July 2011

July 2011

TEXAS DENTAL

BEST OF SHOW The TEXAS Meeting Photo Contest Winner “The Violinist” Texas Dental Journal l www.tda.org l July 2011

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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.

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Texas Journal Dental Journal l www.tda.org August 747 Texas Dental l www.tda.org l Julyl 2011 607

Contents

TEXAS DENTAL JOURNAL n Established February 1883 n Vol. 128, Number 7, July 2011

ON THE COVER Best of Show winner by Dr. John Kostohryz.

“This photo was taken during a walk in Florence, Italy, in May, 2010. Once I observed the ‘Violinist’ and the surrounding environment, I knew it was a ‘Kodak moment.’ After receiving permission (via body language) from this unique Italian musician, I was fortunate to capture this image. I expressed my gratitude by adding a few euros to his coin collection in his violin case.”

CLINICAL REPORT 620 Cone Beam Computed Tomography in the Diagnosis of

Dental Disease

Sotirios Tetradis, D.D.S., Ph.D. Paul Anstey, D.D.S. Steven Graff-Radford, D.D.S.

The authors discuss and illustrate the advantages of cone and beam computed tomography to display third dimensional features for dental diagnosis. Copyright 2010, California Dental Association CDA Journal 2010;139(1):27‐32. Used by permission.

PUBLIC HEALTH REPORT 631 Hispanics with Disabilities in Texas Congressional Districts

H. Barry Waldman, D.D.S., M.P.H., Ph.D. Dolores Cannella, Ph.D. Steven P. Perlman, D.D.S., M.Sc.D., D.H.L. (Hon.)

The authors review Census Bureau data at the Congressional District level to illustrate an approach to personalize the information for community residents and health practitioners in regards to the burgeoning Hispanic population with disabilities in Texas.

CLINICAL REPORT 639

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An Access to Care Study for the Pre-surgical Nasoalveolar Molding and Other Treatments for Cleft Lip and Palate

Carlen P. Blume, D.D.S. Timothy B. Henson, D.M.D.

This study done by the authors is designed to show whether a regional bias and reference exists to those seeking various modalities used in pre-surgical intervention for cleft lip and palate either for their own patients or educational purposes.

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

MONTHLY FEATURES

BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION

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President’s Message

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The View From Austin

648

Dental Artifacts

650

Oral and Maxillofacial Pathology Case of the Month

656

Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management

659

In Memoriam / TDA Smiles Foundation Memorial and Honorarium Donors

660

Value for Your Profession

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Calendar of Events

667

Advertising Briefs

682

Index to Advertisers

EDITORIAL STAFF Stephen R. Matteson, D.D.S., Editor Associate Editor Harvey P. Kessler, D.D.S., M.S., Nicole Scott, Managing Editor Lauren Oakley, Publications Coordinator Barbara 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

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

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Protecting & Defending www.dds4dds.com

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

President’s Message J. Preston Coleman, D.D.S., TDA President

What is the Price?

Let me first say I am deeply honored to be serving for the next year as President of the Texas Dental Association — an Association with a rich historical legacy of being The Voice of Dentistry in Texas. As legislative and regulatory issues continue to evolve at both the federal and state levels, rest assured that the TDA will tirelessly represent your profession. However, to be successful, advocacy must also include the efforts of individual TDA members. The “price” for complacency may be losing the strong practice environment Texas dentists now enjoy.

Checking the e-mail the other day, I received a message from Dr. Ray Gist, ADA President. I spent 3 days in Washington, D.C. seeking support for national dental issues.

Dr. Gist stated that the US Department of Health and Human Services Centers for Disease Control and Prevention (CDC) recently proposed to downgrade its Division of Oral Health from a “division” to a “branch”. The concern is that if the Division of Oral Health becomes a branch, oral health issues may not remain a priority within the CDC. He further explained that Representatives Mike Simpson, D.D.S. (R-ID) and Elijah Cummings (D-MD), co-chairs of the oral health caucus, are asking their colleagues to sign a letter to the Chairman of the House Appropriations Subcommittee on Health to ensure that the Division of Oral Health is not reduced in stature. Dr. Gist asked that we individually write to our members of Congress and ask that he or she sign onto the letter from Reps. Simpson and Cummings.

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At the airport I responded to an earlier e-mail from Dr. Rick Black concerning HB 1776, the TDA bill that prevents insurance companies from capping fees on services they refuse to cover. Dr. Black’s e-mail was a request to all TDA members to reach out to their respective Texas House and Senate members to let them know how important this legislation is and to please support it. I was able to talk to key staff members of five San Antonio legislators to tell them that the dental profession and the insurance industry had agreed to the terms proposed in the bill and if the bill failed many dentists might opt out of insurance contracts compromising dental care for many patients struggling in our present economic situation. Yes it took some time, but it was well worth the results.

As the process played out, HB 1776 stalled, but the TDA legislative team successfully ushered the companion bill, SB 554, through the Texas Senate and the House of Representatives before the close of the regular session. SB 554 is currently in Governor Perry’s office awaiting either his signature or June 19th— the deadline for the Governor to veto legislation. The TDA legislative team will continue to work the bill through the lengthy process.

The legislature focused much of its attention during the regular session to closing an unprecedented budget shortfall. Medicaid dental and CHIP dental were each cut 10 percent in a proposed version of the budget, but thanks to strong advocacy work by TDA members and the legislative team, the approved version of the 2012-2013 budget makes no further cuts to either program. It is important to note that the legislature is in special session and the process is not yet complete. The TDA legislative team will continue its work to protect funding for these important programs until the process is complete.

So what is the real price of your practice, your profession, your education, your livelihood, you and your families’ future, if all of these things are dependent upon your ability to practice dentistry in Texas and earn your living in a free system, minimally hampered by government regulation that is mainly for the good of your patients and the integrity of our profession? I suggest the price is your involvement and participation in the professional arena as an active member of the TDA as well as your participation in the political arena as a citizen who cares about your patients, your staff and your profession. If leadership is your desire, there are a lot of ways to take part in your local society, the TDA or the ADA, but if that is not your desire and if you really care about all of these things, become known to your Texas legislators. You’ll be surprised at how much information you can bring to the arena and how much you can help our legislative team protect and keep our profession as we want it.

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

CATs The use of Critically Appraised Topic (CAT) documents has become a popular method to disseminate new research findings in the field of evidence-based practice. Translation of new information from the bench-to-the-bedside in medicine has been shown to be up to 9 years (1). This so-called “gap” in the clinical application of new scientific information in dentistry may be assumed to be similar, although data on that interval is sparse. One can search the literature for CAT documents in many fields of medicine.

A CAT is usually a one page document listing a PICO* focused clinical question, a clinical bottom line statement, documentation of the research evidence used to reach the stated conclusion, comments on the level of evidence, an evaluation of the evidence and the applicability of the information. Details on this approach can be found in the 2011 February special issue of this Journal on evidence-based practice.

In collaboration with Dr. John Rugh, Director of the Evidence-Based Practice Program at the University of Texas Health Science Cen-

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ter in San Antonio Dental School, the Texas Dental Journal has instituted a “CAT OF THE MONTH” program with this 2011 July issue.

Students at that dental school are required to write CATs with a faculty mentor as a component of their course work and clinical encounters. These documents will be the source of these monthly publications. Please see the next page to view the first example of this series.

The editor looks forward to an informative series of CATs in our Journal. * P I C O

= the patient or problem = the intervention = the comparison treatment/diagnosis = the outcome

Reference 1. Green LW, Ottoson JM, Garcia C, Hiatt RA. Diffusion theory and knowledge dissemination, utilization, and integration in public health. Annu Rev Public Health 2009;30:151-174.

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TX-APR-2011.pdf

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CLINICAL REPORT

Cone Beam Computed Tomography in the Diagnosis of Dental Disease Copyright 2010, California Dental Association CDA Journal 2010;139(1):27-32.

Used by permission.

Sotirios Tetradis, D.D.S., Ph.D. Paul Anstey, D.D.S. Steven Graff-Radford, D.D.S.

Periapical, bitewing, occlusal, and panoramic radiographs are used in everyday dental practice to provide valuable diagnostic information in dental disease diagnosis. However, these radiographic projections offer a 2-D representation of 3-D anatomic structures with resultant structure superimposition and unpredictable distortion. This major limitation obscures anatomic conspicuity and poses difficulties in radiographic interpretation during caries, periodontal, oral surgery, and endodontic applications.

Abstract Conventional radiographs provide important information for dental disease diagnosis. However, they represent 2-D images of 3-D objects with significant structure superimposition and unpredictable magnification. Cone beam computed tomography, however, allows true 3-D visualization of the dentoalveolar structures, avoiding major limitations of conventional radiographs. Cone beam computed tomography images offer great advantages in disease detection for selected patients. The authors discuss cone beam computed tomography applications in dental disease diagnosis, reviewing the pertinent literature when available.

Key words: Dr. Tetradis is a professor and chair in the Section of Oral and Maxillofacial Radiology at the University of California, Los Angeles, School of Dentistry.

Dr. Anstey is a diplomate of the American Board of Endodontics and maintains a private practice in Beverly Hills, California, specializing in microendodontics and implant surgery.

Dr. Graff-Radford is the director of The Program for Headache and Orofacial Pain at the Cedars-Sinai Medical Center and an adjunct professor at the University of California, Los Angeles, School of Dentistry.

To request a printed copy of this article, please contact Sotirios Tetradis, D.D.S., Ph.D., University of California, Los Angeles, School of Dentistry, 53-068 CHS, 10833 Le Conte Ave., Los Angeles, California, 90095.

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cone beam computed tomography, tooth diseases, diagnosis

Tex Dent J 2011;128(7): 620-628.

Cone beam computed tomography, (CBCT), offers an alternative to conventional intraoral and panoramic imaging that circumvents the superimposition and distortion problems. At a significantly lower cost compared to conventional medical CT and utilizing a radiation exposure comparable with other dental radiographic modalities, CBCT provides a true 3-D imaging of the orofacial structures. Although its utilization in dentistry focuses mostly on implant, orthodontic and TMJ evaluation, CBCT technology has potential advantages in common dental disease diagnosis (1).

During the last decade, an increasing number of CBCT systems have become available.

CBCT units can be classified according to the imaged volume or field of view, (FOV), as large FOV (6 inch to 12 inch or 15 to 30.5 cm) or limited FOV systems (1.6 inch to 3.1 inch or 4 to 8 cm). In general, the greater the FOV the more extensive the anatomic area imaged, the higher the radiation exposure to the patient, and the lower the resolution of the resultant images. Alternatively, limited FOV systems image only a small area of the face, deliver less radiation and produce a higher resolution image. With the limited FOV CBCT scanners, isotropic voxel resolutions below 100 Îźm can be achieved (2).

Comparative radiation exposure risk from various imaging modalities utilized in dental practice is beyond the scope of the current manuscript. The reader is referred to recent publications comparing effec-

tive radiation doses of large, medium, and limited FOV CBCT scanners, medical CT, and conventional intraoral and extraoral radiographs according to the 2007 International Commission on Radiological Protection recommendations (3,4). An important consideration regarding radiation exposure is that because of the small volume more than one limited FOV scans might be required to examine the whole area of interest, thus increasing the total radiation delivered to the patient.

Applications that do not need highly detailed depiction of structures, but require imaging a significant portion of the face, such as for orthodontics or extensive implant reconstruction, could benefit from a moderate to large FOV CBCT scan. Alternatively, applications that require imaging of a small part of the orofacial complex are more appropriately imaged by a limited FOV CBCT system. Typically, dental disease diagnosis falls in the second category. The CBCT parameters should be chosen such that the highest resolution scan can be obtained. This will not only limit patient radiation exposure, but more importantly will provide appropriate diagnostic detail for periodontal and endodontic applications (5).

In the subsequent sections, the authors review CBCT use for the diagnosis and treatment planning of common dental disease such as caries detection, periodontal evaluation, endodontic applications, tooth impaction, root resorption, and trauma to the teeth.

Caries Detection Studies comparing the caries detection efficacy of CBCT versus conventional modalities, such as bitewing and periapical intraoral radiographs, are inconclusive. CBCT is reported to more accurately assess proximal caries depth compared to film or storage phosphor periapical radiographs (6). In a similar study of noncavitated teeth, a large FOV CBCT performed poorer in detection of caries, while a limited CBCT had higher sensitivity only for occlusal caries compared to digital or conventional periapical radiographs (7). Finally, no difference in the detection of a carious lesion between a limited CBCT and film in proximal premolar surfaces was observed (8).

Although these and similar reports outline the potential benefit of CBCT technology in caries detection, they are performed in well-controlled experimental settings that do not reflect the reality of everyday dental practice. Beam hardening artifacts are frequent in the imaging of dental structures and particularly tooth crowns (2). Such artifacts originate from metallic restorations, implants, endodontic restorative material, or other dense objects and create distortion of structures, streaks of bright and dark bands and noisy projection reconstructions that project over adjacent teeth and render diagnosis difficult or unfeasible. In particular, the dark bands may convey the Texas Dental Journal l www.tda.org l July 2011

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Cone Beam false impression of recurrent caries. Patient movement decreases structure sharpness and definition, and further complicates these artifacts. It has been the authors’ experience that at the present time, CBCT technology is not practical or advantageous over intraoral radiography for caries detection. However, if a CBCT scan is taken for other purposes, all teeth present in the imaging volume, should be evaluated for coronal integrity and pathosis.

Periodontal Evaluation

behaved similarly in the detection of interdental bone level (9). When assessing periodontal bone in dry skulls, CBCT provides better diagnostic and quantitative assessment of periodontal defects compared to periapical radiographs.

