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TEXAS DENTAL JOURNAL Established February 1883

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ABOUT THE COVER

Every May, the Texas Dental Journal publishes its special issue on oral cancer, which includes information for practitioners to educate patients about risk factors, prevention and detection, and treatment methods of the disease.

Designed by Grady Basler.

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EDITOR MESSAGE Daniel L. Jones, DDS, PhD TDA Editor Dr Daniel L. Jones introduces this special issue on oral cancer and the importance of early detection and diagnosis.

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COMMENT AND EDITORIAL K. Vendrell Rankin, DDS The author interprets the November 2013 U.S. Preventive Services Task Force’s Recommendation Statement, which concludes that current evidence is insufficient to make a recommendation either for or against routine oral cancer screenings by primary care providers.

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ORAL CANCER SCREENING FOR ASYMPTOMATIC ADULTS: DO THE UNITED STATES PREVENTIVE SERVICES TASK FORCE DRAFT GUIDELINES MISS THE PROVERBIAL FOREST FOR THE TREES? Paul C. Edwards, MSc, DDS

Reprinted with permission from Elsevier. Originally printed in: Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, Vol. 116, No. 2, Aug. 2013.

In this insightful commentary reprint from Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, the authors clarify and explain the implications of the November 2013 U.S. Preventive Services Task Force’s Recommendation Statement.

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HUMAN PAPILLOMAVIRUS: THE FUNDAMENTALS OF HPV FOR ORAL HEALTH CARE PROVIDERS Katharine Ciarrocca, DMD, MSED; Lana L. Jackson, MD, PHARMD, FACS; and Scott S. de Rossi, DMD. Reprinted with permission from the California Dental Journal, Vol 41, No 5.

The authors provide an overview of the human papillomavirus (HPV), its association with HIV, and information on HPV vaccinations in this California Dental Journal reprint.

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PREVALENCE OF HPV ASSOCIATED OROPHARYNGEAL CANCER AMONG SOUTH TEXANS Stephanie D. Rowan, RN, MSN; Mark DiBurro, RDH. MPH; Steven Westbrook, DMD; Spencer W. Redding, DDS, MEd; Frank R. Miller, MD, FACS The study assesses the prevalence of oropharyngeal cancer among all oral cancers and thus the potential role of HPV in this disease in the south Texas region, which is served by the University of Texas Health Science Center at San Antonio and the University Health System in San Antonio, Texas.

MONTHLYFEATURES

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Critically Appraised Topic of the Month Oral and Maxillofacial Pathology Case of the Month In Memoriam Memorial and Honorarium Donors Dental Artifacts Question Dental Artifacts Answer

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Value for Your Profession Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management Calendar of Events Advertising Briefs Index to Advertisers

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

Editorial Staff

Editorial Advisory Board

BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION

Daniel L. Jones, DDS, PhD, Editor Harvey P. Kessler, DDS, MS, Associate Editor Nicole Scott, Managing Editor Billy Callis, 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: www.tda.org Texas Dental Journal (ISSN 0040-4284) is published monthly (1 issue per year is a directory issue( by the Texas Dental Association, 1946 S IH-35 Ste 400, Austin, TX 78704-3698; Phone: 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. Copyright 2014 Texas Dental Asociation. All rights reserved.

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 Texas Dental Journal is a does not constitute a guarantee or endorsement by the member of the American Association of the quality of value of such product or of the Association of Dental Editors. claims made of it by its manufacturer.

Member Publication

PRESIDENT David H. McCarley, DDS 972-562-0767, drdavid@mccarleydental.com PRESIDENT-ELECT Craig S. Armstrong, DDS 832-251-1234, drarmstrong01@gmail.com IMMEDIATE PAST PRESIDENT David A. Duncan, DDS 806-355-7401, davidduncandds@gmail.com VICE PRESIDENT, NORTHEAST Jerry J. Hopson, DDS 903-583-5715, dochop@verizon.net VICE PRESIDENT, SOUTHEAST William S. Nantz, DDS 409-866-7498, wn3798@sbcglobal.net VICE PRESIDENT, SOUTHWEST Joshua A. Austin, DDS 210-408-7999, jaustindds@me.com VICE PRESIDENT, NORTHWEST Steven J. Hill, DDS 806-783-8837, sjhilldds@aol.com SENIOR DIRECTOR, NORTHEAST William H. Gerlach, DDS 972-964-1855, drbill@gerlachdental.com SENIOR DIRECTOR, SOUTHEAST Karen A. Walters, DDS 713-790-1111, kwalters@sms-houston.com SENIOR DIRECTOR, SOUTHWEST John B. Mason, DDS 361-854-3159, jbmasondds@aol.com SENIOR DIRECTOR, NORTHWEST Charles W. Miller, DDS 817-572-4497, cwdam@sbcglobal.net DIRECTOR, NORTHEAST Dennis E. Stansbury, DDS 903-561-1122, drstansbury@gmail.com DIRECTOR, SOUTHEAST Duc “Duke” M. Ho, DDS 281-395-2112, ducmho@icloud.com DIRECTOR, SOUTHWEST James R. Foster, DDS 956-969-2727, fosterdds@gmail.com DIRECTOR, NORTHWEST W. Kurt Loveless, DDS 806-797-0341, wklovedds@gmail.com SECRETARY-TREASURER Ron Collins, DDS 281-983-5677, roncollinsdds@yahoo.com SPEAKER OF THE HOUSE John W. Baucum III, DDS 361-855-3900, jbaucum3@gmail.com PARLIAMENTARIAN Arthur C. Morchat , 903-983-1919 arthurmorchat@suddenlink.mail.com EDITOR Daniel L. Jones, DDS, PhD 214-828-8350, djones@bcd.tamhsc.edu EXECUTIVE DIRECTOR Mike Geeslin 512-443-3675 ext 136 , mike@tda.org LEGAL COUNSEL Mr. William H. Bingham 512-495-6000, bbingham@mcginnislaw.com

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DIGITAL DenTIsTry ConneCTeD Dental Implants & Cosmetic Dentistry

Texas Dental Journal l www.tda.org l April 2014 279 Mariner Dental Laboratory • 281.440.9222 • www.marinerdental-lab.com

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JKJ Pathology Oral Pathology Laboratory

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Oral and Maxillofacial Pathology Case of the Month Case History The dentist of a 45-year-old male noticed an asymptomatic gingival swelling on the buccal aspect of his mandibular left first premolar and cuspid during a routine annual exam.

The mass was associated with deep probing depths and local bone loss, although no teeth were loose. The area was initially debrided on the assumption that it represented an abscess, but a week later there was no improvement. In fact, the condition appeared even more proliferative and had developed surface ulceration.

Referral to a periodontist was made.

When that specialist saw the patient 2 weeks later, the mass was larger yet and had a granulomatous appearance (Figure 1). A biopsy was scheduled.

Juliana Robledo, DDS, oral and maxillofacial pathologist, South Texas Oral Pathology, San Antonio, Texas Steven Maller, DDS, MS, periodontics and implantology, San Antonio, Texas Joseph S. Boyle, DDS, general dentistry, San Antonio, Texas

Robledo

Maller

Boyle

Higgins

Russell A. Higgins, MD, hematopathologist, University of Texas Health Science Center San Antonio, Department of Pathology, San Antonio, Texas

An incisional biopsy was performed 10 days later, at which time the lesion had substantially enlarged, extending above the occlusal plane and posteriorly to the distal of the second molar, with considerable lingual gingival involvement and extensive ulceration, sometimes showing a greenish-blue tint, especially at the periphery of the ulcer bed (Figure 2).

The patient at that time complained of moderate pain and had developed severe halitosis.

His medical history was unremarkable up to this point. However, at the time of biopsy the he reported a “lump� on his chest and, in fact, there were 2 palpable masses, one on his sternum and another on his lateral left chest wall. Referral to a physician resulted

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Figure 1. Lesion appearance 1 week after initial presentation and debridement.

Figure 2. Clinical presentation of the lesion at the time of biopsy, 1 month after initial presentation at a routine dental examination. Notice the increase in size, ulceration and grayish-green and grayish-blue discoloration.

in 3 incisional biopsies of the chest lesions, along with routine blood testing. His hematologic workup resulted in a diagnosis of acute myelogenous leukemia (AML).

The oral biopsy showed a mass surfaced by partially ulcerated stratified squamous epithelium. Beneath the epithelium the connective tissue was diffusely infiltrated by a large number of apparently neoplastic lymphoid cells with partially condensed chromatin, prominent central or eccentric nucleoli, nuclear indentation, and scant to moderate amounts of amphophylic cytoplasm with distinct borders (Figure 3). Numerous atypical mitoses and apoptotic bodies were seen (Figure 4). There was a scant background stroma of thin collagen fibers. With immunohistochemistry, the atypical cells were reactive for CD4, CD33, CD45RB, lysozyme (Figure 5), CD43, CD117, CD68 and negative for CD3, CD20, MPO among others. The oral lesion was similar microscopically to the chest lesions.

What is the final diagnosis?

Figure 3. Microscopic appearance (100x). There is a diffuse and dense cellular infiltrate of atypical or immature mononuclear leukocytes (myeloid cells), with minimal fibrous stroma.

Figure 4. Higher power microscopic appearance (600x). Lesional cells are large and irregular in shape, with dispersed chromatin, prominent nucleoli and nuclear clefting. Scattered mitotic figures and apoptotic bodies are also seen.

See page 386 for the final diagnosis.

Figure 5. Immunoperoxidase stain for lysozyme shows variable positivity (brown color) (40x).

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MEMORIAL and HONORARIUM Donors to the Texas Dental Association Smiles Foundation

Those in the dental community who have recently passed

IN MEMORY OF:

Alderson, Lawrence M.

Ann Konisberg Dr Paul Pearce

Michele Marie Tagliabue Dr John Baucum

Dr Stephen R. Matteson Dr John Baucum

Dr David C. Hildebrand Dr Trey Kaliner

Richmond, Texas February 1, 1930 – March 20, 2014 Good Fellow: 1984 • Life Member: 1995 50 Year: 2009

Hunter, Walter David Jr

Waco, Texas July 10, 1922 – March 28, 2014 Good Fellow: 1972 • Life Member: 1987 50 Year: 1997

Newkirk, John Gilbert

JoAnn Tumlinson Dr Robert Cody

The Woodlands, Texas February 4, 1942 – March 23, 2014 Good Fellow: 1997 • Life Member: 2008

Mrs Eddie Anderton

Maberry, Robert T. Sr

Ms Sandy Blum

Mr Nick Bartkowiak Ms Sandy Blum

Phillip Boswell, DDS Dr Sam Padres

Dr David C. Hildebrand Dr Robert Lee

James M Kramer, DDS Dr Robert Lee

Mrs Duane Loy Ms Sandy Blum

Robert T. Maberry, Sr, DDS Martha Slover

Phillip Boswell, DDS

Dr George Crosthwaite, III

Charles G. Shears Dr Anthony Leger

Your memorial contribution supports: • •

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

Please make your check payable to:

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

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In MEMORIAM

Texas Dental Journal l www.tda.org l May 2014

Abilene, Texas November 25, 1924 – April 2, 2014 Good Fellow: 1972 • Life Member: 1989 50 Year: 1998

Moore, James W.

Garland, Texas August 25, 1935 – March 28, 2014 Good Fellow: 1994 • Life Member: 2001 50 Year: 2012

Reeves, George Wesley

Arlington, Texas November 8, 1928 – March 13, 2014 Good Fellow: 1982 • Life Member: 1993 50 Year: 2007

Sampeck, Adrian J.

Dallas, Texas April 4, 1920 – March 25, 2014 Good Fellow: 1981 • Life Member: 1985 50 Year: 2001

Traeger, Kimble Andrew

San Marcos, Texas January 21, 1921 – April 10, 2014 Good Fellow: 1993 • Life Member: 1986 50 Year: 1997

White, Elmer J. Jr

Beaumont, Texas August 14, 1921 – March 8, 2014 Good Fellow: 1970 • Life Member: 1986 50 Year: 1994

Dental Artifacts question Why Would You Want to Weight?

Kim Freeman, MA, DMD, MS

E

very so often a collection comes along with some item that is dental related and truly intriguing. What you see pictured are clipped weights, ranging in weight from 1.5 ounces to 3 ounces.

As you can tell, they came in a variety of shapes, and most were marked by the manufacturer.

I asked some of my colleagues where I teach part time if they knew what they were and none knew. It wasn’t that I didn’t know, but it was just a fun survey of some very learned people to see if they knew. I have to tell you, quite honestly, it was fun asking and getting a wide variety of answers.

So as to not miss out on the fun, I am going to do the same thing with this article. For what do you think they

are used? To the first person who emails me the correct answer at kimfreeman31@att.net, I will send one in the mail. Of course, if you were asked by me before, you are not eligible! Now to make this a little more fair, 2 hints.

One, this is dental related, and they were made from the 1880s to the 1920s; and 2, they were not large earwear for the fashionable assistant.

Now for those of you who cannot “weight” to find out, somewhere in the journal, the answer, with an ad for the items, will be presented. Obviously, since this is a contest, I am entirely dependent on your honesty to tell me if you knew what they were without looking it up. No cheating!

Remember, the ghost of S.S. White can still wreak havoc with you.

See page 384 for the answer.

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Editor Message

T Daniel L. Jones, DDS, PhD TDA Editor

his month, as we have each May for some time, we focus on oral cancer. A continuing theme in this area is early detection and diagnosis. Last year we examined the correlation between clinical oral examination and histologic diagnosis, noting that although clinical examination does not always predict the definitive histological diagnosis of dysplasia or carcinoma, there is nonetheless significant intrinsic value in performing oral cancer examinations regularly on our patients. A report first published late last year by the U.S. Preventive Services Task Force, stating that there was insufficient evidence to make a recommendation either for or against routine oral cancer examinations in asymptomatic adults, created controversy in some circles. To help make clear what the recommendation statement said (and did not say), as well as the implications for practitioners, we have included a very insightful commentary by Dr Paul C. Edwards of the University of Michigan School of Dentistry.

Elsewhere in this issue, we turn to the topic of risk factors and the etiology of oral cancer, specifically the role of human papilloma virus (HPV). Over the past 2 decades, evidence has mounted that HPV causes not only cervical and anal cancer, but also a subset of head and neck cancers. With the concurrent development of HPV vaccines, public awareness of HPV infection has also increased. It is now more likely than ever that dental professionals will be asked by our patients about oral HPV infection and its prevention. We offer 2 articles on the subject, the first an excellent review of the fundamentals of HPV for oral health care providers, reprinted from the California Dental Journal. The second is an original submission by researchers from the University of Texas Health Science Center at San Antonio Dental School, evaluating the prevalence of oropharyngeal cancer as a subset of all types of oral cancers. The data in this study are from patients in south Texas who sought treatment in San Antonio. To our knowledge, this is the first study to examine the epidemiology of HPV-related oral cancer in our state.

As always, seeking out the latest information on educating our patients about risk factors, preventing and detecting oral cancer, and providing appropriate treatment is incumbent on the dental practitioner. To this end, we sincerely hope you find this information useful.

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Interpreting the U.S. Preventive Services Task Force Recommendation on Oral Cancer Screening and Examination

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Comment and Editorial

I Dr K. Vendrell Rankin, DDS, Professor and Associate Chair Department of Public Health Sciences, Texas A&M University Baylor College of Dentistry

n November 2013, The United States Preventive Services Task Force (USPSTF) released a Recommendation Statement concluding that the current evidence is insufficient to make a recommendation either for or against routine oral cancer screenings by primary care providers. This is an update of the 2004 recommendations, with the distinction that the newest version focuses on “… screening (visual inspection and palpation) of the oral cavity performed by primary care providers and not dental providers or otolaryngologists,” essentially limiting the scope of this recommendation to physicians. In the December 12, 2013, issue of the ADA News, the chair of the ADA Council on Scientific Affairs pointed out that this recommendation places even greater importance on regular periodic evaluation by dentists, if indeed primary care providers in medicine are not encouraged to assess the oral cavity. It was further noted that, while the recommendation reinforces the primacy of dentists as caretakers of the oral cavity, oral cancer should not be singled out for a screening guideline apart from other potential serious conditions of the oral cavity.

The dental profession has long advocated for increasing the hours dedicated to oral health education in the medical curriculum. This interprofessional collaboration is supported by the 2000 Report of the U.S. Surgeon General, which affirmed that oral health is integral to general health. It has also been suggested that annual physical examinations by physicians should include an oral examination. There is considerable evidence suggesting that the individuals being seen in physicians’ offices are not necessarily those visiting the dentist, particularly with respect to older individuals.

In 2010, the last year for which the Centers for Disease Control and Prevention has complete data, approximately 85% of people age 65 or older had at least 1 physician visit within the previous year. The corresponding figure for dental visits was only 59% of individuals of the same age. These data suggest that oral examination by physicians could potentially identify oral disease that might otherwise be missed, and conversely that improved oral health could have a positive effect on the management of systemic health and may in fact improve the overall health of our nation.

With regard to the USPSTF recommendation, the conclusion was based on a lack of evidence with respect to 3 questions: 1) How well do oral cancer screening exams detect disease?; 2) Do the harms associated with screening outweigh the potential benefits?; and, 3) Does detection of oral cancer through screening reduce morbidity or mortality? For an examination of these questions from a clinical perspective and a very cogent commentary on the impact of the 2013 recommendations, we offer the following editorial that first appeared in the August 2013 issue of Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, written by Dr Paul C. Edwards of the department of Periodontics and Oral Medicine at the University of Michigan.

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Oral Cancer Screening for Asymptomatic Adults: Do the United States Preventive Services Task Force Draft Guidelines Miss the Proverbial Forest for the Trees?

