May Texas Dental Journal

May 2013

TEXAS DENTAL

Oral Cancer Screening: A Closer Look

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Texas Dental Texas DentalJournal Journal l l www.tda.org www.tda.orgl lJune May 2010 2013

Pre-screened vendors. Excellent customer service. Exclusive discounts and benefits.

FINANCIAL COLLECTIONS

DISPOSAL/RECYCLING

INSURANCE INSURANCE

AMALGAM SEPARATION

Bank of America Business: (866) 570-1601 (Code: UABOI9) Consumer: (800) 932-2775 (Code: VABQ92)

INSURANCE INFORMATION

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

CREDIT CARD PROCESSING

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

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

CREDIT CARD — TDA PERKS

Best Card: (877) 739-3952

LOANS (PRACTICE)

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

PATIENT FINANCING

CareCredit: (800) 300-3046 ext. 4519

HUMAN RESOURCES EMPLOYMENT AGENCY, ONLINE DentalSpots.com: (800) 971-8008

MEDICAL PLAN, DISCOUNT

TDA Perks Card has three available packages.

This is NOT insurance, nor is it intended to replace insurance. http://tinyurl.com/perkscard

TDA Financial Services Insurance Program All types: office and personal: (800) 677-8644 Insurance Answers Plus: (800) 683-2501

ELECTRONIC CLAIMS PROCESSING

Solmetex: (800) 216-5505

SHARPS DISPOSAL (BY MAIL) Sharps: (800) 772-5657, ext. 140

SUPPLIES

OFFICE, SETUP/STARTUP NEW! EQUIPMENT, USED (BUY, SELL) Atlas Resell Managment: (512) 377-6077

IT, DATA BACKUP

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

REAL ESTATE (COMMERCIAL)

Dental Space Advisors: (972) 231-8900 Corporate Headquarters: Dallas/Ft. Worth (With Offices in Houston & Austin/San Antonio)

MARKETING

DEFIBRILLATORS

HeartSafe America: (877) 731-7467

DISINFECTANT, SPORE TESTING OSHA Review, Inc.: (800) 555-6248

GLOVES The Glove Group: (800) 570-1492 OFFICE SUPPLIES

Office Depot: (512) 284-3392

PHILIPS SONICARE, ZOOM! Philips Zoom!: (800) 422-9448 Philips Sonicare: (800) 676-7664

Free CE Credits Are Just a Click Away.

COMPLIANCE/TRAINING NEW! COMPLIANCE

TRAINING (OSHA, HIPAA, HB300)

Smart Training, LLC: (469) 342-8300

TRAINING/RECERTIFICATION (ACLS, PALS, BLS, CPR) HeartSafe America: (877) 731-7467

SEDATION EQUIPMENT, SUPPLIES

ON-HOLD PHONE MESSAGING

Sedation Resource: (800) 753-6376

aceOnHold.com: (800) 892-9179

AUTO

ONLINE MARKETING AND COMMUNICATIONS

AUTO • LEASING

Demandforce: (800) 210-0355

Autoflex Leasing: (800) 678-3539

PATIENT TEXT COMMUNICATIONS

• • (800) 331-1212; Use Code: W220700 AVIS: • Budget: (800) 527-0700; Use Code: Z930600 • • •

AUTO RENTALS

theTEXTdoctor.com: (888) 330-7291

NEW! PRINTING, PROMOTIONAL PRODUCTS, DIRECT MAIL PrintCity.com: (800) 757-5110

Scan QR code to learn more about TDA Perks.

WEBSITE DESIGN

ProSites: (888) 932-3644

Taking New Steps

Revised 03/13

• • • •

For more information, call:

To view courses online, visit(512) www.txhealthsteps.com.

443-3675

• •

Or visit Perks online:

tdaperks.com 391

Texas Dental Journal l www.tda.org l May 2013

TEXAS DEnTAl Dental JournAl Journal Established February 1883 Established February 1883

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Vol 130, No 5 Vol 130, No 5

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May 2013 May 2013

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SPECIAL ISSUE: ORAL CANCER SCREENING: A CLOSER LOOK Early of oral cancer in the dental office poses what psychologists would call a vigilance task — detecting an event that over cover detection info to come long periods occurs infrequently or perhaps not at all, but which nonetheless has serious consequences. Staying abreast of the latest information on educating patients and communities on risk factors, preventing and detecting oral cancer, and providing appropriate treatment are incumbent on the dental practitioner.

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GUEST EDITORIAL: ORAL CANCER: WHAT TO DO? Daniel L. JonesEDITORIAL: DDS, PhD, Professor and Chair, Department of Public Health Sciences, Texas A&M University Health Science Center GUEST ORAL CANCER: WHAT TOTheDO? Baylor College of Dentistry

410 410

THE LIMITATIONS OF THE CLINICAL ORAL EXAMINATION IN DETECTING THE LIMITATIONS THE CLINICAL ORAL EXAMINATION IN DETECTING DYSPLASTIC ORAL OF LESIONS AND ORAL SQUAMOUS CELL CARCINOMA DYSPLASTIC ORAL AND ORAL CELL Joel B. Epstein, DMD, MSD, FRCD(C),LESIONS FDS RCS(Edin); Pelin Güneri, DDS, PhD;SQUAMOUS Hayal Boyacioglu, PhD; Elliot Abt, CARCINOMA DDS, MS, MSc

Daniel L. Jones DDS, PhD, Professor and Chair, Department of Public Health Sciences, The Texas A&M University Health Science Center Baylor College of Dentistry

Joel B. Epstein, DMD, MSD, FRCD(C), FDS RCS(Edin); Pelin Güneri, DDS, PhD; Hayal Boyacioglu, PhD; Elliot Abt, DDS, MS, MSc

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IT’S NOT JUST AN “ORAL CANCER” EXAM Michaell A. Huber,JUST DDS, andAN Vidya Sankar, DMD, MHS IT’S NOT “ORAL CANCER” EXAM

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CIGARETTES: WHAT’S WHAT’S KNOWN, KNOWN, WHAT’S WHAT’S UNKNOWN UNKNOWN EE CIGARETTES:

Michaell A. Huber, DDS, and Vidya Sankar, DMD, MHS

ORAL CANCER: FAQ ORAL CANCER: Daniel L. Jones, DDS, PhD, andFAQ K. Vendrell Rankin, DDS Daniel L. Jones, DDS, PhD, and K. Vendrell Rankin, DDS

K. Vendrell Rankin, DDS K. Vendrell Rankin, DDS

MONTHLYFEATURES 396

President’s President’s Message Message

457

In Memoriam / TDA Smiles Foundation In Memoriam / TDA Smiles Foundation

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Oral Oral and Maxillofacial Pathology Case and Maxillofacial Pathology Case

and Memorial and Honorarium Donors and Memorial and Honorarium Donors

of the Month of the Month

458

of Events Calendar of Events Calendar

436

Critically Appraised Topic of the Month Critically Appraised Topic of the Month

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Value for Your Profession Value for Your Profession

456

Oral Oral and Maxillofacial Pathology Case of and Maxillofacial Pathology Case of

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Advertising Briefs Advertising Briefs

the Month Diagnosis and Management the Month Diagnosis and Management

478

Index to Advertisers Index to Advertisers

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Texas Dental Journal l www.tda.org l May 2013

TDA members, use your TDA members, use your smartphone smartphone to scan this QR to scan this QR Code and access the Code and access the online Texas Dental Journal. online Texas

Editorial Staff

Editorial Advisory Board

BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION

Stephen R. Matteson, DDS, Editor-in-Chief Daniel L. Jones, DDS, PhD, Associate Editor Harvey P. Kessler, DDS, MS, Associate Editor Nicole Scott, Managing Editor Lauren Oakley, Publications Coordinator Barbara Donovan, Art Director Paul H. Schlesinger, Consultant

Ronald C. Auvenshine, DDS, PhD Barry K. Bartee, DDS, MD Patricia L. Blanton, DDS, PhD William C. Bone, DDS Phillip M. Campbell, DDS, MSD Michaell A. Huber, DDS Arthur H. Jeske, DMD, PhD Larry D. Jones, DDS Paul A. Kennedy Jr, DDS, MS Scott R. Makins, DDS Daniel Perez, DDS William F. Wathen, DMD Robert C. White, DDS Leighton A. Wier, DDS Douglas B. Willingham, DDS

The Texas Dental Journal is a peer-reviewed publication.

Texas Dental Association 1946 S IH-35 Ste 400, Austin, TX 78704-3698 Phone: 512-443-3675 • FAX: 512-443-3031 E-Mail: tda@tda.org • Website: 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, TX, 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 IH 35, Austin, TX 78704.

Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, Out-ofstate ADA Affiliated $49.50. In-state Non-ADA 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 NonADA 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. Electronic submissions are required. 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: 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 Texas Dental Journal is a member of the its manufacturer.

American Association of Dental Editors.

Member Publication

PRESIDENT Michael L. Stuart, DDS 972-226-6655, mstuartdds@sbcglobal.net PRESIDENT-ELECT David A. Duncan, DDS 806-355-7401, davidduncandds@gmail.com IMMEDIATE PAST PRESIDENT J. Preston Coleman, DDS 210-656-3301, drjpc@sbcglobal.net VICE PRESIDENT, NORTHEAST Arthur C. Morchat, DDS 903-983-1919, amorchat@suddenlink.net VICE PRESIDENT, SOUTHEAST Rita M. Cammarata, DDS 713-666-7884, rmcdds@sbcglobal.net VICE PRESIDENT, SOUTHWEST T. Beth Vance, DDS 956-968-9762, tbeth55@yahoo.com VICE PRESIDENT, NORTHWEST Michael J. Goulding, DDS 817-737-3536, mjgdds@sbcglobal.net SENIOR DIRECTOR, NORTHEAST Jean E. Bainbridge, DDS 214-388-4453, jbainbridgedds@sbcglobal.net SENIOR DIRECTOR, SOUTHEAST Gregory K. Oelfke, DDS 713-988-0492, greg@oelfke.com SENIOR DIRECTOR, SOUTHWEST Yvonne E. Maldonado, DDS 915-855-2337, yvonnedent2000@yahoo.com SENIOR DIRECTOR, NORTHWEST David C. Woodburn, DDS 806-358-7471, olddave1@gmail.com DIRECTOR, NORTHEAST Jerry J. Hopson, DDS 903-583-5715, dochop@verizon.net DIRECTOR, SOUTHEAST William S. Nantz, DDS 409-866-7498, wn3798@sbcglobal.net DIRECTOR, SOUTHWEST Joshua A. Austin, DDS 210-408-7999, jaustindds@me.com DIRECTOR, NORTHWEST Steven J. Hill, DDS 806-783-8837, sjhilldds@aol.com SECRETARY-TREASURER Ron Collins, DDS 281-983-5677, roncollinsdds@hotmail.com SPEAKER OF THE HOUSE John W. Baucum III, DDS 361-855-3900, jbaucum3@msn.com PARLIAMENTARIAN David H. McCarley, DDS 972-562-0767, drdavid@mccarleydental.com EDITOR Stephen R. Matteson, DDS 210-277-8595, texdented@gmail.com EXECUTIVE DIRECTOR Aaron Washburn 512-443-3675, aaron@tda.org LEGAL COUNSEL William H. Bingham 512-495-6000, bbingham@mcginnislaw.com

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Dr. Frank Boyar, a Fortress Dentist.

When you choose Fortress Insurance Company for your professional

I live in Delray Beach, Florida. I like the laid-back style. I’ve been here for 30 years, bought my practice from my mother’s dentist in 1975.

I practice general and geriatric dentistry. Many patients, I’ve seen three generations in the family.

I’ve always volunteered in the community. I’m a past president of Project Dentist Care, and helped to expand it.

I recharge by fly fishing, especially in salt water flats. It’s the most technically demanding type of fishing, a lot like hunting. It’s all catch and release, and generally we target bonefish, permit, or tarpon.

I plan to find a dentist to take over my practice. I’d like a smooth transition.

I recommend Fortress for professional liability coverage. They specialize in dentistry, so they understand our language.

In fishing, bring foul weather gear and it won’t rain. In dentistry, you need to get the right protection for peace of mind.

liability coverage, you can be confident that your practice is protected.

We are owned and operated by dentists and only insure dentists.

Aggressive claims defense, valuable risk management and outstanding customer service are why dentists all over the country have selected Fortress. Our local agents are responsive and knowledgeable too. To get Fortress protection* call Kyle Wallace at Wallace Specialty Insurance Group, 855-505-1121 or 972-663-5190. Tell him Dr. Boyar sent you.

Over 14,000 dentists trust Fortress with their professional liability insurance. *The language contained in each policy of insurance establishes the specific terms and conditions of insurance, and will supersede any statements contained herein.

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Protecting & Defending

www.dds4dds.com

Texas Dental l www.tda.org l 2013 August 747 Texas Dental JournalJournal l www.tda.org l May 395 Texas Dental Journal l www.tda.org l August 2011 691

President’s Message Michael L. Stuart, DDS, TDA President

A

s I write my final article for the Texas Dental Journal, I am reflecting on the things I will miss and not miss about being TDA President.

Among others, I will miss: •

As you can see, the “miss” list is longer than the “not miss” list, because it is such an awesome job!

Thank you for the privilege to serve!

• • • • • • • • •

The awesome reception the TDA president receives from all across the state.

Seeing parts of Texas I had never visited.

Being “the guy” who makes decisions affecting dentistry in Texas.

Representing Texas dentists in national meetings.

Presiding at TDA Board meetings.

Having a platform to write about topics for which I feel passionate.

Being introduced as “TDA President”.

Being “A-list preferred” on Southwest Airlines.

Working closely with TDA ED Aaron Washburn, as well as all of the TDA staff.

Having the best job in organized dentistry.

I will not miss: • • • • • • • •

Running out of my dental office like my hair is on fire to catch a plane.

Being in my dental office one day a week (not always).

Trying to meet a deadline for writing an article and not having any idea how to start.

Putting my patients on “hold” until I am back in the office next week.

Having my dental staff say, “Where are you headed this week?” and “When will you be back?”

The pressure of performance when not feeling my best.

Being “the guy” if things do not go as they should.

Having the ED call and say, “We are having this problem ...”

As you can see, the “miss” list is longer than the “not miss” list, because it is such an awesome job! Thank you for the privilege to serve!

Good luck to Dr David Duncan of Amarillo as he is the next TDA president!

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Free CE credits. Available 24/7.

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The CE courses are developed by the Texas Department of State Health Services and the Texas Health and Human Services Commission. All courses are accredited for eligible participants.* *Accredited by the UTHSCSA Dental School Office of Continuing Dental Education, Texas Medical Association, American Nurses Credentialing Center, National Commission for Health Education Credentialing, Texas State Board of Social Worker Examiners, Accreditation Council of Pharmacy Education, Texas Academy of Nutrition and Dietetics, Texas Academy of Audiology, and International Board of Lactation Consultant Examiners. Continuing Education for multiple disciplines will be provided for these events.

Taking New Steps

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

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CE Courses Include: • First Dental Home • Oral Health Examinations

by Dental Professionals • Oral Evaluations and Fluoride Varnish • Children with Diabetes • Children with Asthma • Case Management • Texas Health Steps Overview • Many others Referral Guidelines • Pediatric Depression • High Blood Pressures in the Office • Atopic Dermatitis • Gastroesophageal Reflux in Infants • Exercise-Induced Dyspnea • Referral Guidelines Overview

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

LOCATION

DEMOGRAPHICS STUDY

APPEARANCE OF YOUR OFFICE

TAKE PHOTOS OF EVERY AREA

SIZE OF PATIENT BASE

3 YEARS OF GROWTH TRENDS

NEW PATIENT FLOW

EXPLORE INTERNET MARKETING

ACTIVE RECALL

20% – 30% OF GROSS

“OPERATING PROFITS”

HYGIENE PROFITS MOST IMPORTANT

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

FOR OVER YEARS NO CHARGE FOR37REAL ESTATE YOU HAVE SEEN THE NAME…

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

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

GARY CLINTON Senior Appraiser

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

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Journal l www.tda.org l June 2011 2011 TexasTexas DentalDental Journal l www.tda.org l October

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Botox速 & Dermal Filler Training UPCOMING COURSE DATES Jul 26-27 ......................................... Houston Aug 2-3........... Orange County (Level I, III) Sep 20-21 ........ Atlanta w/ GDA (Level I, II)

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AAFE-DJ-Texas-3.3125x9.5.indd 1

4/9/13 11:45 AM

Anesthesia Education & Safety Foundation, Inc. Call us at 214-384-0796 or e-mail us at sedationce@aol.com; website: www.sedationce.com

ACLS & PALS Now Available! Contact us for details.

OUR MISSION: To provide affordable, quality anesthesia education with knowledgeable and experienced instructors, both in a clinical and academic manner while being a valuable resource to the practitioner after the programs. Courses are designed to meet the needs of the dental profession at all levels.

OUR GOAL: To teach safe and effective anesthesia techniques and management of medical emergencies in an understandable manner.

WHO WE ARE: We are licensed and practicing dentists in Texas, and we understand your needs. While other providers are in the process of contemplating program development, our courses have met the ADA Guidelines for more than 10 years. The new anesthesia guidelines were recently approved by the Texas State Board of Dental Examiners. As practicing dental anesthesiologists and educators, we have established continuing education programs to meet these needs.

Approved PACE Program Provider FAGD/MAGD Credit.

Approval does not imply acceptance by a state of provincial board of dentistry or AGD endorsement.

8/1/2011 to 7/31/2014.

Provider ID# 217924.

Dr David Canfield

Dr Clark Whitmire

Nitrous Oxide/Oxygen Conscious Sedation Course for Dentists: McKinney, Texas Credit: Time:

Each course date is by appointment with Dr. Canfield, please call for details 14 hours (clinicians must complete the online portion, first) 7:00 am – Registration; 7:30 am – 5:00 pm – Clinical Presentation

Level 1 and Level 2 Enteral Sedation Renewal Courses (only 1 day needed to renew): McKinney, Texas: Rockport, Texas: Tyler, Texas: Credit: Time:

Friday or Saturday, June 7 or 8, 2013 Saturday, July 6, 2013 Saturday, July 13, 2013 8 hours lecture 7:00 am – Registration; 7:30 am – 5:00 pm – Presentation

McKinney, Texas: Credit: Time:

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Level 1 Initial Minimal Sedation Permit Courses:

Level 1 to Level 2 Transitional Moderate Sedation Permit Course (must have a Level 1 permit): McKinney, Texas: Credit: Time:

Saturday, June 8, 2013 8 lecture/participation hours with clinical experiences and 3 live sedations 7:00 am – Registration; 7:30 am – 4:30 pm – Presentation

NEW >>>>> Airway, ECG, Pharmacology Program (satisfies Level 3 & Level 4 Anesthesia hours): Houston, Texas: Credit: Time:

Friday, June 14, 2013 (includes Level 3 & 4 Update with Anesthesia Hours) 8 hours lecture/Participation 7:30 am – Registration; 8:00 am – Presentation start time

ACLS (Advanced Cardiac Life Support) & PALS (Pediatric Advanced Life Support) Program: Houston, Texas: Credit: Time:

Friday, June 14, 2013 8 hours lecture/Participation 7:30 am – Registration; 8:00 am – Presentation start time

Houston, Texas: Credit: Time:

Friday and/or Saturday, June 14-15, 2013 16 hours lecture for 2-day program; or 8 anesthesia hours for 1 day program 7:30 am – Registration; 8:00 am – 5:00 pm - Presentation

McKinney, Texas: Credit: Time:

Thursday – Saturday, June 6-8, 2013 24 hours lecture/participation with clinical experiences and 3 live sedations 7:00 am – Registration; 7:30 am – 5:00 pm – Presentation

Level 3 & Level 4 Parenteral Sedation Permit Renewal & ACLS Course:

Level 2 Initial Moderate Sedation by Oral Administration Permit Course:

AGD Codes for all programs: 132 Anesthesia & Pain Control; 163 Conscious Sedation; 164 Oral Sedation The above continuing education programs fulfill the TSBDE Rule 110 practitioner requirement in the process to obtain selected Sedation permits.

We are continually adding programs to help you satisfy your requirements.

This is only a partial listing of sedation courses. Please consult our website for updates and new programs.

Find us on the web at www.sedationce.com Call us at 214-384-0796 to register for any program

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Oral and Maxillofacial Pathology Case of the Month Clinical Presentation

Juliana Robledo, DDS, Diplomate of the American Academy of Oral and Maxillofacial Pathology, South Texas Oral Pathology, San Antonio, Texas.

A 66-year-old female presented with a complaint of swelling of her left maxilla of several months duration. She also had a history of dental implant placement 5-6 years previously, which had never been restored.

Her past medical history was significant for hypertension, depression, and fibromyalgia. Her medications included Imiprimine, Pristiq, Plavix, Clonazepam, Zolpidem, Losartin, and Prevacid. She had an allergy to Indocin.

Her past surgical history included a hysterectomy, partial thyroidectomy, cholecystectomy, and an appendectomy.

Robledo

Rominger

James W. Rominger, DDS, MD, Oral and Maxillofacial Surgery, Alamo Maxillofacial Surgical Associates, San Antonio, Texas.

Her physical exam demonstrated a large (2.5X5 cm) red, exophytic, multilobulated mass on the left maxillary ridge, involving the edentulous premolar and molar areas. The ulcerated and erythematous mass appeared to wrap around the maxillary ridge (Figure 1). Extraorally, there was a slight bulge on the left side of the patient’s face (Figure 2). On the panoramic radiograph, the mass appeared to be overlying 2 dental implants in the area, which demonstrated mild superficial bone loss (Figure 3).

The patient underwent surgical excision of the lesion. It was found to be pedunculated and the top of a dental implant was noted in the base of the lesion (Figure 4).

Further exploration found that the 2 implants were mobile and they were removed. The patient healed uneventfully and has had no recurrence 1 year postoperatively.

Figure 2. Slight bulge on the patient’s left side of the face.

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Figure 1. Large multilobulated mass wrapping around the left maxillary ridge. The mass is erythematous with areas of ulceration.

Figure 3. The underlying implant after removal of the mass.

Differential Diagnosis Based on the clinical presentation of an ulcerated multilobulated mass of the maxillary edentulous alveolar ridge mucosa, a reactive lesion, a benign neoplasm, or a malignant process were all considered. The differential diagnosis for a benign process included: fibroma, pyogenic granuloma, peripheral giant cell granuloma, peripheral ossifying fibroma, and a peripheral odontogenic tumor. Fibroma is a reactive fibrous lesion caused by chronic local trauma or irritation to an area, most likely occurring on the tongue or buccal mucosa (1). Pyogenic granuloma presents as a painless, lobulated mass that can bleed easily, often arising from the interdental gingival papilla and may show rapid growth (1–3). Peripheral giant cell granuloma, a reactive lesion of the gingiva, may originate from the periosteum or periodontal ligament as a result of local trauma or chronic irritation. Clinically, it appears as a red-purple nodule involving the gingiva or edentulous alveolar ridge that can produce superficial erosion of the underlying bone (1,4). The peripheral ossifying fibroma, is a reactive proliferation of fibrous tissue with metaplastic bone formation that usually arises from the interdental papilla. It appears as an exophytic mass that may be either smooth surfaced or ulcerated and pink to red in color. Occasionally, the underlying bone can be resorbed in the shape of a shallow saucer-like depression (“saucerization�) and sometimes small calcifications in the center of the lesion can be seen in the radiographic images, a feature that was not present in this case (1,2,5).