CBCT is particularly advantageous for the buccal and lingual, as well as furcational assessment of periodontal defects (10,11). These in vitro findings translate to the clinical setting where CBCT outperformed intraoral radiography in precision and accuracy for the detection of periodontal bone levels following regenerative periodontal therapy

(12). The high agreement of CBCT with surgical measurements prompted the authors to suggest that CBCT may replace surgical re-entry as a technique for assessing regenerative therapy outcomes. The superior ability of CBCT imaging to evaluate periodontal bone levels can be appreciated in Figure 1. Although on the periapical radiograph (Figure 1A) periodontal bone levels around tooth No. 4 appear to be relatively normal, CBCT imaging reveals a deep avertical defect extending from the lingual alveolar crest to the apex of No. 4 (Figures 1-D).

Interdental bone levels can be assessed with conventional radiographs. However, little information can be gained when buccal, lingual, or fractional periodontal bone height needs to be determined because of superimposition of the alveolar bone with the teeth or roots. Furthermore, partial loss of interdental bone thickness can be difficult to determine on 2-D radiographs.

CBCT imaging, by allowing the 3-D evaluation of the periodontal tissues, solves these projection problems of periapical and bitewing radiographs.

Indeed, CBCT performs superiorly in the assessment of artificial buccal or lingual periodontal defects compared to periapical radiographs.

However, the two modalities

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Figure 1. Periapical (a), sagittal (b), cross-sectional (c), and axial (d) CBCT sections of tooth No. 4. The arrow on CBCT images points to periodontal defect. CBCT images in this and the remaining figures were generated by the limited FOV 3-D Accuitomo CBCT scanner by J. Morita.

Periapical Disease

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CBCT showed improved sensitivity, positive and negative predictive values, and diagnostic accuracy compared to conventional radiographs in experimental periapical lesions in pig and human jaws, and in 888 consecutive patients (13-15). In a patient study including 74 posterior maxillary and mandibular teeth with a total of 156 roots, CBCT detected 34 percent more periapical lesions compared to periapical radiographs and demonstrated, with higher frequency, periapical lesion expansion into the maxillary sinus, thickening of the sinus mucoperiosteal lining and the presence of untreated root canals (16).

In a similar study of 46 teeth with periapical lesions, the increased CBCT sensitivity for disease detection led to the uniform observer agreement that in 70 percent of the cases, CBCT images provided clinically relevant additional information not detected in periapical radiographs, including improved root and root canal visualization, lesion localization, and relation to vital anatomic structures. The same authors also noted that beam hardening artifacts from

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Similar to periodontal disease, the ability of CBCT imaging to bypass anatomic structure superimposition and evaluate the teeth and their supporting structures three-dimensionally is advantageous for detecting periapical disease presence and severity.

Figure 2. Periapical (a), sagittal (b), cross-sectional (c), and axial (d) CBCT sections of tooth No. 15. Curved arrow points to disruption of buccal cortication and straight arrow points to periodontal ligament space widening.

endodontic restorative material can distort image quality and create diagnostic difficulties (16).

Figure 2 demonstrates the advantages of CBCT imaging in evaluating the status of periapical tissues. The periapical radiograph Figure 2a) clearly demonstrates radiolucency at the apex of No. 15 mesiobuccal and distobuccal roots. However, the palatal root cannot be clearly seen due to slight distortion, and the superimposition of the roots and zygomatic process of the maxilla. Sagittal (Figure 2b), crosssectional (Figure 2c) and axial (Figure 2d) sections clearly depict the extent of periapical disease around all three roots. Furthermore, these sections demonstrate disruption of the buccal cortex suggesting possible fistula formation (C&D curved arrows),

and widening of the periodontal ligament space at the palatal surface of the palatal root suggesting formation of an endo-perio lesion (straight arrow).

In addition to improved diagnostic accuracy, limited field of view CBCT imaging demonstrates an increased ability to detect and localize anatomic features of the root and root canal system that can affect treatment planning. CBCT more accurately identified root canals compared to digital periapical radiographs. Interestingly, observers utilizing digital periapical radiographs failed to identify one or more root canals in 40 percent of teeth examined. The authors suggested that in these cases, the failure to identify root canals can result in a less optimal healing outcome (17).

Additionally, CBCT produces Texas Dental Journal l www.tda.org l July 2011

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Cone Beam

å

Figure 3. Sagittal (a) and cross-sectional (b) images of tooth No. 29 demonstrate the location of canal opening in relation to existing restorative material.

accurate measurements of root angulation, compared to conventional imaging, and can be used for the evaluation of root curvature (18,19). Figure 3 demonstrates CBCT images of No. 29 with a partially calcified canal. Although initial access of the canal opening was unsuccessful, CBCT sections provided useful information for angulation and distance of the canal opening that allowed canal identification.

Root Resorption Although no experimental or clinical studies have evaluated its usefulness in diagnosing external or internal tooth resorption, several case reports demonstrate the advantage of CBCT technology over conventional radiographs not only in detecting but further

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Figure 4. Panoramic radiography (a), sagittal (b), cross-sectional (c), and axial (d) CBCT sections of tooth No. 27 demonstrate the presence and severity of external (straight arrow) and internal root resorption. Curved arrow points to the extension of internal resorption to the lingual tooth surface.

in evaluating the extent of resorption (20-23). There is general agreement that CBCT provides valuable information allowing the exact localization and extent of tooth resorption, as well as possible perforation and communication with the PDL space (21,24). The authors’ experience with many internal and external root resorption cases is in agreement with that assessment.

The authors further found CBCT imaging advantageous in the diagnosis, assessment of prognosis, treatment planning, and treatment follow-up of external and internal resorption cases. In the authors’ view, limited FOV CBCT is a technological breakthrough in the management of these types of cases.

Figure 4 shows a periapical radiograph and CBCT sec-

tions of tooth No. 6. On the periapical radiograph internal resorption of No. 6 can be seen. However, the extent and location of the resorption cannot be determined.

CBCT sections demonstrate internal root resorption that has eroded a significant part of the tooth toward the lingual aspect of the cervical area.

However, the resorption has not perforated the lingual tooth surface (curved arrow).

Lack of perforation supports a favorable outcome in this case after endodontic intervention.

Tooth Impaction CBCT technology offers clear advantages over conventional radiography for the evaluation of impacted teeth. CBCT demonstrates great usefulness in localizing maxillary canine

Figure 5. Sagittal (a), cross-sectional (b), and axial (c) CBCT sections of impacted tooth No. 17. The arrow points to the lingual position of the inferior alveolar canal.

impaction, evaluating canine angulation and determining resorption of adjacent lateral and central incisors (25,26).

Root development, relation to vital anatomic structures including the inferior alveolar canal, IAC, maxillary sinus and adjacent teeth, the 3-D orientation of the impacted tooth within the alveolus and the detection of any associated pathosis that might cause the impaction can be more accurately determined by CBCT imaging (27,28). Figure 5 demonstrates CBCT images of impacted No. 17. The close relation of the roots with the inferior alveolar canal, which is positioned lingually to the roots (straight arrow), can be appreciated in detail.

Although CBCT scans provide a more precise assessment of tooth impaction, not all impacted teeth require CBCT imaging for diagnosis and treatment planning. It is argued that in the great majority of cases, the relation of the IAC with the roots of impacted mandibular third

molars can be evaluated by conventional radiographs. If such films reveal an intimate relationship between the IAC and the roots, CBCT imaging can provide important information for the management of the impacted tooth (29).

Dental Trauma One of the more difficult diagnostic tasks in dentistry is dental trauma evaluation. Minimal fracture fragment displacement, structure superimposition, softtissue swelling, and the presence of foreign objects can complicate the appearance of tooth fracture in conventional radiographs. Unless the X-ray beam is oriented through the plane of the fracture it may not be possible to separate the fractured root fragments.

Furthermore, obtaining good quality intraoral radiographs can be challenging in noncooperative patients.

radiography for the evaluation of trauma and suspected root fractures (30,31). CBCT shows increased sensitivity and greater interobserver variability over conventional periapical radiographs in the detection of experimentally induced horizontal root fractures of central and lateral human incisors.

Interestingly, the specificity of both modalities was similar (32). Additionally, CBCT is statistically significantly more accurate than periapical radiographs in fracture detection of 20 patients with suspected root fractures (33).

Figure 6 illustrates a case where limited FOV CBCT imaging provided central information for the definitive diagnosis of tooth No. 9 root fracture. Periapical radiograph of No. 9 (Figure 6a) is inconclusive, while sagittal (Figure 6b) and cross-sectional (Figure 6c) CBCT images clearly demonstrate the oblique root fracture through the whole root thickness.

CBCT imaging is clearly advantageous over conventional Texas Dental Journal l www.tda.org l July 2011

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Cone Beam

Figure 6. Periapical radiograph (a), sagittal (b), and cross-sectional (c) CBCT images of tooth No. 9.

Dental Treatment Complications The authors are not aware of any clinical or experimental studies that have addressed CBCT usefulness in dental treatment complications. However, in the authors’ experience, CBCT imaging can prove valuable in cases where a patient’s symptoms persist despite appropriate intervention or in cases where a patient develops adverse symptomatology, such as paresthesia, anesthesia, pain, or loss of function. The ability of CBCT to capture the 3-D relation of teeth to anatomic structures such as the inferior alveolar canal, mental foramen/anterior loop, maxillary sinus, restorative materials, dental implants, and other areas of pathosis without any superimposition artifacts, can reveal crucial diagnostic information not available in conventional radiographs.

Figure 7 illustrates a case of an endodontically treated tooth No. 14. Although the dentist felt that the endodontic treatment was successful and the panoramic (Figure 7a) and periapical (not shown) radiographs were unremarkable, the patient complained of persistent pain. CBCT sagittal and axial sections demonstrated the existence of an unfilled second canal in the mesiobuccal root of No. 14 (straight arrows).

Importantly, a periapical radiolucency indicative of persistent periapical disease is seen at the apex of the mesiobuccal root.

In Figure 8, radiographs of a patient who developed pain after an endodontic treatment of tooth No. 18 are shown. Periapical radiograph (Figure 8a) demonstrated endodontic cones significantly extruding past the radiographic apices of both the mesial and distal roots of No. 18. Although the inferior alveolar canal appears to be in close proximity to the apices of No. 18 roots and to the extruded material, the exact relationship of these structures could not be evaluated on conventional radiographs. CBCT

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images demonstrated that the endodontic cone perforated the roof and extended to the floor of the inferior alveolar canal at the center of the canal (straight arrow, Figures 8b-d). The endodontic cone in the mesial root was located on the buccal of the inferior alveolar canal (curved arrow, Figure 8d). Also note persistent periapical radiolucency around the apex of the mesial root of No. 18 seen on periapical and CBCT images.

Conclusions Over the last decade, CBCT imaging has revolutionized oral and maxillofacial imaging. CBCT technology finds utilization not only in implant and orthodontic applications, but almost in every facet of clinical dentistry. When CBCT scanning is considered, the smallest volume that will image the area of interest should be selected. This will provide higher resolution and lower patient radiation exposure.

The ability of CBCT to visualize the 3-D relation of anatomic structures and dental pathology improves diagnosis and treatment planning.

To the best of the authors’ knowledge, clear guidelines and evidence-based selection criteria for CBCT utilization have not been established thus far. Based on the published literature and the authors’ personal experience, they believe the majority of

Figure 7. Panoramic radiograph (a), sagittal (b), and axial (c) CBCT sections of tooth No. 14. The arrow points to the unfilled canal in the mesio-buccal root of tooth No. 14.

patients are appropriately managed utilizing conventional radiographs. However, CBCT imaging can be greatly beneficial in diagnosing and treatment planning of select dental patients.

The authors found no indication for CBCT use in caries

detection. In cases where periodontal surgery is considered, CBCT provides valuable qualitative and quantitative assessment of periodontal defects. When periodontal or periapical disease cannot be clearly confirmed on periapical radiographs, but is highly suspected based on patient

ĂĽ Figure 8. Periapical radiograph (a), sagittal (b), crosssectional (c), and axial (d) CBCT sections of tooth No. 18. Straight arrow points to the endodontic cone in the distal, while curved arrow points to the endodontic cone in the mesial root of No. 18.

symptomatology, CBCT imaging could be a great diagnostic aid. Additionally, if conventional radiographs suggest anatomic variants such as root curvature or accessory canals, CBCT scans can facilitate accurate assessment and endodontic treatment planning. In most external and internal root resorption cases, CBCT provides valuable information as to whether treatment of these lesions can lead to a favorable outcome.

Impacted teeth in close proximity to vital structures are accurately evaluated by CBCT imaging. Dental trauma can be a very challenging diagnostic task. When conventional radiographs are inconclusive, CBCT can add valuable diagnostic information in suspected root fractures.

Finally, suspected dental treatment complications can be assessed and corrective interventions, if necessary, can be promptly designed. The treating dentist should determine whether the diagnostic benefits gained by CBCT imaging exceed the patient’s risk from increased radiation exposure as well as the financial cost.

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Cone Beam References 1. Tyndall DA, Rathore S, Cone beam CT diagnostic applications: caries, periodontal bone assessment, and endodontic applications. Dent Clin North Am 52(4):825-41, vii, 2008.

2. Scarfe WC, Farman AG, What is cone-beam CT and how does it work? Dent Clin North Am 52(4):707-30, v, 2008.

3. Ludlow JB, Davies-Ludlow LE, White SC, Patient risk related to common dental radiographic examinations: the impact of 2007 International Commission on Radiological Protection recommendations regarding dose calculation. J Am Dent Assoc 139(9):1237-43, 2008.

