN ANTONIO: Five operatory, 28-year-old practice in high visibility retail center. Excellent location, very good equipment. Solid patient base and hygiene program. ID #127.

NEW! WEST OF SAN ANTONIO: Doctor retiring. Four operatories in modern, open, free-standing 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.

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 seven figures for last 3 years. Great location with super upside potential. ID #055.

SAN ANTONIO NORTHWEST: 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, 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, 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.

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) 737-0100 or (888) 656-0290; in Austin, David McLerran, (512) 7506778; 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.

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

481

g

in s i t r e dv

A

Briefs

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, 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;

482

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

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 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+-year-old 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. Seven-figure 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. Seven-figure 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-l 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 Angelo — 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 fund-

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

483

g

in s i t r e dv

A

Briefs

ing. 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.

GARY CLINTON / PMA NORTH DALLAS / MCKINNEY AREA PRACTICE FOR SALE: One of the best and fastest growing areas in Texas. Very nice newer office. Average productivity. 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

484

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

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

GARY CLINTON / PMA WEATHERFORD / WEST OF FORT WORTH AREA TEXAS PRACTICE FOR SALE: Retiring dentist; excellent practice for a recent graduate. Building and practice are both to be offered 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.

GARY CLINTON / PMA CORPUS CHRISTI PRACTICE FOR SALE: Enjoy the beach and beautiful ocean. Retiring dentist, excellent restorative practice.

Building and practice both to be offered 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.

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) 8561955. 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) 8561955. Visit us at www.thehindleygroup. com.

WEST TEXAS GENERAL DENTAL PRACTICE — SALE: Well-established and growing practice with 2-year revenues over seven figures. Health profit margin on 4 days per week. Four fully equipped operatories. Wonderful mentor with plenty of room to grow. 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.

SOUTH OF HOUSTON GENERAL DENTAL PRACTICE — SALE: Our condolences extend to the family of Vernon 0.

Boswell, Sr. Thirty-seven-year-old practice immediately available with sale terms appropriate to transition risk. Three fully equipped operatories. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

DFW METROPLEX ORAL SURGERY PRACTICE — SALE: Well-established practice enjoying 2010 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.

SOUTH OF HOUSTON GENERAL DENTAL PRACTICE — SALE: Established practice in mid-size town generating revenues approaching very high six figures the last 3 years. Wonderful mentor to assist in transition. Associate in place providing orthodontic treatment. Building is also for sale. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

GALVESTON GENERAL DENTAL PRACTICE — SALE: Strong revenues with an above-average profit margin in this wellestablished practice. Excellent mentor, both as a general dentist and as a practice manager. Ten operatories. Dedicated, experienced staff. One- to 2-year associateship with predetermined buy-out. Building also for sale. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www. thehindleygroup.com.

DFW METROPLEX GENERAL DENTAL PRACTICE — SALE: Great location! Wellestablished practice in area for more than 45 years. The 2010 revenues exceeded mid six-figures. Seven operatories with plenty of room to grow and expand patient treatment including orthodontics, oral and maxillofacial surgery, pediatrics, or merge with another general dental practice. Building in which practice is located is also for sale. Contact The Hindley Group, LLC, 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, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

FORT WORTH ORTHODONTIC PRACTICE — SALE: Small practice that would provide 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,

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

485

g

in s i t r e dv

A

Briefs

LLC, at (800) 856-1955. Visit us at www. thehindleygroup.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.

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.

ARLINGTON ORAL SURGERY PRACTICE — SALE: Highly successful practice with strong revenue history of more than

486

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

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. Practice is 30+ years old. Excellent revenues and profit margin. Four fully-equipped operatories. Perfect opportunity for new or recent graduate. 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. Predetermined purchase and partnership terms. Wonderful mentor looking for an “equally-yoked” individual. Excellent Staff. SAN ANTONIO PERIODONTAL AND ENDODONTAL ASSOCIATESHIPS — Periodontal associateship with predetermined buy-in for very active, multioffice 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 profit margin. 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. SOUTHWEST HOUSTON ENDODONTIC ASSOCIATESHIP — Excellent profit margin and strong revenues. Extensive referral base.

