April 2010

April 2010

Journal TEXAS DENTAL

Removable Partial Dentures — Treatment Now and for the Future Functional Impressions for Complete Denture Fabrication A Modified Jump Technique

Edentulism and Comorbid Factors

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xa Texas Dental Journal l www.tda.org l April 2010 Te

349

2011 save the

date

5-8

may

san antonio, tx

The Texas Dental Association’s ADA Golden Apple award-winning website is the official website of the Texas Dental Association.

Log in using your ADA # with dashes (123-45-6789) and TX + license number for your password, with TX in caps (TX1234) The member side is for TDA member dentists and Texas dental students. It includes top stories and TDA news, an online job board, upcoming meetings and events, the online discussion group “Ask a Colleague,” online member dues, TDA publications and references, component society web pages, personal web pages, a searchable member directory and contact information. Members can also update their personal contact information online.

The public side of TDA’s website is for patients and the public, non-member dentists and non-dentist dental professionals.

It includes information about TDA, how to join TDA, general oral health information, resources for dental insurance, financial help, charitable activities, careers in dental health, TDA contact information, and a “Find a Dentist” search function.

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ARCHIVES Dr. John Findley Elected ADA President-elect New TDA Website!

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The DENPAC website (denpac.org) offers general information about DENPAC, legislative, leadership, and contact information, news articles and membership information. Users can also sign up as DENPAC club member online.

The TDA Smiles website (tdasf.org / tdasmiles.org) includes program information on oral health education, Texas Mission of Mercy (TMOM), and Donated Dental Services (TXDDS). It also includes a calendar of upcoming events, history, and contact information. Users can also sign up for upcoming events and make contributions online.

The Freedom-of-Choice Dental Plan website (freedom-of-choicedental.com / paiddental.com) offers detailed information on Direct Reimbursement and Paid Dental.

The TDA Perks Program website (tdaperks.com / tdamemberbenefits.com) includes links to all TDA Member Benefits Endorsed Vendors, Board of Directors contact information, and additional helpful articles.

The TEXAS Meeting website (texasmeeting.com) allows users to register for courses and housing for the TEXAS Meeting, as well as access general information, education, travel, special events, exhibits, and governance information.

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

Contents

TEXAS DENTAL JOURNAL n Established February 1883 n Vol. 127, Number 4, April 2010

NOTICES

357 361

Official Call to the 2010 TDA House of Delegates Upcoming ADA Appointive/Elective Positions Notice

ARTICLES

365

Removable Partial Dentures — Treatment Now and for the Future

John D. Jones, D.D.S.; Ilser Turkyilmaz, D.D.S., Ph.D.; Lily T. Garcia, D.D.S., M.S.

377

Functional Impressions for Complete Denture Fabrication

Stephan J. Haney, D.D.S, Roxanna Nicoll, D.D.S., Michael Mansueto, D.D.S., M.S.

Dr. Haney et al. describe a modified jump technique for remaking complete dentures.

389

Edentulism and Comorbid Factors

David A. Felton, D.D.S., M.S.

Dr. Felton reviews comorbid factors that exist for the completely edentulous patient. Reprinted with permission. Journal of Prosthodontics, copyright American College of Prosthodontics. Published by Wiley-Blackwell.

352

Dr. Jones et al. review four removable partial denture treatment modalities that represent viable treatment options for the partially edentulous patient.

Texas Dental Journal l www.tda.org l April 2010

MONTHLY FEATURES

356

The President’s Message

360

The View From Austin

404 406 410 412 414 422

Dental Artifacts

424 427 428 442

Calendar of Events

BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION President Matthew B. Roberts, D.D.S. (936) 544-3790, crockettdental@gmail.com President-elect Ronald L. Rhea, D.D.S.

(713) 467-3458, rrhea@tda.org

TEXAS Meeting Preview

Immediate Past President Hilton Israelson, D.D.S.

In Memoriam / TDA Smiles Foundation

(972) 669-9444, drisraelson@yahoo.com Vice President, Southeast Craig S. Armstrong, D.D.S.

Oral and Maxillofacial Pathology Case of the Month

(832) 251-1234, carmst@aol.com

Value for Your Profession

Vice President, Southwest Johnny G. Cailleteau, D.D.S.

(915) 581-3391, endoman@att.net

Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management

Vice President, Northwest J. Brad Loeffelholz, D.D.S.

(817) 924-0506, jbldds@birch.net Vice President, Northeast Arlet R. Dunsworth, D.D.S.

What’s on tda.org?

(214) 363-2475, arletd@sbcglobal.net

Advertising Briefs

Senior Director, Southeast R. Lee Clitheroe, D.D.S.

(281) 265-9393, rlcdds@adamember.net

Index to Advertisers EDITORIAL STAFF

Stephen R. Matteson, D.D.S., Editor Nicole Scott, Managing Editor Barbara S. Donovan, Art Director Paul H. Schlesinger, Consultant

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

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

Senior Director, Southwest John W. Baucum III, D.D.S.

Texas Dental Journal (ISSN 0040-4284) is published monthly, one issue will be a directory issue, by the Texas Dental Association, 1946 S. IH-35, Austin, Texas, 78704-3698, (512) 4433675. Periodicals Postage Paid at Austin, Texas and at additional mailing offices.

POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S. Interregional Highway, Austin, TX 78704.

Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, Out-of-state ADA Affiliated $49.50. In-state 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 Non-ADA Affiliated. For in-state orders, add 8.25% sales tax.

Contributions: Manuscripts and news items of interest to the membership of the society are solicited. The Editor prefers electronic submissions although paper manuscripts are acceptable. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. For more information, please refer to the Instructions for Contributors statement printed in the September Annual Membership Directory or on the TDA website: www.tda.org. Every effort will be made to return unused manuscripts if a request is made but no responsibility can be accepted for failure to do so. 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.

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

aa de

(361) 855-3900, jbaucum3@msn.com Senior Director, Northwest Kathleen Nichols, D.D.S.

(806) 698-6684 toothmom@kathleennicholsdds.com Senior Director, Northeast Donna G. Miller, D.D.S.

(254) 772-3632 dmiller.2thdoc@grandecom.net Director, Southeast Karen E. Frazer, D.D.S.

(512) 442-2295, drkefrazer@att.net Director, Southwest Lisa B. Masters, D.D.S.

(210) 349-4424, mastersdds@mdgteam.com Director, Northwest Robert E. Wiggins, D.D.S.

(325) 677-1041, robwigg@suddenlink.net Director, Northeast Larry D. Herwig, D.D.S.

(214) 361-1845, ldherwig@sbcglobal.net Secretary-Treasurer J. Preston Coleman, D.D.S.

(210) 656-3301, drjpc@sbcglobal.net Speaker of the House Glen D. Hall, D.D.S.

(325) 698-7560, abdent78@sbcglobal.net Parliamentarian Michael L. Stuart, D.D.S.

(972) 226-6655, mstuartdds@sbcglobal.net Editor Stephen R. Matteson, D.D.S.

(210) 277-8595, smatteson@satx.rr.com Executive Director Mary Kay Linn

(512) 443-3675, marykay@tda.org Legal Counsel William H. Bingham

(512) 495-6000 bbingham@mcginnislaw.com

Texas Dental Journal l www.tda.org l April 2010

353

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Texas Dental Journal l www.tda.org l April 2010

355

President’s Message Matthew B. Roberts, D.D.S., TDA President

In less than a month, the Texas Dental Association will gather once again in San Antonio to conduct the business of this organization.

I have traveled across this great state and visited the members who daily represent the best that dentistry has to offer. I have also been fortunate to travel outside of Texas and see firsthand the many different ideas and goals of our colleagues across the country.

So what have I learned this past year in my travels as president? At the risk of being accused of bragging or stretching the truth, here are a few thoughts.

We have a great staff that supports our membership and the policies of the Texas Dental Association every day. The effort to get it right and on time is part of the very fiber with which they go about their job. The TDA Board of Directors, the council and committee members, and all of the other volunteer dentists who give of their time to this Association are unequaled in their efforts to make dentistry the best profession in this state, and in my opinion, make the State of Texas the best place to practice dentistry. The enthusiasm and optimism of the newest members of our profession give me great hope that our future is in good hands.

While the State of Texas is in good hands, there are challenges we must face in the future. President

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Texas Dental Journal l www.tda.org l April 2010

Abraham Lincoln once said, “Always bear in mind that your own resolution to succeed is more important than any other.” In order to be successful, we must identify and plan for the future we see coming. The word “proactive” is tossed about quite often to define where and how we must go. I believe we can and will identify those issues which will stretch and challenge our future road. Having laid the foundation for success by being proactive will not alleviate the necessity to be nimble and reactive. If there is one bit of knowledge that I have gained over my year as president it is this — what you plan for and what actually happens are often completely different. How one reacts to the changing environment makes proactive planning look successful. Will we be successful in all we attempt? Not likely.

Have we strategically planned to meet the challenges?

Absolutely. Will everyone be happy? No way. Bill Cosby was once asked what the key to success was. He responded, “I don’t know the key to success, but the key to failure is trying to please everybody.” The leadership, the membership, and the staff all want success for the Texas Dental Association. I believe we have been and will continue to be a successful association.

This month’s Journal will focus on prosthetics and feature articles dealing with removable partials, functional impressions, and post and core issues. The Texas Dental Journal continues to be a visible representation of dentistry in Texas, and I am grateful for the quality and professionalism contained in these monthly pages. Enjoy the articles and continue to be successful in all you do.

Official Call to the 2010 Texas Dental Association House of Delegates HOUSE OF DELEGATES: In accordance with Chapter IV, Section 70, paragraph A of the Texas Dental Association (TDA) Bylaws, this is the official call for the 140th meeting of the Texas Dental Association House of Delegates. The opening session of the House will convene at 8:00 a.m. on Thursday, May 6, 2010, in Ballroom B on the street level of the San Antonio Convention Center in San Antonio, Texas. The second meeting of the House will be at 8:30 a.m. on Saturday, May 8, 2010, in Ballroom B. The Sunday, May 9, 2010, meeting will be in the Marriott Rivercenter Hotel, starting at 8:30 a.m.

REFERENCE COMMITTEE HEARINGS: Reference Committees will meet on Thursday, May 6, 2010, in the Convention Center (please see the on-site program for specific room assignments). Reference Committee A will start at 11:00 a.m. or 15 minutes after the adjournment of the House of Delegates, whichever is later. Reference Committee E will start at 12:00 noon. Reference Committee B will start at 1:00 p.m. Reference Committee C will start at 1:30 p.m. Reference Committee D will start at 2:00 p.m. The agendas for these meetings will be sent to the Delegates and Alternate Delegates prior to the meetings.

REFERENCE COMMITTEE REPORTS: Reference Committee Reports will be available on Friday, May 7, 2010, at 9:00 a.m. outside Room H062, the TDA Convention Office in Exhibit Hall C, and may be downloaded at TDA’s Internet CafÊ near the entrance to the exhibits.

CANDIDATES FORUM: As a reminder, the TDA / ADA Candidates Forum will be held on Friday, May 7, 2010, from 3:00 p.m. to 4:00 p.m. in the Convention Center (please see the on-site program for specific room assignment).

DIVISIONAL CAUCUSES: Divisional Caucuses (Northwest, Northeast, Southwest, Southeast) will be held at 5:15 p.m. on Friday, May 7, 2010 (please see the on-site program for specific room assignments).

DELEGATE BOOK: In accordance with TDA Bylaws, the Delegate Book will be sent 30 days prior to the Annual Session. The supplement to the Delegate Handbook, containing the agenda and subsequent reports, will be sent after the spring TDA Board of Directors meeting, March 26-27, 2010. Delegates and alternates will receive their House book in a searchable PDF format.

Texas Dental Journal l www.tda.org l April 2010

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Texas Dental Journal l Journal www.tda.org l April 2010 Dental l May 2009 TexasTexas Dental Journal l February

359 403 139

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

“Goal” A very loud hockey announcer

screams after the puck zips by the goal tender. Fans go wild, especially if the home team has just scored, and hugs go around by the scoring team.

Then come the close-up pictures of the smiling team members and there are all those missing teeth; nobly lost during a past encounter with a hockey stick or a fist during a fight with an opponent. There must be a bunch of removable partial dentures in those locker rooms. A former colleague of mine at the University of Connecticut was a hockey fan and was the team dentist for the Hartford hockey team. His stories about dental trauma during games were engaging as he relayed his experiences doing “immediate tooth replantations” during the contests. He said it worked pretty well. The use of mouthguards in professional hockey seems

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to be a personal decision by the players. Some do, many don’t.

The feature articles this month are on the subject of prosthodontics. Authors at the University of Texas Health Science Center Dental School, Dr. Jones and colleagues, report on current technologies for the fabrication of removable partial dentures using dental implants to enhance their stability, and Dr. Haney and his co-authors describe a functional technique for the fabrication of full dentures.

Thank you to Dr. David Felton at the University of North Carolina for his permission to reprint his article originally published in the Journal of Prosthodontics.

His paper explores the aspects of general health that relate to edentulism.

Changing the subject, the upcoming Annual Meeting of the Texas Dental Association in

May will be in my hometown, San Antonio, and will mark the end of my first year as your Editor. I hope you will be attending the sessions and enjoy the many continuing education courses and social events. You will also find that an extension of the River Walk has been completed.

Your suggestions and feedback about the Journal would be most welcome. Please stop by my table up front at the delegates meeting and say hello.

Also, let me point out to readers the “Going Green” poster on page 419. This could be a useful item to post in your dental office informing patients about the “green practices” in the office. Go to the online Journal at tda.org/tdapublications and click on page 419 to download this poster.

See you soon.

Notice:

Upcoming ADA Appointive / Elective Positions 1. ADA Council Appointments: Our trustee, Dr. S. Jerry Long, forwards the names of interested and able persons to the ADA for consideration for these appointments. Dr. Long’s next opportunity for recommending an individual will be to the Council on ADA Sessions and Council on Access, Prevention and Interprofessional Relations.

2. ADA Delegate and Alternate Delegate positions: Become available annually; work through your local Society to be nominated at the division caucus in May in San Antonio.

3. ADA Trustee-elect: This is the year for individuals interested in serving as the next ADA Trustee to make that intent known by submitting in writing a statement of your intent along with your credentials to the TDA Secretary/Treasurer to be received by July 30, 2010.

The individual to be put forth by the 15th District Delegation is selected at the second delegation caucus in August 2010. Trustee election will take place at the ADA Annual Meeting in Las Vegas in October 2011.

4. ADA 2nd Vice President: This position is available on an annual basis. Make your interest in this position known to the Planning and Review Committee as early as possible prior to July 1, 2010, if you want to present a brochure.

Contact Dr. Long immediately or contact the Planning and Review Committee of the 15th District Delegation through Donna Cortez, (800) 832-1145.

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Texas Dental Journal l www.tda.org l April 2010

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Texas Dental Journal l www.tda.org l April 2010

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Texas Dental Journal l www.tda.org l April 2010

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Removable Partial Dentures — Treatment Now and for the Future John D. Jones, D.D.S.; Ilser Turkyilmaz, D.D.S., Ph.D.; Lily T. Garcia, D.D.S., M.S.

Introduction removable partial dentures have been used since the mid19th century, and with the development of porcelain teeth by s.s. white and Vulcanite rubber by B.F. Goodyear, both removable partial dentures and complete dentures gained broader use. Since then, significant developments in materials, techniques, designs, and impression materials have occurred that have improved the quality of the removable partial dentures (rPDs) and the lives of partially edentulous patients. this article describes four removable partial denture treatment modalities that represent viable treatment options for the partially edentulous patient well into the future.

Implant Supported RPD Partially edentulous patients with a poor prognosis and minimal number of remaining teeth for a conventional rPD can now have an excellent prognosis with the advent of osseointegrated dental implants.

Jones

Turkyilmaz

Garcia

John D. Jones, D.D.S., Professor, Department of Prosthodontics, University of Texas Health Science Center at San Antonio Dental School San Antonio, Texas.

Ilser Turkyilmaz, D.D.S., Ph.D., Assistant Professor, Department of Prosthodontics, University of Texas Health Science Center at San Antonio Dental School, San Antonio, Texas.

Lily T. Garcia, D.D.S., M.S., Professor and Chair, Department of Prosthodontics, University of Texas Health Science Center at San Antonio Dental School, San Antonio, Texas.

Correspondence: Dr. John D. Jones, Department of Prosthodontics University of Texas, Health Science Center at San Antonio Dental School, 7703 Floyd Curl Drive, MSC 7912, San Antonio, Texas 78229-3900, Phone: (210) 567-6450 • Fax: (210) 567-6376 email: jonesjd@uthscsa.edu

Abstract The use of a removable partial denture (RPD) in clinical practice remains a viable treatment modality.

Various advancements have improved the quality of a RPD, subsequently improving the quality of life for the individuals that use them.

This article describes four removable partial denture treatment modalities that provide valuable treatment for the partially edentulous patient. These modalities include: the implant supported RPD, attachment use in RPDs, rotational path RPDs, and Titanium and CAD/CAM RPDs. Data on future needs for RPDs indicate that while there is a decline in tooth loss in the U.S., the need for RPDs will actually increase as the population increases and ages. With the growth in the geriatric population, which includes a high percentage of partially edentulous patients, the use of RPDs in clinical treatment will continue to be predictable treatment option in clinical dentistry.

KEY WORDS: RPD, implant, CAD/CAM, retention, mandible, maxilla Tex Dent J;127(4):365-372.

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Removable Partial Dentures — Treatment Now

Figure 1. Locator abutments on dental implants in a partially edentulous patient.

Implant use in removable partial denture therapy enhances retention and vertical support compared with a standard tooth/ tissue supported RPD (Figures 1, 2). The use of dental implants with a retentive component stabilizes the RPD and improves esthetics by the elimination of clasps on adjacent natural teeth.

For years the design and maintenance of distal extension removable partial dentures have been recurring problems for practitioners (1). The forces of mastication may affect the supporting teeth, mucosa, and underlying residual alveolar ridges that provide valuable hard and soft tissue support for a distal extension

Figure 2. Locator attachments in a distal extension removable partial denture.

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RPD. Denture base stability and support are affected by the fit of the framework, extent of denture base design, and the amount of displacement of the RPD. The use of dental implants reduces the vertical displacement and functional movements of the RPD by providing vertical stops under the distal extensions.

Although attachments or conventional clasps that have been used widely and denture bases that are well-adapted to the supporting soft- and hard-tissue structures contribute to reducing RPD movement under function, these forces cannot be eliminated completely regardless of the fit or design (2, 3). However, placement of a single implant at the distal-most aspect of a posterior edentulous space — as in a Kennedy Class I or II classification — can be used to minimize resultant distal extension dislodgement (4). The distal location of implants can effectively change the occlusal forces from Kennedy Class I or II RPDs to the biomechanics associated with a

and for the Future Kennedy Class III RPD. A tooth and implant-supported RPD requires minimal number of implants placed, as few as one implant, to provide stability, creating a reasonable option for the patient under financial constraints as compared to costs associated with an implant-supported fixed partial denture (4).

Attachments Use of attachments in RPDs continues to gain popularity with clinicians using dental implants for maximizing esthetic results with crowns and natural teeth, while maintaining good retention. Four types of attachments will be described: intracoronal, extracoronal, overdenture, and bar attachments.

Intracoronal attachments may involve a key-keyway (patrix-matrix, respectively) mechanism or a spring-plunger mechanism. Besides the advantage of esthetics for the key-keyway attachment, it provides a deep internal rest seat that shifts the vertical forces closer to the long axis of the abutment tooth (5). The disadvantages associated with use of intracoronal attachments include requiring extensive preparation of the abutment teeth, difficulties with wear and repair, and complications with lack of “stress director� when used in mandibular distal extension removable partial dentures.

Extracoronal attachments also provide excellent esthetic results but unlike many intracoronal attachments, these attachments provide effective stress directors for the distal extension RPD (6). However, the problems associated with extracoronal attachments include requiring additional space outside the normal contours of the abutment tooth that encroaches on space for the adjacent denture tooth, metal-minor connector — the proximal plate of the framework, and acrylic resin in the RPD. In addition, extracoronal attachments have elements such as springs and parts that can wear over time, fracture, and require adjustment or replacement.

When considering use of overdenture abutment as an additional design feature, the complexity, available space, and expense are all concerns when considering overdenture attachments.

Overdenture attachments are available for use on natural tooth abutments and dental implants. Some of the attachments are designed and classified as low profile to minimize the vertical space needed to accommodate the elements in the overdenture attachment. They provide good retention, versatility, tolerance to poorly aligned abutments, ease of maintenance, ease of adjustment and repair, and also have the potential for use on tipped or tilted abutments (7). When considering use of overdenture abutment as an additional design feature, the complexity, available space, and expense are all concerns when considering overdenture attachments.

Bar attachments can be custom cast, milled (mechanical or EDM-electrodischarge milling), or purchased prefabricated with the intention of a cast-to laboratory option. The matrix portion is designed typically

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Removable Partial Dentures — Treatment Now as a clip retainer, but may also use other designs in conjunction with the bar. A bar attachment provides rigid splinting, cross-arch stabilization and may be indicated particularly when there is considerable bone loss (8). Bar attachments are not classified as low profile since the interocclusal arch space required includes thickness for rigidity of the bar, in addition to the clips, framework, denture teeth and resin material. Soldering procedures may be necessary to connect to adjacent abutments and plaque control is more difficult with bars than with other attachments, requiring dexterity for hygiene maintenance.

