August 2010

August 2010

Journal TEXAS DENTAL

Texas Dental Association 140th Annual Session 2010 TEXAS Meeting Photo Contest Award: Best of Show Photographer: Dr. Roy Tiemeyer Title: “Skimmers” Texas Dental Journal l www.tda.org l August

725

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

If you do not have a Facebook or LinkedIn account, you can set one up in minutes!

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

Join us on facebook.com/texasdental or groups.to/texasdental Follow us on twitter.com/theTDA Get LinkedIN at linkedin.com, search “Texas Dental Association�

Contents

TEXAS DENTAL JOURNAL n Established February 1883 n Vol. 127, Number 8, August 2010

ON THE COVER The cover photo, “Skimmers,” was taken by Dr. Roy Tiemeyer of Corpus Christi. It won Best in Show at the May 2010 TEXAS Meeting Photo Contest in San Antonio. Wildlife and bird photography is Dr. Tiemeyer’s hobby, and he took the photo in August 2009 at the Leonabelle Turnbull Birding Center in Port Aransas. With a clear blue summer sky and no breeze, these skimmers were the only movement that morning. Dr. Tiemeyer is a 1978 graduate of the University of Texas Dental Branch at Houston and operates a general practice in Corpus Christi.

For more information on the 2011 TEXAS Meeting Photo Contest, please visit texasmeeting.com or call the TDA central office, (512) 443-3675.

ARTICLES

735 Conflicts of Interest in Research: Is Clinical

Decision-Making Compromised?

An Opinion Paper

The authors discuss how a lack of transparency in funded research can compromise clinical decision-making in an evidence based practice.

Shawn Abidi, D.D.S. Richard D. Bebermeyer, D.D.S., M.B.A.

749 Fluoride Varnish: The Top Choice for Professionally

Applied Fluoride

The authors discuss how fluoride varnish combines caries prevention and efficacy with safety and versatility.

Ryan L. Quock, D.D.S., Donna P. Warren-Morris, R.D.H., M.Ed.

767 Texas Medicaid — TDA Dentists Making a Difference

William D. Steinhauer, D.D.S.

The author reports on the state’s Medicaid program statistics and TDA’s involvement to improve access to dental care for children in Texas.

728

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

MONTHLY FEATURES

BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION

730

President’s Message

732

The View From Austin

776

What’s on tda.org?

778

Value for Your Profession

784

In Memoriam / TDA Smiles Foundation

782

Calendar of Events

786 788

Oral and Maxillofacial Pathology Case of the Month

Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management

790

Advertising Briefs

806

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

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. 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

PRESIDENT Ronald L. Rhea, D.D.S. (713) 467-3458, rrhea@tda.org PRESIDENT-ELECT J. Preston Coleman, D.D.S. (210) 656-3301, drjpc@sbcglobal.net IMMEDIATE PAST PRESIDENT Matthew B. Roberts, D.D.S. (936) 544-3790, crockettdental@gmail.com VICE PRESIDENT, SOUTHEAST R. Lee Clitheroe, D.D.S. (281) 265-9393, rlcdds@windstream.net VICE PRESIDENT, SOUTHWEST John W. Baucum III, D.D.S. (361) 855-3900, jbaucum3@msn.com VICE PRESIDENT, NORTHWEST Kathleen M. Nichols, D.D.S. (806) 698-6684, toothmom@kathleennicholsdds.com VICE PRESIDENT, NORTHEAST Donna G. Miller, D.D.S. (254) 772-3632, dmiller.2thdoc@grandecom.net SENIOR DIRECTOR, SOUTHEAST Karen E. Frazer, D.D.S. (512) 442-2295, drkefrazer@att.net SENIOR DIRECTOR, SOUTHWEST Lisa B. Masters, D.D.S. (210) 349-4424, mastersdds@mdgteam.com SENIOR DIRECTOR, NORTHWEST Robert E. Wiggins, D.D.S. (325) 677-1041, robwigg@suddenlink.net SENIOR DIRECTOR, NORTHEAST Larry D. Herwig, D.D.S. (214) 361-1845, ldherwig@sbcglobal.net DIRECTOR, SOUTHEAST Rita M. Cammarata, D.D.S. (713) 666-7884, rmcdds@sbcglobal.net DIRECTOR, SOUTHWEST T. Beth Vance, D.D.S. (956) 968-9762, tbeth55@yahoo.com DIRECTOR, NORTHWEST Michael J. Goulding, D.D.S. (817) 737-3536, mjgdds@sbcglobal.net DIRECTOR, NORTHEAST Arthur C. Morchat, D.D.S. (903) 983-1919, amorchat@suddenlink.net SECRETARY-TREASURER Ron Collins, D.D.S. (281) 983-5677, roncollinsdds@hotmail.com SPEAKER OF THE HOUSE Glen D. Hall, D.D.S. (325) 698-7560, abdent78@sbcglobal.net PARLIAMENTARIAN 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 Ms. Mary Kay Linn (512) 443-3675, marykay@tda.org LEGAL COUNSEL Mr. William H. Bingham (512) 495-6000, bbingham@mcginnislaw.com

Texas Dental Journal l www.tda.org l August

729

President’s Message Ronald L. Rhea, D.D.S., TDA President

Time does fly. Even though still enveloped by the oppressive heat that blankets us in a Texas summer, we realize that the time for vacations and recreation is coming to a close. We must recommit ourselves to the new beginnings brought by commencement of a new school year and all the changes in activities and attitudes that this brings. Even those of us who no longer have school aged children cannot avoid the change in pace dictated by the arrival of fall activities. I hope you are all refreshed and anxious to begin the cycle of learning, regardless of your age.

Each of us must either learn and grow or wither and perish. Eric Hoffer said, “In times of change, the learners will inherit the earth while the learned will find themselves superbly equipped to live in a world that no longer exists.” I hope you will find helpful the articles presented here by the professors from the University of Texas Dental Branch at Houston.

With thoughts now naturally turning toward children and in our case specifically toward their continued oral health, the article “Fluoride Varnish: The Top Choice for Professionally Applied Fluoride” by Dr. Ryan L. Quock and Ms. Donna Warren-Morris should be of special interest. The American Dental Association Council on Scientific Affairs recommends fluoride varnish as the

730

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

only professionally applied fluoride for moderate to high risk patients of all age groups. Professors Quock and Morris discuss this modality’s effectiveness, safety enhancement, and acceptability.

This time of year should also bring to us a recommitment to ethical behavior in all of our endeavors. The news media constantly remind us of the failures of our politicians, entertainers, and public servants. We, as professionals, are held to a higher standard of ethical behavior and must cognizantly strive to perceive the ethical dilemmas presented to us daily. Many of our decisions must rely on the results of research over which we have little control. The article “Conflicts of Interest in Research; Is Clinical Decision-Making Compromised?” by Drs. Shawn Adibi and Richard Bebermeyer deserves consideration. Professors Adibi and Bebermeyer bring to bear again the almost clichéd concept of transparency as it applies to ethics in research. They discuss how full disclosure of conflicts of interest in funded research is critical to our evaluation of the material and conclusions. They suggest methods for assuring this transparency.