Highly qualified mentor and experienced staff. Predetermined buy-in and partnership terms. Don’t miss this opportunity.

EAST OF HOUSTON GENERAL DENTAL PRACTICE — Well established practice in small town seeks associate desiring practice buy-in with pre-determined terms. Steady new patient flow and revenues. Contact The Hindley Group, LLC, 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.

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.

DALLAS: Dental One Partners is opening new offices in Dallas and the surrounding areas. Each practice is unique in that it has a individual name like Preston Hollow Dental care or Waterside Dental Care.

Our patient base consists of approximately 70 percent PPO and 30 percent fee-forservice. We do not do HMO or Medicaid.

Our facilities are warm and inviting with state of the art equipment. The practices have intra oral cameras and digital radiography. We offer competitive compensation packages with benefits. We also offer equity buy-in opportunities. To learn more about working with one of Dental One Partners practices, please contact Andy Davis at (602) 391-4095.

HOUSTON DENTAL ONE is opening new offices in the upscale suburbs of Houston. Dental One is unique in that each office of our 50+ offices has its own individual name. All our offices have topof-the-line Pelton and Crane equipment, digital X-rays, and intra-oral cameras.

We are 100 percent FFS with some PPO plans. We offer competitive salaries, benefits, and equity buy-in opportunities. To learn more about working for Dental One, please call Andy Davis at (602) 391-4095.

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) 315-4584 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

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

487

g

in s i t r e dv

A

Briefs

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, doctors’ 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) 3426565.

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.

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

488

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

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.

HOUSTON: Retiring dentist is seeking his successor. Located in the Heights area of Houston, this two operatory practice consistently generates revenue in the low six figures because the owner wanted it that way. What’s really remarkable about this practice is the number of active patients.

A maintenance practice like this will usually have a high active patient count but relatively low revenue, which makes this acquisition a dream come true for the dentist that appreciates value and growth. The potential for this practice will only be limited by you, so open your mind and let your eyes see. Inquire to practiceinfo@comcast.net.

EXPERIENCED RESTORATIVE DENTIST (PANKEY/LVI TYPE) who enjoys aesthetics and full-mouth rehab needed to lead a first-class, full service practice.

Unique practice model affords the opportunity to earn high income doing big cases and coordinating patient care with our specialty teams. Practice with the support of a veteran team in a beautiful practice. Contact Dr. John Bond at jbond@6daydental.com.

6 DAY DENTAL & ORTHODONTICS is an established group practice model, providing all dental services to our patients under one roof. Our general dentists and specialists work together to provide the most convenient and quality dental care possible. We are growing and have an immediate opportunity for a general dentist

or prosthodontist with future partnership/equity opportunity. 6 Day Dental & Orthodontics just may be the premier feefor-service alliance of dental practices in the country. Our doctors earn more, see fewer patients, and have plenty of time off to enjoy a rich and healthy lifestyle.

New grads and experienced dentists/ prosthodontists welcomed. Our dentists earn in the top 10 percent of extractions, as well as performing all types of dentistry. Please send CV or contact Dr. John Bond at jbond@6daydental.com. Visit www.6daydental.com.

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) 2389250; or call (512) 238-9250 for additional information.

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 direction. 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.

SOUTHWEST FT. WORTH — GENERAL DENTAL PRACTICE WITH BUILDING FOR SALE OR LEASE: This very successful, well-established practice has an excellent patient base with referrals from near and far. The seller is retiring immediately or will negotiate a comfortable transition. With a low overhead and excellent profit margin, this practice makes a great investment for just the right person. Five treatment rooms, 3,200 sq. ft. plus 800 sq. ft. for additional expansion or rental space. The practice is located in a high visibility and stable economic community. With this practice comes an experienced staff, computers in all treatment rooms, nice equipment, imaging software, and much more. Get out of that associate position and be an owner!

Appraisal performed by a CPA/CFP/CVA. Call (972) 562-1072 or (214) 697-6152 or e-mail sherri@slhdentalsales.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.

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

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

489

g

in s i t r e dv

A

Briefs

spending, and 401(K) with employer contribution. New graduates and dentists with experience are welcome. Be a part of our outstanding team, providing care for Texas’ kids. Please contact Anna Robinson at (913) 322-1447; e-mail: arobinson@amdpi. com; FAX: (913) 322-1459.