Attachments provide additional design options not available with conventional removable partial denture treatment. The clinical advantages related to esthetics, retention, and versatility have been described to assist the clinician understand the nuances of each attachment and limitations associated with the clinical choices.

Figure 3. Metal framework try-in for rotational path RPD.

Rotational Path RPD Another removable partial denture option that may be used to eliminate conventional clasps in the esthetic zone is the rotational path RPD design. While this treatment modality is not limited to the esthetic zone, the rotational path design provides benefits clinically. The best indication for this design is in the maxillary arch, in particular the Kennedy Class IV classification replacing the two maxillary central incisors and the two maxillary lateral incisors; other indications include a Kennedy III modification I situation and a bilateral tooth-supported clinical situation in which the edentulous spaces are moderately extensive (Figures 3, 4).

The rotational path design provides advantages of improved esthetics, shortened treatment duration, cleanliness, and reduced treatment cost over implants or fixed partial dentures (9). The need for an esthetic RPD replacing anterior teeth resulted in the rotational path or referred also as dual path RPD concept was first introduced in 1978 (10).

This design technique utilizes the proximal undercuts of the adjacent natural teeth on either side of the edentulous space for retention, thereby elimi-

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Figure 4. Completed rotational path RPD eliminating clasps in the esthetic zone.

and for the Future nating the need for incorporating clasps on anterior teeth. The dual path design was originally limited to tooth-borne situations with missing anterior teeth, however, clinicians can apply the concept to other edentulous spaces (11).

The concept utilizes the minor connector — the proximal plate portion of the framework to fit directly into the adjacent proximal undercut as the retentive component; the laboratory technician does not blockout the undercut in order to cast the framework into this area. This rigid retainer provides retention through its excellent adaptation with the

tooth surface below the height of contour at a zero-degree tilt.

These components — the proximal plates — engage the undercuts when initially seated which appears tilted into the patient’s mouth, then the RPD is rotated to firmly seat the RPD to complete the path of insertion (10).

These proximal plates, rigid retainers on the framework into the undercut is all that is needed for retention in the anterior region.

The effectiveness of the dual path design is influenced by not only by the rigid retainers, but also the conventional clasp design included on the other abutments of the RPD.

Many advantages of the rotational path RPD have been previously described (12). This design concept requires a minimal number of clasps reducing tooth coverage which also decreases plaque accumulation. The esthetics result is improved by eliminating anterior clasps. Preparation of the posterior abutment teeth require an occlusal rest seat that resembles a deep channel rest versus the traditional spoon-shaped rest seat to meet the functions of a traditional clasp assembly such as support, reciprocation, bracing, encirclement, passivity, and retention. Despite many of these advantages, the rotational path RPD design also has some dis-

Figure 5. Overview of computer-aided design/computer-aided manufacturing systems for dentistry. Strub JR, Rekow D, Witkowski S. Computer-aided design and fabrication of dental restorations. Current systems and future possibilities. JADA 2006;137(9):1289-96. Copyright © 2006 American Dental Association. All rights reserved.

Reprinted by permission.

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Removable Partial Dentures — Treatment Now advantages. The rigid retentive component is difficult to adjust and fabrication of the prosthesis is technique sensitive in both the framework fabrication and the final prosthesis processing. Although there are more advantages than disadvantages in utilizing rotational path RPD, as was described earlier when using the attachments, clinicians should evaluate patients on an individual basis and determine if a rotational path design is possible (12).

CAD/CAM and Titanium Computer-aided Design (CAD) RPD Several options with CAD/CAM have been presented in Figure 5.

CAD/CAM systems obtain data from models, using mechanical or optical digitizers of various types (13, 14). For example, mechanical digitizers must map the entire surface of a prepared tooth while accurately maintaining the relative position of the device to the tooth. The scanner used to capture data is an integral part of the CAD/CAM system and operates only in combination with dedicated CAD software.

Several CAD software programs are available commercially for designing virtual 3-D dental restorations on a computer screen.

Although the user generally has the option to modify the automatically-designed restoration to fit preferences, these programs can design restorations nearly matching the excellence of restorations produced by master den-

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tal technicians. When the design of the restoration is complete, the CAD software transforms the virtual model into a specific set of commands which in turn, drive the CAM unit to fabricate the designed restoration.

Computer-aided Manufacturing (CAM) CAM uses computer-generated paths to shape a part (13, 14).

A diverse set of technologies has been used to create dental restorations or frameworks. Previous systems used a method cutting the restoration from a prefabricated block with the use of burs or disks. This technique, in which material is removed to create the desired shape, is termed a “subtractive method”; material is subtracted from a block to leave the desired shaped part (the restoration). A recent alternative known as “additive” CAM method have used a rapid prototyping (also called “solid freeform fabrication”) technology.

Rapid Prototyping is a process which produces a physical, 3-D object, a “conceptual model” or “master pattern.” A stereolithography machine uses a computer controlled laser to cure a photosensitive resin, layer by layer, to create the 3D part (1, 3).

Many kinds of metal alloys have been used traditionally in fabrication of RPD frameworks and the choice for prescription must take into consideration for allergies and biocompatibility (15, 16). Commercially pure (CP) titanium and titanium alloys have been used for the last 20 years to make removable denture frameworks because of

their excellent biocompatibility, outstanding corrosion resistance and mechanical properties which are comparable to those of gold alloy (17). Compared with other metals employed for removable partial denture frameworks, the advantages of titanium include its light weight, better accuracy of fit and excellent biocompatibility (18).

Ideally computer-aided design⁄computer-aided manufacturing (CAD⁄CAM) would be used to fabricate titanium frameworks rather than conventional dental casting (19). However, CAD/ CAM RPD frameworks cannot be fabricated with clasps. The minute cutting of the CAM is difficult because there are problems with selection of tool size making it almost impossible to cut a clasp in three-dimensions with an undercut (16). With the limitations associated with the technology, RPDs will continue to be fabricated using a casting process. It is possible to fabricate individual components of an RPD

by CAD⁄CAM technology with the exception of the clasps which require a casting process followed by the need for laser-welding the clasp to the framework (16).

Until these problems are rectified to facilitate manufacture of RPD frameworks, the use of a casting process to fabricate a RPD framework will continue.

One problem associated with titanium casting is the reactivity of titanium with the investment that forms a hard, brittle reaction layer on the cast surface.

Another concern is the high incidence of casting porosity in clasp assemblies evident on

and for the Future radiographic analysis of titanium frameworks which has shown cast titanium is more prone to porosity than frameworks made of conventional dental casting alloys (20, 21). However, it has also been reported which through meticulous attention to detail the casting accuracy, internal porosity and surface roughness of CP titanium RPD frameworks were comparable to Co-Cr frameworks (22).

In the future, the fabrication method of choice for fabricating titanium prostheses is CAD/ CAM when compared with casting techniques (23). These RPDs may consist of a combination of casting, superplastic forming and CAD⁄CAM. The four grades of CP titanium (1–4) have mechanical properties ranging from flexible to rigid. Each of these RPD components requires different grades for different mechanical properties. These components would be made separately with a different grade of CP titanium. Clasps should be made with CP titanium grade 2 because of its flexibility, the teeth should be made with grade 3 for wear resistance and the major connectors should be made with grade 4 because of its rigidity.

Each component can be joined using laser welding (24).

Although problems have been identified for cast titanium RPDs, their use has gradually increased (25). The literature has shown that the use of titanium for the production of cast RPD frameworks has gradually increased and there appears to be no metallic allergies caused by CP titanium dentures. Laboratory

concerns such as the reaction layer formed on the cast surface, porosity, and the difficulty of polishing and high costs still remain viable issues; however, patient concerns such as discoloration of the titanium surfaces, unpleasant metal taste, a decrease of clasp retention, plaque adherence, and wear of titanium teeth have gradually been resolved.

Conclusion With new and innovative techniques, research in dental implants, biomaterials, and CAD/ CAM development, removable partial denture technology will continue to evolve and improve for the benefit of partially edentulous patients. Data on future population needs for removable partial dentures indicate that while there is a decline in tooth loss in the U.S, the need for RPDs will actually increase as the population increases and ages. With this increase in geriatric population and a high percentage of these patients that have been treated with removable partial dentures, the RPD will continue to be a viable treatment option in clinical dentistry.

References 1. Starr NL. The distal extension case: an alternative restorative design for implant prosthetics. Int J Periodontics Restorative Dent 2001;21(1):61-7.

2. Ganz SD. Combination natural tooth and implant-borne removable partial denture: a clinical report. J Prosthet Dent 1991;66(1):1–5.

3. Battistuzzi PG, van Slooten H, Kayser AF. Management of an anterior defect with a removable partial denture supported by implants and residual teeth: case report.

Int J Oral Maxillofac Implants 1992;7(1):112–115.

4. Giffin KM. Solving the distal extension removable partial denture base movement dilemma: a clinical report. J Prosthet Dent 1996;76(4):347-9.

5. Baker J. and Goodkind R. Theory and practice of precision attachment removable partial dentures. St. Louis.

1978; The C.V. Mosby Co. 6. Mensor, MC. Classification and selection of attachments, J. Prosthet Dent 1973; 29(5):494-7.

7. Jones, JD. , Garcia, LT. Removable Partial Dentures – a clinician’s guide attachments, 2009 Wiley-Blackwell.

8. Preiskel, HW. Precision attachments in dentistry; 3rd edition St. Louis, 1979, Henry Kimpton Publishers.

9. Ancowitz S. Esthetic removable partial dentures. Gen Dent 2004;42(5):452–3.

10. Jacobson TE, Krol AJ. Rotational path removable partial denture design. J Prosthet Dent 1982;48(4):370–6.

11. Becker CM, Kaiser DA, Goldfogel MH. Evolution of removable partial denture design.

J Prosthodont 1994;3(3): 158–66.

12. Krol AJ, Jacobson TE, Finzen FC. Removable partial denture design. 5th ed. San Rafael (CA): Indent; 1999, pp.

78–93.

13. Strub JR, Rekow ED, Wit-

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kowski S. Computer-aided design and fabrication of dental restorations: current systems and future possibilities. J Am Dent Assoc.

2006;137(9):1289-96.

14. Williams RJ, Bibb R, Eggbeer D, Collis J. Use of CAD/CAM technology to fabricate a removable partial denture framework. J Prosthet Dent 2006;96(2):96-9.

15. Suzuki N. Metal allergy in dentistry: detection of allergen metals with X-ray fluorescence spectroscope and its application toward allergen elimination. Int J Prosthodont 1995;8:351– 9.

16. Shimpo H. Effect of arm design and chemical polishing on retentive force of cast titanium alloy clasps. J Prosthodont 2008 Jun;17(4):3007.

17. Mori T, Togaya T, Jean-Louis M, Yabugami M. Titanium for removable dentures. I. Laboratory procedures. J Oral Rehabil 1997;24:338–341.

18. Nakajima H, Okabe T. Titanium in dentistry: development and research in the U.S.A. Dent Mater J. 1996;15:77–90.

19. Wang RR, Fenton A. Titanium for prosthodontic applications: a review of the literature.

Quintessence Int 1996;27:401–408.

20. Ohkubo C, Hosoi T, Ford JP, Watanabe I. Effect of surface reaction layer on grindability of cast titanium alloys. Dent Mater 2006;22:268– 74.

21. Baltag I, Watanabe K, Kusakari H, Miyakawa O. Internal porosity of cast titanium removable partial dentures: influence of sprue direction on porosity in circumferential clasps of a clinical framework design. J Prosthet Dent 2002;88:151–8.

22. Jang KS, Youn SJ, Kim YS. Comparison of castability and surface roughness of commercially pure titanium and cobaltchromium denture frameworks. J Prosthet Dent 2001;86:93–8.

23. Witkowski S, Komine F, Gerds T. Marginal accuracy of titanium copings fabricated by casting and CAD ⁄CAM techniques. J Prosthet Dent 2006;96:47–52.

24. Suzuki M, Ohkubo C, Aoki T, Suzuki Y, Hanatani S, Abe M et al. The cast framework combined with 3 grades of CP titanium by laser welding. 13th Society for Titanium Alloys in Dentistry (proceedings). Yokohama 2000;68–9 (in Japanese).

25. Hosoi T, Mizuno Y. Statistical evaluation of titanium metal base dentures used in vivo.

Journal of Society for Titanium Alloys in Dentistry 2007;5:44–5.

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Functional Impressions for Complete Denture Fabrication A Modified Jump Technique Stephan J. Haney, D.D.S Roxanna Nicoll, D.D.S. Michael Mansueto, D.D.S., M.S.

INTRODUCTION Jump techniques are commonly used in dentistry for rebasing complete dentures. they are methods that use the existing denture as a custom tray to impress the edentulous arch while the denture is simultaneously held in occlusion. in that way the occlusal table is accurately oriented to the underlying tissue surface. that orientation is captured in the lab with a denture flask or an indexing jig, and it is preserved while the old denture base material is replaced with new. The term “jump” conveys the figurative leap of that tooth-to-tissue relationship from one denture base to another.

Abstract Tissue conditioners are used with great success in dentistry as functional impression materials for rebasing removable prostheses. In the rebase procedure, a functional impression is made in an existing denture to create a master cast. The orientation of the occlusal surface to the underlying tissue surface is captured with a reline jig or denture flask and transferred to the new denture base in what is called a “jump” in laboratory jargon.

Functional impression methods are not commonly considered, however, for the fabrication of new dentures despite their popularity and ease of use. This article describes a modified jump technique for remaking complete dentures. The method uses functional impressions in existing maxillary and mandibular dentures to create master casts and to act as stabilized carriers for jaw relation records. More precise esthetic and phonetic assessments of the existing prostheses are accommodated, and prescriptive changes may be referenced to the current tooth arrangement.

KEY WORDS: Haney

Nicoll

Mansueto

Dr. Haney is Assistant Professor, Dr. Nicoll is a second year Resident in Prosthodontics and Dr. Mansueto is an Associate Professor, all in the Department of Prosthodontics at the University of Texas Health Science Center Dental School in San Antonio, Texas.

Correspondence: Stephan J. Haney, D.D.S., 7703 Floyd Curl Dr. MSC 7912, San Antonio, Texas 78229, haneys2@uthscsa.edu, (210) 567-6451 • (210) 567-6376 FAX.

Complete denture, dental impression, functional impression, jump technique Tex Dent J;127(4):377-384.

No disclaimers. Reprint requests to Dr. Haney. No disclosures

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Functional Impressions for Complete Denture Fabrication A related method has been described for fabricating a single complete denture using a conventional elastomeric impression in a duplicate denture (1). However, application of the jump principle as a technique of choice for fabricating opposing dentures has not. The technique described in this article is a direct clinical application of the jump principle to procedures for remaking existing dentures.

The modified jump technique for fabricating complete dentures uses functional impressions in existing dentures to create master casts and to act as carriers for jaw relation records. Justifying the choice of a functional impression over more traditional static impression methods hardly seems necessary.

Most dentists are familiar with the use of tissue conditioning materials and most have very positive experiences when those materials are used for functional impression making. Instead, justification of this technique should be couched in terms of a broader treatment philosophy.

Treatment Philosophy Complete denture therapy requires more than just execution of rote steps, regardless of the technique employed. To be successful, denture treatment must engage the patient as a collaborator in the process. That begins with careful analysis of the patient’s expectations and an assessment of the limitations imposed by their edentulous anat-

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omy. Defining the anticipated results of treatment in terms of anatomical constraints can help shape the patient’s perception of success. An informed patient is more likely to be a happy patient at the end of treatment.

It is critical to establish a rapport with patients that demonstrate a genuine concern for their well-being. The modified jump technique provides an excellent venue to accomplish that objective. Patients leave each appointment in the jump protocol more comfortable and functional than when they arrived, or they will have previewed an anticipated result that they have helped create. Each step in this method builds confidence in the process and helps patients identify with the resulting prostheses.

To be considered successful, any clinical procedure must prove efficient and profitable for the clinician as well as provide valuefor-dollar for the patient. Clinical efficiency can be improved with the modified jump technique over conventional methods, not because of a reduced number of appointments, but because each appointment is less technically demanding and of more predicable length. Patient comfort and familiarity with their own stabilized dentures permit more accurate jaw relation records to be made and allow a much more realistic assessment of occlusal vertical dimension and desired tooth positioning for esthetics and phonetics. While the patient’s existing dentures are seldom ideal, they do provide a starting point for setting teeth. In fact, the ex-

isting dentures provide a wealth of diagnostic information that can be used to guide and improve tooth positioning (2, 3).

To provide a precise starting point for any desired changes from the existing prostheses, cameo impressions are made of the polished surfaces of the dentures to create reference casts.

Those cameo casts are oriented to the edentulous master casts with a common jaw relation record. A detailed study of the existing dentures in the mouth can then be used to identify specific areas for improvement compared to the existing prostheses (e.g. “increase the maxillary incisal display 2.5 mm from the current position”). The laboratory technician can use the cameo reference casts as the starting point from which such precise changes can be made. Any patient input at this stage regarding changes they might prefer can be helpful and may contribute to their sense of “buy-in.” It is worth remembering that the patient’s desired appearance is subjective. The greater the patient’s participation in the process, the fewer surprises at delivery and the more predictable treatment becomes.

Clinical Indications A patient with healthy tissues in the denture bearing areas who presents for remake of historically successful dentures is a prime candidate for the modified jump technique. Typically such patients recognize the need for new prostheses as a result of normal wear and tear or as a consequence of

Figure 2. Maxillary arch pretreatment Figure 1. Initial patient presentation. Existing dentures in place.

instability produced by resorptive changes in their intraoral anatomy.

The patient shown in Figure 1 is such a patient.

She has been wearing her existing dentures satisfactorily for 27 years. She has noted a progressive loss of stability with her mandibular denture and is concerned with the unnatural appearance of her teeth. A clinical exam tentatively suggests the occlusal vertical dimension of the existing prostheses to be somewhat diminished as suggested by the facial appearance. Intraorally, the edentulous maxilla suggests a favorable denture outcome with good supporting tissue, adequate anatomy for denture stability, and peripheral seal facilitated by a Class I House palatal throat form (Figure 2)

The edentulous mandible is a different story, however. Adequate tissues are available for denture support, but denture stability will be severely compromised by the extent of alveolar resorption (Figure 3). Although not visualized in the photographs, the patient consistently demonstrates a normal tongue posture. That finding suggests a reasonable expectation for passive peripheral seal, but one that will likely be compromised by the extent of denture movement anticipated in function.

After the anatomical expectation is defined, the existing dentures are evaluated. Although the patient has no subjective concerns with the maxillary denture, it is not as stable or retentive as the anatomy would suggest. The patient’s perception of

Figure 3. Mandibular arch pretreatment

the mandibular prosthesis is more accurate, however.

While the anatomical expectation for the mandibular denture is clearly compromised, the existing prosthesis fails to achieve what little support and stability the edentulous anatomy affords. Tentative evaluation of the existing esthetics and phonetics confirmed the patient’s concerns regarding an unnatural appearance secondary to denture tooth color and wear.

Presented with the findings, expectations, and alternatives to treatment, the patient elected to pursue remake of her existing dentures. She was advised of the modified jump technique, and she agreed to allow her existing dentures to be modified in the course of treatment. Her treatment is outlined in the “Step-by-step procedures,” and it typifies the treatment sequencing for this method. Had the patient preferred no modification of the existing dentures, they could have been duplicated. The duplicates could then have been used instead.

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Functional Impressions for Complete Denture Fabrication Step-by-step procedures Step 1

Figure 4. Relined denture as removed after initial period of gelation.

Figure 5. Trimmed initial impression ready for reinsertion.

Clinic • Relieve the existing maxillary denture intaglio surfaces as needed to remove undercuts and overextended borders.

• Reline with tissue conditioner, taking care to cover the borders with tissue conditioner before insertion.

(Although any tissue conditioner can be used for a functional impression, some materials prove to be more enduring for use as interim liners. The product chosen for this technique should be one that can be used for a few months as an interim liner after the impression process has been completed.

Lynal (DENTSPLY Caulk, Milford, DE) and Viscogel (DENTSPLY DeTrey GmbH, Konstanz, Germany) seem particularly good choices among a host of acceptable products. Lynal is the product shown in use for this patient).

• Remove after 10-12 minutes gelation, handling the denture by the anterior teeth to avoid distorting the tissue conditioning gel.

• Trim the excess under cold running tap water to minimize the tackiness of the material, leaving the borders fully covered with tissue conditioner that extends about 5 mm onto the facial of the flanges (Figures 4, 5).

• Reinsert the denture.

• Have the patient leave both dentures in place overnight or at least long enough to have a normal meal, removing them only to rinse clean. The patient should avoid brushing the impression side of the denture and avoid use of denture adhesive products until after the next visit.

Step 2 (Typically the next day)

Figure 6. Hard denture base showing through functional impression material, requiring relief and reimpression.

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Clinic • Critically assess the impression. n No areas of hard denture base acrylic should be

visible on the impressed surfaces, including

borders. (If hard acrylic has surfaced (Figure 6), it

should be relieved and the impression remade (Figure 7)).

n The tissue conditioner should be firmly attached

to the denture base and supported by hard

acrylic. (If the impression has detached

from the base or is unsupported and easily

displaced, the impression should be remade (modifying the denture base if necessary to support displaceable material)).

Figure 7. The denture after relief of penetrating denture base areas and reimpression.

•

Maxillary facebow transfer. Impress cameo surfaces of maxillary and mandibular dentures in alginate (Figure 8).

Figure 8. Alginate impression of maxillary denture cameo surfaces.

