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June 2011

Journal TEXAS DENTAL

49th

ANNUAL

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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.


Free CE Credits Are Just a Click Away. • • • • • • •

Taking New Steps

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

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Contents

TEXAS DENTAL JOURNAL n Established February 1883 n Vol. 128, Number 6, June 2011

ON THE COVER The 49th annual El Paso Dental Conference will be September 22-23, 2011, at the El Paso Convention Center. For more information, please visit elpasodentalconference.org.

TDA GOVERNANCE 512

Outgoing President’s Address, May 5, 2011

520

American Dental Association 15th District Trustee’s Address, May 7, 2011

526

Incoming President’s Address, May 8, 2011

Ronald L. Rhea, D.D.S.

S. Jerry Long, D.D.S.

J. Preston Coleman, D.D.S.

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El Paso Dental Conference

CLINICAL RESEARCH 541

Latex and Non-Latex Orthodontic Elastic Force Loss Due to Cyclic Temperatures

The study compares the force loss of medium latex elastics to non-latex elastics after being cycled between different temperatures.

Sebastian Z. Paige, D.D.S.; Jeryl D. English, D.D.S., M.S.; Gary N. Frey, D.D.S.; Harry I. Bussa, D.D.S., M.S.; Kathleen R. McGrory, D.D.S., M.S.; Randy K. Ellis, D.D.S., M.S.; Joe C. Ontiveros, D.D.S., M.S.

CLINICAL REVIEW 547

Materials, Clinical Strategies, and Procedures for Restoration of Access Cavities: A Review

The authors review current methods of “bonding” to tooth structure, ceramic materials, and metals, with emphasis on those aspects that are important to endodontics.

504

Adhesive Dentistry and Endodontics:

Richard S. Schwartz, D.D.S.; Ron Fransman, D.D.S.

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MONTHLY FEATURES

BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION

508

The View From Austin

572

Oral and Maxillofacial Pathology Case of the Month

576

Oral and Maxillofacial Pathology Case of the Month

Diagnosis and Management

579

In Memoriam / TDA Smiles Foundation Memorial and

Honorarium Donors

580

Value for Your Profession

584

Calendar of Events

586

Advertising Briefs

602

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 J. Preston Coleman, D.D.S. (210) 656-3301, drjpc@sbcglobal.net PRESIDENT-ELECT Michael L. Stuart, D.D.S. (972) 226-6655, mstuartdds@sbcglobal.net IMMEDIATE PAST PRESIDENT Ronald L. Rhea, D.D.S. (713) 467-3458, rlrhea@swbell.net VICE PRESIDENT, SOUTHWEST Lisa B. Masters, D.D.S. (210) 349-4424, mastersdds@mdgteam.com VICE PRESIDENT, NORTHWEST Robert E. Wiggins, D.D.S. (325) 677-1041, robwigg@suddenlink.net VICE PRESIDENT, NORTHEAST Larry D. Herwig, D.D.S. (214) 361-1845, ldherwig@sbcglobal.net VICE PRESIDENT, SOUTHEAST Karen E. Frazer, D.D.S. (512) 442-2295, drkefrazer@att.net SENIOR DIRECTOR, SOUTHWEST T. Beth Vance, D.D.S. (956) 968-9762, tbeth55@yahoo.com SENIOR DIRECTOR, NORTHWEST Michael J. Goulding, D.D.S. (817) 737-3536, mjgdds@sbcglobal.net SENIOR DIRECTOR, NORTHEAST Arthur C. Morchat, D.D.S. (903) 983-1919, amorchat@suddenlink.net SENIOR DIRECTOR, SOUTHEAST Rita M. Cammarata, D.D.S. (713) 666-7884, rmcdds@sbcglobal.net DIRECTOR, SOUTHWEST Yvonne E. Maldonado, D.D.S. (915) 855-2337, yvonnedent2000@yahoo.com DIRECTOR, NORTHWEST David C. Woodburn, D.D.S. (806) 358-7471, olddave1@gmail.com DIRECTOR, NORTHEAST Jean E. Bainbridge, D.D.S. (214) 388-4453, jbainbridgedds@sbcglobal.net DIRECTOR, SOUTHEAST Gregory K. Oelfke, D.D.S. (713) 988-0492, greg@oelfke.com 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 David H. McCarley, D.D.S. (972) 562-0767, drdavid@mccarleydental.com EDITOR Stephen R. Matteson, D.D.S. (210) 277-8595, texdented@gmail.com EXECUTIVE DIRECTOR Ms. Mary Kay Linn (512) 443-3675, marykay@tda.org LEGAL COUNSEL Mr. William H. Bingham (512) 495-6000, bbingham@mcginnislaw.com

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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


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

The American Way at the TDA “Microphone 2 is reserved for speakers against a resolution under consideration. Microphone # 1 is reserved for speakers who support the resolution. Microphone 3 is provided for delegates to raise points of order,” Dr. Glen Hall, the TDA Speaker of the House, announced at the Texas Dental Association House of Delegates 2011 annual meeting earlier last month.

The atmosphere in the large room resembled a political convention with vertical signs in the corners of the room designating the four districts of the TDA. The delegates grasped green voting cards in ready for upcoming votes. Officers of the organization were seated at a raised table facing the assembled delegations and the speaker of the house sat at a raised chair behind a podium prepared to conduct the meeting. Members of the TDA Board of Directors were seated along the first row. Rules of order were close by for referral when conduct of the meeting was in question. Placards stating names and the delegate’s district or officers of the TDA were present on the table at each seat. A junior ROTC color guard presented the colors of the USA and Texas. The young women in the color guard performed the ceremony in military precision. Many delegates opened their computers to access the House Book containing the many resolutions to come to the group for consideration. The TDA Awards Committee gathered at the front of the room to present the various service and other awards of the Association. Committee members presented the awardees with their plaques as they walked across a platform. Dr. Jerry Long’s 15th ADA District Trustee’s report was well received.

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Election of officers was held during the Sunday morning meeting. The floor was open for additional nominations for each office and voting took place. The traditional swearing in of the new officers was conducted and photographs were taken. The newly elected president, Dr. J. Preston Coleman of San Antonio, introduced his family and office staff. He The 2011 House of Delegates convenes at the 141st then gave his President’s TEXAS Meeting. address. The outgoing president, Dr. Ronald L. Rhea of Houston, was presented the beautiful sculpture framed award that appeared quite heavy to those who carried it. The newly constituted Board of Directors held its first meeting after the close of the session and the yearly cycle of TDA events restarted. What a wonderful example The floor of the 2011 TDA House of Delegates. of representative government at work. All delegates and officers are elected by members of a decision, tellers assigned by the their delegations or as officers by the speaker of the house count the votes TDA at large. Resolutions to come to of standing delegates. The elected the floor of the House of Delegates are officers and TDA staff must follow the considered by Reference Committees will of the House during their year of that deliberate each item and recomoperations. mend approval or denial. This process ensures careful consideration of items This editor comes away from each anby the House of Delegates and estabnual meeting believing the “American lishes procedures for delegates to give Way” has been preserved well by our oral arguments in support or against Association; elected representatives the reference committee recommenand officers, the right to assemble dations. Delegates raise their green peacefully, freedom of speech, and voting cards to approve or not approve rule by majority are demonstrated at resolutions. If visual assessment of these meetings. Congratulations to all the raised voting cards cannot confirm participants.


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The 141st Annual Session of the Texas Dental Association

Dr. Ronald L. Rhea, President President’s Address to the Texas Dental Association House of Delegates, May 5, 2011 Mr. Speaker, TDA Board of Directors, House of Delegates, and distinguished guests. Congratulations! I am here with you today to celebrate! Dentistry and the Texas Dental Association are alive and well in Texas! This would not be the case without your wisdom and leadership. The decisions that you have made in this House, the selection of members you have sent to Austin and Chicago, and the activities of the local dental societies which you represent are in large part responsible for the good health of the profession, particularly in Texas, and the dental health of the citizens of Texas. The health of dentistry in Texas is no accident. Hard battles have been fought this year. You can be proud of your members who have lead these battles in Texas and at the national level. 512

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Forces exist which would degrade dentistry into a retail trade with marketing, not professionalism, being the driving force.

There are states in our nation where the profession of dentistry as we know it is not secure. Forces exist which would degrade dentistry into a retail trade with marketing, not professionalism, being the driving force. Caveat emptor — “let the buyer beware” — would replace ethics as the core principle, and educational expedience and profitability would guide our dental schools. Two years ago, almost immediately after being installed, your then president Dr. Matt Roberts of Crockett, TDA executive director Ms. Mary Kay Linn, TDA Council on Legislative and Regulatory Affairs chair Dr. Rick Black of El Paso, and I flew to Washington, D.C., for the American Dental Association (ADA) Washington Leadership Conference. Dentists from across the country gather at this annual conference to learn about state and national issues affecting dentistry and to discuss these issues with their senators and representatives. Time is also available for state leaders to discuss with each other the status of dental practice in their districts. I often sat aghast at the tales of woe. It was the first time ever that I gave an embarrassed Rick Black a hug and thanks for his leadership of CLRA in preserving dentistry in Texas. In his final address last year, Dr. Roberts spoke of the formation of the Austin Group.

TDA president Dr. Ronald L. Rhea speaks to the 2011 TDA House of Delegates in San Antonio.

Dismayed by developments coming from the ADA which seemed to be promoting mid-level providers, the TDA Board of Directors approved funding for a conference of like-minded states to meet in Austin. Lead by Dr. Black and Dr. Roberts, this coalition, which became known as the Austin Group, orchestrated strategies to reinforce ADA policy against those other than a dentist performing irreversible surgical procedures. As we approached the ADA Annual Session last year, a task force from the ADA Council on Dental Practice (CDP) presented four resolutions which would have changed the fundamental policy of the ADA by allowing delegation of irreversible surgical procedures to someone other than a dentist. At the end of June, Dr. Craig Texas Dental Journal l www.tda.org l June 2011

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Dr. Ronald L. Rhea, President

Armstrong of Houston, Texas’s member on this CDP taskforce, with help from the TDA staff, wrote the dissenting minority report urging defeat of these resolutions by the ADA House of Delegates. With strong input from your representative Dr. Jim Condrey of Houston, the ADA Council on Governmental Affairs recommended that the ADA House of Delegates defeat these resolutions. It was the first time that one ADA council recommended defeat of another council’s resolutions. Next, Dr. Jerry Long, the 15th District Trustee, joined by other trustees, led the defeat of these resolutions by the Board of Trustees. It was a close vote. Finally, at the ADA annual session in October in Orlando, these leaders, supported by the members of the Austin Group, orchestrated the defeat of the resolutions on the House floor, and strongly reinforced ADA policy on anyone but a dentist performing irreversible surgical procedures.

(L-R) ADA 15th District Trustee Dr. S. Jerry Long greets TDA president Dr. Ronald L. Rhea, both of Houston, at the 2011 TDA House of Delegates.

Is this fight over? It certainly is not. As you all know, the ADA does not decide who practices dentistry in Texas or any other state. In Texas, the state legislature writes and modifies the dental practice act, which is codified and enforced by the Texas State Board of Dental Examiners. Those who would allow midlevel providers to practice dentistry in Texas are not coming to you, the governing body of the TDA for permission. They will approach the legislature directly, very likely without even consulting you. Indeed this year, one foundation allocated $16 million dollars to lobby for Dental Health Aide Therapists (DHATs) in five states. Texas is not one of those states, but our nearest neighbor New Mexico is. It is imperative that you maintain and improve your relationships with your legislators. We cannot compete on a dollarfor-dollar basis with these wealthy foundations, but we can compete in the personal relationships we have with our legislators.

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Dr. Ronald L. Rhea, President

Unfailingly, as I mention becoming involved in the political process, some well-meaning dentist will say, “Oh, I don’t want anything to do with politics, it is such dirty business.” That is certainly a common opinion. In January at the ADA Lobbying Conference in Tucson, Arizona, the leaders from the 50 state dental associations received a T-shirt to commemorate the meeting. The quote on the back by Ronald Reagan says it all, “It has been said that politics is the second oldest profession. I have learned that it bears a striking resemblance to the first.” All Texas dentists are political animals. You are allowed to practice dentistry in Texas not because you graduated from one of our fine dental schools, but because the state of Texas allows you to practice dentistry. The state can also tell you what you can and cannot do as a dentist. The state might also allow others to practice dentistry. Whether you are active or passive in the political process determines the future of dentistry in Texas. At this time, the 82nd Session of the Texas legislature is approaching the end of its 140day session. The dominant themes in Austin have been the

budget shortfall and mandatory redistricting. As we strive not to get crushed by these two giants lumbering in Austin, I am reminded of an old Godzilla meets King Kong movie! Tremendous amounts of time have been expended by your Board, CLRA, legislative staff, and legislative consultants. The battle still rages. I will leave it for Dr. Black to give you the blow by blow and to speculate on the outcome. Much will not get done during this session. I am asking for your direction and approval to take the fight to the next session for several initiatives. •

Expand the enforcement powers of the Texas State Board of Dental Examiners to include those who practice dentistry without a license. This would also include the bleaching of teeth by those other than a licensed Texas dentist and his or her staff. Because of the likely increased enforcement cost, this may require a fiscal note. Require mandatory dental examinations for schoolaged children. Write into law that no member of the Texas State Board of Dental Examiners may testify as an expert

witness in a dental malpractice case in Texas. Identify a new Expanded Function Dental Assistant based on the U.S. Army model to be allowed for those dentists practicing in federally defined underserved areas. This should be sent to the Council on Dental Education Trade and Ancillaries for study with recommendations to the Board and next year’s House for final approval.

During this House of Delegates, we will consider a number of resolutions. I would like to speak for a moment about your deliberations. Each of you certainly must have noticed the trend towards decentralization of authority in the governance of the Texas Dental Association. Why have the president make a decision if the three presidents can get together? Why have the Executive Committee make a decision if the whole Board of Directors can be convened to deliberate? Why have the Board of Directors make a decision if the House of Delegates can make the call? And, at the extreme, why have the House of Delegates decide if the whole membership can be polled?

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Dr. Ronald L. Rhea, President

We all believe in the democratic process. Each of us wants to have a say in processes that affect our lives and livelihood. However, as the group size grows, the idea of representative democracy becomes important and may indeed give better decisions for two reasons: •

Elected leaders, like you, are those who have said they are willing to allocate the time and energy to thoroughly study the issues. The smaller the group, the more quickly a decision can be made when it is needed.

In one of my early articles, I expressed that I never cease to be amazed at the wisdom of the decisions made by this House. An issue provided to this House for consideration may seem at first to be irrevocably contentious. Yet with discussion and deliberation a consensus is reached. The policies of our Association should always be decided by this body. However, since the House is only in session for 3 days each year, the Board of Directors must take over the operations of our organization. Here we must trust our elected representatives to make decisions for the good of us all. The operative word here is “trust.” Select

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How fortunate are we as dentists that we can know our leaders and trust what they tell us to be true.

consent on many of our procedures. Faced with the need for consent forms in our offices, each of us would like to go to the TDA website and print out a form for whatever procedure we are contemplating. In reality, such consent forms should be designed by an attorney who is willing to go with his or her client and defend the forms should they be called into question. The TDA does not practice law and give legal advice. We have, however, come upon a process that will provide for us a governmentally certified form and list of procedures with possible complications. We all know that informed consent is a conversation that occurs between a dentist and a patient, not a form. But for a listed procedure, having discussed the associated possible complications with your patient, if you use the form and had your patient sign that you had had the conversation, you have a very defensible state supported argument that informed consent was given.

For a number of years, members have requested that the TDA design and furnish informed consent forms to bring our dentists into compliance with the Texas State Board of Dental Examiners’ requirements for written informed

This process is now in place for medicine in Texas through the Texas Department of State Health Services, Texas Medical Disclosure Panel. Last Friday, TDA program manager Ms. Cassidy Neal and I visited a meeting of the Texas Medical Disclosure

your representatives with care and then entrust and empower them to operate in your best interests during your absence. If you attempt to write rules to replace judgment you will paralyze the functionality of the TDA. The most successful organizations and businesses in our country are characterized by three steps: 1. careful selection, 2. good training, and 3. empowerment. Please keep this in mind as you make your decisions this weekend. Things happen in our world at a frighteningly rapid pace. Since I wrote this speech, our CIA and Navy Seals have located, killed, and buried Osama bin Laden! As I listened to the news while driving to San Antonio yesterday, the debate raged on whether to release photos of bin Laden’s body to prove to the skeptics that he was indeed dead.


Dr. Ronald L. Rhea, President

Panel. The members of the panel seemed very willing to help us in providing a list of services we perform that require written informed consent, a list of possible complications for each procedure, and a form upon which to list these and have the patient sign. The panel is in place to help doctors inform their patients and is not in any way punitive. Use of the forms is at the discretion of the doctor. I urge you at this meeting of the House, to empower the Board of Directors to go forward with this process. The Board can then return to you a state approved form and list of procedures with possible complications. You may then exercise your professional judgment to elect to use this form and list. We have accomplished many things this year, but two stand out in my mind. On February 23rd the TDA Extension building was officially opened and on February 24th and 25th we held our first Board meeting in the new facility. The Extension will provide us with a state of the art Board room and meeting space and additional leasable square footage. This year also marks the beginning of the new TDA state

student organization. The TDASO, which is the first state student group in the nation, was the creation of our 2009 TDA Externs, Summer Adkins, Blake Johnston, and Megan Holme. We are proud to have some of the 2011-2012 officers with us today as guests of the House. Would those officers please stand? The goal of these officers for the next year will be to build student awareness of the organization and to educate their peers about organized dentistry. We thank you for volunteering to serve and are here to support you in your new roles. I would be totally remiss if I failed to thank those who make

the operations of the TDA possible. All of us dentist volunteers are experts in our fields, but never once in all my years in the TDA office in Austin have I ever found myself with a dental drill in my hand! Fortunately, we do have experts in the central office. Many of our staff have multiple college degrees in such things as accounting, public policy, ethics, meeting management, English composition, and on and on. Without our superb staff, the TDA would not have the cachet it enjoys in Austin and at the ADA. I thank you all for allowing me this opportunity to serve.

(L-R) Pictured are TDA president Dr. Ronald L. Rhea of Houston, Dr. Thomas N. Ewing of Houston, and Dr. J. Gregory Condrey of Sugar Land at the 2011 TDA Legislative Day in February in Austin.

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The 141st Annual Session of the Texas Dental Association

Dr. Jerry S. Long, ADA 15th District Trustee Trustee’s Address to the Texas Dental Association House of Delegates, May 7, 2011 Good morning everyone! This will be my fourth and final report to the TDA House of Delegates as your 15th District Trustee. It’s been quite an honor for me to represent the dentists of Texas in Chicago as your Trustee for the past 4 years. Being part of the managing body of American Dental Association (ADA) is an enormous responsibility, and I promise you that I have not accepted it lightly. Thanks for your trust. During the past 4 years, ADA has undergone many positive changes. Allow me to list a few of these highlights: • • •

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Almost all of the senior management in Chicago is new. The ADA Foundation and our for-profit subsidiary, ADABEI have undergone almost total reorganization. The audit process in general and the Audit Committee specifically, have moved into the post-Enron era by transforming itself into a true watchdog of the financial and reputational risks of your ADA. A Board of Trustees initiative added

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I would like to talk about recent trends in four areas of our Association that concern me, and the potential for any one of these issues to threaten the very foundation of ADA: membership, revenue, dental education, and accountability to governance.

two members of the House of Delegates to sit on the Audit Committee with four Trustee members. The external and internal audit firms were replaced with KPMG and RMS McGladrey to provide a new direction in the audit process. It’s been a whirlwind of activity on the ADA financial front. ADA’s new strategic plan emphasizes an unprecedented commitment to member dentists, while maintaining our longstanding commitment to our patients and the nation’s public health. Opened new avenues of collaboration with diverse groups in the profession. Dentists and dental leaders of the future will not look like the demographic represented in this hall today. Especially rewarding for Texas is that we saw action in the 2010 ADA House that validated many of TDA’s longstanding positions on midlevel providers and scope of practice. Recently negotiated an exciting, new internet public relations project for ADA with Dr. Oz, Harpo Productions (Oprah Winfrey) and the founder of WebMD, that will reach millions of Americans with oral health messages and answers to their questions, while re-

directing internet traffic to ada.org. We are hopeful that this will also result in more opportunities to enhance our non-dues revenue in the future. The website is sharecare. com. ADA’s debut is still a few weeks away, but log on for a preview. Debuted a new, revamped ada.org.