I hope you enjoy this issue of the Texas Dental Journal and incorporate the new ideas presented into your daily professional decisions.

The Hindley Group, LLC, announces the release of

Getting Down to Business — Success in Each Stage of Your Dental Career

Your Practice is as unique as your thumbprint...

The Hindley Group, LLC We assist with acquisition terms and conditions, the financing process, and other practice transition issues in order to effect a timely and orderly transition.

This resource and reference book, which draws on the experience and expertise of 12 collaborators, will help you evaluate your business practices and determine where you are and how to get where you want to be. Please visit www.yourpracticeasset.com for information and resources referenced in the book.

For a listing of available practices and associateship opportunities, visit our website at www.thehindleygroup.com.

L. Norton Hindley III, ASA 2202 Timberloch Place, Suite 218 The Woodlands, Texas 77380 281-367-1955 • FAX 281-363-9296 • 1-800-856-1955 norton@thehindleygroup.com http://www.thehindleygroup.com

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

Superior teachers are a fabulous asset to society. Students know who these people are; although, sadly, sometimes the teachers do not receive the recognition that they deserve by members of the public or school officials.

Dr. Thomas (Tom) D. Marshall was one of those fabulous teachers.

He died recently in San Antonio, and his students did appreciate his special efforts to help them learn operative dentistry skills.

Think back, and I’ll bet readers can identify several teachers who had major impacts in their lives. I can think of several. Doc Summers was the acknowledged best chemistry teacher at Columbia High School in Maplewood, New Jersey. Today, his class would be designated as a college prep course. The learning in his class helped yours truly pass three college chemistry courses and the biochemistry in dental school.

He asked his students to send their college chemistry course exams to him so he could evaluate colleges and relay that information to his high school students. His rankings helped many of us select the college we would attend.

732

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

Then there was Professor McKinney who was professor of chemistry at Rutgers University and taught the quantitative analysis course. He wrote the book on that subject and his lectures followed the chapters in that book precisely. One could sit in lecture and follow along with the principles and chemistry problems along with the textbook. I found that a great way to learn. He was also a very kind person who would help students with their studies individually.

At dental school, there were several of these superior teachers of the dental profession. Dr. Lester W. Burkett was dean of the University of Pennsylvania’s School of Dental Medicine and also wrote the oral medicine textbook of the day. During the lectures with 140 students in the lecture hall, he would call on a student and ask a question from the reading that was to be done before class. If that student could not answer the question, he asked that student to call on one of his classmates. This caused considerable stress for all attending students and oral medicine was recognized by students as one not to ignore.

One day, he was seen walking among the steel workers who were engaged in the construction of an adjacent building. During his next

lecture, he told us how hard the steel workers had to work and that we should emulate their work ethic.

He was highly regarded by the students and faculty.

Dr. Louis Grossman demonstrated the meticulous attention to detail required by dentists in his endodontic classes and clinic. His secretary appeared at the beginning of one of his lectures with a tape recorder. He was known for his timeliness and she started the taped lecture at 1:00 PM sharp. Towards the end of the session, all eyes were on the wall clock and sure enough, his taped lecture ended at exactly 1:50 PM to the second. Also, small lights that blinked on and off every 20 seconds were installed at each dental chair so that we could time exactly the endodontic files in our bead sterilizers. He also wrote the textbook of the day on his subject. Students had to check out their final cases with him personally, and it had to look right.

Finally, Dr. Harrison Berry, professor of radiology, gave the lectures on radiographic diagnosis. His slides of all the conditions were very high quality and one could find most of the examples in his textbook. I found what he was doing as very attractive and I am sure that his

example led to my eventual career in dental radiology.

Texas has lost one of these expert teachers.

Dr. Tom Marshall, professor of restorative dentistry at the University of Texas Health Science Center at San Antonio Dental School, was one of those men. He was the beloved teacher and mentor of thousands of students. He would show up Saturday mornings to help students who were working on their operative dentistry skills. Students related years later that he always brought orange juice and donuts along with a toolbox that contained ivoreen teeth each with the succeeding step of class II preparations.

He extended his mentoring into the student clinics and is remembered for his kind supervision during students’ early clinical experiences.

If you knew him, you know what I mean. If you did not know him, you may think of those teachers in your life that had major impact on you. This Editor would welcome Letters to the Editor describing the great teachers in your experience. Please send them to Ms. Nicole Scott, managing editor of this journal, nicole@tda.org. You can also post them on the TDA Facebook group wall.

For more information, please see “What’s on tda.org” on page 776 of this issue.

Obituary Thomas Donald Marshall, D.D.S. Thomas Donald Marshall D.D.S., died at home, of ALS, Monday, May 31, 2010, surrounded by his loving family. He was the best husband, father, grandfather, brother, uncle, teacher, and friend in this world. He will be deeply missed.

Dr. Marshall was born in Detroit, Michigan, on September 18, 1925, to William Wilford Marshall and Florence Emma (Field) Marshall. He married Carolyn Darice Emmett on June 14, 1949, in South Bend, Indiana. Dr. Marshall grew up in Milford, Michigan, and enlisted in the Army Air Corps in 1943, and was stationed at San Antonio Aviation Cadet Center (now Lackland Air Force Base). In 1949, he graduated from Indiana University with an A.B. (Bachelor’s Degree) in Chemistry and in 1953, he graduated with an M.S.Ed in Educational Counseling, also from Indiana University. In 1953, he entered the Indiana University School of Dentistry from which he graduated in 1957 with a Doctor of Dental Surgery degree, with honors. From 1957 to 1972, Dr. Marshall was in private dental practice in Indianapolis, Indiana. From 1974 to 1978, he was on the faculty at the University of Texas Health Science Center Dental Branch in Houston, Texas. From 1978 to 1980, he was on the faculty at the University of Mississippi School of Dentistry. In 1980, he joined the faculty at the University of Texas Health Science Center at San Antonio Dental School where he taught thousands of dental students until his retirement in 2006. He won every teaching award at the University of Texas Health Science Center at San Antonio Dental School including the Omicron Kappa Upsilon National Dental Honor Society’s Stephen H. Leeper Award for Teaching Excellence in 2003. Dr. Marshall worked as a forensic specialist for National Geographic/UTSA expedition in Rio Azul, Guatemala in 1986. In May of 1997, he lectured at Chulalongkorn Dental Hospital’s first International Geriatric Dentistry Conference in Bangkok, Thailand. In November of 1997, he worked as practitioner/faculty for the King of Thailand’s Annual Public Health Dental Treatment Program in villages of Northeast Thailand. Dr. Marshall lectured at the GuangHua College of Stomatology Sun Yat-Sen University, Guanzhou, R. P. China in 2005.

Drs. Tom and Carolyn Marshall enjoyed several hobbies, including archaeology, weaving, and photography. They traveled a great deal and particularly enjoyed their camping and hiking trips to the southwestern United States. He was preceded in death by his parents as well as his brother, Wilford Jerry Marshall, and his sister, June Delores Marshall Fields.