Lab Steps • •

• • • •

•

Pour and base the cameo impressions (Figure 9).

Box and pour the maxillary master cast from the functional impression.

(Do not separate the functional impression from the master cast until it has been mounted and the mounted position has been indexed).

Inspect the cameo casts carefully and remove nodules that might interfere with accurate seating in the facebow or in a jaw relation record.

Mount the maxillary cameo cast via the facebow (Figure 10).

Index the tooth positions of the mounted cameo cast with a remount jig.

Trim the maxillary master cast with the impression still seated on the cast and mount it with the indexing jig (Figure 11). (The tissue surface of the maxillary master cast will now be accurately oriented to the cameo surface by means of these cross-mounted casts, and the 1st “jump” will be complete).

Carefully separate the maxillary functional impression. If the liner remains largely intact, trim any lose tags of liner, recontour the borders, and polish with wet pumice (Figure 12).

Figure 9. Trimmed and indexed maxillary and mandibular cameo casts.

Figure 10. Maxillary cameo cast mounted via facebow transfer.

Figure 11. Maxillary master cast mounted via remount jig before impression is separated.

Figure 12. Recontoured and pumiced functional impression ready for reinsertion and use as interim reline while new denture being fabricated.

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Functional Impressions for Complete Denture Fabrication Step 3 (Usually later in the day of Step 2) Clinic • Reinsert the maxillary denture with the tissue conditioning material retained as an interim liner.

• Relieve the existing mandibular denture to remove undercuts and overextended borders (Figure 13) or add to underextended borders.

• Reline with tissue conditioner and trim excess after gelation (Figure 7).

• Patient again wears dentures overnight or, at least, for a meal.

Lab •

Box and pour the mandibular functional impression. (Do not separate the functional impression from the master cast until after it has been mounted).

• Trim the centric relation and protrusive records so that only cusp tip contact occurs with the casts when occluded.

• Mount the mandibular master cast versus the previously mounted maxillary cameo cast using the trimmed centric relation record (Figure 15).

• Use the protrusive record to set the condylar inclinations on the articulator.

• Separate the mandibular impression from the cast. Trim and polish the tissue conditioning material with wet pumice for use as an interim liner.

• Use the same centric relation record to mount the mandibular cameo cast (Figure 16). (The cameo surface of the denture will now be accurately oriented to the tissue surface of the edentulous mandible by means of these “cross-mounted” casts, and the second “jump” will be complete).

Figure 13. Relieved mandibular denture ready for placement of tissue conditioner.

Step 4 Clinic • Critically assess the impression as previously.

• Critically analyze the existing dentures (Figure 14).

n Assess occlusal vertical dimension,

esthetics, and phonetics.

n Record in detail any changes needed in

vertical dimension, occlusal plane

orientation, or tooth position.

• Select denture teeth and gingival color with the patient’s input.

• Make a centric relation record at the desired occlusal vertical dimension using the existing dentures as record bases.

• Make a protrusive record using the dentures as record bases.

Figure 14. Existing dentures critically analyzed.

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Figure 15. Mandibular master cast mounted with CR record before impression separated from cast.

Figure 16. Mandibular cameo cast crossmounted to maxillary cameo with same CR record.

Clinic • Reinsert the mandibular denture with the impression material liner.

• Advise patient to resume normal hygiene and denture wearing schedule.

• Provide the lab with mounted master casts, cross-mounted cameo casts, and a detailed prescription delineating changes desired (Figure 17). A photo of the patient smiling with their natural teeth is helpful for nuances in denture tooth arrangement.

Step 5 Clinic • Full wax try-in (Figure 18). Modify the tooth arrangement to refine the esthetic presentation and create phonetic competency. Patient input with this step is helpful, and patient approval is essential.

Figure 17. Mounted master casts and cross-mounted cameo casts provided to laboratory.

Lab • Process, recover, remount, adjust, and repolish the dentures.

• Fabricate maxillary and mandibular remount casts.

• Remount the maxillary denture using the previous index.

Step 6 Clinic • Insert maxillary and mandibular complete dentures.

• Disclose and adjust for distributed load and patient comfort.

• Centric jaw relation record and protrusive record for clinical remount.

Figure 18. Facial profile at wax try-in.

Lab • Mount the mandibular denture using the maxillary remount cast provided by the laboratory using the new centric relation record, and reset the condylar inclinations on the articulator with the new protrusive record.

• Reconcile denture occlusion, repolish.

Clinic • Reinsert maxillary and mandibular dentures

(Figure 19).

Figure 19. Completed prostheses.

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Functional Impressions for Complete Denture Fabrication Conclusion The technique described in this article is a time-tested adaptation of historical methods. It is not a difficult process, but it involves closely integrated clinical and laboratory steps. The method does not guarantee success. But functional impression materials have a long record of successful use in dentistry, and the intimate adaptation of the impression material to the underlying tissues creates ideal record bases out of the existing dentures. Of even greater benefit, stabilization of the existing prostheses improves comfort and function for the patient during the course of treatment and permits a more critical appraisal of occlusal vertical dimension and tooth positioning with phonetic methods. Once the existing dentures have been closely evaluated, the use of properly related casts of the existing dentures provides an accurate reference from which changes can be made. The modified jump technique is an efficient method for remaking most dentures and is well-suited for contemporary dental practice.

Bibliography 1. Rodrigues, AHC, Morgano, SM. An expedited technique for remaking a single complete denture for an edentulous patient. J Prosthet Dent Sep 2007;98(3): 232-234.

2. Sosin, Max. “Diagnosis and Treatment Planning for Edentulous Patients.� Graduate prosthodontics lecture series. 1977. University of Southern California. Los Angeles, CA. 3. Vig, RG. Taking advantage of existing dentures. J Prosthet Dent Sep 1971; 26(3):247250.

4. Sprigg, RH. Diagnostic procedures using the patient’s existing dentures. J Prosthet Dent Feb 1983;49(2):153-161.

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In recognition of the Beverly Bane Lectureship Fund, the TDA Smiles Foundation is proud to support the following lectures:

Thomas Dawson, DDS & Jack Shirley, DDS Thursday, May 6, 2010 8:30 AM - 11:30 AM Has Your Practice Ceased To Function?

Course Code: #T20

1:30 PM - 4:30 PM Tough Cases Made Simply Beautiful Course Code: #T21

Founded in 1990 as the nonprofit, philanthropic arm of the TDA, the TDA Smiles Foundation seeks to improve patient care in Texas through the support of education and research. To forward these efforts, the TDA Smiles Foundation hosts the Beverly Bane Honorary Lectureship, which fosters continuing education to broaden the scope of Texas dentists and enables them to better serve their patients.

The Medicaid and Children’s Health Insurance Programs (CHIP) in Texas improve the health of children who might otherwise go without health care.

CHIP and Medicaid help provide dental treatment to children in need. Partnered with caring dentists, these programs make a difference in children’s lives by restoring one smile at a time!

In keeping with TDA's long-standing commitment to recruit more Medicaid/CHIP providers, we're offering various Medicaid/CHIP information opportunities at this year’s Texas Meeting.

CONTINUING EDUCATION PROGRAMS: Linda Altenhoff, DDS and Paul Kennedy, Jr., DDS Thursday, May 6 | 2:00 PM – 5:00 PM | Course Code #T01 | $15 FIRST DENTAL HOME TRAINING FOR DENTISTS - Presented by Linda Altenhoff, DDS First Dental Home training includes necessary information and reviews skills needed to provide dental checkups and dental anticipatory guidance for children 6 months through 35 months of age. This training is required in order for Texas Medicaid enrolled dentists to bill CDT D0145 and receive enhanced reimbursement. Educational funding provided by the Committee on Access to Dental Care, Medicaid, and CHIP. AGD SUBJECT CODE 430 HEAD START DENTAL HOME INITIATIVE – Presented By Paul Kennedy, Jr., DDS The Texas Dental Association is partnering with the American Academy of Pediatric Dentistry and the Office of Head Start to provide dental homes to all Head Start children in Texas. A dental home means that each child's oral health care is delivered in a comprehensive, continuously accessible, coordinated and family-centered way by a licensed dentist. This course explains how your office can participate in this ground breaking project. Educational funding provided by the Committee on Access to Dental Care, Medicaid, and CHIP. AGD SUBJECT CODE 430 Linda Altenhoff, DDS and William Steinhauer, DDS Friday, May 7 | 2:00 PM – 5:00 PM | Course Code #F01 | $15 TAKING THE MYSTERY OUT OF TEXAS MEDICAID Recent increases in Medicaid reimbursement rates in Texas have made the inclusion of Medicaid patients into a dental practice very feasible. You will learn how to incorporate Medicaid patients successfully into your practice and how to effectively bill Medicaid. This is a must for doctors and staff! Educational funding provided by the Committee on Access to Dental Care, Medicaid, and CHIP. AGD SUBJECT CODE 430.

Legal Representation for Texas Dentists

Successfully Serving Texas Dental Professionals Since 1994 TSBDE Complaint Defense Counsel TSBDE Compliance Evaluation Texas Dental Jurisprudence Malpractice Litigation Defense Counsel Commercial Leases: Review & Negotiation Dental Practice Transitions: Purchase & Sale Employment Agreements Professional Associations Corporations & Partnerships

Attorney at Law

Telephone: (281) 304-1000 Toll Free: (888) LAW-DENT

Not Certified by the Texas Board of Legal Specialization

www.legaldental.com

Boyd W. Shepherd, D.D.S., J.D.

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Edentulism and Comorbid Factors David A. Felton, D.D.S., M.S. Reprinted with permission. Journal of Prosthodontics, copyright American College of Prosthodontists. Published by Wiley-Blackwell.

Edentulism is defined as the loss of all permanent teeth, and is the terminal outcome of a multifactorial process involving biologic processes (caries, periodontal disease, pulpal pathology, trauma, oral cancer) as well as nonbiologic factors related to dental procedures (access to care, patient preferences, third party payments for selected procedures, treatment options, etc.) (1). chronic oral disease represents an enormous global health care burden that is often neglected in developed and developing countries; because of its economic impact, and association with other life-threatening entities such as coronary artery disease, stroke, and cancer, the treatment of chronic oral diseases, including the completely edentulous condition, should not go unnoticed. the distribution and prevalence of complete edentulism between developed and less-developed coun-

Felton

Dr. Felton is a professor, Department of Prosthodontics, University of North Carolina School of Dentistry, Chapel Hill, NC. Correspondence to: David A. Felton, Department of Prosthodontics, UNC School of Dentistry, CB 7450, Chapel Hill, NC 27599. E-mail: dave_felton@dentistry.unc.edu.

Presented as part of the FDI 2008 World Dental Congress: “Facing the Future of Edentulism: 21st Century Management of Edentulism—A World of Challenges in a Universe of Helpful Technologies.” September 26, 2008, Stockholm, Sweden.

Abstract Introduction: Complete edentulism is the terminal outcome of a multifactorial process involving biological factors and patient-related factors. It continues to represent a tremendous global health care burden, and will for the foreseeable future. The purpose of this review is to determine what comorbid factors exist for the completely edentulous patient.

Methods: This literature review evaluated articles obtained via the National Library of Medicine’s PubMed website, using keywords of edentulism with various combinations of the terms comorbidity, incidence, health, nutrition, cancer, cardiovascular health, diabetes, osteoporosis, smoking, asthma, dementia, and rheumatoid arthritis. Abstracts were selected and screened, and selected full-text articles were reviewed. Articles were limited to those with adequate patient cohorts and a minimum of 2-year follow-up data.

Results: Edentulism was found to be a global issue, with estimates for an increasing demand for complete denture prostheses in the future. Completely edentulous patients were found to be at higher risk for poor nutrition, coronary artery plaque formation (odds ratio 2.32), to be smokers (odds ratio 2.42), to be asthmatic and edentulous in the maxillary arch (odds ratio 10.52), to being diabetic (odds ratio 1.82), to having rheumatoid arthritis (odds ratio 2.27), and to having certain cancers (odds ratios varying from 1.54 to 2.85, depending on the type of cancer).

Chronic residual ridge resorption continues to be the primary intraoral complication of edentulation, and there appear to be few opportunities to reduce bone loss in the edentulous patient.

Conclusions: While the completely edentulous patient seems to be at risk for multiple systemic disorders, whether development of these disorders is causal or casual has not been determined. To minimize the loss of residual alveolar ridges, exemplary complete denture therapy, along with the establishment of routine recall systems, should be the ultimate goal of treatment of this patient cohort.

KEY WORDS: Comorbidity; complete dentures; residual ridge resorption; chronic oral disease.

Tex Dent J;127(4):389-401.

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Edentulism and Comorbid Factors tries may be associated with a complex interrelationship between cultural, individual, access to care, and socioeconomic factors. World Health Organization databanks indicate that caries is still prevalent in the majority of countries internationally, with some reporting 100 percent incidence in their populations; severe periodontal disease is estimated to affect 5 percent to 20 percent of the population, and the incidence of complete edentulism has been estimated between 7 percent and 69 percent internationally (2). However, estimates of the impact of total tooth loss on overall health, and the estimated costs associated with long-term treatment and maintenance of edentulous patients, are lacking. While chronic periodontal disease and caries are regarded as the leading contributors to edentulism, one cannot say for certain whether the cumulative damage on the systemic health of individuals who have been subjected to chronic periodontal disease or caries partially persists in the edentulous patient.

Comorbidity In medicine, the term comorbidity relates to one or more disorders (diseases) in addition to the primary disorder or disease, or the effect such additional coexisting conditions might have on the individual.

The Charlson Comorbidity Index is the most widely accepted, validated method for quantifying the effects of the additional diseases/disorders on the individual (3). The Charlson Index predicts the 1-year mortality for a patient who may have a wide variety of comorbid conditions, such as heart disease, cancer, or AIDS, with a total of 22 possible conditions. These 22 conditions are weighted with scores of 1, 2, 3, or 6 depending on the risk of the patient dying with the additional condition. The scores for an individual are summed, and given a total score, which is used to predict mortality. While the incidence of mortality has not been linked directly to the loss of teeth, emerging studies deal with the specifics of a multitude of conditions that may either contribute to, or be related to complete tooth loss. The purpose of this review article is to identify those clinical conditions that can coexist with, or contribute to, complete edentulism, and to alert the practicing dentist to the relationship between these conditions and the lack of a functional natural tooth complement.

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Methods This review evaluated literature obtained via searching the National Library of Medicine’s PubMed website. Keywords included the following, in combinations to include edentulism and comorbidity, edentulism and clinical trials, edentulism incidence, edentulism and health, edentulism and nutrition, along with combinations of the term edentulism and tooth loss with cancer, cardiovascular health, diabetes, osteoporosis, smoking, asthma, dementia, and rheumatoid arthritis. Available abstracts were reviewed, and full-text articles of selected abstracts obtained online or via the inter-library loan program at the UNC Health Sciences Library.

Additional information was obtained through the US Centers for Disease Control website., and others as noted. Except where otherwise noted in the article, all articles selected had to include patients who were completely edentulous in at least one arch, have adequate patient cohorts for examination (>30 patients), and contain follow-up data recorded for a minimum of 2 years.

Incidence of edentulism Tooth loss in the United States According to Oral Health–Healthy People 2010: Objectives for Improving Health, 26 percent of the US population between the ages of 65 years and 74 years are completely edentulous (4).

The rate of edentulism is estimated at 30 percent for African Americans, American Indians, or

Alaska Natives for this age group, 26 percent for Caucasians, and 24 percent for Hispanics (5). Low-income adults aged 65 years and older had the highest rate of edentulism (48 percent in 1993), and there were dramatic differences between similar populations in the 50 states (13 percent in Hawaii to 47 percent in Kentucky are edentulous) (6, 7). Low education levels have been found to have the highest and most consistent correlation with tooth loss (8). Early loss of teeth has shown to be a significant factor leading to complete edentulism, with 7.4 percent of dentate Americans experiencing early tooth loss becoming edentulous within the next decade (9).

And, while reports indicate a 6 percent reduction in total edentulism between 1988 and 2002, significant growth in the US population, along with declining access to dental care, has other authors predicting a steady state or growth of edentulism in one or more dental arches over the next two decades (10–11). These authors predict that edentulous patients will need or demand an increase of approximately 230,000 units of complete dentures per year.

International edentulism rates Complete edentulism is an international problem, particularly in the 65 years and older age groups; the condition does not appear to be concentrated in developing countries, as Ireland (48.3 percent), Malaysia (56.6 percent), the Netherlands (65.4 percent), and Iceland (71.5 percent) report some of the highest levels (12). While women have been reported to lose all their teeth at a higher rate (approxi-

Complete edentulism is an international problem, particularly in the 65 years and older age groups; the condition does not appear to be concentrated in developing countries, as Ireland, Malaysia, the Netherlands, and Iceland report some of the highest levels (12). While women have been reported to lose all their teeth at a higher rate (approximately 3 percent higher in the United States) than men, this trend appears to be very country-specific (13-15). mately 3 percent higher in the United States) than men, this trend appears to be very country-specific (13-15). The rate of edentulism appears to be inversely related to education, with the relative risk being approximately twice as great for those with little education compared to those with higher levels of education (16–19). Additionally, the rate of edentulism appears to be inversely proportional to one’s income level; however, while government subsidies of dental care should abate disparities between income levels, one study of two countries with government-sponsored dental care subsidies showed dramatic differences in rates of edentulism, irrespective of income levels, with one country exhibiting twice the edentulous level as the other (20, 21).

Where one lives in his/her country may be an indicator of the levels of edentulism, as several countries have demonstrated a correlation of edentulism rates to rural versus urban location; perhaps the edentulism rates (which vary from two to three times higher in rural areas)

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Edentulism and Comorbid Factors can be attributed to differences in the dentist/patient ratios between the areas (22, 23). All these studies suggest that edentulism appears to be multifactorial, and that the known predictors of edentulism, that is, gender, income, and education levels, appear to be reasonable prognosticators of edentulism rates, while other socioeconomic factors such as culture, dental aptitude, and access to care, may be more difficult to quantify.

Consequences of edentulism on overall health According to World Health Organization criteria, people with no teeth are considered physically impaired.

Edentulous patients could also be considered disabled, due to their inability to eat and speak effectively, which are two of the essential tasks of life; they could be considered handicapped, as they tend to avoid eating and speaking in public (24, 25).

Diet, nutrition, and overall health Having a functional masticatory system is critical for the individual to replace the body’s nutrients and maintain optimal overall health. Studies have demonstrated that edentulous patients have a poorer diet than their dentate counterparts (26). In this NHANES III study, 3,794 individuals were studied, of which 36 percent were completely edentulous. Denture wearers were found to be older, African-American, female, of lower socioeconomic status, smokers, and were found to not take daily vitamins or dietary supplements, when compared to their fully dentate counterparts. In a follow-up study of 6,985 patients, the authors found that patients with less than a full complement of teeth had reduced intake of carrots, salads, and dietary fiber than did fully dentate patients, with reductions in serum levels of beta carotene, folate, and vitamin C (27). In another investigation, denture wearers were found to be at a nutritional disadvantage, and consumed statistically fewer carrots and tossed salads than the fully dentate (28).

Additionally, these authors demonstrated significantly reduced intake of dietary fiber and foods with adequate levels of beta carotene, folate, and vitamin C than did dentate patients. Other studies have indicated that edentulous patients have more difficulty chewing foods, with resultant reduced intakes of Vitamin B6 and carbohydrates than dentate patients

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In a follow-up study of 6,985 patients, the authors found that patients with less than a full complement of teeth had reduced intake of carrots, salads, and dietary fiber than did fully dentate patients, with reductions in serum levels of beta carotene, folate, and vitamin C (27).

(29). A study of institutionalized elders compared physical activity and mortality between groups of edentulous patients without dentures to the partially edentulous patient (> 20 teeth); in this 6-year study, edentulous patients with no replacement dentures experienced a decline in physical ability and an increase in mortality rates (30). While a third group of patients with complete dentures was not studied, the necessity to replace missing teeth in the edentulous population seems apparent. The Healthy Eating Index (HEI) has been used as a measure of the overall quality of an individual’s diet (31). The HEI score is a measure of ten components, with a maximum combined score of 100; a score of less than 51 is deemed a poor diet, a score of 51 to 80 is categorized as “needs improvement,” and one above 80 is considered a good diet. In a study of nutritional status of patients with and without opposing pairs of posterior teeth or those wearing dentures, those with fewer than four pairs of opposing posterior teeth were statistically at risk for poor nutrition. Interestingly, those with complete dentures scored better (but not statistically) than those with no posterior replacement teeth or those with 1 to 4 opposing pairs of posterior teeth, but the edentulous patients were still at risk for poor nutrition (32). A study by Slade investigated dentate and edentulous patients’ chewing capacity. He found that 58.6 percent of edentulous patients reported difficulty in chewing various food groups, compared to 6.1 percent of patients with fewer than nine missing teeth; higher rates of complete edentulism were found in older, female, less educated Australian-born individuals (33).

Finally, a study of body mass index (BMI) in Great Britain suggests a strong correlation with the

number of remaining teeth and a maintenance of a normal BMI (34). This study found that patients with fewer than 21 natural teeth were three times more likely to be obese than those with 21 to 32 teeth, and those patients who were completely edentulous had the same likelihood of being obese than those with 21 or fewer teeth.

The longitudinal effects of obesity on the overall health of the public are an enormous global health care burden that requires immediate attention in both developed and developing countries.