Malignant soft tissue tumors and metastatic tumors were considered because of the relatively fast growth of this lesion; however, the lesion did not appear to be a destructive mass and a malignant process was deemed unlikely (6). The lesion was completely excised and submitted for histologic evaluation.

Figure 4. Panoramic radiograph show the implants in the area directly underneath the mass.

Figure 5. Mass surfaced by partially ulcerated squamous epithelium with a vascularized, loose stroma.

Histologic Description Upon microscopic examination, the nodular specimen was surfaced by stratified squamous epithelium with an area of ulceration. The underlying stroma consisted of organized granulation tissue with variable sized vascular channels. Some of the vascular channels were engorged with erythrocytes. A mixed inflammatory cell infiltrate composed of neuthrophils, plasma cells, lymphocytes, and histiocytes was present throughout the stroma (Figures 5 and 6).

Figure 6. Variable sized vascular channels intermixed with a heavy mixed inflammatory infiltrate.

What is the diagnosis? See page 456.

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David M. Chei, D.M.D. has acquired the practice of Richard L. Brown, D.D.S. - Dallas, Texas Savita S. Brenner, D.D.S. has acquired the practice of

Call 1-800-232-3826 or visit us online at www.aftco.net for a free practice appraisal, a $2,500 value!

John S. Truitt, D.D.S. -

AFTCO is pleased to have represented all parties in these transactions.

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

“Over $1.5 Billion in Practice Sales�

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Houston, Texas

REPRESENTING DENTISTS THROUGHOUT TEXAS BEFORE THE STATE BOARD OF DENTAL EXAMINERS

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Guest Editorial

Oral Cancer: What to Do? Daniel L. Jones DDS, PhD, Professor and Chair, Department of Public Health Sciences, The Texas A&M University Health Science Center Baylor College of Dentistry Jones

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his issue of the Texas Dental Journal traditionally focuses on oral cancer, and this month we will attempt to provide some insight into the latest issues in prevention and early detection of oral cancer. In the December 2012 issue of the Journal of the American Dental Association, Dr Joel Epstein and colleagues demonstrated that clinical oral examination does not reliably predict the histologic diagnosis of dysplasia or oral squamous cell carcinoma. So are oral cancer examinations of no value, and what then are we to do to provide our patients with the best care? We’ve reprinted that study this month, along with a further examination of the issue, which we hope will address this question.

Early detection of oral cancer in the dental office poses what psychologists would call a vigilance task – detecting an event that over long periods occurs infrequently or perhaps not at all, but which nonetheless has serious consequences. Humans tend not to be innately good at these types of tasks. The answer lies in establishing a routine — the pre-flight checklists that all pilots perform is a good example. I remember being told in dental school that the order in which you perform an examination is not as important as having an order that you use consistently, and that’s still good advice. We propose that the most effective preventive strategy is to help our patients reduce or eliminate dangerous habits, and to remain alert for

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signs of potentially malignant or early-stage lesions, by performing routine visual and tactile examinations on all patients. To this end, we present a FAQ for oral cancer — the most frequently-asked questions and most important facts to remember with regard to risk factors, signs and symptoms, and early detection of oral cancer. Drs Michaell Huber and Vidya Sankar present a collection of cases underscoring that the clinician performing a thorough clinical examination is often in the best position to detect cancer of the head and neck and beyond.

Lastly, Dr Kay Rankin presents some much-needed information about the e-cigarette, a fast-growing phenomenon and a worrisome development in the area of tobacco control, education, and cessation. These products are not currently regulated by the Food and Drug Administration as nicotine delivery devices, but rather as tobacco products, meaning that oversight is much less stringent. Chances are good that some of your patients are already users or may ask you about e-cigarettes. We have at least some of the answers you will need.

Staying abreast of the latest information on educating patients and communities on risk factors, preventing and detecting oral cancer, and providing appropriate treatment are incumbent on the dental practitioner. To this end, we sincerely hope you find this information useful.

Early detection of oral cancer in the dental office poses what psychologists would call a vigilance task – detecting an event that over long periods occurs infrequently or perhaps not at all, but which nonetheless has serious consequences.

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A clinical oral examination (COE), which is the principal strategy used to detect abnormal oral mucosal changes including cancer, requires a thorough head and neck examination, evaluation of oral mucosa by means of visual inspection under incandescent overhead or halogen illumination, and palpation

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The Limitations of the Clinical Oral Examination in Detecting Dysplastic Oral Lesions and Oral Squamous Cell Carcinoma Joel B. Epstein, DMD, MSD, FRCD(C), FDS RCS(Edin); Pelin Güneri, DDS, PhD; Hayal Boyacioglu, PhD; Elliot Abt, DDS, MS, MSc Epstein JB, Guneri P and colleagues. The limitations of the clinical oral examination in detecting dysplastic oral lesions and oral squamous cell carcinoma. JADA 2012;143(12):1332-42. Copyright © 2012 American Dental Association. All rights reserved. Reprinted by permission.

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he prognosis of oral squamous cell carcinoma (OSCC) is improved when it is detected at stage I or II, and the cost of care is reduced (1–3). Unfortunately, approximately two-thirds of OSCCs are diagnosed at an advanced stage (stage III or IV) (4,5). The overall 5-year survival rate of patients with OSCC in the United States is 60.8%. The survival rates are higher (82.3%) when the cancer is diagnosed with localized disease (stage I or II), and they are lower (55.6%) if nodal metastases have occurred. When a patient’s OSSC has metastasized, the survival rate is 33.5% (6).

These findings indicate the importance of early detection and diagnosis of dysplasia and early-stage OSCC (2,5,7).

Early-stage OSCC and epithelial dysplasia may manifest clinically as erythroplakia, leukoplakia, mixed red and white lesions, a mass or a persisting ulceration (Figures 1–3). These clinical lesions may be benign or dysplastic leukoplakia, hyper-plastic candidiasis, dysplastic lichenoid lesions, oral submucous fibrosis, or OSCC (8). The clinical presentation of oral dysplastic lesions or OSCC includes changes in surface texture, color and size, loss of surface integrity, contour deviations, or mobility of intraoral or extraoral structures (5,9).

A clinical oral examination (COE), which is the principal strategy used to detect abnormal oral mucosal changes including cancer, requires a thorough head and neck examination, evaluation of oral mucosa by means of visual inspection under incandescent overhead or halogen illumination, and palpation (8,10). Relying on a COE to detect oral dysplasia and OSCC, however, may be inadequate, as suggested by the finding that more than 30% of patients with OSCC and oropharyngeal cancer had undergone oral cancer screening during the 3 years before receiving a diagnosis of OSCC (10–13). Lesions may go unnoticed. When they are detected, the practitioner’s Texas Dental Journal l www.tda.org l May 2013

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Abstract Background. The clinical oral examination (COE) is the criterion standard for the initial detection of oral lesions that harbor dysplasia or oral squamous cell carcinoma (OSCC) at an early stage when they are most treatable. The authors conducted a systematic review to assess the effectiveness of the COE in predicting histologic diagnosis of dysplasia or OSCC. Methods. The authors conducted automated searches of PubMed, Web of Knowledge, and the Cochrane Library from 1966 through 2010 for randomized controlled trials and observational studies that included the terms “oral mucosal lesion screening” and “oral lesions.” They determined the quality (sensitivity, specificity, positive predictive value, negative predictive value and diagnostic odds ratio) of selected studies by using the Quality Assessment of Diagnostic Accuracy Studies tool.

Results. The overall diagnostic odds ratio was 6.1 (95% confidence interval, 2.1–17.6); therefore, the COE was considered to have poor overall performance as a diagnostic method for predicting dysplasia and OSCC. Clinical Implications. On the basis of the available literature, the authors determined that a COE of mucosal lesions generally is not predictive of histologic diagnosis. The fact that OSCCs often are diagnosed at an advanced stage of disease indicates the need for improving the COE and for developing adjuncts to help detect and diagnose oral mucosal lesions.

Key words Oral cancer; precancerous conditions; mouth diseases; mouth neoplasms; oral diagnosis.

Tex Dent J 2013;130(4): 412-425.

clinical impressions can affect whether and when steps are taken to make a diagnosis. Therefore, lesion detection and clinical impressions are important in diagnosing oral dysplastic lesions and OSCC. We conducted a systematic review to evaluate how effective the COE is in predicting a diagnosis of oral dysplasia or OSCC in mucosal lesions submitted for biopsy.

Methods Because we conducted a review of articles in which clinically detected oral mucosal lesions had been subjected to tissue biopsy and diagnosed histologically, we included screening and observational studies, as well as randomized controlled trials, that met our inclusion criteria. We included only studies in which investigators had biopsied the lesions and made a histologic diagnosis; in which patients sought care at either primary care medical or dental practices or in which they were referred to a clinic because they had an oral mucosal disease or after they received cancer therapy at a cancer treatment center; and in which all patients had either primary oral mucosal lesions or recurrent second oral malignancies not limited by stage or grade.

The steps we followed when conducting our meta-analysis were formulation of the problem to be addressed, collection and analysis of the data, and reporting of the results. We established a detailed research protocol to define the objectives, the hypotheses to be tested, the subgroups of interest, and the proposed methods and criteria used to identify and select relevant studies and extract and analyze information a priori.

About the Authors Dr Epstein is an adjunct professor and the director of oral medicine, City of Hope National Medical Center, Duarte, CA, and a staff member, Cedars Sinai Medical Center, Los Angeles, CA. Dr Güneri is a professor, Department of Maxillofacial Radiology, School of Dentistry, Ege University, Bornova, Izmir 35100, Turkey, e-mail peleen_2000@ yahoo.com. Address reprint requests to Dr Güneri.

Epstein

Dr Boyacioglu is a lecturer, Department of Statistics, Faculty of Science, Ege University, Izmir, Turkey.

Dr Abt is an attending staff member, Department of Dentistry, Advocate Illinois Masonic Medical Center, Chicago, IL. None of the authors reported any disclosures.

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We conducted an automated literature search of articles published from January 1, 1966, through January 20, 2010, by using the following databases: PubMed, Web of Knowledge, and the Cochrane Library. Using the search terms “oral mucosal lesion screening” and “oral lesions,” we followed the search strategy and flow diagram presented in the box on page 414 and Table 4, respectively. We identified additional articles by reviewing the reference lists of relevant articles, archives of oral medicine journals’ websites and related journals.

We also evaluated unpublished articles that had been peer- reviewed and accepted for publication when we were able to access them. In addition, we included articles regarding clinically detected lesions that were identified by means of visual examination as subsets of data in studies whose investigators assessed the COE and the use of adjunctive techniques. We found 1,252 articles that met our criteria (1,195 studies in PubMed, 38 in the Cochrane Library and 19 in Web of Knowledge) that met our criteria. We identified an additional 264 articles after we hand searched the reference lists of the relevant articles, archives of oral medicine journals’ websites and related journals. After we excluded duplicate articles, case reports, expert opinions, unpublished articles, non–English-language studies, and animal studies, the number of articles was 85. We eliminated a total of 45 articles that included data regarding only the detection of a particular lesion (for example, leukoplakia) or whose investigators evaluated the frequency of oral lesions in a selected population sample (for example, patients with previous OSCC). We excluded 16 studies that did not include histologic diagnosis of oral mucosal lesions (Table 1) (1,4,5,10,11,14–24). To make

Figure 1. An oral squamous cell carcinoma lesion manifesting as a chronic mass with red and white components and ulceration. (A white paper dot was used to calibrate light).

Figure 2. An exophytic oral mucosal lesion that was diagnosed histologically as erythroleukoplakia and oral squamous cell carcinoma. (A white paper dot was used to calibrate light).

ABBREVIATION KEY COE: Clinical oral examination. F: Female. FN: False negative. FP: False positive. M: Male.

OML: Oral mucosal lesion. OSCC: Oral squamous cell carcinoma. PMEL: Potentially malignant epithelial lesion. QUADAS: Quality Assessment of Diagnostic Accuracy Studies. SCC: Squamous cell carcinoma. TB: Toluidine blue. TN: True negative.

TP: True positive.

Figure 3. A patient with oral squamous cell carcinoma that manifested as a chronic ulceration. (A white paper dot was used to calibrate light).

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these exclusions, we determined the quality of the 40 remaining studies by using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. QUADAS is an evidencebased quality assessment tool used in systematic reviews to determine the accuracy of diagnostic tests; however, this tool does not incorporate a quality score (25). We also used QUADAS to assess the risk of bias level (low, medium or high) of the studies using the following criteria: study design, selection of study sample, patients receiving both experimental and reference tests, definition of positive and negative outcomes for both the COE and a biopsy, and masking of each test without knowledge of the other test results. The results of the QUADAS tool assessments are shown in the eTable, available as supplemental data to the online version of this article (found at http://jada.ada.org).

The remaining 24 studies’ investigators reported histologic confirmation of clinically detected lesions identified by means of visual examination as subsets of data in studies assessing the COE and the use of adjunctive techniques (Table 2) (9,12,26–47). We abstracted data relating to sampling and characteristics of the study group, study design, interventions, and reported lesional diagnostic outcomes from each article. Two authors (J.B.E., P.G.) extracted independent data by using data extraction sheets. For each study, we calculated the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), positive predictive value, negative predictive value, accuracy, and area under curve (48) (Table 3). As clinically normal mu-

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Literature search strategy #1 (oral mucosal lesion)

#2 (oral lesion screening)

#3 (oral mucosal lesion screening) #4 (oral lesions) #5 (#1 AND #2) #6 (#1 OR #2)

#7 (( #1 AND #4 ) OR #5) #8 oral NEAR/5 mucosal #9 (#3 AND #4)

#10 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9)

Flow diagram showing an overview of the article selection process Articles identified through database searching (PubMed, the Cochrane Library, Web of Knowledge) (n = 1,252)

Articles identified through other sources (reference lists, journals’ websites) (n = 264)

Total no. of articles identified (n = 1,516) Articles remaining after duplicate articles were removed (n = 1,278

Articles excluded (reviews about detection of oral squamous cell carcinoma, case reports, animal studies, expert opinions, unpublished articles, non-English language studies, nonrelevant articles) (n = 1,193)

Full-text articles assessed for eligibility (n = 85)

Full-text articles excluded (only a group of lesions or patients was investigated) (n = 45)

Full-text articles included in qualitative synthesis (n = 40)

Full-text articles excluded (no histologic evaluation for all lesions) (n = 16)

Full-text articles included in qualitative synthesis (n = 24)

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cosa would not have been biopsied, we added 0.5 to appropriate cells of 2 × 2 tables so that we could calculate specificity. Provided that clinically normal mucosa would not be biopsied, 0.5 was added to all cells of the data analysis table to calculate specificity.

The authors of the 24 included studies classified the patients’ degrees of dysplasia in different ways. Therefore, we subgrouped the data (true positive, true negative, false positive, false negative and other related test statistics’ data) according to how dysplasia was classified and performed all further analyses considering these 5 groupings (Table 4) (9,12, 26–47): • A. All types of dysplasia were considered as test positive for potentially malignant epithelial lesions or oral squamous cell carcinomas; • B. Mild dysplasia was considered as test negative, and moderate and severe dysplasia was considered as test positive; • C. Mild and moderate dysplasia was considered as test negative, but severe dysplasia was considered as test positive; • D. All dysplasia was considered as test negative; • E. Only a dichotomous evaluation (that is, benign or malignant lesions) was conducted.

Thus, we identified the influence of how dysplasia was classified clearly. In articles in which only the presence of dysplasia was reported, we considered them as test positive and reclassified them from group E to group A (12,34,37,40).

In our meta-analysis, we reported all of the outcomes by using the random-effects model (DerSimonian-

Table 1. Studies excluded from the analysis owing to a lack of biopsy results or the use of histologic examination on a subgroup of the patient population.

AUTHOR, YEAR

REASON FOR EXCLUSION

Warnakulasuriya and Colleagues,1 1984

No biopsy

Mehta and Colleagues,14 1986

No biopsy

Warnakulasuriya and Colleagues,15 1990

No biopsy

Ikeda and Colleagues,16 1991

No biopsy

Downer and Colleagues,17 1995

No biopsy

Ikeda and Colleagues,18 1995

No biopsy

Jullien and Colleagues,19 1995

No biopsy

Mathew and Colleagues,20 1997

No biopsy

Nagao and Colleagues,21 2000

No biopsy

Huber and Colleagues,10 2004

Limited biopsy*

Kerr and Colleagues,11 2006

Limited biopsy

Seoane and Colleagues,4 2006 Oh and Colleagues,22 2007

No biopsy Limited biopsy

Epstein and Colleagues,5 2008

No biopsy

Morse and Colleagues,23 2009

No biopsy

Su and Colleagues,24 2010

Limited biopsy

* Limited biopsy refers to having biopsy results from only a group of the lesions observed.

Laird method) to allow for inter-study variability. We evaluated heterogeneity between studies by means of the Cochran Q test and the inconsistency index (I2), each of which has been proposed as a measure for quantifying the degree of heterogeneity between studies (48–50). We assessed publication bias by using the Egger weighted regression method (48–50). We performed statistical analyses by using Meta-DiSc statistical software, Version 1.4 (Unit of Clinical Biostatistics, Ramón y Cajal Hospital, Madrid)51 and SPSS 11.0 (SPSS, Chicago). We considered a P value ≤ .05 as significant.

Results Twenty-four observational studies that included 7,079 patients and 1,956 biopsies met the inclusion criteria. Because we included only lesions with histologic diagnoses, the overall sample size was 1,956. The included studies’ designs and their risks of bias are described in Table 2. We conducted an overall meta-analysis of the included studies that considered all dysplasia as test positive. In this step, by contemplating that the nature of dysplastic lesions requires close monitoring, biopsy or both, we Texas Dental Journal l www.tda.org l May 2013

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Table 2. Characteristics of included articles (N = 24).

AUTHOR, YEAR

STUDY SETTING

PARTICIPANTS’ SEX

PARTICIPANTS’ AGES IN YEARS

DISEASE

STUDY DESIGN

PROCEDURES

RISK OF BIAS

Onofre and Colleagues,26 1997

Specialty clinic

M* and F†

18-85

PMEL‡

Cohort

COE§ and biopsy

Low

Prout and Colleagues,27 1997

Community

M and F

59 (mean)

OML¶

Cohort

COE and biopsy

Low

Zheng and Colleagues,28 2002

Specialty clinic

M and F

31-85

PMEL and OSCC#

Cohort

COE and fluorescence endoscopy and biopsy

Moderate

Epstein and Colleagues,29 2003

Specialty clinic

M and F

61.5 (mean)

Treated OSCC

Cohort

COE and TB** and biopsy

Low

Epstein and Colleagues,30 2003

Specialty clinic

M and F

NA††

PMEL and OSCC

Cohort

COE and TB and loss of heterozygosity analysis

Moderate

Remmerbach and Colleagues,31 2003

Specialty clinic

M and F

22-91

PMEL

Case control

COE and exfoliative cytology and biopsy

Low

Maraki and Colleagues,32 2004

Specialty clinic

M and F

25-87

PMEL

Cohort

COE and exfoliative cytology and DNA cytometry and biopsy

Low

Ram and Siar,33 2005

Specialty clinic

M and F

35-80

PMEL and OSCC and treated PMEL or OSCC

Case control

COE and TB and chemiluminescence and biopsy

Moderate

Chen and Colleagues,34 2007

Specialty clinic

NA

NA

PMEL

Cohort

COE and methylene blue and biopsy

Low

Du and Colleagues,35 2007

Specialty clinic

M and F

50.1 (mean)

PMEL

Cohort

COE and rose bengal and colorimetry and biopsy

Moderate

Farah and McCullough,12 2007

Specialty clinic

M and F

57.7

Leukoplakia

Cohort

COE and chemiluminescence and biopsy

Low

Bhalang and Colleagues,36 2008

Specialty clinic

M and F

39-77

PMEL

Cohort

COE and acetic acid and biopsy

Moderate

Epstein and Colleagues,9 2008

Specialty clinic

M and F

59.6 (mean)

PMEL

Cohort

COE and chemiluminescence and TB and biopsy

Moderate

Mehrotra and Colleagues,37 2008

Specialty clinic

M and F

10-87

PMEL

Cohort

COE and exfoliative cytology and biopsy

Low

Allegra and Colleagues,38 2009

Specialty clinic

M and F

42-82

OML

Case control

COE and TB and biopsy

Low

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Table 2, Continued AUTHOR, YEAR

STUDY SETTING

PARTICIPANTS’ SEX

PARTICIPANTS’ AGES IN YEARS

DISEASE

STUDY DESIGN

PROCEDURES

RISK OF BIAS

Arduino and Colleagues,39 2009

Specialty clinic

M and F

63.8 (mean)

PMEL (oral epithelial dysplasia)

Cohort

Retrospective COE and biopsy

Low

McIntosh and Colleagues,40 2009

Specialty clinic

M and F

26.0-87.2

OML

Cohort

COE and acetic acid and diffuse illumination and biopsy

Low

Wilder-Smith and Colleagues,41 2009

Specialty clinic

NA

NA

PMEL

Cohort

COE and optic coherence tomography and biopsy

Low

Jerjes and Colleagues,42 2010

Specialty clinic

NA

NA

PMEL

Cohort

COE and optic coherence tomography and biopsy

Moderate

Mehrotra and Colleagues,43 2010

Specialty clinic

NA

NA

PMEL

Cohort

COE and chemiluminescence and autofluorescence and biopsy

Low

Nagaraju and Colleagues,44 2010

Specialty clinic

M and F

NA

PMEL and OSCC

Cohort

COE and TB and Lugol iodine and biopsy

Low

Güneri and Colleagues,45 2011

Specialty clinic

M and F

56.2 (mean)

OML

Cohort

COE and TB and exfoliative cytology and biopsy

Low

Koch and Colleagues,46 2011

Specialty clinic

M and F

62.8 (mean)

PMEL

Cohort

COE and exfoliative cytology and biopsy

Low

Koch and Colleagues,47 2011

Specialty clinic

M and F

61.7 (mean)

PMEL and OSCC

Cohort

COE and autofluorescence and biopsy

Moderate

* M: Male. † F: Female. ‡ PMEL: Potentially malignant epithelial lesion. § COE: Clinical oral examination. ¶ OML: Oral mucosal lesion. # OSCC: Oral squamous cell carcinoma. ** TB: Toluidine blue. †† NA: Not available.

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regarded the dysplastic lesions as serious and grouped them with the test positive lesions. The results for overall estimation of the COE efficacy in predicting potentially malignant epithelial lesions or OSCCs are presented in Table 5).

Generally, the sensitivity of the COE was good (0.93), but it was not 100%, because patients who had oral mucosal dysplasia or OSCC that had not been biopsied ultimately underwent histologic examination at some point, usually after surgical excision of the lesion. We considered the lesions that were not biopsied initially but were found to have dysplasia or OSCC histologically to be false negative, which lowered the sensitivity. On the other hand, the specificity of the COE was

relatively poor (0.31). This finding is clinically relevant in that oral dysplasia or OSCC are likely to be detected during the COE. However, the results of the COE were unlikely to rule out dysplasia or OSCC in asymptomatic patients who did not have recognized risk factors for cancer. These findings follow trends for other diagnostic adjunctive tests such as VELscope (LED Dental, White Rock, British Columbia, Canada) and Vizilite (Zila Pharmaceuticals, Phoenix), which generally have good sensitivity but poor specificity (9,12,22,43,52–55).