He is survived by his wife, Dr. Carolyn Marshall; his daughter, Dr. Cynthia Marshall Kennedy; his son, Shawn Marshall; and grandson, Joseph Emmett Kennedy; as well as his brother, Richard William Marshall; and sister, Mary Joyce Marshall Wolff; and also numerous nieces and nephews. At Dr. Marshall’s retirement, he was recognized for 32 years of professional excellence and total dedication to dental education as a master clinician, educator, mentor, and friend. He rests from his labors and his works do follow him.

Reprint permitted by Dr. Marshall’s family, Porter Loring Mortuary, and the San Antonio Express-News.

Texas Dental Journal l www.tda.org l August

733

Dr. Frank Boyar, a Fortress Dentist.

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

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

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

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

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

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

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

When you choose Fortress Insurance Company for your professional liability coverage, you can be confident that your practice is protected.

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

Aggressive claims defense, valuable risk management and outstanding customer service are why dentists all over the country have selected Fortress. Our local agents are responsive and knowledgeable too. To get Fortress protection, call Kyle Wallace at Bell Insurance Group, 800-521-2355 X4871. Tell him Dr. Boyar sent you.

Protecting & Defending

Over 14,000 dentists trust Fortress with their professional liability insurance.

734

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

www.dds4dds.com

Conflicts of Interest in Research: Is Clinical Decision-Making Compromised?

An Opinion Paper Shawn Abidi, D.D.S. Richard D. Bebermeyer, D.D.S., M.B.A.

Introduction Currently, there is a perception that ethical principles are eroding and that research data can be biased. These research outcomes, biased or not, are used for clinical decision-making in the evidence-based practice. Relationships among practitioners, investigators, patients, and the healthcare industry can be affected when commercialism taints research outcomes and/or clini-

Abstract Lack of transparency in funded

research can compromise clinical decision-making in an evidencebased practice. Transparency

can be defined as full disclosure of all financial assistance and

support to authors and investigators. There is a perception that

ethical principles are eroding and that research data can be biased

due to conflicts of interest. These research outcomes biased

or not, are used for clinical

decision-making in the evidencebased practice. One suggested solution to this common ethi-

cal dilemma is to continue the dialogue on transparency in

research and to create oversight

bodies which include representatives from business and industry, private practice, academia, and research. There is increasing

evidence of the need for more ethics education at all levels.

KEY WORDS: Ethics, professional misconduct, bioethics, conflict of interest,

research personnel, ethics com-

mittees, evidence-based practice (EBP), research disclosure, Institutional Review Boards Abidi

Bebermeyer

Dr. Adibi is an assistant professor, Department of Diagnostic Sciences, University of Texas Health Science Center at Houston Dental Branch (UTDB). In addition to practice leadership responsibilities, the author teaches diagnostic sciences, including in the Treatment Planning Clinic, Assessment Clinic, and courses such as Introduction to Clinic and Laser Dentistry (elective) at UTDB.

(IRBs)

Tex Dent J 2010;127(8):735-741.

Dr. Bebermeyer is professor and chairman, Department of Restorative Dentistry and Biomaterials, University of Texas Health Science Center at Houston Dental Branch. The department is responsible for curriculum on ethics, professionalism, and jurisprudence, among other restorative dentistry and biomaterials courses for predoctoral dental students and general dentistry residents.

Texas Dental Journal l www.tda.org l August

735

Conflicts of Interest in Research

cal decision-making (1). Gifts and financial support from commercial business and industry to practitioners, educators, and investigators have potential for conflicts of interest (2). The investments in health care research, for example by the den-

Gifts and financial

tal materials, oral health care products, or pharma-

support from

objectivity of the results from sponsored research.

ceutical companies, can lead to doubts about the

commercial business

Issues pertaining to conflicts of interest have risen

and industry to

that many investigators are not aware of all legal

practitioners, educators, and investigators have potential for conflicts of interest.

for several reasons. One reason, for example, is and ethical aspects of working with healthcare and pharmaceutical businesses and industries.

The call for an increase in evidence-based practice (EBP) seems to face many obstacles (3). The need for more ethics education — education in research ethics, clinical ethics — to increase investigators’ and practitioners’ awareness of these everyday ethical dilemmas has become increasingly evident. Whether this increase in ethics education is needed for predoctoral, postdoctoral or continuing dental education — or even for license renewal — is left for future discussions in each locale.

Many ethical and legal problems can be prevented by avoiding conflicts of interest and through transparency, i.e., full disclosure to all audiences of all financial assistance and support to authors and investigators. For example, patients recruited for studies are quite often given consent forms to sign, and procedures are completed, without the patient thoroughly understanding all risks versus benefits involved with the treatment. Patients may not be aware of the financial assistance and support given the investigators; there

736

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

is no transparency to the study. This can often contribute to problems with the doctor-patient relationship, and can lead to patient dissatisfaction. Patients often have high expectations for treatment outcomes in a clinical investigation.

Time spent with the patient discussing treatment expectations and outlining all aspects of the investigation is essential. Patients benefit from clear discussion of possible risks versus benefits and the potential benefits to society through scientific discovery. Moreover, patients must be made aware of the research funding and the potential conflicts of interest. Not only will this increase compliance with protocols, but this also creates the transparency required among investigators, subjects, and the scientific community and health professions (4).

Conflicts of Interest in Research In many instances, investigators are under pressure to participate in research, to seek funding to support this research, and then to recruit enough subjects to conduct a statistically significant project. In addressing these needs, conflicts of interest can arise. If these conflicts of interest are not dealt with transparently, the ethics of the study are compromised. Are there any restrictions in the amount of money or other incentives offered to a patient for participation in study?

Are practitioners given money to recruit or refer patients to study centers? Are study subjects vulnerable when offered financial incentives?

These questions describe some of the potential conflicts of interest and present the ethical questions or dilemmas (5). It is clear that ethical questions arise when financial incentives are used to attract subjects to a study. These questions influence the doctor/patient relationship— and the investigator/subject relationship.

The amount of financial incentive ethically and legally acceptable may be dependent on the ethical standards of the locale in the very same way that issues with human subject protection are addressed by local Institutional Review Boards (IRBs). Accepting money for referring patients to a research center can be ethical if it is within the cultural norm of that community.

Oral health care professionals can collect and interpret patient data for internal use, but when they seek to publish these findings, specific ethical standards apply, including approval by an independent review board or as stipulated by the specific biomedical journal. Private practitioners wishing to publish results of an investigation or a case study, and seeking help, can contact an IRB at a local academic institution or they can contact an independent review board or ethics board (6).

Commercial Influence of Sponsors Can commercially sponsored and published results be ethically sound? It is now obvious to many in the research community that biomaterials and pharmaceutical companies are engaged actively in the “ghost management” and sometimes “ghost writing” of the scientific literature. Management and manipulation of investigations by companies can allow self-serving interests. This undue influence on the investigation and the research community is a matter of ethical concern in that it serves more the commercial interests of profitability and marketing, rather than furthering the contributions to the science for broader human benefits. For instance, in a survey of National Institutes of Health researchers, one-third of the scientists reported that they had been involved in some sort of research misbehavior during the past 3 years (7).