Paul C. Edwards, MSc, DDS Reprinted with permission from Elsevier. Originally printed in: Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, Vol. 116, No. 2, August 2013.

About the Author Paul C. Edwards, MSc, DDS Professor, Department of Periodontics and Oral Medicine, University of Michigan, Ann Arbor, MI http://dx.doi.org/10.1016/j.oooo.2013.05.002

A

s experts in the field and regular readers of this journal, we are all acutely aware of the sobering statistics on oral cancer: in the United States there are an estimated 275,000 men and women alive with a prior diagnosis of oral cavity or pharyngeal cancer (1). It is estimated that an additional 41,000 cases will be diagnosed in 2013 alone, with just under 8000 individuals dying of their disease (2). For the period 2003-2009, the estimated 5-year relative survival rate for patients diagnosed with oral and pharyngeal cancer is 62% (1). For black men, the results are more discouraging, with a 5-year relative survival of just under 40%. Looking at lifetime risk, a child born today has an estimated 1.1% likelihood of developing oral cavity or pharyngeal cancer at some point during his or her life (3). The stage at which the cancer is diagnosed has a significant effect on overall survival. Localized disease, representing disease confined to the primary site, is associated with an 83% 5-year survival rate. With spread to the regional lymph nodes, the 5-year survival drops to just under 60%. The statistics are even grimmer in the presence of distant metastasis, with the 5-year survival dropping to 36%.

With that backdrop in mind, the United States Preventive Services Task Force (USPSTF) recently released a draft Recommendation Statement, which concluded that for adults age 18 years or older seen in the primary care setting, the “current evidence is insufficient to assess the balance of benefits and harms of screening for oral cancer in asymptomatic adults. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.”

Rather than representing a paradigm shift, this statement is simply an update of the 2004 USPSTF recommendations, which similarly concluded “there was insufficient evidence to recommend for or against routine screening for oral cancer in adults (4).” Other expert groups have reached comparable conclusions. For example, the reader is referred to the “Evidence-based clinical

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recommendations regarding screening for oral squamous cell carcinomas” recently published by a panel convened by the American Dental Association (ADA) Council on Scientific Affairs, which, however, takes a more pragmatic approach to this question (5).

Specifically, the USPSTF was unable to offer a recommendation on the benefits versus risks of routine visual oral cancer screening of asymptomatic patients who present in the primary care setting. This decision was based on their assessment of a lack of evidence with respect to 3 questions: how well do oral cancer screening exams detect disease? Do the harms associated with screening outweigh the potential benefits? Does detection of oral cancer through screening reduce morbidity or mortality?

Rather than arbitrarily denouncing the entirety of these recommendations, the authors are to be at least commended for highlighting the risk factors for developing oral cancer: smoking, heavy alcohol consumption, betel quid use, and, for a subset of oropharyngeal cancers, infection with high-risk human papillomavirus virus (although I disagree with the suggestion that there is sufficient evidence at this point to include infection with candida or bacterial flora as definitive oral cancer risk factors). These comments may help to educate both the general public as well as those health care providers who may have less experience in this area. The guidelines also accurately note that potential screening adjuncts, such as toluidine blue, chemiluminescence, autofluorescence and brush cytopathology lack sufficient evidence to recommend their routine use in the primary

the screening examination should be defined as a thorough visual and tactile inspection of the head and neck structures and the accessible oral cavity executed by a well-trained general dentist in the primary care dental setting care setting. In low risk populations, reliance on the results of these screening adjuncts, in the absence of clinical correlation, is associated with an unacceptable rate of false positives. Likewise, the absence of well-designed studies evaluating the risks and benefits of oral cancer screening that are of direct relevance to the population of the United States (the target audience of this draft statement) must be acknowledged.

However, an alternative approach to looking at this question should be considered, one that also requires examining this issue from a clinical perspective (curiously, there is no indication that the USPSTF sought input from clinical specialists in this area; namely oral pathologists, oral surgeons, general dentists, public health dentists, etc.). Let me clarify, before being misquoted, that I am not implying that biomedical science and clinical care are opposing paradigms.

We are all acutely aware that, as health care providers, treatment decisions must be based on a solid evidence-based foundation backed by rigorous scientific investigation.

Rather, the approach that should be followed in answering this question is one that reconciles the available evidence, or lack thereof, with a more clinically applicable approach that takes into account the realities of the primary questions care dental setting.

With that in mind, lets review these areas:

1.

How well do oral cancer screening exams detect disease (ie, their performance characteristics)?

For the purpose of this discussion, the screening examination should be defined as a thorough visual and tactile inspection of the head and neck structures and the accessible oral cavity executed by a well-trained general dentist in the primary care dental setting, and performed on all patients of record as part of the routine patient assessment process (6). As needed, this is supplemented by biopsies of any areas of suspicion, with the goal being to identify all variations from normal, including but not restricted to potentially preneoplastic conditions (I prefer this term over the World Health Organization’s terminology of “potentially malignant disorders”) and early stage oral cancer.

As noted in the USPSTF report, the 2 studies that most approximate these characteristics are from the United Kingdom, which has an oral cancer prevalence similar to that of the United States. These studies reported sensitivities in the low 70s and specificities approaching 100%, although these also highlighted the dilemma of identifying the gold standard, which in these studies was a second examination by a specialist in oral pathology, oral medicine.

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Examining this from a more pragmatic perspective, considering that greater than 90% of intraoral malignancies are represented by squamous cell carcinomas, a neoplasm of surface epithelium, a thorough visual and tactile examination by a well-trained dentist in the primary care setting, coupled with a reasonable degree of suspicion for all white, red or ulcerated lesions of undetermined etiology, should permit identification of the vast majority of early oral squamous cell carcinomas. Clearly, the accuracy with which dental providers in the primary care setting can identify and triage potentially preneoplastic conditions and early stage oral cancer is dependent on both their training and clinical experience. Consequently, as educators, it is critical that our dental school graduates are both proficient and confident in their ability to assess soft tissue lesions.

Additionally, as suggested in the recent guidelines from the ADA’s Council on Scientific Affairs referred to previously, “the clinician can reduce the risk of performing unnecessary biopsies by obtaining an opinion by a dental or medical care provider who has advanced training and experience in diagnosis of oral cancer and its precursor lesions (5).”

More importantly though, these guidelines fail to recognize that it is not realistic to separate the oral cancer screening component from the overall comprehensive head and neck examination that all primary care dental providers perform on their patients. This intraoral and extraoral examination is arguably the most important component of every dental patient’s routine assessment, and includes a thorough review not just of the teeth and periodontal supporting structures, but of all hard and soft tissues of the visible oral cavity, as well as the cervical area and the skin of the face. The purpose of this examination is to identify every departure from normal, ranging from the more common toothrelated conditions, such as necrotic teeth and periodontal disease, to infectious processes (eg, candidiasis; oral manifestations of human immunodeficiency virus infection; deep fungal infections), reactive soft tissue lesions (eg, mucoceles, fibromas), and immune-mediated processes (eg, lichen planus, pemphigoid), to name a few. The diagnosis and management of these non-malignant processes is a critical component of the day-to-day practice of dentistry, and consequently the identification of these conditions cannot be arbitrarily separated from the “oral cancer” screening exam (7).

Other than the minor potential surgical risks associated with a biopsy procedure, where deemed necessary, routine oral screening is in no way an invasive, time consuming, or costly procedure, and is not associated with any significant potential intraprocedural morbidity

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2.

Do the harms associated with screening outweigh the potential benefits?

The draft version of the USPSTF report states that “none of the studies in our review reported on harms from the screening test itself or from falsepositive or false-negative test results.

Screening using visual inspection and palpation should be low risk.

However, any time devoted to it would reduce opportunity for other interventions that might have greater impact on health outcomes.�

is also an opportunity to start a dialogue between clinician and patient on modifying risk factors that are associated with an increased risk of developing oral cancer. As practitioners, we have all experienced the patient who, after undergoing a routine oral cancer examination, volunteers that he or she is interested in quitting smoking. There is also evidence that patients with potentially preneoplastic conditions of the oral cavity, such as idiopathic leukoplakia, may benefit from the elimination of risk factors such as smoking (8).

In reality, a thorough head and neck examination by a well-trained and competent dentist in the primary care setting requires no special equipment (good lighting, a dental mirror, and gauze), no additional expense, and at most 2-3 minutes of the practitioner’s time. Other than the minor potential surgical risks associated with a biopsy procedure, where deemed necessary, routine oral screening is in no way an invasive, time consuming, or costly procedure, and is not associated with any significant potential intraprocedural morbidity (eg, perforation following colonoscopy for the detection of colorectal cancer) or long-term sequelae resulting from exposure to ionizing radiation (eg, mammography for the detection of breast cancer).

It is also accepted that many potentially preneoplastic conditions of the oral cavity, such as verrucous hyperplasia, have an unpredictable natural course, and overtreatment could result in adverse consequences for the patient. But rather than discount the potential benefits of early detection in these situations, would it not be better to instead develop clinically relevant guidelines for the assessment and management of patients identified with these conditions that would help guide our colleagues in the primary care setting?

It is also worth pointing out that the potential benefits of performing an oral cancer screening examination are not simply limited to detecting patients with oral cancer or potentially preneoplastic conditions. In addition to the many more commonly encountered conditions that are identified by means of the examination, this

3.

Ultimately however, the balance as to whether the potential benefits of routinely screening for oral cancer outweigh the risks depends on the answer to the following question: Does detection of oral cancer through screening reduce morbidity or mortality?

As with other position papers in this area, the USPSTF statement bases much of its analysis on the findings from the Trivandrum Oral Cancer Screening Study, in which administrative units in the Trivandrum

district, an area of India known to have a high risk of oral cancer, were randomized so that residents received either 3 rounds of home-based oral screening at 3-year intervals by nonmedical university graduates with minimal training in oral pathology or were assigned to a non-intervention control group (9). The overall mortality rate from oral cancer did not differ between the groups in the screened districts versus those in the control districts. However, participants from the intervention group who smoked or used alcohol had lower overall mortality rates from oral cancer than participants from the unscreened control group. Among subjects who did not use tobacco or alcohol, these differences were not significant.

While not intending to critique the methods of this study, there are recognized differences in study parameters that preclude directly extrapolating from these findings to the U.S. situation: the incidence of oral cancer is much higher in the geographic area studied than in the U.S., tobacco use in the study area consists predominantly of bidi, a locally produced cigarette associated with a potentially greater risk of oral cancer development than conventional cigarettes, minimally trained non-health care workers performed the screening examinations, the study involved home visits to the study participants with the explicit goal of performing an oral cancer examination as opposed to being a limited part of a routine dental examination and only 62% of study participants with identified lesions complied with referral for follow-up treatment (10).

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Interestingly, patients in the intervention group who were identified with oral cancer were more likely to have early stage disease (41% versus 23% stage I or II) and had higher 5-year survival rates (50% versus 34%) compared with the control group. This segues to another issue posed by the USPSTF, namely the uncertainty regarding how much of the improved survival associated with early diagnosis is due to lead time bias (implying that an earlier diagnosis leads to an apparent longer survival regardless of whether the earlier access to treatment affects the natural history of the disease), or length time bias (the observation that because there are subsets of oral cancers that progress at different rates, those that progress more rapidly than others, and hence lead to earlier death, are less likely to be detected by routine screening; the inference being that those cancers that are detected at an earlier stage through screening examinations may inherently have less aggressive biologic potential, thereby making it appear that early diagnosis leads to improved survival).

The USPSTF draft statement also argues that “harms of treatment for screen-detected oral cancer and its potential precursors may result from complications of surgery, radiotherapy, and chemotherapy. The natural history of screen-detected oral cancer is not well understood and, as a result, the harms from overdiagnosis and overtreatment are not known.”

There is no doubt, as alluded to above, that tumor growth rates vary, based on factors such as the inherent biologic properties of the tumor, host resistance and anatomic location. But how does this “limited knowledge”

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The purpose of this examination is to identify every departure from normal, ranging from the more common tooth-related conditions, such as necrotic teeth and periodontal disease, to infectious processes of the natural history of screendetected oral cancer translate to the clinical setting? As a clinician, upon diagnosing an early stage cancer in an otherwise healthy patient, would you ever consider advising your patient that the benefits of undergoing treatment are unknown, since “the natural history of screen-detected oral cancer is not well understood and the harms from overtreatment are not known?”

The implication that we should not perform routine screenings in the primary care setting is clearly not in our patients’ best interests. Not attempting to identify cancerous lesions at their earliest stage, particularly when this can be accomplished by means of a simple non-invasive examination while the patient is already sitting in the dental chair, should be viewed as paternalistic at best. While there clearly can be indications for not

proceeding with treatment for a small subset of patients diagnosed with oral cancer through screening, eg, due to poor overall health status, even in these cases, this decision should only be made following a dialogue that recognizes the patient’s wishes, the likelihood of a favorable outcome and the recommendations of the treatment team (ie, informed consent). Ultimately, in order for the patient to make an informed decision, does the cancer not have to first be identified?

In summary, several questions come to mind after reading these guidelines. Why the arbitrary attempt to separate “oral cancer screening” from the overall head and neck examination? What guidance, if any, do these recommendations offer to the patient or the practicing clinician?

Do the inevitable news headlines suggesting that there is no clear benefit to screening for oral cancer send the right message at this point in time, considering the progress that has been made in reducing the death rate from oral cancer over the past several decades? Does the emphasis on the absolute need for suitably powered randomized controlled trials conclusively supporting the benefit of routine oral cancer screening in the primary care setting ultimately benefit our patients? By not performing a routine oral cancer examination as part of a comprehensive overall oral health assessment, what impact does this have on potential “teachable moments” with our patients? Finally, if primary care dental providers, who have the depth and breadth of knowledge to identify which oral lesions are potentially worrisome and which are not, don’t provide this crucial service, who will?

I leave the reader with the following insightful comments from Dr Robert A. Faiella, president of the ADA, and Dr Paul D. Freedman, immediate past president of the American Academy of Oral and Maxillofacial Pathology (AAOMP), written in response to similarly worded recommendations published in Consumers Reports magazine: “Oral cancer screenings are not intended to be a stand-alone or separate procedure. Oral cancer screenings should be part of the complete dental examination that is to be performed on all patients (11). During these complete exams your dentist is checking for all oral diseases and pathologic conditions.

These non-invasive visual and tactile examinations, which are generally included with no additional fee for the cancer screening component, can result in earlier diagnosis of oral cancer specifically but also a multitude of other oral diseases in general. The ADA and AAOMP will continue to support and encourage scientific investigations regarding detection of oral cancer, with the firm belief that one missed oral cancer is one too many (12).”

References 1.

2.

3.

4.

If primary care dental providers, who have the depth and breadth of knowledge to identify which oral lesions are potentially worrisome and which are not, don’t

5.

From DevCan — Probability of Developing or Dying of Cancer, Surveillance Epidemiology and End Results, National Cancer Institute, U.S. National Institutes of Health. Available at: http:// www.seer.cancer.gov/statfacts/ html/oralcav.html. Accessed April 30, 2013.

From Surveillance Epidemiology and End Results, National Cancer Institute, U.S. National Institutes of Health. Available at: http://www.seer.cancer.gov/ csr/1975_2010/results_single/ sect_01_table.01.pdf. Accessed April 30, 2013.

Data estimated on January 1, 2010, Surveillance Epidemiology and End Results, National Cancer Institute, U.S. National Institutes of Health. Available at: http://seer.cancer.gov/ csr/1975_2009_pops09/results_ merged/topic_lifetime_risk.pdf.

Accessed April 30, 2013.

U.S. Preventive Services Task Force. Screening for Oral Cancer: Recommendation Statement. AHRQ Pub. No. 050564-A. Rockville, MD: Agency for Healthcare Research and Quality; 2004.

Rethman MP, Carpenter W, Cohen EE, et al; American Dental Association Council on Scientific Affairs Expert Panel on Screening for Oral Squamous Cell Carcinomas. Evidencebased clinical recommendations regarding screening for oral squamous cell carcinomas. J Am Dent Assoc. 2010;141:509-520.

6.

National Institute of Dental and Craniofacial Research. Detecting Oral Cancer: a Guide for Health Care Professionals. Bethesda, MD: National Institutes of Health; 2011. Available at: http://www.nidcr.nih.gov/ OralHealth/Topics/OralCancer/ DetectingOralCancer.htm.

Accessed May 2, 2013.

7. Bouquot JE. Common oral lesions found during a mass screening examination. J Am Dent Assoc. 1986;112:50-57.

8. Roosaar A, Yin L, Johansson AL, Sandborgh-Englund G, Nyrén O, Axéll T. A long-term follow-up study on the natural course of oral leukoplakia in a Swedish population-based sample. J Oral Pathol Med. 2007;36:78-82.

9. Sankaranarayanan R, Ramadas K, Thomas G, et al. Effect of screening on oral cancer mortality in Kerala, India: a clusterrandomised controlled trial. Lancet. 2005;365:19271933.

10. Rahman M, Sakamoto J, Fukui T. Bidi smoking and oral cancer: a meta-analysis. Int J Cancer.

2003;106:600-604.

11. Save your life: 8 cancer tests you need, plus 3 you don’t.

Consumer Rep Mag; March 2013: pp. 28-31.

12. Letter submitted to Consumers Union, March 1, 2013. Personal communication, American Dental Association media relations.

provide this crucial service, who will?

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Human Papillomavirus: The Fundamentals of HPV for Oral Health Care Providers katharine ciarrocca, dmd, msed; lana l. jackson, md, pharmd, facs; and scott s. de rossi, dmd Reprinted with permission from the California Dental Journal, Vol 41, No 5.

About the Authors Katharine Ciarrocca, DMD, MSED, is an assistant professor in the Department of Oral Health and Diagnostic Sciences at Georgia Regents University, College of Dental Medicine.