Time does not permit me to list all of the recent accomplishments of ADA; however, to paraphrase the 1970’s Peggy Lee song, “Is That All There Is”: “If that’s all there is my friend — then let’s keep dancing — let’s break out the booze and have a ball. If that’s all there is.” Unfortunately there is more. Success and celebration must be tempered with caution, because an organization such as ADA, despite all of the good news, always seems to have another challenge or threat lurking right around the corner. Today, I would like to talk about recent trends in four areas of our Association that concern me, and the potential for any one of these issues to threaten the very foundation of ADA: membership, revenue, dental education, and accountability to governance. But haven’t those “concerns” been with us forever? Absolutely!

ADA 15th District Trustee Dr. S. Jerry Long of Houston addresses the 2011 TDA House of Delegates.

However, new developments have made the board refocus its efforts and resources on making certain these concerns are not ignored. Let’s start with membership. I know you’ve heard me say this before, but here goes again: “No members, no ADA; no ADA, no profession.” And let me congratulate the Texas Dental Association because through the efforts of all of you, the TDA staff, and your component societies, the ADA 15th Trustee District will send three additional delegates and up to three alternates to next year’s House of Delegates. Only a handful of Trustee districts gained members in the recent calculations performed every 3 years. Most of the districts stayed the Texas Dental Journal l www.tda.org l June 2011

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Dr. S. Jerry Long, ADA 15th District Trustee

Dr. S. Jerry Long, the ADA 15th district trustee, speaks to the 2011 TDA House of Delegates.

same (ADA policy states that the House grows to provide for increasing membership, with little or no chance a district will lose delegates in the reapportionment.) Membership is a good news/bad news proposition. The good news: since 2007, ADA membership has increased. And the bad news — the market share of all U.S. dentists that ADA represents has decreased from 71 percent to 68.2 percent from ’07 to 2010. The “pie” is larger, but ADA’s slice is getting smaller. Also, never has our profession seen such diversity in membership; and never before has ADA had to make itself fit into so many different expectations being brought to the table by our newest colleagues. Men, women, blacks, Hispanics, Asians, first or second generation Americans, rural, urban, the Boomers, and the Gen X’s and Y’s — we all come with our own unique set of demands of how ADA must relate to us personally. Paraphrasing President Kennedy, whatever happened to “Ask not what ADA can

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do for us, ask what we can do for ADA.” Ladies and gentlemen, there’s a new member mentality in our profession. Incidentally, the diverse groups I mentioned (excluding Caucasian males) are demographic categories that produce members at around the 50-60 percentile range, and some below 50 percent. If young dentists truly are evaluating memberships on what ADA does for them, the perception is we are not meeting their needs. Further complicating the future of membership is the approaching retirement of the most loyal group of ADA members, the Traditionalists and Baby Boomers. It doesn’t take a calculator to see the potential long term effect these trends will have on the future market share of ADA dentists. Last year in this House, I mentioned the alarming news that recent graduates of our three Texas schools were in the bottom half of all dental schools in converting new graduates to full ADA member-


Dr. S. Jerry Long, ADA 15th District Trustee ship. Many of you went back to Dallas, San Antonio, and Houston and started addressing this issue with the local schools. On the bright side, I recently attended “National Signing Day” at the Houston school and graduating seniors responded by signing almost 100 percent of their class into full ADA membership. A positive trend for the Texas schools? Let’s hope so. Just keep it up! Membership affects everything. At stake are the standards of the profession from ethics to education, our advocacy efforts in federal and state legislatures on behalf of our practice and businesses — not to mention that member dues are the largest source of ADA revenue.

policy that uses a portion of the reserves to maintain a manageable dues structure; extraordinary legal and accounting expenses associated with recent changes in senior management; as well as, an increasing reluctance for Houses of Delegates to grant dues increases. These membership and financial concerns are realities that ADA trustees, staff, the Finance Committee, and the Audit Committee have lived with during my four years on the board. Is there a magic bullet for all of this? Probably not! But growing the market share of our membership is a good place to start.

First of all, dues revenue is flat, and predicted to trend downward as the Baby Boomers and Traditionalists retire and are replaced by the more diverse member groups.

To switch direction, let’s take a look at dental education. Government funding in today’s economy remains a problem, especially when our schools depend on grants to stoke the fires of the science and research components of dental education. State funding for the Texas schools is in the 20-30 percent level, and I understand that the State of California only provides 11 percent of its dental schools’ revenue.

Other factors challenging the financial health of the association are: the economy (return on the investment of reserves and “sticker shock” from dues statements); the reorganizations of ADABEI and the Foundation and their associated legal and accounting expenses; our dues stabilization

Over the next 10 years, I have heard that possibly 10-15 new dental schools will be coming online. The applicant pools continue to increase because dentistry remains an attractive career choice — increasing tuitions and huge student debt seem not to matter.

Did I just mention revenue? You bet I did, and it just happens to be the second pillar of concern that I want to discuss with you.

A large number of these new schools are branches of osteopathic medical centers and they are utilizing revolutionary, and new educational models that are, quite frankly, foreign to traditional health science center dental schools. This new approach features predominantly off site clinical instruction to small groups of students in public health settings and Community Health Centers, and many of these osteopathic institutions have very limited or no clinic facilities at their central campus. Osteopathic teaching models utilize a more streamlined approach to the basic sciences and research. Permanent full-time faculty members are small in number, since part time and visiting lecturers are often utilized. Less emphasis on research is not uncommon. This new brand of dental education is being touted as an important factor in improving access to oral health care, and as a system that produces dentists with a greater sense of social responsibility. And where is the ADA in all of this? To date, the Council on Dental Accreditation (CODA) has been involved in providing oversight and accreditation to ensure that this new approach maintains the traditionally high standards of American dentistry.

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Dr. Jerry S. Long, ADA 15th District Trustee There are some who question whether CODA will eventually be forced to compromise those standards, just to keep all dental education institutions and their unique models, under the same umbrella. If ADA is about anything, it’s about maintaining high standards in all aspects of the profession. How the standards of our profession evolve in the future to accommodate this new trend in dental education, will certainly affect the standing of dentistry in the eyes of our patients, society, and government policy makers. ADA must get this right away! It’s always good to think out of the box — but not too far out of the box — because there are probably many good reasons that box is there in the first place! This year, the House of Delegates Mega Discussion will feature Dr. Jack Dillenberg, dean of A.T. Still School of Dentistry and Oral Health in Arizona and Dr. Michael Glick, dean of SUNY/ Buffalo School of Dentistry, presenting their cases for each type of dental education. That will be interesting! My fourth and final point concerns governance and the roles officers and delegates must play for the benefit of our profession. Ever avoid buying a raffle ticket because the rules of the contest said, “You have to be present to

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win”? Making the extra effort to claim “the prize” can be very difficult at times. Yesterday, we attended our TDA regional caucuses to choose our delegates to the 2012 House of Delegates. Hopefully, those elected will make a full effort for our profession to “claim its prize.” Last year, I was very disappointed in the ADA House of Delegates when that body voted not to receive attorney-client information that I — and seven other Trustees — believed to be vital to the best interest of the ADA. In my mind, that vote was about apathy and irresponsibility on the part of a majority of the delegates in the 2010 House. Lesson learned for me: You can’t force feed members of the House — unless, they are committed to the exercise of their duties and responsibilities. If the ADA House of Delegates is truly the supreme “governing authority” of ADA, the 2010 ADA delegates, in my mind, fell short of their fiduciary responsibilities to 150,000+ dentists. A former president of the TDA, Dr. Michael Vaclav, honored his leadership team in 1996 by designating them as “Keepers of the Profession.” Those words and that theme have stayed with me over the years. Today, all of you have been designated “Keepers of the Profession”

by virtue of your seats in this House. Please take that responsibility seriously in the conduct of your business this weekend. Another TDA president and former ADA trustee, Dr. Frank Eggleston, once told me that he never made a decision as ADA trustee that he did not ask himself the question: “When I cast this vote, how will it affect the dentists on Main Street in Houston”? I took this to heart and have followed his advice in my trustee position for the past 4 years. This model has been a tremendous measuring stick during my time as your trustee, and is certainly worth remembering as you serve your colleagues from along Main Street in your home towns. What’s the future of American dentistry? Have we already fired our best shot and its only downhill from here? If you answer that question, “Yes”, then “let’s keep dancing, let’s break out the booze and have a ball — if that’s all there is”. If your answer is, “Heck no! — the best is yet to come,” then roll up your sleeves and go to work — all of you — “Keepers of the Profession.” There is much left to be done. It’s been a pleasure representing the dentists of Texas and the ADA 15th Trustee District over the past 4 years. Thanks for the honor!


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The 141st Annual Session of the Texas Dental Association

Dr. J. Preston Coleman, President-Elect Incoming President’s Address to the Texas Dental Association House of Delegates, May 8, 2011 Mr. Speaker, TDA Board of Directors, House of Delegates, and distinguished guests. I thank you for the privilege and honor of serving as your president. Mr. Speaker allow me a few moments to introduce the people that mean the most to me and help me to care for my patients and who care for me. Staff: Crystal Dennison is our insurance coordinator, front desk assistant, and bookkeeper. Crystal has been with us for 7 years working her way through college and starting full time in 2008. Christine Robledo is our receptionist and has been making patients HAPPY for 12 years. She keeps us in touch with our referring offices especially their scheduling staff. JoNell Hagan transcribes exam charts and assists with anesthesia cases. JoNell has been with us 28 years but it seems like 5 years longer than I have been there. JoNell always remembers patients by faces and names. Lily Morado has been with us for 12 years. Lily is an able assistant and she keeps our inventory up to date. Sara Garza is my primary assistant and cat herder for 4 years. Sara keeps me on time as much as anyone can keep me on time.

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A wise person once observed that “You don’t need to know all of the answers. No one is smart enough yet to ask all of the questions!”

Next I would like to introduce two special people who have traveled a long way to share this special event with me. My favorite sisters, Christine Coleman, a registered nurse is from Tulsa, Oklahoma, and Cindy Kessler, an accountant and business owner, is from New Orleans, LA. My brother, Ronald Coleman, could not come because his daughter is graduating from Tulane University this weekend. Family: April McLain also known as #1 is our first born. She says that she was the most wanted. April & Glenn have been married 18 years. They have one handsome son, Forrest McLain, who is 10 years old. They live in Bulverde, Texas. Glenn has been with USAA about

15 years in their IT department. April earned a bachelor’s degree in nutrition at the University of The Incarnate Word in San Antonio. She wrote a column in the Express News for 10 years in the Food and Wine section. She is presently in an internship that will complete her requirements for her Dietitians License. Vanessa Pehl also known as #2. They live in Round Rock, Texas. Vanessa says she was the favorite. Her husband, Gavin, is a financial analyst for the Dell Corporation. The Pehls are the parents of my two beautiful granddaughters Julea, 11, and Sophia, 8. Vanessa is a graduate of the Southwest Texas State University in San Marcos. She earned her bachelor’s de-

Dr. Coleman and his office staff members are pictured at the 2011 TDA House of Delegates in San Antonio

gree in fashion merchandising, clothing and textiles. She was a manager and a buyer for GAP and Guess locations in Dallas. Preston, also known as #4 was our 40-year-old surprise. He says he was the best child. Preston is a graduate of Texas A&M University where he earned his bachelor’s degree in psychology. He earned a master’s degree in clinical psychology at Boston College. In Boston he interned with a psychiatric group and became interested in medicine. He is now taking courses in preparation to apply to medical school. Jareth is known as #5. He is also known as the professor and expert! Jareth is 9 years old and enjoys school, swimming, and bike riding. George is known as #6. George is 8 years old. George is our happy-go-lucky guy who never meets a stranger. George enjoys school, bike riding, and playing basketball. He may have a future with Lida if he can keep the romance going long enough.

Dr. Coleman is pictured with his family at the 2011 TDA House of Delegates in San Antonio

And then there is my favorite! My love, my confidant, my mate, my main squeeze, Sue

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Dr. J. Preston Coleman, President-Elect Ann! We have been married almost 46 years (that’s before I went to dental school)! It’s been a great life and I couldn’t have picked a better mate for this journey!

• •

the 2010 independent Audit Report, the total report is 40 pages. Granted it’s complicated and your understanding of the report may be limited by your accounting knowledge and experience as well as your interest in understanding the facts presented. I intend to see that the Board of Directors at each of its meetings and you as delegates receive complete information in an organized format to help you fulfill your over site responsibilities. George Bernard Shaw, said “The problem with communication is the illusion that it has been accomplished.”

The TDA encourages membership and involvement in organized dentistry from the earliest days of the formation of our young dentists. This past year we have helped to establish the Texas Dental Association Student Organization (TDASO). The TDASO will work closely with the American Dental Student Association (ASDA) and will provide additional leadership opportunities that introduce the strength we have as a professional organization. TDA supports the mentoring programs of the three Texas dental schools. We encourage involvement of our retired members in local societies and in charitable events throughout the state, many of which are sponsored by TDA The Smiles Foundation. As a result of these membership efforts, the TDA received awards from ADA for the greatest net gain of new dentists, the greatest net gain of nonmembers and the greatest net gain overall in membership in 2010. These are but a part of a longer list of such awards.

What is the best measure of the greatness of our organization and our profession? There are several points one might consider: • How are the youngest and oldest members treated? • What opportunities does it offer to outsiders? • How does it respond to the needs of the membership as a whole?