Systemic comorbid factors Osteoporosis Osteoporosis is an increasingly common skeletal condition that affects middle-aged and older individuals (35). The condition is characterized by bone loss, leading to fragility of the skeleton (36). The measurements of bone mineral content (BMC) and bone mineral density (BMD) are used to diagnose and monitor the condition. Both parameters are used to determine peak bone mass when an individual has matured, and the loss of bone following maturity. Osteoporosis is assumed to occur when both parameters are greater than 2.5 standard deviations below the reference value established for a given patient (37). In osteoporosis, the degree of bone resorption typically exceeds bone formation, with a net result of generalized bone loss. Several studies have found a significant correlation between the severity of osteoporosis and height of the residualmandibular ridge, but two other studies failed to demonstrate a similar correlation (38–42).

Finally, a recent literature review of 11 publications suggests that,

at best, there is weak evidence to suggest a correlation between the severity of osteoporosis and any alteration of the oral tissues in the completely edentulous osteoporotic patient (43). Of greater concern may be the relationship between the long-term use of several pharmaceutical regimens for the treatment of osteoporosis (long-term use of bis-phosphonates) and potential for adverse effects.

Hypertension and coronary artery disease Periodontal disease and tooth loss have been associated with an increased risk of several vascular-related conditions such as coronary heart disease, cerebral vascular disease, and peripheral arterial disease (44–46). In a recent study of agematched postmenopausal women with and without missing teeth, Taguchi et al. demonstrated a statistically significant association between the incidence of hypertension and tooth loss (47). Unfortunately, their patient cohort compared those with some missing teeth (mean of 22 remaining teeth) to those with no missing teeth (mean of zero missing teeth); whether any correlation can be made to the edentulous population is purely speculative.

However, tooth loss is known to change people’s diet and nutrition, which may have a direct effect on the risk of coronary artery disease and cerebrovascular diseases (48). Desvarieux et al. studied over 700 subjects with no history of stroke or myocardial infarction. Adjusting for conventional risk factors such as age, sex, smoking, diabetes, systolic blood pressure, cholesterol levels, race-ethnicity, education, and physical activity, they found that tooth loss is a marker of past periodontal disease in this patient cohort, and that tooth loss is related to subclinical

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Edentulism and Comorbid Factors atherosclerosis (carotid artery plaque formation), which could provide a pathway for subsequent clinical complications (49). Those patients who were completely edentulous were 2.32 times more likely to have carotid artery plaque formation than patients missing fewer than nine teeth; however, the authors are quick to point out that, like all cross-sectional studies, the relationship between tooth loss and carotid artery plaque formation, while robust, should not be interpreted as causal. An investigation by Schwahn et al studied the relationship between periodontal disease, complete edentulism, and increased levels of plasma fibrinogen, a known marker for inflammation with regard to cardiovascular disease (50). Their study of 2,738 subjects between 20 and 59 years of age, and a corresponding group of 52 completely edentulous patients, indicated a 1.88 increased risk for those partially edentulous patients with periodontal disease for increased plasma fibrinogen levels compared to the edentulous cohort; however, as plasma fibrinogen is an indicator of inflammation, one might speculate that there would be minimal inflammation associated with the edentulous patient. While a direct correlation between periodontal disease and coronary artery disease appears likely, the long-term cumulative effects of periodontal disease leading to complete edentulism on coronary artery disease is speculative at this time.

Smoking and asthma Smoking has been identified as a major risk factor in a multitude of systemic and oral conditions, including heart disease, lung cancer, respiratory disease, peripheral vascular disease, and chronic periodontal disease leading to tooth loss. In an analysis of 33,777 Canadians aged 18 years and older, 48 percent of current smokers aged 65 years or older were edentulous, compared to 30 percent in the nonsmoking cohort. Current smokers were least likely to use dental services, regardless of degree of tooth loss (51). Unfortunately, as in previous cross-sectional studies, no causal inferences between smoking and tooth loss could be made. Xie and Ainamo studied the association of various systemic factors to complete tooth loss in ambulatory elders living at home in Helsinki, Finland in 124 completely edentulous compared to 169 dentate (in at least one jaw) patients (52). All subjects were 75 years of age or older. Adjusting for age and gender, they found that those who smoked were 2.42 times more likely to be completely edentulous, and that bone fracture (a possible predictor of osteoporosis) was more prevalent in the edentulous elderly. When evaluating the edentulous maxilla, they found that, in addition to smoking and bone fractures, those with asthma were 10.52 times more likely to be edentulous in this arch than nonasthmatics. The authors postulated that those with inhaled corticosteroids could experience both systemic and local effects on the maxillary bone, resulting in suppression of bone formation, accelerated bone loss, and tooth loss resulting ultimately in edentulism of the maxilla. In another study of 177 edentulous subjects aged 76 or greater, Xie et al. found that elderly with asthma were six times more likely to experience severe reduction of the mandibular ridge than nonasthmatic controls (53). After adjustments for length of time edentulous and age, elderly women experienced a greater amount of mandibular ridge loss than men.

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Patient satisfaction/perception and quality of life measures Tooth loss associated with periodontal disease and caries has an apparent impact on an individual’s quality of life and has been associated with lower levels of satisfaction with life and a lower morale (54-56). In a 10-year prospective cohort study of 1992 rural Americans, Klein et al. reported that 68 percent of the sample was missing some teeth, and an additional 15.3 percent were completely edentulous. Of the sample population, 10.7 percent reported they could not enjoy some foods due to problems associated with their teeth. Those with missing teeth were more likely to have poorer self-related health issues than those with teeth (57).

Diabetes The US Centers for Disease Control and Prevention estimates that 7 percent of the US population (20.8 million) has diabetes; approximately 171 million are believed to be affected worldwide in estimates by the WHO. Diabetes is projected to become one of the world’s main killers and disablers within the next quarter century; however, studies on the relationship between diabetes and complete edentulism are sparse. One such study investigated the relationship of complete edentulism to diabetes in Mexico (58, 59). The National Performance Evaluation Survey 2002-2003, was a collaborative effort between the WHO and the Ministry of Health of Mexico.

In this study of nearly 14,000 people, the rate of complete edentulism in 20 of 32 states of Mexico was found to be 10.2 percent of the total population; it was 30.6 percent of those above the age of 65 years. Additionally, age, smoking, diabetes, gender, marital and health insurance

status, and wealth index were positively correlated with edentulism. The edentulous patient had a 1.82 times greater risk of having diabetes than the dentate patient. The relationship of adequate salivary quantity and flow to the retention of complete dentures is well known. A study

by Moore et al. has shown the relationship between Type I diabetes and complications associated with salivary production (xerostomia and/or hyposalivation) in the dentate population; while the edentulous patient cohort was not evaluated, the potential impact of diabetes on maxillary complete denture retention can be assumed (60). Additionally, a cross-sectional study of 370 patients revealed that functionally edentulous older men had a 4.06 times greater risk for developing non-insulin-dependent diabetes mellitus, regardless of age or race, than those with partial or complete dentitions (61). Clearly, additional longitudinal studies of the relationship of diabetes to the completely edentulous patient cohort need to be conducted.

Neuropathy and dementia As one might expect, patients suffering with dementia are more likely to experience poor oral health than those with normal cognitive functions; however, studies that assess whether becoming edentulous can contribute to any subsequent risk of developing cognitive impairments or dementia are sparse (62-64). A study by Riviere et al. suggested, in a postmortem examination of brain tissues, that oral microbes may spread to the brain via branches of the trigeminal nerve.

One recent study examined dental records of 144 Roman Catholic nuns residing in Milwaukee, WI (65, 66). These individuals had 12 years of longitudinal assessments of their cognitive

abilities coupled with 40 years of dental records from a single provider. Of the study participants, 22 percent had one or more copies of the Apo lipoprotein E4 allele, a major genetic risk factor for Alzheimer’s disease. Completely edentulous patients were compared to those with varying degrees of partial edentulism.

Cognitive function was assessed by trained gerontologists, and 118 of the study participants received postmortem examination of their brain tissues by a neuropathologist blinded to their cognitive function scores. In this prospective longitudinal study, the authors found a direct correlation between the numbers of missing teeth and the incidence of dementia. The authors suggested that complete edentulism may be a predictor for dementia later in life.

Rheumatoid arthritis Rheumatoid arthritis (RA) is a potentially debilitating chronic inflammatory disease characterized by synovial inflammation that can result in considerable destruction of joint tissues. Additionally, due to similar characteristics with periodontal disease (cytokine profiles, inflammatory markers, association with IL1beta and TNF-alpha), several clinical studies have suggested a possible association of RA between periodontitis and tooth loss, while others have not found a positive association (67–70). A recent investigation by de Pablo et al. evaluated 4461 individuals aged 60 years or older as part of the NHANES III patient cohort (71). The authors found a statistically higher incidence of edentulism in RA patients (56 percent) than in the non-RA cohort (34 percent), with the RA patients having 2.27 times greater risk for edentulism than the non-RA cohort. Adjusting

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Edentulism and Comorbid Factors for age, sex, race-ethnicity, and smoking, the risk increased to 3.34 times (9.64 times the risk for periodontal disease). Overall, RA patients sought dental care on a less frequent basis. Although causality was not established, the authors conclude that RA, and in particular seropositive RA, was clearly associated with periodontal disease and complete edentulism.

Cancer The association between tooth loss and an increased risk of esophageal and gastric cancers, and pancreatic cancer has been reported (72–76). Recently, Hiraki et al. compared tooth loss and 14 common cancers in 5240 cancer subjects with 10,480 ageand sex-matched non-cancer control patients. The authors found a statistically significant correlation between tooth loss and risk of head and neck, lung, and esophageal cancer, when adjusted for confounding variables.

Patients who were completely edentulous were 1.54 times more likely to get lung cancer, 1.68 times more likely to get head and neck cancer, 2.36 times more likely to get esophageal cancer, and 2.85 times more likely to get bladder cancer than those with 21 or more remaining teeth. Additionally, those patients above the age of 70 years were more likely to get the same cancers than those who were 70 years of age or younger. The authors suggest that maintenance of tooth number, especially before old age, might prevent these disorders (77).

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Oral-facial comorbid factors Reduction of the residual ridge (RRR) Perhaps the most noticeable response to the removal of all the teeth is the hard and soft tissue changes following extraction. This has been termed residual ridge resorption and is used to describe the diminishing quantity and quality of the residual alveolar ridge after teeth are extracted (1). Classic studies on the longitudinal loss of residual ridge height have demonstrated that once the teeth are extracted, bone loss is a continuing process, and that the mandibular edentulous ridge may resorb at approximately four times the rate of the maxillary edentulous ridge (78,79). Factors responsible for RRR have been reported as either local factors or systemic factors. Local factors include the length of time edentulous, the size of edentulous ridges, the amount of occlusal stress transmitted through removable prostheses to the underlying hard and soft tissues, the number of dentures previously worn, 24-hour wearing of dentures, and a previous history of wearing removable partial dentures. Systemic factors include age and gender, presence of asthma, reduced calcium intake, osteoporosis, thyroid disease, smoking, obesity, and others (80, 81). While two factors postulated to accelerate RRR are poorly fitting removable prostheses and the use of denture adhesives, little definitive evidence exists to support these premises; however, one study suggests a direct correlation between BMI and resorption of the residual ridges beneath complete dentures in edentulous Finnish women. The study of 128 postmenopausal women who had been edentulous in both jaws for a mean of 23 or more years suggested that women with larger residual ridge mass (more height and width of themandibular ridge) had less chewing difficulty due to loose dentures than those with more associated residual ridge loss. The authors postulated that the patient’s size may play an important role in the impact of RRR (82). A study at the University of Iowa suggested that RRR was associated with the length of time edentulous in women, but no corresponding association was found in the male patients studied (83). Similar findings were reported by Xie et al. (53). For comprehensive reviews of the literature on RRR, see Jahangiri and colleagues and Kingsmill (84, 85). Despite the volume of materials published on RRR, no single dominant causative factor has emerged, and clinical or biologic therapies aimed at reducing or slowing the chronic loss of bone are sparse. One such study evaluated 230 postmenopausal women taking part in a 5-year study on osteoporosis in Finland. All patients were edentulous in the maxillary arch, and 128 were completely edentulous (mean term of edentulousness was 26.9 years in the maxilla and 22.8 years in the mandible). The use of fluoridated water for more than 10 years in this patient cohort was found to positively correlate with improved retention of the residual ridges in both dental arches. A subsequent preliminary study of 35 edentulous patients suggested a positive correlation between total serum calcium levels and retention of residual mandibular edentulous ridge height irrespective of length of denture use (86). It appears that

additional studies of fluoride and calcium uptake for patients anticipating complete denture therapy may be warranted. And, while not the focus of this review

article, it appears that the use of dental implants to retain maxillary and mandibular overdenture prostheses not only enjoys high levels of success, but may

dramatically reduce the loss of alveolar bone in the overdenture patient population, as emerging 10-year data strongly suggest (Table 1).

Table 1. Seven- to 15-year data on implant-retained overdentures

Reference

Trial length (years)

Number of patients

Maxillary or mandibular prostheses

Retention type

Success rate (%)

Implant type

Comments

10 36 Mand Bar and ball 100% Nobel Naert et al. IJOMI 2004 (93)

Splinting = freestanding

Bergendal & Engquist IJOMI 1998 (94) 7 49

Max (18) Bar and ball Mand (32)

74% max 100%mand

Nobel

Visser et al. IJP 2006 (95) 10 29 Mand Bar 92% IMZ and

Nobel

ODs require more maintenance over time

10 37 Quirynen et al. COIR 2005 (96)

Both OD and FP have good outcomes

Attard & Zarb IJP 15.5 45 2005 (97)

Mand (25 OD, 12 FPD)

25 bars, ball, & 100% Nobel magnets

Mand (42) NA 90% Nobel Max (5)

Requires pros maintenance

Meijer et al. COIR 10 61 Mand 93% (IMZ) IMZ and 2004 (98) 86% (Nobel) Nobel

Deporter et al. CIDRR 10 52 Mand Ball 92.7% Endopore 2002 (99)

No worsening outcomes after 10 years

Esthetics and soft tissue profiles Several classic prosthodontic articles have outlined the consequences of long-term edentulism and complete denture wear on the underlying hard and soft tissues, the relationship between the maxilla and mandible, and

occlusal relationships of the removable prostheses (87–90).

Within a 2-year period of tooth extraction and immediate denture placement, there is sufficient loss of bone to result in anterosuperior rotation of the mandible, and associated softtissue profile changes, leading

to protrusion of the chin and pronounced lip and chin displacements (91). Each of these changes on the individual’s facial proportions and profile appearance can have a dramatic effect on a patient’s appearance and self-esteem.

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Edentulism and Comorbid Factors Other intraoral responses While not the focus of this article, other intraoral responses to complete denture use, such as soft tissue and mucosal reactions, hyposalivation or xerostomia, or temporomandibular dysfunction can exist as a consequence of tooth loss and complete denture fabrication. For a review of such consequences, see Carlsson (92).

Summary Edentulism continues to represent an enormous global healthcare burden that is often neglected in both developed and developing countries. At a time when global economic conditions are faltering, access to adequate care for the completely edentulous patient, or for the partially dentate patient with a terminal dentition, may lead to a growing need to provide prostheses and other dental services to completely edentulous patients in the future. It does not appear that the necessity for complete denture therapy, and by extrapolation, complete denture education, will disappear over the next four or five decades. While the consequences of complete edentulism on the oral and facial structures are well known, criteria for predicting the long-term effects of tooth removal on any individual patient are currently lacking. While the effects of chronic periodontal disease have been closely linked to tooth loss and other systemic conditions, whether the cumulative effects of this inflammatory disease have long-range clinical implications for the completely edentulous patient remains speculative;

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however, it appears that the completely edentulous patient may be at risk for development of other comorbid conditions, including diabetes, cardiovascular conditions, dementia, cancer, asthma, and others, but whether these comorbid conditions are casual or causal has not been clearly determined. Additional research is needed to determine the relationship of these various systemic diseases with the removal of all teeth. And, while the long-term effects of tooth extraction on residual ridge resorption

is well known, the prognosis for maintenance of the edentulous ridge height and width without dental implant therapy appears to be poor at this time. To minimize bone loss, chronic mucosal irritation, and functional problems for the denture patient, provision of exemplary complete denture therapy and low-cost dental implant therapies, along with establishment of routine recall systems for these patients, should be the ultimate goal for the dental professional.

TIPS FOR THE PRACTICING DENTIST 1. Whether casual or causal, edentulism is related to several comorbidities. Keep the overall health of patients in mind, particularly their ability to maintain a balanced and nutritional diet.

2. To minimize bone loss, chronic mucosal irritation, and functional problems, edentulous patients must be provided exemplary denture therapy.

3. Place all edentulous patients, regardless of therapy, on strict, regular recall schedules.

4. When treatment planning patients who are contemplating removal of their natural teeth, advise them of the potential for development of comorbid systemic conditions that are associated with tooth removal and tooth loss.

References 1. Academy of Prosthodontics: Glossary of prosthodontic terms.

J Prosthet Dent 2005;94:10-92.

2. Petersen PE, Bourgeois D, Ogawa H, et al: The global burden of oral diseases and risks to oral health. Bull World Health Org 2005;83:661-669.

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12. Feine JS, Carlsson GE (eds): Implant Overdentures: The Standard of Care for Edentulous Patients. Carol Stream, IL, Quintessence, 2003, p. 6.

13. Budtz-Jorgensen E. Epidemiology: dental and prosthetic status of older adults. In Budtz-Jorgensen E: Prosthodontics for the

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14. Suominen-Taipale AL, Alanen P, Helenium H, et al: Edentulism among Finnish adults of working age, 1978-1997. Community Dent Oral Epidemiol 1999;27:353-365.

15. Osterberg T, Carlsson GE, Sundh V: Trends and prognoses of dental status in the Swedish population: analysis based on interviews in 1975 to 1997 by Statistics Sweden. Acta Odontol Scand 2000;58:177-182.

16. Eklund SA, Burt BA: Risk factors for total tooth loss in the United States; longitudinal analysis of national data. J Public Health Dent 1994;54:5-14.

17. Palmqvist S, Soderfeldt B, Arnbjerg D: Explanatory models for total edentulousness, presence of removable dentures, and complete dental arches in a Swedish population. Acta Odontol Scand 1992;50:133-139.

18. Marcus SE, Kaste LM, Brown LJ: Prevalence and demographic correlates of tooth loss among the elderly in the United States. Spec Care Dentist 1994;5414:123-127.

19. Uneil L, Soderfeldt B, Halling A, et al: Explanatory models for oral health expressed as number of remaining teeth in an adult population. Community Dent Health 1998;15:155-161.

20. Dolan TA, Gilbert GH, Duncan RP, et al: Risk indicators for edentulism, partial tooth loss and prosthetic status among black and white middle-aged and older adults. Community Dent Oral Epidemiol 2001;29:329340.

21. Palmqvist S, Soderfeldt B, Vigild M: Influence of dental care systems on dental status. A comparison between two countries with different systems but similar living standards. Community Dent Health 2001;18:16-19.

22. Tuominen R, Rajala M, Paunio I: The association between edentulousness and the accessibility and availability of dentists. Community Dent Health 1984;1:201206.

23. Bouma J, van de Poel F, Schaub RM, et al: Differences in total tooth extraction between an

urban and a rural area in the Netherlands. Community Dent Oral Epidemiol 1986;14:181183.

24. Bouma J, Uitenbroek D,Westert G, et al: Pathways to full mouth extraction. Community Dent Oral Epidemiol 1987;15:301305.

25. Lund JP: Introduction: it is time to tackle denture disability. In Feine JS, Carlsson GE (eds): Implant Overdentures: The Standard of Care for Edentulous Patients. Carol Stream, IL, Quintessence, 2003, p. 1.

26. Nowjack-Ramer RE, Sheiham A: Association of edentulism and diet and nutrition in US adults.

J Dent Res 2003;82:122-126.

27. Nowjack-Raymer RE, Sheiham A: Numbers of natural teeth, diet, and nutritional status in US adults. J Dent Res 2007;86:1171-1175.

28. Hines K, Gregory JR: National diet and nutrition survey: people aged 65 years or over. Vol. 2: Report of the Oral Health Survey.

London, Stationary Office, 1998.

29. Fontijin-Tekamp FA, van’t Hof MAK, Slagter AP, et al: The state of dentition in relation to nutrition in elderly Europeans in the SENECA study of 1993. Eur J Clin Nutr 1996;50:S117-S122.

30. Shimazaki Y, Soh I, Saito T, et al: Influence of dentition status on physical disability, mental impairment, and mortality in institutionalized elderly people. J Dent Res 2001;80:340-345.

31. Kennedy ET, Ohis J, Carlson S, et al: The Healthy Eating Index: design and applications. J Am Diet Assoc 1995;95:1103-1108.

32. Sahyoun NR, Lin C-L, Krall E: Nutritional status of the older adult is associated with dentition status. J Am Diet Assoc 2003;103:61-66.

33. Slade GD: Tooth loss and chewing capacity among older adults in Adelaide. Aust J Public Health 1996;20:76-82.

34. Sheiham A, Steele JG, Marcenes W, et al: The relationship between oral health status and Body Mass Index among older people: a national survey of older people in Great Britain. Br Dent J 2002;192:703-706.

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NIH Consensus Development Panel: Osteoporosis prevention, diagnosis, and therapy. J Am Med Assoc 2001;285:785-795.

Kanis JA: Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. WHO Study Group. Osteoporos Int 1994;4:368-381.