Conflict of Interest Disclosure: None reported.

Scott S. De Rossi, DMD, is an associate professor of oral medicine and chairman of oral health and diagnostic sciences at Georgia Regents University, College of Dental Medicine.

Conflict of Interest Disclosure: None reported.

Lana L. Jackson, MD, PHARMD, FACS, is an assistant professor of otolaryngology/ head and neck surgery at Georgia Regents University and director of the interprofessional Head and Neck Cancer Tumor Board.

Conflict of Interest Disclosure: None reported

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W

ithin the last 10 years, it has become evident that human papillomavirus (HPV) not only causes cervical and anal cancers, but also causes a subset of head and neck squamous cell carcinomas (HNSCCs). This increased awareness has subsequently amplified interest in a more specific knowledge regarding oral HPV infections. Dental patients may inquire about their risk of infection, their risk of developing a malignancy and even if there is potential protection in commonly used HPV vaccines. In addition, salivary diagnostic tests are commercially available for HPV, and dentists need to understand the sensitivity and specificity of those tests to determine clinical utility. Therefore, it is incumbent upon dental professionals to be educated on the fundamentals of HPV and to be capable of counseling patients appropriately as a comprehensive approach to preventive oral health care.

abstract Human papillomavirus (HPV) has become widely known as the causative agent of cervical cancer and some oropharyngeal cancers. The development of HPV vaccines has further piqued public interest. As a result, dentists will have increasing numbers of patients who will inquire about oral HPV infection and its prevention by means of vaccination. Dental professionals must be informed. This review provides an overview of HPV, its association with HIV and oropharyngeal cancer, and information on HPV vaccinations.

The Basics of HPV Acquisition and Diagnosis Classification Papillomaviruses are small, doublestranded DNA viruses that infect the stratified epithelium (basal cells) of the skin or mucous membranes. The human papillomavirus is a member of the Papillomavirus genus of the family of Papovaviridae (1,2). Human papillomavirus is a DNA virus that can cause lesions anywhere on the cutaneous surface, including the extremities, genitalia and oral mucosa. Lesions involving the oral cavity can be transmitted sexually or by patient nail-biting with periungual warts.

Based on their DNA, more than 120 specific types have been fully cloned and characterized (2). Furthermore, classification of HPVs as high-risk types and low-risk types is based on epidemiologic data regarding the behavior of the lesions caused by different HPV types (3). To date, investigators have identified 30 HPV genotypes: 15 high-risk types, 3 types that probably are high risk and 12 lowrisk types (1-3). Low-risk types of HPV cause benign oral hyperplasias that usually are painless and nonulcerated.

High-risk types HPV-16 and HPV-18 are associated with approximately 70 percent of cervical cancers, whereas HPV-16 alone is associated with about 85-95 percent of HPV positive oropharyngeal cancers (4,5).

Acquisition of Oral HPV Infection

Diagnosis of Oral HPV Infection

Infectious HPV is spread most often via sexual contact; however, it is unclear whether HPV can be casually transmitted to the oral cavity. Oral sex has been hypothesized to be the main transmission mode of HPV infection (5). Oral HPV infection is uncommon in children, despite reports that it can also be spread through passage through the cervical canal during delivery (5,6). Autoinoculation is also possible, but very uncommon, as evidenced by lack of concordance of oral and cervical HPV infections (7).

Human papillomavirus infection can be identified through various measures, such as the detection of HPV DNA in biopsy specimens, detection of serum antibodies to HPV proteins and the detection of HPV DNA in oral specimens (9-13).

Archival cytology slides can be used for HPV DNA detection with in situ hybridization (ISH) (13). Presence of HPV DNA by ISH in metastatic lesions from HNSCC using alcohol-fixed, archival, cytopathological material was studied by Umudum et al, and the cytologic features of HPV-positive metastatic lesions of HNSCC were characterized; HPV DNA and origin of metastatic lesions were correlated (9).

The prevalence of HPV DNA in cancer specimens, however, varies greatly based on tumor site and geographic variability in risk factors. Recent studies suggest that HPV is more likely to be detected in oropharyngeal cancers than in oral cancers (10,11).

Several other risk factors have been consistently associated with increased odds of prevalent oral HPV in crosssectional studies (6-9). Current smoking and HIV infection are both associated with significantly increased oral HPV prevalence, suggesting that tobacco-related and HIV-related immunosuppression may impact oral HPV natural history (8). In addition, oral HPV prevalence also appears to increase with older age, which is unusual for a sexually transmitted infection. Speculation on possible causes of this pattern includes decreased oral HPV clearance with older age or age-related changes in the immune system (8).

Current smoking and HIV infection are both associated with significantly increased oral HPV prevalence, suggesting that tobacco-related and HIV-related immunosuppression may impact oral HPV natural history.

Serum antibodies have been used as a marker of cumulative exposure to HPV (13). Several studies show strong associations between serum HPV and oropharyngeal cancers, and weak associations with oral and laryngeal cancers (9-13). Studies of seroprevalence of HPV demonstrate exposure to HPV but do not specify the mucosal site of infection. In addition, seroprevalence likely shows cumulative exposure to HPV, but not all individuals develop an antibody response, and HPV antibodies diminish over time, making the clinical utility of this in predicting cancer risk yet to be determined. Detection of HPV DNA in oral specimens likely indicates current oral HPV infection

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(12). However, this begs the question, “Does salivabased HPV testing establish cancer risk and guide patient management?�

It is estimated that 20 million Americans are currently infected with HPV and 6 million new infections occur annually (3). Fifty percent of sexually active adults will be infected in their lifetime, and 33,000 will develop an HPV-associated malignancy (12,000 will be HNSCC). The rationale and need for screening tests is clear; however, methods for collecting exfoliated cells (eg, saliva, swab, oral rinse) have not been standardized, and oral rinses cannot determine the origin of HPV infection. It is vital to establish the significance of this relationship between presence of HPV and cancer risk in the oral cavity and oropharynx. This is made difficult as the clinical spectrum of HPV-associated premalignant lesions has not been fully described, and there are no unique clinical features of HPV-associated premalignant lesions. HPV-related HNSCC develops in hard-to-examine locations (eg, tonsillar crypts) making early clinical detection challenging. How can we identify patients who are at risk for harboring an HPV-associated premalignant lesion of HNSCC? Saliva-based HPV testing has been developed by OralDNA Labs. According to the manufacturer, the test is ideal for patients with traditional risk factors for oral cancer, with signs and symptoms of oral cancer, for those who are sexually active and for those with suspicious lesions (12). Serious questions remain regarding this technology: Will my patient develop HNSCC if he or she has a positive test? What should I do for my patient if he or she has a positive test? In order to establish management protocols and to determine the utility of community-based HPV screening, more research is necessary (12).

FIGURE 1. Squamous papilloma on the lower labial mucosa in a 34-yearold, otherwise healthy, male. (Courtesy of Scott De Rossi, DMD).

FIGURE 2. Focal epithelial hyperplasia on buccal mucosa. (Courtesy of Scott De Rossi, DMD).

HPV and Oral Mucosa Benign Lesions Low-risk HPV genotypes are often responsible for benign oral mucosal lesions such as ordinary warts (verrucae), condylomas, focal epithelial hyperplasia (FEH), and squamous papillomas. The most common low-risk genotypes are HPV-6 and HPV-11. The skin types HPV-2, HPV-4 and HPV-57 have been found in oral wart lesions (13,14).

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FIGURE 3. Condyloma acuminatum on anterior givingiva. (Courtesy of Scott De Rossi, DMD).

Squamous papilloma. Squamous papillomas are the most common benign neoplasm of the oral mucosa with a predilection for the mucosa of the hard and soft palate including the uvula and the vermillion of the lips (13). A harmless lesion that is neither transmissible nor threatening, the lesion raises concern because of its clinical appearance, which may mimic exophytic carcinoma, verrucous carcinoma or condyloma acuminatum. Oral papillomas can be recognized by their small, fingerlike projections, resulting in an exophytic lesion with a rough or cauliflower-like, verrucous surface (Figure 1) that is often white. Squamous papilloma lesions are thought to be induced

by HPV-6 or HPV- 11 (13). All lesions resembling a squamous papilloma are recommended for excision at the base with a 1-mm margin to the depth of the submucosa, and removal should be considered the cure. Recurrence or appearance of new lesions suggests the possibility of retransmission of a condyloma acuminatum or a carcinoma.

difficult to differentiate clinically between a verruca vulgaris lesion and a squamous papilloma; however, the treatment is the same (surgical excision).

Verruca vulgaris. Also known as the common wart, verruca vulgaris is the most prevalent HPV skin lesion, but it can also be found in the oral cavity. This lesion is usually associated with HPV-2 and HPV-4 (14).

In the oral cavity, verruca vulgaris is most often found on keratinized mucosa, namely the gingiva and palate. Verruca vulgaris lesions are contagious, and autoinoculation does occur. Verruca vulgaris lesions rapidly enlarge (average size < 5 mm) and then remain unchanged, sometimes for several years. Often times, it is

Condyloma acuminatum. Normally, condyloma acuminatum lesions are found in the genital area and are considered a sexually transmitted disease. Oral condylomas do occur, however, and are associated with HPV-2, HPV-6 and HPV-11 (14).

Clinically, these lesions are similar in appearance to papillomas but are usually larger and more clustered. In addition, condylomas are known to be more diffuse and deeply rooted than papillomas. These lesions are most commonly found on the labial mucosa, soft palate and lingual

Focal epithelial hyperplasia. Focal epithelial hyperplasia (FEH), also known as Heckâ&#x20AC;&#x2122;s disease, is a rare, benign lesion associated with HPV13 and HPV-32 and was originally diagnosed in the Inuit population (1517). Factors that have been associated with the disease include communal lifestyle, poor hygiene, and poverty.

FEH frequently affects children but is increasingly seen in the HIV positive population, as well (16,17).

This lesion is typically located in the labial, buccal and lingual mucosa and is characterized by multiple soft, circumscribed, sessile nodules that usually resemble the normal mucosal color, but may occasionally appear white and papillary (Figure 2). The lesions often persist for months or even years and spontaneously resolve with no treatment. The risk of recurrence is minimal.

frenum. Condylomas in the oral cavity are usually related to oral-genital contact but can rarely occur because of autoinoculation or as a result of maternal transmission (Figure 3).

When these lesions are diagnosed in children, the examining clinician should be aware that their presence may be an indication of sexual abuse, thus necessitating intervention with the proper authorities. Condylomas are difficult to treat, and very often cause scarring and disfigurement.

It is best to surgically remove all of the lesions simultaneously to lessen the probability of autoinoculation.

Excision with lasers may lead to spreading of the virus via airborne particles and is not advised.

Podofilox (Condylox, Watson Pharma, Parsippany, NJ), an antimitotic topical agent used to treat genital and anal condylomas, has not been approved by the FDA for oral use but may be effective in treating oral condylomas.

HIV and HPV HPV-related diseases are increased in the oral cavity of HIV-positive individuals. HIV carriers have more frequent infections and a wider variety of HPV types, in addition to an increased frequency of HPVassociated oral lesions (Figures 4 and 5). Additionally, studies have demonstrated an increase in the incidence of oral warts related to HPV infection since the advent of antiretroviral therapy (16-18).

Compared with immunocompetent patients, immunocompromised patients often present with HPV infections that are atypical or more extensive, recurrent, and recalcitrant

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to therapy. While no specific association between warts and highly active retroviral treatment was found, a significant reduction in viral load in the previous 6 months was related to an increased incidence of oral warts (16,17).

It has been suggested that this phenomenon of increasing incidence of oral warts associated with a decreasing viral load may represent a form of immune reconstitution syndrome (16-18).

HPV and Oropharyngeal Cancer Cancers of the head and neck arising from the mucosa lining the oral cavity, oropharynx, hypopharynx, larynx, sinonasal tract, and nasopharynx represent a considerable burden worldwide, being the fifth most common cancer in 2008 (18,19). Tobacco use and alcohol consumption are known risk factors for many of these cancers, but more recently HPV infection has been found to be strongly associated with oropharyngeal cancer (19-21).

There are epidemiological differences between HPVDNA-positive and HPV-DNA-negative head and neck cancers. HPV-DNA-positive cancers are associated with younger age and higher numbers of sexual partners, but are less associated with tobacco smoking as compared with HPV-DNA negative cancers (22,23). The proportion of head and neck cancers that are HPV-DNA positive varies considerably. A recent systematic review found that the average HPV-DNA positivity was 35.6 percent for oropharyngeal cancer and 23.5 percent for oral cavity cancer (24). Nevertheless, this review classified all tongue cancers as oral cavity cancers and did not differentiate between base of tongue (classified anatomically as an oropharyngeal site) and surface and border of tongue (classified anatomically as an oral cavity site) (24). HPVDNA positivity varies by site and is highest in the tonsil and base of tongue (25).

This review may have underestimated oropharyngeal cancer HPV-DNA positivity and overestimated oral cavity cancer positivity. This review also showed that there is substantial variation in the proportion of HPV-DNApositive cancers by country and study; part of this may be due to the different distributions of risk factors other

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FIGURE 4. Palatal view of aggressive condyloma acuminatum in HIVpositive patient. (Courtesy of Scott De Rossi, DMD).

FIGURE 5. Aggressive condyloma acuminatum in HIV-positive patient.

(Courtesy of Scott De Rossi, DMD).

than HPV infection (such as tobacco consumption) as well as to the accuracy of cancer site classification.

Although the incidence of head and neck cancers associated with tobacco and alcohol consumption has decreased considerably in the developed world, that of oropharyngeal cancers has increased (19,26,27). Given the etiological role of HPV in some oropharyngeal cancers, it is possible that the incidence of these cancers may decline after HPV vaccination (23).

The epidemiology of HNSCC has changed over the past 20 years. As tobacco use, historically the most significant risk factor for HNSCC, has decreased in the United States, the incidence of tobacco-associated but HPV-unrelated HNSCC has also decreased (26,27). Comparatively, the incidence of HPV-associated oropharyngeal cancers overall is increasing (28,29). Alcohol and smoking are the primary risk factors for head and neck carcinomas (19).

The fact that 15 percent to 20 percent of patients develop HNSCC in the absence of exposure to these agents or without any obvious predisposing genetic defects strongly suggests the possibility of other risk factors, including the presence of HPV. Although certain subsets of HNSCC have become less prevalent with the decrease in smoking, rates of oropharyngeal cancers — particularly tongue and tonsillar cancers — have risen steadily among men and women aged 20 to 44 (28).

The possible link between certain HPV types and oral and oropharyngeal carcinomas is of great interest to clinicians. HPV has a clearly defined role in almost all cases of cervical cancer…

In HNSCC, there are now 2 definitive subgroups: those associated with HPV and those not associated with HPV. The latter are associated with long-standing use of tobacco and alcohol. However, investigators have shown that tobacco and alcohol use increases the risk not only of developing HPV-independent HNSCCs but also of developing HPVassociated HNSCCs (21,22). HPVassociated HNSCCs are histologically less differentiated and usually at a higher tumor stage than are HPVindependent HNSCCs (26).

The possible link between certain HPV types and oral and oropharyngeal carcinomas is of great interest to clinicians. HPV has a clearly defined role in almost all cases of cervical cancer, and the similar morphologic features of genital and oral HPVassociated lesions was one of the early findings that suggested HPV might be involved in oral and laryngeal squamous cell carcinomas.

HPV-16 and HPV-18 are the most commonly detected high-risk types.

In most studies, HPV DNA has been

found in 25 percent to 35 percent of oral carcinomas (25).

The likelihood of detecting HPV increases with the progression from normal mucosa to premalignant lesions to oral cancer. HPV is 2 to 3 times more likely to be observed in precancerous oral mucosa and 4.7 times more likely to be found in oral squamous cell carcinoma than in normal mucosa (29). HPV may play a more important role in some tumors than in others. For example, HPVrelated cancers arise mainly from the tonsils and base of the tongue rather than the ventrolateral tongue, gingivae, cheek, palate, and floor of the mouth (29).

The risk of developing an HPV associated oropharyngeal carcinoma is directly related to the number of lifetime sexual partners (oral and vaginal), young age at first sexual activity and a history of samesex partners (25). HPV-positive carcinomas are usually detected as laterstage disease with regional lymph node involvement and metastasis as compared to HPV-negative cancers (30). Yet, despite the later stage at diagnosis, HPV-positive carcinomas of the head and neck have higher survival rates, better response to radiation therapy and chemotherapy, and are less likely to progress or recur (21,22,25).

Although HPV status may prompt less aggressive treatment strategies, no clinical trials have been published to date that confirm that modifying cancer therapy based on HPV status can improve patients’ outcomes.

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Treatment and Prevention Current treatment of HPV infections depends on the area involved and the extent of the lesions, but can include surgical excision, laser ablation, cryosurgery, immunostimulants (eg, interferon) and application of caustic agents (eg, podophyllotoxin, retinoic acid). With HPV recurrence, however, these various treatments often fail. Even if success is achieved, recurrences are common. Over the last few years, new and exciting information has been elucidated regarding novel pharmacologic approaches in the treatment of viral diseases (31-37). Cidofovir, a nucleoside analog to deoxyciytidine monophosphate, is effective against a number of DNA viruses including recurrent herpes viruses, Kaposi sarcoma, molluscum contagiosum and HPV-related skin lesions. The topical use of cidofovir appears to cause significant shrinkage and resolution of gingival HPV recalcitrant to traditional therapies (31).