Likelihood ratios are used with diagnostic tests to indicate how likely a patient is to have the disease after a positive test (that is, PLR) and unlikely to have it after a negative test (that

is, NLR). In general, a PLR above 5.0 and NLR below 0.2 indicate that the diagnostic test is effective, with a value of 1.0 being the null value (for which the test provides no information about the likelihood of disease after a diagnostic test is performed) (56). In our study, PLRs and NLRs were poor, with PLRs hovering around the null or unity value and NLRs more than 2.0. Perhaps the most telling were values for DOR. As the DOR is PLR divided by NLR, DOR values of 25.0 (5.0/0.2) or greater represent an effective diagnostic test. The overall DOR was 6.1 (95% confidence interval [CI], 2.1–17.6), which indicates the ineffectiveness of the COE to predict oral dysplasia or OSCC, especially because the upper limit of the CI is lower than clinically relevant values.

Table 3. Commonly used test indicators in diagnostic research.* TEST INDICATOR

FORMULA

DEFINITION

Sensitivity

TP†/(TP + FN‡)

Proportion of positive test results among participants with disease

Specificity

TN§/(TN + FP¶)

Proportion of negative test results among healthy participants

Positive Predictive Value

TP/(TP + FP)

Proportion of participants with disease among those with a positive test result

Negative Predictive Value

TN/(TN + FN)

Proportion of healthy participants among those with a negative test result

Positive Likelihood Ratio

Sensitivity/(1-specificity)

Ratio of a positive test result among participants with disease to the same result among healthy participants

Negative Likelihood Ratio

(1-sensitivity)/specificity

Ratio of a negative test result among participants with disease to the same result among healthy participants

Diagnostic Odds Ratio

(TP/FN)/(FP/TN)

Single indicator of a diagnostic test performance

Accuracy

(TP + TN)/(TP + TN + FP + FN)

Proportion of correctly identified participants

* Source: Glas and colleagues. (48) † TP: True positive. ‡ FN: False negative. § TN: True negative. ¶ FP: False positive.

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Table 4. Grouping of studies using standard criterion for dysplasia of potentially malignant epithelial lesions.

GROUP* A

AUTHOR, YEAR Onofre and Colleagues,26 1997 Zheng and Colleagues,28 2002 Epstein and Colleagues,30 2003 Maraki and Colleagues,32 2004 Ram and Siar,33 2005 Du and Colleagues,35 2007 Epstein and Colleagues,9 2008 Allegra and Colleagues,38 2009 Arduino and Colleagues,39 2009 Wilder-Smith and Colleagues,41 2009 Jerjes and Colleagues,42 2010 Nagaraju and Colleagues,45 2010 Koch and Colleagues,47 2011

B

Onofre and Colleagues,26 1997 Epstein and Colleagues,30 2003 Maraki and Colleagues,32 2004 Ram and Siar,33 2005 Du and Colleagues,35 2007 Epstein and Colleagues,9 2008 Allegra and Colleagues,38 2009 Arduino and Colleagues,39 2009 Wilder-Smith and Colleagues,41 2009 Jerjes and Colleagues,42 2010 Nagaraju and Colleagues,45 2010 Koch and Colleagues,47 2011

C

Onofre and Colleagues,26 1997 Epstein and Colleagues,30 2003 Ram and Siar,33 2005 Epstein and Colleagues,9 2008 Allegra and Colleagues,38 2009 Arduino and Colleagues,39 2009 Wilder-Smith and Colleagues,41 2009 Jerjes and Colleagues,42 2010 Nagaraju and Colleagues,45 2010 Koch and Colleagues,47 2011

D

Zheng and Colleagues,28 2002 Epstein and Colleagues,30 2003 Maraki and Colleagues,32 2004 Ram and Siar,33 2005 Epstein and Colleagues,9 2008 Allegra and Colleagues,38 2009 Arduino and Colleagues,39 2009 Wilder-Smith and Colleagues,41 2009 Jerjes and Colleagues,42 2010 Koch and Colleagues,47 2011

E

Prout and Colleagues,27 1997 Epstein and Colleagues,29 2003 Remmerbach and Colleagues,31 2003 Chen and Colleagues,34 2007 Farah and McCullough,12 2007 Bhalang and Colleagues,36 2008 Mehrotra and Colleagues,37 2008 McIntosh and Colleagues,40 2009 Mehrotra and Colleagues,43 2010 Güneri and Colleagues,45 2011 Koch and Colleagues,46 2011

* A: All types of dysplasia were considered as test positive for potentially malignant epithelial lesions or oral squamous cell carcinomas. B: Mild dysplasia was considered as test negative, and moderate and severe dysplasia were considered as test positive. C: Mild and moderate dysplasia were considered as test negative, but severe dysplasia was considered as test positive. D: All dysplasia was considered as test negative. E. Only a dichotomous evaluation (that is, benign or malignant lesions) was conducted.

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When we conducted a subgroup analysis, we found that no group of studies had a DOR greater than 10.0, which reinforced the idea that no matter how dysplasia was classified as either test negative, test positive or combinations of milder dysplasia as test negative and more severe forms as test positive, the COE was ineffective as a diagnostic test. Owing to variations in clinical parameters, heterogeneity was significant among the included studies. Publication bias did not appear to be a factor in this review.

Discussion Early-stage oral malignant lesions, dysplasia and carcinoma in situ can be managed with less intensive, often single-modality therapy, with less acute and chronic toxicity and at lower cost than can those at an advanced stage (29). Therefore, a number of screening models have been used for early detection of oral lesions that may represent dysplastic or malignant changes. However, the differences between the patient population selection criteria, the expertise of the examiners and the variations in study settings affect the outcomes of the results of detection and screening studies and those of the accuracy of the diagnostic methods. In addition, variability in the clinical and histologic classification of the lesions, differences in histologic evaluation (that is, variation in diagnosis among pathologists, which includes the range of potential diagnoses from dysplastic to malignant, although less variability is seen at the extremes of the continuum) and the assessment of epithelial dysplasia (either malignant or benign) affect the outcomes of the detection and screening studies and the accuracy of the diagnostic methods (19,21). These differences can cause wide variations that affect outcomes, thus affecting heterogeneity and the ranges of the 95% CIs. In our study, we used the QUADAS tool to establish the quality of the studies. Most questions in the QUADAS tool related to issues of bias (questions 3–7, 10–12 and 14), but 2 items were associated with variability (questions 1 and 2) and 3 with reporting (questions 8, 9 and 13). (The QUADAS tool questions are shown in the eTable, available as supplemental data to the online version of this article [found at http://jada.ada.org]).

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Table 5. Overall estimation of clinical oral examination efficacy in prediction of potentially malignant epithelial lesions/oral squamous cell carcinomas.

STATISTICAL PARAMETERS No. of Studies

VALUES 24

Sensitivity (95% CI*)

0.93 (0.91-0.94)

Specificity (95% CI)

0.31 (0.28-0.34)

PLR† (95% CI)

1.26 (1.09-1.46)

NLR‡ (95% CI)

0.36 (0.18-0.69)

DOR§ (95% CI)

6.1 (2.1-17.6)

χ2 Value of Sensitivity (I2,¶ P)

231.06 (90%, .01)

χ2 Value of Specificity (I2, P Value)

857.8 (97.3%, .01)

Q# of PLR (I2, P Value)

1,191.5 (98.1%, .01)

Q of NLR (I2, P Value)

97.81 (76.5%, .01)

Q of DOR (I2, P Value)

78.28 (70.6%, .01)

AUC**

0.89

SE†† (AUC)

0.05

Q

0.82

SE(Q)

0.055

Publication Bias

P = .79

Effect of Publication Year

P = .45

Effect of Sample Size

P = .32

* † ‡ § ¶ # ** ††

420

CI: Confidence interval.

PLR: Positive likelihood ratio.

NLR: Negative likelihood ratio.

DOR: Diagnostic odds ratio.

I2: Inconsistency index.

Q: Cochran Q test.

AUC: Area under curve.

SE: Standard error.

Texas Dental Journal l www.tda.org l May 2013

The QUADAS tool does not incorporate a quality score because this score is required only when an overall indicator of quality is needed to weight the meta-analysis results (25). With the QUADAS tool, the assessment of the quality of a study is associated with the demonstration of the study’s results. Even if a study is well conducted, it could receive a poor quality assessment score if the methods and results are not presented in detail (25). As all of the studies we included in our review were observational, we need to consider the distortional effects of bias and confounding factors on the summary estimates.

The ability of a clinician to achieve an accurate provisional diagnosis for a particular oral mucosal lesion after synthesizing all of the related clinical information is important because a clinician who makes accurate diagnoses may take the steps necessary for further analysis of a lesion by means of biopsy when appropriate. Unfortunately, different pathological stages of oral mucosa may appear clinically similar, irrespective of the etiology (15). Study results have shown that a COE alone may not detect and discriminate reliably between benign, dysplastic lesions and OSCC, because oral mucosal conditions such as frictional keratosis, leukoedema and leukoplakia may appear clinically similar to potentially serious oral lesions (15,21). Mucosal or dysplastic lesions or even early-stage cancer may manifest in mucosa that appears to be normal clinically (57,58).

This premise is supported by Thomson, who found that “mirror image” biopsies from clinically normal-appearing mucosa may contain cellular atypia that are compatible with pathologies ranging from chronic irritation to OSCC (59). The site of the lesion and the ability of the clinicians to recognize the mucosal aberrations and make the most objective diagnostic decision possible also can interfere with the diagnosis (19). Therefore, performing a histologic examination that is accepted as the criterion standard is necessary. Unfortunately, the variability in pathologic diagnosis among pathologists also influences the true diagnosis and leads to versatile sensitivity and specificity values of any diagnostic modality (60,61). As observed in some studies, when only the suspicious lesions are subjected to histologic examination, a false-negative clinical evaluation cannot be assessed, and appropriate data for determining

Oral Cancer Screening

specificity, accuracy, and positive and negative predictive values of the COE will be lacking (21).

There are some points to be noted.

The 95% CIs we obtained from the included studies were wide, a finding that indicates the lack of precision of the test parameters stated in the articles. All of the point estimates (DORs) were well below 25, which is a minimal value for efficacy. This finding suggests that diagnoses made on the basis of COEs correlate poorly with diagnoses made on the basis of biopsy results. Therefore, a COE alone may not detect the nature of an oral mucosal lesion accurately, thus creating the potential for missed clinical lesions, which can affect the true outcomes of care. These findings follow trends seen for other diagnostic adjunctive tests such as VELscope and Vizilite, which generally have good sensitivity but poor specificity (9,12,22,43,52–55). We assessed data derived primarily from clinical trials in high-risk settings, which may have led to higher detection and clinical diagnoses rates compared with those seen in the general population. The experience of the health care worker, the clinical setting, and the risk level of the patients examined may affect detection and clinical diagnosis.

Practitioners need to be vigilant when conducting comprehensive head and neck and oral and oropharyngeal examinations, as well as during lymph node palpation. Considering that the dental office is the most common site for detecting oral cancer, proper education and training of dental professionals may assist in improving the sensitivity, specificity and accuracy of oral cancer screening (19,62–64).

Our findings that OSCCs are diagnosed most often at an advanced stage in two-thirds of cases emphasize the potential role that adjuvants to the COE can play. One concern about making a diagnosis on the basis of the COE is the potential for false-positive results that may lead to unnecessary treatment and side effects from the treatment provided. However, the most significant concern is false-negative findings in which significant disease is present but not detected and diagnosed and, therefore, not treated.

Improving making a diagnosis depends on training, experience, care during examination, appropriate testing and accurate interpretation of test results, and therefore adjuncts continue to be sought to improve the findings and accuracy of the COE (7). Even though Seoane and colleagues have reported that only 9.4% of general dental practitioners have used toluidine blue before performing a scalpel biopsy, the results of other studies showed that use of adjuncts in oral mucosal lesion diagnosis improved the accuracy of clinical diagnosis by providing additional information (4,45,57,58). The goal of adjunctive application of technology to highlight such lesions may increase the diagnostic yield (7,10,40,53). Further development of adjunct technologies, however, is needed.

Conclusions On the basis of our review of the available literature, we determined that a COE of mucosal lesions generally is not predictive of their histologic diagnosis. The fact that OSCCs often are diagnosed at an advanced stage emphasizes the need for improving

the COE and the need to develop adjuncts to assist in oral mucosal lesion detection and diagnosis.

References 1. Warnakulasuriya KA, Ekanayake AN, Sivayoham S, et al. Utilization of primary health care workers for early detection of oral cancer and precancer cases in Sri Lanka. Bull World Health Organ 1984;62(2):243-250.

2. Boyle P, Autier P, Bartelink H, et al. European Code Against Cancer and scientific justification: third version (2003). Ann Oncol 2003;14(7):973-1005.

3. Epstein JD, Knight TK, Epstein JB, Bride MA, Nichol MB. Cost of care for early- and late-stage oral and pharyngeal cancer in the California Medicaid population. Head Neck 2008;30(2):178-186.

4. Seoane J, Warnakulasuriya S, Varela-Centelles P, Esparza G, Dios PD. Oral cancer: experiences and diagnostic abilities elicited by dentists in North-western Spain.

Oral Dis 2006;12(5):487-492.

5. Epstein JB, Villines D, Drahos G, Kaufman E, Gorsky M. Oral lesions in patients participating in an oral examination screening week at an urban dental school.

JADA 2008;139(10):1338-1344.

6. National Cancer Institute, Surveillance Epidemiology and End Results. SEER Stat fact sheets: oral cavity and pharynx. www.seer. cancer.gov/statfacts/html/oralcav. html#survival. Accessed Oct. 3, 2012.

7. Rethman MP, Carpenter W, Cohen EE, et al: American Dental Association Council on Scientific Affairs Texas Dental Journal l www.tda.org l May 2013

421

Oral Cancer Screening

Expert Panel on Screening for Oral Squamous Cell Carcinomas.

Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. JADA 2010;141(5):509-520.

8. Epstein JB, Gorsky M, Cabay RJ, Day T, Gonsalves W. Screening for and diagnosis of oral premalignant lesions and oropharyngeal squamous cell carcinoma: role of primary care physicians. Can Fam Physician 2008;54(6):870-875.

9. Epstein JB, Silverman S Jr, Epstein JD, Lonky SA, Bride MA. Analysis of oral lesion biopsies identified and evaluated by visual examination, chemiluminescence and toluidine blue (published online ahead of print Nov. 8, 2007; published correction appears in Oral Oncol 2008;44[6]:615).

Oral Oncol 2008;44(6):538544. doi:10.1016/j.oraloncology.2007.08.011.

10. Huber MA, Bsoul SA, Terezhalmy GT. Acetic acid wash and chemiluminescent illumination as an adjunct to conventional oral soft tissue examination for the detection of dysplasia: a pilot study.

Quintessence Int 2004;35(5):378384.

11. Kerr AR, Sirois DA, Epstein JB. Clinical evaluation of chemiluminescent lighting: an adjunct for oral mucosal examinations. J Clin Dent 2006;17(3):59-63.

12. Farah CS, McCullough MJ. A pilot case control study on the efficacy of acetic acid wash and chemiluminescent illumination (ViziLite) in the visualisation of oral mucosal white lesions (published online ahead of print Dec. 13, 2006). Oral Oncol 2007;43(8):

422

Texas Dental Journal l www.tda.org l May 2013

820-824. doi:10.1016/j.oraloncology.2006.10.005.

13. Jemal A, Murray T, Samuels A, Ghafoor A, Ward E, Thun MJ. Cancer statistics, 2003. CA Cancer J Clin 2003;53(1):5-26.

14. Mehta FS, Gupta PC, Bhonsle RB, Murti PR, Daftary DK, Pindborg JJ. Detection of oral cancer using basic health workers in an area of high oral cancer incidence in India. Cancer Detect Prev 1986;9(34):219-225.

15. Warnakulasuriya S, Pindborg JJ. Reliability of oral precancer screening by primary health care workers in Sri Lanka. Community Dent Health 1990;7(1):73-79.

16. Ikeda N, Ishii T, Iida S, Kawai T. Epidemiological study of oral leukoplakia based on mass screening for oral mucosal diseases in a selected Japanese population.

Community Dent Oral Epidemiol 1991;19(3):160-163.

17. Downer MC, Evans AW, Hughes Hallet CM, Jullien JA, Speight PM, Zakrzewska JM. Evaluation of screening for oral cancer and precancer in a company headquarters. Community Dent Oral Epidemiol 1995;23(2):84-88.

18. Ikeda N, Downer MC, Ishii T, Fukano H, Nagao T, Inoue K. Annual screening for oral cancer and precancer by invitation to 60-year-old residents of a city in Japan. Community Dent Health 1995; 12(3):133-137.

19. Jullien JA, Downer MC, Zakrzewska JM, Speight PM. Evaluation of a screening test for the early detection of oral cancer and precancer. Community Dent Health 1995;12(1):3-7.

20. Mathew B, Sankaranarayanan R, Sunilkumar KB, Kuruvila B, Pisani P, Nair MK. Reproducibility and validity of oral visual inspection by trained health workers in the detection of oral precancer and cancer. Br J Cancer 1997;76(3):390-394.

21. Nagao T, Ikeda N, Fukano H, Miyazaki H, Yano M, Warnakulasuriya S. Outcome following a population screening programme for oral cancer and precancer in Japan. Oral Oncol 2000;36(4):340346.

22. Oh ES, Laskin DM. Efficacy of the ViziLite system in the identification of oral lesions. J Oral Maxillofac Surg 2007;65(3):424-426.

23. Morse DE, Psoter WJ, Cuadrado L, et al. A deficit in biopsying potentially premalignant oral lesions in Puerto Rico (published online ahead of print Feb. 27, 2009). Cancer Detect Prev 2009; 32(5-6):424-430. doi:10.1016/j. cdp.2009.01.004.

24. Su WW, Yen AM, Chiu SY, Chen TH. A community-based RCT for oral cancer screening with toluidine blue (published online ahead of print June 4, 2010). J Dent Res 2010;89(9): 933-937. doi:10.1177/ 0022034510373763.

25. Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 2003;3:25.

26. Onofre MA, Sposto MR, Navarro CM, Motta ME, Turatti E, Almeida RT. Potentially malignant epithelial oral lesions: discrepancies between clinical and histological

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diagnosis. Oral Dis 1997;3(3): 148-152.

27. Prout MN, Sidari JN, Witzburg RA, Grillone GA, Vaughan CW. Head and neck cancer screening among 4611 tobacco users older than forty years. Otolaryngol Head Neck Surg 1997;116(2):201-208.

28. Zheng W, Soo KC, Sivanandan R, Olivo M. Detection of squamous cell carcinomas and pre-cancerous lesions in the oral cavity by quantification of 5-aminolevulinic acid induced fluorescence endoscopic images. Lasers Surg Med 2002;31(3):151-157.

29. Epstein JB, Feldman R, Dolor RJ, Porter SR. The utility of tolonium chloride rinse in the diagnosis of recurrent or second primary cancers in patients with prior upper aerodigestive tract cancer. Head Neck 2003;25(11):911-921.

30. Epstein JB, Zhang L, Poh C, Nakamura H, Berean K, Rosin M. Increased allelic loss in toluidine blue-positive oral premalignant lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003; 95(1):45-50.

31. Remmerbach TW, Weidenbach H, M端ller C, et al. Diagnostic value of nucleolar organizer regions (AgNORs) in brush biopsies of suspicious lesions of the oral cavity. Anal Cell Pathol 2003;25(3): 139-146.

32. Maraki D, Becker J, Boecking A. Cytologic and DNA-cytometric very early diagnosis of oral cancer. J Oral Pathol Med 2004;33(7): 398-404.

33. Ram S, Siar CH. Chemiluminescence as a diagnostic aid in the detection of oral cancer and potentially malignant epithelial

lesions (published online ahead of print Jan. 26, 2005). Int J Oral Maxillofac Surg 2005;34(5):521527. doi:10.1016/j. ijom.2004.10.008.

34. Chen YW, Lin JS, Fong JH, et al.

Use of methylene blue as a diagnostic aid in early detection of oral cancer and precancerous lesions (published online ahead of print Nov. 1, 2006). Br J Oral Maxillofac Surg 2007;45(7):590-591. doi:10.1016/j.bjoms.2006.08.017.

35. Du GF, Li CZ, Chen HZ, et al. Rose bengal staining in detection of oral precancerous and malignant lesions with colorimetric evaluation: a pilot study. Int J Cancer 2007;120(9):1958-1963.

36. Bhalang K, Suesuwan A, Dhanuthai K, Sannikorn P, Luangjarmekorn L, Swasdison S. The application of acetic acid in the detection of oral squamous cell carcinoma (published online ahead of print June 11, 2008). Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106(3):371376. doi:10.1016/j.tripleo.2008.01.017.

37. Mehrotra R, Singh MK, Pandya S, Singh M. The use of an oral brush biopsy without computer-assisted analysis in the evaluation of oral lesions: a study of 94 patients (published correction appears in Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106[4]: 621). Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 106(2):246-253.

38. Allegra E, Lombardo N, Puzzo L, Garozzo A. The usefulness of toluidine staining as a diagnostic tool for precancerous and cancerous oropharyngeal and oral cavity

lesions. Acta Otorhinolaryngol Ital 2009;29(4):187-190.

39. Arduino PG, Surace A, Carbone M, et al. Outcome of oral dysplasia: a retrospective hospitalbased study of 207 patients with a long follow-up (published online ahead of print May 18, 2009). J Oral Pathol Med 2009;38(6):540544. doi:10.1111/j.16000714.2009.00782.x.

40. McIntosh L, McCullough MJ, Farah CS. The assessment of diffused light illumination and acetic acid rinse (Microlux/DL) in the visualisation of oral mucosal lesions (published online ahead of print Oct. 1, 2009).

Oral Oncol 2009;45(12):e227e231. doi:10.1016/j.oraloncology.2009.08.001.

41. Wilder-Smith P, Lee K, Guo S, et al. In vivo diagnosis of oral dysplasia and malignancy using optical coherence tomography: preliminary studies in 50 patients. Lasers Surg Med 2009;41(5):353-357.

42. Jerjes W, Upile T, Conn B, et al. In vitro examination of suspicious oral lesions using optical coherence tomography (published online ahead of print Sept. 1, 2009). Br J Oral Maxillofac Surg 2010; 48(1):18-25. doi:10.1016/j. bjoms.2009.04.019.

43. Mehrotra R, Singh M, Thomas S, et al. A cross-sectional study evaluating chemiluminescence and autofluorescence in the detection of clinically innocuous precancerous and cancerous oral lesions (published correction appears in JADA 2010;141[4]:388).

JADA 2010; 141(2):151-156.

44. Nagaraju K, Prasad S, Ashok L. Diagnostic efficiency of toluTexas Dental Journal l www.tda.org l May 2013

423

Oral Cancer Screening

idine blue with Lugol’s iodine in oral premalignant and malignant lesions. Indian J Dent Res 2010;21(2):218-223.

45. Güneri P, Epstein JB, Kaya A, Veral A, Kazandı A, Boyacioglu H. The utility of toluidine blue staining and brush cytology as adjuncts in clinical examination of suspicious oral mucosal lesions (published online ahead of print Nov. 26, 2010). Int J Oral Maxillofac Surg 2011;40(2):155-161. doi:10.1016/j.ijom.2010.10.022.

46. Koch FP, Kunkel M, Biesterfeld S, Wagner W. Diagnostic efficiency of differentiating small cancerous and precancerous lesions using mucosal brush smears of the oral cavity: a prospective and blinded study (published online ahead of print July 1, 2010). Clin Oral Investig 2011;15(5):763-769. doi:10.1007/s00784-010-0434-6.

47. Koch FP, Kaemmerer PW, Biesterfeld S, Kunkel M, Wagner W. Effectiveness of autofluorescence to identify suspicious oral lesions: a prospective, blinded clinical trial (published online ahead of print Aug. 17, 2010). Clin Oral Investig 2011;15(6):975-982. doi:10.1007/ s00784-010-0455-1.