Kribbs PJ, Smith DE, Chestnut CH III: Oral findings in osteoporosis: part I: measurement of mandibular bone density. J Prosthet Dent 1983;50:576-579.

Kribbs PJ, Smith DE, Chestnut CH III: Oral findings in osteoporosis: part II: relationship between residual ridge and alveolar bone resorption and generalized skeletal osteopenia. J Prosthet Dent 1983;50:719-724.

Hirai T, Ishijima T, Hashikawa Y, et al: Osteoporosis and reduction of residual ridge in edentulous patients. J Prosthet Dent 1993;69:49-56.

Klemetti E, Vainio P, Lassila V, et al: Cortical bone mineral density in the mandible and osteoporosis status in postmenopausal women. Scand J Dent Res 1993;101:219-223.

Klemetti E, Vainio P, Lassila V, et al: Trabecular bone mineral density in the mandible and alveolar height in postmenopausal women. Scand J Dent Res 1993;101:166-170.

Slagter KW, Raghoebar GM, Vissink A: Osteoporosis and edentulous jaws. Int J Prosthodont 2008;21:19-26.

Loesch WJ, Schork A, Terpenning MS, et al: Assessing the relationship between dental disease and cerebral vascular accident in elderly United States veterans. Ann Periodontol 1998;3:161-174.

Joshipura KJ, Hung HC, Rimm EB, et al: Periodontal disease, tooth loss, and incidence of ischemic stroke. Stroke 2003;34:4752.

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46. Hung HC, Willett WC, Merchant A, et al: Oral health and peripheral arterial disease. Circulation 2003;107:1152-1157.

47. Taguchi A, Sanada M, Suei Y, et al: Tooth loss is associated with an increased risk of hypertension in postmenopausal women.

Hypertension 2004;43:12971300.

48. Lowe G, Woodward M, Rumley A, et al: Total tooth loss and prevalent cardiovascular disease in men and women: possible roles of citrus fruit consumption, vitamin C, and inflammatory and thrombotic variables. J Clin Epidemiol 2003;56:694-700.

49. Desvarieux M, Demmer RT, Rundek T, et al: Relationship between periodontal disease, tooth loss, and carotid artery plaque: The Oral Infections and Vascular Disease Epidemiology Study (INVEST). Stroke 2003;34:21202125.

50. Schwahn C, Volzke H, Robinson DM, et al: Periodontal disease, but not edentulism, is independently associated with increased plasma fibrinogen levels. Thromb Haemost 2004;92:244-252.

51. Millar WJ, Locker D: Smoking and oral health status. J Can Dent Assoc 2007;73:155.

52. Xie Q, Ainamo A: Association of edentulousness with systemic factors in elderly people living at home. Community Dent Oral Epidemiol 1999;27:202-209.

53. Xie Q, Ainamo A, Tilvis R: Association of residual ridge resorption with systemic factors in home-living elderly subjects. Acta Odontol Scand 1997;55:299-305.

54. McGrath C, Bedi R: Population based norming of the UK oral health-related quality of life measure. Br Dent J 2002;193:521524.

55. Yoshida Y, Hatanaka Y, Imaki M, et al: Epidemiological study on improving the QOL and oral conditions of the aged. Part 1: the relationship between the status of tooth preservation and QOL. J Physiol Anthropol Appl Human Sci 2001;20:363-368.

56. Locker D, Matear D, Stephens M, et al: Oral health-related quality of life of a population of medically compromised elderly people. Community Dent Health 2002;19:90-97.

57. Klein BEK, Klein R, Knudtson MD: Life-style correlates of tooth loss in an adult Midwestern population. J Public Health Dent 2004;64:145-150.

58. Priority area report, scientific themes and issues to be addressed in diabetes research.

US-Ireland Research and Development Partnership Steering Group. March 14, 2006.

59. Medina-Solis CE, Perez-Nunez R, Maupome G, et al: Edentulism among Mexican adults aged 35 years and older and associated factors. Am J Public Health 2006;96:1578-1581.

60. Moore PA, Guggenheimer J, Etzel KR, et al: Type 1 diabetes mellitus, xerostomia, and salivary flow rates. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:281-291.

61. Cleary TJ, Hutton JE: An assessment of the association between functional edentulism, obesity, and NIDDM. Diabetes Care 1995;18:1007-1009.

62. Chalmers JM, Carter KD, Spencer AJ: Oral diseases and conditions in community-living older adults with and without dementia. Spec Care Dentist 2003;23:7-17.

63. Weyant RJ, Pandav RS, Plowman JL, et al: Medical and cognitive correlates of denture wearing in older communitydwelling adults. J Am Geriat Soc 2004;52:596-600.

64. Shimazaki Y, Soh I, Saito T, et al: Influence of dentition status on physical disability, mental impairment, and mortality in institutionalized elderly people. J Dent Res 2001;80:340-345.

65. Riviere GR, Riviere KH, Smith KS: Molecular and immunological evidence of oral Treponema in the human brain and their association with Alzheimer’s disease. Oral Microbiol Immunol 2002;17:113-118.

66. Stein PS, Desrosiers M, Donegan SJ, et al: Tooth loss, dementia and neuropathology in the Nun Study. J Am Dent Assoc 2007;138:1314-1322.

67. Mercado FB, Rarshall RI, Klestov AC, et al: Relationship between rheumatoid arthritis and periodontitis. J Periodontol 2001;72:779-787.

68. Al-Shammari KF, Al-Khabbaz AK, Al-Ansari JM, et al: Risk indicators for tooth loss due to periodontal disease. J Periodontol 2005;76:1910-1918.

69. Laurel L, Hugoson A, Hakansson J, et al: General oral status in adults with rheumatoid arthritis.

Community Dent Oral Epidemiol 1989;17:230-233.

70. Yavuzyilmaz E, Yamilik N, Calguner M, et al: Clinical and immunological characteristics of patients with rheumatoid arthritis and periodontal disease. J Nihon Univ Sch Dent 1992;34:8995.

71. de Pablo P, Dietrich T, McAlindon TE: Association of periodontal disease and tooth loss with rheumatoid arthritis in the US population. J Rheumatol 1008;35:70-76.

72. Wang YP, Han XY, Su W, et al: Esophageal cancer in Shanxi Province, People’s Republic of China: a case-control study in high and moderate risk areas. Cancer Causes Control 1992;3:107-113.

73. Abnet CC, Qiao YL, Mark SD, et al: Prospective study of tooth loss and incident esophageal and gastric cancers in China. Cancer Causes Control 2001;12:847854.

74. Abnet CC, Kamangar F, Dawsey SM, et al: Tooth loss is associated with increased risk of gastric non-cardio adenocarcinoma in a cohort of Finnish smokers. Scand J Gastroenterol 2005;40:681-687.

75. Stolzenberg-Solomen RZ, Dodd KW, Blaser MJ, et al: Tooth loss, pancreatic cancer, and Helicobacter pylori. Am J Clin Nutr 2003;78:176-181.

76. Michaud DS, Josipura K, Giovannucci E, et al: A prospective study of periodontal disease and pancreatic cancer in US male health professionals. J Natl Cancer Inst 2007;99:171-175.

77. Hiraki A, Matsuo K, Suzuki T, et al: Teeth loss and risk of cancer at 14 common sites in Japanese.

Cancer Epidemiol Biomarkers Prev 2008;17:1222-1227.

78. Tallgren A: The continuing reduction of the residual alveolar ridges in complete denture wearers: a mixed-longitudinal study covering 25 years. J Prosthet Dent 2003;89:427-435.

79. Atwood DA: Reduction of residual ridges: a major oral disease entity. J Prosthet Dent 1971;26:266-279.

80. Devlin H, Ferguson MWJ: Alveolar ridge resorption and mandibular atrophy. A review of the role of local and systemic factors. Br Dent J 1991;170:101-104.

81. Siemenda CW, Hui SL, Longcope C, et al: Cigarette smoking, obesity, and bone mass. J Bone Miner Res 1989;4:737-741.

82. Klemetti E, Vainio P, Lassila V, et al: Relationship between body mass index and the remaining alveolar ridge. J Oral Rehabil 1997;24:808-812.

83. Nahri TO, Ettinger RL, Lam EWM: Radiographic findings, ridge resorption, and subjective complaints of complete denture wearers. Int J Prosthodont 1997;10:183-189.

84. Jahangiri L, Devlin H, Ting K, et al: Current perspectives in residual ridge remodeling and its clinical implications: a review. J Prosthet Dent 1998;80:224-237.

85. Kingsmill VJ: Post-extraction remodeling of the adult mandible. Crit Rev Oral Biol Med 1999;10:384-404.

86. Zmystowska E, Ledzion S, Jedrzejewski K: Factors affecting mandibular residual ridge resorption in edentulous patients: a preliminary report. Folia Morphol 2007;66:346-352.

87. Tallgren A: The effect of denture wearing on facial morphology. Acta Odontol Scand 1967;25:563-592.

88. Tallgren A: Positional changes of complete dentures. Acta Odontol Scand 1969;27:539-561.

89. Tallgren A, Lang BR, Walker GF, et al: Roentgen cephalometric analysis of ridge resorption and changed in jaw and occlusal relationships in immediate complete denture wearers. J Oral Rehabil 1980;7:77-94.

90. Tuncay OC, Thomson S, Abadi B, et al: Cephalometric evaluation of the changes in patients wearing complete dentures: a ten-year longitudinal study. J Prosthet Dent 1984;51:169-180.

91. Tallgren A, Lang BR, Miller RL: Longitudinal study of soft-tissue profile changes in patients receiving immediate complete dentures. Int J Prosthodont 1991;4:9-16.

92. Carlsson GE: Clinical morbidity and sequelae of treatment with complete dentures. J Prosthet Dent 1998;79:17-23.

93. Naert I, Alsaadi G, van Steenberghe D, et al: A 10-year randomized clinical trial on the influence of splinted and unsplinted oral implants retaining mandibular overdentures: peri-implant outcome. Int J Oral Maxillofac Implants 2004;19:695-702.

94. Bergendal T, Engquist B: Implant-supported overdentures: a longitudinal prospective study.

Int J Oral Maxillofac Implants 1998;13:253-262.

95. Visser A, Meijer HJ, Raghoebar GM, et al: Implant-retained mandibular overdentures versus conventional dentures: 10 years of care and aftercare. Int J Prosthodont 2006;19:271-278.

96. Quirynen M, Alsaadi G, Pauwels M, et al: Microbiological and clinical outcomes and patient satisfaction for two treatment options in the edentulous lower jaw after 10 years of function. Clin Oral Implants Res 2005;16:277-287.

97. Attard NJ, Zarb GA: Long-term treatment outcomes in edentulous patients with implant overdentures: the Toronto study. Int J Prosthodont 2004;17:425-433.

98. Meijer HJ, Raghoevar GM, Van’t Hof MA, et al: A controlled clinical trial of implant-retained mandibular overdentures: 10 years’ results of clinical aspects and aftercare of IMZ implants and Branemark implants. Clin Oral Implants Res 2004;15:421427.

99. Deporter D, Watson P, Pharoah M, et al: Ten-year results of a prospective study using poroussurfaced dental implants and a mandibular overdenture. Clin Oral Implants Res 2002;4:183189.

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Dental Artifacts

Early Sit-Down Dentistry Kim Freeman, M.A., D.M.D., M.S. Before the 1940’s, dentists by and large stood during every dental procedure.

When I first graduated, the old joke was, “How can you tell by looking that someone is a retired dentist?”

The answer is, “He wears thick glasses and is permanently stooped over.”

While it is true that “sit-down dentistry” did not reach popularity until the 1960’s, operating stools were available as early as 1900. In 1915 ads, three types of stools were available (Figures A, B). The photograph shows the “noratchet” variety. It is of note that the

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claim is made, in writing, that the stool preserves health and lengthens life. Obviously this was written before truth-inadvertising laws. Certainly, if the claim were true, I would be using it.

That it can’t slip from under the operator is personally disputed.

I tried it! It went out from under me on the polyurethane floor, and I ended up on my backside.

Figure A

Figure B

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P

w e i v e r

The Office Safety and Health Coordinator

Charles John Palenik, M.S., Ph.D., M.B.A., Director/Infection Control Research & Services, Indiana University School of Dentistry, Indianapolis, Indiana

A dental office’s health and safety program involves a wide Improving The Effectiveness And Effi ciency Of Your Infection Prevention Program Thursday, May 6, 2010 8:30 AM - 11:30 AM Infection Prevention Today, Infection Prevention Tomorrow 1:30 PM – 4:30 PM Infection Prevention That Is Both Effective And Sensitive To The Environment Friday, May 7, 2010 8:30 AM – 11:30 AM

The TDA makes every effort to present high caliber speakers in their respective areas of expertise at the TEXAS Meeting. Speakers presented by TDA are offered for the purpose of providing information only and not as dental, financial, accounting, legal, or other professional advice. Attendees must consult their own professional advisors for such advice. The ideas and comments expressed during the seminars and the articles presented herein are not necessarily endorsed by, or those of, the TDA. Programs actually presented at the TEXAS Meeting may be subject to change by the TDA.

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variety of issues. Central, of course, is a collection of infection prevention and control procedures. Also included are proper hazardous chemicals and regulated waste management, emergency (e.g., fire or weather) response and employee awareness and training.

Successfully operating an office health and safety program is challenging. The program is first established then maintained through regular monitoring. In addition, changes in rules and regulations occur on a regular basis. New safety and health products and equipment enter the market regularly. Research evaluates current procedures and offers improvement through changed materials and concepts. The result is a continuously evolving process that requires constant attention (1).

An Office Health & Safety Coordinator In December 2003, the Centers for Disease Control and Prevention (CDC) issued a set of infection control recommendations. These recommendations updated those made in 1986 and 1993 (2).

The CDC specifically stated, “Dental practices should develop a written infectioncontrol program to prevent or reduce the risk of disease transmission. Such a program should include establishment and implementation of policies, procedures, and practices (in conjunction with selection and use of technologies and products) to prevent work-related injuries and illnesses among DHCP as well

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as healthcare–associated infections among patients. The program should embody principles of infection control and occupational health, reflect current science, and adhere to relevant federal, state, and local regulations and statutes. An infection-control coordinator (e.g., dentist or other DHCP) knowledgeable or willing to be trained should be assigned responsibility for coordinating the program. The effectiveness of the infection-control program should be evaluated on a day-to-day basis and over time to help ensure that policies, procedures, and practices are useful, efficient, and successful.”

Although the infection-control coordinator remains responsible for overall management of the program, creating and maintaining a safe work environment ultimately requires the commitment and accountability of all.

An Office Health and Safety Coordinator (OHSC) is the person designated to help protect patients, visitors and office personnel and to help ensure that the facility is in compliance with all applicable federal, state and local rules and regulations. This person should be a knowledgeable member of the office team willing to accept the responsibility for management of the program (2, 3).

It would be beneficial if the OHSC had a basic understanding of microbiology and disease transmission in dental environments. A good background concerning infection prevention and control procedures and equipment would be very helpful, as would be a familiarity with federal, state and local rules and regulations. Extra training may be necessary.

There are several desirable characteristics of an OHSC. No single person could likely possess full measures of all sought-after traits. However, given opportunity, time, and training, many office employees could function effectively and effciency (3).

Desirable Characteristics of an OHSC • • • • • • • • • • • •

personally interested in human health and safety respected by other staff employees as well as by management compliance oriented willing to accept additional and/or different responsibilities detailed/fact oriented — well organized willing to learn and maintain an expertise in infection prevention and control can handle supervisory responsibilities places workplace safety above personal popularity communicates well both orally and in writing capable of maintaining safety records (computer literate) can handle and maintain confidential and/or sensitive information capable of providing sincere praise and objective criticism

OHSC Training In order to function optimally, most OHSC would need additional training at the time of appointment and occasionally over time. This may include formal courses, independent study and interactive instruction available on the Internet.

Any training that increases understanding of microbiology is beneficial. This would include additional information concerning the physical nature of microorganisms. Insight into how microbes grow, reproduce, and perish is valuable (4).

An OHSC needs to know the pathways through which microorganisms can spread (cross-contaminate) in dental environments.

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Office Safety and Health Coordinator Microorganisms present on and in patients can spread to dental team members. Team members can share their infections with patients. Poor infection prevention and control between patients, such as by inadequate instrument sterilization, could cause one patient to indirectly infect another.

There is an absolute need to break the chain of transmission. Dental offices can spread contamination to the surrounding community through improper storage, handling, and disposal of regulated medical waste. The outside environment can affect health and safety within a dental office. This could involve poor air quality or more likely by use of microbially contaminated water.

A great portion of an OHSC’s work involves infection prevention and control. The most effective way to become and stay current is through membership in the Organization for Safety and Aseptic Procedures (OSAP, www.osap. org or 800.298.6727). OSAP can provide information concerning current health and safety issues as well as regulations, rules and recommendations (e.g., OSHA Bloodborne Pathogens and Hazard Communication Standards).

OSAP has developed a library of instructional materials (e.g., textbooks, workbooks, videos, posters, guidelines, charts, web links, newsletters and online forums).

Membership allows an OHSC to work with other coordinators and to interact with experts in the field.

OSAP has members from a variety of areas — academe, government, military, private practice, and the for-profit sector. Having many corporate members helps ensure that

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information is available concerning manufacturers and suppliers of infection prevention and control equipment, materials and supplies.

OSAP also conducts a 3.5-day annual symposium (4, 5).

OHSC must possess adequate communication skills. Improved verbal skills can result from practice, improved organization and training courses. Written communication is also very important.

Today, keyboard and computer literacy are expected entrance behaviors. Writing can involve the generation of office manuals, training materials and lists of standard operating procedures. OHSC may have to communicate with other offices, agencies or organizations by written letters or email messages.

One goal of an OHSC’s work is to establish “a culture of safety.” There is an atmosphere of mutual trust and cooperation in which all office staff members speak freely about safety issues and how to solve them in the absence of blame and punishment. In a culture of safety, people are not merely encouraged to work toward change; they take action when it is needed (4, 5).

Education and Training The employer is ultimately responsible for health and safety in the office. However, assignment of most duties can go to the OHSC (2, 3).

Success is usually a cooperative effort. The CDC recommendations indicate...Although the infectioncontrol coordinator remains responsible for overall management of the program, creating and main-

taining a safe work environment ultimately requires the commitment and accountability for all (1).

A key element of an office’s safety and health programs is the preparation of a multifaceted written personnel health program. This is a collection of office policies, procedures, and guidelines. It covers employee education and training, immunization, exposure prevention and postexposure management, employee medical conditions, work-related illness and associated work restrictions, contact dermatitis and latex allergy. Also included are maintenance of records, data management, and issues of confidentiality.

References 1. Miller CH and Palenik CJ. Infection Control and Management of Hazardous Materials for the Dental Team, 4th edition, 2010, St. Louis, MO, Mosby Elsevier, pp.248-249.

2. Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings, 2003.

MMWR 52(RR-17):1-68, 2003.

Also available at: www.cdc. gov/mmwr/PDF/RR/RR5217.pdf.

3. Palenik CJ. The role of the infection control coordinator. Dent Today. 23(September):66-68, 2004.

4. Miller CH. So you just became the office safety coordinator — what do you do now?

Infection Control In Practice 8(March):1-8, 2009.

5. Institute for Healthcare Improvement. Develop a culture of safety. Available at: www.ihi. org/IHI/Topics/PatientSafety/ SafetyGeneral/Changes/ Develop+a+Culture+of+Safety. htm. Accessed: March 2010.

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In Memoriam Those in the dental community who have recently passed

Bowman, George Wilton Temple, Texas August 6, 1924 – January 30, 2010 Good Fellow, 1974 Life, 1989 Fifty Year, 1999

Clark, Bill Ray Tyler, Texas May 27, 1929 – February 18, 2010 Life, 1997

Merriweather, Mark

Memorial and Honorarium Donors to the Texas Dental Association Smiles Foundation

In Memory of: Frank Byers

By Dr. and Mrs. Don A Lutes Lillian Sauer, mother of Dr. Ed Sauer

By Dr. and Mrs. Don A Lutes Jenkins Garrett

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

Plano, Texas April 5, 1949 – December 22, 2009

Ramey, Jack A. Kerrville, Texas February 29, 1932 – February 8, 2010 Good Fellow, 1989 Life, 1998

Please make your check payable to:

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

Snider, Richard A. Arlington, Texas April 30, 1914 – February 20, 2010 Good Fellow, 1964 Life, 1982 Fifty Year, 1987

Whinery, John Graham Amarillo, Texas March 18, 1921 – January 30, 2010 Good Fellow, 1977 Life, 1986 Fifty Year, 1994

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Oral and Maxillofacial Pathology Case of the Month

Case History A 13-year-old Hispanic female was referred by her pediatric dentist to the Baylor College of Dentistry—Texas A&M Health Science Center Department of Oral and Maxillofacial Surgery regarding a radiopacity of the right posterior mandible that was noticed on routine radiographic exam. The patient’s past medical history was non-contributory.

Her intraoral exam revealed minimal restorative needs and benign migratory glossitis (geographic tongue) on the dorsal and lateral tongue. Radiographically, a well circumscribed, 2.25 x 1.50 cm, elliptical, radiopaque lesion was noted in the right posterior mandible overlying impacted tooth #31, which was displaced inferiorly (Figure 1). There was no obvious clinical expan-

Naidu

Ding

Schow

Aparna Naidu, D.D.S., M.S., Assistant Professor, Department of Diagnostic Sciences, Texas A&M Health Science Center, Baylor College of Dentistry, Dallas, Texas Michael P. Ding, D.D.S., M.D., Resident, Department of Oral and Maxillofacial Surgery, Texas A&M Health Science Center, Baylor College of Dentistry, Dallas, Texas Sterling R. Schow, D.M.D., Professor, Department of Oral and Maxillofacial Surgery, Texas A&M Health Science Center, Baylor College of Dentistry, Dallas, Texas

Figure 1. Panoramic radiograph shows a radiopacity surrounded by a well-defined radiolucent border in the right posterior mandible. Tooth #31 has been displaced to the inferior border of the mandible.