Currently in the United States, 2 commercially available prophylactic HPV vaccines are available: a bivalent (HPV-16 and HPV-18) vaccine (Cervarix, GlaxoSmithKline, Brentford, Middlesex, England) and a quadrivalent (HPV-6, HPV-11, HPV16 and HPV-18) vaccine (Gardasil, Merck, Whitehouse Station, NJ). The quadrivalent vaccine was first licensed in 2006 for use in females ages 9-26 for the prevention of cervical, vaginal and vulvar cancers (32). In 2009, the license was expanded to include

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males in this age range because clinical trial data demonstrated the vaccine’s efficacy in preventing genital warts in both genders (32).

Research as of late has demonstrated the vaccine to provide effective prevention against anal precancers, therefore expanding the vaccine’s clinical indications to include anal cancer prevention (33,34). In addition, clinical trials of this vaccine have revealed very high vaccine efficacy (> 98 percent) for the prevention of anal, cervical, vaginal, and vulvar precancers among vaccine-typenaïve individuals (35,36). As would be expected, efficacy is lower (50 to 78 percent) when analyses also include individuals already infected with vaccine type HPV at the time of vaccination (36).

The second HPV vaccine, Cervarix, is a bivalent vaccine that provides protection against HPV-16 and HPV18. This vaccine was licensed for use in the U.S. in 2009 for the prevention of cervical cancers (37). Genital warts protection is not conferred from this vaccine because it does not contain low-risk HPV types associated with this disease. At the moment, however, the accepted indications for the bivalent vaccine are only cervical cancer and its precursors.

HPV vaccines have a clear role in preventing many anogenital cancers and conditions related to HPV infection. Overall, the high efficacy of the vaccines and excellent safety profile suggest that these vaccines will provide major health benefits to the population. More data needs to be established on the effectiveness

of these vaccines against HPVrelated head and neck cancer. In addition, further research needs to be performed to evaluate the longterm efficacy of the vaccine against both anogenital and nonanogenital endpoints. When this information is available, it is likely that an even greater benefit from these vaccines will be realized.

It is unclear how effective traditional visual and tactile examinations are in screening for oropharyngeal cancers.

Oropharyngeal cancers are likely to be less visible and share many symptoms with benign conditions such as tonsillitis and pharyngitis.

Oral health care providers need to perform comprehensive oral and head and neck examinations including lymph node examination and be on alert for symptoms that may suggest a malignancy, such as dysphagia, otalgia, unexplained weight loss, and hemoptysis. Currently, there is no evidence that detection of highrisk HPV is useful to predict the development of oropharyngeal cancer or disease in the oral cavity accurately.

Conclusion HPV has gained much interest recently among the dental community because of its accepted association with cervical cancer, the morphologic similarity of cervical warts to oral warts and the development of effective vaccination against anogenital HPV disease. Oral HPV infections have not been studied to the degree of those of the genital tract, although the evidence of association between certain

Oropharyngeal cancers are likely to be less visible and share many symptoms with benign conditions such as tonsillitis and pharyngitis. Oral health

11.

care providers need to perform comprehensive oral and head and neck examinations tumors and HPV infection today is indisputable. Oncogenic HPVs are associated with oral malignancies, but its prevalence varies widely in different studies. Oral HPV infections need to be studied and investigated thoroughly so the resulting information can help to direct oral health professionals for future cancer prevention programs, including oral HPV vaccination for oral HPV infections.

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6. Saini R, Khim TP, Rahman SA, et al. High-risk human papillomavirus in the oral cavity of women with cervical cancer, and their children. Virol J 2010;7:131.

7. Termine N, Giovannelli L, Matranga D, et al. Oral human papillomavirus infection in women with cervical HPV infection: new data from an Italian cohort and a metanalysis of the literature. Oral Oncol 2011;47:244–250.

8. D’Souza G, Fakhry C, Sugar EA, et al. Six-month natural history of oral versus cervical human papillomavirus infection. Int J Cancer 2007;121:143–150.

9. Umudum H, Rezanko T, Dag F, Dogruluk T. Human papillomavirus genome detection by in situ hybridization in fineneedle aspirates of metastatic lesions from head and neck squamous cell carcinomas.

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Carneiro T, Marinho SA, Verli FD, Mesquita ATM, Lima NL, Miranda JL (2009). Oral squamous papilloma: clinical, histologic and immunohistochemical analyses. J Oral Sci, 51(3): 367–372.

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Fakhry C, Sugar E, D’Souza G, et al. Two-week versus six-month sampling interval in a short-term natural history study of oral HPV infection in an HIV-positive cohort. PLoS One 2010; 5:e11918.

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19. Lubin JH, Gaudet MM, Olshan AF, Kelsey K, Boff ett a P, Brennan P, et al. Body mass index, cigarette smoking, and alcohol consumption and cancers of the oral cavity, pharynx, and larynx: modeling odds ratios in pooled case-control data. Am J Epidemiol 2010; 171(12): 1250-1261.

20. Pierce JP, Messer K, White MM, et al. Prevalence of heavy smoking in California and the United States, 1965–2007. JAMA 2011; 305:1106–1112.

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Prevalence of HPV Associated Oropharyngeal Cancer Among South Texans Stephanie D. Rowan, RN, MSN; Mark DiBurro, RDH, MPH; Steven Westbrook, DMD; Spencer W. Redding, DDS, MEd.; Frank R. Miller, MD, FACS

About the Authors Stephanie D. Rowan, RN, MSN, senior clinical research nurse, Department of Comprehensive Dentistry, Division of Research, University of Texas Health Science Center at San Antonio, San Antonio, Texas Mark DiBurro, RDH, MPH, clinical instructor, Dental Hygiene Program, Department of Periodontics, University of Texas Health Science Center at San Antonio, San Antonio, Texas Steven Westbrook, DMD, Clinical Instructor, Department of Comprehensive Dentistry, Division of Research, University of Texas Health Science Center at San Antonio, San Antonio, Texas Spencer W. Redding, DDS, MEd, Professor and Chairman, Department of Comprehensive Dentistry, University of Texas Health Science Center at San Antonio, San Antonio, Texas.

Correspondence: 7703 Floyd Curl Dr, Mail Code 7719, San Antonio, TX 78229-3900; Ph# 210-567-3458, Fax: 210-562-9374; redding@uthscsa.edu Frank R. Miller, MD, FACS, professor and deputy chairman, Department of Otolaryngology â&#x20AC;&#x201D; Head and Neck Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas

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Introduction

O

ral cancer (OC), including oral cavity cancer (OCC) and oropharyngeal cancer (OPC), is the sixth most common cancer in the world.

(1,2). Individuals who are diagnosed with such cancers have an approximate 60% 5-year survival rate (3). Historically oral cancer was associated with the chronic and excessive use of tobacco and alcohol. More recently, it has been shown that human papilloma virus (HPV) is associated with oral cancer, particularly in the oropharynx. The prevalence of HPV-related OPC has been increasing over time, rising from 16% in 1984 to 72% in 2004. It is reported to be up to 90% currently and represents the fastest growing group of

Abstract The goal of this study was to begin to assess the prevalence of oropharyngeal cancer among all oral cancers and thus the potential role of human papillomavirus (HPV) in this disease in the south Texas Region served by the University of Texas Health Science Center at San Antonio (UTHSCSA), and University Health System (UHS) in San Antonio, Texas. This health system represents the largest catchment area for oral cancer serving the south Texas populations, extending from the U.S.-Mexico border, north to Williamson County, west to Eagle Pass, and east to Gonzales County. With the move towards electronic medical records (EMR) nationwide, our team conducted a feasibility study to answer this question utilizing electronic record coding data across both local networks.

Key Words Oral cancer, oropharyngeal cancer, human papilloma virus (HPV)

oral cancers among Americans under 50 years of age (1, 4, 5, 6, 7, 8, 9).

Current findings indicate the incidence of HPV-related OPC is increasing while the incidence of tobacco/alcoholrelated OC is decreasing (1).

There are unique characteristics emerging in patients with HPV-related OPC. HPV has long been recognized as a sexually transmitted disease. The increase in prevalence of HPV-related OPC appears to reflect a change in behaviors of individuals who engage in sexual activity. Throughout the world, the age of individuals who engage in sexual activities continues to decrease while the number of sexual partners continues to increase.

The occurrence of HPV-related oropharyngeal cancer triples among individuals who have 6 or more oral sex partners or have a high number of lifetime vaginal sex partners (26 or more) (1,2). There is a greater prevalence in the U.S. of HPV-related OPC among males compared to females and among Caucasians compared to African Americans, Caucasian males being the subgroup with the highest prevalence (1,7). In addition, subjects diagnosed with HPV-related OPC are almost 10 years younger compared to those diagnosed with oral cancers not related to HPV (2). As compared to patients with OC, patients with HPV-related OPC tend to be diagnosed at a more advanced stage of disease but paradoxically respond better to therapy, with twice the 5-year survival rate (1,2).

As our understanding of HPV-related OPC evolves, it will be critical to identify patients with this disease as a group separate from other oral cancer patients. Most prevalence and incidence studies of HPV-related OPC have been conducted outside

There is a greater prevalence in the U.S. of HPV-related OPC among males compared to females and among Caucasians compared to African Americans with Caucasian males being the subgroup with the highest prevalence

the state of Texas. Our goal was to determine the epidemiology of HPV-related OPC in South Texas to better understand our unique patient population, particularly Hispanics. We were unable to collect HPV testing results, as this was not a routine test throughout our survey time.

Therefore we used diagnosis of OPC as a surrogate, since data from other investigators have shown that up to 90% of these cancers are HPV-related (10, 11, 12).

Methods This was a retrospective, crosssectional study to determine the prevalence of HPV-related oropharyngeal cancers in the South Texas region served by clinicians from the University of Texas Health Science Center at San Antonio (UTHSCSA) and included dental school clinics, the Department of Otolaryngology - Head and Neck Surgery, and the Bexar County University Health System (UHS), the health care system affiliated with UTHSCSA. The institutional review board at the University of Texas Health Science Center at San Antonio gave approval for the study.

The study extracted data from electronic medical records (EMR) utilizing coding data within the

UTHSCSA and UHS systems. The data collected encompassed every patient who was diagnosed with oral and/or oropharyngeal cancer from January 1, 2008, through July 1, 2013. This data was identified utilizing International Classification of Diseases, 9th Revision (ICD-9) codes: 141.0-9, 145.2-9, 146.09, 147, 149.8-9, 198.89, and 230 (13).

For the purposes of this study, oral and oropharyngeal squamous cell carcinoma (cancers) are any malignancies that invade the following structures: The oral cavity including contiguous sites with all mucosa; the tongue including anterior (twothirds), ventral and dorsal surfaces, base (dorsal surface), border (lateral), and other specified sites (NEC); the hard palate; the soft palate including the nasopharyngeal and posterior surfaces, the junction of the hard and soft palate; the oropharynx including the base of tongue (BOT), and the tonsils including fauces, lingual, palatine, pharyngeal, anterior and posterior pillars (the anatomic area termed Waldeyerâ&#x20AC;&#x2122;s ring). Excluded were patients with parotid or submandibular gland malignancies.

The data were collected according to a specific sequence to ensure valid selection of subjects to support study objectives. All data was collected according to the following sequence: 1.

2.

Data were collected from all patients diagnosed with oral and/ or oropharyngeal cancer within target dates.

All data collected from selected databases were imported into Excel 2010 and processed to eliminate duplicate patients, diagnosis, and service payment providers. Duplicate listings were eliminated based on date

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3.

of diagnosis. Patient listings with multiple diagnosis codes for the same anatomical site within 9 months of initial date of diagnosis were eliminated. Additionally, multiple EMR numbers or insurance methods were also removed.

Validation of the data was accomplished utilizing a 20% comparison of data collected with University Health System Head and Neck Tumor Board weekly case review.

Results Patient Demographics

A database of 473 patients was generated using the ICD-9 codes listed in the Methods section. Patient characteristics data are shown in Table 1. The average age at time of diagnosis of the total population was 61, with a range from 18 to 93 years. Seventy-one percent of the total population was male and 29% female. The population race/ethnicity was 1% Asian, 2% African American, 39% Caucasian – Hispanic and 57% Caucasian – Not Hispanic. Insurance billing data related to the ICD-9 codes listed revealed 39% of the population with full coverage or Medicare, 38% with limited coverage via Medicaid or county of residence, and 23% were indigent-out-of-county care, self-pay, or had no insurance information available.

A total of 129 patients met the inclusion criteria with an initial diagnosis of oropharyngeal cancer.

The distribution of ICD-9 codes for this subset show the location of tumors identified (Table 2A & B),

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Table 1. Patient Characteristics Patient Demographics Oral Cancer N=344 (72.7%) / Oropharyngeal Cancer N=129 ( 27.3%) Total Cancer N=473

Oropharyngeal N=129

61 (Range 18-93)

58 (Range 32-82)

Gender N(%) Male Female Not Specified

336 (71) 133 (28) 4 (1)

104 (81) 25 (19)

Race/Ethnicity N(%) Asian African-American Caucasian — not Hispanic Caucasian — Hispanic Not identified

5 (1) 11 (2) 271 (57) 184 (39) 2 (1)

1 (1) 2 (1) 72 (56) 54 (42)

Insurance Coverage N(%) Self-Pay/Indigent Out of County/ No Insurance Medicaid/County Coverage Full Insurance/Medicare

107 (23) 185 (39) 181 (39)

25 (19) 60 (46) 47 (35)

Average Age

with the majority found in the base of tongue (31%), tonsils (29%), and oropharynx, not otherwise specified (NOS) (23%). The average age at time of diagnosis of the oropharyngeal subset was 58, with a range from 32 to 82 years. Eight-one percent of the oropharyngeal population was male and 19% female. The oropharyngeal cancer patient population race/ ethnicity distribution was <1% Asian,

1% African American, 42% Caucasian – Hispanic and 56% Caucasian – Not Hispanic. Insurance billing data for the ICD-9 codes listed indicated 35% of the population had full coverage or Medicare, 46% with limited coverage via Medicaid or county of residence, and 19% identified as indigent-outof-county care, self-pay, or had no insurance information available.

Table 2A. 5-Year Oropharyngeal Cancers by ICD-9 Codes

Discussion

5-Year Oropharyngeal Cancers

by ICD-9 Codes 41 38 30

6

8

2 BOT

Tonsil, lingual

Tonsil

Tonsillar fossa

Tonsil Pillar

2

2

Oroph, posterior

Oroph, NEC

Oroph, NOS

Table 2B. 5-Year Hispanic Oropharyngeal Cancers by ICD-9 Codes

5-Year Oropharyngeal Cancers

by ICD-9 Codes 14

14

5 1 BOT

15

Tonsil, lingual

Tonsil

Tonsillar fossa

4

Tonsil Pillar

0

0

Oroph, posterior

Oroph, NEC

Oroph, NOS

In all, 27.3% of our patients with OC were diagnosed with OPC and were thus at risk for HPV-related OPC. This is consistent with other reports that have shown a range of 23% to 35%.

(14) The gender breakdown was interesting when comparing all OC patients to OPC patients. Both groups showed a larger number of males as would be expected for all oral cancers.

However, there was a 10% increase in male patients in the OPC group. This is consistent with other studies that have shown an increased prevalence of HPV-associated OPC for males.

Age at diagnosis was approximately the same for both groups, which is in contrast to other studies where OPC patients tended to be younger. The racial breakdown between all OC and OPC patients were approximately the same as was the funding mix for care.

This has to be viewed with caution as the numbers of African American and Asian patients were quite small. The percentage of Hispanic patients in the OPC group was similar to that in the all OC group.

Limitations

With the move towards electronic medical and dental records (EMR) nationwide, our teamâ&#x20AC;&#x2122;s feasibility study objective was to identify the prevalence of oropharyngeal cancers utilizing electronic record coding data across both local networks.

Utilizing only ICD-9 codes to identify subjects is the greatest limitation, as it depends solely on clinician coding practices. ICD-9 codes were not available in the UTHSCSA UT-Medicine EPIC EMR system until June 2009.

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Additionally, during this data review, it was found that within the health system, American Medical Association Current Procedural Terminology (CPT) codes were not used as standard practice to bill for HPV testing. As mentioned earlier, we did not collect actual HPV-infection data on the patients but used a diagnosis of OPC as a surrogate marker. Therefore we may have overestimated the prevalence of HPV-related OPC.

Conclusion

survival to better assess the progress made towards decreasing the burden of cancer in the United States (18).

Our study suggests that over 25% of the oral cancers developed by South Texans are HPV-associated oropharyngeal cancers. We found similar rates in our local Hispanic population. National data suggests that HPV-associated OPC will increase over time. Therefore it will be critical to follow this evolving epidemiology.

We plan to initiate laboratory testing for HPV to determine the true role of this virus in OPC in South Texas.

Nationally, the incidence of oral and oropharyngeal cancer for 2013 was 41,380 cases in the U.S. The population of Texas accounted for 6.5% of all cases with an incidence of 2,683 persons being diagnosed with such cancers. In addition to new cases, the National Cancer Institute expected 7,890 persons to succumb to oral cancer in 2013.

Texas residents accounted for 8.1% of this total, resulting in 633 deaths (15, 16). Among Hispanics in Texas, the incidence rate of oral and/oropharyngeal cancer is 6.5 per 100,000 persons, with males doubling the rate of females 4.4 to 2.1 respectively. Current demographics indicate the continuous growth of the Hispanic population throughout the state of Texas. In 2000, the Hispanic population was 32.0% and in 2010 it rose to 37.6% (17,18,19). This trend indicates the need to address this public health dilemma for this continually growing population. By doing so, we can address the cancer objectives for Healthy People 2020, which support monitoring trends in cancer incidence, mortality, and

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4. Anderson, K.S., Wong, J., Dâ&#x20AC;&#x2122;Souza, G., Reimer, A.B., Lorch, J., Haddad, R., Pai, S.I., Longtine, J., McClean, M., LaBaer, J., Kelsey, K.T. & Posner, M. Serum Antibodies to the HPV16 Proteome as Biomarkers for Head and Neck Cancer. British Journal of Cancer (2011).104, 1896-1905.