48. Glas AS, Lijmer JG, Prins MH, Bonsel GJ, Bossuyt PM. The diagnostic odds ratio: a single indicator of test performance. J Clin Epidemiol 2003;56(11):1129-1135.

49. Jones CM, Athanasiou T. Summary receiver operating characteristic curve analysis techniques in the evaluation of diagnostic tests.

Ann Thorac Surg 2005;79(1):1620.

424

Texas Dental Journal l www.tda.org l May 2013

50. Rosman AS, Korsten MA. Application of summary receiver operating characteristics (sROC) analysis to diagnostic clinical testing. Adv Med Sci 2007;52:76-82.

51. Zamora J, Abraira V, Muriel A, Khan KS, Coomarasamy A. MetaDiSc: a software for meta-analysis of test accuracy data. BMC Med Res Methodol 2006;6:31.

52. Westra WH, Sidransky D. Fluorescence visualization in oral neoplasia: shedding light on an old problem. Clin Cancer Res 2006; 12(22):6594-6597.

53. Patton LL, Epstein JB, Kerr AR. Adjunctive techniques for oral cancer examination and lesion diagnosis: a systematic review of literature. JADA 2008;139(7):896905.

54. Seoane Lestón J, Diz Dios P. Diagnostic clinical aids in oral cancer (published online ahead of print April 3, 2010).

Oral Oncol 2010;46(6):418422. doi:10.1016/j.oraloncology.2010.03.006.

55. Balevi B. Assessing the usefulness of three adjunctive diagnostic devices for oral cancer screening: a probabilistic approach (published online ahead of print Oct. 5, 2010). Community Dent Oral Epidemiol 2011;39(2):171176. doi:10.1111/j.16000528.2010.00579.x.

56. Deeks JJ. Systematic reviews in health care: systematic reviews of evaluations of diagnostic and screening tests. BMJ 2001; 323(7305):157-162.

57. Guo Z, Yamaguchi K, SanchezCespedes M, Westra WH, Koch D, Sidransky D. Allelic losses in

OraTest-directed biopsies of patients with prior upper aerodigestive tract malignancy. Clin Cancer Res 2001;7(7):1963-1968.

58. Zhang L, Williams M, Poh CF, et al.

Toluidine blue staining identifies high-risk primary oral premalignant lesions with poor outcome.

Cancer Res 2005;65(17):80178021.

59. Thomson PJ. Field change and oral cancer: new evidence for widespread carcinogenesis? Int J Oral Maxillofac Surg 2002;31(3): 262-266.

60. Fischer DJ, Epstein JB, Morton TH, Schwartz SM. Interobserver reliability in the histopathologic diagnosis of oral pre-malignant and malignant lesions. J Oral Pathol Med 2004;33(2):65-70.

61. Fischer DJ, Epstein JB. Management of patients who have undergone head and neck cancer therapy. Dent Clin North Am 2008; 52(1):39-60, viii.

62. Holmes JD, Dierks EJ, Homer LD, Potter BE. Is detection of oral and oropharyngeal squamous cancer by a dental health care provider associated with a lower stage at diagnosis? J Oral Maxillofac Surg 2003;61(3):285-291.

63. LeHew C, Epstein JB, Koerber A, Kaste LM. Training in the primary prevention and early detection of oral cancer: pilot study of its impact on clinicians’ perceptions and intentions. Ear Nose Throat J 2009;88(1):748-753.

64. LeHew CW, Epstein JB, Kaste L, Choi YK. Assessing oral cancer early detection: clarifying dentists’ practices. J Public Health Dent 2010;70(2):93-100.

LAW OFFICES OF HANNA & ANDERTON EXPERIENCED LAWYERS REPRESENTING TEXAS DENTISTS MARK J. HANNA, JD Former General Counsel, Texas Dental Association

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The purpose of this article is not to adjudicate the validity of OPC screening, but to present 3 brief patient vignettes demonstrating the OHP’s continued critical role in detecting abnormalities of not only the oral cavity and pharynx, but also the head and neck.

To further emphasize the point, all 3 cases occurred within the same month.

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It’s Not Just an “Oral Cancer” Exam Michaell A. Huber, DDS Vidya Sankar, DMD, MHS

Introduction

T

he American Cancer Society estimates 41,380 patients in the United States will be diagnosed with oropharyngeal cancer (OPC) in 2013, of which approximately 63% will be diagnosed with advanced disease (1). Early detection remains an essential element in improving the outcome of OPC, and the oral health care professional (OHP) remains the individual in the best position to identify OPC in its earliest stage (2,3). In a report evaluating 51 patients with newly diagnosed OPC, Holmes and colleagues determined that early stage disease was more likely to be detected by the OHP during the performance of routine examination that is not symptom-driven, while later stage disease was more likely to be detected as a consequence of a symptom-driven examination, often by a physician (2).

Efforts to improve public awareness regarding OPC have been undertaken by numerous professional and patient advocacy groups (4-7). These efforts focus largely on promoting risk factor awareness and reduction (eg, tobacco cessation, alcohol moderation, etc.) and the attainment of regularly scheduled oral examinations or screenings. As a consequence of these efforts, the phrase “oral cancer screening” has become a commonly discussed topic both in the dental profession and in the lay community. Screening is the process of checking for disease when there are no symptoms (8). Recently, oral cancer screening has come under scrutiny, with recently published reports questioning it validity and value (9-12). Indeed, Consumer Reports magazine recommends patients avoid oral cancer screening, unless they are at high risk (10). Such a recommendation may erroneously lead some patients to question the importance of obtaining regularly scheduled comprehensive oral examinations.

The purpose of this article is not to adjudicate the validity of OPC screening, but to present 3 brief patient vignettes demonstrating the OHP’s continued critical role in detecting abnormalities of not only the oral cavity and pharynx, but also the head and neck. To further emphasize the point, all 3 cases occurred within the same month.

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Case 1 A 55-year-old African American female patient of record in University of Texas Health Science Center at San Antonio Dental School (UTHSCSA) Hygiene clinic was referred to the Oral Medicine clinic for the evaluation of a newly noted “ulcer in her mouth.”

The patient acknowledged having a “strange feeling” in the area prior to being told about the lesion, but reported no paresthesia in the lower lip, tongue, or floor of the mouth and no tenderness or pain associated with the ulcer. Her medical history was significant for seasonal allergies, mixed connective tissue disease and hypertension. Her current medications included mycophenolate, hydroxychloroquine, pantoprazole, atenolol, hydrochlorothiazide, loratadine, vitamin C, vitamin D, and multivitamins. Her family history was significant for bladder cancer,

hypertension, and stroke. The patient denied recreational drug exposure, but acknowledged smoking about 2 packs of cigarettes per week since the age of 19 and consuming about 2 beers per week.

The extraoral examination was within normal limits, and there was no lymphadenopathy or limitation to opening. Intraorally, a 9x5 mm oblong ulcer was noted in the area of the left retromolar/palatoglossal arch (Figure 1). The ulcer had a necrotic center with indurated margins. The color of the surrounding mucosa was normal but increased surface vascularity was noted on the medial aspect of the lesion. The differential diagnosis included squamous cell carcinoma, salivary gland tumor, deep fungal infection or granuloma. The patient consented to an immediate biopsy. The pathology report revealed an adenocarcinoma not otherwise

Texas Dental Journal l www.tda.org l May 2013

A 54-year-old Caucasian male presented to the UTHSCSA dental emergency clinic with a complaint of, “Something is wrong with me, and I’m not sure if it is medical or dental.” His past medical history was essentially non-contributory with occasional reflux, and he reported having impetigo 2 weeks earlier that was successfully treated with a course of Augmentin. His family history was non-contributory and he denied tobacco or alcohol use but admitted to occasional cannabis use. He was now experiencing persistent dizziness and lightheadedness on standing, chills, cough, sleep deprivation, and

Michaell A. Huber, DDS, associate professor and oral medicine subject expert, Department of Comprehensive Dentistry, The University of Texas Health Science Center at San Antonio Dental School, San Antonio, Texas.

Huber

Sankar

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Case 2

About the Authors

Abstract The early identification and treatment of cancer of the head and neck, including oropharyngeal cancer (OPC), is associated with an improved survival rate.

Specific efforts to promote screening to improve the early detection of OPC have come under scrutiny, largely due to the low prevalence of the disease.

However, screening the patient for OPC does not occur as an isolated event in contemporary practice, but as an integral component of the hard and soft tissue examination to determine the totality of the patient’s oral health. Three patient vignettes are presented to demonstrate that, regardless the outcome of the debate over OPC screening, the oral health care professional who performs a thorough examination of the head and neck is often in the best position to discover early cancer affecting the head and neck.

specified and the patient was recommended for referral to head and neck surgery, but she opted to seek follow-up care through her primary health care physician.

Vidya Sankar, DMD, MHS, associate professor and oral medicine clinic director, Department of Comprehensive Dentistry, The University of Texas Health Science Center at San Antonio Dental School, San Antonio, Texas.

Corresponding author: Michaell A. Huber, Department of Comprehensive Dentistry, The University of Texas Health Science Center at San Antonio Dental School, 7703 Floyd Curl Dr, San Antonio, Texas 78229.

Telephone: 210-567-3360; Fax: 210-567-3334; Email: huberm@uthscsa.edu

Oral Cancer Screening

malaise. His oral complaint consisted of swollen sore gums that bled on brushing and a boggy swollen sensation on the right side of his tongue. He had recently seen his physician and was advised to seek a dental evaluation for his complaint.

Vital signs were BP 135/86 and pulse 102 RRR. The extraoral examination was within normal limits, and there was no tenderness to palpation or limitation to opening. Intraorally, an intact dentition was noted with erythematous swollen gingiva and areas of papillary necrosis (Figures 2 and 3). There was also an illdefined small nodular ulcer noted on the right side of his tongue.

Based upon the patient’s history and presenting signs and symptoms, the differential diagnosis consisted of acute necrotizing gingivitis and a possible systemic condition to include a hematological, immunosuppressive, or infectious source. Treatment consisted of gentle gross debridement and oral hygiene instruction. He was prescribed Peridex oral rinse to be used BID and Augmentin 500 mg x 10

Figure 1. Chronic ulcer in the area of the left retromolar/palatoglossal arch.

tabs; sig: 1 tab q 8h until gone. He was advised to return to the clinic in 2 to 3 days and was referred to the oral medicine clinic.

Three days later the student contacted the patient by phone, and the patient stated he felt better. Nine days later the patient called in distress

and stated he was getting worse and that he had not returned to his physician due to financial constraints.

He was subsequently seen in the oral medicine clinic 2 days later. His appearance had deteriorated and he was now pale and more fatigued. Vital signs were BP 132/74, pulse 100 RRR, temp 98.5F. The previously described

Figures 2 & 3. Initial presentation of gingival swelling with focal necrosis.

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gingival swelling was still present and the tongue lesion had increased significantly to present as a firm 6-cm diameter ulcerated nodule (Figures 4 and 5). Given the progression of his signs and symptoms, the patient was escorted to the University Hospital Emergency Room for evaluation with a presumptive diagnosis of leukemia.

Critical findings of his laboratory assessment were WBC: 248.5 K/uL (normal = 3.4 – 10.4 K/uL); monocytes 166.5 cells/mm3 (normal = 0.4 – 0.9 K/uL); platelets: 76,000 K/uL (normal 140 – 377 K/uL); RBC: 1.78 M/uL (normal = 4.20 – 5.80 M/uL); hemoglobin: 5.4 G/dL (normal = 12.8 – 17.1 G/dL); and hematocrit: 15.6% (normal = 38.6 – 52.1%). The patient was immediately admitted for acute myeloid leukemia (AML).

Case 3 A 61-year-old Caucasian female patient presented to the UTHSCSA Dental School with a chief complaint of, “I have discolored fillings on my front teeth.” Her medical history was significant for hypertension and seasonal allergies. Her current medications consisted bisoprolol and loratadine. Her family history was significant for maternal and sibling coronary artery disease. She denied tobacco and recreational drug use but acknowledged social alcohol consumption.

The extraoral examination was remarkable for a large ulcerated nodular mass on the posterior base of her left ear (Figures 6 and 7). The lesion was firm and exhibited a rolled border with extensive superficial

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vascularity. Upon further questioning, the patient recalled that she had seen a physician a year or 2 earlier for a spot behind her ear, for which she was prescribed a steroid cream. She appeared surprised by the current findings. The differential diagnosis included basal cell carcinoma (BCC), squamous cell carcinoma, and granulomatous or infectious process, and she was promptly referred to the UTHSCSA Head and Neck Surgery Department for further evaluation and biopsy, which confirmed basal cell carcinoma.

Discussion Numerous forms of cancer may occur in the head and neck region, such as OPC, salivary gland tumors, leukemia, lymphoma, BCC, squamous cell carcinoma of the skin, melanoma, and thyroid cancer. The 3 cases cited here provide a glimpse into the wide variability of cancer affecting the head and neck. In the first case, the patient presented for routine hygiene care and the suspect lesion was noted as part of the comprehensive examination accomplished by the student and referred for further evaluation. In the second case, the patient presented to the dental emergency clinic on the recommendation of his physician, to assess oral discomfort that was ultimately suggestive of an underlying systemic disorder. The appropriate same-day referral on follow-up led to the prompt diagnosis and initiation of necessary medical therapy. In the third case the malignancy behind the ear was discovered as a consequence of due diligence by the dental student

accomplishing a thorough head and neck exam.

Malignant salivary gland tumors are uncommon lesions, with an estimated incidence of 0.4 – 2.6 /100,000 (13). They may present as intraoral or extraoral lesions and 24 types are recognized by the World Health Organization (13,14). Most salivary gland malignancies occur in the fifth and sixth decade (15). A salivary gland malignancy typically presents as painless swelling or nodule, indistinguishable from a benign salivary tumor (14,15). An estimated 15% - 32% of parotid tumors are malignant; 41% - 50% of submandibular tumors are malignant; and 70% - 90% of sublingual tumors are malignant (13). The rate of malignancy in minor salivary gland tumors varies by location and an estimated 40% - 60% of palatal tumors are malignant, and up to 90% of tumors occurring in the floor of the mouth, tongue, or retromolar pad area are malignant (14).

In 2013, an estimated 48,610 cases of leukemia will be diagnosed, of which 14,590 cases will be of the AML type (1). Five percent of AML cases (roughly 730 cases for 2013) will present initially as gingival inflammation (16). Common presenting signs and symptoms are non-specific and include weight loss, fatigue, fever, night sweats, and loss of appetite (17).

Lymphoma will be diagnosed in an approximate 79,030 patients in 2013 (69,740 non-Hodgkin cases and 9,290 Hodgkin cases) (1). Lymphoma represent about 5% of all head and

Oral Cancer Screening

Figure 4. Two-week reevaluation of gingival swelling.

neck malignancies and about 75% will be of the non-Hodgkin type (18).

Lymphoma is widely considered an “opportunistic neoplasm,” due to its frequent occurrence in the immunocompromised patient (19,20).

Most cases present as painless cervical lymphadenopathy, that is typically less indurated or hard when compared to the lymphadenopathy observed with metastatic squamous cell carcinoma (20). Extra-nodal sites of occurrence may affect the head

Figure 5. Firm, tender ulcerated nodule on right side of tongue.

and neck, most often Waldeyer’s ring and common presenting signs and symptoms include dysphagia, pharyngitis, and unilateral tonsil enlargement (20,21).

Cutaneous cancers such as BCC, squamous cell carcinoma of the skin and melanoma occur in the head and neck region with great frequency.

BCC and squamous cell carcinoma of the skin are collectively termed non-melanoma skin cancer (NMSC).

Figure 6. Ulcerated nodular lesion posterior aspect of base of left ear.

The most controllable risk factor for NMSC is excess sun exposure (see Box 1) Death due to NMSC is uncommon (22). In the United States, the annual number of cases of NMSC is a staggering 3.5 million (2.2 million individual patients), of which 75% are BCC (22-24). Up to 90% of BCC lesions present in the head and neck and approximately 30% - 40% of those who develop a BCC will develop 1 or more lesions within 10 years (24). BCCs typically present

Figure 7. Suspect lesion obscured by normal hair pattern.

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Finally, of 76,690 predicted cases of melanoma for 2013, approximately 20% will occur in the head and neck (1,26). The etiopathogenesis is unresolved, but sunlight is considered a major risk factor (27). The most important warning sign for melanoma is a new spot on the skin or a spot that is changing in size, shape, or color. The typical melanoma lesion follows the established rules of “ABCDE” (28) (see Box 2).

Box 1.

Risk Factors for NMSC (22) Exposure to ultraviolet radiation Male sex Older age Fair skin Family history Residence at latitudes near the equator as pearly, waxy nodules with visible surface blood vessels and well defined central ulceration (24). Metastasis is rare (<0.05%), but local invasion and resultant disfigurement is not.

An estimated 75% of squamous cell carcinoma of the skin lesions occur in the head and neck (25). Typical lesions present as a skin-colored papule or plaque with a central necrosis arising from an area of sun-damaged skin (24).

Palpable thyroid nodules occur in 4% to 7% of the population and are 4 times more common in women than men (29,30). While most nodules are asymptomatic and benign, 5% are malignant, most typically papillary carcinoma. An estimated 60,290 cases of thyroid cancer will be diagnosed in the United States in 2013 (1). Factors that increase the risk of malignancy are summarized in Box 3.

The cases of malignancy reported here clearly demonstrate that the oral health care professional plays an integral role in the identification

Box 3.

Thyroid Nodule Risk Factor for Thyroid Cancer (30) Male sex Age of <20 or >65 years Rapid growth Dysphagia, neck pain, hoarseness History of radiation to the head and neck Family history of thyroid cancer or Gardner’s syndrome and diagnosis of both localized and systemic diseases affecting the head and neck region. OHPs are experts as it pertains to the identification and diagnosis of abnormalities affecting oral cavity. Furthermore, while not primarily responsible for the diagnosis of abnormalities affecting the pharynx and extra-oral areas of the head and neck, the oral health care professional is also a good judge of recognizing abnormalities affecting these areas.

Box 2. ABCDE of Melanoma (28)

Asymmetry Border that is irregular

Color that is uneven

Diameter

The shape of one half does not match the other half.

The edges are often ragged, notched, or blurred in outline. The pigment may spread into the surrounding skin.

Shades of black, brown, and tan may be present. Areas of white, gray, red, pink, or blue may also be seen.

There is a change in size, usually an increase. Melanomas can be tiny, but most are larger than 6 millimeters wide (about 1/4 inch wide).

Evolving

The mole has changed over the past few weeks or months.

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Oral Cancer Screening

In daily practice, when the oral health care professional examines the patient, he or she looks for any and all anomalies, not simply OPC (31). OPC screening does not exist as an isolated procedure in contemporary dentistry, but as an integral component of the comprehensive hard and soft tissue examination (31). Perhaps the recommendations from the American Cancer Society express our professional obligation best: “When individuals see a health care professional for a preventive health examination, there is an opportunity for more comprehensive counseling and testing. These encounters should include the performance or referral for conventional cancer screening tests as appropriate by age and gender, as described earlier, but such visits also are an opportunity for casefinding examinations of the thyroid, testicles, ovaries, lymph nodes, oral region, and skin. In addition, self-examination techniques or an increased awareness of the signs and symptoms of skin cancer, breast cancer, or testicular cancer can be discussed (32).”

Conclusion Oral cancer screening is a component of a complete comprehensive examination performed by the OHP, and the OHP often has the opportunity to identify abnormalities affecting the head and neck before other health care professionals.

Patients should be assured that, much like the patrolman walking the beat, dental professionals are ever vigilant for detecting problems affecting their patients.

The cases of malignancy reported here clearly demonstrate that the oral health care professional plays an integral role in the identification and diagnosis of both localized and systemic diseases affecting the head and neck region.

References 1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin 2013;63:11-30.

2. Holmes JD, Dierks EJ, Homer LD, et al. Is the detection of oral and oropharyngeal cancer by dental health care provider associated with a lower stage at diagnosis? J Oral Maxillofac Surg 2003;61:285291.

3. Mignogna MD, Fedele S, Lo Russo L, Ruoppo E, Lo Muzio L. Oral and pharyngeal cancer: lack of prevention and early detection by health care providers. Eur J Cancer Prev 2001;10(4):381-3.

4. American Dental Association.

American Dental Association Encourages Public to Get Screened For Oral Cancer.

Available at: http://www. ada.org/5735.aspx Accessed February 20, 2013.

5. Nagao T, Warnakulasuriya S. Annual screening for oral cancer detection. Cancer Detect Prev 2003;27:333-337 6. Oral Cancer Foundation. Cancer screening protocols. Available at: http://oralcancerfoundation.org/ dental/screening.htm Accessed February 20, 2013.

7. Rethman MP, Carpenter W, Cohen EE, Epstein J, Evans CA, et al; American Dental Association Council on Scientific Affairs

8.

9.

10.

11.

12.

Expert Panel on Screening for Oral Squamous Cell Carcinomas.

Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. J Am Dent Assoc 2010;141:509-20.

National Cancer Institute. NCI Dictionary of Cancer Terms.

Available at: http://www.cancer. gov/dictionary?cdrid=46171 .

Accessed February 20, 2013.

Brocklehurst P, Kujan O, Glenny AM, Oliver R, Sloan P, et al.

Screening programmes for the early detection and prevention of oral cancer. Cochrane Database Syst Rev 2010 Nov 10;(11):CD004150.

Consumer Reports. Save your life. Cancer screening is oversold.

Know the tests to get – and those to skip. Consumer Reports March 2013:28-33.

National Cancer Institute. Oral Cancer Screening (PDQ®).

Available at: http://www.cancer. gov/cancertopics/pdq/screening/ oral/HealthProfessional .

Accessed February 20, 2013.

U.S. Preventive Services Task Force. Screening for oral cancer: recommendation statement.

2004. Available at: http://www. uspreventiveservicestaskforce. org/3rduspstf/oralcan/oralcanrs. htm . Accessed February 20, 2013.

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13. Eveson JW. Salivary tumours. Periodontol 2000 2011;57:150-9.

14. Rice DH. Malignant salivary gland neoplasms.

Otolaryngol Clin North Am 1999;32:875-86.

15. Guzzo M, Locati LD, Prott FJ, Gatta G, McGurk M, Licitra L. Major and minor salivary gland tumors. Crit Rev Oncol Hematol 2010;74:134-48.

16. Wu J, Fantasia JE, Kaplan R. Oral manifestations of acute myelomonocytic leukemia: a case report and review of the classification of leukemias. J Periodontol 2002;73:664-668.

17. American Cancer Society. Leukemia--Acute Myeloid (Myelogenous): Early Detection, Diagnosis, and Staging. How is acute myeloid leukemia diagnosed?

Available at: http://www.cancer.org/cancer/leukemiaacutemyeloidaml/detailedguide/leukemia-acute-myeloidmyelogenous-diagnosed . Accessed February 20, 2013.

18. Boring CC, Squires TS, Tong T (1993). Cancer statistics. CA Cancer J Clin 43: 7–26.

19. National Cancer Institute. AIDS-Related Cancer. Available at: http://www.cancer.gov/cancertopics/types/AIDS .

Accessed February 20, 2013.

20. Zapater E, Bagán JV, Carbonell F, Basterra J. Malignant lymphoma of the head and neck. Oral Dis 2010;16:119-128.

21. Beasley MJ. Lymphoma of the thyroid and head and neck. Clin Oncol 2012;24:345-351.

22. Wehner MR, Shive ML, Chren MM, Han J, Qureshi AA, Linos E. Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis. BMJ 2012;345:e5909. doi: 10.1136/bmj.e5909.