4. Ludlow JB, Ivanovic M, Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 106(1):106-14, 2008.

5. Farman AG, Field of view. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 108(4):477-8, October 2009.

6. Akdeniz BG, Grondahl HG, Magnusson B, Accuracy of proximal caries depth measurements: comparison between limited cone beam computed tomography, storage phosphor and film radiography. Caries Res 40(3):202-7, 2006.

7. Haiter-Neto F, Wenzel A, Gotfredsen E, Diagnostic accuracy of cone beam computed tomography scans compared with intraoral image modalities for detection of caries lesions. Dentomaxillofac Radiol 37(1):18-22, 2008.

8. Tsuchida R, Araki K, Okano T, Evaluation of a limited cone beam volumetric imaging system: comparison with film radiography in detecting incipient proximal caries.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 104(3):412-6, 2007.

9. Misch KA, Yi ES, Sarment DP, Accuracy of cone beam computed tomography for periodontal defect measurements. J Periodontol 77(7):1261-6, 2006.

10. Mol A, Balasundaram A, In vitro cone beam computed tomography imaging of periodontal bone. Dentomaxillofac Radiol 37(6):319-24, 2008.

11. Vandenberghe B, Jacobs R, Yang J, Detection of periodontal bone loss using digital intraoral and cone

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beam computed tomography images: an in vitro assessment of bony and/or infrabony defects. Dentomaxillofac Radiol 37(5):252-60, 2008.

12. Grimard BA, Hoidal MJ, et al, Comparison of clinical, periapical radiograph, and cone beam volume tomography measurement techniques for assessing bone level changes following regenerative periodontal therapy. J Periodontol 80(1):48-55, 2009.

13. Stavropoulos A, Wenzel A, Accuracy of cone beam dental CT, intraoral digital and conventional film radiography for the detection of periapical lesions. An ex vivo study in pig jaws.

Clin Oral Investig 11(1):101-6, 2007 14. Patel S, Dawood A, et al, Detection of periapical bone defects in human jaws using cone beam computed tomography and intraoral radiography. Int Endod J 42(9):831-8, September 2009.

15. Estrela C, Bueno MR, et al, Accuracy of cone beam computed tomography and panoramic and periapical radiography for detection of apical periodontitis. J Endod 34(3):273-9, March 2008.

16. Low KM, Dula K, et al, Comparison of periapical radiography and limited cone-beam tomography in posterior maxillary teeth referred for apical surgery. J Endod 34(5):55762, 2008.

17. Matherne RP, Angelopoulous C, Use of cone beam computed tomography to identify root canal systems in vitro. J Endod 34(1):87-9, 2008.

18. Estrela C, Bueno MR, et al, Method for determination of root curvature radius using cone beam computed tomography images. Braz Dent J 19(2):114-8, 2008.

19. Peck JL, Sameshima JT, et al, Mesiodistal root angulation using panoramic and cone beam CT. Angle Orthod 77(2):206-13, 2007.

20. Patel S, Dawood A, The use of cone beam computed tomography in the management of external cervical resorption lesions. Int Endod J 40(9):730-7, 2007.

21. Cotton TP, Geisler TM, et al, Endodontic applications of cone-beam volumetric tomography. J Endod 33(9):1121-32, 2007.

22. Maini A, Durning P, Drage N, Resorption: within or without? The benefit of cone beam computed

tomography when diagnosing a case of an internal/external resorption defect. Br Dent J 204(3):135-7, 2008.

23. Patel S, Kanagasingam S Pitt Ford T, External cervical resorption: a review. J Endod 35(5):616-25, 2009.

24. Patel S, New dimensions in endodontic imaging: part 2. Cone beam computed tomography. Int Endod J 2009.

25. Liu DG, Zhang WL, et al, Localization of impacted maxillary canines and observation of adjacent incisor resorption with cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 105(1):91-8, 2008.

26. Walker L, Enciso R, Mah J, Threedimensional localization of maxillary canines with cone beam computed tomography. Am J Orthod Dentofacial Orthop 128(4):418-23, 2005.

27. Tamimi D, ElSaid K, Cone beam computed tomography in the assessment of dental impactions.

Semin Orthod 15(1):57-62, 2009.

28. Mah J, Enciso R, Jorgensen M, Management of impacted cuspids using 3-D volumetric imaging. J Calif Dent Assoc 31(11):835-41, November 2003.

29. Flygare L, Ohman A, Preoperative imaging procedures for lower wisdom teeth removal. Clin Oral Investig 12(4):291-302, 2008.

30. Cohenca N, Simon JH, et al, Clinical indications for digital imaging in dentoalveolar trauma. Part 2: root resorption. Dent Traumatol 23(2):105-13, 2007.

31. Cohenca N, Simon JH, et al, Clinical indications for digital imaging in dentoalveolar trauma. Part 1: traumatic injuries. Dent Traumatol 23(2):95-104, 2007.

32. Kamburoglu K, Ilker Cebeci AR, Grondahl HG, Effectiveness of limited cone beam computed tomography in the detection of horizontal root fracture. Dent Traumatol 25(3):256-61, 2009.

33. Bernardes RA, de Moraes IG, et al, Use of cone beam volumetric tomography in the diagnosis of root fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 108(2):270-7, 2009.

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

509

PUBLIC HEALTH REPORT

Hispanics with Disabilities in Texas Congressional Districts H. Barry Waldman, D.D.S., M.P.H., Ph.D. Dolores Cannella, Ph.D. Steven P. Perlman, D.D.S., M.Sc.D., D.H.L. (Hon.)

Introduction The Census Bureau report on the 2010 Census indicated that there were more than 54 million U.S. residents (16.3 percent of the population) of Hispanic-origin.

Forty-seven percent of this population lived in California or Texas (1). Federal agencies detailed that in 2006 disability associated health care expenditures ($397.8 billion) accounted for 26.7 percent of all health care expenditures for adults in the U.S., ranging from $598 million in Wyoming to $40.1 billion in New York. In Texas, $24 billion was associated with health care expenditures for 2,782,000 individuals with disabilities (including 859,800 Hispanics with disabilities) (2-5).

Waldman

Cannella

Perlman

Dr. Waldman is a distinguished teaching professor, Department of General Dentistry School of Dental Medicine, Stony Brook University, NY 11794-8706. E-mail: hwaldman@ notes.cc.sunysb.edu Dr. Cannella is director of behavioral sciences and assistant professor, Department of General Dentistry, Stony Brook University, NY. Dr. Perlman is global clinical director, Special Olympics, Special Smiles, and clinical professor of Pediatric Dentistry, The Boston University School of Dental Medicine, Boston, MA. 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.

Abstract It is difficult to comprehend the difficulties faced by individuals with special needs and their families when they are couched in “mega numbers.” These complications are magnified further in considering the burgeoning Hispanic population with disabilities in Texas. The need is to somehow “personalize” these numbers if we are to bring increased attention to these individuals with special needs. To this end, Census Bureau data at the Congressional District level were used to illustrate an approach to personalize the information for community residents and health practitioners.

Key words: Hispanic Americans, disabled persons, Texas Tex Dent J 2011; 128(7): 631-636.

This article has been peer reviewed.

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Hispanics with Disabilities

54 Million

Number of people in the U.S. who have some level of disability. They represent 19 percent of the population.

34.9 Million

Number of people in U.S. with a severe disability.

They represent 12 percent of the population.

14.1 Million

Number of people 65 years and over in U.S. with a disability. They represent 37 percent of seniors (2,4).

8.2 Million

Number of people 80 years and older in U.S. with a disability. They represent 72 percent of the 11.5 million older age seniors; the population group with the highest proportion of disabled (6).

Unfortunately, the use of “mega numbers” (whether it is millions of individuals with disabilities or billions of dollars for needed services) is difficult for any person to gain a proper perspective. We tend to generalize and gloss over such numbers, unable to comprehend the impact of these costs, and the particular conditions on individuals and their families.

The need is to somehow “personalize” these numbers if we are to bring increased attention to these individuals with special needs.

A previous presentation in the Texas Dental Journal (TDJ) emphasized the need to support efforts for dental services of underserved Texas residents in terms of income, health insurance, and race/ethnicity from the perspective of the state, county and school district levels (7). The availability of current data regarding residents with disabilities in each of the Congressional Districts in Texas provides an opportunity to extend further the earlier TDJ report to document the number of Hispanics with disabilities in one’s community.

In terms of the needs of Hispanics with disabilities, such an effort may help to overturn the recent newspaper headline that, “Latinos rise in number, not influence” (8).

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Number of Noninstitutionalized Hispanic Residents with Disabilities In 2009, there were more than an estimated 100,000 Hispanic residents in 30 of the 32 Congressional Districts in Texas, including over a half million Hispanics in six Congressional Districts; and ranging as high as more than 598,000 Hispanics in the 15th District and more than 644,000 Hispanics in the 28th District.

Children with disabilities: There were more than a thousand children with disabilities in 31 of the 32 Districts, including more than 11,000 in the 15th and 27th District, and more than 13,000 in the 28th District.

18-64 years with disabilities: There were over 3,000 individuals with disabilities in their working years in each district, ranging as high as more than 11,000 in 14 Districts; including over 30,000 in the 16th, 20th and 23rd Districts, and more than 40,000 in the 15th, 27th and 28th Districts.

65 and over years with disabilities: There were more than 20,000 seniors with disabilities in the 15th, 16th, 20th 23rd, 27th and 28th Districts.

(Table 1)

Table 1. Estimated non-institutionalized Hispanic population with disabilities by age and Texas Congressional Districts (111th Congress): 2009 (9) Total Hispanic

District 1 2 3 4 5

Population

95,697 155,200 199,400 98,647 147,404

<18 years

Hispanic population with disabilities

18-64 years

898 2,470 2,238 1,724 1,920

65 and over years

3,396 5,596 5,844 4,610 5,516

1,431 2,171 2,044 849 1,563

8,253 5,855 3,270 9,190 7,609

1,367 1,892 1,377 4,241 3,886

6 7 8 9 10

188,611 2,774 182,150 1,188 106,627 1,138 305,681 1,874 261,266 2,833

11 12 13 14 15

238,386 3,955 14,572 234,332 2,576 8,688 140,834 1,820 7,248 207,565 1,989 11,490 598,224 11,731 44,695

6,674 3,343 2,806 5,748 26,133

16 17 18 19 20

569,364 5,386 31,478 145,951 3,100 7,532 310,215 3,283 11,114 216,883 4,059 14,113 481,458 7,108 36,917

25,120 2,600 4,890 6,718 20,632

21 22 23 24 25 26 27 28 29 30 31 32

228,920 3,134 239,084 2,739 516,231 6,604 213,028 1,979 306,711 3,872 187,755 2,876 512.821 11,037 644,408 13,357 503,536 6,981 312,020 2,843 168,096 2,113 288,209 2,757

5,850 4,090 23,013 3,702 4,739 1,456 24,313 27,971 10,686 4.439 2,885 3,130

11,748 8,344 38,753 7,962 14,611 6,824 43,750 47,367 24,055 11,500 8,300 7,435

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Hispanics with Disabilities Table 2. Prevalence of disabilities among non-institutionalized Hispanic and non-Hispanic people by age group in Texas, 2008 (10) Age

Hispanic

Non-Hispanic

All ages

9.9%

< 5 yrs

0.8

0.5

5-15

5.4

5.1

16-20

5.6

6.0

21-64

10.0

10.9

65-74

40.0

28.7

75+

65.0

54.9

12.7%

Table 3. Percent of Texas Hispanic population with one or more disabilities by type of disability: 2008 (10,12)

Percent Disabled*

Hispanic population with a disability**

All disabilities

9.9%

859,800

Visual

2.7 235,000

Hearing 3.4 295,900 Ambulatory 6.8 591,700 Cognitive 4.7 409,000 Self-Care 2.7 235,000 Independent living

5.3

461,000

* Percents individual disabilities are based upon the disability rates for the total population of Texas. ** Based upon total 2008 Texas Hispanic population of 8,702,000. Numbers are rounded.

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Proportion of Noninstitutionalized Hispanic Residents with Disabilities The proportion of Hispanics with disabilities and non-Hispanics with disabilities increased with age, but with major differences.

• Among 65-74 year olds — 40 percent of Hispanics and 29 percent of non-Hispanics had disabilities.

• Among 75 years and older — 65 percent of Hispanics and 55 percent of non-Hispanics had disabilities.

In some younger years, the proportion of Hispanics with disabilities was somewhat lower than their non-Hispanic counterpart (Table 2).

The variations in the enumeration of Hispanic children with special needs may be a reflection of: 1) the fact that government agencies only recently have expanded demographic reports to better describe the burgeoning Hispanic population, 2) Hispanic adults may be more willing to describe their own disabilities than those of their children, and 3) cultural values, language, economics, and a vast array of related factors alter the response to circumstances of children with special health care needs (11).

Types of Disabilities Hundreds of thousands of Hispanic residents reported a wide range of disabilities, ranging from 235,000 individuals with visual and/or self-care limitations to 591,700 with ambulatory limitations (Table 3). (Note: the Census Bureau has not reported the Hispanic population by disability categories at the state level. The numbers were developed using the statewide population proportion distributions.)

Dental Perspective Studies at the national level indicate that a smaller percent of the general Hispanic popu-

lation had a dental visit in the previous year and a greater percent of the Hispanic (MexicanAmerican) population had untreated dental caries (Tables 4 and 5).