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5. Gillison, M.L., Dâ&#x20AC;&#x2122;Souza, G., Westra, W., Sugar, E., Xiao, W., Begum, S., & Viscidi, R. (2008).

Distinct Risk Factor Profiles for Human Papillomavirus Type 16-Positive and Human Papillomavirus Type 16-Negative Head and Neck Cancers. Journal of National Cancer Institute 2008;100:407-420.

6. Von Buckwald, C. & Lajer, C.B. The Role of Human Papillomavirus in Head and Neck Cancer. APMIS, 2010; 118: 510-519.

7. Howlader N, Noone AM, Krapcho M, Garshell J, Neyman N, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds).

SEER Cancer Statistics Review, 1975-2010, National Cancer Institute. Retrieved June 6, 2013 from http://seer.cancer. gov/csr/1975_2010/, based on November 2012 SEER data submission, posted to the SEER web site, 2013.

8. Westra, W.H. The Changing Face of Head and Neck Cancer in the 21st Century: The Impact of HPV on the Epidemiology and Pathology of Oral Cancer. Head and Neck Pathology (2009).

9. Chaturvedi, A.K., Engels, E.A., Pfeiffer, R.M. et al.

Human papillomavirus and rising oropharyngeal cancer incidence in the United States.

Journal of Clinical Oncology.

2011;29(32):4294-301.

10. Gillison, M.L., Koch, M.L., Carpone, R.B, et al. Evidence for a causal association between human papillomavirus and a subset of head and neck cancers.

Journal of National Cancer Institute 2000;92:709-720.

11. Dâ&#x20AC;&#x2122;Souza, G., Kreimer, A.R, Viscidi, R., et al. Case-control study of human papillomavirus and oropharyngeal cancer. New England Journal of Medicine 2007; 356: 1944-1956.

12. Ang, K.K., Harris, J. Wheeler, R. et al. Human papillomavirus and survival of patients with oropharyngeal cancer. New England Journal of Medicine 2010; 363: 24-35.

13. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).

American Medical Association.

2013.

14. Kreimer AR, Clifford GM, Boyle P, Franceschi S. human papilloma virus types in head and neck squamous cell carcinomas worldwide: a systemic review.

Cancer Epidemiol Biomarkers Prev. 2005; 14: 467-475.

15. National Cancer Institute. (2013).

Expected Incidence of Oral Cavity and Pharynx, 2013. Retrieved June 7, 2013 from, http://www.cancer. gov/cancertopics/types/oral.

16. Texas Cancer Registry. (2013).

Expected Incidence of Oral Cavity and Pharynx, 2013.

Retrieved June 7, 2013 from, http://www.dshs.state.tx.us/

WorkArea/DownloadAsset. aspx?id=8589976495.

17. U.S. Consensus Bureau. (2013).

The Hispanic Population: Census 2000 Brief. Retrieved June 7, 2013 from, http://www.census.gov/ prod/2001pubs/c2kbr01-3.pdf.

18. U.S. Consensus Bureau. (2013).

State and County QuickFacts.

Retrieved June 7, 2013 from, http://quickfacts.census.gov/qfd/ states/48000.html.

19. HealthPeople.gov. (2013). Cancer.

Retrieved June 7, 2013 from, http://www.healthypeople. gov/2020/topicsobjectives2020/ overview.aspx?topicid=5.

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Traits of Practices With Highly-Effective Periodontal Protocols

By Rhonda R. Savage, DDS Consultant / Philips Oral Healthcare, Makers of Sonicare and ZOOM!

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D

o you place your patients’ best interests first? If you do, you lower your risk of engaging in malpractice and are likely increasing your income.

But most important, your patients receive the care they deserve and expect.

As you’re probably aware, the majority of research indicates that periodontal disease is linked to or has an association with cardiovascular disease, diabetes, low-birthweight babies, hormonal changes, obesity, metabolic syndrome, smoking, nutritional deficiency and autoimmune diseases. How do you evaluate your periodontal protocol?

The following are questions you should consider: 1.

2.

3.

Are you doing routine periodontal probing and complete periodontal charting annually?

During a new-patient exam, do you set the stage for periodontal disease by performing only minimal spot probing and assessments of tissue health?

Is your hygiene production lower than one third of your overall production? If you have a strong periodontal program, on average, 33% of your hygienist’s production will fall under the 4000 codes: periodontal scaling and root planing, periodontal maintenance, and adjunct services.

4.

Do most of your hygiene services fall under the adult scaling and prophy code?

5.

Do your patients have bloody bibs? (A bloody bib does not mean a prophy was provided.)

6.

Are your hygienists doing “the best they can in the time they’ve got” and charging for a prophy?

7.

Do you have most adult patients scheduled in a 45-50 minute time slot?

8.

Are your hygienists current in technique, providing excellent scaling and root planing services?

9.

Look at your recall/reactivation process. How effective is it? Are you at risk of being sued for abandonment?

1.

Hygienist and doctor need to sit down as a team and talk about diagnosis.

What are your standards? Reach a consensus regarding the type of periodontal probe that’s preferred and provides the most accurate readings. Also be on the same page regarding the proper location and angle of the probe, and amount of pressure on the probe. Practice on each other!

2.

10. Do you have the tools/ instrumentation needed to provide definitive periodontal care?

Is it time to reevaluate your standard of care for periodontal disease?

Missed or monitored neglect is one of the top causes of litigation. Proper examinations, diagnostic x-rays, charting, patient informed consent, proper timely referrals or treatment are important for your practice and the care of your patients. Following are traits of practices with highlyeffective periodontal protocols.

They have a written periodontal protocol.

The dental assistant prefaces the doctor’s exam with an oral evaluation—at the doctor’s second chair.

The total new-patient examination time is 45-60 minutes and can be dovetailed into the schedule, prior to an hour of hygiene time. Some doctors do the entire examination.

However, having the dental assistant gather information at the doctor’s second chair is ideal. Fees for the patient’s cleaning can be estimated properly.

The assistant can begin gathering information by doing the following: • • • • •

Connect with the patient Review a patient’s health history Take a baseline blood pressure reading Chart existing restorations Take necessary x-rays

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value for your

profession

•

•

Use the intraoral camera; chart missing, crowded, rotated, yellow teeth; and ask the patient: o Has anyone explained the importance of replacing this missing tooth? o [Your gums look red and irritated, and you have a lot of tartar build up.]

Do your gums bleed when you brush? Has anyone ever talked with you about gum disease? o [This filling has been there a long time and it’s done a good job for you. It looks like it’s wearing down along the edges.] Do you have any sensitivity to temperature or sweets there? Bite sensitivity? o Does food get wedged in between your teeth?

Ask the patient: o What brought you to our practice? o If there was one thing you would change about your smile, what might it be? o How do you feel about keeping your teeth the rest of your life? o [You have a nice smile!]

Have you ever been interested in whitening your teeth? We have the Zoom WhiteSpeed in our office and it’s amazing!

An assistant can be invaluable in connecting with a new patient and— once trained—setting the stage for

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case acceptance. Case acceptance often increases when an assistant is involved in the exam process, because as laypersons, patients often relate well with them. Patients hear what you say differently when it comes from a team member.

The assistant can also present information about products that can help a patient become healthier or more satisfied with his smile. This is an ideal time to present a new electric brush, for example. Though team members might think whitening is old news, patients still want whiter, straighter teeth. Case acceptance is directly proportional to the enthusiasm of the presenter.

3.

X-rays are a large part of the diagnostic process.

If a patient dictates on the phone that he wants a cleaning, does not want x-rays and has no current x-rays, he’s waving a huge red flag.

In many states, it is malpractice to attempt to diagnose oral conditions without x-rays. Even if you have the patient sign a consent/release form refusing x-rays, you can still be liable.

If you agree and skip the x-rays, do restorative treatment on #14 but fail to diagnose significant bone loss between #14 and #15, you will be liable. The patient cannot sign away his consent to the standard of care.

Create a written x-ray protocol for your team. This would include the interval, age of the patient, caries index, and periodontal status.

4.

The doctor conducts a thorough examination.

The doctor’s examination is typically 10-15 minutes during a new-patient appointment.

She ideally first sees a new patient in her chair. After connecting with the patient, she does a complete exam, looking at every tooth, as well as soft tissues and bone. Then she conducts an oral cancer screening.

Some doctors are too quick and don’t connect with the patient. Others take too much time and “talk the patient to death.” The goal of the case-acceptance process is to gauge a patient’s need for communication through his or her questions. Most patients don’t want or need a lengthy discussion regarding treatment. If the needs are significant, consider offering the patient a complimentary consultation.

5.

The doctor makes the periodontal diagnosis.

At the new-patient exam, the doctor should at minimum conduct a spot probe of the tissues and have a sense of the periodontal status of the patient. I prefer the full probing be completed by the health care provider that’s going to provide the hygiene services. (The hygienist may be able to complete this.)

Even with a standardized protocol, different providers will have different probe readings.

The doctor’s role is to help the patient understand the need for the recommended periodontal treatment.

The doctor should use layman terms, and be simple and clear when providing explanations.

“Fred, you have signs of gum disease.

Gum disease is caused by bacteria that cause an infection. It’s often called a silent disease because it’s not always painful. Most people know there’s something wrong when their gums bleed when they brush. If you had an infection in your eye like you do in your mouth, you’d see it and rush to the eye doctor. We need to get you with our hygienist who can help your gums be healthy and give you tools to take care of them.”

The hygienist’s role is to go into more detail with regard to the etiology and the doctor’s treatment protocol.

If you end up with a very clean and healthy patient, and the hygienist’s services didn’t warrant an hour, the hygienist can help with other responsibilities such as clean up and set up, instrument sterilization, and recall and reactivation calls.

6.

The 7 stages of treatment planning are routinely followed.

You know the 7 stages of treatment planning; unfortunately, I often see doctors and team members jump from step 1 to step 5 without considering the ramifications:

1.

2.

3.

4.

5.

6.

7.

Comprehensive Evaluation Diagnosis and Treatment Planning Treatment Consultation Preventive and Periodontal Treatment Restorative Dentistry Cosmetic Dentistry Maintenance

Some doctors are too quick and don’t connect with the patient. Others take too much time and “talk the patient to death.”

To prevent engaging in malpractice, and to treat your patients with their best interests in mind first, we need to be attentive to each phase of dentistry. Refine your hygiene services with a written periodontal protocol.

Keep in mind that the diagnosis is key.

Know when to refer. Also consider tapping into the talents of your dental assistant. Economically, having the majority of the examination time be allocated to an assistant is more affordable for the practice. The more the assistant does, the more the doctor can have a drill in his hands, doing things only a doctor can do. The same is true for hygienists. Moving a new patient exam to the assistant’s chair creates more time for the hygienist to provide services only he or she can.

TDA Perks Program partner Philips Sonicare and Zoom! provides significant discounts to TDA members on all its Sonicare and Zoom! whitening products. For more information regarding Sonicare discounts, please call 800-676-7664.

For more information regarding discounts on Zoom! products, please call 800-422-9448. When calling, please mention you have a “key account” with TDA Perks Program. For more information regarding these and other TDA Perks Program, please visit tdaperks.com, or call 512-443-3675.

Rhonda Savage, DDS, is an author and lecturer, and CEO of Miles Global, an international dental training and consulting firm. She is a past president of Washington State Dental Society, an affiliate faculty member of University of Washington School of Dentistry, and a member of the Pierre Fauchard Academy, American College of Dentists, and International College of Dentists.

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Oral and Maxillofacial Pathology Diagnosis and Management

Myeloid Sarcoma With Monocytic Differentiation Oral and Maxillofacial Pathology Case of the Month (from page 350)

Discussion Myeloid sarcoma (MS) is a solid, locally destructive neoplasm of myeloblasts or immature myeloid cells. These cells reside normally in the marrow but the tumor can occur in a variety of extramedullary sites as well as within the bone. MS has also been called chloroma, granulocytic sarcoma, or extramedullary myeloid tumor (1). The chloroma designation comes from the Greek word “chloros,” meaning green, and was derived from a faint green tint created in the lesion by the presence of myeloperoxidase (1). The present example shows a small amount of this discoloration in the ulcer bed, especially along the borders of the ulceration (Figure 2).

MS may occur as a solitary tumor preceding or occurring simultaneously with acute or chronic myeloid leukemia, or other myeloproliferative disorders. It may also represent an initial manifestation of relapse in a patient in remission from a previously treated acute myelogenous leukemia (AML), the most common form of adult leukemia (2-5). Our case represents a solitary lesion in a patient with an undiagnosed AML. He had no systemic symptoms (b symptoms) even suggestive of AML and yet the hematologic workup revealed the presence of leukemia.

The most common sites of occurrence

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for MS are subperiosteal bone, skull, paranasal sinuses, sternum, ribs, vertebrae and pelvis. It is also common in skin (“leukemia cutis”), lymph nodes, gastrointestinal tract, soft tissue, and testis. The occurrence of this tumor in the oral cavity is unusual but, when present, the patient almost always has a prior diagnosis of a myeloproliferative disorder, unlike the patient in our case (2,4,6).

Although uncommon in the mouth, up to 16% of MS cases occur in the head and neck region. The most common intraoral locations are the maxillary and mandibular jaws and soft tissues, followed by cheek, tongue, parotid, hard palate, soft palate, and lips (2,79). Children as well as adults may be affected.

As in our case, the tumor typically appears as a solitary, localized mass with minimal to moderate pain (2).

It is not unusual to see ulceration or hemorrhage and occasionally multiple MS tumors occur intraorally (5,9).

The clinical diagnosis of MS is very difficult and therefore a biopsy with histological examination and additional immunohistochemical analysis is required (1-9). In our case the clinical presentation of the mass, with rapid growth, ulceration and bone destruction, was very worrisome for a malignant neoplasm. Lesions to

consider in the differential diagnosis are all life-threatening diseases: lymphoma, squamous cell carcinoma, metastatic carcinoma, and sarcoma.

The immunohistochemistry pattern (immunophenotype) coupled with the morphologic characteristics, supported a myeloid sarcoma with monocytic differentiation. Also, his hematologic work up confirmed AML, as has been mentioned. The patient received several treatments of chemotherapy and radiation therapy.

His oral lesion disappeared under this regimen, but the AML continued to become more severe, and he died of the disease 10 months after his diagnosis.

When myeloid sarcoma occurs in association with a myeloproliferative disorder or a myelodysplastic syndrome, the prognosis is associated with blast transformation. When the myeloid sarcoma is associated with AML, the prognosis is poor and depends on the clinical course of the underlying leukemia. AML occurring at an older age or with multiple MS tumors significantly diminishes the prognosis. Even for patients affected only with isolated MS, without hematologic evidence of an underlying leukemia, it is suggested that aggressive chemotherapy be used, possibly followed by bone marrow transplantation (10,11).

References 1. Jaffe ES, Harris NL, Stein H, Vardiman JW (Eds.): World Health Organization Classification of Tumours, Pathology and Genetics of Tumours of Haematopoietic and Lymphoid Tissues. IARC Press; Lyon 2001.

2. Kurdoğlu B, Oztemel A, Barış E, Sengüven B. Primary Oral Myeloid Sarcoma: Report of a Case. J Oral Maxillofac Pathol.

2013; Sep;17(3):413-6.

3. Papamanthos MK, Kolokotronis AE, Skulakis HE, Fericean AA, Zorba MT, Matiakis AT. Acute Myeloid Leukemia Diagnosed

by Intra-oral myeloid Sarcoma.

A case Report. Head and Neck Pathol. 2010; 4: 132-135.

4. Amin KS, Ehsan A, McGuff HS, Albright SC. Minimally differentiated acute myelogenous leukemia (AML-M0) granulocytic sarcoma presenting in the oral

5.

6.

7.

8.

cavity. Oral Oncol. 2002;38:516– 9.

Xie Z, Zhang F, Song E, Ge W, Zhu F, Hu J. Intraoral granulocytic sarcoma presenting as multiple maxillary and mandibular masses: A case report and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.

2007;103:e44–e8.

Yilmaz AF, Saydam G, Sahin F, Baran Y. Granulocytic Sarcoma: A Systematic ReviewAm J Blood Res. 2013 Dec 18;3(4):265-70.

Srinivasan B, Ethunandan M, Anand R, Hussein K, Ilankovan V. Granulocytic Sarcoma of the lips: report of an unusual case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Jan;105(1):e34-6.

Lee SS, Kim HK, Choi SC, Lee JI, Granulocytic Sarcoma occurring in the Maxillary Gingiva demonstrated by Magnetic

Resonance Imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001; 92 689-93.

9. Da Silva-Santos PS, Silva BS, Coracin FL, Yamamoto FP, Pinto-Junior DS, Magalhaes MG. Granulocytic Sarcoma of the Oral Cavity in a Chronic Myeloid Leukemia patient, an unusual presentation. Med Oral Patol Oral Cir Bucal. 2010; Mar 1; 15(2) e350-2.

10. Breccia M, Mandelli F, Petti MC, et al. Clinico-pathological characteristics of myeloid sarcoma at diagnosis and during follow-up: report of 12 cases from a single institution. Leukemia Research. 2004;28: 1165-1169.

11. Pileri SA, Ascani S, Cox MC, et al. Myeloid sarcoma: clinicopathologic, phenotypic and cytogenetic analysis of 92 adult patients. Leukemia 2007;21:34050.