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 seller.

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

BRYAN/COLLEGE STATION AREA: Well-established 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.

490

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

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 sixfigure 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-year-old 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) 9308017.

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.

HEART OF HOUSTON: High end, well established periodontal practice with new office and great amenities. Well-trained staff, great patient base and great referral base. Associate opportunity and/or practice sale. Three operatory, two hygiene, longer transition available. Call DDR Practice Sales at (800) 930-8017.

CORPUS CHRISTI: Well established general dentistry practice, high visibility, great location, excellent staff, new equipment, space to expand. Traditional fee-for-service, highly productive, transition as needed, five operatory/hygiene, excellent full recall and new patient flow.

Excellent, profitable turnkey practice.

Call DDR Practice Sales at (800) 9308017.

SAN ANGELO, ABILENE: Associates — 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, smalltown 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.

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.

SAN ANTONIO NORTH WEST: Associate needed. Established general dental practice seeking quality oriented associate.

New graduate and experienced dentists welcome. GPR, AEGD preferred. Please

contact Dr. Henry Chu at (210) 684-8033 or versed0101@yahoo.com.

GREAT PRACTICE IN BEAUTIFUL EAST TEXAS. This fee-for-service practice was established by a prominent communityinvolved 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) 562-1072 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.

ENDODONTIST NEEDED TO JOIN WITH HOUSTON PERIODONTIST. Fullor part-time. 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.

EAST TEXAS GENERAL PRACTICE NEEDS ASSOCIATE TO TRANSITION TO OWNER/PARTNER, buyout to fit situation. Thirty-five-year-old practice

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

491

g

in s i t r e dv

A

Briefs

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 X-rays 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, Ruido-

492

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

so, NM 88345; FAX: (575) 257-5170; or e-mail: jnbennett@windstream.net.

HOUSTON: Pediatric dental office seeking full-time pediatric dentist. Associate with buy-in/partner opportunity. Fast-growing office looking to expand. Please e-mail CV to cvanalfen@yahoo.com.

ASSOCIATE DENTIST NEEDED IN SOUTH TEXAS. Well-established general practice seeking full-time associate to meet the demands of a growing practice.

Excellent benefits and location. Great earning potential. Interested candidates should call (956) 655-8295 and/or e-mail or send resumes to vickypad@yahoo.com.

AUSTIN: Associate needed for busy and rapidly growing dental office in north Austin. Family-owned office with patients of all ages. Probably 75 percent teens and children; 3-4 days/week available, Monday, Wednesday, Friday with possibility of Tuesday or Thursday. Good compensation possible. Please send resume to atxdentalhiring@gmail.com.

ASSOCIATE / PEDIATRIC DENTISTS NEEDED IN SAN ANTONIO: New stateof-the-art and fun dental office is experiencing rapid growth and expansion.

Excellent compensation. E-mail resume to nora.sspllc@gmail.com.

AUSTIN: A well-established pediatric practice is seeking an energetic dedicated full-time pediatric dentist. We have an extensive client base with continued growth. Our office is a leader in all aspects of pediatric dentistry including sedation and anesthesia dentistry. We have two offices with state-of-the-art technology and a highly trained support staff. We are looking for the right fit for our practice. Ideally, someone who is looking for a long-term opportunity. Buy-in is a possibility for the right person. New grads are welcome to apply. Please e-mail resume to tal@austinchildrensdentistry.com.

ATTENTION DENTISTS! Enjoy the benefits of compensation based on private fee-for-service dentistry with a highly skilled team which can further enhance your dental education and clinical skills in a small private setting. Has an abundant patient flow, lots of dentistry!

Convenient location in the heart of Clear Lake between Friendswood, Webster, Dickinson, League City, Kemah, and South Shore Harbor, 20 minutes from Houston. Established long-term practice.

Has been a dental practice in this building for 56 years. Learn advanced surgical reconstructive and prosthetic skills. Two locations: 1801 Broadway, Galveston, TX, and 1901 East Main, League City, TX. All brand new equipment and facility, brand new building, paperless computerized system with the latest in technology.