The TDA seeks opportunities to communicate with people outside the organization. The TDA web site offers articles on dental health as well as articles explaining the relation of oral disease to systemic disease. Also it provides information about dental insurance, public assistance programs like Medicaid and CHIP and information about charity clinics across the state.

~~~~~~~ A wise person once observed that, “You don’t need to know all of the answers. No one is smart enough yet to ask all of the questions!” Dissecting this observation leads one to understand that although you don’t need to know all of the answers but you surely need to be thinking on your feet because questions asked by our members are important to more than one member. Many of these questions are two edged swords. If you answer one way, you please some and are insensitive to others while if you choose another side you offend the first. So which way do you go? How do you answer? You could give your honest opinion but when you speak for the organization, the “me” is not important. It’s the “we” that counts. In recent years there has been a great deal of turmoil in many areas of organized dentistry and the TDA has not been immune to this trend. The knee jerk reaction has been to make drastic changes in everything. Change should be made thoughtfully and carefully. The TDA is about as “transparent” as an organization can be (if you like that term). An example is our budget process and financial reports to the House of Delegates. Including the budget, budget explanation, financial report, supporting reports, and

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The leaders it chooses and follows? How does it honor its heritage?

Dr. J. Preston Coleman, 2011-12 TDA president, is pictured with his wife Sue Ann.


Dr. J. Preston Coleman, President-Elect Although the term “Access to Care” continues to be a mantra in the legislative world it has yet to be defined and explained. Nonetheless the TDA has taken a leadership role to provide quality care for people in need of care. We all know the details of our significant increase in Medicaid providers at the settlement of the Frew law suit. The Medicaid and CHIP children in Texas have reaped the benefits. Daily and weekly I see children referred to my practice who have perfect or near perfect oral health. But now we are faced with two more issues. The budget crisis that has swept state governments across the nation has not spared Texas. At this time the Texas Legislature has proposed taking the Medicaid program for children from a “fee for service” model to a “managed care” model. Our Council on Legislative and Regulatory Affairs (CLRA) has been working tirelessly since before the legislative session began as soon as the plan was revealed to protect the interest of the children that benefit from the programs and to steer an outcome that will maintain the enthusiasm of our members who provide the needed care. In my estimation, our lobby team in this legislative session has guided us through the greatest mine field I can recall in 27 years of political involvement with TDA and DENPAC. To quote our sitting president, “make no mistake.” Make no mistake, we will not be doing business as

usual in the Medicaid and CHIP arena but your CLRA leadership will diligently work toward a solution that will do the least harm to the patients we serve. We were warned by our lead lobbyist, Dr. David Sibley, of the contentious legislative atmosphere before the beginning of the session and indeed there is a shortage of friendly canine pets in Austin since January of this year. The other issue is the continued pressure by private foundations namely the infamous Kellogg (sugar cereal) Foundation and the PEW (we know better than you) Foundation. They are pouring millions of dollars into state political arenas nationwide to tell the public and the dental profession how mid-level providers can provide the same quality of care that a dentist provides. I think you know the song and verse “...a mid-level provider with a high school diploma plus about 2 years of mostly un-supervised “on job training” can provide comparable care to that provided by a DDS or DMD who has a college degree and 4 years of intense didactic and supervised clinical training. Well I won’t bore you with the details that you already know but suffice it to say the DHAT report on 5 years of DHAT care in Alaska was far from convincing and even with the excuses offered showed no evidence that their hypothesis has been proven. But “make no mistake” (remember the famous American) we will have real prob-

lems if they bring their large wagons of money and their “dog and pony show” to Texas for our 2013 legislative session. The legislative arena has been on fire this year and CLRA has responded in every way possible to protect the interest of our members. I refer to the opposition the insurance industry has mounted against us. After diligent negotiation on the topic of “the capping of non-covered dental services,” a compromise was struck and we were told that the insurance industry would not oppose the compromise. Along with the old saying “the check is in the mail,” we now find our lobby team responding to their opposition. And who knows how much money has been pumped into the debate! The roller coaster ride has begun and it’s only a matter of days until we know the outcome. If you are called upon to contact your legislators this week or next, PLEASE make it a priority and act immediately because your response could be the one that sways the outcome. (Enjoy the wisdom of our Texas founders limiting our legislative sessions to 140 days every other year.) The TDA has maintained an “arm’s length” and a constructive relationship with the Texas State Board of Dental Examiners (TSBDE). The recent vote by TSBDE to implement the proposed new rules and regulations governing Anesthesia and Sedation Permitting was not supported by all Texas Dental Journal l www.tda.org l June 2011

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Dr. J. Preston Coleman, President-Elect of our members. Patient care and safety are the important points. In light of the ADA’s polices on this subject changes were needed. The TSBDE has long been criticized over its disciplinary actions. There are some people who think that every violation is deserving of license suspension or revocation. In a spirit of fairness and justice the TSBDE has established an “Investigative Process Flowchart” and a “Disciplinary Matrix” to help licensees and the public understand the process. The goal being to increase voluntary compliance while lessening complaints that those violations are not dealt with in a severe fashion. One of the goals of the TDA 2014 Strategic Plan is “Public Image”. This House of Delegates has been briefed on the progress of this goal by the Task Force on Public Image. The TDA Smiles Foundation has had a strong influence on Public Image since its beginning. The TDA Smiles Foundation programs, Texas Missions of Mercy, Texas Smiles on Wheels, and Donated Dental Services, have put the profession’s reputation in the spot light in many communities across the state. These efforts have literally changed lives for people in most need of a fresh start in life. These efforts are our most effective public relations activities to date. The TDA, thanks to its dedicated membership, has consistently elected strong leaders who have

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consistently contributed to the strength of the organization. Today at the ADA level, Dr. Jerry Long has served as the ADA 15Th District’s Trustee. Dr. Long has served us well in a sometimes hostile and lonely environment in Chicago. He has staunchly defended the principles we stand for and consistently delivered our message to the ADA Board of Trustees. Dr. Patricia Blanton, past TDA president, serves as 2nd Vice President of the ADA. She has been well received in Chicago and also presents our point of view consistently. ADA 2009 president and TDA past president Dr. John Findley led the ADA through some of its hardest times in that year. Dr. Hilton Israelson, past TDA president, will be taking office as the ADA 15th District Trustee upon Dr. Long’s retirement. There are many other Texans who have served on councils and committees and in offices at the ADA level. They all deserve our appreciation and thanks. I am honored to follow a long line of officers who have willingly given their time and effort to the TDA and its causes. I would like to mention Dr. Rick Black, past TDA president, and present CLRA chair. Dr. Black and his council along with Dr. David Sibley and our lobby team practice the “dark arts” in the political arena. Dr. Black is nearing the end of his third legislative session and I know he can’t wait for the closing gavel. Dr. David May,

past TDA president and former chair of FSI, and my mentor Dr. Dick Smith, past TDA president and past secretary-treasurer, and many others deserve our thanks. I cannot fail to mention and express my gratitude to Dr. Ron Rhea and Dr. Matt Roberts who have helped me prepare for the challenges that lie ahead. And there are many, many others, one of those dentist I have to mention at this time. From my earliest exposures to organized dentistry I was in awe of a man who was so generous to and caring of our profession. He never stopped giving well past his retirement. Dr. Robert V. Walker who passed away last week was that person. I am so honored to have known this wonderful man for more than 40 years. What is the noblest profession of all? In my estimation and according to something I read, the noblest profession in life is one that allows you to use all of your talents, most of the time, for many of the nicest people, to achieve meaningful results. The worst profession in life is one in which you can work for a lifetime and earn nothing but money. And so the heritage of our Association continues the persistent challenge to be the “VOICE OF DENTISTRY IN TEXAS,” to advocate for our members and our patients in the political arena, to BE the “keeper of our profession,” and to provide “Health Care That Works.” Thank you again for this honor!


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DENTAL CONFERENCE

On behalf of the El Paso District Dental Society, it is a pleasure to welcome the members of the Texas Dental Association to the 49th Annual El Paso Dental Conference, September 22-23, 2011, at the El Paso Convention Center.

Surrounded by the Chihuahuan Desert, El Paso is situated in the westernmost corner of the state. The only major Texas city on Mountain Time, it’s flanked by the Rio Grande River and the Franklin Mountains that extend north into New Mexico. This year we will be kicking off our First Annual 5K run/1-mile walk. The “Tooth Trot” will be held at Sunland Park Racetrack and Casino on September 24, 2011. Proceeds from the race will benefit the Child Crisis Center of El Paso. Come see our lovely city and enjoy our sunny weather! Experience the hospitality of this unique area of Texas while partaking in the world-class CE offered at this year’s conference. For more information about the conference and the race, please visit elpasodentalconference.org or call Ms. Yoli Alva-Corella, (915) 540-1705.

Gerard J. Chiche, DDS

September 22, 2011 (All Day) Title: Recipes for Predictable Anterior Esthetics Date: Thursday, 8:30 AM–11:30 AM, 1:30 PM–4:30 PM Course Code: T01 • CE: 6 Hours In this exciting presentation, globally known speaker and clinician Dr. Chiche will discuss the key areas for efficient esthetic diagnosis and smile design. These are designed to achieve predictable esthetic results with optimum occlusion and laboratory support. This presentation will also offer an outline of all necessary techniques for tooth preparations, bonding sequence, and cementation for all-ceramic crowns and veneers. Topics to be covered include: methodical treatment sequences applicable for both major and minor anterior restorations, step-by-step esthetic analysis for maximum predictability, identifying occlusal red flags, rules of comprehensive smile design with complex cases, communication with the dental laboratory, shading and provisional strategies, soft tissue treatment planning. Intended Audience: dentists, hygienists, dental assistants, lab technicians

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Robin Wright, PhD

September 22, 2011 (All Day) Title: Top 10 Skills for Success in Dental Communication Date: Thursday, 8:30 AM–11:30 AM, 1:30 PM–4:30 PM Course Code: T02 • CE: 6 Hours This seminar builds on the 10 communication skills that dentists and team members need most for communication success. You will leave this seminar ready to achieve patient satisfaction and treatment acceptance more effectively and more often. You will also reap the benefits of knowing how to resolve staff conflicts and be a true team player. Learn to turn challenging conversations into a chance to sell patients on your dental practice, solve patient problems in less time, and work more productively with every member of the practice. This “true to life” seminar is based upon research with dental teams across the U.S. and presents proven communication strategies you can adapt to your personal style. The participant will be able to: project a quality image of the practice; build patient trust and rapport; present practice messages with confidence and power; bring patients step-by step to treatment acceptance; resolve conflicts with staff members and patients. *Special Feature: Videotaped clips from actual case presentations made by dentists around the country. Intended Audience: dentists, hygienists, dental assistants, office staff

Mary Govoni, CDA, RDA, RDH, MBA September 22, 2011 (All Day)

Title: Maximizing Ergonomics and Chair Side Efficiency Thursday, 8:30 AM–11:30 AM, 1:30 PM–4:30 PM Date: Course Code: T03 • CE: 6 Hours Dental teams face many challenges in daily practice, including those posed by the physical stressors associated with patient care. Awkward posture, repetitive tasks and cumbersome equipment can all contribute to inefficiency, fatigue, stress and musculoskeletal injuries. In turn, these factors can negatively affect the productivity and profitability of a practice. This seminar examines these physical and economic challenges and provides practice solutions for creating a comfortable, efficient and productive work environment. You will learn to: recognize optimal or neutral posture in the dental work environment and factors that contribute to incorrect posture; evaluate the work environment for factors that contribute to incorrect posture; identify musculoskeletal disorders common to dentistry and methods of preventing occurrence; assess existing equipment and evaluate new equipment for adherence to principles of ergonomics; implement process improvements to increase efficiency and productivity in the practice. Intended Audience: dentists, hygienists, dental assistants, office staff, lab technicians

Daniel L. Martinez, DDS September 22, 2011 (All Day)

Title: Digital Dentistry — Do you need it? Date: Thursday, 8:30 AM–11:30 AM, 1:30 PM–4:30 PM Course Code: T04 • CE: 6 Hours In an exciting full-day program, Dr. Martinez will get your office and team up to speed on today’s most significant technologies in today’s high-tech dental offices. Well known for his cutting edge dentistry focused philosophy, Dr. Martinez will simplify the ever perplexing advances in today’s dental technologies. Attendees will gain an understanding of new technologies that are becoming mainstream, comprehend an optimal balance of old and new technologies, and gain an understanding what technologies may fit their practice best. Intended Audience: dentists, hygienists, dental assistants, office staff Educational funding provided by Patterson Dental

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DENTAL CONFERENCE Cynthia Fong, RDH, MS September 23, 2011 (All Day)

Title: Clinical Application of Ultrasonic Debridement Date: Friday, 8:30 AM–11:30 AM, 1:30 PM–4:30 PM Course Code: F01 • CE: 6 Hours This presentation will discuss the fundamentals of ultrasonic debridement to formulate a nonsurgical periodontal treatment strategy. A variety of clinical cases will be used to select the appropriate equipment and technology; to consider the impact of the patient’s medical/dental histories; to define treatment sequencing; and to comprehend the correct ultrasonic instrumentation techniques. Participants will be able to immediately apply the knowledge gained in this course in clinical practice. The participant will be able to: develop an ultrasonic treatment plan based on the needs of a patient; match the needs of the patient with the proper ultrasonic equipment; understand the indications and contraindications of ultrasonics; describe the protocol for preparing the patient, clinician and equipment; recognize the appropriate instrumentation criteria for gross ultrasonic debridement, definite debridement and de-plaquing. Intended Audience: dentists, hygienists, dental assistants

Robin Wright, PhD

September 23, 2011 (All Day) Title: Optimize Your Practice Through Powerful Communication Date: Friday, 8:30 AM–11:30 AM, 1:30 PM–4:30 PM Course Code: F02 • CE: 6 Hours Through effective communication, your team has the power to build productivity, profitability and patient literacy in your practice. This seminar offers the latest in communication research on improving the oral health literacy of your patients. It gives practical suggestions on managing diversity within the team and the practice. Learn how to build better relationships between team members, enhance team involvement in the practice and resolve team conflicts through constructive criticism. Finally, learn the essential qualities and skills of leadership, how each staff person can become a leader in the practice and build upon the communication power of every member of the dental team. The participants will be able to: improve the oral health literacy of their patients; develop stronger leadership skills for every member of the team; improve team performance and work relationships; resolve and even prevent conflicts through constructive communication; manage diversity in the team and the practice.

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Intended Audience: dentists, hygienists, dental assistants, office personnel

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Peter L. Jacobsen, PhD, DDS September 23, 2011 (All Day)

Title: Date: Course Code:

The Art of Dental Therapeutics — Modern Dental Pharmacology Friday, 8:30 AM–11:30 AM, 1:30 PM–4:30 PM F03 • CE: 6 Hours

What is the best of the new antifungals for yeast infections? Can antiviral drugs be used prophylactically for herpes infections? What is the current recommended regime for sinus infections? Is penicillin still the best drug for oral infections? A dentist makes an average of 5-10 drug prescribing decisions a week. This course will be a concise, informative, and entertaining update on the drugs of choice and related techniques for the treatment of infections, and the control of pain and anxiety necessary in modern dentistry. The course focuses on clinically relevant information that is immediately useable in the dental practice. Intended Audience: dentists, hygienists, dental assistants

Stephen Wagner, DDS, FACP September 23, 2011 (All Day)

Title: Date: Course Code:

Predictable Prostheses — Creating Implant-Based Removable Complete Dentures Friday, 8:30 AM–11:30 AM, 1:30 PM–4:30 PM F04 • CE: 6 Hours

Dr. Wagner will demonstrate the techniques required to make denture fabrication a predictable and profitable service in any general dental practice. Implants have changed the nature of fabricating removable complete dentures, making the experience much more satisfying for both the patient and dentist. Above all, the lecture stresses a practical and common sense approach to caring for the edentulous patient. Following completion of the program, the participant should have the knowledge to: understand the skills and techniques required to diagnose and treatment plan the edentulous patient; understand the treatment choices available for restoring the edentulous patient; prescribe and use implants to support removable complete dentures; organize and implement a simplified but highquality denture service in a contemporary general dental practice. Intended Audience: dentists, hygienists, dental assistants, lab technicians Educational funding co-sponsored by Astra Tech Inc.

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


CLINICAL RESEARCH

Abstract

Latex and Non-Latex Orthodontic Elastic Force Loss Due to Cyclic Temperatures Sebastian Z. Paige, D.D.S.; Jeryl D. English, D.D.S., M.S. Gary N. Frey, D.D.S.; Harry I. Bussa, D.D.S., M.S. Kathleen R. McGrory, D.D.S., M.S.; Randy K. Ellis, D.D.S., M.S. Joe C. Ontiveros, D.D.S., M.S.

Introduction Elastics are commonly used in orthodontics to apply force at various vectors. The most common elastics are made of latex, but non-latex alternatives have also been developed. In dental offices in particular, latex allergies are predicted to be one of the most common allergies (1). In addition to

Paige

English

Frey

Bussa

McGrory

Ellis

Ontiveros

Dr. Paige is a second year orthodontic resident, The University of Texas School of Dentistry at Houston, Houston, Texas. E-mail: sebastian.z.paige@uth.tmc.edu. Dr. English is chair and program director of orthodontics, The University of Texas School of Dentistry at Houston, Houston, Texas. E-mail: jeryl.d.english@uth.tmc.edu. Dr. Frey is an associate professor of restorative dentistry and biomaterials, The University of Texas School of Dentistry at Houston, Houston, Texas. E-mail: gary.n.frey@uth.tmc.edu. Dr. Bussa is a clinical associate professor of orthodontics, The University of Texas School of Dentistry at Houston, Houston, Texas. E-mail: harry.i.bussa@uth.tmc.edu. Dr. McGrory is a clinical assistant professor of orthodontics, The University of Texas School of Dentistry at Houston, Houston, Texas. E-mail: kathleen.r.mcGrory@uth.tmc.edu. Dr. Ellis is an assistant professor of orthodontics, The University of Texas School of Dentistry at Houston, Houston, Texas. E-mail: randy.ellis@uth.tmc.edu. Dr. Ontiveros is an associate professor of restorative dentistry The University of Texas School of Dentistry at Houston, Houston, Texas. E-mail: joe.c.ontiveros@uth.tmc.edu. Send correspondence to Dr. Jeryl D. English: 6516 M.D. Anderson Blvd., Ste. 473 Houston, TX 77030-3402; phone (713) 500-4470; FAX (713) 500-4372. Reprints will not be available. The authors have no declared 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.

The purpose of this study was to compare the force loss of ¼ inch (6.35mm) 3.5oz (99g) medium latex elastics from Ormco Corp. to non-latex elastics from ClassOne Orthodontics and Phoenix after being cycled between different temperatures. Elastics were stretched to 1.57 inches (40mm) on jigs and cycled in water baths for 4 minutes at 5˙C and 37˙C, 21˙C and 37˙C, 5˙C and 50˙C, 37˙C and 50˙C, and a control group was held at 37˙C. The force produced by new elastics and elastics after incubation was measured using a Mini 44 Instron. Results: All elastics experienced increased force loss that correlated with increased temperatures with the exception of Ormco latex elastics. The latex elastics had the greatest force loss upon cycling between 5˙C and 50˙C while the non-latex elastics had the greatest force loss while cycling between 37˙C and 50˙C. All elastics were strongest when cycled between 5˙C and 37˙C. Conclusion: This study suggests that hot liquids reduce the force of latex and non-latex elastics even when cycled between hot temperatures for brief periods of time.

Key words: force,

latex, elastics, orthodontic, temperature Tex Dent J 2011;128(6):541545.

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Elastics being hypoallergenic, ideal orthodontic elastics would also maintain a constant force for the duration they are used in the oral environment. The majority of research on latex and non-latex elastics have been focused on the force produced after static or cyclic stretching (2-8). Russel et al. demonstrated that medium latex and nonlatex elastics maintained 80-85 percent of their force after 1 hour of static extension (2). Further, Kersey et al. discovered that four brands of non-latex elastics undergoing 1 hour of cyclic extension and relaxation under water maintained 75 percent of their original force (4). Other studies found that after 48 hours of in vivo use, latex elastics maintained 61 percent of their force. In comparison to the above studies, less has been done concerning the effect of temperature on elastics. Genova et al. demonstrated that power chains undergo greater force loss when cycled between 15°C and 45°C water when compared to being held at 37°C (10). Stevenson and Kusy demonstrated that nonlatex power chains incubated for 10 days at 44°C maintained less of their force than those incubated at 34°C (11). These studies focused on power chains instead of interarch elastics. Beattie and Monaghan took on the difficult task of testing the effect of a simulated diet on elastics, but the study had too many variables to draw a clear conclusion about the effect of temperature alone (12).

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Although the current body of literature explains a great deal about orthodontic elastic force loss, there is still much to be discovered. This study tested the effect of cycling latex and nonlatex interarch elastics between water baths at various temperatures to understand how elastics respond to intermittent temperatures.