PLACE YOUR NEXT DISPLAY AD HERE! Display advertising in the Texas Dental Journal is one of the best ways to reach the majority of Texas dentists. The Texas Dental Journal is the official publication of the Association. Established in 1883, it is the longest, continuously published dental journal in the Americas and second in the world to the British Dental Journal. Published monthly, the Journal’s circulation exceeds 9,000, its readership exceeds 50,000, and it’s the only statewide publication of its kind to reach the majority of Texas dentists. TDA Perks Partners, allied groups, and non profits receive discounts!

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CALENDAR OF EVENTS JUNE2014 6-7

The Texas Academy of General Dentistry will host its annual New Dentist Conference at the Omni Southpark Hotel in Austin, Texas. For more information, please contact Lindsey Robbins, Education Director at TAGD, 409 W Main St, Round Rock, TX, 78664; Phone: 512-2440577; FAX: 512-244-0476; Email: lindsey@tagd.org; Website: tagd.org.

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14

The TDA Smiles Foundation will hold a 14-chair Texas Mission of Mercy in Mineral Wells. For more information, please contact Foundation Manager Judith Gonzalez at TDASF, 1946 S IH35 Ste 300, Austin, TX 78704; Phone: 512448-2441; Email: judith@tda.org; Website: tdasmiles.org.

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The American Academy of Periodontology presents its annual meeting in San Francisco, CA. For

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of Prosthodontists, present

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OCTOBER2014 9-14

The American Dental Association presents its annual meeting at

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org; Website: perio.org.

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SEPTEMBER2014 8-13

The American Association of Oral and Maxillofacial Surgeons

THE TEXAS DENTAL JOURNAL’S CALENDAR will include only meetings, symposia, etc., of statewide, national,

presents its 96th annual meeting

and international interest to Texas dentists. Because of

at the Hawaii Convention Center in

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advertisements of courses that appear elsewhere in the Journal.

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ADVERTISING BRIEFS PRACTICE OPPORTUNITIES ABBEVILLE DENTISTRY: We are seeking an honest, hardworking, patient focused dentist who wants to contribute to a culture of caring, nurturing and skilled professionals.

If you have the desire to be a part of a team where you can focus on patients and not worry about the headaches that come with the business side of dentistry, please call us. If you are seeking an environment that provides stability, growth and continuing education, we’d like to share with you how you can fit into that plan. Twenty years ago, I started my practice simply dedicated to serving my patients and community. Now, I’m privileged to guide over 10 practices and 80 wonderful staff. I’ve turned the administrative, operations and marketing efforts over to people who enjoy doing those sorts of things so our doctors and staff can focus on their patients. I’ve also been able to provide young doctors with an environment where they can grow and practice what they love doing without the worry of costly overhead or administrative headaches. At the same time, we offer the potential for significant income and a great life balance. You’ll enjoy a great environment with no egos and no political barriers. We’re growing and need a few quality individuals to join us in creating something truly special. We’re forming a new, interactive, fun environment that kids and their parents will find refreshing and exciting.

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a call. I’d be happy to share the vision, the success and the expectations we have while answering your questions candidly and openly. I hope you’ll consider this position and give me a call. Britt Bostick, DDS. 806-438-5745 or email bbost35821@aol.com.

ADS WATSON, BROWN & ASSOCIATES: Excellent practice acquisition and merger opportunities available. DALLAS AREA: 5 general dentistry practices available (East Dallas, Richardson, Southeast of Dallas, and north of McKinney).

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ASSOCIATE FOR TYLER GENERAL DENTISTRY PRACTICE: Well-established general dentist in Tyler with over 34 years experience seeks a caring and motivated associate for his busy practice. This practice provides exceptional dental care for the entire family. 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. The practice offers excellent production and earning potential with a possible future equity position available. Our knowledgeable staff will support and enhance your growth and earning potential while helping create a smooth transition.

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

ASSOCIATE NEEDED FOR DENTAL OFFICE in small, quaint town. Potential for practice purchase. 361-645-8148.

AUSTIN: A busy pediatric dentistry office in Austin, TX is looking to add a general dentist. Please submit a resume via email to tal@austinchildrensdentistry.com.

AUSTIN: Progressive, patient-centric office is seeking an experienced dentist; must be friendly, caring and professional. Opportunity is available (if desired) for practice ownership. Serious inquiries email: fahoosha@ gmail.com, mike@miloinc.com.

AUSTIN PEDIATRIC PRACTICE SEEKING FULL TIME ASSOCIATE: Great benefits! Progressive, fast-paced practice. Capable, caring staff. We are looking for a bright

DDR Dental Trust

Serving Texas Dentists for more than 40 Years

• Practice Appraisals • Practice Sales • Associate Agreements

800-930-8017

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ADVERTISING BRIEFS 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. For consideration send your confidential resume to dentalresume27@yahoo.com.

AUSTIN PRIVATE PRACTICE SEEKS ASSOCIATES (GPs, Prosthodontists) due to growth and increased capacity.

Excellent compensation / benefits. Email resume to operations@omnidentalgroup.com or call 512-773-9239.

AUSTIN, SAN ANTONIO & DALLAS-AREA PRACTICE OPPORTUNITIES MCLERRAN & ASSOCIATES: CORPUS CHRISTI AREA (ID # T238): This established, fee-for-service general family practice is located in a single story professional complex with excellent visibility off of a major thoroughfare. The practice has 5 fully equipped and computerized operatories with digital x-ray. The practice boasts consistent gross collections over mid-6 figures annually, strong cash flow, a committed and well-trained staff, strong hygiene recall, and a solid fee-for-service patient base. This is a turnkey practice with strong growth potential. CORPUS CHRISTI AREA (ID #T231): This is an opportunity to purchase an established, general dentistry practice located on the south coast of Texas in an area that is experiencing rapid growth as a result of oil drilling in the nearby Eagle Ford Shale. The practice has a large, fee-forservice/PPO patient base, strong new patient flow, consistent annual revenue of approximately mid-6 figures, and solid cash flow. The office occupies a free-standing building with 2 fully equipped operatories (digital X-ray units and computers) and ample room to add 2-3 additional operatories. The real estate is owned by the seller and being offered for sale at fair market value. Given its close proximity to the Gulf of Mexico, this turnkey practice is an ideal opportunity for an avid fisherman/outdoorsman or beach lover. SOUTH OF SAN ANTONIO (ID #T235): This established general dentistry practice is located on a main thoroughfare in a quaint, rural town located approximately 90 miles southeast of San Antonio. This practice is in a high growth, low competition area in the Eagle Ford Formation.

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The practice has realized consistent annual revenue of approximately low-6 figures over the past 2 years while maintaining low overhead, strong profitability of 50%, and solid new patient flow. The office space of the practice encompasses 1,200 sq ft and has 3 fully equipped operatories with digital X-ray units and computers (one additional plumbed operatory for expansion). The building is also being offered for sale. NEW BRAUNFELS (ID #T226): This established, fee-for-service general family practice is located in the rapidly growing area of New Braunfels along the IH-35 corridor between Austin and San Antonio. The practice boasts a 100% fee-for-service patient base and is located in a free-standing building with 3 three fully equipped operatories. The practice is not in network with any PPOs and relies solely on word-of-mouth referrals for new patients, and refers out a substantial amount of specialty work, providing the new owner with solid upside potential. The annual revenue of the practice has consistently been just over low-6 figures per year. Excellent opportunity to purchase an established practice for much less than the cost of a start up! SAN ANTONIO (ID T239): A thriving multi-office pediatrics practice in the Seguin/San Marcos area is seeking a full-time associate to work between both locations. Both facilities are state-of-the-art, featuring 12 treatment areas and the latest amenities, including a movie theater, arcade, ceiling mounted televisions, and toddler play areas. Both offices are designed for high volume patient flow. The patient base reflects the local blue-collar and educational communities.

There is a mix of insurance, self-pay and state funded patients. The offices provide a full range of pediatric dental services and have very active sedation general anesthesia schedules. The associate doctor must be a graduate of a U.S. dental school and hold a U.S. pediatric dental training certificate. Spanish speaking is highly desired but not required. To learn more about this associate opportunity, please contact us at 512-900-7989 or texas@dental-sales. com. Please also send a current CV. SAN ANTONIO (ID #T218): This general family practice on the northwest side of San Antonio, just outside of loop 410, is located in a high traffic retail location and presents a unique opportunity to

ADVERTISING BRIEFS attract and retain patients. The practice is located in a turnkey, 7 operatory (6 equipped) office, boasts an active patient base. The practice has collected around high-6 figures over the last 12 months with strong cash flow. This is an excellent opportunity with tremendous upside potential.

Priced to sell! SAN ANTONIO (ID #T209): This established pediatric practice is located in east central San Antonio in a medical/dental building. The practice has seen consistent annual revenue of approximately mid-6 figures over the last 3 years with strong net income. The office has 3 fully equipped operatories, strong upside potential, and would be an attractive stand-alone practice or ideal satellite location. SAN ANTONIO (ID #T181): This general, family practice is located in west/central San Antonio and boasts a large, PPO/Medicaid patient base. This turnkey office is paperless and computerized, has 4 fully equipped operatories with recently updated equipment, and provides room for expansion. The practice has seen consistent annual revenue of approximately mid-6 figures over the past few years with strong net cash flow. This is an ideal solo practice or satellite office with tremendous upside potential. AUSTIN (ID T237): This is a rare opportunity to purchase an established perio practice with a large, diverse referral base, outstanding hygiene production (40% of total production), consistent annual revenue of seven figures, and exceptional profitability of over 60% of collections. The practice also offers tremendous upside potential by increasing production related to implant placement.

COUNTRY WEST OF AUSTIN (ID #T236) This predominately fee-for-service general family practice is located in a desirable community in the heart of the Texas Hill Country.

It boasts a great reputation and has been in its current location since 1980. The office has 3 fully equipped operatories, with the ability to add an additional operatory.

There is a strong opportunity for growth, as the owner is not actively marketing the practice, does not participate in any PPOs and is referring out a fair amount of specialty procedures. The practice has a strong foundation of active patients with a good amount of upside potential. This is an excellent opportunity for someone who enjoys the beautiful Hill County and wants to get away from the big city.

NORTHWEST AUSTIN (ID #T234) This established practice is located in a busy retail center in a rapidly growing community located just a few minutes Northwest of Austin.

The practice has a fee for service/PPO patient base, consistent annual collections of mid-6 figures, and strong upside potential. The office has a modern decor, 4 fully equipped operatories with computers and digital X-ray units, and room for expansion. The selling doctor is available for a transition. AUSTIN (ID #T233) Unique opportunity to purchase a high cash flowing prosthodontic and general practice, with a focus on implants, in rapidly growing Austin. The practice has excellent cash flow, high-end equipment, year-over-year growth and is truly a turnkey opportunity for the right doctor. For more information, please contact us immediately. AUSTIN (ID # T222) This is a unique opportunity to purchase a practice located in a busy retail center in Austin. The practice is ideal for a doctor or company looking for a large facility to establish a multiple doctor and hygienist office for less than the cost of building out a shell space and equipping a startup. The practice has a total of 18 plumbed operatories with 6 operatories currently equipped. The practice revenue was on pace to be around mid-6 figures in 2013 with only one doctor producing. Serious inquiries only as this is a unique opportunity not suited for most solo practitioners looking to acquire a practice. CENTRAL AUSTIN (ID #T225): Located in a very desirable area of north central Austin, this established fee-for-service general family practice offers a lot for an incoming dentist. The practice is located in a 1,500 sq ft, 4-operatory facility within a 2-story professional condominium building. The practice boasts a committed and well-trained staff, strong hygiene program, solid active patient base and gross annual revenues averaging over mid-6 figures over the last 3 years. While the practice is a strong opportunity â&#x20AC;&#x153;as-is,â&#x20AC;? an incoming owner doctor would have ample opportunity to grow the practice given that the current owner is not accepting any PPOs, relies only on word-of-mouth referral to generate new patient flow and is referring a significant amount of specialty work out of the office. Contact McLerran & Associates: David McLerran or Brannon Moncrief in Austin, Texas Dental Journal l www.tda.org l May 2014

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ADVERTISING BRIEFS 512-900-7989; San Antonio, 210-737-0100. Practice sales, appraisals, buyer representation, and lease negotiations. To request more information on our listings, register at dental-sales.com.

AUSTIN: A well-established pediatric practice is seeking an energetic dedicated full-time pediatric dentist. We have an extensive client base with continued growth. Our office is a leader in all aspects of pediatric dentistry including sedation and anesthesia dentistry. We have 3 offices with state-of-the art technology and a highly trained support staff. We are looking for the right fit for our practice. Ideally, someone who is looking for a long-term opportunity. New grads are welcome to apply. Please email resume to tal@ austinchildrensdentistry.com.

AWESOME PRACTICE IN EAST TEXAS FOR SALE: SLH is looking for a qualified associate or new graduate, with an option to buy, that would like the opportunity to immediately transition into a general dentistry practice 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 new member and future owner that will allow their current dentist to pursue other opportunities. The office space is 1,500 square feet with 4 treatment rooms equipped, 2 private offices, and 6 highly experienced employees. The new practitioner will lease space from the group dental practice. The group practice occupies a portion of the building complex and is looking to transfer ownership of the patient base and/or equipment within six months.

Listing #3050 CB. Pictures can be made available. For more information contact our office at 972-562-1072 or email sherri@slhdentalsales.com or visit our website at www. slhdentalsales.com.

COLORADO DENTAL PRACTICE FOR SALE. Located in southwest Colorado near the San Juan mountains. Ski, fly fish, hike, and hunt. Itâ&#x20AC;&#x2122;s all in your backyard. Established

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fee-for-service restorative practice with state-of-theart equipment and furnishings is waiting for you in this mountain town community. Collecting mid-6 figures with the potential to do way more. Owner is relocating to pursue a new phase in his dental career. Get of the Texas heat and the rat race and enjoy real living again. Practice is attractively priced to sell. Email inquiries to t1h2oyd3@ yahoo.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 email cjpatterson@ kosservices.com.

DALLAS AREA: New and beautiful general dentistry practice on I-30 near Rockwall. Over 5 years of clinical experience required. Perfect for dentists who refer endo!

Pay based on collections. PPO and Medicaid accepted.

M-F 2:00 PM - 8:00 PM and Saturdays available. Visit mockingbirddentalgroup.com.

DALLAS TOLLWAY & LBJ: Dentists needed part-time and full-time for new, extended-hours, high-production, treatment-oriented practice opening just prior to Memorial Day. Must be comfortable with most molar endo and wisdom tooth extraction cases. Implants experience a huge plus. Plenty of C&B. Dentures also an opportunity. 1099 contract position with generous commission. For immediate consideration, please email your CV and availability to CV@ erdentist.com.

DDR DENTAL â&#x20AC;&#x201D; AUSTIN: GENERAL PRACTICE. Wellestablished Austin practice in terrific north Austin location.

Well designed and decorated office. Fronts high-traffic Hwy 182. Four operatories in use and plumbed for 4 more. Mid6 figure gross and high net income. Free-standing building also available for sale. Contact Chrissy Roehm Dunn at 800-930-8017 or view the practice at DDRDental.com (DDR Dental Trust Member).

ADVERTISING BRIEFS DDR DENTAL — SOUTHWEST HOUSTON (FONDREN): GENERAL PRACTICE. High-7 figure gross with mid-high-6 figure net income. Four fully-equipped operatories on small inexpensive footprint. Well-established patient base.

Contact Chrissy Roehm Dunn at 800-930-8017 or view the practice at DDRDental.com.

DDR DENTAL — PANHANDLE TEXAS: ORAL SURGERY PRACTICE. Seven figure gross with expected high-6 figure net income. Four fully-equipped operatories with surgical suite. Option to purchase building also available. Wellestablished referral and patient base. Contact Chrissy Roehm Dunn at 800-930-8017 or view the practice at DDRDental.com. To obtain timely information about the practices that we have for sale and recently sold, please visit our website at DDRDental.com.

DENTAL PRACTICE FOR SALE: Retiring dentist offering 36 year-old one-chair practice with original equipment. Great potential for younger dentist who wants to work full-time.

Approx 900 sq ft with adequate space for 2nd operatory.

One employee with 36-years experience in this office.

Located in Muenster TX, a quaint small town, at 204 N. Main #C. About 70 miles north of Dallas near the Red River.

Two outstanding school systems both K-12. One private and one exemplary public. Two football and basketball teams. Very good hospital. Home of “German Fest,” a widely-known yearly celebration held each April in the New Heritage Park. Call (O) 940-759-2889 (H) 817-488-1207 Contact email: brnrd.luke@gmail.com.

DENTISTS: A practice of 1 year looking for a BC/BE pediatric dentist to come on board as employee with possible buy-in.

This is an all pediatric dentists’ office. You would be working next to a BC pediatric dentist. Good terms with great pay and work hours. Must be able to get Board Certified within 1 year. OR cases done at El Paso’s Children’s Hospital.

Excellent opportunity. Contact 719-671-5617 or tparco@ dentalquestions.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 email to jennifer@smileworkshop.com or call our office at 214-757-4500.

EAST TEXAS: Well-established dental practice seeks caring, proficient, and motivated dentist for associate employment.

Our office is located in a mid-sized town with abundant outdoor activities including hunting and fishing and a “small town” atmosphere. We offer all phases of dentistry.

Interested candidates should email correspondence and resume to mloon242@aol.com.

EDINBURG: Falcon Dentistry PA dba Falcon Dental Center seeks dentist in Edinburg. Doctor of Dental Surgery degree required. Texas dental license required. Qualified applications may submit resume directly to Atlantis Gloria Moya, office manager, via fax at 956-287-4926 or via email at falcondentistry@gmail.com.

EL PASO: Full-time position for a general dentist. Do not 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 fulltime in our office in El Paso. Applicant must be licensed in the state of Texas and have 1 year of experience. If interested please submit a resume with an accurate contact number and email address to the following: drdarj@gmail.com.