Table 4. Proportion of U.S. population with a dental visit in the past year by age, race/Hispanic origin: 2005-2008 (13)

Hispanic

2+ yrs

2-17 yrs

18-64 yrs

65+ yrs

56.0%

73.0%

48.1%

47.9%

Black 59.9 76.7 55.9 38.1 White 66.3 79.1 63.1 61.8

Table 5. Proportion of U.S. population with untreated dental caries by age, race/Hispanic origin: 2009 (13) 6-19 yrs

20-64 yrs

Hispanic (Mexican)

22.3%

34.6%

31.9%

Black

22.1

39.0

31.3

White

12.8 18.8 16.6

In addition, children with special health care needs (CSHCN), “… particularly lower income and severely affected (children), are more likely to report unmet dental care needs compared with unaffected children…. Dental care remains the most frequently cited unmet health need for CSHCN” (14-16). In addition, the increased levels of periodontal disease and dental caries, and the difficulties faced by individuals with special needs in securing needed services continue into adulthood (17-18). (Note: Use of dental services and levels of untreated oral health needs are not reported at the state level by racial/ethnic groups.)

The Challenge The particular economic difficulties faced by Texans have resulted in budgets which “…make huge cuts in public education, nursing homes and health care for the poor” (19). In such an environment, any effort that can personalize the needs of a large special group among the residents in our communities enhances awareness and the potential for support. For example:

65-74 yrs

• There were more than an estimated 100,000 Hispanic residents in 30 of the 32 Congressional Districts, including more than a 500,000 Hispanics in six Congressional Districts.

• There are more than a 1,000 Hispanic children with disabilities in 31 of the 32 Congressional Districts.

• There are more than 3,000 working age Hispanic constituents with disabilities in every Congressional District, and as many as 30,000 and 40,000 in some of the Districts.

• There are thousands of Hispanic seniors with disabilities in almost every Congressional District and more than 20,000 in some of the Districts.

Nevertheless, “mega numbers” do have their place and should be emphasized together with “personalized” information when making a presentation to community residents and health practitioners.

The combination of these numbers can demonstrate the magnitude of the problem and increase the potential for attention to needed services for Hispanics with disabilities in Texas.

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Hispanics with Disabilities References 1. Elliot S. Pretty as a (Census) picture. NY Times, March 28, 2011.

2. Census Bureau. 20th Anniversary of Americans with Disability Act: July 26.What is the cost or economic impact associated with mental retardation? Web site: http://www.census. gov/newsroom/releases/ archives/facts_for_features_ special_editions/cb10-ff13. htmlnb Accessed March 16, 2011.

3. Anderson WL, Armour BS, Finkelstein EA,Wiener JM. Estimates of state-level health-care expenditures associated with disability.

Public Health Rep. 2010; 125(1): 44â&#x20AC;&#x201C;51.

4. Census Bureau. United States: Table S1810: disability characteristics.

Web site: http://factfinder. census.gov Accessed April 1, 2011.

5. Center for Disease Control and Prevention. Disability and Health. Web site: http://www.cdc.gov/ ncbddd/disabilityandhealth/economic-data-html Accessed April 1, 2011.

6. Census Bureau. Facts for features. Americans with Disabilities Act: July 26, 2006. Web site: http:// census.gov/Press-Release/ www/releases/archives/ facts_for_features Accessed December 16, 2010.

7. Waldman HB, Cinotti DA. Lobby for dental services of

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underserved Texas residents. Texas Dent J, 2009; 126(1):13-17.

8. Van Natta Jr D. Latinos rise in numbers, not influence.

NY Time, April 8, 2011.

9. Census Bureau. American Factfinder. Age by disability status (Hispanic or Latino) non-institutionalized population: Texas.

Website: http://factfinder. census.gov/servletDTG eoSearchByListServlet? ds_name=ACS_2009_1YR_ G00_&state=dt&mt_ name=ACS_2009_1YR_ G2000_B18101I&_ lang=en&ts=320230377032 Accessed April 7, 2011.

10. Cornell University. 2008 Disability Status Report: Texas. Web site: http:// www.ilr.cornell.edu/ edi/disabilitystatistics/ StatusReports/2008PDF/2008-StatusReport_TX .pdf?CFID=3455037&CFTO KEN=48829945&jsessionid =f0309882715d0242fe8767 97a4d7d2f206a4 Accessed April 8, 2011.

11. Census Bureau. Census 2000 Demographic Profile Highlights: Selected Population Group: Hispanic or Latino (of any race). Web site: http://factfinder.census.gov Accessed April 4, 2011.

12. Pew Hispanic Center. Demographic profile of Hispanics in Texas, 2008. Web site: http://pewhispanic. org/states/?stateid=TX Accessed April 8, 2011.

13. U.S. Department of Health and Human Services.

National Center for Health Statistics. Health, United States, 2010: with special feature on death and dying.

Hyattsville, MD: National Center for Health Statistics, 2011.

14. Lewis CW. Dental care and children with special health care needs: a populationbased perspective. Acad Pediatr. 2009;9(6):420-6.

15. Unmet dental needs/child trends data bank. Web site: http://www.childtrendsdatabank.org/?q=node/77 Accessed April 11, 2011.

16. Lewis C, Robertson AS, Phelps S. Unmet dental care needs among children with special health care needs: implications for the medical home. Pediatrics 2005;116(3):e426-31.

17. Glassman P, Folse G. Financing oral health services for people with special needs: projecting national expenditures. J Calif Dent Assoc. 2005;33(9):731-40.

18. Waldman HB, Perlman SP, Lopez del Valle LM. A review of the oral health of individuals with disabilities in Puerto Rico and among U.S. Hispanics. Spec Care Dentist 2007;27(1):26-30.

19. McKinley Jr JC. After years of cost cuts, Texas tries to find more. NY Times April 9, 2011. pA12.

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CLINICAL REPORT

An Access to Care Study for the Pre-surgical Nasoalveolar Molding and Other Treatments for Cleft Lip and Palate Carlen P. Blume, D.D.S. Timothy B. Henson, D.M.D.

Introduction Cleft lip and palate is the second most common birth defect to clubfoot occurring in 1:700 live births (5,8,14). Different methods for pre-surgical interventions in cleft lip and palate patients have been studied since the 1950â&#x20AC;&#x2122;s. Some of the earlier interventions included only lip adhesion surgery prior to the complete

Blume

Henson

Dr. Blume is in full-time private practice of Pediatric Dentistry in San Antonio, Texas. She is on the Craniofacial Anomalies Team at Christus Santa Rosa Hospital where she also serves as adjunct faculty for The University of Texas Health Science Center, San $QWRQLR 7H[DV É&#x2018; Dr. Henson is Associate Professor and Pediatric Dentistry Postdoctoral Program Director, Department of Developmental Dentistry, University of Texas Health Science Center, San Antonio, Texas.

Abstract Purpose: This study is designed to ascertain whether a regional bias exists, as well as provide a reference to those seeking the various modalities used in pre-surgical intervention for cleft lip and palate either for their own patients or educational purposes.

Methods: A survey was constructed using Survey Monkey and distributed via e-mail to American Academy of Pediatric Dentistry members. Approximately 3,689 surveys were delivered consisting of 12 questions asking whether they provide pre-surgical intervention to cleft lip and palate patients, and what type of interventions they use.

Results: A total of 572 members responded.

Of the respondents, 480 reported they treat children affected by cleft lip and/or cleft palate.

Of these, only 102 reported that they provide pre-surgical treatment. Pre-surgical nasoalveolar molding (PNAM) represented 29.2 percent of the interventions used and was most heavily concentrated in Texas. Other modalities used included the Latham appliance, lip adhesion/ tacking, the passive appliance, and a category â&#x20AC;&#x2DC;otherâ&#x20AC;&#x2122; was included. Those checking â&#x20AC;&#x2DC;otherâ&#x20AC;&#x2122; most often described alveolar grafting prior to later surgical procedures than were of interest in this study. The University of Texas Health Science Center San Antonio had the largest number of respondents using the PNAM. Conclusions: A very small proportion of pediatric dentists are providing pre-surgical intervention of any kind to patients with cleft lip and palate. However, those that are providing the service are spread around the country enough to consider PNAM as the standard of care for pre-surgical infant cleft treatment.

KEY WORDS: Pre-surgical nasoalveolar molding, cleft palate, cleft lip Tex Dent J 2011;128(7): 639-645.

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Pre-surgical Nasoalveolar Molding cheiloplasty (23). Lip adhesion is still used alone or in conjunction with other appliances today. It has been shown that lip adhesion allows pressure to be placed on the premaxilla and anterior portions of the lateral segments causing segmental alignment from muscular forces (4,6,7,23). One study showed that 61 percent of surgeons use lip adhesion either alone or with an adjunct therapy, so it is clearly a valued tool in the armamentarium to treat patients with cleft lip and palate (25).

While it is the most popular intervention, lip adhesion is not without complications (25). A recent study by Nagasao et.al. in 2009 showed that lip adhesion in the absence of alveolar bone graft resulted in an exacerbation of facial asymmetries. They attributed the upper lip pressure to a dislocation of the cleft side to a posterior position affecting the orbit, nasal bone, piriform margin, and anterior wall of the maxillary sinus (21). Pool showed in 1994 that similar results to lip adhesion could be gained with tape alone, thereby reducing the surgical risks, cost, and scarring since all lip adhesion techniques require a second, definitive cheiloplasty (23).

On the other hand, some believe that the tape is less powerful than the surgical approach for stabilizing the arch (7). Finally, it has also been shown that the pressure placed on the maxilla by the lip may restrict maxillary growth (18). While some believe that is a product of a growth deficiency inherent in cleft patients, this study maintained that patients without early labioplasty had anterior-posterior maxillary measurements similar to that of unaffected patients.

Hildebrand and Henson performed a cephalometric study of patients that had received taping to simulate lip adhesion in conjunction with the pre-surgical nasoalveolar molding (PNAM). They found that the patients treated in this manner had deficient cephalometric comparisons to those patients treated in a solely surgical approach.

It did not specify whether these patients had early labioplasty and may explain the differences (14).

Some of the appliances used in conjunction with lip adhesion are passive and some are active. For example, the Latham Appliance is a pin-retained, active system that is surgically placed and adjusted daily to align the segments using directed forces (1,16). The appliance has an acrylic component with a 25mm screw that is activated over a period of 9-20 days. Four pins in the alveolar segments placed while the infant is under sedation retain it. When the desired result is achieved, the appliance remains without activation for approximately 10 days for retention and is then removed a week before gingivoperiosteoplasty (GPP) surgery (4,13,16,20). A survey of surgeons providing cleft treatment found that 26 percent of surgeons prefer active appliances like the Latham (25). Several studies showed an increase in cross bites and open bites, in addition to decreased maxillary protrusion and height compared to secondary bone grafting only (4,13,20). It is unclear whether some of these deficiencies are related to the Latham or the GPP being performed at a young age instead of at the onset of puberty as seen in the secondary bone grafting (20). Case selection may be important with the use of GPP, as it is also used in conjunction with the PNAM. There are passive combination early maxillary orthopedic appliances often used in conjunction with lip adhesion or taping to stabilize the posterior segment and allow the lip to shape the premaxilla.

This provides transverse stabilization and a fulcrum for the ante-

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rior segment and lip musculature to utilize (7).

The Pre-surgical Nasoalveolar Molding, or PNAM, was developed in the early 1990â&#x20AC;&#x2122;s by Grayson and Cutting (11,12). This is considered a passive appliance because it does not produce a direct force on the alveolar segments. It acts as a guide to allow the body to remodel itself (7). The PNAM is most often used in conjunction with lip taping as opposed to lip adhesion, but may be used in Figure 1. Pre-treatment

either case. The goals of the PNAM are numerous.

Some of them include: elongation of the columella in bilateral cleft cases, expansion of nasal mucosa, improvement of nasal tip symmetry, movement of alveolar segments (Figures 1,2,3), reduction in number and complexity of surgeries, arch width stabilization, monetary savings, reduced scarring, and improved columellar angle (1,2,5,7, 11,12,15,17,22,24,26).

Figure 2. After PNAM

Figure 3. Post-graft

Photos below show a unilateral right complete cleft lip and palate case in three stages (Figures 4, 5, 6).

Figure 4. Pre-treatment

Figure 5. PNAM in place

Each method has its unwanted side effects. Some of the drawbacks for lip adhesion and the Latham Appliance have already been mentioned. The PNAM also has its list of problems, although most of them are manageable. The most significant problems include irritation of the oral mucosa, gingival tissues, cheeks, nasal lining from the appliance itself and the taping. Relieving the appliance in affected areas and providing a base layer, like a Band-aid, in areas where tape is causing skin irritation can address these issues (1,7,14).

Grayson addresses the unlikely risk that the appliance may be dislodged and pose a respiratory hazard by placing a 5mm hole in the palatal portion of the appliance. If an obstruction occurs, that hole allows the passage of sufficient air until the appliance can be retrieved (12,14). Other

Figure 6. 8 months post-cheiloplasty.

studies have shown relapses in width, height, and columellar angle in the first year (19,22). It is suggested that these risks are compensated for by making sure cleft is as narrow as possible with PNAM prior to GPP, overcorrecting nasal vertical dimension in surgery and maintaining results with a nasal conformer (19).

Unique to the PNAM is its attention to the difficulties in attaining nasal symmetry in cleft patients.

Lip adhesion alone has been shown to improve nasal base width, however, it does not address the nasal tip, columellar length and angle, or nostril symmetry (23). These problems are addressed with a nasal stent (or stents in a bilateral case) being attached to the appliance base (Figure 5).

At sequential appointments, material is added to Texas Dental Journal l www.tda.org l July 2011

641

Pre-surgical Nasoalveolar Molding the stent to apply pressure to the nasal cartilage improving symmetry and increasing columellar length (1,12).