MATERIALS AND METHODS All elastics used were ¼ inch (6.35mm) diameter, 3.5 ounce (99g) orthodontic elastics (Z-Pack Fox latex elastics from Ormco Corp, Glendora, CA; non-latex elastics from ClassOne Orthodontics, Lubbock, Texas, and Phoenix, Blue Springs, Missouri). All elastics were tested soon after being received from the companies and long before their expiration dates. Elastics were chosen randomly from five bags of the same lot from each company for all experiments. Twenty new elastics from each company were used for the initial force measurement and for each of the experiments for a total of 300 elastics for this study. Each elastic was stretched to 1.57 inches (40mm) when dry to measure their force using a universal testing machine (Mini 44 Instron, Instron, Canton, MA). A measure of 40mm was chosen as an approximation of the distance between a maxillary lateral incisor and a mandibular 2nd molar when the mouth is closed. For each experiment the elastics were stretched to 40mm on jigs and then submerged in distilled water and either cycled between water baths of 5˙C and 37˙C, 21˙C and 37˙C, 5˙C and 50˙C, 37˙C and 50˙C, or held at 37˙C for 4 minutes. Each experiment lasted 4 minutes and consisted of 20 cycles of 3 seconds in each water bath. The two water baths were part of an apparatus that had temperature sensors, cooling and heating coils, and a mechanical arm that automatically transferred a basket containing the samples between the water baths that were held at the desired temperatures. The entire


process for all experiments was continually monitored to ensure that the water baths were at the appropriate temperature and that the transfer apparatus functioned properly. The bands were removed from their baths and their force measured once the experiment was complete. The force data were analyzed using a two sample T-test assuming equal variance (Excel, Microsoft Corp., Redmond, Washington). Standard error bars were also calculated and displayed on Figure 1.

RESULTS Both latex and non-latex elastics displayed a correlation between greater force loss and higher temperature water baths (Figure 1). Ormco latex elastics, however, experienced the greatest force loss during the 5˙C and 50˙C cycle, which was statistically significant (P<0.05) when compared to the 37˙C control. There were also statistically significant (P<0.05) differences between brands when one of the water baths was 50˙C. The difference within brands was statistically significant (P<0.05) when comparing to the 37˙C control, except for the 21˙C and 37˙C cycle for Ormco latex and Phoenix non-latex elastics and the 5˙C and 37˙C cycle for Ormco latex elastics.

% Force

Figure 1. Percent of Original Force After Cycles

Ormco (latex)

ClassOne

Phoenix

Figure 1. The force produced by elastic bands after cyclic incubation at various temperatures expressed as a percentage of the force produced when measured without any incubation. Graphs include standard error bars.

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Elastics DISCUSSION As mentioned previously, the effect of cyclic temperatures on orthodontic elastic force loss has received little attention in research journals. Tran et al. found that interarch non-latex elastics lose force more rapidly than latex elastics when they are incubated at 37˙C in simulated saliva (13). This experiment suggested latex and non-latex elastics respond differently in a simulated oral environment. Paige et al. found that interarch non-latex elastics experience greater force loss than latex elastics at elevated temperatures (14). That study suggested that temperature may play a key role in the amount of force elastics are able to produce. The temperatures and cycle times used in this study may loosely correlate to the temperatures of beverages people regularly consume and the time they are in the mouth. A temperature of 50˙C was chosen since it was a temperature that is warm but will not burn the mouth and had been used in a previous study (14). The 5˙C temperature was chosen because it was the coldest temperature our instruments could reliably maintain throughout the course of the experiment. Overall, we found that as the temperatures of the water baths increased so did the loss of force of the elastics. The difference in force between brands of elastics and elastics within a brand

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when compared to the control became more pronounced at elevated temperatures. The only exception was the 5˙C and 50˙C cycle for Ormco latex elastics which had the greatest force loss for that brand (Figure 1). This result was unexpected but may reveal that latex elastics are sensitive to cycling between hot and cold temperatures. Our data supports previous papers that suggest that non-latex elastics are more sensitive to higher temperatures than latex elastics (14). This difference is likely due to fundamental differences in the two materials. For example, latex is a natural product consisting of cross-linking and covalent bonds between chains while non-latex elastics are synthetic polymers that rely on weaker hydrogen bonds and van der Waals forces to hold chains together. These weaker bonds can be disrupted by water (15). Studies of the degradation products of elastics in water suggest that the initial force degradation is caused by weaker intermolecular forces and then later by chemical degradation (15). This study supports previous literature that elevated temperatures result in accelerated force loss for non-latex elastics when compared to latex elastics. Further, this study demonstrates that even relatively short periods of intermittent elevated temperatures a result in a statistically significant loss of force. These results add to the growing body of evidence that even though patients are instructed to change their

elastics regularly, hot liquids may have a deleterious effect on the force produced by their elastics. In particular those patients who consume hot liquids soon after placing their elastics may experience reduced force from their elastics for the duration they are worn. Although further research is needed, it may be prudent for patients, especially those wearing nonlatex elastics, to change their elastics after consuming hot liquids. Further research is needed to determine the clinical significance of this study.

CONCLUSION •

This study suggests that non-latex elastics undergo greater force loss than latex elastics at intermittent elevated temperatures. Latex elastics lose the most force when cycled between hot and cold temperatures.

References 1. Gawkrodger DJ. Investigation of reactions to dental materials. Br J Derm 2005; 153:479-485. 2. Russel KA, Milne AD, Khanna RA, et al. In vitro assessment of the mechanical properties of latex and nonlatex orthodontic elastics. Am J Orthod Dentofacial Orthop 2001; 120:36-44. 3. Kanchana P and Godfrey K. Calibration of force extension and force degradation characteristics of orthodontic latex elastics. Am J Orthod Dentofacial Orthop 2000;118:280-287.


4. Kersey ML, Glover K, Heo G, et al. An in vitro comparison of 4 brands of nonlatex orthodontic elastics. Am J Orthod Dentofacial Orthop 2003;123:401-407. 5. Gioka C, Zinelis S, Eliades T et al. Orthodontic latex elastics: A force relaxation study. Angle Orthod 2006;76:475-479. 6. Hwang C and Cha J. Mechanical and biological comparison of latex and silicone rubber bands. Am J Orthod Dentofacial Orthop 2003;124:379-386. 7. Taloumis LJ, Smith TM, Hondrum SO, et al. Force decay and deformation of orthodontic elastomeric ligatures. Am J Orthod Dentofac Orthop 1997;111:1-11. 8. Wong AK. Orthodontic elastic materials. Angle Orthodontist. 1976;46:196-205. 9. Wang T, Zhou G, Tan X, et al. Evaluation of Force Degradation Characteristics of Orthodontic Latex Elastics In Vitro and In Vivo. Angle Orthod 2007;77:688-693. 10. Genova DC, McInnes-Ledoux P, Weinberg R, et al. Force degradation of orthodontic elastomeric chains-A product comparison study. Am. J. Orthod. 985;87:377-384. 11. Stevenson JS and Kusy RP. Force application and decay characteristics of untreated and treated polyurethane elastomeric chains. Angle Orthod 1994;64:455-467. 12. Beattie, S and Monaghan P. An in vitro study simulating effects of daily diet and patient elastic band change compliance on orthodontic latex elastics. Angle Orthod 2004;74:234-230. 13. Tran AM, English JD, Paige SZ, Powers JM, Bussa HI, and Lee RP. Force relaxation between latex and non-latex orthodontic elastics in simulated saliva solution, Texas Dental Journal 2009;126:981-985. 14. Paige SZ, Tran AM, English JD, and Powers JM. The Effect of Temperature on Latex and Non-latex Orthodontic Elastics. Texas Dental Journal 2008; 125:244-249. 15. Huget EF, Patrick KS, and Nunez LJ. Observations on the elastic behavior of a synthetic orthodontic elastomer. J Dent Res 1990;69:496-501. Acknowledgments The authors would like to thank The Orthodontic Foundation for their support. The authors would also like to thank ClassOne Orthodontics, Lubbock, Texas, and Phoenix, Blue Springs, Missouri, for their donation of elastics for this study. Texas Dental Journal l www.tda.org l June 2011

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Orthodontic Technologies disk enclosed

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Adhesive Dentistry and Endodontics Contamination of the Root Canal System One of the primary goals of root canal treatment is to eliminate bacteria from the root canal system to the greatest possible extent (2, 3). Bacteria have been shown to be the etiology for apical periodontitis and to be the cause of endodontic failure (2–5). One of the goals in restoring of the tooth after root canal treatment should be to prevent recontamination of the root canal system. Gross contamination can occur during the restorative process from poor isolation or poor aseptic technique. Contamination can also occur from loss of a temporary restoration or if leakage occurs. The same things can occur with a “permanent” restoration, but “permanent” materials tend to leak less than temporary materials (6). Exposure of gutta-percha to saliva in the pulp chamber results in migration of bacteria to the apex in a matter of days (2, 7–9). Endotoxin reaches the apex even faster (10). The importance of the coronal restoration in successful endodontic outcomes is widely accepted and has been supported by studies by Ray and Trope, Hommez et al., Tronstad et al., Iqbal et al., and Siqueira et al (11–14). However, studies by Riccuci et al., Ricucci and Bergenholz, Heling et al., and Malone et al. indicate that contamination may not be as important a factor in failure as is commonly believed (2, 15–18). Therefore, it must be concluded that the significance of bacterial contamination as a cause of endodontic failure is not fully understood. Because there is clearly no benefit to introducing bacterial contamination into the root canal system, and since it may be a contributing factor in endodontic failure, a basic premise of this review will be that every effort should be made to prevent contamination.

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Temporization To minimize the likelihood of contamination, immediate restoration is recommended upon completion of root canal treatment (19–21). When immediate restoration is not possible, and the tooth must be temporized, a thick layer of temporary material should be used, preferably filling the whole chamber. The majority of restorative dentists prefer a cotton pellet in the chamber, however (22). If a cotton pellet or sponge is to be used, orifice barriers are recommended to provide a second layer of protection against contamination in addition to the temporary material at the occlusal surface. Recommended procedure for placing orifice barriers: 1. Countersink the orifice with a round bur. 2. Clean the orifices and floor of the pulp chamber thoroughly with alcohol or a detergent to remove excess cement and debris. Air abrasion provides a dentin surface that is free of films and debris. 3. Place a temporary or “permanent” restorative material in the orifices and over the floor of the chamber. A bonded material such as composite resin or glass ionomer cement is preferred (23–27). Temporary materials may also be used (28). Mineral trioxide aggregate (MTA) may also be used (29). There is probably some benefit to using a material that is clear so that the restorative dentist can see the underlying obturating material if re-entry is needed into the canal system (1) (Figure 1). Results varied in studies that evaluated temporary materials for the access cavities (21, 30–36). The most common materials tested were zinc oxide eugenol (such as IRM, Dentsply Int.), zinc oxide/calcium sulfate (Cavit, Premier Corp.) or resin based materials including composite resin and resin modified glass ionomer materi-


Figure 1. (A). The pulp chamber has been thoroughly cleaned. (B). There was 37 percent phosphoric acid applied to the orifices and floor of the chamber for 15 s. (C). The floor and orifices are sealed with unfilled resin. (Courtesy of Dr. Fred Barnett, Philadelphia.)

als. Generally, all of the temporary materials were adequate if placed in a thickness of 3 mm or greater (21, 33â&#x20AC;&#x201C;36). All temporary materials leak to some extent (20, 21, 37â&#x20AC;&#x201C; 40). The zinc oxide/calcium sulfate materials are more resistant to microleakage than the zinc oxide eugenol materials, probably because of setting expansion and water sorption (21, 33, 34). Although the zinc oxide eugenol materials tend to leak

more, they possess antimicrobial properties, making them more resistant to bacterial penetration (21, 34, 41). Both materials are simple to use. One study reported less leakage with the use of two materials in combination (42). Resin based temporary materials must be bonded to provide an effective seal, because they undergo polymerization shrinkage of 1 to 3 percent (30, 43). This is offset somewhat by the

fact that they swell as they absorb water (30). Generally, bonded resin materials provide the best initial seal, but lack antimicrobial properties (30). They require more steps and more time to place than materials such as IRM or Cavit. Bonded resins are recommended for temporization that is likely to last more than 2 to 3 weeks (42, 44). Resin modified glass ionomer materials are also a good choice for long term temporization because they

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Adhesive Dentistry and Endodontics provide a bond to dentin and enamel, and many have antimicrobial properties (44). Teeth requiring temporary post/ crowns are a particular challenge because of the difficulty in obtaining a good seal (45, 46). To minimize the chances of contamination of the obturating material, a barrier may be placed over it with a self-curing material. The post space should be restored as soon as possible and it may be beneficial to flush the post space with an antimicrobial irrigant when the temporary post is removed.

Figure 2. Caries detector was applied to the inside of an access cavity. Note how the caries detector accentuates the caries under the composite buildup. (Courtesy of Dr. Gary Carr, San Diego.)

Restoring Access Openings When an access opening is made through an existing restoration, several things should be considered. Removal of all existing restorations is desirable if possible because it allows more complete assessment for the presence of cracks and caries (47). This is particularly recommended for old class 1 and class 2 restorations because they are likely to be removed later anyway in the process of preparing the tooth for a crown. Magnification and caries detector are helpful in identifying cracks and for complete removal of caries (48). If the existing restoration is a crown or onlay that appears to be clinically satisfactory and replacement is not planned, the chamber and internal restorative materials should be examined carefully with magnification. Caries detector should be painted on the internal tooth surfaces. Any areas stained by the caries detector, particularly adjacent to restorations, should be examined carefully for softness or gaps (Figure 2). Caries detector may also stain sound areas of dentin that have decreased mineral content (49). The key to the presence of caries is determined by whether the stained areas are hard or soft. Many times caries can be identified internally, necessitating replacement of the crown. Access openings made through an existing restoration results in loss of retention and strength (50â&#x20AC;&#x201C;53). When the access opening is restored, loss of retention is reversed (51, 52). If a post is added, additional retention is gained (51).

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Ideally, we would like to restore access cavities with a restorative material that provides a permanent, leak proof seal. Unfortunately, no such material is available. All materials that we use and restorations that we place leak to some extent. This includes intracoronal restorations including bonded resin and glass ionomer materials as well as the metal or ceramic extra-coronal restorations (38, 54–56). To minimize leakage, bonded restorations are recommended, regardless of the restorative material (6, 57). Access openings are made through a number of different restorative materials, including gold alloys, base metal alloys, and porcelain, as well as enamel and dentin. Bonding to each of these substrates present specific challenges which require specific strategies and materials. Often the access opening is prepared through two or three different substrates. The structural integrity of the tooth may also influence the choice of restorative materials. Each substrate will be addressed separately.

Bonding to Enamel Enamel is often present along the margins of access preparations of anterior teeth. The resin bond to etched enamel is strong and durable. The technique dates back to 1955 (58). Etching of enamel with an acid such as 30 to 40 percent phosphoric acid results in selective dissolution of the enamel prisms and creates a surface with a high surface energy that allows effective wetting by a low viscosity resin. Microporosities are created within and around the enamel prisms that can be infiltrated with resin and polymerized in-situ (59). These “resin tags” provide micromechanical retention. Bond strengths are typically in the range of 20 megapascals (Mpa) (60). Megapascals are a measure of the force per unit area that is required to break the bond. Self-etching adhesive systems, which will be discussed in the section on bonding to dentin, etch ground enamel fairly well, but do not etch unground, aprismatic enamel effectively (61– 63). Therefore, enamel margins should be beveled when using self-etching adhesive systems. It is critical to prevent contamination of etched enamel with blood, saliva or moisture (64). Poorly etched enamel leads to staining at the margins of the restoration (65). A good enamel bond protects the underlying dentin bond which is less durable (66).

Bonding to MetalCeramic and All-Ceramic Restorations Access cavities are often made through metalceramic or all-ceramic materials, so attaining an effective, durable bond is important when restoring them. The literature is unambiguous that the best method to bond to porcelain is to first roughen the surface by acid etching and then apply a silane coupling agent, followed by the resin (67–70). Bond strengths of 13 to 17 Mpa have been reported, and failure is often cohesive within the porcelain, meaning that the interfacial bond strength exceeds the strength of the porcelain itself (71–73). Bonding to porcelain was initially developed as a method for repair of fractured metalceramic crowns. Improvements in the technique allowed porcelain veneers to become a common clinical procedure. Etched ceramic materials form a strong, durable bond with resin (74). Micro mechanical bonding can be attained by roughening the porcelain with a bur, air-abrasion or etching with hydrofluoric acid. However, acid etching is the most effective method (73, 75, 76). The first to introduce acid etching of porcelain was Calamia in 1983 (77). Adhesion between the resin and porcelain may be enhanced by the use of a silane-coupling agent. Silane acts as a surfactant to lower surface tension and forms double bonds with OH groups in the porcelain, forming a siloxane bond. At the other end of the silane molecule is a methacrylate group that copolymerizes with resin. The use of a silanecoupling agent with porcelain was first described by Rochette in 1975 (78).

Hydrofluoric Acid

Hydrofluoric acid provides greater surface roughness to porcelain than air abrasion or roughening with a bur (75). It works by dissolving the glass particles (leucite) within the porcelain (Figure 3). Most of the porcelains used in metal-ceramic restorations are feldspathic porcelains that contain leucite. Some ceramic materials, such as low fusing porcelains, do not contain leucite and are not etched effectively by hydrofluoric acid (79). However, hydrofluoric acid is effective with most of Texas Dental Journal l www.tda.org l June 2011

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Adhesive Dentistry and Endodontics the current ceramic restorative materials (80–83). Hydrofluoric acid is usually provided in a 10 percent concentration in a syringe. It is very important to follow the manufacturer’s instructions, as an application time that is too short will produce an inadequate etch, while an application time that is too long may render the porcelain brittle and thus more prone to fracture (84).

Silane

Silane acts as a “coupling agent” enhancing the bond between the resin and ceramic materials. It is supplied premixed or as a two bottle system that is mixed at the time of use. It is applied to the etched surface and must be thoroughly air dried (85). A low viscosity resin adhesive is then flowed over the surface and polymerized. Once again, it is very important to follow the manufacturer’s instructions. Silane has a limited shelf life. Storage in the refrigerator will extend its useful life, but it should be used at room temperature (86). The two bottle silanes have the longest shelf life (71). Silane that is past the expiration date or that contains precipitates should be discarded (86).

Air Abrasion

Air abrasion is sometimes recommended to clean the porcelain and provide surface roughness. Several companies sell “micro-etchers” that can be used

Figure 3. SEM of etched porcelain. (Courtesy of Dr. Bart VanMeerbeek, Leuven, Belgium.)

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chairside. Aluminum oxide particles are sprayed onto the surface at about 80 psi. Fifty micron particles have been shown to produce a more retentive surface than 100 m particles (87). Two studies reported that air abrasion has a negligible effect on bond strength, however (76, 88). Etching and application of silane are the two most important steps.

Cosmetics

When restoring the access cavity of a ceramic crown, it is often a challenge to produce a good cosmetic result. Many times it is difficult to mask the underlying metal of a metal-ceramic crown. This is particularly true if the porcelain is thin. It is not uncommon to see the metal showing through the composite. The second challenge is to match the optical properties of the porcelain. This is true for metal-ceramic crowns as well as all-ceramic crowns. Most composites are too low in value (too gray and translucent) to effectively match the surrounding porcelain (Figure 4). Several products are available that may be used to mask the underlying metal before the restorative composite is placed. Most of these are composite resins that contain opaquers. They may be covered with more translucent composite materials. Several composites are available that are quite opaque and work well when restoring access cavities in metalceramic crowns. Composite stains can be used to accentuate pits and fissures to further enhance the cosmetic result (Figure 5).

Several studies have shown tin plating of metal enhances mechanical retention (92â&#x20AC;&#x201C;96). Chromium plating also works well (96). Plating devices are available that can be used intraorally. Although effective, this procedure has never gained popularity. Metal primers are an alternative that enhances the bond between metal and resin. They have been shown to be effective and do not require any special equipment (97â&#x20AC;&#x201C;99).

Bonding to Dentin: Resin Materials Bonding to dentin with resin materials is more complex than bonding to enamel or porcelain. Dentin consists of approximately 50 percent inorganic mineral (hydroxyapatite) by volume, 30 percent organic components (primarily type 1 collagen) and 20 percent fluid (100). The wet environment and relative lack of a mineralized surface made it a challenge to develop materials that bond to dentin. Current strategies for dentin adhesion were first described by Nakabayashi in 1982, but his ideas were not widely accepted for a number of years (101). Nakabayashi showed that resin bonding to dentin could be obtained

Bonding to Metal

The metal portion of metal-ceramic crowns is not usually significant when restoring access openings, so no extra procedures are necessary to deal with it. However, for crowns in which all or part of the occlusal surface is metal, adhesion may be desirable. Adhesion to metal is generally obtained by mechanical means. Surface roughness may be created with a bur or air abrasion, which provides micromechanical retention (89). Chemical adhesion is also possible with metals that form an oxide layer (90). Silane has no effect on bonding to metal (91).

Figure 4. Most restorative composites are too translucent (gray) to provide a good match when restoring access cavities in metal-ceramic crowns. Texas Dental Journal l www.tda.org l June 2011