Figure 2. A post-operative radiograph shows an intact inferior mandibular cortex.

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sion of the mandibular cortices and no paresthesia noted. A computed tomography (CT) scan revealed thinning of the mandibular cortex in the area of the radiopaque mass.

Subsequently, the patient underwent a general anesthetic with nasotracheal intubation for her surgical procedure.

Teeth numbers 1, 16, and 17 were extracted surgically in the usual manner.

A full thickness mucoperiosteal flap was then elevated to expose the buccal surface of the right posterior mandible. The cortex of the mandible was grossly intact and no perforation was noted. After the lesion was removed, the impacted tooth #31 could be adequately visualized and sectioned for removal (Figure 2). The radiopaque mass was sent for histopathologic examination.

What is your differential diagnosis?

Figure 3. A low power (4 X) photomicrograph shows a disorganized mass of dentin, cementum, and enamel surrounded peripherally by a dense band of fibrous connective tissue containing linear fragments of odontogenic epithelium.

Microscopic Findings Histologic sections showed a hard tissue specimen composed of a disorganized mass of dentin and enamel matrix (Figures 3 and 4). The mass had a well-defined border with remnants of dental lamina seen peripherally. The dentin was surfaced by cementum in most areas.

What is the final diagnosis?

See page 422 for the answer and discussion.

Figure 4. A higher power (20 X) photomicrograph shows mature, tubular dentin, lined by cementum and small amounts of enamel matrix.

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Provided by TDA Perks Program

value for your

profession

Green Management of Dental Office Waste: Turn Your Red and Black Bags Green Jan Harris, SHARPS, Inc.

Patients today are thinking about the environment more than ever. Many are segregating waste at home and carrying reusable bags to the grocery store. There are many ways to bring that green thinking to the dental office as well, and through management of recyclables, hazardous and medical waste, confidential documents, and trash. Proper waste management is not only important to your patients, in many respects, it’s important to regulators as well.

Traditionally, we view used dental materials and instruments as either disposable or reusable. If disposable, we may not think a lot about where it goes once we’ve tossed it into the red, black, or other colored container. If it’s reusable, we often just think of how to best disinfect or sterilize it to protect our patients. However, implementing some simple green practices can help protect patients, employees, the environment, and even the practice.

The first step in responsible waste management in the office is identifying the waste streams in the office through a waste audit. Waste is always put in some type of container. A simple way to audit is to list your containers and

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record the items found in each one (see Table 1). Determine if those items are in the correct container, and if not, where they belong. For example, chair-side traps containing amalgam must not be found in the medical waste container, but should be placed in the amalgam-recycling container. If the office does not have an amalgam-recycling container, this option should be investigated and discussed to determine if implemen-

tation of this form of waste disposal is appropriate. Regardless, the amalgam must not go into the medical waste container (1).

Objectives for a successful wastesegregation program should include the following: • •

Identify wastes.

Determine proper segregation and containment methods.

• • • •

•

Decide on the types of disposal for each waste stream.

Develop policies and procedures regarding waste disposal and segregation.

Implement management and employee training.

Establish record-keeping programs.

Institute an evaluation program.

Table 1. Sample waste-audit form, including a few possibilities of types of waste.

Waste Audit Date: ________ Item found in container Auditor: ______

Is the item where it belongs?

What alternative disposal option is recommended?

Trash Container

Plastic water bottles Lead foils Expired bottle of acetone

No No No

Recycling bin Dental waste recycling system Hazardous waste container

Non-Sharps Medical Waste Container

Sharps Container

Contact amalgam (in traps) Patient bibs

No No

Dental waste Recycling System Trash

Blood-soaked gauze Carpules with blood in them

No Yes

Non-sharps medical waste container/bag None

The next step is to attempt to determine the approximate volume of each type of waste. Do you need smaller trash containers, larger recycling bins, smaller medical waste containers, etc. Determine the appropriate containers needed, and place them throughout the facility (Figure 1). It’s critical to determine how each waste stream will be disposed before containers are purchased and filled.

Recycling There are obvious recycling practices your office can implement, such as recycling plastics, junk mail, and non-confidential documents. Unfortunately, it’s easy to become confused as to what is and what is not recyclable. Check with your city to determine which items are recyclable and which are not. Place a recycling container next to each trash can in

the office; don’t forget the waiting room. Green Hint: Instead of using those blue recycle containers in your waiting room, get creative and colorcoordinate your waste receptacles.

Place a list on the container lid of what can and cannot go into the recycling bin. These lists are available from your city’s environmental-waste department.

Figure 1. Examples of different containment/disposal systems

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Green Management Dental Hazardous Wastes There are many wastes in the dental office that could be considered hazardous: amalgam, compact florescent bulbs, and thermostats, which contain mercury. X-ray waste contains silver and lead. Most dental offices are considered small-quantity generators of hazardous waste and are exempt from certain hazardous waste regulations. However, some hazardous chemicals may need to be picked up by a hazardous waste disposal service, once determined to be waste (2). It is important to place this waste in the proper containers to assure appropriate disposal. Most of these wastes can be recycled.

Dental Mercury Waste Sources of mercury in dental offices include amalgam from restorations or teeth that have been removed (3). Never place amalgam in the medical-waste container. Mercury can become vaporized upon autoclaving or incineration, contaminate the air, and be exposed to workers (1). Amalgam recycling systems allow transport of this waste to retort facilities that extract the mercury, so it can be recycled. Tracking of this waste is typically not required but can assure you that your waste has been received and recycled properly. Note: Always use non-chlorine cleaners for suction line disinfection, as chlorine breaks down amalgam-releasing mercury vapors (4).

Silver-Containing Waste Dental offices that operate standard radiography equipment must utilize chemicals, including fixer and developer. Fixer contains silver and should be processed safely; not placed in the sewer. Always check with your Publicly Owned Treatment Works (POTW) before placing used fixer solution into the sewer. Typically, waste developer may be flushed down the drain, as long as it’s been used. Exposed X-ray film contains silver, and should be recycled like other dental-office hazardous waste.

Lead Foil and Shields Lead foil and shields should not be placed in the trash, and definitely not in the medical-waste container. Utilize a system that delivers your lead-containing materials to a recognized metals recycler that can provide you with a certificate of recycling.

Sterilizing and Disinfecting Chemicals Sterilization chemicals such as Glutaraldehyde and orthophthaldehyde (OPA) should not be disposed of in the sewer (5). Ideally, they can either be neutralized onsite with a glycine-based compound, or sent offsite and treated as hazardous waste. Check with your local POTW before disposing of any hazardous chemicals in the sewer.

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Dental Medical Wastes Is It Medical Waste or Trash?

The Occupational Safety and Health Administration (OSHA) regulates medical waste handling in order to protect employees. The Texas Commission on Environmental Quality (TCEQ) regulates medical waste disposal in the state of Texas. Too often medical wastes are not segregated properly, costing the office hundreds or even thousands of unnecessary dollars.

What is medical waste? OSHA defines medical waste in a dental office as: • • • • •

Liquid or semi-liquid blood or other potentially infectious materials (OPIM) Items that could release blood or OPIM Items caked with dried blood or OPIM Sharps Path and micro waste (6)

The TCEQ defines medical waste as: • • •

Sharps, including contaminated carpules, endo files, scalpel blades, microscope slides, dental wires, contaminated sharp instruments, and contaminated broken glass Bulk (100 mL) human blood Path and micro waste (7)

It is important to comply with both OSHA and TCEQ guidelines.

When determining if a contaminated item is medical waste (other than sharps), the amount of contamination, and whether the contaminants are absorbed are key considerations. For example, blood absorbed into gauze is contaminated, but it IS NOT regulated medical waste. However, if that gauze is saturated with blood, it’s regulated medical waste.

Reducing CO2 Emissions Texas cities rank as some of the highest in the nation for air pollution (8). What does air pollution have to do with medical waste disposal? Using disposal-bymail systems approved by the United States Postal Service can reduce CO2 emissions into the environment by eliminating the need for having medical waste pickup trucks. Since the mail carrier is coming to your office daily any way, there are no additional emissions.

In addition, always make sure your medical waste is being treated and disposed of in the most environmentally responsible way. Incineration should be reserved for hazardous materials and medication disposal, not medical waste.

Autoclaving medical waste, followed by shredding and compacting, is not only a clean-treatment method, it reduces the resulting volume by more than 80 percent.

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Green Management Confidential Documents

References

When disposing of old patient files and X-rays, consider confidentiality. Shredding the files prior to disposal and placing the X-rays into the dental hazardous waste recycling system will protect patients, the practice, and the environment.

Do not place old X-rays in the medical-waste container, as they contain silver.

1. American Dental Association, Best Management Practices for Amalgam Waste. 2007. Accessed 1/24/2010 at http://www.ada.org/prof/resources/topics/amalgam_bmp.asp 2. Texas Commission on environmental Quality. Exemptions from Hazardous and Industrial Waste Permitting – Conditionally Exempt Small Quantity Generators. Accessed 2/6/2010 at www.tceq.state.tx.us/permitting/waste_ permits/ihw_pemits/ihw_exemptions. html#CESQ 3. U.S. Environmental Protection Agency, Effluent Limitation Guidelines Detailed Studies Dental Amalgam, December 2008. Accessed 2/4/2010 at http:// www.epa.gov/guide/dental 4. Hanu Batchu, MS, Hwai-Nan Chou, MS, Duane Rakowski, BS and P.L. Fan, PhD. J Am Dent Assoc, Vol 137, No 10, 1419 1425. 2006. The effect of disinfectants and line cleaners on the release of mercury from amalgam.

Accessed 2/8/2010 at http://jada.ada. org/cgi/content/full/137/10/1419 5. U.S. Department of Labor, Occupational Safety and Health Administration 3258-08N. Best Practices for the Safe Use of Glutaraldehyde in Health Care.2006. Accessed 2/1/2010 at http://www.osha.gov/ Publications/3258-08N-2006-English. html 6. 29 CFR 1910.1030 Occupational Safety and Health Administration.

Bloodborne Pathogens Standard.

Accessed 1/25/2010 at http://www. osha.gov/SLTC/bloodbornepathogens/ index.html 7. (RMW) not (u) Title 30 Chapter 335, Subchapter Y. Medical Waste Management. Accessed 2/4/2010 at http://info. sos.state.tx.us/pls/pub/readtac$ext.

ViewTAC?tac_view=5&ti=30&pt=1&ch =330&sch=Y&rl=Y 8. Texas Commission on Environmental Quality Texas Attainment Status by Region. Accessed 2/5/2010 at http:// www.tceq.state.tx.us/implementation/ air/sip/siptexas.html#naas.

Trash After segregating your waste, the trash is ultimately where anything that is left goes. Compacting your trash can reduce the volume. It can also reduce your solid-waste costs. Stock your kitchen with real plates, silverware, cups and glasses and an energy-efficient dishwasher. Yes, someone has to wash them, however, many people enjoy eating off of real dishes. Green Hint: Purchase items in bulk to reduce packaging and costs.

Waste and OSHA Management Guidance Virtually every dental office has an OSHA manual. The problem is, most manuals may not have been opened or updated for years; or they are generic, and not specific to dentistry (5). Look for an OSHA manual that’s in full compliance with recently-mandated changes, includes a medical waste management plan, all the forms required by OSHA, resources, regulations, and training.

Green Hint: Think “paperless office.” Be sure you can complete and update your OSHA manual electronically, and keep it on the office computer desktops or on a CD. Remember, all employees must have access to the computer if you keep it there.

Get the Word Out Remember the importance of marketing. After all that work, you may want to create a poster that lists what green initiatives you are pursuing in your office (Table 2). If you really get creative, you can keep up with and list the number of plastic bottles you have kept out of the landfill, the amount of amalgam you have recycled, the gallons of chemicals you’ve kept out of our drinking water, and pounds of CO2 emissions you have kept out of the air we breathe.

SHARPS Compliance, Inc. is a TDA Perks Program partner. Its Medical Professional Disposal System by Mail costs an estimated 33 percent less than a pickup service. Be sure to mention the TDA Perks Program for a special Perks discount. For more information on SHARPS Compliance, Inc., visit: sharpsinc. com, or contact SHARPS Disposal by Mail at: (800) 772-5657. For information on other TDA Perks Programs, please visit tdaperks.com, or call the Perks office at: (512) 443-3675.

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Table 2. “We’re Going Green” Poster

We’re Going Green!

What our office is doing to help protect our community: n

In order to protect our streams, lakes, and drinking water, we recycle: • Amalgam • X-ray waste • Compact fluorescent bulbs • Batteries

n

We reduce waste in our landfills by: • Recycling plastics and office paper • Compacting our trash to reduce trash volume • Using real dishes in our kitchen

n We reduce our energy expenditure by: • Turning off lights and computers when not in use n We are moving toward a paperless office by: • Utilizing computerized patient records • Maintaining binders of documents electronically n We are protecting our air and water by: • Using green chemicals while keeping infection control in the forefront • Using digital X-rays; no processing chemicals • Using heat sterilizers, and reducing or eliminating the use of harsh chemical sterilants • Combining errands and carpooling to reduce vehicle emissions • Reducing CO2 emissions by disposing of medical waste by

mail, instead of using separate medical-waste pickup trucks • Assuring clean-treatment technology by our medical waste disposal company

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Texas Dental Journal l www.tda.org l April 2010

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421

Oral and Maxillofacial Pathology Diagnosis and Management

Odontoma Oral and Maxillofacial Pathology Case of the Month (from page 412)

Discussion

tooth structure surrounded by a well-defined radiolucency. While compound odontomas are seen more often in the anterior maxilla and mandible, complex odontomas tend to occur posteriorly. A developing odontoma may present as mostly radiolucent, with little calcification (2, 3). In rare case, odontomas may develop extraosseously, within the gingival soft tissues (6).

Odontomas are the most commonly occurring odontogenic tumors. They are considered to be non-neoplastic, developmental anomalies. They are categorized by the World Health Organization as hamartomas, tumorlike overgrowths composed of malformed tissues that are normally found in teeth (1, 2). Odontomas usually develop before the age of 20 and the average age at Histologically, the compound type of odontoma is the time of diagnosis is 14 years. Most odontomas composed of several developing tooth germs containare painless and slow-growing, ing dentin and enamel matrix, producing no clinical sympdental papilla, and small islands toms, and are discovered Although odontomas may be and cords of odontogenic during a routine radiographic epithelium in a background suspected radiographically examination (2, 3). In 15 perof fibrous connective tissue and grossly, they are sent for cent of cases in one review, and follicular tissue. Complex patients noticed divergence odontomas often have a fibrous histologic analysis to rule out of the adjacent teeth, pain, or capsule containing a rim of other odontogenic tumors. The secondary infection (4). Almost odontogenic epithelium forming half of all odontomas were asdentin and cementum. Cendifferential diagnosis in this case sociated with unerupted teeth trally, the hard tissue consists would include the ameloblastic (4). Most odontomas measure mostly of tubular dentin, lined less than 3 cm in diameter. in some areas by cementum or fibro-odontoma (AFO).

However, more mature lesions enamel (Figure 3). The dentin may measure up to 6 cm; as often has small circular spaces they increase in size, they can containing loose fibrous connective tissue (2, 3).

cause cortical expansion in up to 10 percent of cases Although odontomas may be suspected radiographi(1, 2, 3). Odontomas show a slight predilection for the cally and grossly, they are sent for histologic analysis maxilla (4, 5). In both the maxilla and the mandible, the to rule out other odontogenic tumors. The differential anterior jaws are affected more frequently. diagnosis in this case would include the ameloblas tic fibro-odontoma (AFO). AFO is a mixed odontoOdontomas are subclassified into compound or comgenic tumor characterized by neoplastic odontogenic plex types, based on their radiographic, gross, and epithelium and fibrous tissue with areas of odontoma histologic appearance. Compound odontomas present formation. Unlike the odontoma, AFO has a higher reradiographically as a cluster of tooth-like fragments currence rate, and is considered to be a neoplasm (7). surrounded by a radiolucent rim resembling a dental AFO may not be as well-circumscribed as an odontofollicle. Grossly they are composed of small fragments ma, and may be more difficult to completely enucleate of malformed tooth structure contained within a fibrous from the adjacent alveolar bone. Calcifying epithelial capsule. The complex type of odontoma, represented odontogenic tumor (Pindborg tumor) also may present in this case, is a solid mass of haphazardly organized

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as a mixed radiolucent/radiopaque lesion. Pindborg tumors may be unilocular or multilocular and usually affect the posterior maxilla and mandible of patients in the 3rd and 4th decade. They tend to be predominantly radiolucent, with areas of calcification scattered throughout the tumor. Pindborg tumors are neoplastic, and have a reported recurrence rate of approximately 15 percent (2).

Benign fibro-osseous lesions, such as ossifying fibroma and focal cemento-osseous dysplasia were also considered. Ossifying fibromas are neoplasms which tend to affect the posterior mandible of individuals in their 30s and 40s, and they can grow large enough to produce clinical expansion and tooth displacement.

They present as well-defined radiolucencies with varying degrees of radiopacity. It is rare for them to be predominantly radiopaque. Most ossifying fibromas do not have a fibrous capsule, but are well demarcated from the adjacent alveolar bone, which allows for enucleation and low rates of recurrence (2). Focal cemento-osseous dysplasia is a condition which usually affects the posterior mandible and can range from being completely radiolucent to densely radiopaque with a radiolucent border. These lesions are usually non-encapsulated and often do not require removal, unless they produce clinical symptoms (2).

The complex odontoma may resemble an osteoma because of its densely calcified appearance radiographically and grossly. Osteomas are osseous neoplasms that tend to be well-circumscribed, rimmed peripherally by a sclerotic border (2, 3). Unlike odontomas, they are not surrounded by a radiolucent follicular space. Both odontomas and osteomas occur at an increased rate in Gardner’s syndrome, which is an inherited autosomal dominant condition resulting from the mutation of a tumor suppressor gene. Ninety percent of individuals with Gardner’s syndrome develop skeletal abnormalities, most commonly osteomas, often occurring in the mandible. Almost all syndromic patients eventually develop malignancies of the gastrointestinal tract (8).

Occasionally, dentigerous cysts arise from the odontogenic epithelium which forms odontomas. In one review, as many as 27 percent of odontomas were associated with dentigerous cysts (4). Radiographically, the cyst produces an enlarged radiolucency surrounding the odontoma centrally. In a large review of calcifying odontogenic cysts (Gorlin cysts), 24 percent occurred in association with odontomas. The mean age at the time of diagnosis was 17 years, while Gorlin cysts with no odontoma component presented more commonly

in the third decade (9). Although Gorlin cysts are considered neoplasms, recurrence of these lesions after complete removal is rare (1).

Treatment by surgical excision is usually curative for odontomas. The fibrous capsule usually enucleates from the adjacent bone easily. Recurrence of odontomas is rare, and when they do recur it is thought to result from an incomplete initial excision (1). In this case, an obvious demarcation between the lesion and overlying mandible was noted during surgery. Upon visual examination of the surgical wound after removal of the odontoma, the neurovascular bundle was present at the inferior aspect of the site, but no gross clinical damage was apparent. It was also noted that the buccal and lingual cortical plates were intact and no clinical evidence of a fracture was noted. Postoperatively, the patient had right inferior alveolar nerve paresthesia that resolved in the first month.

References 1. Barnes L, Eveson JE, Reichart P, Sidransky D. Pathology and Genetics of Head and Neck Tumours (World Health Organization Classification of Tumours). Lyon: IARC Press 2005; 310-11.

2. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. Third Edition. St. Louis: Saunders Elsevier 2008; 651-3, 721-2, 724-6.

3. Cawson RA, Binnie WH, Speight PM, Barrett AW, Wright JM. Lucas’s Pathology of Tumors of the Oral Tissues. London: Churchill Livingstone 1998; 119-25.

4. Kaugars GE, Miller ME, Abbey LM. Odontomas. Oral Surg Oral Med Oral Pathol. 1989 Feb;67(2):172-6.

5. Regezi JA, Kerr DA, Courtney RM. Odontogenic tumors: analysis of 706 cases. J Oral Surg. 1978 Oct;36(10):771-8.

6. Silva AR, Carlos-Bregni R, Vargas PA, de Almeida OP, Lopes MA. Peripheral developing odontoma in newborn. Report of two cases and literature review. Med Oral Patol Oral Cir Bucal. 2009 Nov 1;14(11):e612-15.

7. Chen Y, Li TJ, Gao Y, Yu SF. Ameloblastic fibroma and related lesions: a clinicopathologic study with reference to their nature and interrelationship. J Oral Pathol Med. 2005 Nov;34(10):588-95.

8. Gorlin RJ, Cohen MM, Levin LS. Syndromes of the Head and Neck. New York: Oxford University Press 1990;366-70.

9. Buchner A. The central (intraosseous) calcifying odontogenic cyst: an analysis of 215 cases. J Oral Maxillofac Surg. 1991 Apr;49(4):330-9. Review.