EL PASO: We are hiring a skilled and compassionate dentist to join our stable and successful practice. We are seeking a highly professional dentist with a knack for general dentistry. Prospective candidates must be dynamic, fun loving, and looking for a long term commitment. Our practice is highly productive affording our providers an opportunity to attain competitive compensation.

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ADVERTISING BRIEFS If interested, please forward your CV to annette@ vistahillsfamilydental.com.

EL PASO: Well-established general practice of over 30 years seeking full-time general dentist associate. Associate would be sole dentist at one of 2 office locations with full staff including hygienist. Income opportunity well above average.

Professional opportunity even greater. Send resume to drartbejarano@gmail.com.

ENDODONTIST â&#x20AC;&#x201D; FULL TIME, KILLEEN: Carus Dental, established in 1983 in Austin, has always been committed to the traditional doctor-patient relationship and to the highest quality in dental care and service. We currently have approximately 48 doctors on staff across our 21 practices in Austin, Houston and Central Texas. We offer dental services in general dentistry, oral surgery, orthodontics, pediatric dentistry, endodontics, periododontics and prosthodontics in some or all of our practices. Carus Dental has been accredited by the Accreditation Association of Ambulatory Health Care since 2000. We offer a competitive salary and excellent benefit package including a 401k, health insurance and a professional work environment. To learn more about American Dental Partners and Carus Dental please visit us at www.amdpi.com and www.carusdental. com. If interested, please send CV and cover letter to kateanderson@amdpi.com.

GALVESTON: Well-established, successful practice of 35 years needs FT 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. Visit www. todaysdentistrytexas.com. The Galveston area is just south of Clear Lake 25 minutes 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

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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! Email CV to kkcarroll10yahoo.com or call 832-385-8875.

GARY CLINTON DENTON AREA GENERAL PRACTICE FOR SALE: D-1 Denton Practice. Retiring dentist owns the facility. Five operatories; outright sale with transition; no low fee plans. Buy at a great price and build a successful practice. Contact Gary Clinton, 1-800-583-7765.

GARY CLINTON HOUSTON PRACTICE FOR SALE: H-2 Northwest Houston in Lake Houston area. Well-established practice with high 6-figure estimated gross on 3 days.

Excellent recall. This is a 7-figure practice waiting to happen. Trust your lifeâ&#x20AC;&#x2122;s work to the most experienced appraiser/broker. For over 40 years, you have seen the name, Gary Clinton, working as a management consultant, appraiser, consultant, and sales broker of general dental and specialty practices in Texas. I have buyers for all metro areas of Texas. Knowledgeable buyers are willing to pay the fair market value in growth areas commanding higher values. My certified appraisals use comparables from Texas practices in the same or similar parts of Texas. Senior appraiser, member of The Institute of Business Appraisers, Inc. Call Gary Clinton confidentially at 1-800-583-7765.

GARY CLINTON ORAL SURGERY PRACTICES: D-1 Dallas area. Very nice office; 2-day-a-week practice; excellent referral base. Under served area. SA-1 San Antonio Fast Growing Outlying Community. Lakes, hill country beauty; highly rated schools. Flexible transition. Will phase out PRN. High net on 4 days a week. Mid-sized community. W-1 West Texas central area. Oral surgeon retiring; flexible transition.

Seller phase out. High net. Mid-sized community. All are confidential. Gary Clinton, oral surgery broker/appraiser, 1-800-583-7765.

ADVERTISING BRIEFS GARY CLINTON DALLAS PRACTICE NEAR TRINITY RIVER GREENBELT FOR SALE. Doctor retiring for health reasons; well-established 30+-year-old practice. High demand.

Trust your life’s work to the most experienced appraiser/ broker. For over 40 years, you have seen the name, Gary Clinton, working as a management consultant, appraiser, consultant, and sales broker of general dental and specialty practices in Texas. I have buyers for all metro areas of Texas.

Knowledgeable buyers are willing to pay the fair market value in growth areas commanding higher values. My certified appraisals use comparables from Texas practices in the same or similar parts of Texas. Senior appraiser, member of The Institute of Business Appraisers, Inc. Call Gary Clinton confidentially at 1-800-583-7765.

GARY CLINTON PANHANDLE AND WEST TEXAS PRACTICES FOR SALE. W-1 7-figure collections, high net on 4 days a week. Only dentist in small community. Progressive family dentist retiring to travel. Upgraded equipment. Nice office. Doctor will sell or lease building. Trust your life’s work to the most experienced appraiser/broker. For over 40 years, you have seen the name, Gary Clinton, working as a management consultant, appraiser, consultant, and sales broker of general dental and specialty practices in Texas.

I have buyers for all metro areas of Texas. Knowledgeable buyers are willing to pay the fair market value in growth areas commanding higher values. My certified appraisals use comparables from Texas practices in the same or similar parts of Texas. Senior appraiser, member of The Institute of Business Appraisers, Inc. Call Gary Clinton confidentially at 1-800-583-7765.

GARY CLINTON FORT WORTH AREA, 2 excellent practices for sale. Well-established adult restorative practices.

Doctors are both retiring; both in great southwest area of Fort Worth. Trust your life’s work to the most experienced appraiser/broker. For over 40 years, you have seen the name, Gary Clinton, working as a management consultant, appraiser, consultant, and sales broker of general dental and specialty practices in Texas. I have buyers for all metro areas of Texas. Knowledgeable buyers are willing to pay

the fair market value in growth areas commanding higher values. My certified appraisals use comparables from Texas practices in the same or similar parts of Texas. Senior appraiser, member of The Institute of Business Appraisers, Inc. Call Gary Clinton confidentially at 1-800-583-7765.

GARY CLINTON PEDO/ORTHO OR GENERAL PRACTICE OFFICE SPACE: This is the spot to be. Close to Exxon’s new home office which has 15,000 employees. One space is totally finished out for pedo/ortho. One closest to headquarters is the last space; 2,800 sq ft. Build a practice from start that is a sure bet to be very successful. Call Gary Clinton, 214-503-9696.

GENERAL PRACTICE: Sugarland, Texas. Six-operatory practice for sale. Four operatories equipped; turnkey operations; 2013 collections were mid-6 figures. Working only 3 days per week; all equipment and building less than 2 years old. Very clean, very modern office; all digital. Great opportunity for any specialist as well as general dentist.

Asking $325K. For more info, please email sugarrichdental@ gmail.com.

GREAT DENTIST TO WORK WITH KIDS: Good opportunity for someone who likes children. Busy practice. Great personality. Competent dentist not afraid to work. Great pay. Sedation will be taught Send resume ASAP to Carol Erickson, info@txkidsdental.com, 9411 Alameda Avenue Ste P, El Paso, TX 79907. Call 602-309-2180.

HOUSTON: Well-established private endodontic practice seeking a quality-oriented friend and motivated endodontist for a part-time with full-time possilibities.

Equipped with Zeiss microscopes, CBCT, digital radiography, and electronic patient records. Please fax resume to 713572-3722 or send CV to manager@dentalendo.com 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 for energetic full-time general dentists and pediatric dentists to join Texas Dental Journal l www.tda.org l May 2014

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ADVERTISING BRIEFS our team. We offer a comprehensive compensation and benefits package including medical, life, long- and shortterm 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 kids of Texas. Please contact Anna Robinson at 913-322-1447; email arobinson@amdpi.com; FAX: 913-322-1459.

HOUSTON AREA PRACTICE OPPORTUNITIES! MCLERRAN & ASSOCIATES â&#x20AC;&#x201D; PRACTICE SALES OF TEXAS: NEW! HOUSTON: This general practice is located in a very welleducated, high-income area of Houston and is conveniently located close to 3 major highways. Collections have been steady over the past three years and 38% are hygiene collections. The practice features 2 operatories, 2 hygiene rooms and 1 unequipped operatory. This practice has seen approximately 1000 active patients in the past 24 months. (#H239) NEW! SOUTHEAST HOUSTON: Visible general/ pedo/oral surgery practice located on a major boulevard in the southeast Houston area in a recently built-out 3,500 sq ft lease space with 7 operatories, digital panoramic x-ray, and an inviting dĂŠcor. Strong net income for a buyer. With an excellent new patient flow of 60+ patients per month, a solid employment base, and numerous marketing opportunities, the practice has tremendous upside. (#H235) NEW! HOUSTON: Over 80% fee-for-service orthodontic practice in a highly visible, retail location along a main thoroughfare. With almost 3,000 square feet, 5 equipped treatment rooms, digital radiography, computers throughout, and a very elegant build-out, this office is turnkey; 2013 revenues and production increased over 26% from 2012. Great location with lots of future growth in the area. (#H245) NORTH OF HOUSTON: Established general cosmetic practice located in one of the fastest growing communities in the Houston area. The turnkey, five operatory facility has a comfortable, cozy ambiance, equipment that is in very good condition, room for expansion and solid growth potential. (#H234) NEW! NORTHWEST HOUSTON: Established orthodontic practice located in a fast growing area of Houston in a visible retail

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strip center. The facility is state of the art with high quality finishes, digital radiography (pan/ceph), and equipment that is in excellent condition. With a solid base of private pay patients, and a young family demographic, the practice has strong upside potential. 2013 revenues were over mid6 figures for the 7-chair facility, with room for expansion. (#H247) SOUTHWEST OF HOUSTON: Established general practice with a highly visible location, 4 operatories, strong employment base, and a healthy new patient flow with majority PPO/FFS. The owner is looking for an experienced practitioner that will exhibit an ownership attitude in order to maximize income for both parties. (#H193) SOUTHWEST HOUSTON: PPO/FFS practice, visible retail location on main thoroughfare in growing Southwest family oriented area. With low overhead, a recently remodeled interior, 3 operatories, and 1,100 square feet, the practice represents a value purchase with significant upside potential.

Recent website and social media platform development will also allow the buyer to effectively reach out to the community to further enhance patient flow. Very limited schedule for the owner and significant outbound referrals for endo, perio, oral surgery and orthodontics. (#H243) NORTHWEST HOUSTON: This general and orthodontic dentistry practice is located on a well-traveled road in the northwest Houston/Hockley area. The area is expected to grow tremendously over the next few years with the expansion of major roads in the area. The practice sees approximately 30 new patients per month and hygiene produces 27% of production. With a strong hygiene department, high new patient flow and low overhead, the practice is set for continued profitability and growth. (#H231) PRICE REDUCED! UPPER WEST GALVESTON BAY: Profitable general practice located in a highly visible office building in the heart of a vibrant oil and gas commercial center and community. 3 fully equipped operatories, strong hygiene revenues, and over 1,100 active patients. (#H194) NORTHEAST of HOUSTON: Established, extremely profitable general practice in single tenant, 3,400 sq ft professional building; 5 plumbed and equipped operatories, steady level of annual collections over past 4 years. (#H232) NORTHWEST HOUSTON: This general dentistry practice has

ADVERTISING BRIEFS established for 11 years in the northwest Houston area. The practice is located in a Kroger and CVS Pharmacy shopping center with great visibility and high foot traffic. The practice is conveniently located close to 3 major highways in the Houston area. (#H226) GALVESTON: Established fee for service practice, collections have been increasing in recent years and are consistently over 6 figures. With a solid economic base, the practice enjoys a strong recall system, an experienced and stable staff, and has seen over 2,500 patients in the last 24 months. The facility is free standing and has 8 equipped operatories with room for expansion (#H161) SOUTHEAST HOUSTON: Well-established general practice, located in highly visible shopping center, 5 operatories, stable patient base, room for expansion, comfortable dĂŠcor. (#H197) To see our most up to date listings, please go to www.dental-sales.com. Contact McLerran & Associates in Houston: Tom Guglielmo, Patrick Johnston, Mac Winston 866-756-7412 OR 281-362-1707, houstoneasttx@dental-sales.com. Practice sales, appraisals, buyer representation, and partnership consulting.

HOUSTON/CLEAR LAKE â&#x20AC;&#x201D; DENTAL OFFICE: In high visibility smaller professional building at highest traffic corner location in adjacent family oriented, high income master planned community. Adjacent CVS, nearby schools, retail and office centers, NASA and other long-term tenants (UTMB orthopedic and urgent childcare center, podiatrist and chiropractor) drive patient traffic. Nice finishes and all plumbing and electrical in place for 6 or more operatories, offices and consult rooms. Lease incentives, negotiable terms. Dwight Donaldson, Monument Real Estate, 281-2400077, ddonaldson@terramarktx.com.

HOUSTON-AREA PRACTICE OPPORTUNITIES! MCLERRAN & ASSOCIATES-PRACTICE SALES OF TEXAS: NEW! SOUTHWEST OF HOUSTON: Established general practice with a highly visible location, 4 operatories, strong employment base, and a healthy new patient flow with majority PPO/FFS. The owner is looking for an experienced practitioner that will exhibit an ownership attitude in order to maximize income for both parties. Partial buy-in

opportunity will be available in the future for the right doctor (#H93).

NEW! NORTH OF HOUSTON: This general family practice was started in 2008 when the seller purchased the existing build-out and equipment of an established dentist who relocated his practice. Upgrades include digital radiography (intraoral and panoramic) and flat screen TVs in the operatories. With an active base of over 800 patients, new patient flow of 25 patients per month, a visible retail strip center location, and opportunity for expanded office hours, growth potential is solid. Value acquisition with strong upside potential (#H236).

NORTHWEST HOUSTON ASSOCIATE POSITION WITH FUTURE BUY-IN: Established general dentistry practice is located near a high traffic intersection in the booming Northwest Houston/Copperfield area. Revenues in low 7-figures, a strong hygiene department, and a very healthy new patient flow, the practice is set for continued profitability and growth. (#H225) SOUTHWEST OF HOUSTON: Established general practice, 4 operatories, stable blue collar patient base, petrochemical economic base, 2,000 sq foot building available. Doctor working only part-time (#H174). To see our most upto-date listings, please go to dental-sales.com. Contact McLerran & Associates in Houston: Tom Guglielmo, Patrick Johnston, Mac Winston, 866- 756-7412 or 28-362-1707, houstoneasttx@dental-sales.com. Practice sales, appraisals, buyer representation, and partnership counseling.

HOUSTON ENERGY CORRIDOR. LOCATION, LOCATION, LOCATION. Employment based patient population in highly visible location within 1/2 mile or less of large multi-national oil services and technology companies.

Office is currently open 3.5 days/week. Substantial growth opportunity for full-time dentist as many nearby oil company employees work 24/7. Over 3,000 active patients, new patients growing at rate of 25 per month. First class equipment and build out, 4 operatories, below market rents in Kroger Signature retail center with additional retail space available in adjacent spaces(s) for expansion (up to additional 3,500 sq ft). Lots of upside potential! Practice for Texas Dental Journal l www.tda.org l May 2014

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ADVERTISING BRIEFS sale, but lease will also be considered. Please contact Toni Pham at 281.686.1280 or toni@toniphamlaw.com for more info.

IMMEDIATE OPENING FOR ASSOCIATION DENTIST. Busy, multi-location general practice providing care for the entire family with heavy emphasis on pediatrics, located in West Texas. Supportive owner/doctor and team makes this a great opportunity. Outstanding candidates only. Contact Terry@smilecraftersad.com or call 325-428-9973 for more information. FAX your resume to 325-646-0516.

LAREDO: We are looking for a pediatric dentist for a rapidly growing practice. Strong referral sources. Hospital cases performed twice a week at local hospital. State-of-the-art practice with digital X-rays and charts. If part-time, then dentist can fly in to see patients and still maintain living at their current city. Partnership in future is an option if candidate interested. Please email t2tpdlaredo@gmail.com.

LONGVIEW PEDIATRIC PRACTICE SEEKING FULL-TIME ASSOCIATE: Sherri L. Henderson & Associates, LLC is looking for a qualified associate to transition into an active pediatric dental practice. The associate will be working with a knowledgeable staff and a great new patient flow.

This practice is dedicated to performing high quality dental care for the children and adolescents of the surrounding communities. The dentist/owner established the practice 14 years ago, and offers a future opportunity to buy-in.

This beautiful pediatric practice is 5,000 sq ft, with 4 doctor chairs and 4 hygiene chairs, plus a quiet room and a new patient room. A full-time schedule of 4.5 days per week is offered, with salary based on 40% of production. Health insurance and benefit plans are negotiable. Listing #3435.

Photos available. For more information, please contact our office at 972-562-1072, email sherri@slhdentalsales.com, or visit our website at www.slhdentalsales.com.

MIDLAND: One of the fastest growing cities in Texas needs a dynamic, caring, patient-focused dentist to join our growing practice. Associate and buy-in opportunities are available.

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

NORTHEAST TEXAS DENTAL OFFICE FOR SALE: Private, free-standing, attractive, 1,300 plus sq ft, brick veneer office with concrete parking lot, a covered parking area and additional 320 sq ft storage, located on .5 acre newly landscaped lot, located on major U.S. highway in small town of approximately 5,000 population which as county seat of Bowie County serves a large drawing area. Office offers 3 plumbed ops, 2 completely equipped with Marus units and chairs (third op will be equipped upon request), digital x-rays, well-appointed reception room, business office, pano and recovery room, lab, private doctor’s office, utility room, and storage unit. All dental chairs, units, equipment, instruments, supplies, and furniture included.

Current appraisal is available upon request. Local dentists who were consulted regarding highest and best use of the office to further enhance their practices and offer services not now readily available in the community recommended seeking a practitioner to whom they could refer their non-Medicaid, pediatric patients that are currently having to be referred to doctors 20 to 35 miles away not only for general care, but also for ortho, and surgical procedures.