High levels of hyaluronic acid allow for the susceptibility of cartilage to respond to the programmed pressure (24). It has been suggested that the earlier the intervention, the better prevention of memory cartilage fixation which results in less relapse (3).

It has been suggested that parent compliance is a primary reason surgeons and other providers avoid use of the PNAM. Applying tape, an appliance, and elastics is a daunting task and requires meticulous adherence to the protocol. Collins and Henson addressed this concern in a survey of parents who had their affected child treated with the PNAM. The results showed 100 percent of parents understood the directions, were able to feed their child with the appliance in place, were happy with the esthetic results, and would do it again if they had another affected child (8). Another reason surgeons donâ&#x20AC;&#x2122;t recommend PNAM to their patients is a lack of pediatric dentists or orthodontists in their area able to provide the service (25). In one study, only 38 percent had ever used the PNAM and only 13 percent of surgeons responding said they routinely use any type of pre-surgical adjunct device.

642

Methods A survey was constructed and distributed via Survey Monkey to American Academy of Pediatric Dentistry members. A total of 3,689 surveys were delivered via e-mail. There were a total of 12 questions listed below in order: 1. Do you treat children affected by cleft lip/palate in your office? _____ Y/N 2. If so, do you participate in or provide pre-surgical treatment? _____ Y/N 3. Which method of pre-surgical intervention do you use?

(Check all that apply) _____ Pre-surgical Nasoalveolar Molding (PNAM) _____ Latham _____ Lip adhesion/tacking _____ Passive appliance _____ N/A (I do not provide pre-surgical treatment for cleft lip and

palate patients) _____ Other (please specify) 4. Where do you practice (city, state)?

5. Do you provide this service in any other locations? Please provide their

locations (city, state) in the comment box. (Please check all that apply) _____ Dental school _____ Underserved areas _____ Mission trips _____ Other (please describe with city, state below) 6. Do you participate in a Craniofacial Anomalies Team?

7. Do other practitioners in your area provide pre-surgical interventions? (Check all that apply) _____ Orthodontist _____ Oral and Maxillofacial Surgeon _____ Plastic Surgeon _____ Other (please specify) 8. If you do not participate in a CFA team, do you know of one in your

area? _____ Y/N 9. If you do not provide pre-surgical intervention, is there another specialist in your area providing this service to whom you refer? _____ Y/N What type of specialist? City, State.

10. In which age group do you fall? _____ Under 30 _____ 30-40 _____ 40-50 _____ 50-60 _____ Over 60 11. If you are a pediatric dentist, where did you attend residency?

12. If applicable, what year did you complete your residency?

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

Results A total of 572 members responded to the survey.

Of those, 102 reported that they provide pre-surgical treatment. PNAM represented 29.2 percent of the interventions used and was most heavily concentrated in Texas. Those checking “other” most often described alveolar grafting prior to secondary surgical procedures. PNAM was provided most often in centers where dental schools were present. Eighty percent of respondents report the presence of a craniofacial anomalies team in their area and 64 percent refer patients to another provider in their area that offer presurgical treatment (Figure 7). The University of Texas Health Science Center San Antonio had the largest number of graduates using the PNAM. Maps are included below that depict the distribution of services provided across the country.

Yellow tacks represent the PNAM. Red boxes represent lip adhesion. Silver triangles represent the Latham appliance. Purple pins represent another passive appliance like an obturator. Finally, turquoise circles represent the category of ‘other’.

Which method of pre-surgical intervention do you use? (Check all that apply)

Pre-surgical Nasoalveolar Molding (PNAM) Latham

Lip adhesion/tacking Passive appliance

N/A (I do not provide presurgical treatment for cleft lip & palate patients) Other (please specify)

Discussion As depicted in the maps, the different types of pre-surgical interventions are spread reasonably equally across the country. Some have suggested that the PNAM may be considered as the standard of care and an argument against that has been access to the treatment (26). These maps show that there is a lack of availability of care for cleft patients in general, but it is not limited to PNAM. In fact, the PNAM is available in Alaska and Puerto Rico, where no other modalities were listed in responses in those areas.

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Pre-surgical Nasoalveolar Molding It was suggested by a respondent that the survey wasn’t specific enough. Rewording to exclude the secondary autologous graft procedures at puberty should include asking providers if they provide therapy to infants prior to initial cheiloplasty. Also, when asking about other providers in their areas, such as orthodontists, it may have been prudent to ask if they know what method is employed by those to whom they refer.

Clearly, with 82 percent responding that they don’t provide pre-surgical treatment to cleft lip and palate patients; there is a need to determine if there really is a lack of access to care, or are other specialists providing it. In addition, it may be considered that plastic surgeons need more information and need to see the positive results in that they are typically the providers who decide what modality is prudent and refer in kind. Sitzman’s study reported that 86 percent of surgeons use the same surgical procedure for every unilateral case. Only 13 percent use pre-surgical adjunct therapy on a regular basis (25). It is also unclear whether the PNAM is being taught consistently among pediatric dentists or orthodontists. Many respondents cited that their local orthodontist provides pre-surgical orthopedic appliances. On the other hand, some orthodontic residencies do not address cleft care. It can be suggested that pediatric dentists have more training in

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dealing with infants and craniofacial deformities, and it may be more appropriate for pediatric dentistry to add PNAM to its required training.

Conclusions Ultimately, there were fewer responses indicating pediatric dentists’ involvement in presurgical therapy for cleft lip and cleft palate infants than expected. There is not a significant regional pattern and most treatment options are centered around educational institutions. With cleft lip and palate representing the second most common birth defect, this study shows a deficit pediatric dentistry’s involvement in the treatment of this population.

In order to better determine access to care for these patients, a similar survey should be sent to orthodontists and plastic surgeons.

Finally, it is reasonable to consider PNAM as the standard of care in treating cleft lip and palate patients given the comparable distribution of availability as compared to other treatment modalities.

References

1. Aminpour, S., Tollefson, T. Recent Advances in Pre-surgical Molding in Cleft Lip and Palate.

Curr. Opin. Otolaryngol. Head.

Neck. Surg. 16: 339-346, 2008.

2. Baek, S., Son, W. Difference in Alveolar Molding Effect and Growth in the Cleft Segments: 3-Dimensional Analysis of

Unilateral Cleft Lip and Palate Patients. Oral. Surg. Oral. Med. Oral. Pathol. Oral. Radiol. Endod. 102: 160-8, 2006.

3. Bennun, R.D., Langsam, A.C. Long-Term Results After Using Dynamic Presurgical Nasoalveolar Remodeling Technique n Patients With Unilateral and Bilateral Cleft Lips and Palates.

J. Craniofac. Surg. 20: 00-00, 2009.

4. Berkowitz, S.B., Mejia, M., Bystrik, A. A Comparison of the Effects of the Latham-Millard Procedure With Those of a Conservative treatment Approach for Dental Occlusion and Facial Aesthetics in Unilateral and Bilateral Complete Cleft Lip and Palate: Part I. Dental Occlusion.

Plast. Reconstr. Surg. 113: 1, 2004.

5. Billick-Gerling, S., Henson, T.B. Longitudinal Study of the Clinical Success of the Presurgical Nasal Alveolar Molding (PNAM) Appliance in Cleft Lip and Palate Infants.

6. Byrd, H.S., Ha, R.Y., Khosla, R.K., Gosman, A.A. Bilateral Cleft Lip and Nasal Repair.

Plast. Reconstr. Surg. 122: 1181, 2008.

7. Cho, B.C. Unilateral Complete Cleft Lip and Palate Repair using Lip Adhesion Combined with Passive Intraoral Alveolar Molding Appliance: Surgical Results and the Effect on the Maxillary Alveolar Arch. Reconstr. Surg.

117: 1510, 2006.

8. Collins, Henson, T.B., Parental Attitudes Toward the Use of Presurgical Nasoalveolar Molding (PNAM) in Cleft Lip/Palate Infants.

9. Corbo, M. Dujardin, T., De Maertelaer, V., Malevez, C., Glineur, R. Dentocraniofacial Morphology of 21 Patients With Unilateral Cleft Lip and Palate: A Cephalometric Study. Cleft Palate-Craniofacial Jour. 42: 618-24, 2005.

10. Cutting, C.B., Dayan, J.H. Lip Height and Lip Width after

Extended Mohler Unilateral Cleft Lip Repair. Plast. Reconstr. Surg. 111: 17, 2003.

11. Grayson, B.H., Cutting, C.B. Presurgical Nasoalveolar Orthopedic Molding in Primary Correction of Nose, Lip, and Alveolus of Infants Born With Unilateral and Bilateral Clefts. Addendum to Cleft Palate Craniofac J. 37: 528-532, 2000.

12. Grayson, B.H., Maull, D. Nasoalveolar Molding for Infants Born With Clefts of the Lip, Alveolus, and Palate.

Clin. Plastic Surg. 31: 149-158, 2004.

13. Henkel, K.O., Gundlach, K.K.H. Analysis of Primary Gingivoperiosteoplasty in Alveolar Cleft Repair. Part I: Facial Growth. J. Cranio-Max. Surg. 25: 266-269, 1997.

14. Hildebrand, D.D.S., Henson, T.B. Cephalometric Analysis of Midface Development in Cleft Infants Treated With Pre-surgical Nasoalveolar Molding.

15. Jacobson, B.N., Rosenstein, S.W. Early Maxillary Orthopedics for the Newborn Cleft Lip and Palate Patient. An Impression and an Appliance. The Angle Orthodontist.

54: 247-263, 1984.

16. Latham, R.A. Orthopedic Advancement of The Cleft Maxillary Segment: A Preliminary Report. Cleft Palate J. 17: 227-233, 1980.

17. Lee, C.T., Garfinkle, J.S., Warren, S.M., Brecht, L.E., Cutting, C.B., Grayson, B.H. Nasoalveolar Molding Improves Appearance of Children with Bilateral Cleft LipCleft Palate. Plast. Reconstr. Surg. 122: 1131, 2008.

18. Li, Y., Shi, B., Song, Q., Zuo, H., Zheng, Q. Effects of Lip Repair on Maxillary Growth and Facial Soft Tissue Development in Patients With a Complete Unilateral Cleft of Lip, Alveolus and Palate. Journ. Cranio-Max. Surg.

34: 355-361, 2006.

19. Liou, E.J., Subramanian, M., Chen P.K.T., Huang, C.S. The Progressive Changes of Nasal Symmetry and Growth after Nasoalveolar Molding: A Three-Year Follow-Up Study. Plast. Reconstr. Surg. 114: 858, 2004.

20. Matic, D.B., Power, S.M. The Effects of Gingivoperiosteoplasty Following Alveolar Molding with a Pin-Retained Latham Appliance versus Secondary Bone Grafting on Midfacial Growth in Patients with Unilateral Clefts.

Plast. Reconstr. Surg. 122: 863, 2008.

21. Nagasao, T., Miyamoto, J., Konno, E., Ogata, H., Nakajima, T., Isshiki, Y. Dynamic Analysis of the Effects of Upper Lip Pressure on the Asymmetry of the Facial Skeleton in Patients With Unilateral Complete Cleft Lip and Palate.

Cleft Palate-Craniofacial J. 46: 154-160, 2009.

22. Pai, B.C., Ko, E.W., Huang, C., Liou, E.J. Symmetry of the Nose After Presurgical Nasoalveolar Molding in Infants With Unilateral Cleft Lip and Palate: A Preliminary Study. Cleft Palate-Craniofac. J. 42: 658-663, 2005.

23. Pool, R., Farnworth, T.K. Preoperative Lip Taping in Cleft Lip. Ann. Plast. Surg. 32: 243-249. 1994.

24. Singh, G.D., Levy-Bercowski, D., Santiago, P.E. ThreeDimensional Nasal Changes Following Nasoalveolar Modling in Patients With Unilateral Cleft Lip and Palate: Geometric Morphometrics. Cleft Palate-Craniofacial Journal. 42: 403-409, 2005.

25. Sitzman, T.J., Girotto, J.A., Marcus, J.R. Current Surgical Practices in Cleft Care: Unilateral Cleft Lip Repair.

Plast. Reconstr. Surg. 121: 261e, 2008.

26. Spengler, A.L., Chavarria, C., Teichgraeber, J.F., Gateno, J., Xia, J.J. Presurgical Nasoalveolar Molding Therapy for the Treatment of Bilateral Cleft Lip and Palate: A Preliminary Study. Cleft Palate-Craniofac. J. 43: 321-328, 2006.

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Dental Artifacts

Live Long and Prosper Kim Freeman, M.A., D.M.D., M.S.

A

t age 10, waiting for a muchwanted chemistry set for a seasonal gift was unending, it seemed. When I finally received the set, one of the experiments was placing sulphur in a test tube and melting it over a gas flame. It was like magic when I dropped a fragment of rubber into the molten sulphur.

When the rubber was removed it had been transformed into a hard but somewhat pliable mass.

This process was discovered by Nelson Goodyear, brother of Charles Goodyear (of rubber fame) in 1851 and is called vulcanization. Within a short period of time dentists were using vulcanite as denture base material. It was much less expensive than gold as a base on which to affix porcelain denture teeth. When I was in dental school in the early 1980â&#x20AC;&#x2122;s occasionally I saw an elderly person come into our dental school clinic with a set of vulcanite dentures that, after decades of use, were either broken or became so impregnated with stains and odors that the owner was forced to part with them. Vulcanite when new is red and used as the entire denture base. The exception was in esthetic areas where porcelain teeth had a more gingival color added below where the interproximal gingival would have been (Figure 1). This particular maxillary denture was on a formed aluminum base and was manufactured close to 1910. Other vulcanite dentures were like current acyclic bases in which porcelain teeth were filled directly into the material (Figure 2).