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Calendar of Events 424

May 2010 6–9 The Texas Dental Association will hold its 140th annual meeting, The TEXAS Meeting, at the San Antonio Convention Center in San Antonio, TX. More than 530 booths will be on exhibit.

For more information, please contact Ms. Sandy Blum, TDA, 1946 S. IH35, Ste. 400, Austin, TX 78704. Phone: (512) 443-3675; FAX: (512) 443-3031; E-mail: sblum@tda.org; Web: texasmeeting.com.

21 & 22 The TDA Smiles Foundation will hold a Smiles on Wheels in Goliad. The 2-day event will include hygiene on day 1 and clinical on day 2. For more information, please contact the TDA Smiles Foundation, 1946 S. IH 35, Ste. 300, Austin, TX 78704. Phone: (512) 448-2441; Web: tdasf.org.

20 – 23 The Society of American Indian Dentists will hold its annual conference at the Embassy Suites in Omaha, NE. For more information, please contact Dr. Tamana Begay, Society of American Indian Dentists, 4212 N. 16th St., Phoenix, AZ 85016. Phone: (602) 263-1200; Email: doctorbegay@hotmail.com.

27 – 30 The American Academy of Pediatric Dentistry will hold its 63rd annual session at the Hilton Chicago in Chicago, IL. More than 120 booths will be on exhibit. For more information, please contact Ms. Kristin Olson, AAPD, 211 E. Chicago Ave., Ste. 1700, Chicago, IL 60611-2663.

Phone: (312) 337-2169; FAX: (312) 337-6329; E-mail: kolson@aapd.org; Web: aapd.org.

June 2010 10 – 13 The Organization for Safety & Asepsis Procedures will hold its annual Infection Prevention and Safety Symposium at the Hyatt Regency Tampa in Tampa, FL. For more information, please contact Ms. Therese Long, OSAP, PO Box 6297, Annapolis, MD 21401. Phone: (410) 571-0003; FAX: (410) 571-0028; E-mail: tlong@osap.org; Web: osap.org.

11 & 12 The TDA Smiles Foundation will hold a Texas Mission of Mercy in Williamson County, Taylor, Texas. For more information, please contact the TDA Smiles Foundation, 1946 S. IH 35, Ste. 300, Austin, TX 78704. Phone: (512) 448-2441; Web: tdasf.org.

11 & 12 The Southwest Prosthodontic Society will hold its annual meeting at the Marriott Hotel at the Galleria on Westheimer in Houston, TX. Speakers include Dr. Todd Schreyer, periodontist on dental implants; Dr. Deter Moya, oral surgeon with an update on biophosphonates; and Dr. Alejandro James on occlusion. The registration fee is $300. For more information, please contact Dr. John Watkins, jwatkindsdds@gmail.com.

18 & 19 The Southwestern Society of Oral Medicine will hold its 61st annual meeting, “Current Issues in Oral Radiology,” at the Marriott Plaza San Antonio Hotel in San Antonio, TX. For more information, please contact Dr. Ron Trowbridge, 2943 Thousand Oaks, Suite 4, San Antonio, TX, 78247. Phone: (210) 653-7174; FAX (210) 653-8204.

24 – 26 The ADA will hold its 24th New Dentist Conference in San Diego, CA. For more information, please contact Mr. Ron Polaniecki, ADA, 211 East Chicago Avenue, Chicago, IL 60611.

Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org.

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July 2010 8 – 11 The Academy of General Dentistry will have its annual meeting at the Ernest Morial Convention Center in New Orleans, LA. For more information, please contact Ms. Rebecca Murray, AGD, 211 E. Chicago Avenue, Suite 900, Chicago, IL 60611-2616. Phone: (312) 440-3368; FAX: (312) 440-0559; E-mail: agd@agd.org; Web: agd.org.

8 – 13 The American Dental Association Kellogg Executive Management Program will be held in Chicago, IL. For more information, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Avenue, Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@ ada.org; Web: ada.org.

16 – 20 The National Dental Association will hold its 97th annual convention at the Hilton Hawaiian Village Resort in Honolulu, HI. For more information, please contact Ms. LaVette Henderson, NDA, 3517 16th Street NW, Washington, DC 20010-3041. Phone: (202) 588-1697; FAX: (202) 588-1244; E-mail: 1henderson@ndaonline.org; Web: ndaonline.org.

22 – 24 The American Academy of Craniofacial Pain will have its 25th Anniversary International Clinical Symposium at the Grand America Hotel in Salt Lake City, UT. For more information, please contact Mr. Gary Shaw, AACFP, 1901 N. Roselle Rd., Suite 920, Schaumburg, IL 60195. Phone: (847) 885-1272; FAX: (847) 885-8393; E-mail: central@aacfp.org; Web: aacfp.org.

August 2010 3–6 The American Academy of Esthetic Dentistry will hold its 35th annual meeting at the Ritz-Carlton Kapalua in Maui, HI. For more information, please contact Ms. Jennifer Hopkins, AAED, 737 N. Michigan Ave., Ste. 2100, Chicago, IL 60611. Phone: (312) 981-6774; FAX: (312) 981-6787; E-mail: info@estheticacademy.org; Web: estheticacademy.org.

13 & 14 The TDA Smiles Foundation will hold a Texas Mission of Mercy in Waco. For more information, please contact the TDA Smiles Foundation, 1946 S. IH 35, Ste. 300, Austin, TX 78704. Phone: (512) 448-2441; Web: tdasf.org.

September 2010 10 – 15 The ADA will hold its Kellogg Executive Management Program (ADAKEMP) in Chicago, IL. For more information, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org.

27 – October 2 The American Association of Oral Maxillofacial Surgeons will hold its 92nd annual meeting at McCormick Place in Chicago, IL. For more information, please contact Dr. Robert C. Rinaldi, AAOMS, 9700 W. Bryn Mawr, Rosemont, IL 60018. Phone: (847) 678-6200; FAX: (847) 6786286; Web: aamos.org.

Calendar of Events

24 – 26 The American Association of Women Dentists will hold its annual meeting, A Taste of Dentistry in Chicago, in Chicago, IL. For more information, please contact Ms. Deborah Gidley, AAWD, 216 W. Jackson Road, Ste. 625, Chicago, IL 60606. Phone: (800) 920-2293; Fax: (312) 7501203; E-mail: info@aawd.org; Web: aawd.org.

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October 2010 2 & 3 The Indian Dental Association (USA) will hold its convention in Queens, NY. For more information, please contact Dr. Chad P. Gehani, Indian Dental Association (USA), 3540 82nd St., Jackson Heights, NY 11373-5159. Phone: (718) 639-0192; FAX: (718) 639-8122; E-mail: ngehani@aol.com; Web: ida-usa.org.

6&7 The American Association of Dental Editors (AADE) will hold its annual conference in Orlando, FL. For more information, please contact Mr. Detlef Moore, AADE, 750 N. Lincoln Memorial Dr., Suite 422, Milwaukee, WI 53202. Phone: (404) 272-2759; FAX: (404) 272-2754; E-mail: aade@dentaleditors.org; Web: dentaleditors.org.

7&8 The American College of Dentists will hold its annual meeting at the Rosen Centre Hotel in Orlando, FL. For more information, please contact Dr. Stephen A. Ralls, ACD, 839J Quince Orchard Blvd., Gaithersburg, MD 20878-1614. Phone: (301) 977-3223; FAX: (301) 977-3330; E-mail: info@facd.org; Web: facd.org.

9 – 12 The American Dental Association will hold its 151st annual session at the Orange County Convention Center in Orlando, FL. For more information, please visit ada.org.

20 – 23 The American Society of Dental Aesthetics will hold the 34th Annual American Society of Dental Aesthetics International Conference in San Antonio, TX. For more information, please contact Dr. Dan Lambert, ASDA, 635 Madison Ave., New York, NY 10022. Phone: (800) 4542732; E-mail: ddssmile@aol.com; Web: asdatoday.com.

20 – 24 The American Academy of Implant Dentistry will hold its 59th annual meeting at the Boston Marriott Copley Place in Boston, MA. For more information, please contact Ms. Sara May, AAID, 211 East Chicago Ave., Suite 750, Chicago, IL 60611-2637. Phone: (312) 335-1550; FAX (312) 335-9090; E-mail: info@aaid.com; Web: aaid.com.

28 – 30 The Hispanic Dental Association will hold its annual meeting in Chicago, IL. For more information, please contact Ms. Rita Brummett, HDA, 3085 Stevenson Drive, Suite 200, Springfield, IL 62703. Phone: (217) 529-6517; FAX: (217) 529-9120; E-mail: hispanicdental@ hdassoc.org; Web: hdassoc.org.

30 – November 2 The American Academy of Periodontology will hold its 96th annual meeting at the Hawaii Convention Center in Honolulu, HI. For more information, please contact Ms. Susan Schaus, AAP, 737 N. Michigan Ave., Suite 800, Chicago, IL 60611. Phone: (312) 787-5518; FAX: (31) 787-3670; E-mail: susan@perio.org; Web: perio.org.

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

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Stefanie Clegg, TDA Web and New Media Manager Department of Member Services & Administration

The Texas Dental Association has created groups on Facebook, LinkedIN and Twitter. The goal of these groups is to provide updates on events and current issues.

To join us on Facebook, go to groups.to/texasdental

To join us on Linkedin, Log in at linkedin.com and type in “Texas Dental Association” in the search box in the top-right corner.

To follow us on Twitter, go to twitter.com/theTDA If you do not have a Facebook, LinkedIn, or Twitter account, you can set one up in minutes!

Sign up online for your Personal Web Page! A personal web page offers office, background, special services, insurance information and, includes a photo of the dentist or dental staff. When a user on the public side of the website looks up a dentist, they can click on the dentist’s name and go to that dentist’s web page. TDA members can also access personal web pages on the member side of the site.

Get your personal web page or link to an existing website for only $25 a year!

Get both for only $35 a year.

To sign up online for your personal web page or link to your existing website, log in at tda.org click on “Personal Web Pages” under Membership Info -> CONTACTS. Questions? Contact Stefanie Clegg, TDA web and new media manager, at stefanie@tda.org.

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

For example, for an ad brief to be included in the January issue, it must be received no later than November 20th. Remittance must accompany classified ads. Ads cannot be accepted by phone or fax. * Advertising brief rates are as follows: 30 words or less — per insertion…$35. Additional words 10¢ each.

If TDA box number is used, add $5 when figuring a cost.

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

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

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

Briefs

Practice Opportunities MCLERRAN AND ASSOCIATES: NEW! AUSTIN: Quality, fee-for-service family practice located in affluent, quickly growing area of town. Practice grossed mid-six figures on part-time work schedule. Solid history of production, excellent retail location, and established patient base give this practice tremendous upside potential.

AUSTIN: High grossing, family practice located in retail center with seven operatories was recently remodeled. Practice boasts solid, well-established patient base.

HILL COUNTRY AREA: Well-established family practice located in desirable hill country town. Practice would be an excellent satellite office or starter practice. The doctor currently works 2 days per week.

The practice is located in growing area with new subdivisions being built, is 20 minutes from Concan Country Club (a top rated new course in Texas) and is in an excellent retirement area. ID #063.

AUSTIN: Five operatory general family practice with high quality fee for service patient base. State-of-the-art, all digital and paperless office is as attractive as they come. Grossing above mid-six figures with very low overhead. ID #103.

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

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

CHILDRESS: Free-standing brick building in excellent location. All new equipment, 44-year-old pactice, fee-for-service, excellent opportunity. ID #019.

RIO GRANDE VALLEY: Three op Medicaid oriented practice grossing high six figures on part-time work week. Excellent opportunity. ID #100.

CORPUS CHRISTI: Three operatory, feefor-service crown and bridge oriented family practice in a great location. The practice is grossing high six figures. ID #098.

SAN ANTONIO AREA: Three operatory offices in small town with no competition.

Very good income and low, low overhead.

Priced to sell. ID #013.

CORPUS CHRISTI: Doctor retiring, six op office with excellent visbility and access.

Good numbers, excellent patient base, good upside potential. Excellent practice for starting doctor. Priced to sell. ID #023.

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NEW! HILLL COUNTRY: Four operatory, “bread and butter” family practice located in attractive, quickly growing hill country town near San Antonio. Practice is in beautiful, hill country style free-standing building with nice equipment.

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NEW! SAN ANTONIO: Eight operatory, high grossing, fee-for-service family practice in historic free-standing building in affluent neighborhood.

SAN ANTONIO: High gross and net income general family practice located in high income area in very visible retail of-

fice center. The seven op office is in excellent condition, has a modern design, and is equipped with almost new equipment, all digital X-rays, and is fully computerized. Practice grossed seven figures last year. Price slashed! ID #094.

lent opportunity.

SAN ANTONIO: Excellent four-chair general family practice in high traffic retail center across from busy mall location.

Solid income on 30 hours a week. Ideal opportunity for doctor wanting a quick start in low overhead operation. ID #086.

WACO AREA: Modern and high-tech, three op general family practice grossing in mid-six figures with high net income.

Office is well equipped for a doctor seeking a modern office.

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

Very high numbers, incredible net. ID #021.

SAN ANTONIO — Prosthodontic practice with almost new equipment and build out.

Doctor wants to sell and continue to work as associate. Beautiful office! Perfect for stand alone or satellite office. ID #060.

HOUSTON AREA PRACTICE OPPORTUNITIES! MCLERRAN & ASSOCIATES. GOLDEN TRIANGLE — Eight op general family practice grossing more than seven figures. Modern, open concept design, in a highly residential area. Strong new patient flow and net. #H107.

SAN ANTONIO — Three operatory general practice in condominium located in highly desirble and conveniently located medical center area. This practice would be an excellent starter practice and has tremendous upside potential. The condo is also for sale. ID #084.

NEW! HOUSTON: Established, crown and bridge/removable practice with digital Xrays, great new patient flow, production in high six figures. PPo and fee-for-service only. Tremendous cash flow. #H109.

SAN ANTONIO, NORTH CENTRAL — Small, two-op practice just off major freeway; perfect starter office. Terrific pricing.

ID #009.

NEW! HOUSTON — Buy-in opoprtunity with premier group practice. Requires existing patient base close to Texas Medical Center area. Beautiful 12 operatory, high tech office, with low overhead. Partner financed. #H115.

NEW! SAN ANTONIO: Solid, five op general family practice located in high visibility retail project in medical center. Good equipment, nice decor, and loyal patient base.

SAN ANTONIO: Four operatory general family practice located in professional office building off of busy thoroughfare in affluent north central side of town.

Very nice equipment and decor. Excel-

NEW! HOUSTON — General family practice located southwest of Houston, high visibility, grossing mid-six figures. Five oepratories, two ready for expansion.

Building and up to four acres of real estate ready for development included in sale. #H108.

NEW! HOUSTON — Established Medicaid/PPO practice, high visibility, located

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near middle to low income housing and several schools. Five operatories with three equipped, including pano. #H118.

NEW! HOUSTON — Established general and family practice inside 610 Loop. Four operatories, nice equipment, grossing near mid-six figures. Seller available for transition. #H112.

NEW! HOUSTON — Beautiful four operatory general practice, very new equipment, digital X-rays, grossing in mid-six figures.

Located in premier Houston neighborhood. Fee-for-service only. #H106.

Contact McLerran Practice Transitions, Inc.: statewide, Paul McLerran, DDS, (210) 737-0100 or (888) 656-0290; in Austin, David McLerran, (512) 750-6778; in Houston, Tom Guglieimo and Patrick Johnston, (281) 362-1707. Practice sales, appraisals, buyer representation, and lease negotiations. See www.dental-sales. com for pictures and more complete information.

GARY CLINTON / PMA ORAL SURGERY PRACTICE FOR SALE, HOUSTON AREA: Northwest Houston (many referring dentists). Outright sale / transition as associate PRN. Seven figure gross. Seller will work 1-2 days as associate for purchaser PRN, phased retirement. We have the best sources for 100 percent buyer funding.

Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables.

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More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 5039696; WATS: (800) 583-7765.

GARY CLINTON / PMA SOUTH TEXAS / BROWNSVILLE / HARLINGEN AREA: Excellent practice with flexible transition. Primarily fee-for-service and Delta Dental. High operating profits; more than seven figures in collections. Lovely office.

Some ortho easily expanded to larger percentage of practice. Outright sale. Seller with transition / work for new owner as needed. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.”

I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/ escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential.

DFW: (214) 503-9696; WATS: (800) 5837765.

GARY CLINTON / PMA BRYAN / COLLEGE STATION PRACTICE FOR SALE. Retiring dentist. Beautiful office; will transition as needed. Restorative practice.

Well-established recall. We have the best sources for 100 percent buyer funding.

Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified

appraisals based upon the comparables.

More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 5039696; WATS: (800) 583-7765.

appraisals based upon the comparables.

More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 5039696; WATS: (800) 583-7765.

GARY CLINTON / PMA ABILENE: Retiring dentist outright sale / PRN transition; great location southside of Abilene. Wellestablished practice; three operatories; excellent full recall and new patient flow.

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

I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/ escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential.

DFW: (214) 503-9696; WATS: (800) 5837765.

GARY CLINTON / ORTHODONTIC PRACTICES ASSOCIATE / TRANSITION OR OUTRIGHT SALES: O1 Within 90 miles of Austin — Flexible, will transition; seven-figure practice; planned practice value from the beginning. Beautiful office. O2 West Central Texas Mid-sized to larger community —Professional referral based; traditional fee-for-service, referral, highly productive. Gorgeous building with room for two in this 50/50 partnership.

O3 South Texas — Retiring orthodontist.

Transition flexible. Seven-figure practice collections; over 60 percent profits; lovely building. He is ready to spend time with his grandchildren. We have the best sources for 100 percent buyer funding.

Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables.

More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 5039696; WATS: (800) 583-7765.

GARY CLINTON / PMA SAN ANGELO PRACTICES FOR SALE: S1 San Angelo area — Very sharp office. Plenty of patients to work 5 days a week; exceptional value. S2 San Angelo: Excellent well-established restorative practice. Very nice equipment. Dentist relocation. Transitional / outright sale. We have the best sources for 100 percent buyer funding.

Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified

GARY CLINTON / PMA LUBBOCK / PANHANDLE AREA PRACTICE FOR SALE: Well-established practices. Doctor will sell/transition. High collections/net. Five oepratories; full hygiene. We have the best sources for 100 percent buyer funding.

Gary Clinton is a senior member of the

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Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables.

More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 5039696; WATS: (800) 583-7765.

GARY CLINTON / PMA ORTHODONTIC NORTH DALLAS AREA: Highly desirable area. Great high traffic location; near schools; mid-size practice; latest digital equipment. Expandable to over 4,800 sq. ft. Work 3-4 days per week; staff to stay with the practice; outright sale/transition.

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

I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/ escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential.

DFW: (214) 503-9696; WATS: (800) 5837765.

SOUTHEAST HOUSTON GENERAL DENTAL PRACTICE — SALE: Incredible general dental practice with six operatories in a new facility. High revenues with excellent profit margin. Doctor relocating but is most interested in smooth transition.

This is a wonderful opportunity to accumulate a substantial retirement “nest

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egg” with a low level of risk. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

CORPUS CHRISTI GENERAL DENTAL — SALE: Moderate revenues with a very healthy profit margin. Experienced and loyal staff. Totally digital and highly efficient facility layout. If you need to practice to refund your retirement but don’t want to fight the competitiveness of the city, come see this practice. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

EAST TEXAS ORAL & MAXILLOFACIAL SURGERY PRACTICE — SALE: Beautiful and spacious facility located in the heart of a rapidly growing Texas metropolis.

Great opportunity for highly qualified surgeon with desire to assume responsibility for a wide spectrum of OMS procedures, expand surgical treatment, and dramatically increase income. Strong revenues and high profit margins; flexible acquisition terms! Must see opportunity! Contact The Hindley Group at (800) 856-1955.

Visit us at www.thehindleygroup.com.

SAN ANTONIO PROSTHODONTIC — SALE: Located inside the 410 loop, this 10-year-old practice produces moderate revenues on 3 days per week. Specializing in prosthodontics, the office could be expanded to a broader scope of restorative general dental treatment. Located in beautiful new offices, there are three treatment rooms with new equipment.

Outstanding staff. Doctor must sell for health reasons but can transition over period of 3-6 months. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

HOUSTON ORAL SURGERY PRACTICE FOR SALE: Well-established 35-year-old practice with strong revenues and high profit margin due to limited competition.

Outstanding mentor to transition. Wonderful staff. Practice building also available for sale. Whether you are just completing your residency or after 20 years in practice, you are tired of the snow, call us and come and meet this doctor. Contact The Hindley Group, (800) 856-1955. Visit us at www.thehindleygroup.com.

GOLDEN TRIANGLE GENERAL DENTAL PRACTICE — SALE: Outstanding practice for sale developed by published mentor. Supported by outstanding staff and latest in dental equipment. Strong revenues and profit margin. Excellent new patient flow. Given high level of FFS revenues, doctor to transition to comfort level of purchaser. Come build your retirement in low competition community. Contact The Hindley Group at (800) 856-1955.

Visit us at www.thehindleygroup.com.

CENTRAL EAST TEXAS — SALE: Outstanding practice for sale in beautiful East Texas. Moderate FFS revenues with three fully equipped operatories and an excellent staff. Doctor leaving for the mission field and interested in optimal transition.

If you are an older doctor who needs to recomplete his retirement package after the stock market drop, and want to practice in a less competitive more relaxed environment, this is a must-see opportunity.

Contact The Hindley Group at (800) 8561955. Visit us at www.thehindleygroup. com.