There is no doubt that the relationship between healthcare professionals and business and industry is presently under intense scrutiny. Many accusations of corrupt practices have been reported in both professional and business publications. Many in business and industry believe that they need to adapt and change with the needs of society. They claim that self-regulation is increasing. However, to facilitate improvements in regulations and practices, there is need for more effective dialogue between business and industry, investigators and health professionals (8). Some in the professions believe that if health care journals want to ensure that the research they publish

Texas Dental Journal l www.tda.org l August

737

Conflicts of Interest in Research is ethically sound, they should not publish articles that are commercially sponsored (9). However, transparency measures can be set out to disclose all relevant ethical issues, as well as conflicts of interest inherent in projects. It is a primary responsibility of a publisher and its editing staff to evaluate the ethics of a study, any possible conflicts of interest, and the transparency of a study before approval for publishing.

Research support from business and industry continues at an active level, but investigators increasingly find themselves in positions that present conflicts of interest, affecting the patients who are their research subjects. One of the suggested solutions to this common ethical dilemma has been to create an oversight body consisting of pharmaceutical and manufacturing representatives, marketing representatives, investigators, private practitioners, and educators, to establish an ethical common ground that is mutually respectful of all, and which includes patient protection and public trust (10).

Public Policy Influence in Research The Bayh-Dole Act (PL 96–517) was passed in 1980 to speed the transfer of technology developed at university laboratories to private industry and ultimately to the public sector. It has also helped to stimulate academic research as investigators have become increasingly involved in privately funded work. Although this legislation appears to have led to the creation of many new companies, jobs, and innovative technologies, it has also created ethical ground unfamiliar to many in the academic research environment.

Increases in funding, especially from private, for-profit pharmaceutical and biotechnology firms, appear to have increased concerns in the scientific community, in professional organizations, and in the public sector about conflicts of interest experienced by investigators (11). Conversely, support for education and research is somewhat dependant on the continued financial support of private business and industry. Consequently, the patients’ quality and quantity of care can be indirectly affected (12, 13).

Ethics Education Comprehensive reviews of the literature reveal lack of sufficient education pertaining to ethics education for dental and medical students (14). Publications mention that studying ethics as a part of a predoctoral dental curriculum does not necessarily translate to behavioral changes (15, 16). There may be several reasons for

738

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

this disconnect between knowledge and action which concerns academia. There are tremendous opportunities and needs for predoctoral ethics curricula for medical, dental, and allied health care professionals. Health education programs around the country should modify their curricula to fill this evident deficiency (17). In fact, it is notable that in the dental profession, both the American Dental Association (ADA) and the American Dental Education Association (ADEA) have statements on professionalism (18).

In a study published recently by the University of Minnesota, pretest scores were analyzed for 41 professionals referred for ethics assessment by a dental licensing board. Two were exempt from instruction based on pretest performance on five well-validated measures; 38 completed an individualized course designed to remediate deficiencies in ethical abilities. Statistically significant change was observed for ethical sensitivity, moral reasoning, and role concept. Of particular interest is the way this model helped referred professionals see character and ethics as capacities that can be further developed. The performance-based assessments were particularly useful in identifying shortcomings in ethical implementation. Referred practitioners valued highly the emphasis on ethical implementation, suggesting the importance of addressing what to do and say in ethically challenging cases. Finally, the required self-assessments of learning confirm the value of the process for professional renewal (i.e., a renewed commitment to professional ideals) and of enhanced abilities not only to reason about moral problems, but also to implement actions (19).

Disclosure for Publications Strategies for disclosing investigators’ financial interests to potential research participants have been adopted by many research institutions. However, little is known about how decisions are made regarding disclosures of financial interests to potential research participants, including what is disclosed and the rationale for making these determinations. A study by Weinfurt et al reported the attitudes, beliefs, and practices of institutional review board chairs, conflict of interest committee chairs, and investigators regarding disclosure of financial interests to potential research participants. Respondents cited several rationales for disclosure, including enabling informed decision making, promoting trust in researchers and research institutions, and reducing legal liability.

There was general agreement that disclosure should happen early in the consent process. Respondents in this study had little agreement about whether to disclose the amounts of particular financial interests. However, respondents were in agreement about ensuring the integrity of clinical research (20).

Texas Dental Journal l www.tda.org l August

739

Conflicts of Interest in Research Conclusions and Recommendations •

Transparency and full disclosure: Lack of transparency in funded research can compromise clinical decision-making in an evidence-based practice. Many investigators collaborate with business and industry to succeed with research and career goals, without knowing all the legal and ethical ramifications involved with possible conflicts of interest. Many ethical and legal problems can be prevented by avoiding conflicts of interest, and through transparency, defined as full disclosure of all financial assistance and support to authors and investigators. Transparency and clearly communicated full disclosure not only prevent conflicts of interest between investigators, health care professionals, patients, and subjects, but can also lead to crucial improvements in ethical research behavior. If transparency does not eliminate conflict of interest, it will certainly minimize ethical problems in research and will facilitate decision-making in the evidencebased practice.

•

Expanded ethics education: The need for expanded ethics education for pre- and post-doctoral students is becoming increasingly apparent. Education in ethics and professionalism will increase practitioners’ and investigators’ awareness of ethical and professional dilemmas that present on a routine basis. Whether this ethics education alone can enhance ethical behaviors adequately will be addressed by local licensing authorities and editorial boards, based on the ethical and cultural norms of the locale.

•

Continuation of the dialogue: Additional suggested solutions to these common ethical dilemmas include continuing the dialogue on transparency in research, and creating oversight bodies that include representatives from business and industry, private practice, academia, and research.

References 1. Boyd MA, Roth K, Ralls SA, Chambers DW. Beginning the discussion of commercialism in dentistry. J Calif Dent. Assoc. 2008 Jan; 36(1):57-65.

2. Parker LS, Satkoske VB. Conflicts of interest: are informed consent an appropriate mode and disclosure an appropriate remedy? J Am Coll Dent, 2003 summer; 74(2):19-26.

3. Hannes K, Norre D, Goedhuys J, Aertgeerts B. Obstacles to implementing evidence-based dentistry: a focus group-based study.

J Dent Educ. 2008 Jun; 72(6):736-44.

4. Grandy C. Ethical Principles in Clinical Research, Chapter 2: Principles and Practice of Clinical Research, 2007.15-26.

5. Draper H, Wilson S, Flanagan S, Ives J. Center for Biomedical Ethics, Department of Primary Care and General Practice, University of Birmingham, Edgbaston, Birmangham B15 2TT,UK. Fam Pract. 2009 Mar 3; (E pub ahead of print).

Transparency and clearly communicated full disclosure not only prevent conflicts of interest between investigators, health care professionals, patients, and subjects, but can also lead to crucial improvements in ethical research behavior.