23. American Cancer Society. Skin Cancer: Basal and Squamous Cell. What are the key statistics about basal and squamous cell skin cancers? Available at: www. cancer.org/cancer/skincancer-basalandsquamouscell/ detailedguide/skin-cancer-basal-and-squamous-cell-keystatistics . Accessed February 20, 2013.

24. McGuire JF, Ge NN, Dyson S. Non-melanoma skin cancer of the head and neck I: histopathology and clinical behavior. Am J Otolaryngol 2009;30:121-33.

25. Kyrgidis A, Tzellos TG, Kechagias N, Patrikidou A, Xirou P, Kitikidou K, Bourlidou E, Vahtsevanos K, Antoniades K. Cutaneous squamous cell carcinoma (SCC) of the head and neck: risk factors of overall and recurrence-free survival. Eur J Cancer 2010;46:1563-72.

26. de Rosa N, Lyman GH, Silbermins D, Valsecchi ME, Pruitt SK, Tyler DM, Lee WT. Sentinel node biopsy for head and neck melanoma: a systematic review. Otolaryngol Head

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Neck Surg 2011;145:375-82.

27. Vikey AK, Vikey D. Primary malignant melanoma, of head and neck: a comprehensive review of literature.

Oral Oncol 2012;48:399-403.

28. American Cancer Society. Melanoma skin cancer. Can melanoma skin cancer be found early? Available at: http://www.cancer.org/cancer/skincancer-melanoma/ detailedguide/melanoma-skin-cancer-detection .

Accessed February 20, 2013.

29. Krikorian A, Kikano G. Thyroid nodules: when is an aggressive evaluation warranted? J Fam Pract 2012;61:205-8.

30. Welker MJ, Orlov D. Thyroid nodules. Am Fam Physician 2003;67:559-66.

31. American Dental Association. 2012-2013 CDT, The ADA practical guide to dental procedure codes. Chicago, 2012.

32. Smith RA, et al. Cancer screening in the United States, 2009: A review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin 2009;59:27-41.

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Making a diagnosis on the basis of a clinical examination may result in a falsepositive finding and unnecessary treatment, which is not an ideal outcome.

A more significant concern however, would be a falsenegative finding, in which disease is present but not detected.

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Oral Cancer: FAQ Daniel L. Jones, DDS, PhD, and K. Vendrell Rankin, DDS

Introduction

F

indings by Epstein et al first published in the December issue of the Journal of the American Dental Association and reprinted here, demonstrate that clinical oral examination does not reliably predict the histologic diagnosis of dysplasia or oral squamous cell carcinoma. Given that these lesions are often first seen in the dental office, what is the concerned clinician to make of this conclusion?

It is clear that the results of the meta-analysis undertaken by Epstein and colleagues supports the conclusion that clinical oral examination does not reliably predict histologic diagnosis. However, that point may not be most important with regard to ensuring early detection of oral cancer. Epstein et al state that making a more accurate provisional diagnosis is important because the clinician is then more likely to proceed with a biopsy of the lesion. This certainly may be true, but doesnâ&#x20AC;&#x2122;t necessarily mean that uncertainty as to a diagnosis would mean a clinician is less likely to pursue further examination of a particular lesion.

Making a diagnosis on the basis of a clinical examination may result in a falsepositive finding and unnecessary treatment, which is not an ideal outcome. A more significant concern, however, would be a false-negative finding, in which disease is present but not detected. The use of adjunctive diagnostic aids has been shown to improve the accuracy of clinical diagnosis, although these tests typically have good sensitivity but poor specificity. Certainly, the development of better, more specific diagnostic adjuncts to aid in detection and diagnosis will serve to improve the efficacy of clinical examination in the early detection of oral cancer.

An equally important way to ensure that clinical examination provides a more accurate provisional diagnosis is to concentrate on the foundational knowledge underlying oral cancer detection and diagnosis, with the goal of improving the skill and consistency with which the examination is conducted. A working knowledge of the epidemiology of oral cancer serves to alert the clinician as to when and where the disease is more likely to present. Familiarity with the risk factors, signs and symptoms of oral cancer, together with continued vigilance in the form of regular, systematic, and thorough clinical examination remains the most basic means of ensuring early detection of oral cancer and providing the best care possible.

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Clinical Epidemiology Although relatively rare in comparison to breast, lung, or prostate carcinoma, the incidence and mortality figures for oral cancer are higher than cervical cancer and malignant melanoma.

Approximately 10.5 adults per 100,000 adults in the U.S. will develop oral cancer over their lifetime. As with most types of cancer, oral cancer rates increase with age. The increase becomes more rapid after age 50 and peaks between ages 60 and 70. The ratio of cases seen in males versus females is approximately 2:1 and has remained static since the 1950s.

Rates are higher for Hispanic and black males than for white males.

These statistics provide guidance, but do not suggest that individuals who fall outside these generalizations not receive the same attention.

Overall, 60% of patients with oral cancer survive for 5 years and survival rates have steadily improved since 1975. However, rates remain significantly lower for African American males. The 5-year relative survival rate varies widely by stage at the time of diagnosis, from roughly 82% for patients diagnosed in localized stages and 52% for patients with regional lymph node involvement to approximately 25% for patients with distant metastasis.

Unfortunately, oral and pharyngeal cancer is diagnosed at a localized stage in only one-third of patients

Daniel L. Jones, DDS, PhD, professor and chair, Department of Public Health Sciences, The Texas A&M University Health Science Center Baylor College of Dentistry, Dallas, Texas

Jones

The most effective preventive strategy is to help patients reduce or eliminate dangerous habits, and to remain alert for signs of potentially malignant or early-stage lesions, and perform routine visual and tactile examinations of all patients.

A working knowledge of the clinical epidemiology of oral cancer, familiarity with the risk factors, signs and symptoms, together with continued vigilance in the form of regular, systematic and thorough clinical examination remains the most basic means of ensuring early detection of oral cancer and providing the best care possible.

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In contrast to the decrease in oral cancer in the U.S. overall, the incidence of cancer at the base of tongue and tonsillar cancers has increased. The increase seems to be more pronounced in young adults. Researchers attribute this

About the Authors

Abstract The efficacy of clinical examination in detecting intraoral malignances has recently been called into question, as it does not accurately predict the histological diagnosis. A brief reexamination of one study provides some insights into what this means to the clinician. Making a diagnosis on the basis of a clinical examination may result in a false-positive finding and unnecessary treatment.

However, a more significant concern would be a false-negative finding, in which disease is present but not detected and therefore not treated.

in the U.S. Survival rates are also dependent on the site of the lesion.

A large percentage of lesions occur on the lip, but mortality rates for cancer of the lip are low, owing to the increased likelihood of early detection. As a general rule, the likelihood of detection decreases as we consider sites farther back in the oral cavity and pharynx, and the stage at diagnosis grows later.

Concomitantly, mortality rates rise and survival rates fall.

Rankin

K. Vendrell Rankin, DDS, professor and associate chair, Department of Public Health Sciences, The Texas A&M University Health Science Center Baylor College of Dentistry, Dallas, Texas Corresponding author: Daniel L. Jones, DDS, PhD, professor and chair Department of Public Health Sciences The Texas A&M University Health Science Center Baylor College of Dentistry, 3302 Gaston Ave, Dallas, Texas 75246 Phone 214-828-8350; Fax 214 874-4555; Email: djones@bcd.tamhsc.edu

Oral Cancer Screening

site-specific increase to an increased rate of human papilloma virus (HPV) infection. There is evidence that this sub-group of oral cancers carry a better prognosis.

Oral self-examination can also help increase the probability of early detection and improve the prognosis.

From the perspective of the clinician, improved screening tools and national guidelines may increase early detection in high-risk groups.

Education of medical professionals in early detection is essential, as the population at highest risk (>65 years) present to physicians 5 times more frequently than to dentists.

Oral Cancer Risk Factors Sunlight is a primary risk factor in cancer of the lip and face. The incidence of basal cell carcinoma, the most common epidermal neoplasm, is linked to geographic location, increasing in latitudes closer to the equator.

Tobacco: Smoking cigarettes, cigars, or pipes, or using smokeless tobacco are all strongly linked to oral cancer.

The use of other tobacco products (such as bidis and kreteks) may also increase the risk of oral cancer. For cigarette smokers, the risk of oral cancer increases with the number of cigarettes smoked per day. The risk is greater for people who use both tobacco and alcohol than for those who use tobacco or alcohol alone.

Alcohol, particularly in excess, poses an even greater threat. Drinkers of 6 or more whiskey equivalents (1 oz) per day may be at greater risk than those smoking 2 packs of cigarettes daily. The mechanism linking alcohol and oral cancer is poorly understood, however. The systemic effects of alcohol include a decreased ability of the liver to detoxify carcinogens.

Local effects of alcohol include a solvent action, which may facilitate absorption and thus increase the intensity of exposure to carcinogens.

In addition, the congeners and contaminates in the alcohol may alter epithelial metabolism, posing a greater risk of malignant transformation.

Human Papilloma Virus: More than 90 different human papillomaviruses have been identified and several types of HPV are known to be oncogenic.

There is evidence of heightened HPV titers in oral cancer lesions and nodal metastases, as compared to normal epithelium. The virus also produces 2 inhibitors of cell cycle regulation, binding proteins that play a role in tumor suppression. Studies suggest that 2 types, HPV-16 and HPV-18, may play a role in the malignant transformation of oral lesions and are considered risk factors for oral cancer.

Herpes Viruses: Herpes simplex viruses 1 and 2 (HSV-1 and HSV2) were originally thought to be associated with increased risk of oral malignancies in a manner similar to the association of HSV-2 and cervical cancer. These viruses are now thought to be a cofactor, potentiating the effects of alcohol and tobacco.

Epstein-Barr Virus (EBV) is found in the lymphocytes and frequently in the saliva of healthy persons. EBV infection of human lymphocytes can produce malignant changes, and EBV is associated with certain head and neck cancers. EBV can infect oral epithelial cells and is present in hairy leukoplakia, but is only rarely found in oral cancers. Since hairy leukoplakia is not associated with development of oral cancer, EBV is not considered a risk factor.

Human Herpesvirus 8 (HHV-8) is found in AIDS-associated Kaposiâ&#x20AC;&#x2122;s sarcoma (KS). Because most KS patients have antibodies to HHV-8, and the virus has been shown to produce KS-like lesions in animals, HHV-8 is considered the etiologic agent of KS. Like many of the herpes viruses, HHV-8 is widespread in the healthy population. It may be that impaired immune function along with the presence of HHV-8 influences the development of KS in AIDS patients.

Genetics clearly play a role in the occurrence of some cancers, as the relative risk for an individual who has a parent or sibling with the disease is increased by a factor of approximately 25 times normal.

Nutritional deficiencies: Currently, no deficiencies or excesses of dietary proteins, fats, or carbohydrates have been shown conclusively to be etiologic factors for oral cancer.

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fiber has been associated with a reduced risk of oral cancer.

Chronic hyperplastic candidiasis: Approximately 10% of leukoplakias are infected with Candida albicans. These candidal leukoplakias exhibit dysplasia associated with invasion of candidal hyphae. Development of malignancy is more likely to occur with this form of leukoplakia than with other types. It may be that candidal infection disturbs epithelial cellular activity in a manner that is more likely to induce neoplastic changes. The evidence in this instance is circumstantial, but it is clear that candidal infections are not simply superimposed infections, as there is no evidence of another, preexisting lesion.

Oral lichen planus: Studies have shown rates of malignant transformation in patients with oral lichen planus (OLP) ranging from 1.2-3.27%, measured over a period of 6 to 12 years. The prevalence of oral cancer in these patients was greater than would be expected in the general population. Thus, there appears to be a risk of associated malignancy in patients with OLP, particularly in the erosive form and in erythematous areas, but the evidence to date is not conclusive.

Chronic irritation: Since many oral cancers develop in areas covered by or adjacent to a prosthetic appliance, it is tempting to postulate a possible association between chronic irritation from the denture and oral malignancies. However, at present there is not sufficient data to demonstrate conclusively whether this is an active or passive

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relationship. Denture material itself has not been shown to be carcinogenic. Chronic irritation in combination with other risk factors may promote neoplastic activity, but does not appear to promote carcinogenesis. A simpler explanation of the association between dentures and oral cancer may be that most denture patients tend to be older, and thus at greater risk for the development of oral cancer due to other risk factors.

Clinical Examination Regular, thorough intraoral and extraoral examination by a dental professional is the most effective technique for early detection and prevention of oral cancer. All patients should be examined annually, and those at higher risk should be given more frequent, closer scrutiny. The profile of a high-risk patient includes 50 years of age or over, and/or any of the risk factors listed above (tobacco or alcohol use, etc), either alone or in combination.

Signs and Symptoms UIceration or erosion is loss of epithelial integrity because of disruption of cell maturation, loss of intercellular attachment and disruption of the basement membrane. Malignant ulcers often have elevated or rolled borders secondary to invasion of the tumor under the ulcer margins. These ulcers may be painful or asymptomatic.

Ulcerations present for greater than

10-14 days with no obvious cause (eg, sharp edge of tooth), should be viewed with suspicion and a biopsy performed without delay.

Erythema: Redness as a result of inflammation, thinness, and irregularity of the epithelium and decreased keratinization.

Induration: Because of an increase in the number of epithelial cells and inflammatory infiltrate, the lesion will feel hard when palpated.

Fixation: If the abnormally dividing cells have invaded deeper areas of muscle and bone, the lesions tend not to move when palpated.

Chronicity: Malignant lesions tend not to disappear without treatment.

Lesions of more than 2 weeks duration, with no obvious etiology, should be viewed with heightened suspicion.

Lymphadenopathy: Regional nodes may be enlarged, indurated, and fixed.

Leukoplakia, erythroplasia and erythroleukoplakia: Leukoplakia (a raised white patch on the mucosa that cannot be scraped off), erythroplasia (a reddened, erythematous area), and erythroleukoplakia (white and red components) are the most common clinical manifestations. The clinical appearance of leukoplakia is usually due to hyperkeratosis. Leukoplakia is considered to have a high potential for malignant transformation, but many lesions represent only hyperkeratosis. Nonetheless, some will show histologic evidence of epithelial dysplasia and perhaps

invasive carcinoma. Erythroplasia means “red formation,” and up to 80% of erythroplasias in high risk areas are invasive carcinoma. Erythroplasia can be a very subtle clinical change and can be overlooked on clinical examination. It often appears as a red, slightly roughened, granular mucosal lesion. Erythroleukoplakic lesions may consist of both red and white areas, and are also very likely to undergo malignant transformation.

High-risk sites As noted in the section on clinical epidemiology, there are several areas in which malignant lesions are most frequently seen. The most common site is the floor of the mouth, followed by the ventral surface and lateral borders of the tongue, and the lip.

Other high-risk intraoral sites include the oropharynx, the tonsillar pillars, tonsillar crypt, and the tonsil itself.

Conslusions While it is true, as demonstrated

by Epstein and colleagues, that at present clinical oral examination does not reliably produce an accurate histologic diagnosis of a suspected malignant lesion, this finding is not the final word concerning the real value of clinical examination.

When performed by an informed, experienced clinician, using the appropriate diagnostic adjuncts, clinical examination is a useful approach to early detection of oral cancer. Familiarity with the risk factors, signs, and symptoms of oral cancer, together with continued vigilance in the form of regular, systematic, and thorough clinical examination, remains the most basic means of ensuring early detection of oral cancer and providing the best care possible.

References 1. Epstein JB, Güneri P, Boyacioglu H, Abt E. The limitations of the clinical oral examination in detecting dysplastic oral lesions and oral squamous cell carcinoma. J Am Dent Assoc.

2012 Dec;143(12):1332-42.

2. Silverman, S. Oral Cancer. London, England: BC Decker, 2003.

3. Jones, DL and Rankin, KV. Oral Cancer and Associated Risk Factors, in Prevention in Clinical Oral Health Care, Mobley, CC, Cappelli, DP, eds. Mosby/Elsevier; St. Louis, 2007.

4. CDC website. Surveillance Epidemiology and End Results.

Available at: http://seer.cancer. gov/faststats. Accessed February 15, 2013.

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Considerable debate surrounds the marketing, use and safety of the electronic cigarette, which is also referred to as an electronic nicotine delivery device, e-cigarettes, personal vaporizers, PV, or â&#x20AC;&#x153;vapesâ&#x20AC;?.

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E-Cigarettes: What’s Known, What’s Unknown K. Vendrell Rankin, DDS

C

onsiderable debate surrounds the marketing, use, and safety of the electronic cigarette, which is also referred to as an electronic nicotine delivery device, e-cigarettes, personal vaporizers, PV, or “vapes.” The e-cigarette is a battery-powered device resembling a cigarette. It contains a microcircuit (1), which is activated when a person draws on the mouthpiece (2), like taking a puff of a cigarette. With each puff a small amount of the solution (nicotine plus humectant) contained in a cartridge (3) produces a vapor creating a visible mist without smoke or flame (Figure 1). When an individual uses an e-cigarette, it is referred to as “vaping” rather than smoking.

The device was launched and patented by a Beijing-based company, Ruyan Group (Holdings) Ltd, China in 2004 (1). The e-cigarette was introduced into the U.S. market in 2007 (2). Since the advent of the original device, multiple adaptations of the device have been marketed. The 1-piece e-cigarette is a disposable unit. It contains a pre-charged battery that cannot be recharged, and a nicotine cartridge that cannot be refilled (Figure 2). The 2-piece e-cigarette kit contains a rechargeable battery and a nicotine cartridge with built-in atomizer. The 2-piece design provides a fresh atomizer with every cartridge. The 3-piece design contains a rechargeable battery, an atomizer and a separate replaceable nicotine cartridge. The cartridge of the 3-piece device can be refilled with a bottled liquid referred to as “e-liquid” or “juice” (Figure 1). The liquid is available in different nicotine strengths and a variety of flavors. The cartridge of the 3-piece unit can be removed and 3-5 drops of the liquid dropped directly on the atomizer. This practice is referred to as “dripping.” This practice yields several puffs with a higher concentration of nicotine. The devices are also available in multiple sizes. The pen style is 5 to 6 inches in length and is the original model. The super-mini is 4 to 5 inches long and most similar to a traditional cigarette (Figure 2). The micro unit is 2 to 4 inches in length. The technology is also available in products that resemble a cigar or pipe.

Abstract Use and awareness of the e-cigarette, also referred to in the literature as an Electronic Nicotine Delivery Device, has dramatically increased since its introduction to the U.S. market in 2007. The regulatory power of the Food and Drug Administration over these devices is restricted to their classification as a tobacco product, as the manufacturers do not claim a therapeutic effect, as is the case with nicotine replacement therapy.

The use, safety, chemical content and efficacy of the device for smoking cessation is the subject of considerable debate in the scientific community and poses a challenge to clinicians whose patients have elected to use e-cigarettes as a replacement for (or in addition to) cigarettes, to reduce the number of cigarettes they smoke, or for smoking cessation.

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In 2009 the United States Food and Drug Administration (FDA) classified the e-cigarette as a drug delivery device similar to nicotine replacement therapies and determined that as such the device was subject to regulation under the Food, Drug, and Cosmetic Act (FDCA). The FDA subsequently banned their import. The FDAâ&#x20AC;&#x2122;s Center for Drug Evaluation Division of Pharmaceutical Analysis purchased samples of the 2 leading brands of e-cigarettes.

The samples included 18 of the various flavors, nicotine, and non-nicotine cartridges. Preliminary analysis concluded the following: Diethylene glycol, an ingredient used in antifreeze, was present in one product. Tobacco-specific nitrosamines, a human carcinogen, were present in half of the samples.

Tobacco-specific impurities were detected in a majority of the samples tested. All but 1 of the cartridges labeled as containing no nicotine had low levels of nicotine present. The amount of nicotine per puff ranged from 26.8 to 43.2 mcg nicotine / 100 mL per puff (3). The FDAâ&#x20AC;&#x2122;s ban on importation of e-cigarettes was challenged and subsequently overruled on the grounds that the device is not specifically marketed for therapeutic purposes, ie, to help people quit smoking, and therefore is not subject to regulation as a drug delivery device. The result of this ruling restricted the FDAâ&#x20AC;&#x2122;s purview to the regulation of the e-cigarette as a tobacco product. The rules that apply to regulation of tobacco products are much less stringent than those applied to medical devices. However, the FDA has stated that the safety and efficacy of the e-cigarette has not been fully studied and warns that currently the safety of the device is unknown. No studies have been conducted which suggest that the e-cigarette is effective as an aid for smoking cessation.

Additionally, there is concern that the e-cigarette may lead youth to try other tobacco products, including cigarettes (4).

Figure 1.

About the Author K. Vendrell Rankin, DDS, professor and associate chair, Department of Public Health Sciences, The Texas A&M University Health Science Center, Baylor College of Dentistry, Dallas, Texas

Rankin

Independent studies of the e-cigarette have reported that chemical and nicotine delivery varies across brands and that the stated nicotine content may not be accurate (5). As was the case with cigarette smoking, the long-term effects of

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Corresponding author: K. Vendrell Rankin, DDS, professor and associate chair, Department of Public Health Sciences, The Texas A&M University Health Science Center, Baylor College of Dentistry, 3302 Gaston Ave Dallas, Texas 75246; Phone: 214-828-8113; Fax: 214 874-4555; Email: krankin@bcd.tamhsc.edu

Oral Cancer Screening

Figure 2.

the use of the e-cigarette may not become apparent for some years (6).

Some proponents of the e-cigarette support its use on the basis that it is less toxic than cigarette smoking and may serve as a harm reduction strategy (7). However, given the toxic ingredients known to be in the e-cigarette and erratic quality control in their production, this strategy is questionable at best.

Small pilot studies have reported smoking reduction with the use of the e-cigarette, but sustained abstinence is as yet undetermined (8,9).

There are also concerns about the effect of the e-cigarette on lung function. Drawing air through the e-cigarette to deliver nicotine

requires more suction than the traditional cigarette, which makes dosing non-uniform over time and may be harmful to the userâ&#x20AC;&#x2122;s health (10). Healthy smokers were recruited to participate in a laboratory-based intervention (experimental group n = 30, control group n = 10) to examine the effects of e-cigarettes on lung function (11). Participants used an e-cigarette for 5 minutes. Researchers reported a significant increase in the magnitude of the respiratory load, peripheral airway flow resistance and oxidative stress among healthy smokers in the experimental group.

Despite the unresolved questions surrounding the use of the e-cigarette, public awareness and use is increasing. In a recent study of U.S. adults, awareness of e-cigarettes had doubled, from 16.4% in 2009 to 32.2% in 2010. Not surprisingly the group reporting the largest increase in awareness were current smokers (2009: 20.7%; 2010: 49.6%). The proportion of adults who had actually used e-cigarettes quadrupled from 2009 (0.6%) to 2010 (2.7%) (12). In 2011, e-cigarette awareness increased to 57.9% in the survey population (13).

The e-cigarette is widely available on the Internet. The number of Google searches for e-cigarettes have surpassed searches for any of the FDA-approved smoking cessation drugs (14). A survey of 3,587 e-cigarette users reported that 84% perceived the device as less toxic than tobacco. Approximately three-fourths were using the device to quit smoking, to avoid relapse, and to deal with craving for tobacco and withdrawal symptoms. Just

over half of users stated that they purchased e-cigarettes because they were cheaper than cigarettes. The disposable e-cigarette is sold in a single unit package for approximately $10 at convenience stores in the Dallas area. Package instructions indicate that 1 e-cigarette is comparable to approximately 2.5 packages of regular cigarettes (Table 1). Other less common reasons for using the e-cigarette were to avoid bothering other people with tobacco smoke (44%), to deal with smokefree situations (39%), or to avoid having to go outside to smoke (34%).