Fiber optics, seven ops, two large surgical suites, latest in restorative materials, digital radiography. Long-term trained staff: Mary, 18 years; Myrna, 16 years; Debbie, 17 years; Gina, 15 years; and Amy, 15 years. Experienced help makes your day easier! Senior dentist loves to teach! Compensation and hours, full-time hours available with excellent compensation package. Offering 50 percent CE training for valuable courses such as IV sedation. Guaranteed minimum to start.

Hours are either M-Th (every other Sat) or T-F (every other Sat). You pick your hours. No DMO plans or Medicaid for a more relaxing work environment. E-mail kkcarroll10@yahoo.com or call (281) 3326323.

ASSOCIATE WANTED! Our rapid growing, fast-paced cosmetic and family dental practice located north of Houston in Spring (Champion Forest area) is looking for just the right associate doctor to join our dynamic team. We have a beautiful free-standing practice with twelve operatories, two owner doctors, six hygienists, and numerous knowledgeable staff to help you along the way. We are a wellestablished, all digital, paperless, state-

of-the-art, fee-for-service practice that truly focuses on customer service. Position available for Monday, Thursday, and Fridays to help accommodate a great deal of new patients we are acquiring through marketing as well as existing patients who want same-day service dentistry.

Please call Kimberly or Brenda to find out more about this outstanding opportunity at (281) 320-2000. Visit us at www. stephensgatewood.com.

CARUS DENTAL, a multi-disciplinary growing group practice with more than 30 general dentistry and specialty clinics located throughout the greater Austin, Houston, and Central Texas areas, is looking for an experienced general dentist to join our West Lake practice.

Our doctors enjoy a professional practice experience and comprehensive compensation and benefit package that includes medical, professional liability, disability, and life insurances, flexible spending account, and a 401K program with employer matching contribution. Carus Dental offers a complete range of routine, cosmetic, and specialized dental health services including preventive care, whitening, crowns, veneers, dental implants, oral surgery, periodontics, endodontics, conscious sedation, children’s dentistry, and orthodontics. For more information, please visit our website at carusdental. com. Please contact Lara Masson at (512) 371-1222, e-mail lmasson@ampdi.com, or fax (512) 371-7052.

HOUSTON: Pediatric dental office seeking full-time pediatric dentist. Associate with buy-in/partner opportunity. Fast growing office looking to expand. Please e-mail CV to cvanalfen@yahoo.com.

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

493

g

in s i t r e dv

A

Briefs

OFFICE SPACE FOR SALE OR LEASE, READY TO MOVE IN: Facility and equipment with three to five ops in far North Dallas, just south of Plano between Addison and Richardson. Office is fully equipped including handpieces, instruments, and supplies. Lease hold improvements already in place. Furnishings in great shape. Space is 1,800 sq.ft. with a 5-year lease at $16-$18 per square foot and excellent net. Exceptional rate that is well below market. Fantastic value. For additional details and complete equipment list, please call (972) 978-4832 or e-mail jkg@grinallday.com.

MEDICAID FACILITY FOR SALE OR LEASE/PURCHASE: Ideal situation to get started for little cost. Please call (214) 794-0975 or e-mail jkg@grinallday.com.

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 fastestgrowing counties. Available at $155/sq. ft. For more information, e-mail john@ herronpartners.com or call (512) 4578206.

DENTAL / MEDICAL OFFICE in Medical Center area. Nicely finished out; move-in ready; all bills paid. Up to 3,509 sq. ft.

(1,608 sq. ft. and 1,892 sq. ft.) for $5,800 / month. Call Shannan Schnittger, broker, (210) 930-3700.

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

494

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

large grocer. Offering 5-7 years lease plus extensions. Levin Realty, (323) 954-1934, levinrealty@sbcglobal.net.

INGLESIDE DENTAL BUILDING FOR SALE! REDUCED. BEST OFFER! 1,700 sq. ft., two chairs plumbed. Rental side, near Corpus Christi! Busy main street location. Vacant, no equipment. Landscaping, parking, owner/dentist. 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) 494-0643 or email 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 four-lane road. High growth area has shortage of specialty dentists. Call Jim at (512) 494-0643 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 email 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) 2923156.