740

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

6. Glick M. Ethical considerations in publishing research involving human subjects. J Am Dent Assoc.

2007 Oct; 138(10):1300-2.

7. Martinson BC, Anderson MS, de Vries R. Scientists behaving badly. Nature 2005; 435(7043):737-8.

8. Leather DA, Davis SC. Glaxosmith Kline UK Ltd, Building 10, Stockley Park West, Uxbridge, Middlesex UB11 1BT, UK. Paediatricians and the pharmaceutical industry perspective of the challenges ahead.

Paediatr Respir Rev. 2006 Mar; 7(1):60-6.

9. Sismondo S, Doucet M. Department of Philosophy at Queen’s University.

Publication ethics and the ghost management of medical publications. Bioethics.

2009 Feb10; (E pub ahead of print).

10. Epps CH, Jr. Division of Orthopaedic Surgery, Howard University Hospital, Washington, DC 20060, USA. Ethical guidelines for orthopaedists and industry.

Clin Orthop Relat Res. 2003 Jul; (412):14-20.

11. T. D. Warner, J. P. Gluck.

Department of Psychiatry, 1 University of new Mexico School of Medicine, 2400 Tucker NE, Albuquerque, NM 87131, USA. Psychopharmacology (Berl). 2003 Dec; 171(1):36-46. E pub 2003 Nov 18.

12. Wilson FS. Continuing Medical Education: Ethical Collaboration between sponsors and industry. Clin Orthop Relat Res. 2003 Jul; (412):33-7.

13. Wieting MW, Mevis H, Zuckfeman. The role of industry in internet education. Clin Orthop Relat Res. 2003 Jul; (412):28-32.

14. Eckles RE, Meslin EM, Gaffney M, Helft PR. Division of hematology/oncology, Indiana University School of Medicine, 535 Barnhill Drive, Room 473, Indianapolis, IN 46202, USA. Medical ethics education: Where are we? Where should we be going? A review. Acad Med. 2005 Dec; 80(12): 1134-52.

15. Bertolami CN. School of Dentistry, University of California, San Francisco 94143, USA. Why our ethics curricula don’t work.

J Dent Educ. 2004 Apr; 68(4):414-25.

16. Dunn WJ. Ethical Research. J Am Dent Assoc.

2009 Dec; 138(12):153-5: discussion 1435.

17. Deming N, Fryer-Edwards K, Dudzinski D, Starks H, Culver J, Hopley E, Robins L. Incorporating Principles and Practical Wisdom in Research Ethics Education: A Preliminary Study, Jan 2007; 82:18-23.

18. American Dental Education Association. ADEA Statement on Professionalism in Dental Education as Approved by the 2009 ADEA House of Delegates, March 2009.

19. Bebeau MJ. Enhancing professionalism using ethics education as a dental licensure board’s disciplinary action. Part 2 Evidence of the process. J Am Coll Dent. 2009 Fall; 76(3):3245.

20. Weinfurt KP, Friedman JY, Dinan MA, Allsbrook JS, Hall MA, Dhillon JK, Sugarma J. Disclosing conflict of interest in clinical research: views of institutional review boards, conflicts of interest committees, and investigators. J Law Med Ethics.2006 Fall; 34(3); 58191,481.

Full Disclosure: Dr. Adibi has received honoraria and educational assistance from: Biolase Technology, Hoya Conbio, Ivoclar Vivadent, and Deka Laser Technologies System in support of continuing education presentations.

Acknowledgement: The authors thank the editor and reviewers of the Texas Dental Journal for their contributions and editorial assistance with this manuscript.

Texas Dental Journal l www.tda.org l August

741

“The Aesthetic Restorative Series at C.A.R.D. had the most effect on me and my practice than any other course I have taken in my 32 years of practice.” RON BOSHER, D.D.S., GARLAND, TX “In my opinion, The Aesthetic Restorative Series is the best kept secret in continuing education. After taking these courses, my practice is a different place!” JERRY HERRINGTON, D.D.S., CONROE, TX “C.A.R.D. has provided for me an ‘extreme makeover’ for my attitude toward my profession of dentistry. Through five individual courses over the span of one year, I have come to realize what dentistry can provide in the way of contentment, prosperity and self respect. If you want to know what it means to be a true professional, Dr. Cutbirth can show you. He is there for dentists who want to be great, not just ok.” EDDIE PRUITT, D.D.S., HOUSTON, TX “It is rare in our profession to find a master technical dentist who also possesses exemplary skills in practice systems that lead to high profitability in a dental practice. Steve Cutbirth symbiotically blends both areas to allow each attendee of this seminar to vastly improve their level of success. I strongly recommend that dentists at all stages of their practice attend this seminar.” TOM MCDOUGAL, D.D.S., RICHARDSON, TX “Dr. Cutbirth’s series is a must for any dentist seeking a ‘top tier’ practice. His courses really helped ‘fill in the gaps’ when it comes to complex restorative cases, i.e., occlusion, changing vertical and facial pain. If you seek excellence, as Steve most certainly does, in the quality of your work and the way you run your office then I highly recommend this series.”

MARK SIVLEY, D.D.S., ABILENE, TX “To take your dentistry to the next level, this is the clearest and most concise presentation of advanced aesthetic restorative studies that you’ll find! I am now, confidently and successfully, doing the dentistry that, just two years ago, I thought was relegated to ‘those guys’ on the lecture circuit.” DARREN DICKSON, D.D.S., PLANO, TX “In one wordTERRIFIC! What makes this series different: 1. The small class size encourages interaction. 2. Dr. Cutbirth’s straight forward approach and his willingness to share all his knowledge and experiences.” MICHEAL W. SCOTT, D.D.S., LUBBOCK, TX

reach the highest level of technical excellence and bottom line productivity Advanced Restorative Series Hands-on Training Double, triple, quadruple your practice production while slashing overhead!

• Learn the secrets of highest productivity with

lowest overhead. • Master the highest levels of dentistry. • Learn to restore any case that presents in your office—including complex esthetics cases, severe wear and facial pain.

• Never “sell.” • Patients diagnose themselves and request the treatment. • 5 weekends in Dallas.

Morning lectures with afternoon hands-on laboratory.

steven t. cutbirth, d.d.s. director of c.a.r.d.

contact: jan martinelli 254.744.8673 550 742

Texas Dental Journal l www.tda.org l August June 2010 2010

register on line at www.centerforard.com

Practice This

• Full-time opportunities available in: -Houston, Laredo, and McAllen, TX -Shreveport and New Orleans, LA • Part-time opportunities available in all locations • Generous Benefit plan • Paid Vacation • Reimbursement for CE, liability insurance, fees and licensure • Knowledgeable, professional and experienced support staff • $2,500 bonus for referring a doctor

No Cap on Earning Potential $ Enter your income goal and give us a call For more information: Office of Doctor Recruitment 405-707-6110 www.oceandental.net Equal Opportunity Employer

Paul Apilado, DDS (General Dentist); Chad Hoecker, DDS (General Dentist & Owner) Dental Journal l www.tda.org l August 743 ARKANSAS • INDIANA • IOWA • KENTUCKY • LOUISIANA •TexasOHIO • OKLAHOMA • TEXAS

While you’re at tda.org, be sure to check out the following:

. . . . . .