Fewer used the e-cigarette to reduce tobacco consumption (28%), and far fewer reported being unable to stop using it (4%) (15).

Single use e-cigarette package information and package insert read as follows: PACKAGE INFORMATION 4.5% NICOTINE BY VOLUME. WARNING: Products are not smoking cessation products and have not been tested as such. The U.S. FDA has not approved products for any use and they are not intended to diagnose, cure, mitigate, treat, or prevent disorder, diseases, or physical or mental conditions. Products contain nicotine, a chemical known to the State of California to cause birth defects or other reproductive harm. Nicotine is addictive and habit forming and is very toxic by inhalation, in contact with the skin, or if swallowed. Ingestion of the nonvaporized concentrated ingredients in the cartridge can be poisonous.

Physical effects of nicotine may induce Texas Dental Journal l www.tda.org l May 2013

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increased heart rate and accelerated blood pressure. If the cartridge is swallowed, seek medical assistance immediately. Products are intended for use by adults of legal smoking age (18 or older in California) and not by children, women who are pregnant or breast-feeding, or persons with or at risk of heart disease, high blood pressure, diabetes, or taking medicine for depression or asthma.

Products may not be sold to minors.

Identification of all persons under 16 will be required before purchase. Keep out of reach of children. Results may vary depending on usage.

FDA-approved pharmacotherapy (17).

FDA-approved nicotine replacement products include nicotine gum, lozenge, patch, inhaler, and nasal spray. Current literature indicates that the combined use of varenicline (Chantix®), nicotine patch, and gum or lozenge shows significant improvement in cessation rates compared to single pharmacotherapy (18).

According to Ken Otterbourg of the Business Journal of North Carolina, 2 e-cigarette brands currently dominate the U.S. market. The journal reported that the Lorillard Corporation, manufacturers of Newport cigarettes, recently agreed to purchase of 1 of the e-cigarette companies for $135 million (16).

The nicotine replacement therapy (NRT) most similar to the e-cigarette is the nicotine inhaler. In a study comparing cigarettes, the nicotine inhaler, a 16 mg e-cigarette and a 0 mg e-cigarette, researchers found no significant difference in withdrawal symptoms between the 16 mg e-cigarette and inhaler. However, 58% of participants preferred the e-cigarette, 25% preferred the inhaler, and 13% liked neither. The ease of use was similar for e-cigarettes and inhaler (48% and 45%, respectively).

The time to peak blood nicotine concentration of the e-cigarette was shorter than for the nicotine inhaler, which may be due to some absorption via the respiratory tract compared with buccal absorption for the nicotine inhaler. About one-third of participants showed no increase in blood nicotine when using the e-cigarette. This finding as well as the novelty of the device may explain the increased awareness and use of the e-cigarette. The authors concluded that this reflects the lack of manufacturing standards for the e-cigarette (19).

According to the U.S. Public Health Service Guideline, effective smoking cessation intervention should include behavioral support in conjunction with

Annual cigarette consumption in the U.S. declined 2.6% 2010 to 2011.

However, consumption of loose tobacco and cigars increased 123%

PACKAGE INSERT From its size, feel, and look to its amazing taste, it gives you everything you love about the smoking experience. So go ahead and give it a try. To begin take a long slow puff on the cigarette – no lighting or charging required. The tip will light up each time you puff. Each cigarette lasts up to 2 packs but may vary depending on usage. You’ll know it’s time for a new one when the red light blinks on and off.

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over the same period. These data suggest that certain smokers have switched from cigarettes to other combustible tobacco products and remain nicotine dependent (20).

The population that continues to smoke some form of tobacco have significant co-morbidities such as mental illness. U.S. adults with some form of mental illness have a smoking rate 70% higher than adults with no mental illness. Among adults with mental illness, the quit ratio is 34.7%, compared with 53.4% among adults who did not have mental illness (21). Individuals with mental illness encounter greater difficulty in smoking cessation and many resort to the use of novel products such as the e-cigarette following repeated failure using the FDA-approved pharmacotherapies. This poses a significant challenge in the practice of smoking cessation. The policy of Baylor Tobacco Treatment Services (Texas A&M University Baylor College of Dentistry) is not to recommend the use of the e-cigarette for smoking cessation. However, for individuals who have independently elected to use the e-cigarette for cessation, use is not discouraged. Additional behavioral support is offered in the quit attempt (22).

Future Research With the multitude of e-cigarettes available in the U.S. market it is essential that professionals continue to monitor the progress of research on the e-cigarette. Quality control to prevent such things as exploding e-cigarette products, contaminated and toxic liquid “soups” of components is essential.

Oral Cancer Screening

If e-cigarettes are to be used for smoking cessation, studies should be undertaken to biochemically validate their efficacy. Additionally, research should evaluate whether e-cigarettes foster their dual use with continuing tobacco product use, and/ or the delay of aggressive cessation efforts. Further research should address whether the e-cigarette delivers nicotine solely by absorption through the mucosa of the oral cavity, or if nicotine is also delivered via the lung. This is important in determine pulmonary nicotine levels, in order to assess the abuse liability of the e-cigarette. The research on e-cigarettes is currently rapidly expanding, and the debate continues as to whether e-cigarettes offer a safe method and efficacious adjunct for smoking cessation.

References 1. Hon L. A non-smokable electronic spray cigarette (CA 2518174).

(Patent notice). Canada: Canadian Patent Office Record.

2005;133:129.

2. Henningfield JE, Zaatari GS. Electronic nicotine delivery systems: emerging science foundation for policy. Tob Control.

2010;19:89-90.

3. FDA (22 July 2009). “Summary of Results: Laboratory Analysis of Electronic Cigarettes” . http:// www.fda.gov/NewsEvents/ PublicHealthFocus/ucm173146. htm. Accessed February 15, 2013.

4. http://www.fda.gov/NewsEvents/ PublicHealthFocus/ucm172906. htm. February 15, 2013.

5. Vansickel AR, Cobb CO, Weaver MF, et al. A clinical laboratory model for evaluating the acute

With the multitude of e-cigarettes available in the U.S. market it is essential that professionals continue to monitor the progress of research on the e-cigarette. Quality control to prevent such things as exploding e-cigarette products, contaminated and toxic liquid “soups” of components is essential.

effects of electronic “cigarettes”: nicotine delivery profile and cardiovascular and subjective effects. Cancer Epidemiol Biomarkers Prev. 2010;19:19451953.

6. Cobb NK, Byron J, Abrams DB, Shields PG. Novel nicotine delivery systems and public health: the rise of the “e-cigarette”. Am J Public Health. 2010;100:2340-2342.

7. Cahn Z, Siegel M. Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or a repeat of past mistakes? J Public Health Policy.

2011; 32:16–31.

8. Polosa R, Caponnetto P, Jaymin B Morjaria JB, Papale G, Campagna D, Russo C. Effect of an

electronic nicotine delivery device (e-Cigarette) on smoking reduction and cessation: a prospective 6-month pilot study. BMC Public Health. 2011;11:786.

9. Kralikova E, Kozak JT, Rasmussen T Gunnar Gustavsson G, Jacques Le Houezec JL. Smoking cessation or reduction with nicotine replacement therapy: a placebocontrolled double blind trial with nicotine gum and inhaler. BMC Public Health. 2009(9):433.

10. Trtchounian A, Williams M, Talbot P. Conventional and electronic cigarettes (e-cigarettes) have different smoking characteristics.

Nicotine Tob Res. 2010;12:905-912.

11. Vardavas CI, Anagnostopoulos N, Kougias M, Evangelopoulou Texas Dental Journal l www.tda.org l May 2013

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12.

13.

14.

15.

16.

17.

V, Connolly GN, Behrakis PK. Short-Term Pulmonary Effects Of Using An Electronic Cigarette. CHEST. 2012;141(6):1400-1406.

Regan AK, Promoff G, Dube SR, Arrazola R. Electronic nicotine delivery systems: adult use and awareness of the “e-cigarette” in the USA. Tob Control. 2013 22(1):19-23.

King BA, Alam S, Promoff G, Arrazola R, Dube SR. Awareness and ever use of e-cigarettes among U.S. adults: 2010-2011. Tob Control. 2013 Feb 23 [Epub ahead of print].

Yamin CK, Bitton A, Bates DW. E-Cigarettes: A rapidly growing internet phenomenon. Ann Intern Med. 2010;153(9):607-609.

Etter JF & Bullen C. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy.

Addiction. 2011;106: 2017–2028. cigathttp://www.businessnc.com/articles/2013-03/ vapor-trails-category/ Accessed February 15, 2013 Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco

18.

19.

20.

21.

22.

Use and Dependence:2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Departmentof Health and Human Services. Public Health Service. May 2008.

Shah SD, Wilken LA, Winkler SR, Lin SJ. Systematic review and meta-analysis of combination therapy for smoking cessation. J Am Pharm Assoc. 2008;48(5):659-665.

Bullen C, McRobbie H, Thornley S, Glover M, Lin R, Laugesen M. Effect of an electronic nicotine delivery device (e-cigarette) on desire to smoke and withdrawal, user preferences and nicotine delivery: randomized cross-over trial. Tob Control. 2010;19(2):98-103.

Consumption of Cigarettes and Combustible Tobacco - United States, 2000–2011. MMWR. August 3, 2012;61(30):565-569.

CDC. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥18 Years with Mental Illness — United States, 2009 – 2011. MMWR. February 8, 2013; 62(05);81-87.

Baylor Tobacco Treatment Services 2013. Texas A&M University Baylor College of Dentistry.

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Oral and Maxillofacial Pathology Diagnosis and Management

PYOGENIC GRANULOMA Oral and Maxillofacial Pathology Case of the Month (from page 404)

Discussion Pyogenic granuloma is a tumorlike growth in the oral cavity and is considered to be non-neoplastic in nature. Originally it was considered to be caused by specific pyogenic organisms; however, it is now established to be unrelated to infection. Pyogenic granuloma can arise from the connective tissue of the skin or mucosa in response to various stimuli such as local trauma, chronic irritation, or hormonal factors (1,2).

Clinically, it presents as a smooth or lobulated mass; that is most often pedunculated but can be sessile. The surface may be red to pink and it is usually ulcerated. When pyogenic granulomas originally arise, they are very vascular and appear red, but as the lesions age, they become more pink, with replacement of blood vessels with collagenized and sclerotic areas. The lesions may range in size from a small nodule to a large mass of several centimeters diameter.

Typically, the mass is painless, but it can bleed easily because of its characteristic vascularity. They tend to be firm and somewhat rubbery to palpation. Some pyogenic granulomas may grow rapidly and cause alarm to the patient and the clinician, simulating a malignant entity.

Radiographically there is generally no evidence of any bone involvement; however, in some cases superficial

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bony erosions have been reported (1,2,3,7).

Most pyogenic granulomas have a preference for the gingival tissues; however, they can occur anywhere in the oral cavity. The lips, tongue, and buccal mucosa are the second most common sites. Gingival trauma and irritation due to poor oral hygiene are the most common etiologic factors. Lesions are more common in the maxilla than the mandible.

These lesions can arise at any age; however, they seem to be seen more often in children and young adults.

Most studies demonstrate a female predilection, with a female to male ratio of 2:1. This is believed to be due to the vascular effect of female hormones that occur in women during puberty, pregnancy, and menopause.

The lesions tend to occur more often during the second and third trimesters of pregnancy and these lesions are called “pregnancy tumors” (1–5,7,8).

Complete local excision, extending down to the periosteum is usually the treatment of choice. Other reported treatments include YAG laser excision, intralesional steroid injections, cryosurgery, and injections of absolute ethanol. Recurrence has been reported to occur in approximately 16% of cases, most likely due to incomplete removal, failure to remove the irritative stimulus, or reinjury of the area. Gingival lesions tend to

recur more often than other oral sites (1–5,7,8). The lesion in this patient was completely excised and has not recurred in 12 months.

References 1. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. Third Edition. St. Louis, MI. 2009, 2002 SAUNDERS ELSEVIER. 2. Regezi JA, Sciubba JJ, Jordan RC.ORAL PATHOLOGY: Clinical Pathologic Correlations. 4th Edition. Saunders 2003.

3. Panjwani S, Issrani R, Keluskar V, Naik Z. An unusual presentation of pyogenic granuloma. Indian Journal of dentistry 2012; 3: 178181.

4. Cloutier M, Charles M, Carmichael RP, Sandor GKB. An analysis of peripheral giant cell granuloma associated with dental implant treatment. OOOOE, 2007; 103: 618-622.

5. Flaitz C. Peripheral Ossifying fibroma of the maxillary gingiva.

Am J Dent. 2001; 14, 56.

6. Dhawad MS, Nimonkar PV. Metastatic Carcinoma of Gingiva Mimicking Pyogenic Granuloma.

J Maxillofac Oral Surg. 2011 June 10(2): 163-165 7. Jafarzadeh H, Sanatkhani M, Montasham N. Oral pyogenic granuloma: a review. J Oral Sci ; 2006. Dec 48 (4): 167-75.

Memorial and Honorarium Donors

In Memoriam

to the Texas Dental Association Smiles Foundation

Those in the dental community who have recently passed

In Memory of:

Bean, Ralph I.

Mr Homero Canales Robertson Orchard Dental Associates

Mr S.T. Brown Robertson Orchard Dental Associates

Sherman, Texas January 16, 1931 – November 22, 2012 Good Fellow, 1989 • Life, 1997

Broaddus, Luther L.

Dr Kurt Loveless

San Antonio, Texas January 21, 1929 – February 23, 2013 Good Fellow, 1979 • Life, 1994 • Fifty Year, 2011

Jack Reichert

Guiberteau, James J.

Glenn Eubank

Dr Kurt Loveless

In Honorarium: Diane Bogan - ATDA State President Forth Worth District Dental Society Your memorial contribution supports: • •

educating the public and profession about oral health; and improving access to dental care for the people of Texas.

Please make your check payable to:

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

San Antonio, Texas September 10, 1934 – March 13, 2013 Good Fellow, 1988 • Life, 2000 • Fifty Year, 2012

Owens, John D. Harlingen, Texas March 16, 1924 – March 23, 2013 Good Fellow, 1979 • Life, 1989 • Fifty Year, 2002

Weatherly, Robert H. Jr Corpus Christi, Texas September 4, 1925 – March 23, 2013 Good Fellow, 1974 • Life, 1990 • Fifty Year, 1998

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Retired, but not “retired”?

Mid America Health is seeking qualified dentists in your area to fill part time/PRN clinical positions! These positions are a rewarding, low stress alternative to private practice and offer an accommodating schedule, mileage reimbursement and competitive compensation.

• Must be proficient in screenings, exams, extractions and dentures • Must be willing to travel locally • Current Texas Dental License and DEA Registration are required • Malpractice is provided Visit the “Careers” tab of our website, www.mahweb.com, for more information or to apply today!

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CALENDAR OF EVENTS JUNE2013 13 – 16

14 – 15

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The Colorado Dental Association will host its 126th Annual Session at the Sheraton Steamboat in Steamboat, CO. For more information, please contact Ms Molly Pereira, CDA, 3690 S Yosemite Ste 100, Denver, CO 80237-1808. Phone 303-996-2845; FAX: 303-740-7989; E-mail: molly@cdaonline.org; Web: cdaonline.org.

The Southwestern Society of Oral Medicine will host its annual meeting at the Marriott Plaza, San Antonio, TX. For more information, please contact Dr Brian Karasic, PO Box 819, Eatontown, NJ 07724-0819; Phone: (732) 762-7945; E-mail: diplomatconsulting@hotmail.com.

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14 – 17

28-29

The Mississippi Dental Association will host its 137th Annual Session at the Hilton Sandestin Beach in Destin, FL. For more information, please contact Ms Tamra Shepherd, MDA, 2630 Ridgewood Rd, Jackson, MS 39216.

Phone 601-982-0442; FAX: 601-366-3050; E-mail: tamra@msdental.org; Web: msdental.org.

The TDA Smiles Foundation will hold a 40-chair Texas Mission of Mercy in Amarillo. For more information, please contact Foundation Manager Judith Gonzalez at TDASF, 1946 S IH35 Ste 300, Austin, TX 78704; Phone: 512-448-2441; E-mail: judith@tda.org; Web: tdasmiles.org.

JULY2013

OCTOBER2013

18-20

7-12

The American Association of Oral and Maxillofacial Surgeons will host its 95th annual meeting in Orlando, FL. For more information, please contact Dr Robert C. Rinaldi, AAOMS, 9700 W. Bryn Mawr, Rosemont, IL 60018. Phone: 847-6786200; FAX: 847-678-6286; Website: aaoms.org.

16-19

The American Student Dental Association will host its 37th Annual ASDA Conference in Naples, FL. For more information, please contact Dr Dan Ward, ASDA, 635 Madison Ave, New York, NY 10022. Phone: 800-4542732; E-mail: dward@columbus.rr.com; Website: asdatoday.com.

31-5

The American Dental Association will host its 154th Annual Session in New Orleans, LA. For more information, please contact ADA conference and meeting services, ADA, 211 E Chicago Ave Ste 730, Chicago, IL 60611-2678.

Phone: 312-440-2500; FAX: 312-4402707 ; E-mail: annualsession@ada.org; Website: ADA.org.

31-2

The Alliance of the American Dental Association will host its annual conference in New Orleans, LA. For more information, please contact Ms Patricia Rubik-Rothstein, AADA, 211 East Chicago Ave Ste 730, Chicago, IL 60611-2678. Phone: 312-440-2865; FAX: 312-440-2587; E-mail: manager@ allianceada.org; Website: allianceada. org.

The American Dental Association will host its 26th New Dentist Conference in Denver, CO. For more information, please contact Mr. Ron Polaniecki, ADA, 211 East Chicago Avenue, Chicago, IL 60611. Phone 312-440-2599; FAX: 312440-2883; E-mail: polanieckir@ada.org; Web: ada.org.

AUGUST2013 9-10

15-17

The TDA Smiles Foundation will hold a 20-chair Texas Mission of Mercy in Texarkana. For more information, please contact Foundation Manager Judith Gonzalez at TDASF, 1946 S IH35 Ste 300, Austin, TX 78704; Phone: 512-448-2441; E-mail: judith@tda.org; Web: tdasmiles. org.

The California Dental Association presents The Art and Science of Dentistry at Moscone West in San Francisco, CA. For more information, please contact Ms Deborah Irwin, CDA, 1201 “K” Street Mall, Sacramento, CA 95853. Phone: 916-443-3382 Ext 4470; FAX: 916-554-5937; E-mail: debi@cda. org; Web: cda.org.

SEPTEMBER2013 26-28

The Texas Academy of General Dentistry will host its annual Lone Star Dental Conference in Austin, Texas. For more information, please contact Laura Ceglio, Communications Coordinator, TAGD, 409 W Main St, Round Rock, TX 78664.

Phone: 512-244-0577; FAX: 512-2440476; E-mail: laura@tagd.org; Website: tagd.org.

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

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Your online dental industry job board

Find your next employee!

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Texas Dental Journal l www.tda.org l May 2013

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Provided TDA Perks Program Provided byby TDA Perks Program

value value for for your your

profession

What You Need to Know About the Visa and What You Need to Know About the Visa and MasterCard Anti Trust Lawsuit Settlement MasterCard Anti Trust Lawsuit Settlement Jennifer L. Nieto, President of Best Card, LLC

Jennifer L. Nieto, President of Best Card, LLC

I

f your practice accepted credit card payments between January 1, 2004, and November 28, 2012, you probably received a “legal notice about a class action settlement” by mail. You may also have received solicitations that look like official notices, but are actually a marketing ploy from companies that want you to sign over more than 33% of your portion of the settlement money in exchange for handling your paperwork. Know the difference!

I

f your practice accepted credit card payments between January 1, 2004, and November 28, 2012, you

probably received a “legal notice about a class action settlement” by mail. You may also have received solicitations that look like official notices, but are actually

How can I know a notice is official?

a marketing ploy from companies that

The official notice is 28 pages long, and will have a page that begins as follows:

your portion of the settlement money in

“NOTICE OF CLASS ACTION SETTLEMENT AUTHORIZED

BY THE U.S. DISTRICT COURT, EASTERN DISTRICT OF NEW YORK

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want you to sign over more than 33% of exchange for handling your paperwork.

Know the difference!

b. You’ll

How know a notice is official? will I be entitled to?need to complete a You can mayIalso have received solicitations that lookWhat like official

claim form to receive a The court also gave preliminary approval of $6.05 a proposed The official notice is 28 pages long, and will have a page

portion of the billion but are actually a marketing ploy from companies notices, monetary portion of the settlement.

There is a hearing that begins as follows:

(or whatever final figure is scheduled for September 2013 to decide the fairness of approved).

“NOTICE OF CLASS ACTION SETTLEMENT theportion settlement. that want you to sign over more than 33% of your of • This form is not available AUTHORIZED BY THE U.S. DISTRICT COURT,

today. If you sign

EASTERN DISTRICT OF NEW YORK If this portion of the settlement is approved, there will be

anything before the settlement money in exchange for handling 2 settlement classes:

September 2013, it A $6+ billion settlement will provide payments

is most likely a contract and other benefits to merchants that accepted your 1.paperwork.

Cash Settlement to Class exchange a Visa and MasterCard since 2004.

If you accepted credit card payments between

percentage (often 33%) January 1, 2004, and November 28, 2012, you’re

of your portion of the A federal court directed this Notice. This is not a entitled to be part of this group, which will receive

settlement in exchange solicitation a lawyer.”

A $6+ billionfrom settlement impose on merchants. Visa $6.05 and billion.

for help with the forms. will provide payments and MasterCard complied. It was declared

• If you don’t complete The official websiteto established for beginning January 27, 2013, merchantsby the courtthat other benefits a. You’ll receive a claim form via mail or email, as

the form before the notification of these rulings Visa and is: https://www.some merchants will be allowedwell that accepted to as the deadline for filing this claim.

deadline (which is yet to paymentcardsettlement.com/en.

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be established), you’ll 625-6440 for a recorded explanation and answers to debit — cards. However, — but not portion of the $6.05 billion(or whatever final

forfeit your share of (opt A federal court directed as well as live help. frequently asked questions, several states have regulations figure is approved).

out of) the settlement. this Notice. This is not a forbidding most merchants from• This form is not available today. If you sign

• If you need help with the solicitation a lawyer.” imposing surcharge fees — and Texasanything before September 2013, it is most What is thefrom story behind this lawsuit?

form, you’ll be welcome is one of them. (See: Texas Finance likely a contract to exchange a percentage

to call the claims The official website established § 339.001). (often 33%) of your portion of the In 2005, several companies initiated a classRegulations action

administrator of the by the court forMasterCard notificationand of Visa (and their member settlement in exchange for help with the lawsuit against

court at 800-624-6440, these is:that https://www. banks)rulings alleging MasterCard and Visa violated laws byI be entitled to?forms.

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paymentcardsettlement.com/en.

• If you don’t complete the form before the conspiring to set interchange prices, and by imposing rules Program credit card You alsomerchants’ call 800-625-6440 forsteer a customers The court also gave preliminary deadline (which is yet to be established), thatcan limited ability to to other

processing partner recorded explanation answers to approval of a proposed monetary you’ll forfeit your share of (opt out of) the payment methods (anand anti-trust lawsuit).