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Adhesive Dentistry and Endodontics by applying an acid to expose the collagen matrix and dentinal tubules, applying a hydrophilic (“water loving”) resin material to the demineralized surface and polymerizing the resin in situ. The collagen matrix and dentin tubules, to a lesser extent, provide mechanical retention for the resin. Although not as durable and reliable as enamel bonding, steady improvements have been made in dentin bonding and in simplifying dentinbonding procedures.

Figure 5. With knowledge of color, translucency, and occlusal anatomy, beautiful results are achievable when restoring access cavities with composite resins.

Most in vitro studies of dentin bonding report on bond strengths, microleakage, or both. Like enamel, bond strengths are usually reported in Mpa. Depending on the test method used, initial bond strengths can be obtained that are equal or greater to those of etched enamel. However, dentin bonding is not as durable as enamel bonding or as stable. It is well documented that bond strengths decrease with time and function. This has been shown in vitro and in vivo (66, 102–111). Microleakage is probably a more important issue to endodontics than bond strength. None of the current adhesive systems are capable of preventing microleakage over the long term (65, 112–117). There is not a direct relationship between bond strength and microleakage (116). Dentin adhesive systems utilize an acid as the first step of the bonding process to remove or penetrate through the smear layer and demineralize the dentin surface. The smear layer covers the surface of ground dentin and consists of ground up collagen, hydroxyapatite, bacteria, and salivary components (59). Most dentin adhesive systems can be categorized as “etch and rinse” or “self etching,” based on the acid etching process (59).

“Etch and Rinse” Adhesives

Most of the “etch and rinse” adhesive systems utilize a strong acid such as 30 to 40 percent phosphoric acid. When phosphoric acid is applied to dentin, the surface is demineralized to a depth of about 5m. The acid is rinsed off after about 15 seconds, removing the smear layer and exposing the collagen matrix and network of dentinal tubules for resin bonding. A hydrophilic primer is then applied to the surface to infiltrate the collagen matrix and tubules. The primer contains a resinous material in a volatile carrier/solvent, such as alcohol or acetone, which carries the resinous material into the collagen matrix and dentinal tubules. The surface must be wet (moist) for the primer to penetrate effectively. After the primer is in place a stream of air is used to evaporate the carrier and leave the resin behind. A hydrophobic (“water hating”) resin monomer (adhesive) is then applied and polymerized, which adheres to the infiltrated resin from

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Figure 6. SEM of a demineralized specimen showing resin penetration into the hybrid layer and dentinal tubules. (Courtesy of Dr. Bart VanMeerbeek, Leuven, Belgium.)

the primer. A “hybrid layer” or “interdiffusion zone” is formed that consists of resin, collagen and hydroxyapatite crystals (59) (Figure 6). It bonds the hydrophobic restorative materials to the underlying hydrophilic dentin. Poor bond strengths and increased microleakage result from excessive etching (118). The same is true if residual carrier/solvent is left behind, which makes the bond more subject to hydrolytic breakdown (119).

“Self Etching” Adhesives

Most of the “self etching” products combine an acid with the primer. Rather than removing the smear layer, they penetrate through it and incorporate it into the “hybrid layer.” The acidic primer is applied to the dentin surface and dried with a stream of air. There is no rinsing step. A resin adhesive is then applied and polymerized, followed by the restorative material. The “self etching” systems can be categorized as “strong” or “aggressive” (pH 1), “moderate” (pH 1–2) or “mild” (pH 2) (59, 120, 121). The strong “self etching” systems form a hybrid layer of approximately 5m in thickness, similar to phosphoric acid, whereas the mild systems form a hybrid layer of about 1 micron (120, 121). There does not appear to be clinical significance to this difference in thickness, however (121). The

“strong” systems generally produce a superior bond to enamel than the “weak” systems, particularly with unground enamel (59, 61– 63).

and 6th generations are generally two step procedures, while the 7th generation combines everything (acid, primer and adhesive) into one step.

Dentin Adhesive “Generations”

Many of the “self etching” products require fewer steps and less time than the “etch and rinse” products, and are considered to be less “technique sensitive” (59). There are still a number of questions about them, however, such as the unknown effects of incorporating partially dissolved hydroxyapatite crystals and smear layer into the hybrid layer. There is also the question of how much of the carrier/solvent remains behind. Because they are relatively new, there are currently no long-term clinical studies with the “self etching” adhesive systems. The three step adhesive systems generally perform better in in vitro testing than the adhesive systems that combine steps, although the differences lessen with time as the bonds degrade (59, 65,

Many of the “etch and rinse” adhesive systems require three steps (etch, primer, adhesive), and are known as “4th generation” adhesive systems. The “generation” of a dentin adhesive generally follows the order in which they were developed and each “generation” utilizes different bonding procedures. The “5th generation” adhesive systems are “etch and rinse,” followed by application of a combined primer and adhesive. These are sometimes referred to “single bottle” adhesive systems. Some require several applications of the primer/ adhesive, however. The “6th generation” adhesives utilize an acidic (“self etching”) primer followed by an adhesive. The 5th

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Adhesive Dentistry and Endodontics 66, 107, 121, 122). The “self etching” adhesive systems are also less effective than the “etch and rinse” systems when bonding to sclerotic dentin and caries effected dentin (123, 124). They also have compatibility problems with some composite restorative materials, which will be discussed in the section on self-cure and dual-cure composites. The single step (7th generation) adhesives are a fairly recent addition to the market. At this point in their development, they produce consistently lower bond strengths in vitro than the others and are not compatible with self-cure or dual-cure composites (59, 107, 121, 125, 126). Most of the current research is directed toward improving the performance of the simplified adhesive systems, and they will probably continue to improve. Some of the common acronyms used in resin bonding are shown in Table 1. Examples of commercial dentin bonding systems are shown in Table 2.

Wet Bonding

Most adhesive systems utilize “wet bonding.” If the etched dentin surface is dried excessively, the collagen matrix collapses and prevents effective infiltration of the primer. The result is low bond strengths and excessive microleakage (127–129). Excessive moisture has similar negative effects on adhesion (128, 129). An effective method to provide the proper amount of moisture is to dry the surface thoroughly and then rewet it with a moist sponge, so that the surface is damp, but there is no visible pooling (127, 130).

tooth structure (131). They form an ionic bond to the hydroxyapatite at the dentin surface and also obtain mechanical retention from microporosities in the hydroxyapatite (132, 133). Glass ionomer materials form lower initial bond strengths to dentin than resins, on the order of 8 Mpa. But unlike resins, they form a “dynamic” bond. As the interface is stressed, bonds are broken, but new bonds form. This is one of the factors that allow glass ionomer cements to succeed clinically, despite relatively low bond strengths. Other factors are low polymerization shrinkage and a coefficient of thermal expansion that is similar to tooth structure. Some glass ionomer materials also possess antimicrobial properties (134–136). When placing glass ionomer cements, the surface is cleaned and then treated with a weak acid such as polymaleic acid (131). The acid removes debris from the dentin surface, removes the smear layer, and exposes hydroxyapatite crystals. It creates microporosities in the hydroxyapatite for mechanical retention, but there is minimal dissolution (131, 133). Because glass ionomer cements rely on ionic bonding to the hydroxyapatite, strong acids should be avoided because they cause almost total elimination of mineral from the dentin surface (137). Traditional glass ionomer cements are not widely used for clinical procedures because they set slowly and must be protected from moisture and dehydration during the setting reaction, which in many cases is not complete for 24 hours. They are also relatively weak and generally not as esthetic as other restorative materials.

Bonding to Dentin: Traditional Glass Ionomer Bonding to Dentin: Resin Cements Modified Glass Ionomer Glass ionomer cements are made primarily of alumina, silica, and polyalkenoic acid and are self Materials curing materials. Most glass ionomer cements release fluoride for a period of time after initial placement. They are the only restorative materials that depend primarily on a chemical bond to

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Resin modified glass ionomer (RMGI) materials were developed to overcome some of the undesirable properties of the traditional glass ionomer


TABLE 1. Common abbreviations used in dental adhesive literature Bis-GMA Bisphenol glycidyl methacrylate EDTA

Unfilled resin. The original acrylic matrix material in composite resins

Ethylenediaminetetracitic acid Chelating agent sometimes used to remove the smear layer and demineralize the dentin

HEMA Hydroxyethyl methacrylate

Low viscosity hydrophilic acrylic monomer used in dentin adhesive systems

4-Meta

4-Methacryloxyethyl trimellitate anhydride

Low viscosity acrylic monomer used in dentin adhesives. Also used for metal bonding

MMA

Methyl methacrylate

Basic acrylic molecule

NPG-GMA

N-Phenylglycine glycidyl methacrylate

Low viscosity hydrophilic acrylic monomer used in dentin adhesives

PMDM

Pyromellitic acid dimdiethylmethacrylate

Low viscosity hydrophilic acrylic monomer used in dentin adhesives

TEG-DMA

Triethylene glycol dimethacrylate

Low viscosity hydrophilic acrylic monomer used in dentin adhesives

UDMA Urethane dimethacrylate

Unfilled resin. Alternative composite matrix material for composites. Sometimes combined with Bis-GMA

TABLE 2. Selected dental adhesives systems All-Bond 2

Three step, etch and rinse, ”4th generation“

Bisco

OptiBond Total Etch

Three step, etch and rinse, ”4th generation“

Kerr

Scotchbond Multipurpose

Three step, etch and rinse, ”4th generation“

3M

One Step

Two step, ”single bottle,“ etch and rinse, ”5th generation“

Bisco

Prime & Bond

Two step, ”single bottle,“ etch and rinse, ”5th generation“

Dentsply

Clearfil SE OptiBond Solo SE

Two step, self-etching, ”6th generation“

Kuraray

Two step, self-etching, ”6th generation“

Kerr

Prompt L-Pop 2

One step, self-etching, ”7th generation“

3 M/ESPE

I-Bond

One step, self-etching, ”7th generation“

Kulzer

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Adhesive Dentistry and Endodontics cements. RMGI materials contain glass ionomer cement to which a light-cure resin is added. The purpose of the resin is to allow immediate light polymerization after the material is placed. The resin also protects the glass ionomer cement from dehydration, and improves the physical and mechanical characteristics and optical properties. True RMGI materials utilize similar bonding procedures as glass ionomer cements and do not require a dentin-bonding agent.

Endodontic Issues in Dentin Bonding Some of the materials used in endodontics may have a significant impact on the bonding process. These issues apply not only to restoration of access cavities, but also to the obturating materials that utilize adhesive resin technology, which will be discussed in a subsequent article.

Eugenol

In endodontics, eugenol containing materials are widely used in sealers and temporary filling materials. Eugenol is one of many substances that can prevent or stop the polymerization reaction of resins and can interfere with bonding (138, 139). If resin bonding is planned for a dentin surface that is contaminated with eugenol, additional clinical steps are needed to minimize the effects of the eugenol. The surface should be cleaned with alcohol or a detergent to remove visible signs of sealer. Many temporary cements, whether they contain eugenol or not, leave behind an oily layer of debris that must be removed before bonding procedures (140, 141). Air abrasion is an effective method for cleaning the dentin surface (Figure 7). Once it is clean, the dentin should be etched with an acid, such as phosphoric acid and then rinsed. The acid demineralizes the dentin surface to a depth of about 5m and removes the eugenol rich layer. Several studies have shown that the “total etch” (three step) procedure allows effective bonding to eugenol contaminated dentin surfaces (24, 142).

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An “etch and rinse” adhesive system should be used, because the “self etching” systems incorporate the eugenol rich smear layer into the hybrid layer, rather than removing it. Eugenol has no effect on glass ionomer cements (143).

Sodium Hypochlorite

Sodium hypochlorite is commonly used as an endodontic irrigant because of its antimicrobial and tissue dissolving properties (144). Sodium hypochlorite causes alterations in cellular metabolism and phospholipid destruction. It has oxidative actions that cause deactivation of bacterial enzymes and causes lipid and fatty acid degradation (144). Several studies have shown that dentin that has been exposed to sodium hypochlorite exhibits resin bond strengths that are significantly lower than untreated dentin (145–149). One study reported bond strengths as low as 8.5 Mpa (147). Increased microleakage was also reported (150). This phenomenon probably occurs because sodium hypochlorite is an oxidizing agent, which leaves behind an oxygen rich layer on the dentin surface. Oxygen is another substance that inhibits the polymerization of resins (151). Morris et al. showed that application of 10 percent ascorbic acid or 10 percent sodium ascorbate, both of which are reducing agents, reversed the effects of sodium hypochlorite and restored bond strengths to normal levels. Lai et al. and Yiu et al. reported similar results (149, 150). Because sodium hypochlorite is likely to remain the primary irrigant used in endodontics for the near future, and because adhesive resin materials are used routinely in restoring endodontically treated teeth, this issue will have to be addressed. Future adhesive resin products for endodontic applications may contain a reducing agent to reverse the effects of the sodium hypochlorite. A nonoxidizing irrigant would also solve this problem. Sodium hypochlorite and EDTA have also been shown to reduce the tensile strength and microhardness of dentin (152). These are particularly timely issues for endodontics as adhesive resin materials gain popularity as obturating materials.


Other Materials Applied to Dentin

Other materials that are applied to dentin during endodontic procedures have been tested for their effects on bonding. Not surprisingly, hydrogen peroxide leaves behind an oxygen rich surface that inhibits bonding (147, 148). Reduced bond strengths were shown after the use of RC prep (Premier) (146). Electro-chemically activated water has gained a following as an irrigating solution. It probably reduces bond strengths of adhesive resins because it has the same active ingredient as sodium hypochlorite, i.e. hypochlorous acid (153, 154). No loss of bond strength is reported from chlorhexidine irrigation before resin bonding or placement of resin-modified glass ionomer materials (147, 155–157). Caries detector did not affect resin bond strengths, but chloroform and halothane resulted in significant loss of bond strength (158–160).

Restorative Materials Silver Amalgam Alloy

Not surprisingly, silver amalgam alloy is the most common choice for restoring access cavities in metal crowns (161). The clinical technique is simple, with few steps, and provides a durable restoration. “Bonded amalgam” is often recommended in which a resin adhesive is placed on the cavity walls before condensation of the amalgam alloy (57). The adhesive provides an immediate seal. When amalgam alloy is used without an

adhesive, it leaks initially, but “self seals” with time as corrosion products form at the amalgam interface with tooth structure or other restorative materials (162). One strategy to use with amalgam alloy, that offers theoretical advantages, is to seal only the chamber floor and orifices with adhesive resin to provide initial protection of the root canal system from contamination. With time the amalgam restoration will corrode at the other interfacial areas and provide a seal that may be more durable than resin. There is a theoretical advantage to using ad-mixture alloys over pure spherical alloys. Ad-mixture refers to a mixture of spherical and lathe cut particles. Ad-mixture alloys have slight setting expansion, which tends to reduce leakage, whereas spherical alloys shrink slightly while setting (163).

Composite Resin

Not surprisingly, composite resin is the most common choice for restoring access cavities in ceramic restorations (161). Composite can be bonded to tooth structure and most restorative materials, and can provide a good match of color and surface gloss. Bonded composite materials can also strengthen existing coronal or radicular tooth structure, at least in the short term (164, 165). The limitations of composite resin as a restorative material are primarily related to polymerization shrinkage. Restorative resins are reported to exhibit shrinkage in the range of 2 to 6 percent during polymerization (43, 166). Less filler (such

Figure 7. Example of the cleaning effect of sandblasting. Cleaning with alcohol and chloroform left a film on the dentin surface, shown in the first picture. Note how much cleaner the dentin appears in the second picture, after microabrasion (Courtesy of Dr. Fred Tsusui, Los Angeles). Texas Dental Journal l www.tda.org l June 2011

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Adhesive Dentistry and Endodontics as found in “flowable” composites) results in more shrinkage (166, 167). Polymerization shrinkage causes stress on the adhesive bond that often results in gap formation (43). One study reported the percentage of dentinal gaps found in vivo was 14 to 54 percent of the total interface (168). Marginal deterioration of composite restorations expedites the loss of dentin adhesion (169).

Self-cure materials may be bulk filled because they do not require penetration with a curing light. They polymerize more slowly than lightcure materials, allowing the material to flow during polymerization contraction, and placing less stress on the adhesive bond (43, 167). The same is true for dual-cure materials in the areas that are not irradiated by the curing light.

Composite restorative materials come in several forms: light-cure, self- (chemical) cure or dualcure. Light-cure materials consist of a single paste and polymerization is initiated with a curing light. Self-cure materials consist of two pastes that are mixed together to initiate polymerization. Dual-cure materials also consist of two pastes that are mixed together to initiate polymerization, but may also be light activated. Dual-cure materials have the advantage of rapid polymerization in the areas irradiated by the curing light, but chemical polymerization occurs in areas the light can not reach.

The problem with polymerization shrinkage is amplified in access cavities because of a concept known as C-factor or configuration factor (43, 167). C-factor refers to the ratio of bonded surfaces to free or unbonded surfaces. The higher the C-factor, the greater the stress from polymerization shrinkage (43). Restorations with C-factor higher than 3:1 are considered to be at risk for debonding and microleakage (170). In a class 5 restoration, the ratio might be 1:1. In an access cavity, the C-factor might be 6:1 or even 10:1. In a root canal system obturated with a bonded resin material, it might be 100:1 (43).

Light-cure materials polymerize in a matter of seconds and generally have the best physical properties. However, they have several disadvantages. Because of the rapid polymerization, they tend to stress the adhesive bond to tooth structure more than the slower self-cure composites (167). The stress is sometimes so great that the restorative material debonds at the weakest interface (43, 170). For example, in class 5 composite restorations, they tend to debond at the interface with cementum, which forms a weaker bond than enamel (54). Because most curing lights can only effectively polymerize a thickness of 2 to 3 mm of composite material, cavities must be filled incrementally, a time consuming and tedious task. An access cavity may require 3 to 5 increments. Because curing lights lose intensity with distance, the light intensity may be greatly reduced at the floor of the chamber when curing through an access opening in a crown. In addition, it may not be possible to irradiate all areas inside an access cavity because of undercuts or difficulty in obtaining the proper angle with the light.

An incremental filling technique with light-cure composite resins partially overcomes the problem of C-factor. Incremental filling is possible because atmospheric oxygen prevents complete polymerization on the external surface of the resin. This oily surface is referred to as the “oxygen inhibited layer (151).” Because of the unpolymerized surface layer, additional increments may be added and polymerized and a strong chemical bond is formed between increments (151). Incremental filling allows complete polymerization of each increment, and lessens the stress from polymerization shrinkage because the C-factor is more favorable for each increment than if the cavity was bulk filled (171, 172). Another strategy to lessen the effects of C-factor is to use slow setting selfcured materials that flow during polymerization, thus reducing stress (31, 167).

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If contamination occurs with blood or saliva during incremental filling, the bond between increments may be ruined. However, if the surface is rinsed, dried and a dentin adhesive is applied, there is no loss of bond strength (173).


Glass Ionomer Cement and Resin Modified Glass Ionomer Materials Both types of glass ionomer materials may be bulk filled. Most of the RMGI materials are dualcure. Traditional glass ionomer cements are selfcure and have very little polymerization shrinkage. Because resin is added to RMGI materials, they exhibit some polymerization shrinkage, although less than composite resins. Both types of glass ionomer materials are useful for bulk filling access cavities. Even though they bond to tooth structure, the bond strengths are too low to provide significant strengthening effect (174).

Material Incompatibilities

The “self etching” adhesive systems have generally been shown to result in low bond strengths when used with self-cure composites and dualcure composites that have not been light activated (126, 175–178). This is in part because of residual acid on the dentin surface. Self-cure composites contain tertiary amines in the catalyst that initiate the polymerization reaction and have a high pH. Loss of bond strength results because residual acid from the acidic primer inhibits the basic amines, resulting in incomplete polymerization at the interface between the adhesive and the restorative material (175, 176, 179, 180). Dualcure composites exhibit bond strengths comparable to light-cure composites in the areas that are effectively light-cured, because they are not dependent on the basic amines (177). One study reported lower bond strengths with the self-cure composites than light-cure composites with “etch and rinse,” single bottle (5th generation) adhesives as well (181). The second problem with many of the “self etching” adhesive systems is that they act as permeable membranes. This is a problem when they are used with restorative materials that polymerize slowly. A permeable adhesive layer allows penetration of moisture from the dentin to the interface with the restorative material, which is hydrophobic (122, 179). Moisture penetration can result in a phenomenon known in polymer chemistry as “emulsion polymerization,” in which

there is poor adaptation between the adhesive and restorative material (122). Moisture at the interface probably also contributes to the degradation of the bond over time (122).

Clinical Strategies Most strategies for restoring access cavities require several steps and at least two layers of restorative material. Many approaches utilize an adhesive system and two restorative materials. The exception is unbonded amalgam alloy.

Restoring Access Cavities with Tooth Colored Materials