Update your Profile Pay your Dues Read current/past issues of TDA Today Review TDA References Check out the Calendar of Events Look up peers in the Directory

New Topics have been added to the Third Party web tool (member homepage) Members can also sign up for a Personal Web Page or link to an existing website.

Texas Dental Journal l www.tda.org l August

745

With Liberty Mutual Advantage™, Texas Dental Association members can get more from their auto and home insurance.

Savings of up to $327.96 or more a year on auto insurance* with a College Education Discount and other discounts**

12-month Rate Guarantee

unlike the six-month policies that some other insurers offer

Help when you need it with 24/7 Emergency Roadside Assistance and 24-hour claims service

Additional coverages for added security including Umbrella Liability policies, Accident Forgiveness† and Home Insurance with optional Identity Fraud Expense Coverage

Get More. Save More.

Find out just how much more today.

• Call (800) 524-9400 and mention client #110024.

Monday-Friday, 7am to 12:30am; Saturday 7am to 11pm; Sunday 9am to 10pm (ET)

• Go to www.libertymutual.com/tda • Or visit a Liberty Mutual office near you

AUTO

HOME

This organization receives financial support for allowing Liberty Mutual to offer this auto and home insurance program. *Figure based on a February 2008 sample of auto policyholder savings when comparing their former premium with those of the Liberty Mutual Advantage program. Individual premiums and savings will vary. **Discounts and savings are available where state laws and regulations allow, and may vary by state. Certain discounts apply to specific coverages only. ***Emergency Roadside Assistance is available anywhere in the U.S. and Canada. With the purchase of our optional Towing & Labor coverage, the cost of towing is covered, subject to policy limits. †Accident Forgiveness coverage subject to terms and conditions of Liberty Mutual’s underwriting guidelines and is not available in all states.

Coverage provided and underwritten by Liberty County Mutual Insurance Company and its affiliates, 2100 Walnut Hill Lane, Irving, TX. A consumer report from a consumer reporting agency and/or a motor vehicle report, on all drivers listed on your policy, may be obtained where state laws and regulations allow. Please consult a Liberty Mutual specialist for specific details. ©2008 Liberty Mutual Insurance Company. All Rights Reserved.

SOUTHWEST DENTAL CONFERENCE

January 13-15, 2011  Dallas Convention Center  Dallas, Texas 746

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

747

Texas Dental Journal l www.tda.org l August

Confidential and experienCed LegaL RepResentation

foR

texas physicians

Representation before the Texas Medical Board, The Texas Medical Foundation and Medical Staff Peer Review.

Medical Practice Act and Medical Board Actions (hearings, settlement conferences and licensure) • Personal Counsel in Medical Liability Cases • Probation Modification / Termination • Managed Care Exclusions • Licensure • Reinstatement • Medico-legal Issues • Expert Review • Telemedicine • Medicare/Medicaid Appeals • Medical Ethics Opinions • Physician Assistants. tony cobos*

MichaeL shaRp*

couRtney newton

chRis shaRp Of Counsel

shaRp & cobos, P.C. Attorneys At LAw 4705 spicewood spRings Road • suite 100• austin, texas 78759 • 512 473 2265 • fax: 512 473 8525 • www.sharpcobos.com * Board Certified in Administrative Law by the Texas Board of Legal Specialization.

748

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

Fluoride Varnish: The Top Choice for Professionally Applied Fluoride

Abstract Although various modes of delivery for profession-

Ryan L. Quock, D.D.S., Donna P. Warren-Morris, R.D.H., M.Ed.

ally applied fluoride exist,

Introduction

combines caries prevention

As the dental profession continues to lead the way in providing quality health care in the United States, it must address the challenge still posed by dental caries. Significantly, dental caries is the most common chronic childhood disease in this country (1). Dentistry has the unique privilege and responsibility of treating dental caries, and prevention is the centerpiece of any strategy for treating caries. Of course, discussion of dental caries prevention inevitably turns to the success of fluoride, which has been proven to reduce the incidence of dental caries and favorably alter the progression of existing carious activity (2). Fluoride aids in both protecting tooth structure from acid attack and in remineralizing affected teeth.

one form has emerged that efficacy with safety and versatility. The American Dental Association Council on Scientific Affairs recommends fluoride varnish as the only professionally applied fluoride for moderate to high risk patients of all age groups. In addition to demonstrating effectiveness equivalent to fluoride gels, fluoride varnish provides improved safety and acceptability. Furthermore, fluoride varnish has shown promise in preventing dental caries in special groups, such as orthodontic patients and the elderly.

KEY WORDS: fluoride, fluoride varnish, professionally applied Quock

Warren-Morris

Dr. Quock is an assistant professor, Department of Restorative Dentistry & Biomaterials, University of Texas Dental Branch at Houston.

Ms. Warren-Morris is an associate professor, Department of Periodontics, University of Texas Dental Branch at Houston.

Address correspondence and reprint requests to Dr. Ryan Quock, Department of Restorative Dentistry & Biomaterials, University of Texas Dental Branch, 6516 M. D. Anderson Blvd., Ste. 493, Houston, TX 77030; Phone: (713) 500-4276; Fax: (713) 500-4108; E-mail: Ryan.Quock@uth.tmc.edu.

fluoride Tex Dent J 2010;127(8):749759.

Texas Dental Journal l www.tda.org l August

749

Fluoride Varnish Our patients are exposed to fluoride daily through toothpastes and fluoridated drinking water.

These routes of exposure are certainly beneficial with regard to caries prevention, but many patients at moderate to high risk for caries additionally require professionally administered fluorides (2). While most toothpaste contains fluoride concentrations of 1000-1100 ppm, in-office professionally applied fluorides achieve much higher concentrations (2). Perhaps the most common professionally applied topical fluoride is the gel form, either 1.23 percent acidulated phosphate fluoride (APF) at 12,300 ppm or 2 percent sodium fluoride (NaF) at 9,050 ppm (3). When applied in trays for the recommended 4 minute duration, fluoride gels have demonstrated success in caries prevention

(4). However, the major drawback of professional fluoride gel is accidental ingestion of the fluoride during the required four minute application — resultant adverse gastrointestinal effects due to acute fluoride toxicity are well known to most practitioners (4). Indeed, this risk of over ingestion of fluoride makes fluoride gels not recommended for use in children aged 6 and under, ironically a vulnerable patient population that in many cases benefits from professionally applied fluoride (4). Additionally, APF gel is contraindicated for patients with glass ionomer or porcelain restorations, because the acid in the formulation will etch and damage such restorations (5).