Best Card at 877-739- frequently asked questions, as well as portion of the settlement. There is settlement.

3952, at no charge. live help. a hearing scheduled for September • If you need help with the form, you’ll be What was the outcome?

2013 to decide the fairness of the welcome to call the claims administrator of 2. Rules Changes Settlement Class settlement. the court at 800-624-6440, and/or TDA Perks The federal courtstory ruled that MasterCard and Visa (and What is the behind

This will include any who accept Program credit card processing partner Best the had to ease the restrictions they impose on lawsuit? thisbanks) credit cards as of November 28, of the settlement is Card at 877-739-3952, at no charge. merchants. Visa and MasterCard complied.IfItthis wasportion declared 2012, or after. If you did or do, approved, that beginning 27, 2013, some merchants willthere will be 2 settlement In 2005, severalJanuary companies you won’t have to do anything classes: 2. Rules Changes Settlement Class be allowed to impose initiated a class actionsurcharges lawsuit when taking credit to be included in this class. You’ll This will include any who accept credit cards as of — but not debit — cards.

However, against MasterCard and Visa (and several states have automatically receive a reduction 1. imposing Cash Settlement Class November 28, 2012, or after. If you did or do, you regulations forbidding most merchants from their member banks) alleging that in interchange fees paid for the 8

If you accepted credit card won’t have to do anything to be included in this class. surcharge fees andviolated Texas is laws one of MasterCard and—Visa bythem. (See: Texas months following the settlement. payments between January You’ll1, automatically receive a reduction in interchange Finance Regulations § 339.001). conspiring to set interchange prices, 2004, and November 28, 2012, fees paid for the 8 months following the settlement. and by imposing rules that limited TDA Perks Program’s credit cardyou’re entitled to be part of this merchants’ ability to steer customers processing partner Best Card group, which will receive $6.05 TDA Perks Program’s credit card-processing partner Best to You othermay payment (an anti- solicitations that alsomethods have received welcomes any questions you may billion.

Card welcomes any questions you may have regarding trust lawsuit). have regarding the settlement, or look like official notices, but are actually the settlement, or other credit-card processing related other credit-card processing related

a. You’ll receive aquestions. claim formPlease via contact Best Card at 877-739-3952. For a marketing ploy from companies that questions. Please contact Best Card What was the outcome?

mail or email, more as well as information regarding TDA Perks Program, please at 877-739-3952. For more want you to sign over more than 33% of the deadline for filing this visit tdaperks.com, or call 512-443-3675.

The federal court ruled that information regarding TDA Perks

claim. your portion the money in MasterCard and Visaof (and thesettlement banks) Program, please visit tdaperks.com, had to ease the restrictions they or call 512-443-3675. exchange for handling your paperwork.

Texas Dental Journal l www.tda.org l May 2013

463

ADVERTISING BRIEFS Practice OpportunitieS ADS WATSON, BROWN & ASSOCIATES: Excellent practice acquisition and merger opportunities available.

DALLAS AREA: 6 general dentistry practices available (Dallas, North Dallas, Highland Park, and Plano); 5 specialty practices available (2 ortho, 1 perio, 1 pedo).

FORT WORTH AREA: 2 general dentistry practices (north Fort Worth and west of Fort Worth). CORPUS CHRISTI AREA: 1 general dentistry practice. CENTRAL TEXAS: 2 general dentistry practices (north of Austin and Bryan/College Station). NORTH TEXAS: 1 orthodontic practice. HOUSTON AREA: 3 general dentistry practices.

EAST TEXAS AREA: 2 general dentistry practices and 1 pedo practice. WEST TEXAS: 3 general dentistry practices (El Paso and West Texas). NEW MEXICO: 2 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.

AMARILLO: General dentist for a locally owned practice looking to provide care for our patients as well as build their own patient base. Ownership opportunity available. Please contact Dr Britt Bostick, DDS, bbost35821@aol.com or call 806-438-5745.

AMARILLO: Pediatric dentist for a locally owned practice looking to provide care for our patients as well as build their own patient base. Ownership opportunity

ADVERTISING BRIEF INFORMATION SUBMISSION AND CANCELLATION DEADLINE: 20th, 2 months prior to publication (eg, November 20th for January issue) MONTHLY RATES: First 30 words = $40; each additional word = 10¢ Ads must be submitted via e-mail, fax, or web and are not accepted by phone. Journal editors reserve 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. Advertisements must be not quote revenues or gross or net incomes; only generic language referencing income will be accepted.

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available. Please contact Dr Britt Bostick, DDS, bbost35821@aol.com or call 806-438-5745.

Amazing Practice in the PANHANDLE AREA (SALE PENDING): Sherri L. Henderson & Assoc. General DDS family practice for sale. Owner is relocating and will lease the beautiful free-standing building of 4,086 sq ft. Five existing treatment rooms with plenty of room for expansion. Collection rate 98% - Mid to high 6-figure revenue. The fee-for-service practice was started in 1984 and has a dedicated staff and large loyal patient base with a great hygiene department. #3060 (Pictures available) Contact 972-562-1072 or email: sherri@slhdentalsales.com; www.slhdentalsales.com.

Anxious to sell in the CORPUS CHRISTI AREA: Sherri L. Henderson & Associates. The DDS is relocating to another city. The general practice was established in 1982 in a professional office complex with 1,400 sq ft and 3 existing treatment rooms. This location would make a great place for a start-up or satellite practice and it has plenty of space next door for expansion. The location is on one of the busiest streets with access to Padre Island Drive. This is a cash basis practice with a dedicated loyal staff and great revenue potential.

The current owner has extensive experience with TMJ and sleep apnea and would be willing to return to the practice periodically if the new owner was interested. #3070 (Pictures available) Contact 972-562-1072 or email: sherri@slhdentalsales.com; www.slhdentalsales.com.

ARLINGTON / FORT WORTH: Associate position available. Full-time dentist and specialist needed to join our successful dental group in Arlington and Fort Worth. Interested candidates should email CV to info@ ismiledental.net.

ASSOCIATE FOR TYLER GENERAL DENTISTRY PRACTICE: Well-established general dentist in Tyler with over 30 years experience seeks a caring and motivated associate for his busy practice. This practice provides exceptional dental care for the entire family. The professional staff allows a doctor to focus on the needs of their patients. Our office is located in beautiful east

Texas and provides all phases of quality dentistry in a friendly and compassionate atmosphere. The practice offers a tremendous opportunity to grow a solid foundation with the doctor. The practice offers excellent production and earning potential with a possible future equity position available. Our knowledgeable staff will support and enhance your growth and earning potential while helping create a smooth transition.

Interested candidates should call 903-509-0505 and/or send an e-mail to steve.lebo@sbcglobal.net.

Associate needed for dental office in small, quaint town. Potential for practice purchase. 361-6458148.

ASSOCIATES and PARTNERS AVAILABLE: Sherri L. Henderson & Associates. Is it time for you to add another provider? Is it time for you to go golfing or fishing more? Let us help you find the perfect associate and potential buyer. We have candidates ready in all parts of Texas looking for your specific practice profile.

There are many graduates as well as very experienced dentists looking for the opportunity to transition into your already established practice. These dentists have great people skills, case presentation experience and can be a very valuable and reliable addition to your bottom line. If you are confused about the right timing or simply would like to talk about the opportunities, call us today for a complimentary consultation in person or by telephone. We are experienced in practice sales, associate and partner placement, and can assist you in making that transition dream become a reality. 972562-1072 or e-mail sherri@slhdentalsales.com; www. slhdentalsales.com.

AUSTIN AREA: Hill Country — Sherri L. Henderson & Associate, LLC — This is an exceptional opportunity for a general DDS to become an associate immediately in the Lakeway area; 3,250 sq ft, 7 ops, in house lab, paperless and 7 full-time staff members). Work days: Tuesday - Friday and 1 Saturday per month (5 days per week available and a monthly guarantee if desired).

Minimum 2-year commitment. Location pictures available. Call Sherri at 972-562-1072 or 214-697-6152.

AUSTIN PEDIATRIC PRACTICE SEEKING FULL TIME ASSOCIATE: Great benefits! Progressive, fast-paced practice. Capable caring staff. We are looking for a bright career-oriented pediatric dentist to join an organization committed to providing high quality dental care to children and adolescents. Our dental team strives to offer exceptional care with integrity. Send your confidential resume to dentalresume27@yahoo. com for consideration.

Awesome practice in LONGVIEW, TEXAS: For sale — SLH Dental Sales is looking for a qualified buyer that would like the opportunity to immediately transition into a general dental office in this growing town of east Texas. The owner is willing to stay for a negotiated amount of time if necessary to ensure a smooth transition. The location of the practice is near the hospital in a beautiful scenic area surrounded by many professional buildings. The staff is excited and ready for a future owner that will allow the current owner to pursue other opportunities. The office space is 1,500 sq ft with 4 treatment rooms equipped, 2 private offices, and 6 highly experienced employees. The owner occupies a portion of the building complex and is looking to transfer ownership of both patient base and the building space immediately. For more information, please contact our office at 972-562-1072, e-mail sherri@slhdentalsales.com, or visit our website at www. slhdentalsales.com (Pictures available). Listing #3050.

BEAUMONT AREA: FOR SALE: Well established 3operatory, 17-year-old general practice. Great location with good visibility and high traffic flow. Modern equipment and computer system with Eagle Soft dental software. Staff is excellent and long standing. Practice is fully functional in all aspects and ready for buyer to step in seamlessly. Building is a free standing country style office in beautiful condition and seller will sell or lease.

Please inquire via email at drbob.willis@henryschein.com.

BEAUTIFUL EAST TEXAS: Long-standing general practice in a stable community of over 14,000 with a great referral base. Three ops, full-time hygienist and great staff. Doctor desires a quick sale and will aid in Texas Dental Journal l www.tda.org l May 2013

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ADVERTISING BRIEFS a smooth transition. Opportunity for ownership and start building equity for a minimal investment, with scheduled patients on day one. Contact Dr Guy Walker PARAGON DENTAL TRANSITIONS 573-225-2877. www. paragon.us.com.

BROWNSVILLE 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.

Consulting & Staging For Your Transition!

SLH DENTAL SALES (Sherri L. Henderson & Associates) — Are you prepared for the future? Let us help you make a transition plan — we can analyze the market, review your current patient base, secure the staff, spruce up the office space and much more. We specialize in practice transition consulting and can assist you in a plan to help you create all the right conditions to begin that step from retiring to starting up a new practice. Our team has decades of hands on experience in the dental market place as practice owners, employees and management advisors. We are here to help you prepare for an associate, partner, start-up or practice sale. We have a huge database of qualified applicants waiting and the time could not be better to begin the process. Our contact with you is strictly confidential and we are happy to schedule a complimentary consultation to discuss your options.

Call 972-562-1072 or e-mail sherri@slhdentalsales.com; www.slhdentalsales.com.

CORPUS CHRISTI: Established, successful practice in a niche market limited to removable prosthetics, extractions and related services in Corpus Christi is available for ownership due to current practice owner’s transition to retirement. Opened since 2003, this practice has a history of providing excellent care and services to the patients of southeast Texas. No personal financial investment required — owner is

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willing to finance purchase due to profitability and excellent cash flow. Affiliation with a long-standing dental services organization allows the owner to focus on treating patients and less time on the administrative burdens of a busy practice. Please call, e-mail or fax for additional information and detail. Guaranteed salary plus minimum bonus compensation and full benefits package. Phone: 800-313-3863; E-mail: michele. rowland@affordablecare.com.

CURRENT PRACTICE SALE OPPORTUNITIES FROM DDR DENTAL: Serving Texas dentists for over 40 years.

GENERAL — Houston (Bellaire / Post Oak): Terrific growth practice with great facility nested in neighborhoods and schools. Fronts high traffic Chimney Rock. Interior and equipment rebuilt in 2009. Total of 8 operatories plumbed with 4 operatories in use. Freestanding building with 7,000 total sq ft that is also for sale. Call DDR AT 800-930-8017 or www.DDRDental. com.

PERIODONTAL — Houston (Galleria): Very high-end, well-established periodontal practice, great staff and great referral base. Five operatory with 2 hygiene and surgical suite. Call DDR AT 800-930-8017 or www.

DDRDental.com.

GENERAL — Houston (Memorial): Well-established practice, median gross revenue, great patient base, 6 operatories, (2 hygiene, 4 dental). Fully equipped and GREAT growth opportunity with 2,700 total sq ft available. Call DDR AT 800-930-8017 or www.

DDRDental.com.

DALLAS: Position available for a general dentist in a well-established, progressive private group practice in north Dallas. We offer a modern facility that has been at this location for more than 25 years, outstanding support staff and competitive salary with wonderful earning potential and benefit package. This opportunity is perfect for the recent graduate looking for an associate position where you can concentrate on dentistry and growing your practice. We have some of the latest technologies and encourage professional growth through investing in your continuing education. We are looking for an innovative, empathetic clinician with

ADVERTISING BRIEFS good leadership qualities and a professional demeanor who can thrive in a team atmosphere. Could lead to partnership or buy-in opportunity for the right individual.

Send resume to: tracitwilliams@alfadental.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.

DALLAS AREA: New practice opportunity. Fifteen miles from downtown Dallas. Over 5 years of clinical experience required. We are fair and nice. Pay based on collections. PPO and Medicaid accepted. Application material at www.mockingbirddentalgroup.com.

DALLAS: Solo general practice in North Dallas serving local asian community. Well-maintained facility on busy street with 3 ops and fourth plumbed. Doctor retiring and desires a quick transition. Longtime loyal staff. Mainly FFS with exceptional collection rate and low overhead. Contact Dr Guy Walker, Paragon Dental Transitions, 573-225-2877 www.paragon.us.com.

DENTALONE PARTNERS is opening new offices in Austin 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% PPO and 30% fee-forservice. All our offices have top of the line Pelton and Crane equipment, digital X-rays, and intra-oral cameras.

We offer competitive compensation packages with benefits. To learn more about working with one of DentalOne Partner practices, please contact Andrew Risolvato at 972-755-0838 or andrew.risolvato@ dentalonepartners.com.

DENTALONE PARTNERS 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% PPO and 30% fee-for-service.

All our offices have top of the line Pelton and Crane

equipment, digital X-rays and intra-oral cameras. We offer competitive compensation packages with benefits. To learn more about working with one of DentalOne Partner practices, please contact Andrew Risolvato at 972-7550838 or andrew.risolvato@dentalonepartners.com.

DENTALONE PARTNERS is opening new offices in San Antonio 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% PPO and 30% fee-for-service. All our offices have top of the line Pelton and Crane equipment, digital X-rays, and intraoral cameras. We offer competitive compensation packages with benefits. To learn more about working with one of DentalOne Partner practices, please contact Andrew Risolvato at 972-755-0838 or andrew. risolvato@dentalonepartners.com.

DENTALONE PARTNERS is opening new offices in the upscale suburbs of Houston. Each practice is unique in that it has an individual name like Gulf Breeze Dental Care or Waterside Dental Care. All of our offices have top of the line Pelton and Crane equipment, digital X-rays, and intra-oral cameras. Our patient base consists of approximately 70% PPO and 30% fee-for-service. We offer competitive compensation packages with benefits.

To learn more about working with DentalOne Partner practices, please contact Andrew Risolvato at 972-7550838 or andrew.risolvato@dentalonepartners.com.

DFW AREA: Seeking general dentists and specialists.

Our offices are located in the Dallas / Fort Worth area.

We are looking for caring, energetic associates. New graduate and experienced dentists welcome. We offer benefits, a helpful working environment and an opportunity to grow. We accept most insurance and Medicaid. Please submit your resume via e-mail to jennifer@smileworkshop.com or call our office at 214757-4500.

DFW, AUSTIN, SAN ANTONIO, AND HOUSTON: ASSOCIATE DENTIST OPPORTUNITY â&#x20AC;&#x201D; Pacific Dental Services and its supported owner dentists have Texas Dental Journal l www.tda.org l May 2013

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ADVERTISING BRIEFS exciting associateship opportunities throughout the state of Texas (DFW, Austin, San Antonio, and Houston). Practices are uniquely named (ie, The Woodlands Smiles Dentistry and Orthodontics) and owned by general dentists make all clinical decisions in a traditional, practice setting while PDS provides the business support services. Associates see 12 to 13 patients a day in a PPO/FFS setting (no Medicaid).

Practices are state-of-the-art, fully digital, and equipped with Cerec CAD/CAM 4.0 with Omnicam, lasers, and intra-oral cameras. Exciting comp package with full benefits, CE, malpractice insurance and partnership/ ownership opportunities. To learn more, please visit www.jobs.pacificdentalservices.com.

EAST TEXAS: HAVE YOUR STUDENT LOAN PAID OFF! Small east Texas practice for sale. Will pay off student loan, after sale. Contact David Allen, with AFTCO, to get complete details. 800-232-3826.

EL PASO: Full-time position for a general dentist. Donâ&#x20AC;&#x2122;t waste your best years at dead-end jobs. Great earning potential and future partnership option. Affordable El Paso Dental is looking for a Texas-licensed dentist to work full time in our office in El Paso, TX. Applicant must be licensed in the state of Texas and have 1 year of experience. If interested please submit a resume to the following email address: drdarj@gmail.com. Please provide an accurate contact number and email address.

EL PASO/HORIZON: Orthodontist needed ASAP on the east side of El Paso and Horizon area. This is a parttime position 2 days per week. Excellent salary. Great environment. Send resume to info@txkidsdental.com.

FORT WORTH OUTLYING COMMUNITY: Quality private practice interviewing for a full-time associate / successor. Owner is seeking a highly ethical, moral practitioner to join this predominately fee-forservice practice. Nice facility in high growth outlying community south of Fort Worth. Owner seeking successor, not just an associate. Ideally, the applicant should have more than 1 year of clinical experience.

Please send introductory letter with resume regarding

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DP #373 to Lewis Health Profession Services Inc at 101 W Renner Rd Ste 145, Richardson TX 75082-2002 or by email to dan@lewishealth.com. Fax is 469-546-3645.

For additional information, contact Dan Lewis at 972437-1180.

FULLY EQUIPPED MODERN DENTAL OFFICE SPACE AVAILABLE FOR LEASE. Has 4 ops. Current doctor is only working 2 days a week. Great opportunity to start up new practice (ie, endo, perio, oral surgery). Available days are Monday, Tuesday, Thursday per week. If you are wanting an associate, please inquire. Call 214-3154584 or e-mail ycsongdds@yahoo.com.

GALVESTON: Well-established, successful practice of 35 years needs full-time associate dentist for FFS/PPO practice. Experienced staff, new equipment, Galveston.

Senior owner loves to teach sedation, implants, and other surgical procedures. No Medicaid, no DHMO practice in 6 ops, 2 surgical suites, all operatories computerized with digital X-ray and intra-oral cameras; digital panoramic X-ray; paperless charts for easy documentation. Website: todaysdentistrytexas.com.

The Galveston area is just 25 minutes south of Clear Lake which has planned communities with superior schools, multiple educational, recreational and cultural venues as well as access to all of the Houston cultural and sport venues, shopping and restaurants.

We are minutes away from all types of water sports including several large marinas. http://goo.gl/maps/ lWkF. Possibility of buy-in and partnership possible after an interim term. Interview today! E-mail CV to kkcarroll10@yahoo.com or call 832-385-8875.

GARLAND: Emergency sale. Brand new turn key dental office. Located in south Garland / north Dallas area.

Family emergency is forcing doctor to leave state. Office is in free standing building one block from Wal Mart and Tom Thumb with tremendous street visibility. Office has 7 operatories with 4 equipped and nitrous in each room. Digital X-ray and paperless. Great for start up or second office. Receive 35 to 40 new patients monthly.

Please contact Tina at 214-937-1366 for more details.

ADVERTISING BRIEFS Gary Clinton North Garland Practice off Hwy 190: High growth area. In north Garland, a high growth area of Garland. G-1 Well-established practice; digital with all the bells and whistles. Dentist taking early retirement for health reasons. Excellent opportunity; excellent full recall. Restorative practice high visibility location. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the Institute of Business Appraisers, Inc. I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name…a name you can trust.”

I personally handle every sale/transition and complete Professional Certified Appraisals for which congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge.

Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available.

DFW 214-503-9696. WATS 800-583-7765.

Gary Clinton Houston Practices for Sale: H-1 Far north of Woodlands Area. Near 7-figure gross with 5 operatories; exceptional recall; well-established.

Digital equipment. A premier practice. Hygiene profits will cover debt service. H-2 Southeast Houston/ Pearland area: Retiring dentist. Very desirable practice; digitally equipped with 4 operatories in professional center above average gross on 4 days. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the Institute of Business Appraisers, Inc. I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name…a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is

very confidential. General and specialty appraisals and practice sales. 100% funding available. DFW 214-5039696. WATS 800-583-7765.

Gary Clinton Practices South of Dallas: Waco area near 7-figure gross. 30-year-old general practice for sale — Exceptional practice; excellent recall; cosmetic; implants and restorative; transition and/or complete sale; PRN Transition. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the Institute of Business Appraisers, Inc. I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name…a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available. DFW 214-5039696. WATS 800-583-7765.

Gary Clinton North Dallas/Denton Area General Practices for sale: D-1 Denton practice: Five operatories; nice equipment. 30-plus year dentist retiring. Flexible transition; no low fee plans. D-2 Plano area practice: General dental practice; some implants; fee-for-service/PPO practice; great visibility. Gross is in the 6-figure range. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the Institute of Business Appraisers, Inc. I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name…a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which congress has set guidelines under the North American Business Valuation Standards Texas Dental Journal l www.tda.org l May 2013

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ADVERTISING BRIEFS Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available. DFW 214-5039696. WATS 800-583-7765.

Gary Clinton Practices for Sale: F-1 Fort Worth/Weatherford area. Fast growing area. Average gross; 6 operatories; excellent lease. Few dentists in area. Seller is relocating. Primarily fee-for-service.

A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27year member of the Institute of Business Appraisers, Inc. I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name…a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge.

Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available.

DFW 214-503-9696. WATS 800-583-7765.

Gary Clinton Denton Pedo/Ortho Practice for Sale: Four-chair bay plus 2 operatories equipped; another bay unequipped for 4 more chairs; fast growing area; excellent opportunity. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the Institute of Business Appraisers, Inc. I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions.

“For almost 40 years you’ve seen the name…a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential.

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General and specialty appraisals and practice sales.

100% funding available. DFW 214-503-9696. WATS 800-583-7765.

Gary Clinton Texas Two Oral Surgery Practices: Oral surgeons retiring; flexible transition.

Seller phase out; work for purchaser PRN. High 7 figures collected past 3 years; room for 2 surgeons.

Both are in mid-sized communities. All confidential.

Gary Clinton, Oral Surgery Appraiser. 1-800-583-7765.

Gary Clinton, Broker/Senior Appraiser/ Consultant with almost 40 years in dentistry: We need sellers…general and specialty practices! We have pre-qualified buyers. When we sell your practice, if you own your office, there is no real estate commission. Gary Clinton - PMA. I need practices in or near Austin, San Antonio, DFW and Houston area and other metro Texas locations which are in high demand. Call me confidentially. 1-880-5837765 or 214-503-9696 Dallas area.

Gary Clinton North of Fort Worth Practice for Sale: Urgent as doctor wants to move out of state to pursue other opportunities. Great location with high growth potential. 7,000 records; nice equipment; 6-figure range collections working 112 days in 2012.

Doctor is open to offers. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the Institute of Business Appraisers, Inc. I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name…a name you can trust.”

I personally handle every sale/transition and complete Professional Certified Appraisals for which congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge.

Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available.