Light-cure composite can be used to fill the entire access cavity if it is filled incrementally. This method will provide the strongest bond to tooth structure and is the preferred method when it is necessary to maximize the tooth strengthening effects of the restoration (181). When executed with skill and knowledge of the materials, excellent esthetic results are possible (Figure 8). However, this is a slow, time consuming method. High initial bond strengths are also obtained with dual-cure composites that are placed incrementally and light polymerized (177). This method may be preferred to incremental fill with purely light-cured materials if there are concerns about light penetration to all areas of the cavity. As discussed earlier, the 4th generation adhesive systems are preferable for endodontic restorative applications with composite materials. They tend to form the best bond to dentin, and have few compatibility problems with restorative resins. They are also effective despite the use of eugenol containing sealers or temporary materials. A method to restore access cavities in teeth with ceramic restorations: Light-cure composite. 1. Clean the internal surfaces with a brush or cotton pellet containing a solvent such as alcohol. 2. Sandblast the cavity, metal and ceramic, or lightly refresh them with a bur. 3. Etch the ceramic with hydrofluoric acid or other appropriate etchant. 4. Rinse and dry. 5. Apply phosphoric acid to the inside of the access cavity if restoring with composite. Etching with phosphoric acid adds no retention Texas Dental Journal l www.tda.org l June 2011

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Figure 8. (A) The access cavity is clean and ready to restore. (B) There was 10 percent hydrofluoric acid applied to the porcelain for 1 minute and then rinsed thoroughly. (C) There was 37 percent phosphoric acid applied to the dentin and porcelain for 15 to 20 seconds. It demineralizes the dentin surface and cleans the porcelain. (D) The porcelain is thoroughly air dried and silane is applied and dried.

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to porcelain, but it cleans the porcelain and enhances the silane adaptation (182). 6. Rinse and dry. 7. Apply silane agent to the porcelain and dry. 8. Apply a dentin primer and adhesive to the internal walls and light cure. 9. Fill the cavity incrementally with no increments greater than 3 mm. 10. Light cure each increment for 40 seconds (time depends on type of light used). 11. The restoration should be slightly overfilled so it can be finished back to the margins. 12. Contour and adjust the occlusion. 13. Finish and polish the restoration. In many cases, it is desirable to bulk fill most of the cavity with a glass ionomer material or selfcure or dual-cure composite, then veneer it with a light-cure composite material that is esthetic and will withstand occlusal function. This method is more efficient than using a purely light-cure composite, but the esthetic result may not be as good. A simple method to restore access cavities in teeth with ceramic restorations: Glass ionomer and composite. 1. Treat the dentin with a polyalkenoic acid for 30 seconds. 2. Bulk fill with a dual-cure glass ionomer material to within 2 to 3 mm of the cavo-surface margin and light cure. 3. Etch the ceramic material with 10 percent hydrofluoric acid, or other suitable etching gel for 1 minute, depending on the product. 4. Rinse and dry. 5. Apply silane to the etched ceramic surface and air dry. 6. Apply the dentin primer and adhesive to the glass ionomer material and etched ceramic and light cure. 7. Place the first increment of light-cure composite. The first increment should include the longest vertical wall and taper to the base of the opposing vertical wall. 8. Light cure for 40 seconds (time depends on type of light used). 9. Fill the remaining space with the second increment and light cure. The restoration should be slightly overfilled so it can be finished back to the margins. 10. Contour and adjust the occlusion. 11. Finish and polish the restoration.

A Simple Procedure for Composite Resin The procedures are similar to those described with glass ionomer material, but a 4th generation dentin adhesive system is used on the dentin and a dual-cure composite is substituted for the glass ionomer material. 1. Treat the dentin and enamel, if present, with 30 to 40 percent phosphoric acid for 15 seconds. 2. Thoroughly rinse and dry the dentin then rewet with a moist sponge. 3. Apply primer and adhesive, following the manufacturerâ&#x20AC;&#x2122;s instructions. 4. Bulk fill with a dual-cure or self-cure composite to within 2 to 3 mm of the cavo-surface margin and light cure. 5. Etch the ceramic material with 10 percent hydrofluoric acid, or other suitable etching gel for 1 minute. 6. Rinse and dry. 7. Apply silane to the etched ceramic surface and air dry. 8. Apply the dentin primer and adhesive to the etched ceramic and light cure for 15 seconds. 9. Place the first increment of light-cure composite. The first increment should include the longest vertical wall and taper to the base of the opposing vertical wall. 10. Light cure for 40 seconds. 11. Fill the remaining space with the second increment and lightcure. 12. Contour and adjust the occlusion. 13. Finish and polish the restoration. Dual-cure composites that are bulk filled develop relatively low bond strengths to dentin, comparable to glass ionomer materials. Resin adhesives lose bond strength with time and function, whereas glass ionomer bond strengths are relatively stable. So there is little if any benefit to the use of dual-cure composites over glass ionomer materials for bulk filling the cavity.

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Figure 8 (continued). (E) A dentin primer is applied to all internal surfaces and air dried, and a dentin adhesive is applied to all internal surfaces and light polymerized. (F) A flowable composite is injected into the orifices and on the chamber floor and polymerized. This method minimizes voids between the restorative material and dentin. Because it is somewhat translucent, it makes location the canals easier if re-entry is necessary at a later time. (G) Incremental build-up, light composite over dark. Increments should be only 2 to 3 mm in thickness to allow adequate polymerization. (H) Application of opaque composite. This is often necessary when restoring metalceramic crowns that tend to be quite opaque.

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Figure 8 (continued). (I) Ocre colored modifiers are placed in the grooves. (J) Cusp inclines and triangular ridges are built up. (K) Brown modifiers are added to the grooves and occlusion is checked. (L) Final result.

Conclusions 1. Prevent contamination of the root canal system. 2. Restore access cavities immediately whenever possible. 3. Use bonded materials. 4. The 4th generation (three step) resin adhesive systems are preferred because they provide a better bond than the adhesives that require fewer steps. 5. The “etch and rinse” adhe-

sives are preferred to “self etching” adhesive systems if a eugenol containing sealer or temporary material was used. 6. “Self etching” adhesives should not be used with self-cure or dual-cure restorative composites. 7. When restoring access cavities, the best esthetics and highest initial strength is obtained with an incremental fill technique with composite resin.

8. A more efficient technique which provides acceptable esthetics is to bulk fill with a glass ionomer material to within 2 to 3 mm of the cavo-surface margin, followed by two increments of light-cure composite. 9. If retention of a crown or bridge abutment is a concern after root canal treatment, post placement increases retention to greater than the original. Texas Dental Journal l www.tda.org l June 2011

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acid-etched dentin. Oper Dent 2003;28:3– 8. Van Meerbeek B, Yoshida Y, Lambrechts P, et al. A TEM study of two water-based adhesive systems bonded to dry and wet dentin. J Dent Res 1998;77:50 –9. Ritter AV, Heymann HO, Swift EJ Jr, Perdigao J, Rosa BT. Effects of different rewetting techniques on dentin shear bond strengths. J Esthet Dent 2000;12:85–96. Inoue S, Van Meerbeek B, Abe Y, et al. Effect of remaining dentin thickness and the use of conditioner on micro-tensile bond strength of a glass-ionomer adhesive. Dent Mater 2001;17:445–55. Yoshida Y, Van Meerbeek B, Nakayama Y, et al. Evidence of chemical bonding at biomaterialhard tissue interfaces. J Dent Res 2000;79:709 –14. Yip HK, Tay FR, Ngo HC, Smales RJ, Pashley DH. Bonding of contemporary glass ionomer cements to dentin. Dent Mater 2001;17:456 –70. Perez CR, Hirata R Jr, Sergio PP. Evaluation of antimicrobial activity of fluoridereleasing dental materials using a new in vitro method. Quintessence Int 2003;34: 473–7. Boeckh C, Schumacher E, Podbielski A, Haller B. Antibacterial activity of restorative dental biomaterials in vitro. Caries Res 2002;36:101–7. Coogan MM, Creaven PJ. Antibacterial properties of eight dental cements. Int Endod J 1993;26:355– 61. Van Meerbeek B, Conn LJ Jr, Duke ES, Eick JD, Robinson SJ, Guerrero D. Correlative transmission electron microscopy examination of nondemineralized and demineralized resin-dentin interfaces formed by two dentin adhesive systems. J Dent Res 1996;75:879–88. Macchi RL, Capurro MA, Herrera CL, Cebada FR, Kohen S. Influence of endodontic materials on the bonding of composite resin to dentin. Endod Dent Traumatol 1992;8:26 –9. Ngoh EC, Pashley DH, Loushine RJ, Weller RN, Kimbrough WF. Effects of eugenol on resin bond strengths to root canal dentin. J Endod 2001;27:411– 4. Woody TL, Davis RD. The effect of eugenol-containing and eugenolfree temporary cements on microleakage in resin bonded restorations. Oper Dent 1992;17:175–80. Watanabe EK, Yamashita A, Imai M, Yatani H, Suzuki K. Temporary cement remnants as an adhesion

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inhibiting factor in the interface between resin cements and bovine dentin. Int J Prosthodont 1997;10:440 –52. Peutzfeldt A, Asmussen E. Influence of eugenol-containing temporary cement on efficacy of dentin-bonding systems. Eur J Oral Sci 1999;107:65–9. Capurro MA, Herrera CL, Macchi RL. Influence of endodontic materials on the bonding of glass ionomer cement to dentin. Endod Dent Traumatol 1993;9:75– 6. Estrela C, Estrela CRA, Barbin EL, Spano JCE, Marchesan MA, Pecora JD. Mechanism of action of sodium hypochlorite. Braz Dent J 2002;13:113–7. Morris MD, Lee KW, Agee KA, Bouillaguet S, Pashley DH. Effects of sodium hypochlorite and RCprep on bond strengths of resin cement to endodontic surfaces. J Endod 2001;27:753–7. Ari H, Yasar E, Belli S. Effects of NaOCl on bond strengths of resin cements to root canal dentin. J Endod 2003;29:248 –51. Erdemir A, Ari H, Gungunes H, Belli S. Effect of medications for root canal treatment on bonding to root canal dentin. J Endod 2004;30:113– 6. Nikaido T, Takano Y, Sasafuchi Y, Burrow MF, Tagami J. Bond strengths to endodontically-treated teeth. Am J Dent 1999;12:177– 80. Lai SC, Mak YF, Cheung GS, et al. Reversal of compromised bonding to oxidized etched dentin. J Dent Res 2001;80:1919 –24. Yiu CK, Garcia-Godoy F, Tay FR, et al. A nanoleakage perspective on bonding to oxidized dentin. J Dent Res 2002;81:628 –32. Rueggeberg FA, Margeson DH. The effect of oxygen inhibition on an unfilled/filled composite system. J Dent Res 1990;69:1652– 8. Fuentes V, Ceballos L, Osorio R, Toledano M, Carvalho RM, Pashley DH. Tensile strength and microhardness of treated human dentin. Dent Mater 2004;20:522– 9. Marais JT, Williams WP. Antimicrobial effectiveness of electrochemically activated water as an endodontic irrigation solution. Int Endod J 2001;34:237– 43. Marais JT. Cleaning efficacy of a new root canal irrigation solution: a preliminary evaluation. Int Endod J 2000;33:320 –5. Meiers JC, Kresin JC. Cavity disinfectants and dentin bonding. Oper Dent 1996;21: 153–9. Perdigao J, Denehy GE, Swift EJ Jr. Effects of chlorhexidine on

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dentin surfaces and shear bond strengths. Am J Dent 1994;7:81– 4. Cunningham MP, Meiers JC. The effect of dentin disinfectants on shear bond strength of resinmodified glass-ionomer materials. Quintessence Int 1997;28:545–51. el-Housseiny AA, Jamjoum H. The effect of caries detector dyes and a cavity cleansing agent on composite resin bonding to enamel and dentin. J Clin Pediatr Dent 2000; 25:57– 63. Kazemi RB, Meiers JC, Peppers K. Effect of caries disclosing agents on bond strengths of total-etch and self-etching primer dentin bonding systems to resin composite. Oper Dent 2002;27:238–42. Erdemir A, Eldeniz AU, Belli S, Pashley DH. Effect of solvents on bonding to root canal dentin. J Endod 2004;30:589 –92. Trautmann G, Gutmann JL, Nunn ME, Witherspoon DE, Shulman JD. Restoring teeth that are endodontically treated through existing crowns. Part II: survey of restorative materials commonly used. Quintessence Int 2000;31:719 –28. Guthrom CE, Johnson LD, Lawless KR. Corrosion of dental amalgam and its phases. J Dent Res 1983;62:1372– 81. Craig RG. Restorative Dental Materials, 9th ed. St. Louis: Mosby-Year Book, 1993. Katebzadeh N, Dalton BC, Trope. Strengthening immature teeth during and after apexification. J Endod 1998;24:256 –9. Teixeira FB, Teixeira EC, Thompson JY, Trope M. Fracture resistance of roots endodontically treated with a new resin filling material. J Am Dent Assoc 2004;135: 646 –52. Labella R, Lambrechts P, Van Meerbeek B, Vanherle G. Polymerization shrinkage and elasticity of flowable composites and filled adhesives. Dent Mater 1999;15: 128 –37. Braga RR, Ferrracane JL. Alternative in polymerization contraction stress management. Crit Rev Oral Biol Med 2004;15:176–84. Hannig M, Friedrichs C. Comparative in vivo and in vitro investigation of interfacial bond variability. Oper Dent 2001;26:3–11. Van Meerbeek B, Perdigao J, Lambrechts P, Vanherle G. The clinical performance of adhesives. J Dent 1998;26:1–20. Yoshikawa T, Sano H, Burrow MF, Tagami J, Pashley DH. Effects of dentin depth and cavity configuration on bond strength. J Dent Res 1999;78:898 –905. Lutz F, Krejci I, Oldenburg TR. Elimination of polymerization stresses at the margins of posterior composite resin restorations: a new restorative technique. Quintessence Int 1986;17:777– 84. Kuroe T, Tachibana K, Tanino Y, et al. Contraction stress of composite resin build-up procedures for pulpless molars. J Adhes Dent 2003;5:71–7. Eiriksson SO, Pereira PN, Swift EJ, Heymann HO, Sigurdsson A. Effects of blood contamination on resinresin bond strength. Dent Mater 2004;20:184 –90. Johnson ME, Stewart GP, Nielsen CJ, Hatton JF. Evaluation of root reinforcement of endodontically treated teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:360–4. Sanares AM, Itthagarun A, King NM, Tay FR, Pashley DH. Adverse surface interactions between one-bottle light-cured adhesives and chemical-cured composites. Dent Mater 2001;17:542–56.

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176. Tay FR, Pashley DH, Yiu CK, Sanares AM, Wei SH. Factors contributing to the incompatibility between simplified-step adhesives and chemically-cured or dual-cured composites. Part I: single-step self-etching adhesive. J Adhes Dent 2003;5:27– 40. 177. Foxton RM, Nakajima M, Tagami J, Miura H. Bonding of photo and dual-cure adhesives to root canal dentin. Oper Dent 2003;28:543–51. 178. Asmussen E, Peutzfeldt A. Short- and long-term bonding efficacy of a self-etching, one-step adhesive. J Adhes Dent 2003;5:41–5. 179. Tay FR, Suh BI, Pashley DH, Prati C, Chuang SF, Li F. Factors contributing to the incompatibility between simplified-step adhesives and self-cured or dual-cured composites. Part II. Single-bottle, total-etch adhesive. J Adhes Dent 2003;5:91–105. 180. Ikemura K, Endo T. Effect on adhesion of new polymerization initiator systems comprising 5-monosubstituted barbituric acids, aromatic sulphonate amides, and tert-butyl peroxymaleic acid in dental adhesive resin. J applied Polymer Sci 1999; 72:1655– 68. 181. Swift EJ Jr, Perdigao J, Combe EC, Simpson CH 3rd, Nunes MF. Effects of restorative and adhesive curing methods on dentin bond strengths. Am J Dent 2001;14:137–40. 182. Kato H, Matsumura H, Atsuta M. Effect of etching and sandblasting on bond strength to sintered porcelain of unfilled resin. J Oral Rehabil 2000;27:103–10.


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Oral and Maxillofacial Pathology Case of the Month Clinical History This 45-year-old Hispanic female presented to her new family dentist for routine care. The dentist noticed dozens of small, asymptomatic “brown bumps” along the lateral borders of her tongue (Figure 1). She claimed that these had been present and unchanged since childhood. The pigmentation was strongest on the tips of the papules and the papules were generally a uniform 2 mm in diameter, although several were very much smaller than that (Figure 1B, insert). There was no other pigmentation in the mouth. Her medical history was unremarkable for systemic diseases and, to the best of her knowledge, no other family member had similar “bumps” on their tongue. The dentist biopsied one of the papules and the biopsy showed melanin deposits concentrating in the epithelium near the top of the mass, with abundant melanin seeming to have “dropped off” into the subepithelial stroma (Figure 2).

What is the final diagnosis?

Adibi

Suarez

Bouquot

Dr. Shawn Adibi, assistant professor, Department of Diagnostic Sciences, University of Texas School of Dentistry at Houston; Dr. Patricia Suarez, assistant professor, Department of Diagnostic Sciences, University of Texas School of Dentistry at Houston; Dr. Jerry E. Bouquot, professor and chair, Department of Diagnostic Sciences, Director of Surgical Pathology, University of Texas School of Dentistry at Houston.

See page 576 for the answer and discussion.

A.

B.

Figure 1. A) Small brown papules or “bumps” are streaked along both lateral borders of the tongue; B) multiple small brown “bumps” are scattered amongst the larger ones.

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Figure 2. Large, numerous melanin deposits (brown color) are seen in the basal layer of the epithelium, with a few small deposits within the underlying fibrous tissue, i.e. â&#x20AC;&#x153;pigment incontinence,â&#x20AC;? an innocuous feature of many melanotic lesions.

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Oral and Maxillofacial Pathology Diagnosis and Management

Papillary Tip Melanosis (Pigmented Fungiform Lingual Papillae) Oral and Maxillofacial Pathology Case of the Month (from page 572)

Discussion The dorsal surface of the tongue is, after the floor of the mouth, the least common oral location for melanotic macules and focal melanosis, but occasional patients, especially those with dark skin pigmentation, will present with irregular light-brown to dark-brown macules of that surface (1). This is called physiological or “racial” pigmentation and, typically, the fungiform papillae are spared such pigmentation. Occasional patients, however, will present with papillary tip involvement in combination with more routine mucosal melanosis (Figure 3) and some, like our patient, will present with no melanotic macules, only pigmentation of the tips of the fungiform, and sometimes filiform, papillae. The concentration of pigment at the papillary tips is not surprising, since this portion of the fungiform papilla develops embryologically from a distinct subset of epithelial cells from which taste buds will develop after birth (2). Epithelium from the base of the papilla is more similar to the rest of the oral mucosa and, in fact, has molecular markers suggestive of actual suppression of the kind of dense cells seen at the tips of papillae. Be that as it may, there seems to be no significance to the presence or absence of a background melanotic macule or the presence of such macules elsewhere in the mouth.

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We have recently suggested the term papillary tip melanosis (PTM) for this entity (3). PTM is a simple recognition problem, since no treatment or biopsy is required, and the clinical appearance does not at all suggest an ominous diagnosis. In our experience, these “brown bumps” are life-long entities, probably starting in childhood (or at birth), becoming more pronounced during adolescence and the teen years, and changing very little after that. In this regard, PTM follows the same pattern as physiologic pigmentation (1). We do not believe that this is a new entity, but is, rather, an “orphan disorder” that has always been present in a certain number of individuals but has not been taught because it has remained unnamed, at least in dentistry. In truth, there is a remarkable lack of information in the dental literature about PTM. It has never been discussed as a unique entity or variant of oral melanosis, except for a photo in the detailed and excellent recent review by Meleti et al. of oral pigmentation (4). It was also pictured in an old but highly regarded textbook of oral pathology, the Tiecke book, published in 1965 (Figure 4) (5). Unfortunately, the photo is used incorrectly in the book to illustrate a strawberry tongue of scarlet fever. This dearth is particularly odd since several case reports have been published in the pediatric and dermatology literature, beginning with

a 1967 report (6-13). At least one group of physicians has suggested, in fact, that PTM is quite common, being found in at least 25 percent of adult blacks in their relatively select group of patients (7). That has certainly not been our experience. We recently presented a small series of only 13 new cases, including the first cases in Hispanics (it had only been reported previously in African Americans and Asians), and this appears to be the only series thus far reported in the dental literature. The medical literature, while reporting PTM, has not established a common diagnostic name for this tongue lesion, although some have suggested pigmented fungiform papillae of the tongue (PFPT), black taste buds, or black lingual bumps. We have suggested PTM as a more logical diagnosis because some of our cases, including the present one, demonstrated melanosis at the tips of filiform papillae in addition to the fungiform papillae (Figures 1B and 5). The embryologic explanation for papillary tip filiform involvement is less understandable than the fungiform involvement, but the pigment does seem to concentrate in the superior portions of both types of papillae. It is well known that oral melanosis, in addition to being a racial or ethnic feature, may be produced by certain medications. One of our cases, as seen in Figure 5, did indeed show increased pigmentation with the use of ketoconazole medica-


Figure 3. A patient with a few pigmented fungiform papillae (inset, arrow) on a background of melanotic macules or patches, most of which lack concentrated brown discoloration of the tips of the papillae.

Figure 4. A very rare published example in a dental textbook, an oral pathology text from the 1960â&#x20AC;&#x2122;s, mislabeled a PTM case as a strawberry tongue in scarlet fever (5).

Figure 5. A patient with such mild PTM that she was unaware of it experienced increased brown pigmentation of both fungiform (inset, arrow) and filiform papillae after less than 2 weeks on ketoconazole (antifungal medication known to produce oral melanosis).

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Papillary Tip Melanosis tion for unrelated candidiasis. The increase was dramatic enough, in fact, that the patient wasn’t even aware of pigmented papillae prior to use of the drug. After drug cessation, the pigmentation diminished dramatically, although a mild brown discoloration remained. This experience has led us to believe that any medication capable of producing oral melanosis (Table 1) should also be capable of producing or enhancing PTM pigmentation. In a similar vein, a variety of syndromes (PeutzJeghers, Bloom, McCune-Albright, Laugier-Hunziker) and systemic diseases (Addison, neurofibromatosis, xeroderma pigmentosum, Carney complex, hemochromatosis) have been associated with oral melanosis, but no one has yet reported the PTM variant in those disorders. We present, then, the first dental journal summary of PTM and suggest that it has one of the more strange histories as an oral pathology “disease” entity, in that it occurs exclusively in the mouth and has, with very, very few exceptions, been reported only in the medical literature. References 1. Neville B, Damm D, Allen C, Bouquot J. Oral and maxillofacial pathology, 3rd edition. Philadelphia, W. B. Saunders; 2008. 2. Mistretta CM, Liu H-X. Development of fungiform papillae: patterned lingual gustatory organs. Arch Histol Cytol 2006; 69:199-208. 3. Adibi S, Suarez P, Bouquot J. Papillary tip melanosis – unusual variant of physiologic or druginduced melanosis. Proceedings, Annual meeting, American Academy of Oral & Maxillofacial Pathology, San Juan, Puerto Rico, April, 2011.

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Table 1. Drugs known to occasionally induce brown oral mucosal pigmentation, i.e. melanosis. n Tranquilizers Phenolphthalein n Antibiotics Minocycline n Antifungals Ketoconazole n Antimalarial/lupus/rheumatoid arthritis medications Chloroquine Hydrochloroquine Quinidine Quinacrine n Hormone therapy Estrogen n Miscellaneous Pilocarpine Smoker’s melanosis 4. Meleti M, Vescovi P, Mooi WJ, van der Waal I. Pigmented lesions of the oral mucosa and perioral tissues: a flow-chart for the diagnosis and some recommendations for the management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105:606-616. 5. Tiecke RW. Oral pathology. New York, McGraw-Hill, 1965; plate 12-3. 6. Koplon BS, Hurley HJ. Prominent pigmented papillae of the tongue. Arch Dermatol. 1967; 95:394– 396. 7. Holzwanger JM, Rudolph RI, Heaton CL. Pigmented fungiform papillae of the tongue: a common variant of oral pigmentation. Int J Dermatol 1974; 13:403–408. 8. Isogai Z, Kanzaki T. Pigmented fungiform papillae of the tongue.