Vulcanite was made most durable when placed over an impression and treated with pressure and heat. Pictured are two vulcanizers (Figures 3, 4, and 5). The first is similar to a pressure pot and the second is shaped like a pig, hence its name of pig vulcanizer.

Figure 1

Figure 2

Figure 3

Figure 4

You might be wondering why I chose this topic. Recently I hosted some endodontic residents at my office museum, all of whom were under the age of forty. When I described vulcanite to them, blank looks came over their faces.

Some of you may also be wondering why I chose the title of this article. It makes perfect sense considering that Spock of Star Trek fame had a greeting line that was â&#x20AC;&#x153;Live Long and Prosper.â&#x20AC;? As the average Star Trek fan could tell you, Spock was from the planet Vulcan, named after the ancient Roman god of fire.

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Figure 5

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

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Oral and Maxillofacial Pathology Case of the Month Case History An 11-year-old girl was brought in by her mother for evaluation of a “growth on her gums” that the mother noticed had been growing for a little more than 2 years. The patient had no congenital defects, and presented no other significant medical history, or drug allergies. The patient had no pain associated with the lesional area.

During initial clinical exam, a left maxillary facial gingival growth was noted (Figure 1).

It measured 2 cm in diameter with a smooth and dome shaped surface. The lesion had a broad glistening surface which was normal in color and had no clinical signs of inflammation. The lesion was firm to palpation and was found attached to the underlying gingival tissue. The lesion appeared to be asymptomatic with the surrounding tissues appearing normal. The gingival lesion extended from the mesial of tooth #10 to the mid-facial gingiva of tooth #12. The left canine (#11) had not yet erupted while the right canine had broken through the gingiva approximately 1.5 mm (Figure 2).

The panoramic radiograph showed the patient to have normal dental development of tooth #11, which seemed to be poised for eruption (Figure 3). No significant radiographic findings were noted, and the lesion itself was not noticeable in the radiograph.

No bony destruction was found to be associated with the lesion.

After the patient’s medical history was reviewed and the clinical examination findings were noted, the lesion was photographed and measured for documentation. Based on the history and clinical findings, a differential diagnosis was developed. The differential diagnosis included fibroma, peripheral ossifying fibroma, peripheral giant cell granuloma, and neurofibroma.

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Jennifer T. Phu, senior dental student, Texas A&M Health Science Center—Baylor College of Dentistry; Harvey P. Kessler, DDS, MS, professor, Department of Diagnostic Sciences, Texas A&M University Health Science Center—Baylor College of Dentistry

Phu

Kessler

Figure 1. The lesion presented as a smooth surfaced, dome-shaped, normal colored mass involved the gingival overlying an unerupted #11.

Figure 2. The right maxillary canine showed a normal eruption pattern, with the canine cusp tip visible.

Figure 3. The panoramic radiograph revealed #11 normally developed and close to eruption. No evidence of the soft tissue lesion could be seen radiographically.

A biopsy of the lesion revealed intact overlying stratified squamous epithelium that was unremarkable (Figure 4). In the deep lamina propria there was a proliferation of spindle shaped cells.

The spindle cell proliferation was not encapsulated but appeared demarcated from the overlying lamina propria (Figure 5). The spindle cells proliferated in a somewhat fascicular, interweaving pattern.

The individual tumor cells showed elongated nuclei with a â&#x20AC;&#x153;wavyâ&#x20AC;? architecture. Some of the cells showed sharply pointed nuclei while others were oval with rounded tips.

Mast cells were relatively abundant scattered among the proliferating spindle cells (Figure 6).

What is the final diagnosis?

See page 656 for the

answer and discussion.

Figure 4. Low power photomicrograph shows intact overlying epithelium and a spindle cell proliferation in the deep lamina propria that is demarcated from the overlying lamina propria but not encapsulated. (H&E, 2x magnification).

Figure 5. Medium power photomicrograph shows spindle cell proliferation in a fascicular pattern. (H&E, 10x magnification).

Figure 6. High power photomicrograph shows spindle shaped cells with elongated nuclei and scattered mast cells.

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

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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.

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Oral and Maxillofacial Pathology Diagnosis and Management

Neurofibroma Oral and Maxillofacial Pathology Case of the Month (from page 650)

Diagnosis Neurofibromas are the most common peripheral nerve tumor. They are most prevalent on the skin but oral manifestations are common and worthy of notice. Neurofibromas can occur as either solitary tumors or as multiple lesions. Histologically, neurofibromas are well circumscribed and are composed of Schwann cells, and perinueral fibroblasts. They show interlacing bundles of spindle shaped cells that exhibit unique wavy nuclei and are often surrounded by a myxoid matrix admixed with collagen bundles (3).

Solitary tumors are typically slow growing, soft, and painless (3).

They can occur at any age (4).

The tumors can occur anywhere in the oral cavity. They are most commonly located on the tongue, buccal mucosa, and in the vestibule area (4). Intrabony lesions are sometimes encountered. Malignant transformation of a solitary neurofibroma is extremely rare and almost never occurs in bone (3). Treatment of solitary tumors is typically surgical excision. The recurrence rate with adequate excision is low (4).

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Eighty-five percent of all neurofibromas are solitary lesions, as proved to be the case in this patient. However, multiple lesions are known to occur and should alert the clinician that additional workup of the patient is indicated.

Multiple neurofibromas are seen as part of the syndrome neurofibromatosis (4). Neurofibromatosis, (NF), is an autosomal dominant, genetic disorder that is relatively common, occurring in one in every 3,000 births (3). There are eight forms of NF identified; Neurofibromatosis 1 is the most common form of NF and makes up approximately 91 percent of all NF cases (3).

Neurofibromatosis 1, NF1, is also called von Recklinghausen’s disease of the skin. Classically, NF1 presents skin tumors ranging from very small, discrete papules to larger, soft nodules (3). These tumors can be present at birth and usually have accelerated growth during puberty that continues to adulthood (3). Accelerated growth has also been observed in pregnant women (3). The number of these tumors on one patient can vary from just a few to literarily thousands, causing much social and physical discomfort for the patient (3). An extreme and grotesque clinical form of NF1

produces massive baggy, pendulous folds on the skin and is called elephantiasis neuromatosa (3). At one time, this form of the disease was nicknamed “The Elephant Man Disease” after a famous patient named John Merrick, who was known as “The Elephant Man.” His disfigurement, once thought to be caused by NF1, is now believed to be due to the rare Proteus Syndrome (3).

Although the disease occurs most prevalently on skin, oral manifestations present in approximately 72-92 percent of NF1 cases (3).

A common oral manifestation of NF1 is fungiform papillae enlargement which is found in 50 percent of all affected individuals (3). Due to the possible oral implications and its enormous impact on the life of a patient, patients who have confirmed neurofibromas must be examined for neurofibromatosis.

Although skin tumors are the classic sign of NF1, other characteristics such as pigmentation of the skin, Lisch nodules, and Crowe’s sign have been closely associated with NF1 and can help in diagnosing NF1 patients. Cafe au lait pigmentations are relatively common in patients with NF1, and they are usually smooth edged spots rang-

ing from yellow-tan to a dark brown color. They may range in size from 1-2 mm to several centimeters in diameter. (3). Cafe au lait spots present at birth or developing in the first year of life are specific to NF1 (3). Lisch nodules are translucent brown pigmented spots on the iris that are found in almost all diagnosed NF1 patients (3). Another characteristic of NF1 is axillary freckling or Crowe’s sign. There are seven diagnostic characteristics for Neurofibromatosis 1, and a patient only needs to have 2 of these seven characteristics to be diagnosed with NF1 (3).

Diagnostic Criteria of Neurofibromatosis Type 1 (NF1) include, (3): 1. Six or more café au lait macules over 5 mm in greatest diameter in prepubertal individuals and over 15 mm in greatest diameter in postpubertal individuals 2. Two or more neurofibromas of any type or one plexiform neurofibroma 3. Freckling in the axillary or inguinal regions (Crowe’s sign) 4. Optic glioma 5. Two or more Lisch nodules (iris hamartomas) 6. A distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex with or without pseudoarthrosis 7. A first-degree relative (parent, sibling, or offspring) with NF1 by the above criteria High blood pressure is the most common systemic medical complication with NF1 patients (3). NF1 patients can also exhibit severe exercise limitation, parenchymal lung disease, and pulmonary hypertension leading to dyspnea

and heart failure (2). Pulmonary hypertension in association with NF1 is very rare but a study has shown that this correlation is more common in females (2). NF1 has also been shown to have an effect on craniofacial growth (1). Patients diagnosed with NF1 commonly have short mandibles, maxillas, and cranial bases (1).

A very real fear with NF1, as with any abnormal lesion, is whether or not the disease will cause cancer.

It is estimated that approximately 5 percent of NF-1 patients will show malignant degeneration of a neurofibroma into a malignant schwannoma (3). The 5-year survival rate for patients with this malignancy is only 15 percent (3). NF1 also has other malignancies associated with it, to include leukemia and rhabdomyosarcoma (3). Due to these malignant associations, as well as vascular disorders that may accompany NF1, the average lifespan of a patient diagnosed with NF1 is 15 years shorter than the general population (3).

Treatment for NF1‘s medical complications is geared towards prevention and management (3).

One of the most common and understandable NF1 treatments is the removal of skin tumors with surgery (4). Carbon dioxide laser excision and dermabrasion have shown much success in treating NF1 and allowing patients to gain a more normal appearance (3).

Most patients desire to treat facial tumors first. Genetic counseling is necessary with patients who have NF (3). Immediate biopsy of neurofibromas and referral for appropriate examination and diagnosis of neurofibromatosis is imperative in providing care for patients.

Biopsy of neurofibroma reveals a spindle cell neoplasm within the connective tissue. The tumor is usually not encapsulated but shows a distinct margin with the adjacent fibrous tissue, as was seen in this case. The neoplastic cells are spindle shaped, with elongated nuclei that may be pointed or rounded at the tips, and are believed to be proliferating perineural fibroblasts.

The nuclei often have a “wavy” or serpentine architecture that is characteristic of neural tissue. The cells tend to proliferate in a fascicular pattern. Mast cells are usually present scattered throughout the cellular proliferation.

References 1. Heerva E, Peltonen S, Pirttiniemi P, Happonen RP, Visnapuu V, Peltonen J. Short mandible, maxilla, and cranial base are common in patients with neurofibromatosis 1. Eur J Oral Sci. 2011 Apr, 119 (2): 121-7.

2. Montani D, Coulet F, Girerd B, Eyries M, Bergot E, Mal H, Biondi G, Dromer C, Hugues T, Marquette C, O’Connell C, O’Callaghan DS, Savale L, Jais X, Dorfmuller P, Begueret H, Bertoletti L, Sitbon O, Bellanne-Chantelot C, Zalcman G, Simonneau G, Humbert M, Soubrier F. Pulmonary Hypertension in Patients with Neurofibromatosis Type 1. Medicine (Baltimore). 2011 Apr 21.

3. Neville B, Damm D, Allen C, Bouquot J. Oral and Maxillofacial Pathology. 3rd Edition, St. Louis: Saunders- Elsevier Inc. 2009, 528-31.

4. Regezi, Sciubba, Jordan. Oral Pathology Clinical Pathologic Correlations. 5th Edition.

2008, 171-2.

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Let us make you smile

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* You must be a TDA member, or staff of a TDA member, living in a deregulated area to be eligible to participate.

Texas Dental Journal l www.tda.org l July 2011 ** JLT Energy Consultants develops master programs with multiple energy providers to provide special rates for large groups of individuals. ©2011 Accent Energy Group, LLC. All rights reserved. The Accent Energy logo is a trademarks of Accent Energy Group LLC. Other trademarks are property of their respective owners.

In Memoriam

Those in the dental community who have recently passed Brezner, Stephen David Bellaire, Texas Aug 13, 1941 – April 7, 2011 Good Fellow, 1993 • Life, 2007 Burch, William P., Jr. Fort Worth, Texas July 26, 1920 – May 20, 2011 Good Fellow, 1973 • Life, 1985 Fifty Year, 1994 Cobb, J.W. Fort Worth, Texas Jan 12, 1923 – May 20, 2011 Good Fellow, 1980 • Life, 1988 Fifty Year, 2009 Duff, Tom G. Jacksonville, Texas Feb 13, 1929 – April 22, 2011 Good Fellow, 1985 • Life, 1994 Fifty Year, 2010 Gamble, Robert Warren Georgetown, Texas Jan 23, 1916 – April 17, 2011 Good Fellow, 1966 • Life, 1981 Fifty Year, 1990

Hurst, MaryDawn Pearland, Texas June 27, 1949 – May 7, 2011 Good Fellow, 2010 Laughlin, James R. Beaumont, Texas Dec 19, 1944 – May 6, 2011 Good Fellow, 2000 • Life, 2010 McGinnes, Willie M. Canton, Connecticut Sept 7, 1922 – May 21, 2011 Good Fellow, 1975 • Life, 1986 Fifty Year, 2000 Shackelford, Loyd A. Arlington, Texas June 25, 1920 – March 23, 2011 Good Fellow, 1982 • Life, 1986 Fifty Year, 2005

Memorial and Honorarium Donors to the Texas Dental Association Smiles Foundation

In Memory of: Wendell Gene Fox By: Diana & Ronnie Newberry Lorene Cotton Grill By: S. Jerry Long, D.D.S.