NORTHWEST SAN ANTONIO GENERAL DENTAL PRACTICE — SALE: General dentistry practice with strong revenues and

excellent new patient flow. Practice is located in highly visible location on well-traveled road. Four treatment rooms. Doctor is most anxious to facilitate strong transition. Contact The Hindley Group at (800) 856-1955.

Visit us at www.thehindleygroup.com.

DALLAS / FORT WORTH: Area clinics seeking associates. Earn significantly above industry average income with paid health and malpractice insurance while working in a great environment. Fax (312) 944-9499 or e-mail cjpatterson@kosservices.com.

SOUTH OF HOUSTON GENERAL DENTAL PRACTICE — SALE: Outstanding practice with very high growth potential experiencing a strong new patient flow.

Moderate revenues with a healthy profit margin on 4 days per week. Building also for sale. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

NORTHWEST HOUSTON GENERAL DENTAL PRACTICE — SALE: Located near the intersection of 610 Loop and 290. Five-year-old practice with moderate revenues and healthy new patient flow on 3 days / week. Facilities include three operatories and three additional plumbed for expansion. Excellent opportunity for new grad. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

WEST HOUSTON GENERAL DENTAL PRACTICE — SALE: Wonderful opportunity in rapidly growing west Houston community. Strong revenue and profit margin. Wonderful staff. Practice has ortho emphasis, but seller will stay on to complete cases if necessary. Building also for sale. Contact The Hindley

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Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

WACO PEDIATRIC DENTAL PRACTICE — SALE: Well-established practice with moderate revenues and high profit margin on 4 days per week. Due to limited competition and a large facility, there is ample room to grow in this community that is home to Baylor University. All ortho cases are being completed, unless purchaser would like to expand new cases. No Medicaid being seen, but good opportunity with enhanced state fee schedule. Experienced staff and steady new patient flow. Wonderful mentor. Building also available. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

NORTHWEST HOUSTON GENERAL DENTAL PRACTICE — SALE: New practice in growing area located near welltraveled Highway 290 and Jones Road.

Two fully equipped treatment rooms with three others plumbed for expansion. Digital X-rays. Moderate revenues on 2.5 days / week. If you want to be in the rapidly growing northwest quadrant, this practice is for you. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

ASSOCIATESHIPS: SOUTH CENTRAL TEXAS PERIODONTAL: Wonderful practice completing periodontal treatment seeks long-term associate who desires to be a partner within 1-2 years. Great location with strong new patient flow.

Pre-determined purchase and partnership terms. Wonderful mentor looking for an “equally-yoked” individual. Excellent staff. DFW METROPLEX ORAL AND MAX ILLOFACIAL SURGERY — Park-

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land trained surgeon seeking an “equally yoked” associate desiring to acquire the entirety of his practice within the next 3-5 years. Well-established practice enjoying 2008 revenues exceeding seven figures from two locations. Wonderful opportunity for a resident who has recently completed their program and who desires transition into practice ownership. You could not find a more superior partner!

MIDLAND GENERAL DENTAL PRACTICE — Well established and growing practice with strong revenues and healthy profit margin on 4 days per week. Wonderful mentor with plenty of room to grow. SAN ANTONIO PERIODONTAL — Associateship with pre-determined buy-in for very active, multi-office periodontial practice.

Outstanding mentor and cohesive staff. If you are the right person, this is an oustanding opportunity. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

HOUSTON SOUTHWEST GENERAL PRACTICE: Well-established general practice for sale with recent build out and equipment. Great merger candidate or stand-alone office. Call Jim Robertson, (713) 688-1749 or (713) 822-5705.

HOUSTON CLEAR LAKE GENERAL PRACTICE: Small Clear Lake practice for merger opportunity or second office. Call Jim Robertson, (713) 688-1749 or (713) 822-5705.

HOUSTON PASADENA ORTHO PRACTICE: Small ortho practice for merger opportunity or second office. Call Jim Robertson, (713) 688-1749 or (713) 8225705.

HOUSTON NORTHWEST ORTHO PRACTICE: Profitable, well-established ortho practice for sale. Call Jim Robertson, (713) 688-1749 or (713) 822-5705.

ADS WATSON, BROWN & ASSOCIATES: Excellent practice acquisition and merger opportunities available. DALLAS AREA — Six general dentistry practices available (Dallas, North Dallas, Highland Park, and Plano); five specialty practices available (two ortho, one perio, two pedo). FORT WORTH AREA — Two general dentistry practices (north Fort Worth and west of Fort Worth). CORPUS CHRISTI AREA — One general dentistry practice. CENTRAL TEXAS — Two general dentistry practices (north of Austin and Bryan/College Station). NORTH TEXAS — One orthodontic practice. HOUSTON AREA — Three general dentistry practices. EAST TEXAS AREA —Two general dentistry practices and one pedo practice. WEST TEXAS — Three general dentistry practices (El Paso and West Texas). NEW MEXICO —Two general dentistry practices (Sante Fe, Albuquerque). For more information and current listings, please visit our website at www. adstexas.com or call ADS Watson, Brown & Associates at (469) 222-3200.

DALLAS / FORT WORTH: Dental One is opening new offices in the upscale suburbs of Dallas and Fort Worth. Dental One is unique in that each office of our 60 offices has its own, individual name such as Riverchase Dental Care and Preston Hollow Dental Care. All our offices have top-of-the-line Pelton and Crane equipment, digital X-rays, and intra-oral cameras. We are 70 percent PPO, 30 percent full fee. We take no managed care or Medicaid. We offer competitive salaries and benefits. To learn more about working for

Dental One, please contact Rich Nicely at (972) 755-0836.

HOUSTON DENTAL ONE is opening new offices in the upscale suburbs of Houston.

Dental One is unique in that each office of our 50+ offices has its own individual name. All our offices have top-of-the-line Pelton and Crane equipment, digital Xrays, and intra-oral cameras. We are 100 percent FFS with some PPO plans. We offer competitive salaries, benefits, and equity buy-in opportunities. To learn more about working for Dental One, please call Andy Davis at (713) 343-0888.

FULLY EQUIPPED MODERN DENTAL OFFICE SPACE AVAILABLE FOR LEASE. Have four ops. Current doctor is only using 2 days a week. Great opportunity to start up new practice (i.e., endo, perio, oral surgery). Available days are Monday, Tuesday, Thursday per week.

If you are wanting an associate, please inquire. Call (214) 315-4584 or e-mail ycsongdds@yahoo.com.

TEXAS PANHANDLE: Well-established 100 percent fee-for-service dental practice for immediate transition or complete sale at below market price by retiring dentist. Relaxed work schedule with community centrally located within 1 hour of three major cities. The office building can be leased or purchased separately and is spaciously designed with four operatories, doctors’ private office and separate office rental space. This is an excellent and profitable opportunity for a new dentist, a dentist desiring to own a practice, or a satellite practice expansion. Contact C. Vandiver at (713) 205-2005 or clv@ tauruscapitalcorp.com.

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

EL PASO: FULL- OR PART-TIME ASSOCIATE NEEDED. Would be sole practitioner at location. Three operatories for DDS plus one for hygienist, equipment less than 1 year old. Past compensations up to 5-figures per week. No administrative responsibilities. Call (702) 510-7795 or email drartbejarano@gmail.com.

TOP OF THE HILL COUNTRY GENERAL PRACTICE FOR SALE. Beautiful freestanding building in growing Clifton medical/arts district. Well established, quality oriented, five ops, FFS. Easy proximity to Dallas, Austin, and Lake Whitney. Doctor relocating but willing to provide flexible transition terms. If you are tired of patient turnover and want to make a difference in patients’ lives, this it the opportunity you’ve been looking for. Call (254) 675-3518 or e-mail dnicholsdds@ earthlink.net.

ASSOCIATE NEEDED — NE TEXAS: Pittsburg is surrounded by beautiful lakes and piney woods. Well-established, quality-oriented, busy cosmetic and family practice. Associate to partnership opportunity. Call Dr. Richardson at (903) 856-6688.

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

GALVESTON ISLAND: Unique opportunity to live and practice on the Texas Gulf coast. Well-established fee-for-service, 100 percent quality-oriented practice looking for a quality oriented associate.

Ideal for a new graduate or for an experienced dentist wanting to relocate and become part of an established practice with a reputation for providing comprehensive, quality dental care with a personable approach. Practice references available from local specialists. Contact Dr. Richard Krumholz, (409) 762-4522.

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HOUSTON: Small group practice with three locations in and around Houston area seeking highly motivated general dentist to share in a fee-for-service, wellestablished private practice. High income potential with full doctor autonomy. Please send CV to amihuynh@yahoo.com.

HOUSTON: General dentist with pediatric experience needed. Full-time position available. Excellent compensation. Please send CV to cvanalfen@yahoo.com.

ASSOCIATE PARTNER, SOUTHEAST HOUSTON — WEBSTER: Excellent opportunity for a highly energetic, enthusiastic, hard working general dentist. Beautiful high-tech family practice is seeking an exceptional well rounded individual to take over excisting adult patient base.

Individual must be self motivated, experienced, and willing to work hard to obtain goals. Office is in great location with state-of-the-art equipment with the latest technology. The general dentist area has five treatment rooms with high production potential. Call (281) 488-2483 or fax resume (281) 488-3416.

ASSOCIATE FOR TYLER GENERAL DENTISTRY PRACTICE: Well-established general dentist in Tyler with 30+ years experience seeks a caring and motivated associate for his busy practice.

This practice provides exceptional dental care for the entire family. The professional staff allows a doctor to focus soley on the needs of their patients. Our office is located in beautiful East Texas and provides all phases of quality dentistry in a friendly and compassionate atmosphere.

The practice offers a tremendous opportunity to grow a solid foundation with the doctor. The practice offers excellent production and earning potential with a possible future equity position avaialble.

Our knowledgable staff will support and enhance your growth and earning potential while helping create a smooth transition. Intereted candidates should call (903) 509-0505 and/or send an e-mail to steve.lebo@sbcglobal.net.

HOUSTON: Would you enjoy owning a well-established neighborhood dental practice in the Heights section of Houston? Located in a mixed use professional building, this practice has enabled the current owner to retire without financial stress. My client is ready to transition this great two operatory facility to the right dentist. It is priced right and ready to take you to the next level of your career. Call Jack Sayyah, (877) 905-1515.

EXPERIENCED RESTORATIVE DENTIST (PANKEY/LVI TYPE) who enjoys aesthetics and full-mouth rehab needed to lead a first-class, full service practice. Unique practice model affords the opportunity to earn high income doing big cases and coordinating patient care with our specialty teams. Practice with the support of a veteran team in a beau-

tiful practice. Contact Dr. John Bond at jbond@6daydental.com.

6 DAY DENTAL & ORTHODONTICS is an established group practice model, providing all dental services to our patients under one roof. Our general dentists and sepcialists work together to provide the most convenient and quality dental care possible. We are growing and have an immediate opportunity for a general dentist or prosthodontist with future partnership/equity opportunity. 6 Day Dental & Orthodontics just may be the premier feefor-service alliance of dental practices in the country. Our doctors earn more, see fewer patients, and have plenty of time off to enjoy a rich and healthy lifestyle. New grads and experienced dentists/prosthodontists welcomed. Our dentists earn in the top 10 percent of extractions, as well as performing all types of dentistry. Please send CV or contact Dr. John Bond at jbond@6daydental.com. Visit www.6daydental.com.

ASSOCIATE NEEDED FOR NURSING HOME DENTAL PRACTICE. This is a non-traditional practice dedicated to delivering care onsite to residents of long term care facilities. This practice is centered in Austin but visits homes in the central Texas area. Portable and mobile equipment and facilities are used, as well as some fixed office visits. Patient population presents unique technical medical, and behavioral challenges, seasoned dentist preferred. Buy-in potential high for the right individual. Please toward CV to e-mail renee@austindentalcares.com; FAX (512) 238-9250; or call (512) 2389250 for additional information.

PEDIATRIC DENTIST: Pediatric Dental Wellness is growing and needs a dynamic Texas Dental Journal l www.tda.org l April 2010

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dentist to work full time in our pediatric practice. The perfect complement to our dedicated staff would be someone who is compassionate, goal oriented, and has a genuine love for working with children.

If you are a motivated self-starter that is willig to give us a long-term commitment, please apply. Salary plus benefits. Looking to fill position immediately. Send resumes and cover letters to candice.n.moore@ gmail.com.

GREAT OPPORTUNITY FOR A PEDIATRIC DENTIST OR GP to join our expanding practice. We are opening a new practice in the country (Paris, Texas), just 1 hour past the Dallas suburbs and our original location. The need for a pediatric dentist out there is tremendous, and we are the only pediatric office for 70 miles in any direction. We are looking for someone that is personable, caring, energetic, and loves a fast-paced working environment in a busy pediatric practice. We are willing to train the right individual if working with children is your ambition. This position is part-time initially, and after a short training period will lead to full-time.

If you join our team, you will be mentored by a Board certified pediatric dentist and will develop experience in all facets of pediatric dentistry including behavior managment using oral conscious sedation as well as IV sedation. For more information, please visit our websites at www.wyliechildrensdentistry.com and www.parischildrensdentistry.com. Please e-mail CV to allenpl2345@yahoo.com.

ASSOCIATE — CORPUS CHRISTI: 25-year-old family practice providing quality care in modern operatory office.

Great supportive team, excellent compensation history. Associate to partnership

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opportunity. Contact Dr. Boss for more information, (361) 774-5410 or e-mail abossjr@aol.com.

MEMORIAL DENTISTS currently seeking part-time associate to join our practice.

Minimum 5 years experience. Please send your CV to info@memorialdentists.com.

CENTRAL TEXAS SPECIALIST SERVICES NEEDED to provide endodontic, primarily, but also periodontal and oral surgery services to a 30-year-old general and cosmetic dentistry practice on Fridays and other times negotiable. Perfect satellite or start-up office. Exclusive use of a beautiful and well-equipped three-operatory office, less than 1 hour from Austin with great visibility and surroundings in an historic, affluent community. An assistant is available on request. Please send CV to TDA, Attn.: TDA Box #1, 1946 S. IH35, Austin, TX, 78704.

DENTIST NEEDED FOR NEW FAMILY DENTAL OFFICE IN SAN ANTONIO. Great opportunity and possible future partner/purchase. All dentists considered. Send CV/resume to bkbdmd@gmail. com.

ASSOCIATE SUGAR LAND AND CYPRESS: Large well-established practice with very strong revenues is seeking an associate. Must have at least 2 years experience and be motivated to learn and succeed. FFS and PPO practice that ranks as one of the top practices in the nation.

Great mentoring opportunity. Possible equity position in the future. Base salary guarantee with high income potential.

Two days initially going to 4 days in the near future. E-mail CV to Dr. Mike Kesner, drkesner@madeyasmile.com.

Office Space SPACE AVAILABLE FOR SPECIALIST. New professional building located southwest of Fort Worth in Granbury between elementary and junior high schools off of a state highway with high visibility and traffic. Call (817) 326-4098.

HIGH TRAFFIC SHELL BUILDING IN ROUND ROCK, north of Austin, in one of the fastest-growing counties. Available at $155 / sq. ft. For more information, e-mail jacque@rgtate.com or call (512) 848-2509.

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

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

DENTAL OFFICE SPACE AVAILABLE MARCH 2010 IN WIMBERLEY, a true “small town” in the heart of the Hill Country. Originally designed/built for a dentist; excellent location across the street from Wimberley High School and Middle School. Parking, ADA accessible, highspeed internet available, community wa-

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ter supply. Call Leslie Howe at (512) 8479361.

SHERMAN — 1,750 SQ. FT. DENTAL OFFICE. Building has established general dentist and perio/implant dentist.

Plumbed and ready to go. High traffic and visibility with lots of parking. Sherman is beautiful and growing town 50 miles north of Dallas and near Lake Texoma, the second largest lake in texas. It has great schools, a vibrant arts community, and is home to many, many Fortune 500 companies such as Texas Instruments and Tyson Foods. Call (760) 436-0446.

DENTAL OFFICE FOR SALE / LEASE IN NORTHEAST TEXAS: A 2,800 sq. ft. six operatory office built 10 years ago is available in a town of 12,000 that needs a general dentist. Situated in an attractive professional park, this office features a large sterlization area, dual rear entry operatories, dental cabinetry in five of the six ops, wood floors, and three bathrooms.

A great opportunity for a mature dentist looking for good hunting and fishing in a small town environment, or a new grad wanting an instant patient pool and room to grow. Call Cheryl at (903) 649-8222 or (903) 753-2988 or e-mail buybuilding@ bachteldental.com.

SOUTHWEST FT. WORTH — GENERAL DENTAL PRACTICE WITH BUILDING FOR SALE OR LEASE: This very successful, well-established practice has an excellent patient base with referrals from near and far. The seller is retiring immeidately or will negotiate a comfortable transition. With a low overhead and excellent profit margin, this practice makes a great investment for just the right person. Five treatment rooms, 3,200 sq. ft. plus 800 sq. ft. for additional expansion

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or rental space. The practice is located in a high visibility and stable economic community. With this practice comes an experienced staff, computers in all treatment rooms, nice equipment, imaging software, and much more. Get out of that associate position and be an owner! Appraisal performed by a CPA/CFP/CVA. Call (972) 562-1072 or (214) 697-6152 or e-mail sherri@slhdentalsales.com.

For Sale ESTABLISHED, FULLY EQUIPPED THREE OPERATORY LAB FOR SALE OR LEASE in Plainview. High visibility location. Seller retiring. Mentor to transition possible. Call (806) 293-2686 or (806) 292-3156.

TWENTY STAR 430 SWL HANDPIECES freshly refurbished with brand new turbines, very good fiberoptics and clean, like new appearance. Will sell as a lot or individually — $279 for one, $2,590 for 10, or $5,000 for 20. I have new OEM Star swivel/couplers, too, for $125 each.

Please call (512) 363-9938.

Interim Services TEMPORARY PROFESSIONAL COVERAGE (Locum Tenens): Let one of our distinguished docs keep your overhead covered, your revenue-flow open wide, your staff busy, your patients treated and booked for recall, all for a flat daily rate not a percent of production. Nation’s largest, most distinuished team. Short-notice coverage, personal, maternity, and disability leaves our specialty. Free, no obligation quotes. Absolute confidentiality.

Trusted integrity since 1996. Some of our team seek regular part-time, permanent, or buy-in opportunities. Always seeking

new dentists to join the team. Bread and butter procedures. No cost, strings, or obligations — ever! Work only when you wish. Name your fee. Join online at www. doctorsperdiem.com. Phone: (800) 6000963; e-mail: docs@doctorsperdiem.com.

OFFICE COVERAGE for vacations, maternity leave, illness. Protect your practice and income. Forest Irons and Associates, (800) 433-2603 (EST). Web: www. forestirons.com. “Dentists Helping Dentists Since 1983.”

Miscellaneous LOOKING TO HIRE A TRAINED DENTAL ASSISTANT? We have dental assistants graduating every 3 months in Dallas and Houston. To hire or to host a 32-hour exfcernship, please call the National School of Dental Assisting at (800) 383-3408, www.schoolofdenfcalassistingplano.com.

ESTABLISHED DENTAL ASSISTING SCHOOL searching for general dental office to lease on 1 weekend day and 1 weeknight near Plano. Ongoing 12-week course. Please call Dr. Peter Najim, (800) 509-2864, pnajim@dentalassist.org.

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Your Patients Trust You. Who can YOU Trust?

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

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

Statewide Toll-free Helpline 800-727-5152 Emergency 24-hour Cell: 512-496-7247 PRN Staff Donna Chamberlain, LCSW, CAS Director . . . . . . . . . . 512-615-9176 Paige Peschong, LMSW Social Worker . . . . . 512-615-9155 Courtney Bolin, MSW Social Worker . . . . . 512-615-9182 Professional Recovery Network 12007 Research Blvd. Suite 201 Austin, TX 78759 www.rxpert.org

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SUV Disinfectant & Cleaner The cost-effective way to clean and disinfect your dental operatories Proven effective against H1N1 Swine Flu

Avoid the middleman mark-up – Buy direct and save!

• SUV costs less than other surface disinfectants.

• Spray bottles are provided FREE with your order.

• 1 bottle of SUV’s concentrated formula makes 16 gallons of ready-to-use disinfectant.

Meets Texas State Board of Dental Examiners, OSHA, and EPA requirements and CDC recommendations for surface disinfection.

• SUV is an exceptional ultrasonic cleaning solution and vacuum line cleaner.

© 2009 OSHA Review, Inc.

Texas Dental Journal l www.tda.org l April 2010 443 Call 1-800-555-6248 to place your order or request more information www.oshareview.com

Insure wIth tDA FInAnCIAL serVICes InsurAnCe ProgrAm AnD the hArtForD running a successful dental practice isn’t easy. Attending to patients, handling paperwork, dealing with a hundred little details that need your attention – there are a number of challenges. Finding the right insurance shouldn’t be one of them. the tDA Financial services Insurance Property and Casualty Program features the hartford’s spectrum® business owners’ policy. In addition to financial strength, excellent service and dependable claim handling, the program includes the following features: • Electronic Funds Transfer • 12 Equal Payments (No large down payment!)

If you don’t have your Property, Liability, or workers’ Compensation insurance placed through the tDA Financial services Insurance Program, there has never been a better time to switch.

Contact us today at (888) 588-5420 or quotes@tdamemberinsure.com

the tDA Financial services Insurance Program is administered by the higginbotham & Associates brokerage firm.

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