J Am Acad Dermatol 1993; 29:489–490. 9. Pehoushek JF, Norton S, Bliss RW. Black taste buds. Arch Dermatol 1999; 135:594–598. 10. Scarff CE, Marks R. Pigmented fungiform papillae on the tongue in an Asian man. Australia J Dermatol 2003; 44:149–151. 11. Millington GW, Shah SN. A case of pigmented fungiform lingual papillae in an Indian woman. J Eur Acad Dermatol Ven 2007; 21:705. 12. Muller S. Melanin-associated pigmented lesions of the oral mucosa: presentation, differential diagnosis, and therapy. Dermatol Ther 2010; 23:2020-2029. 13. Romiti R, Molina De Medeiros L. Pigmented fungiform papillae of the tongue. Pediatr Dermatol. 2010; 27:398-399.


In Memoriam Those in the dental community who have recently passed

Carter, Earl L., Jr. Dallas, Texas April 20, 1935 – March 26, 2011 Life, 2001

Meffert, Roland Matthew San Antonio, Texas June 30, 1932 – March 22, 2011 Life, 1998 Fifty Year, 2006

Memorial and Honorarium Donors to the Texas Dental Association Smiles Foundation

In Honor of: Melanie Steglich By: Jill Kralicke

In Memory of: Henry Marschel By: Dr. Kent Macaulay MaryDawn Hurst By: Don & Cathy Lutes Dr. Robert V. Walker By: Don & Cathy Lutes

Ellen Macaulay Jen Banton Dr. & Mrs Paul Stubbs Mr. & Mrs. Gene Rummel Lorene Cotton Grill Mr. & Mrs. Alan Terrill Penman Services, LTD Dr & Mrs. Herb Wade Mr. & Mrs. Robert Brient

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

Please make your check payable to:

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

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value for your

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Strategies for Improving Patient Understanding and Compliance Kathleen M. Roman, MS; Medical Protective Company

The Challenges

How many times, in a follow-up appoint-

ment, have you discovered that a patient has ignored, misunderstood, or forgotten your

instructions? When was the last time a staff

member complained about phone calls from patients who need further instructions for

their post-procedure home care? Have you ever been shocked to discover the dangerous non-compliance of a patient, e.g., “Oh,

I didn’t know you meant one to two Vicodin every 24 hours. I thought you said one to two Vicodin every 2-4 hours”?

The resolution to these concerns lies in improving the way you and your staff provide and reinforce patient education. Over the years, you’ve probably seen many of the studies warning that patients forget somewhere between 40-60 percent of healthcarerelated instructions as soon as they leave the office. But time is money, and in today’s pressing economy, many dentists practice with one eye on the clock. After all, the patient’s insurance company doesn’t offer

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extra compensation for your patient education efforts. Many doctors feel that solvency relies on their ability to finish up with one patient and move on to the next. But let’s factor in the potential “losses” that arise out of the examples above. When a patient ignores, misunderstands, or forgets your instructions, he or she may have a less-than-ideal outcome. How many times have you had to make an emergency trip to your office to treat a patient for dry socket? “Well I didn’t think it would hurt if I smoked just a couple of cigarettes.” What about repairs to orthodontic devices or broken bridges? “I forget to wear the night guard — but I still think you should fix the crowns for free.” Many times, you end up doing extra work as a free patient service and the costs associated with these additional services adds up—not to mention the inconvenience of preventable after hours calls. Every time a patient calls your office to ask for additional information or to “make sure” that he or she is complying with a home care regimen, you’re paying a staff member to manage that call and to reinforce the educational message. Hopefully, your staffer is also documenting the content of the phone call — and that may include a conversation with you to ensure that if you have additional advice for the patient, that information is also passed along. So, two people in your office, each of whom was already engaged in some other activity, are filling in the blanks for the caller, while patients who are already in the office cool their heels. And perhaps most compelling of all are those “near misses” that occur when patients dangerously misunderstand your instructions. You know who they are — the three-pack-a-day smoker who thought you said that you wanted to check that lesion again next year — when you really said next month. And then there’s the woman who decided not to tell you that she’s being treated for breast cancer — and has just completed a round of IV bisphosphonates — because she’s “embarrassed,” and, besides, doesn’t see how her medical condition is “any of your business.” So, the point is that, in many ways, you’re still being forced to engage in those patient education activities — but they’re often happening after-the-fact, when: a) the timing is much less effective; b) the intervention will cost you more money than it would have if you’d formalized the education component at the time of treatment; and c) the patient already may have sustained some sort of injury — possibly increasing your liability exposure.

Strategies Following are some strategies that might help you get a better handle on patient education. Review the education processes in your office. Encourage your staff to participate in the assessment. Your receptionist’s perspective on patient education may differ from your dental hygienist’s. Both may be valid, and their combined suggestions may be more valuable than either individual insight. Together, you and your team can get a clearer picture of how patient education can improve your practice. •

Conduct a random chart audit. Look for documentation of patient non-compliance. When you find it, look for notes that indicate the patient was given educational materials, formal written instructions, hand-written notes, encouraged to ask questions, etc. You may find a correlation between non-compliance and a lack of educational interventions. Regardless of your area of practice, many of the treatments you offer patients should include a formal (signed) informed consent. A key component of any informed consent process is the discussion with the patient about diagnostic results, treatment options, and the risk and benefits associated with each. This type of patient education is essential to the consent process. Without sufficient information — meaning “education” — a patient may be unable to make an appropriate treatment decision. And, there have been times when courts have decided that a signed informed consent document was invalid; often, these rulings note inadequacy of the information given to the patient. When you audit charts, look also for verification of patient education, discussion, and questions and answers, as a part of every formal informed consent process. Ask yourself who in your practice is engaging in patient education. As the clinician, it is your role to educate patients about their diagnoses and treatment plans. Few states allow diagnostics to be handled by anyone other than a dentist. At the same time, your hygienist is probably also an ally in terms of educating patients about their oral health, especially their home oral health regimens. And what about your dental assistants and your receptionists? Within the scope of their job descriptions, they can also be informative and helpful, but require training and acknowledgement of the topics they can address as well as the topics they must refer to you. Texas Dental Journal l www.tda.org l June 2011

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Patient Compliance •

If more than one dentist practices in the same office, are you using the same educational brochures/materials to educate patients? Inconsistency leads to errors. You want your entire dental team to be on the same page when it comes to educational interactions and materials. Are you handing out obsolete educational materials? Periodically, you should review your educational handouts. As dentistry changes and as your practice changes, these materials should be updated. You can write your own educational materials if you wish. Or you can contact companies that specialize in patient education. The American Dental Association and some state or professional specialty associations also have educational materials. Read educational materials carefully, especially those that might be developed by companies that want to sell clinical product. You don’t want to be held accountable for a manufacturer’s marketing hyperbole. Numerous resources for patient education and effective doctor-patient communications can be found on the Internet. Space allows just one example, but if you google “patient education,” you’ll find numerous offerings. One of these is the Teach-Back technique — an excellent resource for helping patients understand the information you want them to take away from their appointments. And, it’s relatively simple to learn.

First, explain to the patient the information that you want to share. Learning experts tell us that pictures, brief brochures, and pictographs (little sketches that you yourself might make on the patient’s chart or on a piece of paper you give to the patient) all help to reinforce retention of the information once the patient leaves. Be consistent in the process. Develop a miniscript if necessary: “Here are the X points I will always want to make when explaining this diagnosis/treatment option to patients.” Second, try not to use complicated language. For example, tell the patient, “You have a type of gum disease that is called periodontitis,” rather than, “You have periodontitis.” Use short sentences. When you’re finished explaining the information to the patient, let him or her know when you’re beginning to give instructions. In other words, this is the point where the patient knows that he or she will have to engage in some subsequent action.

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Third, reinforce the information and written materials you’ve already given to the patient by saying something like, “Well, I’ve given you a lot of instructions, and I want you to be sure to ask any questions that occur to you, but just to be sure that I’ve done a good job of explaining this information, could you please repeat it back to me? Can you tell me what I want you to do at home tonight as your new tooth care plan?” And, finally, if the patient gets it right and can accurately repeat the important components of the conversation, that’s great; if not, you can go back again and try a slightly different approach. If it wasn’t clear the first time, using the exact same words the second time may not be any more effective. Tell the patient, “Well, let’s see if I can make this a little less confusing,” and then try again. The Teach Back method has proven very effective in helping many different healthcare providers reduce patient confusion and non-compliance and increase patient satisfaction as well.

Conclusion Patient education is an important component of the doctor-patient relationship. It helps ensure patient compliance, and may reduce the risks of unsatisfactory clinical outcomes. While formalized approaches to patient education may seem burdensome, in fact, they may ultimately reduce the amount of time invested per patient. And, there is evidence that teaching strategies are valuable in reducing patient risks commonly associated with non-compliance. Kathleen M. Roman is risk management education leader for Medical Protective Company, a TDA Perks Program partner, and the nation’s oldest professional liability insurance company for healthcare professionals. Kathleen can be reached at: kathleen.roman@ medpro.com. For information regarding other TDA Perks Programs, visit www.tdaperks.com, or call (512) 443-3675. © 2011, Medical Protective Company. All rights reserved.


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


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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) 7895172; FAX: (202) 898-2437; E-mail: taylorc@ada.org. 28 – 31 The Academy of General Dentistry will have its annual meeting and exhibition at the Ernest Morial Convention Center in New Orleans, LA. For more information, please contact Ms. Rebecca Murray, AGD, 211 E. Chicago Ave., Ste. 900, Chicago, IL 60611. Phone: (312) 440-3368; FAX: (312) 440-0559; E-mail: agd@agd.org; Web: agd.org. 28 – 30 The International Association of Comprehensive Aesthetics will meet at the Manchester Grand Hyatt in San Diego, CA. For more information, please contact Ms. Mary Williams, IACA, 1401 Hillshire Dr., Ste. 200, Las Vegas, NV 89134. Phone: (888) NOW-IACA; FAX: (702) 341-8510; E-mail: info@theiaca. com; Web: theiaca.com. August 2011 5&6 The TDA Smiles Foundation (TDASF) will hold a Texas Mission of Mercy event in Texarkana, TX. For more information, please contact TDASF, 1946 S. IH 35, Ste. 300, Austin, TX 78704; Phone: (512) 448-2441; Web: tdasf.org. 18 & 19 National Conference on Dentist Health and Wellness will be in Chicago, IL. For more information, please contact Ms. Mary Gilliam, ADA, 211 E. Chicago Ave., Chicago, IL 60611-2678. Phone: (312) 440-2500. FAX: (312) 440-7494; E-mail: online@ada.org; Web: ada.org. September 2011 12 – 17 The American Association of Oral and Maxillofacial Surgeons will meet at the Pennsylvania Convention Center in Philadelphia, PA. For more information, please contact Dr. Robert C. Rinaldi, AAOMS, 9700 W. Bryn Mawr, Rosemont, IL 60018. Phone: (847) 678-6200; FAX: (847) 678-6286; Web: aaoms.org. 14 – 17 The FDI Annual World Dental Congress will meet at the Banamex Convention & Exhibition Centre in Mexico City, Mexico. For more information, please contact Mr. John Hern, FDI/USA Section, ADA, 211 E. Chicago Ave., Chicago, IL 60611; Phone: (800) 621-8099 ext. 2727; FAX: (312) 440-2707; E-mail: hernj@ada.org. 22 – 27 The ADA Kellogg Executive Management Program will be in Chicago, IL. For more information, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Ave., Chicago, IL 60611; Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org. 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) 4402500; Web: ada.org.

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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; Email: 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. December 2011 1–6 The American Dental Association Kellogg Executive Management Program (ADAKEMP) 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. 2&3 The Southwestern Society of Pediatric Dentistry will hold its annual meeting at the Westin Galleria in Dallas, TX. For more information, please contact Ms. Judy Salisbury, SSPD, 10032 Wind Hill Dr., Greenville, IN 47124. Phone: (812) 923-2100; FAX: (812) 923-2900; E-mail: jsalisbury00@gmail.com; Web: flyingdentists.org. 12 & 13 The American Dental Association Institute for Diversity in Leadership will be held at ADA headquarters in Chicago, IL. For more information, please contact Ms. Stephanie Starsiak, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-4699; FAX: (312) 440-2883; E-mail: starsiaks@ada.org; Web: ada.org. The Texas Dental Journal’s Calendar will include only meetings, symposia, etc., of statewide, national, and international interest to Texas dentists. Because of space limitations, individual continuing education courses will not be listed. Readers are directed to the monthly advertisements of courses that appear elsewhere in the Journal.

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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.

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e v Ad IMPORTANT: Ad briefs must be in the TDA office by the 20th of two months prior to the issue for processing. For example, for an ad brief to be included in the January issue, it must be received no later than November 20th. Remittance must accompany classified ads. Ads cannot be accepted by phone or fax. * Advertising brief rates are as follows: 30 words or less — per insertion…$40. Additional words 10¢ each. The JOURNAL reserves the right to edit copy of classified advertisements. Any dentist advertising in the Texas Dental Journal must be a member of the American Dental Association. All checks submitted by non-ADA members will be returned less a $20 handling fee. * Advertisements must not quote revenues, gross or net incomes. Only generic language referencing income will be accepted. Ads must be typed.

Briefs

Practice Opportunities MCLERRAN AND ASSOCIATES: AUSTIN: Associate to purchase. High grossing, family practice located in retail center with seven operatories was recently remodeled. Near major freeway. High growth area. Practice boasts solid, 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: Unique, quality fee-for-service practice in five operatory free-standing building. Grossed near seven figures, boasts quality staff and well-established patient base. ID #123. NEW! AUSTIN: Newly built out, seven operatory (four equipped) practice in high growth, affluent area in northwest. Practice grossed mid-six figures on limited schedule in second year, is equipped and priced like a startup. Excellent opportunity with tremendous upside. ID #124. NEW! AUSTIN: Two operatory practice in free-standing building grossing low six figures on a part-time schedule. Practice and real estate available in transition. ID #125. CORPUS CHRISTI: Doctor retiring, six op office with excellent visibility and access. Good numbers, excellent patient base, good upside potential. Excellent practice for starting doctor. Priced to sell. ID #023.

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and paperless office. Excellent numbers on a 2-day work week. Low overhead. Needs to be worked more hours! Good for stand alone or satellite office. ID #130. 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. 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.

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.

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.

NEW! DALLAS AREA: Small town living within 1 hour of Dallas. High tech digital

SAN ANTONIO, NORTH CENTRAL: Three operatory office in retail/office

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center with great visibility and access. New equipment and nice build out. Good solid numbers, very low overhead. ID #111. SAN ANTONIO: Six operatory practice with three chair ortho bay located in 3,400 sq. ft. building. Modern office with newer equipment. Free-standing building on busy thoroughfare. Practice has grossed in seven figures for last 3 years. Great location with super upside potential. ID #055. SAN ANTONIO 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. NEW! WEST OF SAN ANTONIO: Doctor retiring. Four operatories in modern, open, free-standing building. Excellent fee-forservice patient base. Newer equipment. Very nice decor. Very nice numbers with low overhead. Low competition in mid-sized city. ID #122. 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! 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! SAN ANTONIO: Pediatric dental practice. Doctor retiring from this 31-year-old pediatric dental practice. Excellent location in free-standing building with good visibil-

ity and access. Large pylon and marquee signage. Well-equipped and very nice decor. Solid patient base. Doctor available for transition. ID #129. 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) 750-6778; in Houston, Tom Guglielmo and Patrick Johnston, (281) 362-1707. Practice sales, appraisals, buyer representation, and lease negotiations. See www.dentalsales.com for pictures and more complete information. HOUSTON AREA PRACTICE OPPORTUNITIES. MCLERRAN & ASSOCIATES: NEW! HOUSTON: Pediatric office recently opened to care for lower income patients in a densely populated area of Houston. Highly visible location, very nice buildout, new equipment, five equipped operatories, with two more available for expansion. The office is computerized throughout and has a clean, inviting decor appealing to children and families. There is a tremendous upside potential for a new owner. #H133. NEW! SOUTHWEST HOUSTON: Established for more than 25 years, general, crown and bridge practice located in a high visibility strip center near the Sugar Land / Stafford area. Three operatories, digital X-rays, and computers. Revenue in the high six figures, low overhead, produces significant cash flow. Seller willing to transition. #H130. Texas Dental Journal l www.tda.org l June 2011

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NEW! SOUTHEAST OF HOUSTON: General, crown and bridge family oriented practice, established for 40 years, enjoys a loyal patient following. Gross was near mid six figures in 2010 with good cash flow and a strong hygiene program. There are 1,500+ active patients that are mainly fee-for-service and PPO. The 2,500 sq. ft. building is included in the sale and has four fully equipped with room to add three more. The office is fully computerized with digital radiography and has a great upside potential. #H131. HOUSTON: General, fee-for-service practice, established in the beautiful Memorial area of Houston for more than 30 years. Low fixed overhead costs, with significant outbound referrals, practice has great upside potential for buyer looking to increase revenue to the mid six figures range and still generate a desirable net income. New patients are generated from loyal patient following that is not insurance based, staff is very stable and effective. Seller available for short transition period. #H128. HOUSTON: Forty-year-old practice in just completed new office. Memorial City area. All new equipment, digital X-rays and computerized. Revenues near six figures. Demographics lean towards an adult, middle income earning clientele. Two fulltime hygienists. #H129. Contact McLerran & Associates in Houston: Tom Guglielmo and Patrick Johnston, (800) 474-3049 or (281) 362-1707, houstoneasttx@dentalsales.com. Practice sales, appraisals, buyer representation, and partnership consulting. See www.dental-sales.com for 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. 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

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and specialty practice certified appraisals. DFW: (214) 503-9696; WATTS: (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 financially qualified 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. One hundred percent funding available, even those valued at more than seven figures. Call me confidentially with any questions. 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; WATTS: (800) 583-7765. ORTHODONTIC PRACTICES FOR SALE / TRANSITION —GARY CLINTON / PMA TEXAS: O-1 Near Fort Worth South — Well established early 1990’s practice; transition to outright sale; seller will work for buyer for 2 years. Beautiful newer office and equipment. O-2 Texas mid-sized community — Ideal transition; professional referral based; traditional fee-for-service, referral based; traditional fee-for-service, high productive. Gorgeous building with room for two; lease/purchase facility. Outright sale or associate/transition orthodontist will continue as needed for 1-2 days per week. O-3 Beautiful Nueces Valley South Texas — Transitional sale or immediate buy-out; seller will stay 1-2 days per week as needed. Seven figure practice collections; nice facility to lease/ purchase. He is ready to spend time with his grandchildren. Easy drive to San Antonio. 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; WATTS: (800) 583-7765. GARY CLINTON / PMA ARLINGTON PRACTICE FOR SALE: The ideal place to be in Texas for young families. Texas Rangers baseball. Cowboys football, and Six Flags for entertainment. Well-established practice. Excellent recare program. Near seven figure gross, high operating profits. Buy or lease garden style office/ operatories. 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; WATTS: (800) 583-7765. GARY CLINTON / PMA FORT WORTH AREA/WEATHERFORD GENERAL PRACTICES FOR SALE: F-1 — Excellent patient base; well-established recall. Bread and butter practice. Very fast growing area north of Texas Motor Speedway. Average gross with excellent net. F-2 — Established 30 years ago in southwest Fort Worth/ White Settlement/Lake Worth area. Low overhead excellent net. Transition/outright sale. Associate buy-out or outright sale. Above average gross. W-l Weatherford dentist retiring. Well established patient base. Doctor is highly esteemed member of the community. Purchase or lease/purchase the facility. 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; WATTS: (800) 583-7765. ORAL SURGERY PRACTICES FOR SALE. GARY CLINTON / PMA: OS-1 West Houston area — High growth area. Stateof-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. Sevenfigure gross on 4 days; will transition. 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; WATTS: (800) 583-7765. GARY CLINTON / PMA HOUSTON PRACTICES FOR SALE: H-l North Houston near Lake Houston. Fast growing, most requested area; seven-figure gross, high net. Six operatories, full recall. Very attractive professional center with high visibility. H-2 Well-established practice, retiring dentist. Excellent recall in southwest Houston area. H-3 Clear Lake area practice. Well-established. Average gross. 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; WATTS: (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. 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; WATTS: (800) 583-7765. GARY CLINTON / PMA WEST TEXAS AREA WELL-ESTABLISHED PRACTICES FOR SALE: W-l North of Lubbock — High-