DFW 214-503-9696. WATS 800-583-7765.

ADVERTISING BRIEFS Gary Clinton East Dallas Practice for Sale: Doctor retiring for health reasons; well-established 30-year-old practice. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the Institute of Business Appraisers, Inc. I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name…a name you can trust.”

I personally handle every sale/transition and complete Professional Certified Appraisals for which congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge.

Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available.

DFW 214-503-9696. WATS 800-583-7765.

Geriatric Dental is looking for dentists to work 1 to 3 days a week at nursing homes in the following areas: North Texas: Fort Worth/mid-cities; Central Texas: Waco/Temple; south Texas: Weslaco/McAllen/ Brownsville (bilingual (Spanish) is desired). The days of work are flexible between Monday and Saturday and are typically 8:00 AM to 5:00 PM. The ideal candidate should be a licensed dentist with a background in Geriatric Dentistry and over 3 years of service. Dental Services Offered: cleanings, X-rays, fillings, extractions, dentures, and oral surgery. Description of services: comprehensive exams, explanation of treatment options, training of nursing home staff on proper daily oral hygiene. If you are interested in this position, please email jodywilliamson@gmail.com with your most current resume. You can contact him after submitting your resume at 512-695-3138. This is a contract job. Principals only. Recruiters, please don’t contact this job poster. Please do not contact job poster about other services, products, or commercial interests.

GOLIAD: Associate/buy-in partnership opportunity available in high producing and high collection practice.

100% fee-for-service practice. If you have excellent communication skills, a light touch, and above average

skills, we should meet. Our practice uses Cerec technology, places and restores implants, is 100% digital, and has a high emphasis on cosmetic dentistry.

Great emphasis on patient comfort with oral sedation used extensively. Our town has an excellent school district and our patients have a great appreciation for quality dentistry. Visit our website at www. goliaddentalcare.com. Call Dr Dan Garza at 361-6452381 or email dmolar@sbcglobal.net.

GP / ORTHODONTIC OPPORTUNITY IS KNOCKING! Are you a GP with orthodontic interests? Would you like to learn more about orthodontics with the possibility of limiting to orthodontics some day? Do you like the idea of small town living, no traffic jams, a paradise for outdoor activities and yet only a short ride to large town amenities? Here is your chance. In the small town of Tishomingo, OK, we have an opportunity for the right person to become an associate (with buyout future) to join a busy 9-chair GP-orthodontic clinic with currently over 600 orthodontic cases in progress. The goal is for the right person to start practicing restorative dentistry 90% and orthodontics 10% the first year, with each succeeding year moving forward toward a full orthodontic practice. Even if you have an orthodontic interest but are low on confidence, not a problem. Dr Austin has been teaching orthodontics to GPs for 20 years. If interested, please contact Dr Austin at 580371-2396 or ronaustin79@gmail.com.

HILL COUNTRY WEST AUSTIN AREA: Sherri L. Henderson & Associates, LLC - This is an exceptional opportunity for a general DDS to become an associate in the Lakeway area. (3,250 sq ft, 7 ops, in-house lab, paperless and 7 full-time staff members). Work days: Tuesday-Friday and one Saturday per month (5 days per week available and a monthly guarantee if desired). Training in implants, endodontics and oral surgery would be a great benefit. Location pictures are available. Call Sherri @ 972-562-1072 or 214-697-6152.

HOUSTON AND SAN ANTONIO: Care For Kids, a pediatric focused practice, is opening new practices in the San Antonio and Houston area. We are looking Texas Dental Journal l www.tda.org l May 2013

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ADVERTISING BRIEFS 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 913-322-1447; e-mail arobinson@amdpi.com; FAX: 913-322-1459.

HOUSTON AREA PRACTICE OPPORTUNITIES! MCLERRAN & ASSOCIATES: NEW! HOUSTON: General FFS practice, visible location with easy access on a busy thoroughfare, revenues consistently in the 7 figures.

This one will not last! (#H175) NEW! SOUTHWEST OF HOUSTON: Established general practice, 4 operatories, stable blue collar patient base, petrochemical economic base, 2,000 sq ft building available. Doctor working only part-time. (#H174) NEW SOUTHWEST HOUSTON: General practice in a visible retail location, 6 equipped operatories, digital X-rays, digital pan, computerized throughout. Recently remodeled with a comfortable decor. 2012 revenues near 7 figures. (#H173) NEW! WEST OF HOUSTON: Beautiful general practice located in a high growth area west of Houston. Opened in 2006, the 2,500 sq ft facility has 5 operatories (3 equipped), a quality build out, and an elegant dĂ&#x2C6;cor. With digital X-rays and computers throughout, over 1,100 active patients, and 30 to 40 new patients per month, this office is turnkey and poised for growth. Revenues have been increasing in recent months with 2013 starting out strong. (#H171) NEW! WEST OF HOUSTON: Rural dental clinic, good visibility in a retail strip center, stable patient base, priced to sell. (#H168) to see our most up to date listings, please go to www.dental-sales. com. Contact McLerran & Associates in Houston: Tom Guglielmo and Patrick Johnston, 800-474-3049 OR 281362-1707, houstoneasttx@dental-sales.com. Practice sales, appraisals, buyer representation, and partnership consulting.

HOUSTON AREA: Great opportunity for a pediatric dentist. A part-time position available now in the Houston area. Flexible scheduling and a great work environment. Already established a flow of patients. Requirements: Texas State license. For more information, please e-mail mydentalsmile@gmail.com.

HOUSTON, DALLAS, SAN ANTONIO: HealthDrive is seeking part-time dentists. We are a mobile practice providing the highest standard of dental care to the elderly residents of extended care facilities. Please contact Tanya Jones at 857-255-0293 or tjones@ healthdrive.com.

KILLEEN: Dental office building for sale in a very busy professional plaza, near Killeen Civic Center, 2,407 sq ft. Office condo, 5 ops, 1 steri center, 1 X-ray room for pano, 2 offices, 1 reception room, 1 patient waiting room, 1 break room, 2 storages, 1 unisex restroom, 5 telephones with voicemail, 9 speakers with amp. Entire office is networked with CAT-5. For details please call Jim 254-526-5117 or e-mail jim@jwcrentals.com. Or Laurie at 254-519-2875, e-mail cfdental1@gmail.com.

MCALLEN AREA. Growing and expanding pediatric dental practice has immediate position for a full-time pediatric dentist. We are looking for an enthusiastic, skilled clinician with a strong work ethic. Our core value is to treat our patients as if they were our own family.

Our office has state-of-the-art equipment including digital radiographs and computerized records. We offer conscious sedation in office and general anesthesia at local hospital. We have a well-trained staff. Our practice is located in one of the fastest communities in America.

Rio Grande Valley offers a multitude of activities, a vibrant nightlife and is a short one hour drive to South Padre Island. Compensation based on collection.

Desirable to be fluent in Spanish. We provide work Visa/Green Card sponsorship. Interested candidates please contact Dr Daniel Mego at 956-854-4146, dfmego@gmail.com.

Medical Center Area Practice for sale.

Partnership dissolving. Priced below market. Call Jim Robertson 713-688-1749.

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ADVERTISING BRIEFS MIDLAND: One of the fastest growing cities in Texas needs a dynamic, caring, patient-focused dentist to join our growing practice. Associate and/or buy-in opportunities are available. Please contact Dr Britt Bostick, DDS, at bbost35821@aol.com or call 806-4385745.

MIDLAND: Pediatric dentist who wants flexibility, whose core values are focused on quality patient care and the support to create a legacy in dentistry. Please contact Dr Britt Bostick, DDS, bbost35821@aol.com.

NEW BRAUNFELS / SCHERTZ: Pediatric Dentist â&#x20AC;&#x201D;Well established and growing pediatric practice is seeking a caring and energetic associate for either a part-time or full-time position. We are located in the Schertz/ New Braunfels area. We offer excellent production with incredible earning potential, vacation and other benefits. New graduates are welcome. Please submit your resume to velezluke@yahoo.com.

ORTHODONTIC PRACTICES FOR SALE: Five-chair orthodontic practice in McKinney. Eight-chair orthodontic office in Arlington. Texas Practice Transitions, Inc. Rich Nicely has been serving Texas dentists since 1990. Visit www.tx-pt.com or call at 214460-4468; Rich@tx-pt.com.

PARIS / WYLIE: Great opportunity for a pediatric dentist to join our expanding practice. We are actively looking for the right associate who is interested in a once in a lifetime opportunity. We are opening a third location to our practice just 1 hour outside of Dallas. The need for a pediatric dentist in the area is tremendous and we are the only pediatric office within 50 miles any direction.

We are looking for someone who is personable, caring, energetic, 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. If you join our team, you will be personally mentored by Dr Allen Pearson, a board certified pediatric dentist, and you will be given the opportunity to develop experience in all facets of pediatric dentistry, including: behavior management, using oral conscious sedation, IV sedation

as well as practice and business management. Current associate is producing gross personal income of 6 figures plus on a 4 day work week, working only 11 months a year. For more information, please visit our web sites: www.wyliechildrensdentistry.com and www. parischildrensdentistry.com. Please e-mail your CV to allenp12345@gmail.com.

PEDIATRIC PRACTICE FOR SALE: Very large private pediatric practice in large metropolitan area in Texas, mix of PPO and Medicaid in a beautiful, free standing 5,000 sq ft building with 10 chairs. Highly profitable private practice established 30 years. Texas Practice Transitions, Inc. Rich Nicely has been serving Texas dentists since 1990. Visit www.tx-pt.com or call at 214460-4468; rich@tx-pt.com.

SAN ANGELO: For sale: Excellent 5 operatory, 35-yearold general practice. Recently remodeled location in a busy complex. Solid fee-for-service patient base. All modern equipment. Solid hygiene program. Mid- to high-6 figure collections consistently, 98% collections rate. Recent practice appraisal. Other unique perks to this practice. Doctor moving out of state, willing to negotiate on price, and transition details as well as sell/lease of building. Please inquire by e-mail at texasdentistry@hotmail.com.

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.

SUGAR LAND, CYPRESS, PEARLAND AND THE WOODLANDS: Full and part-time positions available.

Well established and rapidly growing practices that offer great financial opportunity. High income potential and future equity position. E-mail CV to Dr Mike Kesner, drkesner@madeyasmile.com.

Texas Practice Transitions, Inc. Rich Nicely has been serving Texas dentists since 1990. Visit www. tx-pt.com or call at 214-460-4468; rich@tx-pt.com.

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ADVERTISING BRIEFS ORTHODONTIC PRACTICES: 5 chair orthodontic practice in McKinney. Eight-chair orthodontic office in Arlington.

PEDIATRIC: Very large private pediatric practice in large metropolitan area in Texas, mix of PPO and Medicaid in a beautiful, free-standing 5,000 sq ft building with 10 chairs. Highly profitable private practice established 30 years. MCKINNEY: mid-sized collections in 5 treatment rooms in a beautifully finished facility, paperless, 100% digital practice with a digital pano. NORTH TEXAS: Large prosthodontic practice 30 minutes from Dallas, premier free-standing building with 7 ops, 100% digital, 100% full fee. RURAL 30 MINUTES FROM DALLAS. Smaller practice in a nice free standing building, digital X-rays, 100% full fee. DALLAS SUBURB: Large practice, 6 ops, 100% digital, 1,900 full-fee patients, 8 days of hygiene. WEST TEXAS, small practice in Panhandle area. ONE HOUR NORTH OF HOUSTON: Medium-sized full-fee practice, free-standing building, digital X-rays.

EAST TEXAS: Very low overhead, medium-sized full-fee practice in free-standing building.

THE HINDLEY GROUP, LLC: ASSOCIATESHIPS- NEW LISTING SOUTH OF DALLAS ASSOCIATESHIP: Large thriving family general dental practice located in moderate-size suburb south of Dallas. Associate wanted to join a 2 doctor practice and eventually buyout interest of senior doctor. Beautiful new facility; fully digitized with 7 fully-equipped operatories and an additional 3 hygiene rooms and 2 portable hygiene carts. Very strong revenues and healthy profit margin. Outstanding staff and excellent mentors! Pre-determined buy-in terms. SOUTH TEXAS ASSOCIATESHIP: Busy general dental practice in small town near McAllen, Texas. Fully digital office, modern equipment, excellent, dedicated staff! Strong revenues. Doctor wishes to bring on a young associate to train and mentor and eventually sell out 100%. Predetermined buy-in terms secure guess-less opportunity for transition to ownership. SOUTHWEST OF HOUSTON ASSOCIATESHIP: Thriving family general dental practice located in small town approximately 30 minutes from the coast. Doctor has history in the area and good reputation which generates over 50 new patients per month. Very strong one doctor revenues on 4 days per

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week. Excellent mentor! Pre-determined buy-in terms.

EAST OF HOUSTON ASSOCIATESHIP: Well-established general dental practice in small town seeks associate desiring practice buy-in with pre-determined terms.

Steady new patient flow and strong revenues. Excellent opportunity to buy-out retiring owner within the next 2 to 3 years! Call 800-856-1955 or e-mail jenny@ thehindleygroup.com.

THE HINDLEY GROUP, LLC: NEW LISTING- HOUSTON GENERAL DENTAL PRACTICE SALE- Newly established general dental practice just outside 610 loop. Open 6 days a week. 5,200 sq ft facility with 7 fully equipped operatories. Direct digital X-ray. Mostly fee-for-service and PPO. Fifty new patients per month. High revenues.

Call 800-856-1955 or e-mail jenny@thehindleygroup.com.

THE HINDLEY GROUP, LLC: NORTH OF HOUSTON PRACTICE SALE: Well-established 30-year-old general dental practice with high revenues on 4 days per week.

Five fully equipped operatories with 2 dedicated to hygiene. ScanX digital X-ray system! Excellent staff and mentor! Call 800-856-1955 or e-mail jenny@ thehindleygroup.com.

THE HINDLEY GROUP, LLC: SOUTH OF HOUSTON ORTHODONTIC PRACTICE SALE: Recently opened orthodontic practice office in 3,500 sq ft building with 5 fully equipped treatment rooms! Mostly pediatric (40 cases in bands). Limited competition and motivated seller! Great opportunity for start up or satellite! Call 800-856-1955 or email jenny@thehindleygroup.com.

THE HINDLEY GROUP, LLC: DALLAS PRACTICE SALE. Very busy, thriving general dental practice with exceptional revenues and profit margin. Six fully-equipped operatories with OpTime digital X-ray system in 3,000 sq ft facility. New patients average 52 per month. Large Medicaid component. Call 800-856-1955 or e-mail jenny@thehindleygroup.com.

THE HINDLEY GROUP, LLC- NEW LISTING: ALBUQUERQUE, NEW MEXICO GENERAL DENTAL PRACTICE SALE- Same location for 8 years. Three fully

ADVERTISING BRIEFS equipped operatories. Steady growth with 20 to 40 new patients per month. Significant Medicaid with growing PPO revenues. Call 800-856-1955 or email jenny@ thehindleygroup.com.

THE HINDLEY GROUP, LLC — NEW LISTING: NORTHWEST HOUSTON GENERAL DENTAL PRACTICE SALE — Well-established, very traditional practice with moderate fee-for-service revenues and healthy profit margin. Open 4 days a week. 1,200 sq ft facility with 3 fully-equipped operatories. Doctor retiring. Call 800856-1955 or email jenny@thehindleygroup.com.

West Houston Practice for sale. Doctor retiring. All fee-for-service. Call Jim Robertson 713688-1749.

Office Space AUSTIN: Excellent office location just north of the Mueller development. This space not only close to Mueller households but also, University Hills, Windsor Park, French Place, and other East Austin neighborhoods. Built in the late 60s/early 70s, this building is iconic for the period. Specifically built for dental/ orthodontist offices, it would be perfect for a dentist to move into with most of the infrastructure already in place. Simply install operatories and other equipment and you are ready to go. It can also be totally remodeled for your specific needs and taste. This property has 2 buildings. Building 2 stands alone and is 1,100 sq ft. Building 1 is currently set up as a duplex with separate electric meters. Each side is 1,150 sq ft.

All space is currently available. Contact Greg Brooks 512-799-8973, tgregorybrooks@gmail.com.

CARROLLTON: Great opportunity for orthodontist or pedodontist. Fully-equipped orthodontic office with 5 ops in main treatment area, separate private office, consult room, pano/ceph room, and lab. All dental chairs, units, equipment and furnishings included.

Located in professional building with 4 general dentists and a board certified periodontist, all with established

practices and would be good referral sources.

An excellent opportunity for a new orthodontist, pedodontist or one seeking a satellite office. Ready to start patients tomorrow! Space is for rent and/or purchase. Premier location just one block south George Bush turnpike and one block north of Newman Smith High School. Please call 214 850-8087.

Corpus Christi: Dental office, equipped and furnished for sale or lease. Dental medical specialty center. Five ops, 2 doctor offices, lab space, garden area, 1,421 sq ft. Call Don Deaver 361-813-7262 or Allen Doty, Broker 361-851-0214.

EL PASO: New dental offices for lease at Renova Plaza. Seeking complimentary specialties to 3 general practitioners and 1 periodontist. Suites can be finished to suit. Highest quality architecture and construction in upscale neighborhood; strong demographics. Agent: ETZOLD & CO 915-845-6006.

FORT WORTH / TCU DENTAL OFFICE FOR LEASE: Building has 4 dental offices and 1 unit available. Comes with 2 examining rooms with chairs, third room does not have a chair. Has a private office with a 1/2 bathroom, reception plus waiting area, lab room, approximately 1,200 sq ft. Great location near TCU. Very seldom does this building have a vacancy. Our current dentist is retiring. 2417 Park Hill Drive. Contact Sharon May at sharon@maysrealty.com or call at 817-721-3759.

FORT WORTH: Fully equipped dental suites for lease in growing north Fort Worth. Ideal for dental specialist — oral surgeon, endodontist or periodontist. Please contact Jennifer at 817-366-2268.

GRANBURY: Great location, high visibility and traffic.

Approx 6,000 sq ft building, approx 3,000 sq ft of dental; 6 ops. For lease or possible sale. Call 817-2639014 or e-mail jeremy@mirandadentistry.com.

HOUSTON: General practice for sale north of downtown Houston in developing area. Three fully-equipped ops, plumbing to add 2 more. Annual gross high 6 figures- no Texas Dental Journal l www.tda.org l May 2013

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ADVERTISING BRIEFS DMO. Non-practicing owner. Asking price is negotiable.

Low overhead. For inquiry, email nate.1974@yahoo.com.

NORTH DALLAS: Well-established restorative general dentistry practice available for immediate purchase.

Four operatories equipped. Very attractive facility in multi-story mixed use office building. Dentrix dental software, ScanX digital. All fee-for-service patient base.

Owner selling due to disability but will provide long term transition if desired. Three to 4 hygiene days per week. This practice will require a purchaser to have over 2 years of clinical experience. DP#363. Contact Dan Lewis at Lewis Health Profession Services 972-4371180 or dan@lewishealth.com.

NORTH TEXAS DENTAL PRACTICE OPPORTUNITIES: Lewis Health Profession Services has multiple career opportunities available in the greater Dallas/Fort Worth area. Practices for sale, associate opportunities, finished out dental offices, and specialty practice opportunities. Lewis Health Profession Services has 30 years experience in dental practice transitions, with over 1,000 successful transitions completed. Dentistry is our only business. We confidentially deal with all clients.

Lewis Health Profession offers seller representation, buyer representation, opportunity assessments, associate placement and strategic planning services.

Please check out our website at www.lewishealth.com for current opportunities. Contact Dan Lewis at Lewis Health Profession Services 972-437-1180 or dan@ lewishealth.com for additional information.

RICHARDSON: Well-established restorative general dentistry practice available for immediate purchase.

Four operatories equipped. Professional building.

Dentrix dental software. All fee-for-service patient base. Owner selling due to disability. Three to 4 hygiene days per week. DP#367. Contact Dan Lewis at Lewis Health Profession Services 972-437-1180 or dan@lewishealth.com.

ROCKPORT TEXAS has a state-of-the-art dental building seeking motivated dentists or dental group.

Built to accommodate a thriving practice or a group of

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practitioners looking to live near the Gulf of Mexico.

The opportunity for a group practice exists for those in prosthodontics, orthodontics, general dentistry, endodontic, and oral surgery. Room for onsite lab.

Invest in your future. E-mail mark@rockportproperties. com; or call 361-774-9424; or e-mail mary@ rockportproperties.com; or call 361-557-1833.

ROCKPORT, TEXAS: â&#x20AC;&#x153;The place by the bay,â&#x20AC;? has a state of the art dental building seeking motivated dentists or dental group. Built to accommodate a thriving practice, the opportunity for a group practice exists in general dentistry, prosthodontics, orthodontics, endodontic, or oral surgery. Room for onsite lab. Rockport, Texas, is a great place to invest in your future. E-mail mark@ rockportproperties.com; or call 361-774-9424 or e-mail mary@rockportproperties.com; or call 361-557-1833.

ROUND ROCK: Orthodontist needed next to dentist in high-growth, high-traffic area in Round Rock, north of Austin in one of the fastest-growing counties. For more information, e-mail john@herronpartners.com or call 512-457-8206.

SAN ANTONIO FOUR OPERATORY PRACTICE FOR SALE: We have outgrown the space, looking to relocate. Space is perfect for a specialist. Transition available. The space is located right off the Dominion Country Club golf course in San Antonio. Very modern, tranquil, pleasant location, granite countertops, plumbed for nitrous, second floor with balcony. Please contact Dr Stratton at 210-687-1150 or e-mail tiffini@dominiondentalspa.com.

For Sale EQUIPMENT FOR SALE: New handheld portable X-ray unit. New intraoral wall X-ray unit, new mobile X-ray on wheels. New chairs/units operatory packages, new implant motors. Everything is brand new, with warranty.

Contact nycfreed@aol.com.

ADVERTISING BRIEFS Interim Services 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.”

PROFESSIONAL PRACTICE COVERAGE by a Texas colleague during personal, maternity, or disability leave. Keep your cash flowing, your staff busy, overhead covered, and patients treated when you’re not there.

DOCTORS PER DIEM team members perform full production schedules or just baby sitting. Avoid gaping holes in your schedule weeks, and again, months later because patients weren’t seen and booked for more extensive follow-up by you or for hygiene recall. Fee is a standard percent of production. Short notice is ok. Some on our Texas team are seeking partnership and or buy-in opportunities. Try before you buy! All inquiries treated with absolute confidentiality. All team members are fully licensed with liability insurance and DEA authority. DOCTORS PER DIEM INC. has the most distinguished and experienced team of dentists in Texas. Why not join us? There’s no charge and no obligation ever. Our fee is paid by the ‘host’ practice.

Work only when and where you wish. Bread and butter procedures. New dentists welcome. DOCTORS PER DIEM INC. Register: http://www.doctorsperdiem.com/ register. Email: docs@doctorsperdiem.com 1-800-6000963. Trusted integrity, since 1996.

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 hand pieces 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 hand piece servicing facility of choice. We would appreciate a chance to earn your business! Call 800-569-5245 or visit our website: thedentalhandpiecerepairguy.com.

THE NATIONAL SCHOOL OF DENTAL ASSISTING NORTH DALLAS offers the Texas RDA course and exam. Call 800383-3408 for available dates.

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: schoolofdentalassisting-northdallas.com.

THE DENTAL HANDPIECE REPAIR GUY, LLC. I’m pleased to inform you that we are now operating a full-service handpiece repair shop in Friendswood, Texas, where Texas Dental Journal l www.tda.org l May 2013

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

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Texas Dental Journal l www.tda.org l March 2013