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

Walker, Robert V. Dallas, Texas Sept 21, 1924 – April 28, 2011 Good Fellow, 1980 • Life, 1989 White, Charles Steven Cookville, Texas Aug 24, 1950 – Aug 31, 2010 Good Fellow, 2004

Please make your check payable to:

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

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Provided by TDA Perks Program

value for your

profession

Saving Money on Your Health Care Eric Tiedtke, CFP, TDA Financial Services Insurance Program Rising medical costs and health insurance premiums have caused many people to increase their deductibles and coinsurance, or

eliminate such features as office or prescription drug copays, in an effort to save on premiums. Healthcare reform has not changed

the cost curve, and the uncertainty about national healthcare will

probably not be resolved until af-

ter the 2012 elections. What are some options that may help with potential costs, and also save you some money? Here are

some you may want to consider: A Qualified High Deductible Health Plan (HDHP) with a Health Savings Account (HSA) is a health insurance policy that pays medical expenses, including prescription drugs, only after the deductible has been met. These plans are designed to give you a lower premium, while protecting you from catastrophic claims. As a result of the Patient Protection and Affordable Care Act, the following mandated features are now included: no lifetime-benefit limits (based on dollar amounts); first-dollar preventive care for essential benefits, including physicals, well-woman exams,

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well-child care, and immunizations—all without an office visit copay or deductible if they are received in-network; no restricted annual limits (on the dollar value); and dependent coverage up to age 26.

Anyone under age 65 is eligible to establish an HSA, provided there is a qualified high-deductible health plan in place, and no coverage under another health plan. And though you’re not required to contribute the maximum amount per year, or even make a contribution, making a contribution is an opportunity almost too good to pass up. For 2011, the maximum contribution allowed is $3,050 for an individual plan, and $6,150 for a family plan. Contributions not used for medical expenses during the year can be rolled over to the following year — it’s not a “use it or lose it” proposition, as it is with health care flexible spending accounts.

Persons between the ages of 55 and 65 can make additional “catch up” contributions of up to $1,000 a year for 2011 and later. Contributions can be made as late as April 15th of the following tax year.

What you don’t use from the HSA each year is yours to keep. The balance continues to grow on a tax-sheltered, compound basis. Once you reach age 65, the account can basically be used like a traditional IRA, but is not subject to distribution limitations or penalties, and distributions for eligible expenses are still tax-free. And, just as with an IRA, upon death, the funds in the HSA can be transferred to a beneficiary. If the beneficiary is a surviving spouse, the transfer is tax-free. As with any tax issue, always check with your CPA or tax professional to make sure this makes the most sense for your particular situation.

Critical Illness Insurance pays a set amount to the insured when a qualified event occurs. Critical illness insurance typically provides the full policy benefit in a lump sum payment upon diagnosis of a critical illness listed in the policy, such as heart attack, stroke, cancer, Alzheimer’s disease, or organ transplant.

There’s no coordination of benefits with other health or disability insurance. The money can be used to pay medical bills, cover a mortgage, or anything else you want. You are in complete control of how the funds will be used. Critical illness insurance bridges the gap between the health insurance policy and the actual expenses incurred.

Premiums for critical illness insurance are normal-

ly between $25 and $50 per month for around $25,000 of coverage, so it’s a way to provide some additional protection at a low cost.

Discount Prescriptions & Other Savings Plans Everyone likes to save money. You can maximize your savings by using discount programs offered through most pharmacy chains, or the free discount pharmacy card available from TDA Perks Program. (You can print your own card at www.tdaperks.com). When you purchase prescriptions, simply visit a participating discount pharmacy (most major chains participate,) and pay the discounted amount on the spot, directly from your HSA—either by debit card or check. For greater savings, use the bulk-priced Rx mail service; generic or over-the-counter meds; or pill splitting, when appropriate, to get more meds for the dollar.

There are other discount cards available that, for a low monthly cost, give you access to medical programs offering significant savings from healthcare providers across the nation. Programs include: vision products and services (including glasses, contacts and even LASIK surgery), chiropractic care, lab and imaging services, diabetic supplies, vitamins, and many other products. TDA Perks Program now offers a discount card (TDA Perks Card), that also offers the Teladoc service, which is a national network of board-certified physicians who use electronic health records, telephone and online video consultations to diagnose, recommend treatment, and write short-term prescriptions, when appropriate. Teledoc physicians are available 24 hours a day. There are no waiting periods or restrictions on these plans, and for less than $20 per month, you can access a range of discount products and services for the whole family. This is also an inexpensive employee benefit to keep in mind for your staff.

Like most things, there’s no one right answer to managing healthcare costs, but there are ways to save money on premiums and health care expenses. Insurance is about managing risk. By increasing your deductible, or utilizing an HSA with a high deductible health plan, and supplementing this with other types of coverage and discounted products, you can save on your premiums and still be covered in the event of a big claim.

For more information on any of these programs for you, your family, or office staff, please contact TDA Financial Services Insurance Program at: (800) 677-8644, or visit the website: www.TDAmemberinsure.com. For more information regarding other TDA Perks Programs, please visit www.tdaperks.com, or call (512) 443-3675.

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

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Justin L. Morrison, D.D.S. has acquired the practice of

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

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

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

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Calendar of Events 664

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) 6786286; 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) 4402707; 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) 4482441; Web: tdasf.org.

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

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

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

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

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

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 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.

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.

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.

January 2012 26 – 28 The American Dental Association Council on Access, Prevention and Interprofessional Relations (CAPIR) will be held at the ADA headquarters in Chicago, IL. For more information, please contact Ms. Carrie Campbell, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-4699; FAX: (312) 440-2883; Email: campbellc@ada.org Web: ada.org.

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

Calendar of Events

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) 4482441; 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) 4452524; E-mail: dentaltennis@gmail.com; Web: dentaltennis.org.

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Questions? Contact Stefanie Clegg, TDA web & new media manager at (512) 443-3675 or stefanie@tda.org

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g n i rtis

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

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

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

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

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

Briefs

Practice Opportunities MCLERRAN AND ASSOCIATES: AUSTIN, 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: 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.

Antonio. Consistent seven figure gross, low overhead. Free standing, 2,800 sq. ft. building with practice. ID #131.

RIO GRANDE VALLEY: Excellent four operatory, 20-year-old general practice.

Modern, new finish out in retail location with digital radiography. Fee-for-service patient base and very good new patient count. Great numbers. Super upside potential. ID #093.

NEW! SAN ANTONIO, NORTHEAST: Doctor retiring from this orthodontic specialty practice. Very nice 3,500 sq. ft facility with good access and visibility. Excellent staff.

Good numbers and high upside potential.

ID #133.

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.

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! AUSTIN: Associate position with partnership opportunity in a family practice located in high growth affluent area west of Austin. Excellent opportunity to join a quality practice!

NEW! WEST OF SAN ANTONIO: Doctor retiring. Four operatories in modern, open, free-standing building. Excellent fee-for-service patient base. Newer equipment. Very nice decor. Very nice numbers with low overhead. Low competition in mid-sized city. ID #122.

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.

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.

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

NEW! ORTHODONTIC SPECIALTY PRACTICE: Doctor retiring from this thriving practice in mid-sized city south of San

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 visibility and access. Large pylon and marquee signage. Well-equipped and very nice decor. Solid patient base.

Doctor available for transition. ID #129.

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.

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SAN ANTONIO, NORTH CENTRAL â&#x20AC;&#x201D; Two-op practice just off major freeway; perfect starter office. Terrific pricing. ID #009.

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

SAN ANTONIO: Well-established endodontic specialty practice with solid referral base. Located in growing, upper middle income area. Contact for more information. ID #074.

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

Transition available. ID #113.

SAN ANTONIO, NORTH CENTRAL: Six operatory general practice located in high growth area. All operatories have large windows with great views. Very nice equipment, solid patient base, great hygiene program. Priced to sell. ID #112.

SAN ANTONIO: Six opertory 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 SOUTHEAST: Three operatory, 30-year-old practice in high traffic retail center, good equipment, solid patient base, low overhead. Perfect location for a satellite office or high gross Medicaid office. ID #21

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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.

SOUTH TEXAS BORDER: General practitioner with 100 percent ortho practice.

Very high numbers, incredible net. ID #021.

NEW! VICTORIA/CORPUS CHRISTI AREA: Three op office in free standing professional building. Retiring doctor with 40 year old practice. Large patient base, doctor refers many procedures.

Super upside potential. ID #132.

NEW! WACO/DALLAS AREA: Satellite general practice in small city. Fee-forservice practice with good patient flow.

No competition. Can continue as a satellite or can become a full-time office. ID #134 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.dental-sales. com for pictures and more complete information.

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 orth-

odontic, 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.

We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.”

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

Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; 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. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.”

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

Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; 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. Wellestablished practice. Excellent recare program. Near seven figure gross, high operating profits. Buy or lease garden style office/operatories. We have the best source for 100 percent buyer funding.

Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale.

No real estate commission. Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATTS: (800) 583-7765.

GARY CLINTON / PMA FORT WORTH AREA/WEATHERFORD GENERAL PRACTICES FOR SALE: F1 — 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. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No real estate commission. Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATTS: (800) 583-7765.

ORAL SURGERY PRACTICES FOR SALE. GARY CLINTON / PMA: OS-1 Dallas/Fort worth area: Well established practice. Surgeon retiring with minimum transition. OS-2 West Houston area — High growth area. State-of-the-art practice. Many referring doctors for cosmetic and implant, and reconstructive surgery.

Outright sale. Seven-figure gross. Seller and family are relocating out of state; will transition on a limited basis. OS-2 Texas Dental Journal l www.tda.org l July 2011

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Southwest Houston — Retiring surgeon.

Bread and butter practice. Seven-figure gross on 4 days; will transition. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No real estate commission.

Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; 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. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No real estate commission. Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATTS: (800) 583-7765.

GARY CLINTON / PMA BRYAN / COLLEGE STATION PRACTICE FOR SALE: Excellent visible location ready to hand over the ball to a young motivated dentist. Will transition PRN. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale.

No real estate commission. Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATTS: (800) 583-7765.

GARY CLINTON / PMA WEST TEXAS AREA WELL-ESTABLISHED PRACTICES FOR SALE: W-1 North of Lub-

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bock — Highly productive practice; large growing patient base. Doctor will work for purchaser as needed. Purchase building outright or lease/purchase. W-2 Abilene — Retiring dentist outright sale/ PRN transition; great location south side of Abilene. W-3 San Angelo — Excellent well-established restorative practice.

Very nice newer equipment. Dentist relocation. Purchase building or lease/ purchase. Transitional or outright sale.

Well established patient base. Doctor is highly esteemed member of the community. Purchase or lease/purchase the facility. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No real estate commission. Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; 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 patient base.

Doctor is highly esteemed member of the community. Purchase or lease/purchase the facility. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No real estate commission. Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; 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 patient base. Doctor is highly esteemed member of the community.

Purchase or lease/purchase the facility.

We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Ap-

praisers, 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 patient base.

Doctor is highly esteemed member of the community. Purchase or lease/purchase the facility. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No real estate commission. Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; WATTS: (800) 583-7765.

GARY CLINTON / PMA NORTH DALLAS / PLANO / MCKINNEY AREA PRACTICES FOR SALE: The best and fastest growing areas in Texas. High traffic shopping centers. Very nice newer offices. ND-1 All digital; four operatories; new equipment and furnishings. ND-2 Thirty plus year practice. Five operatories. Excellent recall. Patient base. Above average gross. Well established patient base. Doctor is highly esteemed member of the community. Purchase or lease/ purchase the facility. We have the best source for 100 percent buyer funding.

Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale.

No real estate commission. Every call is very confidential. General and specialty practice certified appraisals. DFW: (214) 503-9696; 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) 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 fund 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) 8561955. Visit us at www.thehindleygroup. com.

DFW METROPLEX GENERAL DENTAL PRACTICE — SALE: Great location!

Well-established 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.

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 marTexas Dental Journal l www.tda.org l July 2011

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gin on 4 days per week. Limited competition and a large facility. Ample room to grow in this community that is home to Baylor University. This is a wonderful central Texas community in which to raise your family. All ortho cases are being completed, unless purchaser would like to expand new cases. No Medicaid being seen, but good opportunity with facility capacity. Experienced staff and steady new patient flow. Wonderful mentor. Building also available. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

BRYAN/COLLEGE STATION GENERAL DENTAL PRACTICE — SALE: Well-established practice in mid-size town. Four operatories. 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 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.

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

WEST TEXAS GENERAL PRACTICE — SALE: Large office space with nine fullyequipped operatories. Experienced staff and strong hygiene program. Revenues exceeding six figures and excellent profit margin on four days per week. Forty-four percent Medicaid component. Contact the Hindley Group, LLC, at (800) 8561955. Visit us at www.thehindleygroup. com.

DFW MIDCITIES GENERAL PRACTICE — SALE: Excellent, established practice with revenues exceeding six figures. Office space has 3,500 sq ft with seven fully-equipped operatories. There is definitely room to grow! Steady new patient flow, strong hygiene recall, and experienced staff. Doctor will assist with transition. Building, which is also for sale, has an additional 1,500 sq. ft. 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. Eight operatories. Dedicated, experienced staff. One- to 2-year associateship with predetermined buyout. 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. Pre-determined buy-in terms. SOUTH CENTRAL TEXAS PERIODONTAL — Wonderful practice completing periodontal treatment seeks long-term associate who desires to be a

partner within 1-2 years. Great location with strong new patient flow. Predetermined purchase and partnership terms. Wonderful mentor looking for an “equally-yoked” individual. Excellent staff. SAN ANTONIO PERIODONTAL AND ENDODONTAL ASSOCIATESHIPS — Periodontal associateship with predetermined buy-in for very active, multioffice periodontal practice. Endodontist associate also needed in this practice.

Outstanding mentor and cohesive staff.