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ly 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. Well-established. Average gross. 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; WATTS: (800) 583-7765. GARY CLINTON / PMA AUSTIN PRACTICE FOR SALE: Thirty-year-old well established practice; gross near mid six figures. Building may be purchased with practice or leased with later purchase options. Well-established. Average gross. 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; WATTS: (800) 583-7765. GARY CLINTON / PMA GARLAND PRACTICE FOR SALE: North Garland area. Doctor retiring for health reasons; 20+ year practice. Average gross. Well-established. Average gross. 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; WATTS: (800) 583-7765. GARY CLINTON / PMA NORTH DALLAS / MCKINNEY AREA PRACTICE FOR SALE: One of the best and fastest growing

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areas in Texas. Very nice newer office; all digital; four operatories and two unequipped operatories. Well-established. Average gross. 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; WATTS: (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. Well-established. Average gross. 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; WATTS: (800) 583-7765. GOLDEN TRIANGLE GENERAL DENTAL PRACTICE — SALE: Outstanding practice supported by outstanding staff and latest in dental equipment. Strong revenues and profit margin. Excellent new patient flow. Given high level of FFS revenues, doctor to transition to comfort level of purchaser. Come build your retirement in low competition community. Contact The Hindley Group at (800) 856-1955. Visit us at www. thehindleygroup.com. 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. CORPUS CHRISTI GENERAL DENTAL — SALE: Moderate revenues with a very healthy profit margin. Experienced and


loyal staff. Totally digital and highly efficient facility layout. If you need to practice to refund your retirement, but don’t want to fight the competitiveness of the city, come see this practice. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. DFW METROPLEX ORAL SURGERY PRACTICE — SALE: Well-established practice enjoying 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. The large facility with six fully equipped operatories plus one three-chair open bay for ortho is 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 surgery, pediatrics, or merge with another general dental practice. Building 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. DALLAS / FORT WORTH: Area clinics seeking associates. Earn significantly above industry average income with paid health

and malpractice insurance while working in a great environment. Fax (312) 944-9499 or e-mail cjpatterson@kosservices.com. WACO PEDIATRIC DENTAL PRACTICE — SALE: Well-established practice with moderate revenues and high profit margin on 4 days per week. Limited competition and a large facility. Ample room to grow in this community that is home to Baylor University. This is a wonderful central Texas community in which to raise your family. All ortho cases are being completed, unless purchaser would like to expand new cases. No Medicaid being seen, but good opportunity with facility capacity. Experienced staff and steady new patient flow. Wonderful mentor. Building also available. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. BRYAN/COLLEGE STATION GENERAL DENTAL PRACTICE — SALE: Wellestablished practice in mid-size town. Four operatories. Revenues approaching mid six figures, 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. SOUTHEAST OF HOUSTON GENERAL DENTAL PRACTICE — SALE: Wonderful location on well-traveled street. Practice is 30+ years old. Excellent revenues

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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. FORT WORTH ORTHODONTIC PRACTICE — SALE: Small practice with large Medicaid component utilizing Crozat method. Opportunity for satellite office; general dentist with desire to add ortho; or dentist approaching retirement desiring to utilize orthodontics as less physically taxing exit strategy. Doctor will mentor or assist with transition. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com. ASSOCIATESHIPS: GALVESTON GENERAL DENTAL PRACTICE: Well-established practice with strong revenues and above average profit margin. Excellent mentor. Ten operatories. Dedicated, experienced staff. One- to 2-year associateship with predetermined buy-out. Building also for sale. 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. Predetermined buy-in terms. SOUTH CENTRAL TEXAS PERIODONTAL — Wonderful practice completing periodontal treatment seeks long-term associate who desires to be a partner within 1-2 years. Great location with strong new patient flow. Pre-determined purchase and partnership terms. Wonderful mentor looking for an “equally-yoked” individual. Excellent staff. SAN ANTONIO PERIODONTAL AND ENDODONTAL ASSOCIATESHIPS — Periodontal associateship with pre-determined buy-in for very active, multi-office periodontal practice. Endodontist associate also needed in this practice. Outstanding mentor and cohesive staff. If you are “equally yoked” and the right person, this is an outstanding opportunity. WEST TEXAS GENERAL DENTAL PRACTICE — Purchase is option or associateship with pre-determined buy-in and partnership terms. Nine operatories. Strong mentor and experienced staff. Excellent revenues and profit margin. Medicaid component.

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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 strong revenues. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www. thehindleygroup.com. HOUSTON AREA PRACTICE FOR SALE: Profitable practice for sale. Well-established. Call Jim Robertson at (713) 6881749. 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 is opening new offices in Dallas and the surrounding areas. Each practice is unique in that it has an individual name like Preston Hollow Dental Care or Waterside Dental Care. Ourpatient 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 top-of-the-line Pelton and Crane equipment, digital Xrays, 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 dentist. Relaxed work schedule with community centrally located within 1 hour of three major cities. The office building can be leased or purchased separately and is spaciously designed with four operatories, doctorsâ&#x20AC;&#x2122; private office and separate office rental space. This is an excellent and profitable opportunity for a new dentist, a dentist desiring to own a practice, or a satellite practice expansion. Contact C. Vandiver at (713) 205-2005 or clv@tauruscapitalcorp. com. SUGAR CREEK / SUGAR LAND: General dentist looking for periodontist, endo, ortho specialist to lease or sell. Suite is 1,500 sq. ft. with four fully-equipped treat-

ment rooms, lab, business office, telephone system, computers, reception, and playroom; 5 days per week. If seriously interested, please call (281) 342-6565. AUSTIN: Unique opportunity. Associateship and front-office position available for husband/wife team. Southwest Austin, Monday through Thursday. Option to purchase practice in the future. Send resume and questions to newsmile@onr.com. ASSOCIATE FOR TYLER GENERAL DENTISTRY PRACTICE: Well-established general dentist in Tyler with 30+ years experience seeks a caring and motivated associate for his busy practice. This practice provides exceptional dental care for the entire family. The professional staff allows a doctor to focus on the needs of their patients. Our office is located in beautiful East Texas and provides all phases of quality dentistry in a friendly and compassionate atmosphere. The practice offers a tremendous opportunity to grow a solid foundation with the doctor. The practice offers excellent production and earning potential with a possible future equity position available. Our knowledgeable staff will support and enhance your growth and earning potential while helping create a smooth transition. Interested candidates should call (903) 509-0505 and/or send an e-mail to steve.lebo@sbcglobal.net. ASSOCIATE NEEDED FOR NURSING HOME DENTAL PRACTICE. This is a non-traditional 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 email renee@austindentalcares.com; FAX (512) 238-9250; 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

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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. ASSOCIATE SUGAR LAND AND CYPRESS: Large well-established practice with very strong revenues is seeking an associate. Must have at least 2 years experience and be motivated to learn and succeed. FFS and PPO practice that ranks as one of the top practices in the nation. Great mentoring opportunity. Possible equity position in the future. Base salary guarantee with high income potential. Two days initially going to 4 days in the near future. E-mail CV to Dr. Mike Kesner, drkesner@madeyasmile.com. SEEKING ASSOCIATE DENTISTS. Dental Republic is a well-established general dental practice with various successful locations throughout the Dallas Metroplex. A brand new state-of-the-art facility in a bustling location will be opening soon. Join our outstanding and professional team in creating beautiful healthy smiles for all. Let us give you the opportunity to enhance your professional career with excellent hours, competitive salary/benefits, and by forming long-lasting friendships with our patients and staff members. Please contact Phong at (214) 960-3535 or e-mail CV to phong@dentalrepublic.com.

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CARE FOR KIDS, A PEDIATRIC FOCUSED PRACTICE, is opening new practices in the San Antonio and Houston area. We are looking for energetic full-time general dentists and pediatric dentists to join our team. We offer a comprehensive compensation and benefits package including medical, life, long- and short-term disability insurance, flexible spending, and 401(K) with employer contribution. New graduates and dentists with experience are welcome. Be a part of our outstanding team, providing care for Texasâ&#x20AC;&#x2122; kids. Please contact Anna Robinson at (913) 322-1447; e-mail: arobinson@amdpi. com; FAX: (913) 322-1459. DDR PRACTICE SALES â&#x20AC;&#x201D; 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 six-figure income. Dentists will work as associate if desired. Call DDR Practice Sales at (800) 930-8017. BRYAN/COLLEGE STATION AREA: Wellestablished practice serving rural community of 5,000 just 20 minutes from College Station. Providing seven-figure gross collections with substantial 40 percent net. High quality implant practice. Four fully equipped operatories, private office, two full-time hygienists and a great staff. Ownership of free-standing 1,900 sq. ft. building is optional. Over 4,000 patient base with average age of 45. Call DDR Practice Sales at (800) 930-8017. GALVESTON: Must sell for relocation. Thriving practice in Galveston providing the best of both worlds ... the great outdoors and a laid back lifestyle, yet quick access to metropolitan Houston. This 15-year practice has three fully equipped operatories, private office, full-time hygienist, and a great staff. Half interest in


free-standing building included in price. Generating mid six-figure gross collections on only 3 days per week. Owner currently splits time with out-of-town practice. Call DDR Practice Sales at (800) 930-8017. AUSTIN: Five operatory, two hygienists, one associate dentist, gross of seven figures in 2010. Mature practice; doctor wants to sell practice but is also willing to work contact for buying dentist; great location in beautiful Austin. Practice in the heart of most desired city in Texas. Substantial net income with four fully equipped operatories and two full-time hygienists. Current associate will remain at buyer’s discretion. Call DDR Practice Sales at (800) 930-8017. DALLAS: Practice in high-traffic professional building, run very lean. Mid 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) 930-8017. 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-forservice, 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) 930-8017. 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 have a 25 percent earned equity (no money down) opportunity for a general dentist to prosthodontist. Contact Dr. John Bond at jbond@6daydental.com and Jody Hardy at jhardy@6daydental.com. 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, small-town easy lifestyle, outstanding outdoor recreation. Contact Dr. John Goodman at john@goodman.net or (325) 277-7774. EXPERIENCED DENTIST IS NEEDED FOR AN ESTABLISHED PRIVATE GROUP PRACTICE located in Katy. General dentistry practice with a comfortable and friendly atmosphere without administrative responsibilities. Full- and part-time positions 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 at yourhappydentist@aol.com. 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

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office manager Michelle, (832) 620-6982 or fax resume to (281) 579-6045. FOR SALE â&#x20AC;&#x201D; GREAT 41-YEAR SUCCESSFUL PRACTICE IN SOUTH CENTRAL TEXAS. Owner retiring but will stay through transition period. Five operatories in beautiful building, Pan-O, digital X-ray. Experienced long-term dependable staff. Room for multiple dentists. Please mail letter of interest to Box 1, TDA, 1946 S. IH 35, Ste. 400, Austin, TX 78704. SEEKING ASSOCIATE: Established general dental office in Brownsville (30 minutes away from South Padre Island) is seeking a caring, energetic associate. We are a busy office providing dental care for mostly children. Our knowledgeable staff will support and enhance growth and earning potential allowing the associate to focus on patient dental care. Interested candidates should call (956) 546-8397. 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. Donâ&#x20AC;&#x2122;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. EAST TEXAS GENERAL PRACTICE NEEDS ASSOCIATE TO TRANSITION TO OWNER/PARTNER, buyout to fit situation. Thirty-five-year-old practice in dynamic northeast Texas hub city, centrally located and easily accessible Dallas, Shreveport, and Arkansas. Great for fishing, hunting, and all outdoor activities. Practice is in a 2,300 sq. ft. office (owned) in a professional building across from the

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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, Ruidoso, 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 state-ofthe-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@ austinchildrendentistry.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) 332-6323. 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 well-established, all digital, paperless, state-of-the-art, feefor-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 40IK program with employer match-

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ing 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, childrenâ&#x20AC;&#x2122;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.cpm. MAXIMIZE YOUR POTENTIAL! We have expanded to a beautiful new office located in the heart of Central Texas. Nine operatories with all new A-dec equipment, along with Cerec Cad Cam Dentistry. Begin as an associate with the opportunity to become a partner/owner. Come share in our success. Private or group experience desired. Visit us at dentalimages.com or contact us at (254) 699-9544. CENTRAL AUSTIN ASSOCIATE DENTAL WANTED. Full-time position potentially leading to partnership. Minimum of 1 year experience required. Must be dedicated to continuing education and excellent patient care. E-mail CV to drcook@austincitydental. com. AUSTIN PEDIATRIC DENTIST needed to join our well-established, growing practice. This is a full-time opportunity with excellent salary. Please e-mail your CV to austinpediatricdds@yahoo.com. HOUSTON â&#x20AC;&#x201D; SEEKING FULL-TIME ASSOCIATE to work 3.5 days per week in a well-established, highly regarded, feefor-service dental practice in the Galleria area. This is a remarkable income opportunity with an excellent team already in place. Honesty, integrity, and a patient focus are a must. Three years experience is required; space available to transfer patient base. Please e-mail CV to info@ houstonuptowndentists.com.

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OFFICE SPACE SPACE AVAILABLE FOR SPECIALIST. New professional building located southwest of Fort Worth in Granbury between elementary and junior high schools off of a state highway with high visibility and traffic. Call (817) 326-4098. ORTHODONTIST NEEDED NEXT TO DENTIST IN HIGH GROWTH, HIGH TRAFFIC AREA IN ROUND ROCK, north of Austin in one of the fastest-growing counties. Available at $155/sq. ft. For more information, e-mail john@herronpartners. com or call (512) 457-8206. ALLEN: Prior dental, high end practice that relocated. Five plumbed and ready ops, reception, office, conference, two bath, some built-in cabinets, no equipment. High traffic visibility with lots of parking. Affluent residential, across the street from large grocer. Offering 5-7 years lease plus extensions. Levin Realty, (323) 954-1934, levinrealty@sbcglobal.net. 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) 4940643. 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 fourlane road. High growth area has shortage of specialty dentists. Call Jim at (512) 4940643 or e-mail jim@fazioarchitects.com. AUSTIN — MCNEIL DRIVE DENTAL PARK: Successful general dentist with established practice has two pad sites available. Beautiful wooded area with great traffic volumes. Once you tour this office, you will want to build next door. Call Jim at (512) 494-0643 or e-mail jim@ fazioarchitects.com. 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. ROCKWALL SUBLEASE: Any dental specialty. Share office, attractive terms. Available 3 days per week in one of the fastest growing counties in the country. Call (469) 951-5554 or e-mail rcppersonal@sbcglobal. net. SOUTHEAST SAN ANTONIO CLINIC SPACE. Great location for endo, perio, pedo, or other dental or medical specialty. Thriving ortho practice already established in half of clinic. Free-standing duplex office space in southeast San Antonio near Brooks City Base and Republic Golf Course. Located at the southeast corner of Loop 13 (W.W. White) and Loop 410. Easy access off 1-281. Approximately 1,600 sq. ft. with four operatories plumbed. Lab, private office with bath, business office, and waiting area. Central lobby area shared with co-tenant, $2,480 / month. Call Dr. Chet Eastin at (830) 779-2112 for more information. FOR SALE 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 of these items due to downsizing. Call (561) 703-1961 or e-mail nycfreed@aol. com. CONROE: Fully equipped office for lease or equipment for sale. Four Dental-Eze J chairs, four Pelton-Crane ceiling mount lights (two doubles), four ADEC delivery systems; 1,615 sq. ft. Call (936) 756-1669 Tuesday and Thursday; (281) 363-2009 Monday, Wednesday, and Friday.

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in s i t r e dv

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Briefs

INTERIM SERVICES TEMPORARY PROFESSIONAL COVERAGE (Locum Tenens): Let one of our distinguished docs keep your overhead covered, your revenue-flow open wide, your staff busy, your patients treated and booked for recall, all for a flat daily rate not a percent of production. Nation’s largest, most distinguished team. Shortnotice coverage, personal, maternity, and disability leaves our specialty. Free, no obligation quotes. Absolute confidentiality. Trusted integrity since 1996. Some of our team seek regular part-time, permanent, or buy-in opportunities. Always seeking new dentists to join the team. Bread and butter procedures. No cost, strings, or obligations — ever! Work only when you wish. Name your fee. Join online at www.doctorsperdiem. com. Phone: (800) 600-0963; e-mail: docs@doctorsperdiem.com.

OFFICE COVERAGE for vacations, maternity leave, illness. Protect your practice and income. Forest Irons and Associates, (800) 433-2603 (EST). Web: www.forestirons. com. “Dentists Helping Dentists Since 1983.” 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 School. Class hours are during office downtime one weekend day and one

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weekday evening. Lease payment to office is $500 to $1,500 per month, depending on enrollment. Seeking locations in Dallas, San Antonio, and Houston. Please call the National School of Dental Assisting at (800) 509-2864. THE NATIONAL SCHOOL OF DENTAL ASSISTING â&#x20AC;&#x201D; NORTH DALLAS offers the Texas RDA course and exam. Call (800) 383-3408 for available dates. DOCTORSCHOICEGOLDEXCHANGE.COM: Try our high prices for dental scrap. Check sent 24 hours after you approve our quote. See why we have so many repeat customers. Visit www.DoctorsChoiceGoldExchange. com. THE DENTAL HANDPIECE REPAIR GUY, LLC. Iâ&#x20AC;&#x2122;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 high-speed, 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/

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Advertisers ACEROXT................................................................511

ADS Watson, Brown & Associates.......................546

AFTCO.....................................................................573

Your Patients Trust You. Who can YOU Trust?

A.J. Riggins.............................................................601 Anesthesia Education and Safety

Foundation...........................................................519

DDR Dental Trust....................................................540 Dental Practice Specialists....................................540 Dental Systems.......................................................571

Doctors Per Diem...................................................600

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.

Fortress Insurance.................................................518

Gary Clinton, PMA..................................................509 Hanna, Mark â&#x20AC;&#x201D; Attn. at Law..................................583

Hindley Group.........................................................575

JKJ Pathology........................................................574 JLT Energy Consultants........................................507

Kennedy, Thomas John, D.D.S., P.L.L.C...............601 Knight Dental Group..............................................532

Medical Protective..................................................534

Ocean Dental..........................................................510 Orthodontic Technologies.....................................546 Paragon...................................................................583

Patterson Dental...........................Inside Front Cover Portable Anesthesia Services...............................571 Professional Solutions...........................................533

Professional Recovery Network...........................602 Robertson, James M..............................................570 Shepherd, Boyd W..................................................574

Statewide Toll-free Helpline 800-727-5152

Sharps.....................................................................531

Emergency 24-hour Cell: 512-496-7247

SPDDS.....................................................................518

Southern Dental Associates..................................503

TDA Express...........................................................577 TDA Financial Services Insurance

Program...........................................511/Back Cover

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

TDA Perks Program...................... Inside Back Cover

Texas Health Steps.................................................506

Texas Medical Insurance Company......................525 USA Civilian Dental Corps.....................................575 UTHSCSA................................................................531 UTHSCSA Oral & Maxillofacial Lab.......................540

Waller, Joe...............................................................541

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Unless you’ve registered through Perks, you’re not getting the discount! Buy from Office Depot? By Registering an Account through Perks, You: Get the Perks everyday 10% discount. If you’re

not registered, Office Depot doesn’t know you’re a TDA member. So you don’t get the Perks discount. Increase Perks’ “buying power,” and help

increase your savings. Perks’ ability to negotiate discounts for you is based largely on TDA-member participation. The greater the number of TDA practices registered, the greater the discount Office Depot passes on to you.

It’s Easy to Register for the Perks Office Depot program!

Could win a $200 VISA® gift card! Through July 31st, when you register your practice, you’ll

automatically be entered in a drawing. Encourage your staff members to participate; Perks will

It only takes a few minutes to start saving! • Visit tdaperks.com, click on “Endorsed Partners,” and “Office Depot.” Follow the step-by-step instructions. • OR contact Office Depot’s John Listi at the number below, or: John.Listi@officedepot.com

(512) 284-3392

make sure your practice is credited.

Did You Know? •

If 50% of TDA members register and participate in the Perks/Office Depot discount program, half your annual dues could be eliminated!

Perks negotiated discounts on 26 extra products and services you use in your office daily.

Learn about other TDA Perks Programs at: tdaperks.com, or call: (512) 443-3675. Texas Dental Journal l www.tda.org l June 2011

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May 2011

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Vol. 128, No. 5

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June 2011