Is there a form of professionally applied fluoride that is proven to match the caries preven-

tion efficacy of fluoride gels, while also avoiding the inherent drawbacks of gels? Yes – fluoride varnish combines a higher concentration of fluoride (22,600 ppm in the typical 5 percent NaF form) with a reduced risk of over-ingestion (6). The efficacy and safety of fluoride varnish make it recommended for caries prevention in moderate to high risk patients of all ages by the American Dental Association (ADA) Council on Scientific Affairs (3), the Center for Disease Control and Prevention (2), and the FDI World Dental Federation (5). In addition to the effectiveness and safety of fluoride varnishes, ease of application, increased patient acceptance, and lower overall cost have also been reported as benefits (3,79). Given fluoride varnish’s anti-caries effect and advantag-

Figure 1. Fluoride Varnish Application

Step 1. Remove excess Biofilm and debris.

750

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

es, it would seem the obvious choice for professional fluoride in every dental office; indeed, fluoride varnish has been the standard of practice for professional fluoride in Europe for decades (10-11). This article seeks to present a practical review of fluoride varnish theory and application, so that the dental practitioner may be well equipped to provide the most effective preventive treatment for his or her patients.

Fluoride Varnish is Effective

Understanding how fluoride in general works to prevent dental caries is the key to understanding why fluoride varnish specifically is so effective. Although fluoride ingested systemically during tooth development may incorporate into the crystalline structure of non-erupted teeth, it is currently understood that the primary mechanism of

action of fluoride is topical on already erupted teeth (2, 12, 13). As cariogenic bacteria in dental plaque metabolize carbohydrates and produce acids, surface enamel of teeth begins to demineralize. Minerals like calcium and phosphorus leave the enamel and are retained in the plaque. Ironically, dental plaque now can act as a reservoir for minerals that can be reincorporated into the enamel — remineralization. Fluoride is the chief catalyst that attracts minerals back into the enamel, thereby counteracting the effects of demineralization (2).

Any fluoride present in the mouth can also be retained in dental plaque. As pH levels drop with the increase in acids produced by cariogenic bacteria, fluoride in the plaque is released (14). This fluoride, along with calcium and phosphorus, is incorporated into the surface enamel structure. The resultant remineralized enamel is more resistant to acid attack

(15-16). Thus, fluoride aids in remineralization as well as making enamel more resistant to demineralization. It is important to note that as pH levels rise and fall in the mouth, the pendulum swings between demineralization and remineralization at the tooth-plaque interface throughout the life of a tooth (2). Fluoride, therefore, must be present in the oral environment throughout the patient’s lifetime in order to maximize its anti-caries effect.

As noted earlier, daily use of fluoride toothpaste and fluoridated drinking water introduce fluoride to the oral environment in small quantities. This fluoride remains in the saliva for about 1-2 hours; during that time, dental plaque can be “recharged” with fluoride for future remineralization (17). For patients at low-risk for dental caries, such daily exposures to fluoride may be effective enough for caries prevention (3).

Step 2. Dry teeth with gauze or air syringe.

Texas Dental Journal l www.tda.org l August

751

Fluoride Varnish However, for patients at moderate to high risk for dental caries, professionally applied fluorides of high concentration are recommended (3). Fluoride varnish or gel application results in the formation of calcium fluoride (CaF2) globules directly on the enamel surface; the fluoride in these globules can aid in remineralization.

Paradoxically, CaF2 binds more efficiently to demineralized enamel than to sound enamel (18). Although both varnish and gel applications result in high levels of fluoride release, fluoride varnish has the added benefit of a longer exposure time to enamel. Fluoride varnish consistently elevates salivary fluoride levels for about 24 hours, while fluoride gels and other delivery systems tend to present with dramatic fluoride loss at a much earlier time.

The longer fluoride exposure time demonstrated by fluoride varnish has been associated with greater efficiency and effectiveness in the remineralization process (19,20). In short, increased duration of contact of professionally applied fluoride, as observed with fluoride varnish, is linked to increased efficacy.

Fluoride varnishes were developed in the 1960’s with caries prevention in mind. Specifically, the desire was to increase contact time between fluoride and enamel (21). Fluoride varnish adheres to the enamel surface tenaciously because of the natural resin in its formulation, a neutral colophonium base (6, 20). Varnish is usually applied with a brush and sets upon contact with intraoral moisture (18). In contrast to

Fluoride Varnish Application

Step 3. Mix the varnish thoroughly.

752

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

fluoride gels, which remain in contact with teeth for 4 minutes and then are expectorated, fluoride varnishes remain in contact with teeth for at least several hours. Furthermore, it is the tenacious adherence of fluoride varnish to teeth that minimizes risk for accidental ingestion; fluoride gels do not adhere to teeth and are often ingested, especially by young children. Thus, fluoride varnish combines high fluoride concentration (5 percent NaF, 22,600 ppm) with the ability to remain in contact with teeth for longer durations than other professionally applied fluorides.

Systematic reviews of scientific studies involving fluoride varnish tend to validate its effectiveness. In studies of children up to the age of 16 that lasted at least 1 year, fluoride var-

nishes demonstrated caries prevention efficacy similar (and in some cases slightly higher) to that of fluoride gels (21-23).

It is important to note that fluoride varnish has been shown to be effective in preventing caries regardless of the fluoridation status of a patient’s community drinking water. Data from recent clinical studies of children and adolescents in the United States, Sweden, and Germany have also strongly pointed to the caries preventive efficacy of fluoride varnish, both in primary and permanent dentition (11, 24–26). Furthermore, fluoride varnish has shown promise in preventing dental caries in special populations, like those in orthodontic brackets and the institutionalized elderly (27, 28). Such compelling data has lead the American Dental Association Council on Scientific Affairs to recommend fluoride varnish for the prevention of caries in moderate to high risk patients of any age group (3).

Fluoride Varnish is Safe

Although both fluoride gels and varnishes have been shown to be effective in preventing dental caries, one major drawback of fluoride gels is the real risk of over ingestion of fluoride, especially in younger patients.

When properly administered in trays for 4 minutes, excess fluoride gel can be inadvertently swallowed. Most practitioners are familiar with the adverse effects of acute fluoride toxicity — nausea and vomiting.

In some rare cases, fluoride overdose from gel may result in death (3, 4, 29).

Fluoride varnish minimizes the risk of over ingestion in at least a few ways. To begin, because fluoride varnish sets upon contact with the teeth and clings tenaciously to the enamel, there is little to no excess varnish to be swallowed (18).

Furthermore, a relatively small amount of fluoride varnish is needed to treat each patient. It takes about 0.5 ml of fluoride varnish to treat a child; this quantity contains 3-11 mg of fluoride. The probable toxic dose (PTD) of fluoride is 5 mg/ kg — so even if the child swallowed all of the fluoride varnish applied during a treatment, he or she would have consumed well below the probable toxic dose (21). In contrast, a small tray filled one third full with APF fluoride gel contains about 2.5 ml. The PTD of this product for a 22 pound child would be 4 ml. Clinical studies of plasma fluoride concentration following topical fluoride treatment found that the peak plasma fluoride concentration following fluoride varnish was about the same as that following brushing with fluoride toothpaste, and significantly lower than that following treatment with APF gel (30-31).

Various fluoride varnish manufacturers advise that their

Step 4. Apply a thin coat to all to facial, lingual, and interproximal surfaces with a brush.