If you are “equally yoked” and the right person, this is an outstanding opportunity. 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. Contact the Hindley Group, LLC at 800-856-1955.

Visit us at www.thehindleygroup.com HOUSTON AREA PRACTICE FOR SALE: Profitable practice for sale. Wellestablished. Call Jim Robertson at (713) 688-1749.

ADS WATSON, BROWN & ASSOCIATES: Excellent practice acquisition and merger opportunities available.

DALLAS AREA — Six general dentistry practices available (Dallas, North Dallas, Highland Park, and Plano); five specialty practices available (two ortho, one perio, two pedo). FORT WORTH AREA — Two general dentistry practices (north Fort Worth and west of Fort Worth). CORPUS CHRISTI AREA — One general dentistry practice. CENTRAL TEXAS — Two general dentistry practices (north of Austin and Bryan/College Station). NORTH TEXAS —One orthodontic practice.

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

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. Our patient base consists of approximately 70 percent PPO and 30 percent fee-for-service. 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 buyin opportunities. To learn more about working with one of Dental One Partners practices, please contact Andy Davis at (602) 391-4095.

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

We are 100 percent FFS with some PPO plans. We offer competitive salaries, benefits, and equity buy-in opportunities.

To learn more about working for Dental One, please call Andy Davis at (602) 391-4095.

FULLY EQUIPPED MODERN DENTAL OFFICE SPACE AVAILABLE FOR LEASE. Have four ops. Current doctor is only using 2 days a week. Great opportunity to start up new practice (i.e., endo, perio, oral surgery). Available days are Monday, Tuesday, Thursday per week. If you are wanting an associate, please inquire. Call (214) 315-4584 or e-mail ycsongdds@yahoo.com.

TEXAS PANHANDLE: Well-established 100 percent fee-for-service dental practice for immediate transition or complete sale at below market price by retiring dentist. Relaxed work schedule with community centrally located within 1 hour of three major cities. The office building can be leased or purchased separately and is spaciously designed with four operatories, doctors’ private office and separate office rental space. This is

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

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

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

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 email 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,

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as well as some fixed office visits.

Patient population presents unique technical medical, and behavioral challenges, seasoned dentist preferred.

Buy-in potential high for the right individual. Please toward CV to e-mail renee@austindentalcares.com; FAX (512) 238-9250; or call (512) 238-9250 for additional information.

GREAT OPPORTUNITY FOR A PEDIATRIC DENTIST OR GP to join our expanding practice. We are opening a new practice in the country (Paris, Texas), just 1 hour past the Dallas suburbs and our original location. The need for a pediatric dentist out there is tremendous, and we are the only pediatric office for 70 miles in any direction. We are looking for someone that is personable, caring, energetic, and loves a fast-paced working environment in a busy pediatric practice.

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

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 Metro-

plex. 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 longlasting friendships with our patients and staff members. Please contact Phong at (214) 960-3535 or e-mail CV to phong@dentalrepublic.com.

CARE FOR KIDS, A PEDIATRIC FOCUSED PRACTICE, is opening new practices in the San Antonio and Houston area. We are looking for energetic full-time general dentists and pediatric dentists to join our team. We offer a comprehensive compensation and benefits package including medical, life, long- and short-term disability insurance, flexible spending, and 401(K) with employer contribution. New graduates and dentists with experience are welcome. Be a part of our outstanding team, providing care for Texas’ kids. Please contact Anna Robinson at (913) 3221447; e-mail: arobinson@amdpi.com; FAX: (913) 322-1459.

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

CORPUS CHRISTI: Laid back lifestyle with the benefits of the Gulf Coast.

Lucrative revenues on 4 days per week.

Denture focus could be expanded to a broader scope of restorative general treatment. In-house lab with experienced technician. Great location, great staff, and a great lifestyle. Motivated seller.

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

WE NEED SELLERS. Thinking about selling your practice, we have buyers!! DDR Dental Sales has been representing Dentists since the early 1970’s with the purchase and sale of Dental Practices. The DDR Dental Practice sells practices, helps dentist buy practices, places associates,

handles appraisals, associate agreements, etc.. Call us- we are here to confidentially help you with any practice need- 1-800930-8017 or www.ddrdental.com GREAT PRACTICE IN BEAUTIFUL EAST TEXAS. This fee-for-service practice was established by a prominent community involved dentist with an excellent reputation for quality care. The office has 1,300 sq. ft. with four available treatment rooms and a large private office. Don’t miss the opportunity to become part of this stable economic town with an experienced staff and a growing patient base.

Interested? Call (972) 562-1072 or email sherri@slhdentalsales.com.

AUSTIN: Five operatory, two hygienists, one associate dentist, gross of seven figures in 2010. Mature practice; doctor wants to sell practice but is also willing to work contact for buying dentist; great location in beautiful Austin. Practice in the heart of most desired city in Texas.

Substantial net income with four fully equipped operatories and two full-time hygienists. Current associate will remain at buyer’s discretion. Call DDR Practice Sales at (800) 930-8017.

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

CORPUS CHRISTI: General dentistry practice — location, location, location; 25-year-old practice grossed more than seven figures last year with a single dentist and one hygienist. Updated office, very profitable practice, excellent staff.

Call DDR Practice Sales at (800) 9308017.

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

SAN ANTONIO: Beautiful fast-growing area, exceptional practice with five operatories. Ten-year-old practice, doctor motivated to sell. Earns a seven-figure Texas Dental Journal l www.tda.org l July 2011

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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. Welltrained 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) 9308017.

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

Excellent, profitable turnkey practice.

Call DDR Practice Sales at (800) 9308017.

WEST TEXAS: There’s a reason people are moving to West Texas. No state income taxes, excellent private and public schools, moderate climate, stable and expanding local economy, and excellent area for outdoor activities. We have a great opportunity available for a Pediatric Dental Practitioner in our multi-unit, and expanding, locally owned pediatric dental practice. We are fast-paced, highenergy offices who focus on providing superior dental care. Excellent compensation and benefits package. Please submit CV with cover letter to pedsdental@hotmail.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.

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

FOR SALE — GREAT 41-YEAR SUCCESSFUL PRACTICE IN SOUTH CENTRAL TEXAS. Owner retiring but will stay through transition period. Five operatories in beautiful building, Pan0, 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.

EAST TEXAS GENERAL PRACTICE NEEDS ASSOCIATE TO TRANSITION TO OWNER/PARTNER, buyout to fit situation. Thirty-five-year-old practice in dynamic northeast Texas hub city, centrally located and easily accessible Dallas, Shreveport, and Arkansas. Great for fishing, hunting, and all outdoor activities.

Practice is in a 2,300 sq. ft. office (owned) in a professional building across from the regional hospital. Four ops, two hygienists provide 6 hygiene days/week. Softdent and Kodak digital 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.

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

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

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

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

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

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

Has been a dental practice in this building for 56 years. Learn advanced surgical reconstructive and prosthetic skills.

Two locations: 1801 Broadway, Galveston, TX, and 1901 East Main, League City, TX. All brand new equipment and facility, brand new building, paperless computerized system with the latest in technology. Fiber optics, seven ops, two large surgical suites, latest in restorative materials, digital radiography. Long-term trained staff: Mary, 18 years; Myrna, 16 years; Debbie, 17 years; Gina, 15 years; and Amy, 15 years. Experienced help makes your day easier! Senior dentist loves to teach! Compensation and hours, full-time hours available with excellent compensation package. Offering 50 percent CE training for valuable courses such as IV sedation. Guaranteed minimum to start. Hours are either M-Th (every other Sat) or T-F (every other Sat).

You pick your hours. No DMO plans or Medicaid for a more relaxing work environment. E-mail kkcarroll10@yahoo.com or call (281) 332-6323.

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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.

HOUSTON: 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.

AMARILLO: SEEKING A CARING, ENERGETIC, FULL-TIME ASSOCIATE for a well established general dentistry practice, with potential ownership. Ten operatories available in shopping complex with four hygienists, digital X-rays including a pano machine, and experienced long-term dependable staff. Please mail letter of interest to 3409 S. Georgia, Ste. 12, Amarillo, TX 79109 or fax resume to (806) 463-5205.

ASSOCIATE: RIO GRANDE VALLEY Two well-established general dentists in Mission/McAllen area seeking a caring and motivated associate for two busy practices. Both practices offer excellent production and earning potential with an emphasis on quality dentistry in a friendly atmosphere. Interested candidates should fax (956) 580-4710 or e-mail resume to riveroaksdental02@ hotmail.com or docmc3@aol.com

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.

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ORTHODONTIST NEEDED NEXT TO DENTIST IN HIGH GROWTH, HIGH TRAFFIC AREA IN ROUND ROCK, north of Austin in one of the fastestgrowing counties. Available at $155/sq. ft. For more information, e-mail john@herronpartners.com or call (512) 457-8206.

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.

One-hundred 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. Iâ&#x20AC;&#x2122;d be happy to put you in touch with them to hear of their experiences directly. Weâ&#x20AC;&#x2122;ve helped more than 800 of your fellow dentists achieve their dream during the past 20 years... And look forward to using Chat experience to assist you. Check us out at fazioarchitects.com.

Then, give me a call at (512) 494-0643.

Or e-mail jim@fazioarchitects.com.

ROUND ROCK: Property site available for dental/medical facility on Gattis

School Road near the area’s new high school. Excellent frontage with more than 25,000 cars passing by daily. Demographics for this area are through the roof. Call Jim at (512) 494-0643 or email jim@fazioarchitects.com.

ROUND ROCK — OLD SETTLERS DENTAL PARK: Three pad sites available. Thriving two-doctor general practice already onsite. Good frontage and traffic on four-lane road. High growth area has shortage of specialty dentists.

Call Jim at (512) 494-0643 or e-mail jim@fazioarchitects.com.

AUSTIN — MCNEIL DRIVE DENTAL PARK: Successful general dentist with established practice has two pad sites available. Beautiful wooded area with great traffic volumes. Once you tour this office, you will want to build next door.

Call Jim at (512) 494-0643 or e-mail jim@fazioarchitects.com.

PLAINVIEW, TEXAS, COULD USE TWO NEW DENTISTS. For sale — fully equipped free-standing, high visibility dental office. Excellent opportunity for right person. Contact Dr. J. Irvin Gaynor, jigaynor@suddenlink.net or (806) 292-3156.

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://retail street-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) 7561669 Tuesday and Thursday; (281) 3632009 Monday, Wednesday, and Friday.

Interim Services TEMPORARY COVERAGE (LOCUM TENENS): Professional temporary coverage of your dental practice by a colleague during maternity and disability leaves, vacation, or just some short-term relief.

Short-notice coverage is our specialty.

Flat daily rate. Free quotes. No obligation, ever. A few “superstars” on our Texas Dental Journal l www.tda.org l July 2011

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team seek full-time positions. All inquiries treated with absolute confidentiality.

Since 1996, the nation’s largest team of distinguished dentists. Register online at www.doctorsperdiem.com; (800) 6000963.

DALLAS- FT.WORTH METROPLEX Orthodontic Locum Tenens: Keep office open during absences, illness, rehabilitation. Call 214-724-9754.

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 confidential-

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ity. 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.

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 model 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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Your TDA peers on the Board of TDA Financial Services, Inc.—a wholly-owned affiliate of TDA—reviewed, endorsed and recommend the following TDA Perks Program products and services. Each represents value. Save time and money by buying from these endorsed partners.

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AMALGAM SEPARATION

ELECTRONIC CLAIMS PROCESSING

AUTO LEASING

ENERGY (ELECTRIC)

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GAS (MEDICAL)

Solmetex: (800) 216-5505

Autoflex Leasing: (800) 678-353 AVIS: (800) 331-1212; Use Code: W220700 Budget: (800) 527-0700; Use Code: Z930600

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COLLECTIONS

TekCollect: (866) 652-6500, ext. 539

CREDIT CARD — TDA PERKS

Bank of America | Business: (866) 570-1601 Consumer: (800) 932-2775; (Code: UABAOF)

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E-Claims & Eligibility Connect: (866) 325-2467

MEDICAL EMERGENCY PREP.

Institute of Medical Emergency Preparedness: (866) 729-7333

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TDA Perks Energy Program: (682) 224-1385

Office Depot: (512) 284-3392

ON-HOLD PHONE MESSAGING

LifeGas: (214) 704-2074 | (866)-LIFEGAS

aceOnHold.com: (800) 892-9179

GLOVES

PATIENT FINANCING

The Glove Group: (800) 570-1492

CareCredit: (800) 300-3046 ext. 4519

INSURANCE, DENTAL (PATIENTS)

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DentalQUICK: (888) 350-2416

NetChex: (877) 729-2661, OR (210) 488-5577

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Insurance Answers Plus: (800) 683-2501

The Reynolds Company: (972) 231-8900

INSURANCE

TDA Financial Services Insurance Program All types: office and personal: (800) 677-8644

SCRAP PRECIOUS METAL RECOVERY D-MMEX: (800) 741-3174

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Managed Backup Solutions (MBS) Locate your regional rep; call: (877) MBS-0787

LOANS (PRACTICE)

Banc of America: (800) 497-6076; Code: 1D7F3

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SHARPS DISPOSAL (VIA MAIL) Sharps: (800) 772-5657, ext. 162

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ProSites: (888) 932-3644

Did you know CareCredit gives you access to an entire Practice Development Team (PDT)? The PDT’s job is to help your practice realize all it can from the CareCredit program. To enlist its assistance, call: (800) 859-9975, Option 6.

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

Learn about other TDA Perks Programs at: tdaperks.com. Or call: (512) 443-3675.

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Texas Dental Texas DentalJournal Journal l l www.tda.org www.tda.orgl lMayJuly2011 2011