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.

FORMER APPLE ORTHODONTICS SPACE AVAILABLE FOR LEASE IN COPPELL at Riverchase Plaza, located in the northeast corner of MacArthur Boulevard and Belt Line Road. Space is approximately 4,350 sq. ft. Please visit the following website for photos and information: https://retailstreet.box. net/shared/09xxup2pcx. Please contact Aaron Stephenson at aaron@retailstreetadvisors.com or (214) 443-9335 for more information.

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 64 OB, $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, $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.

FOR SALE: Our office has purchased new intraoral wall X-rays ($1,500), and new mobile, handheld X-rays, chairs/ units, and an implant motor. We need only half due to downsizing. Call (561) 703-1961 or e-mail nycfreed@aol.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

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

495

g

in s i t r e dv

A

Briefs

rate not a percent of production. Nation’s largest, most distinguished team. Shortnotice coverage, personal, maternity, and disability leaves our specialty. Free, no REOLJDWLRQ TXRWHV $EVROXWH FRQÀGHQWLDOity. 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.”

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.

DENTAL OFFICE needed to lease 12 hours per week for Dental Assisting 6FKRRO &ODVV KRXUV DUH GXULQJ RIÀFH downtime one weekend day and one ZHHNGD\ HYHQLQJ /HDVH SD\PHQW WR RIÀFH 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.

trusted integrity

since 1996

DOCTORS PER DIEM INC

TEMPORARY COVERAGE

join tthe team or post a job online, no charge see profiles of our providers or heck....just pick up the phone

www.doctorsperdiem.com email: docs@doctorsperdiem.com

496

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

THE NATIONAL SCHOOL OF DENTAL ASSISTING — 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.

THE DENTAL HANDPIECE REPAIR GUY, LLC. I’m pleased to inform you that we are now operating a full-service handpiece repair shop in Friendswood, Texas, where my father Dr. Ronald Groba has been practicing for over 35 years. I have been doing his handpieces for over 20 years and decided to provide this service to other dentists. First and foremost, we provide expert service for your precision

instruments and are qualified to service nearly every make and movdel of highspeed, low-speed, and electric handpieces on the market. We use quality parts, take less time, and our costs are lower.

We provide free pickup and delivery, warranties, and next-day service on most high-speed units and a 1-week turnaround for slow speeds, ultrasonic sealers, and electrics. The Dental Handpiece Repair Guy wants to be your handpiece servicing facility of choice. We would appreciate a chance to earn your business!

Call (800) 569-5245 or visit our website, www.thedentalhandpiecerepairguy.com.

Temporary Dentists Providers - our assignments range from one month to a year. We provide steady regular assignments for GPs and specialists. Pick and choose assignments. Check available jobs and/or submit availability at: www.ajriggins.com/chs/ Hiring Organizations - We emphasize thorough background checks and a total dedication to quality, in order to create appropriate matches for our clients.

We staff: Private Practices Dental Corporations Community Health Correctional Care Native American Centers Hospitals Military

Camden Healthcare Staffing 1-972-267-3200 www.ajriggins.com/chs/

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

497

Advertisers

Your Patients Trust You. Who can YOU Trust?

The Professional Recovery Network (PRN) addresses personal needs involving counseling services for dentists, hygienists, dental students and hygiene students with alcohol or chemical dependency, or any other mental or emotional difficulties. We provide impaired dental professionals with the support and means to confidential recovery.

If you or another dental professional are concerned about a possible impairment, call the Professional Recovery Network and start the recovery process today. If you call to get help for someone in need, your name and location will not be divulged. The Professional Recovery Network staff will ask for your name and phone numbers so we may obtain more information and let you know that something is being done.