Excellent opportunity for start-up or satellite location. If the idea of living in a small, family-oriented community with a large drawing area, free of traffic jams, long daily commutes, smog free environment in the “green” part of the state surrounded by beautiful lakes where hunting, fishing, outdoor water sports, are readily available, while still being only a short drive to large town amenities sounds appealing, this could be the perfect match. If interested or you have further questions, please contact Dorothy Watts, widow of the late Dr Elie Watts, whose untimely death has caused this office to be offered for sale. Motivated to sell, owner will provide financing, if needed, and advertising budget to the right person. Call 903-278-4746 or email at dotwatts@gmail.com.

NORTH TEXAS: Pediatric dentist needed for busy north Texas practice. Enjoy life in Sherman, Texas, a family-

ADVERTISING BRIEFS oriented city conveniently located just 1 hour north of Dallas, but without the hustle and bustle of the big city!

Excellent practice opportunity for motivated and nurturing pediatric dentist seeking full-time associate with potential for partnership. Practice has a great reputation and is committed to providing quality comprehensive care for our patients and families in a fun and relaxed atmosphere.

State-of-the-art facility with highly trained and dedicated staff. Competitive compensation and benefits. Fee-forservice, limited Medicaid. Must possess high personal standards, strong work ethic, excellent technical and communication skills, and be willing to treat the full range of pediatric dental patients. Opportunities for in office conscious sedation, IV sedation and hospital dentistry.

Please email resume/CV to bth1@cableone.net.

OPPORTUNITY TO TRANSITION INTO A BUSY ORAL SURGERY PRACTICE within a multi-disciplined practice.

Present oral surgeon is retiring. Practice is private fee for service. New i-CAT (3D) in office. For information contact Paul Kennedy, DDS, at pkennedy@gte.net or 361-960-6484.

ORAL SURGEON NEEDED. Oral surgeon will be busy for a full day or two with implant and bone grafts. Competitive pay. Flexible in scheduling. Please call 361-387-3442.

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 214-460-4468; Rich@tx-pt.com.

PRACTICE FOR SALE SOUTHWEST OF FORT WORTH IN FAST GROWING AREA. Average Gross; 6 operatories; Excellent Lease. Seller is relocating. Need to move quickly on this one. DFW 214-503-9696. WATS 800-583-7765.

PRACTICE OPPORTUNITY: We are a Texas-based family group dental practice serving patients of all ages. With

a busy workload and high traffic, our needs extend to General Dentists, Orthodontists, Pediatric Dentists, and Endodontists. Qualified, compassionate and motivated doctors interested in opportunities to provide high quality care in communities in Texas may contact us. Our offices provide: State of the art, high-tech facility; in-house digital X-rays; paperless charting; 3-D models; digital tracing and imaging. Work alongside in-house board certified Pediatric Dentists, Oral Surgeons, Endodontists and General Dentists, allowing one to provide the absolute best care possible to even the most challenging cases. To join our team, please forward your CV to tx.dentistrygroup@gmail.com.

PRACTICE SALE HARKER HEIGHTS: General, in desirable, high traffic area. Approx. 2,700 sq ft w/ 6 ops. Referring out endo, ortho, oral surgery, and implant placement. 2013 GRs mid-six figures. Contact: JohnDavid.Harris@henryschein. com or 214.463.8145. #TX 101.

READY TO SELL â&#x20AC;&#x201D; CORPUS CHRISTI AREA: Sherri L. Henderson & Associates. The DDS is relocating to another city. This cosmetic and general dentistry 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. Listing #3070.

Pictures available. Contact 972-562-1072 or email sherri@ slhdentalsales.com. Visit www.slhdentalsales.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.

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ADVERTISING BRIEFS SAN ANTONIO: Pediatric dentist. Well-established and growing pediatric practice is seeking a caring and energetic associate for a full-time and part-time position. We offer excellent production with incredible earning potential, vacation and other benefits. New graduates are welcome.

Please submit your resume to velezluke@yahoo.com.

SLH DENTAL SALES (SHERRI L. HENDERSON & ASSOCIATES): Consulting and staging for your transition!

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.

ASSOCIATES, PARTNERS AND BUYERS AVAILABLE. Are you seeking an associate, partner, or buyer? SLH has qualified 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. CONTACT US. If you are unsure 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. All contact with you is strictly confidential. Call on our experience to assist you in making that transition dream become a reality. Call 972-562-1072 or email sherri@slhdentalsales.com, website slhdentalsales.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. Email CV to Dr Mike Kesner, drkesner@ madeyasmile.com.

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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. 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. HUNTSVILLE: Medium sized full fee patient base; digital x-rays; free standing building; long term staff; 4 days of hygiene per week. ARLINGTON: Highly visible large sized practice and building on major road; 6 equipped treatment rooms; digital x-rays; 100% paperless; mix of PPO and DHMO patients. EAST TEXAS: Small full fee patient base. Great building with water views from each of the 4 treatment rooms. VICTORIA: Medium sized practice; PPO patient base; free-standing building, long-term staff; doctor refers out lots of dentistry.

MIDLAND: Large sized practice; full-fee patient base; digital x-rays; modern free standing building; long term staff. EL PASO: East side; large practice; full fee patient base. EL PASO: West side; medium sized practice; mostly PPO patient base. OKLAHOMA: 1 hour outside OKC; large full-fee office, 5 treatment rooms, fantastic building; urgent sale situation.

THE HINDLEY GROUP, LLC â&#x20AC;&#x201D; DENTAL PRACTICE SALES: NEW LISTING! WEST HOUSTON PERIODONTIC PRACTICE FOR SALE: Located between Beltway 8 and Highway 6 off I-10, this practice has been in business for 33 years on the west side of Houston with 13 years at this location.

They currently have 1,500 patients with 25 new patients added per month for recall or treatment. The suite is a lease, available for renewal every 5 years, with 2,200 sq ft. This space includes 6 fully equipped operatory rooms, 3 recovery rooms, x-ray room, reception room, business office, private doctors office, staff area and two restrooms.

Using direct digital to provide immediate images using PCH Dental Software, PerioLase MVP7 with the LANAP protocol and PreXion 3-D Imaging Scanner with transferable licensing. Office hours are 4.5 days per week with 1 office manager, 2 full-time surgical assistants, 1 part-time hygienist and 1 part-time assistant manager. Very loyal and

ADVERTISING BRIEFS knowledgeable staff. NEW LISTING! SOUTHWEST HOUSTON GENERAL PRACTICE FOR SALE: Located inside the beltway in Bellaire, this is a very well established practice in business for 55 years and in the same location for the last 22; 1,188 square feet of practice space with 3 fully equipped operatories. Additional 471 square feet upstairs. Practice open 4 days per week, 9-5. Generating moderate revenues, the practice has 1,300 active patients with 13 new patients joining per month. Experienced staff. Doctor is retiring and is anxious to effect a transition to a well-qualified general dentist. This is a wonderful in-town practice at a most reasonable price and a great platform from which to build for the future! Doctor would also like to sell the real estate with the practice. NEW LISTING! HOUSTON-CLEAR LAKE, ORTHODONTIC PRACTICE: Close to Intermediate School and Johnson Space Center. Retiring orthodontist desires to sell remaining patients, equipment and centrally located office condominium of 1,160 sq ft. Optimum purchaser candidates would include: an orthodontist wanting a larger location, an orthodontist desiring a satellite location, or an orthodontist wanting to grow a practice in this affluent Houston area.

Perfect for a new resident graduate wanting to be in the strong Houston economic environment! WEST HOUSTON GENERAL DENTAL PRACTICE FOR SALE: Small general dental practice with high percentage restorative revenues. Average 8 new patients per month. 2 fully equipped operatories with 1 additional hygiene room and another room plumbed for expansion. Digital Pano. Same location for 13 years.

Cash and Insurance revenues. Motivated seller! Excellent opportunity for start up at low cost. SOUTH OF HOUSTON, TEXAS COASTAL PLAINS GENERAL DENTAL PRACTICE FOR SALE: Well-established for 28 years and in same location for last 17. Strong revenues and healthy profit margin on 4 days per week! 2,500 sq ft building with 4 fully equipped operatories also for sale. Experienced, dependable staff.

Great opportunity! WEST CENTRAL TEXAS GENERAL DENTAL PRACTICE: 25-year-old well-established family dental practice for sale. Open 4.5 days per week. 2,400 sq ft building with 4 fully equipped operatories. 3 direct digital X-Ray units in operatories plus numerous other upgrades to

equipment and building, which is also for sale. Steady new patient growth and outstanding staff. Call 800-856-1955 or email kate@thehindleygroup.com.

THE HINDLEY GROUP, LLC â&#x20AC;&#x201D; DENTAL PRACTICE SALES: NEW LISTING! NORTH HOUSTON, ENDO PRACTICE: Highly regarded endodontist selling well established practice due to family relocation. Seven figures in revenues on 3 days per week with very strong profit margin. Friendly, knowledgeable staff. NEW LISTING! THE WOODLANDS, TEXAS, GENERAL PRACTICE: This 44 year old practice has been located in a wonderful Woodlands location for the past 9 years! This general dental practice is open 4 days per week, operating from 2,395 sq ft with 3 fully equipped fully digitized operatories. Upper-Middle class patient demographic, FFS with mostly insurance and some cash revenues. Lower revenues due to lack of marketing and declining health of owner. Substantial upside opportunity! Must Sell! NEW LISTING! SOUTH HOUSTON, ORTHO PRACTICE: Retiring orthodontist desires to sell remaining patients, equipment and centrally located office condominium of 1,160 sq ft. Optimum purchaser candidates would include: an orthodontist wanting a larger location, an orthodontist desiring a satellite location, or an orthodontist wanting to grow a practice in this affluent Houston area. Perfect for a new resident graduate wanting to be in the strong Houston economic environment!

NORTHWEST HOUSTON GENERAL DENTAL PRACTICE: Well established, very traditional practice with moderate fee for service revenues and healthy profit margin. Open 4 days a week. 1,200 square foot facility with 3 fully equipped operatories. Doctor retiring. NORTH OF HOUSTON GENERAL DENTAL PRACTICE: Very well established practice in the same location for 31 years. Moderate cash revenues with some PPO insurance. Practice open 4 days per week. 2,200 sq ft with 2 fully equipped operatories and 3 additional plumbed. Loyal, experienced staff. Doctor is retiring. Call 800-856-1955 or email kate@thehindleygroup.com

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ADVERTISING BRIEFS WACO: Great associate opportunity. Waco practice looking for motivated associate with a desire to join a PPO/fee-forservice practice. Great pay, great work environment with two other dentists and top notch staff. Please contact Dr Johnson at 435-237-2339 or email at johnson.2978@gmail. com.

WE ARE SEEKING A FULL-TIME GP to join our state-ofthe-art, fast-growing, digital office. Once you join us, you will have the full support of our loving and friendly staff and management, as well as the newest dental equipment. We use electric handpieces, isolites, dental vibes, digital intra-oral cameras and digital x-rays, as well as many more of the latest dental technology. We are in full compliance with the latest requirements by the TSBDE, with excellent growth potential. Plase feel free to contact me if you have any questions. Our offices are very laid back, family friendly environment. Please forward your CV to bwolfrodeodental@gmail.com

OFFICE SPACE ABILENE: 2- to 4-operatory stand-alone dental office with all equipment included; digital x-ray and pano. Call 325-7620444.

DALLAS AND ROCKWALL: Orthodontic or other specialty office for lease to share with owner. Furnished and equipped. Dallas office is 4,000 sq ft in Lake Highlands area with 2,500 sq ft leasable residence above. Rockwall office is 1,800 sq ft in antique building and furnishings. Email rcppc@sbcglobal.net.

HOUSTON / LEAGUE CITY: Medical/office space available for lease in a stellar location, right outside the largest school in Texas with 4,200 students on campus. In a fast growing area with a lot of young families, located close to the waterfront, boardwalk, Gulf Coast beaches, Houston downtown, NASA and Hobby Airport. Home to one of the stateâ&#x20AC;&#x2122;s top rated Independent school districts, stunning yet affordable waterfront neighborhood developments, NASA,

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BOEING, UTMB. Contact Vijay Bhagia 832-618-0652 or eduvillageland@gmail.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 web site at www.lewishealth. com for current opportunities. For additional information, contact Dan Lewis at Lewis Health Profession Services 972437-1180 or dan@lewishealth.com.

ORTHO OFFICE SPACE FOR LEASE. Are you a new orthodontist wanting to start a practice but canâ&#x20AC;&#x2122;t afford a full-time lease? Are you an established orthodontist who would like a satellite office? I am a pediatric dentist in Pinehurst. My office is usually closed Friday to Sunday.

I have a beautiful 5,200 sq ft office that would be a great option for an orthodontist. Lease fee would be negotiable depending on how many days per month you need. Orthodontist would be responsible for all equipment, supplies and staff. You may view my office at stagecoachdental.com. If interested, please email me at drcoe@stagecoachdental.com.

SAN ANTONIO 4-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 email tiffini@dominiondentalspa.com.

ADVERTISING BRIEFS SEGUIN: Orthodontic office space for lease in. Office was phased down when orthodontist retired. Office is equipped and functional. Great for a start up or a satellite location.

Email inquiries to lmassadds@gmail.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.

IMTEC IMPLANT SYSTEM. $600, 24 implants, torque wrenches, surgical items and adapters, sterilization kit, instruction disk. Never used. Integral implants. $200, 11 coated implants and surgical drills, placement and retrieval instruments. $500 (regularly $1,500), 4 Misch basic setup physics forceps. Contact Dr. James Grogan, 469-585-9622, docharleyday@sbcglobal.net.

INTERIM SERVICES HAVE MIRROR AND EXPLORER, WILL TRAVEL: Sick leave, maternity leave, deployment, vacation or death, I will cover your office. Call Robert Zoch, DDS, MAGD, at 512-263-0510 or drzoch@yahoo.com.

OFFICE COVERAGE for vacations, maternity leave, illness.

Protect your practice and income. Forest Irons and Associates. “Dentists Helping Dentists Since 1983.” Call 800433-2603 (EST). Visit www.forestirons.com.

MISCELLANEOUS DENTIST/CONSULTANT: Part-time (min 4 hrs/day) for national claim review company. Work form your home or office. Must have active Texas dental license. Fax resume to 212-686-4703.

IV SEDATION TRAINING FOR DENTISTS. This “miniresidency” includes 60 hours of didactic and the administration of IV sedation to at least 20 dental patients while supervised. Program meets requirements to obtain TSBDE Permit Level III for Moderate Sedation. Houston, TX, September 2014, 888-581-4448, www.SedationConsulting. com.

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 800383-3408; Web: schoolofdentalassisting-northdallas.com.

PLACE A CLASSIFIED AD IN THE

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CONTACT

For more information, please visit tda.org or contact Billy Callis at 512-443-3675 ext 150 or by email: bcallis@tda.org.

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

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

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410 730

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ADS Watson, ......................690 ADS WatsonBrown Brown&&Associates Associates ...............353 AFTCO ....................................................................667 AFTCO ............................................................346 A.J. Riggins ............................................................661 American Academy of Facial Esthetics ...............668 Anesthesia Education & Safety....................352 Anesthesia Education and Safety Foundation ..........................................................664 Bhola, DJ, CPA, P.C. ......................................381 DDR Dental Trust ...................................................727 Best DentalCard........................................................385 Handpiece Repair Guy ..............................669 Dental Post .............................................................678 Clinton, Gary ..................................................383 Dental Practice Specialists ...................................705 Dental Spots .......................................................Insert Dental Credentialing of Texas ......................381 Dental Systems ......................................................680 DDR Trust ...........................................395 DentalDental 3D Solutions ...............................................667 Dental Trust ............................................................691 E-VAC, Inc. .....................................................348 DJ Bhola CPA.........................................................661 Fortress Insurance ................................................654 Hamilton, Small and Associates ..................339 Gary Clinton — PMA .............................................658 Hanna, Mark——Attn.

Attn.

Law .........................348 Hanna, Mark at at Law .................................706 HighTex...................................................................661 Hindley Group ................................................342 Hindley Group ........................................................680 JKJ Pathology........................................................668 JKJ Pathology................................................349 Kennedy, Thomas John, DDS, P.L.L.C. ................707 Mariner Dental Laboratory ............................347 Medical Protective .................................................651 North Dallas Anesthesia .......................................678 OSHA Review ....................... Inside Back Cover Ocean Dental..........................................................655 OSHA ............................................

Inside Back Cover Paragon ..........................................................353 Paragon ..................................................................691 Professional Recovery Network...................410 Patterson Dental ..........................Inside Front Cover Professional Recovery Network...........................730 Sherri L. Henderson & Associates ...............345 Professional Solutions..........................................662 Resolve Dental Lab ...............................................706 Special Care Dentistry ..................................385 Shepherd, Boyd W. ................................................681 TDA Services Insurance SherriFinancial L. Henderson & Associates .......................657 Smart Training, LLC ..............................................706 Program ..................................342/Back Cover Smile Brands/Bright Now Dental .........................662 TDA Financial Services............Inside Insurance TDA Perks Program Front Cover Program ..........................................654/Back Cover Texas DentalSpotlight Journal..........................................702 Classifieds.................408 TDA Member TDA Perks Program ...............................................663 Texas Dental Journal Member Spotlight .............382 Texas Dental Journal Classifieds.........................729 Texas Dental Display Ads .......................705 Texas HealthJournal Steps ........................................343 TEXAS Meeting ......................................................659 UTHSC San Antonio Dental School .............375 UTHSCSA Dental School ......................................665 UTHSCSA / South Texas Pathology Lab .............661 UTHSCSA / South Texas Pathology Lab .....385 Veatch Consulting .................................................669 Waller, Joe Waller, Joe..............................................................681 ......................................................349

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