Statewide Toll-free Helpline 800-727-5152 Emergency 24-hour Cell: 512-496-7247

Professional Recovery Network 12007 Research Blvd. Suite 201 Austin, TX 78759 www.rxpert.org

498

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

Academy of General Dentistry .............................439 ADS Watson, Brown & Associates ......................455 AFTCO ....................................................................477 A.J. Riggins............................................................497 Anesthesia Education and Safety Foundation ..........................................................440 Bright Now Dental .................................................438 DDR Dental Trust ...................................................456 Dental Practice Specialists...................................470 Dental Systems......................................................476 Doctors Per Diem ..................................................496 E-VAC......................................................................456 Fortress Insurance ................................................471 Gary Clinton, PMA .................................................425 Hanna, Mark — Attn. at Law .................................477 Henderson, Sherri L. & Associates......................417 Hindley Group........................................................479 JKJ Pathology........................................................462 JLT Energy Consultants .......................................418 Kennedy, Thomas John, D.D.S., P.L.L.C..............497 Knight Dental Group .............................................414 Medical Protective .................................................476 Ocean Dental..........................................................415 OSHA Review............................... Inside Back Cover Paragon ..................................................................441 Patterson Dental ..........................Inside Front Cover Portable Anesthesia Services ..............................455 Professional Solutions..........................................426 Professional Recovery Network...........................498 Robertson, James M .............................................424 Shepherd, Boyd W.................................................463 Southern Dental Associates.................................419 SPDDS ....................................................................476 TDA Express ..........................................................462 TDA Financial Services Insurance Program........................................438 / Back Cover TDA Perks Program...............................................423 Texas Health Steps................................................411 Texas Medical Insurance Company .....................421 USA Civilian Dental Corps....................................424 UTDB Houston .......................................................463 UTHSCSA Oral & Maxillofacial Lab......................424 Waller, Joe..............................................................445

TDA Video Highlights on tda.org Due to the positive feedback and overall success with the TDA New Dentist Committee podcast series and the TDA Video Library on TDA Express, TDA has added a new TDA Video Highlights section on the homepage of tda.org. Members can browse through dozens of videos from TDA events, like the TEXAS Meeting.

Listen to TDA members share their opinions on issues such as, “Why Join TDA” and “The Value of Membership.” Watch shout-outs from various events at the TEXAS Meeting like the House of Delegates, TDA GOLD reception or exhibit hall.

Thank you to all the participants! We hope to include more footage in the future and welcome any feedback.

Questions? Contact Stefanie Clegg, TDA Web & New Media Manager at (512) 443-3675 or stefanie@tda.org

May 2011

You worry patients’ smiles.

We’ll worry about yours ... especially if you’re ever injured or become too sick to work.

Our disability coverage* for professionals is like an ounce of prevention for both you and your practice. It’s some of the finest available -Own-Occupation, the best choice for a professional -- guaranteed-renewable to age 65 or 67 and non-cancellable, so you can’t lose your coverage when you need it most.

You’ll also want to look into our practice protection policies -Overhead Expense**, to reimburse you for many of the expenses of running your practice, Business Reducing Term,*** to fund financial obligations that require regular payments expiring at a given time, and Disability Buy-Out**** coverage.

Most association coverage can’t match it. Call today and we’ll show you why.

* Policy Form 1400 and 1500. ** Policy Form 4100; in Montana, Policy Form NC82. *** Policy Form AH55-A. **** Policy Form 3100; in Montana, Policy Form AH84.

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

Vol. 128, No. 5

1-800-677-8644 TDAmemberinsure.com

Products not available in all states. Product provisions and features may vary by state.

T T

Or

a

c

May 2011

Journal TEXAS DENTAL

Hookah Smoking: A Popular Alternative to Cigarettes The Role of the Human Papillomavirus in Oropharyngeal Cancer Treatment of Nicotine Dependence with Chantix® (varenicline)

For a complimentary examination of your disability income insurance needs, please contact us at:

Disability income products underwritten and issued by Berkshire Life Insurance Company of America, Pittsfield, MA, a wholly owned stocksubsidiary of The Guardian Life Insurance Company of America (Guardian), New York, NY, or provided by Guardian.

500

E

n a lC

Living in Limbo: Ethics and Experience in a Conversation about Persistent Oral Lesions

The Texas Dental Journal – Special Issue – Oral Cancer

about your

Do you know we offer a complete line of high-quality Disability Income insurance designed especially for professionals like you?

SP

A CI

UE S S er LI

/ rg ns o . o a td ati nic al sit blic ectro ourn i V pu el l J a e a td for th Dent

409

Texas Dental Journal l www.tda.org l May 2011 xas Te