Texas Dental Journal l www.tda.org l August

753

Fluoride Varnish product should not be used in patients with ulcerative gingivitis and stomatitis. This may be related to a hypothetical sensitivity to the colophonium resin in the varnish (18). Although fluoride varnish has been the standard professionally applied fluoride in Europe for 30 years, to the authors’ knowledge, only two case studies reporting contact allergy to varnish have been published in that time period (32,33). Fluoride varnish’s benefit of preventing acute fluoride toxicity on a regular basis in our patients will likely outweigh the apparently minimal occurrence of contact sensitivity to it.

Fluoride Varnish is Easy, Accepted, and Affordable It has been noted that fluoride varnish is easy to administer, especially in young children (3, 9). Varnish is simply brushed onto enamel surfaces, hardening upon contact with saliva or water.

This usually takes less time than the required 4 minutes that are necessary for fluoride gel tray application as approved by the ADA (3-4, 8). As a result, fluoride varnish elicits less gagging from patients than tray-based methods (8). In fact, a recent survey reported that hygienists prefer administering, and patients prefer receiving, fluoride varnish over fluoride gel (3, 34). Furthermore, while unit cost of fluoride varnish and APF gel is roughly equivalent (18), fluoride varnish takes less time to apply (3, 8). When labor costs are factored in, fluoride varnish is at least as cost effective, if not more cost effective, than fluoride gel. Patient acceptance is also increased since the required 30 minute wait after fluoride gel administration before eating and drinking is not necessary with fluoride varnish.

Fluoride Varnish Application

Step 5.“Set” the varnish with water or saliva.

754

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

Step 6. Give post-op instructions: No brushing, flossing, or hard foods for 12 hours.

Fluoride Varnish and Geriatric Patients It is widely known that the U.S. population is becoming older, with the group of adults over the age of 65 increasing the most rapidly.

Systemic conditions often force elderly patients to be treated with multiple medications that can result in xerostomic side effects.

This trend, coupled with their lack of dexterity or mental awareness for self-care, make many elderly at moderate or high risk for dental caries (3). Fluoride varnish is an excellent therapy for use with elderly patients or periodontal patients who have clinical attachment loss exposing root surfaces to caries risk. In institutionalized elderly, tray treatments would be very difficult to apply unless suction was available. Even with available suction, tray treatments are not an option for use with an intubated or unconscious patient.

American Dental Association Recommendations

Based upon a review by its Council on Scientific Affairs of the best available evidence, the American Dental Association recently published its recommendations for use of professionally applied topical fluoride (3). A summary of the recommendations, especially as they relate to fluoride varnish, follows: • •

•

•

•

Patients at low risk for caries may not benefit from professionally applied topical fluoride (3).

Fluoride varnish applied every 6 months is effective in preventing caries in primary and permanent dentition of children, adolescents, and high-risk populations (3).

For patients younger than 6 years old of moderate or high risk for caries, fluoride varnish applied at least every 6 months is the only professionally applied fluoride that is recommended (3, 6).

For patients aged 6 to 18 years of moderate or high risk for caries, fluoride varnish or gel applied at least every 6 months is recommended (3).

For patients older than 18 years of moderate or high risk for caries, fluoride varnish or gel applied at least every 6 months is recommended (3).

Although fluoride varnish has been the standard professionally applied fluoride in Europe for 30 years, to the authors’ knowledge, only two case studies reporting contact allergy to varnish have been published in that time period.

Thus, fluoride varnish is the only professionally applied fluoride that is recommended by the American Dental Association (ADA) for use in all age groups. It is beneficial to note that the ADA strongly endorses this “off-label” use of fluoride varnish for caries prevention; the Federal Drug Administration officially approves fluoride varnish for use as a cavity liner or desensitizer.

Texas Dental Journal l www.tda.org l August

755

Fluoride Varnish Table 1. Fluoride Varnish Products and Manufacturers NAME

CHARACTERISTICS

MANUFACTURER

CavityShield® 5 percent NaF

3M ESPE www.3MESPE.com/preventivecare

ClearShield®

5 percent NaF, Xylitol, clear varnish, gluten free

Zenith Dental www.zenithdental.com

Duraflor Halo ®

5 percent NaF, Xylitol, white varnish, gluten free

Medicom www.medicom.com

DuraShield®

Amber tinted, 5 percent NaF, Xylitol

Sultan Dental Products info@sultandental.com

Enamel Pro Varnish®

Delivers ACP (Amorphous Calcium Phosphate), 5 percent NaF, white varnish

Premier Dental Products Company http://www.premusa.com/dental/hygiene. asp#enamelprovarnish

Fluoride Varnish

5 percent NaF, white varnish

Oral BioTech info@carifree.com

PreviDent ®Varnish 5 percent NaF,

white varnish

Colgate Oral Pharmaceuticals http://www.colgateprofessional.com/products/ Colgate-PreviDent-Varnish-Rx-only/specifics

VANISH®

5 percent NaF, white varnish

3M ESPE www.3MESPE.com/preventivecare

Vanish™ XT Extended Contact Varnish

Resin-modified glass ionomer; delivers fluoride, calcium, and phosphate to seal dentinal tubules

3M ESPE www.3MESPE.com/preventivecare

VarnishAmerica™

5 percent NaF, natural tooth colored

Medical Products Laboratories http://www.medicalproductslaboratories.com/

Vella

5 percent NaF, Xylitol, white varnish

Preventech http://www.preventech.com/

Waterpik UltraThin®

5 percent NaF, thinner consistency

Waterpik www.ultrathin.waterpik.com

This list not intended to be an exclusive listing of all fluoride varnish products.

756

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

Clinical Application of Fluoride Varnish Fluoride varnish application is very simple and requires less than a minute to apply.

A review of studies that investigated the most efficacious techniques for fluoride varnish application reported the following steps, which are outlined and illustrated in Figure 1 (6). Excess biofilm and debris should be removed with either a toothbrush or rubber cup.

Even though manufacturers suggest that varnish can be applied to moist teeth, all of the reviewed studies applied the varnish to dry teeth and one study that reported the results of applying it to wet tooth surfaces found fluoride uptake to be greater on dry teeth (35).

The teeth can be dried with air or gauze. Since some varnishes have a tendency to separate, be sure to mix the product well with the applicator brush before applying. The varnish is then applied to facial/lingual surfaces with a small brush and can be applied to interproximals with dental floss.

The teeth are then rinsed with water or the patient can simply close and allow saliva to set the varnish. The last step is to give the patient post-operative instructions to eat soft foods for 12 hours and to abstain from toothbrushing and flossing for 12 hours as well, allowing the varnish to remain in contact with the teeth.

Fluoride varnish products have been in use in the United States since 1994 when they were approved as cavity liners and used off-label for fluoride applications (18). The first generation of varnishes was amber colored colophonium resins that were met with some resistance due to imparting a temporary yellowing of the teeth. The second generation products are tooth colored and are invisible after application.

A non-exhaustive list of products and their manufacturers is listed in Table 1.

Fluoride Varnish Reduces Hypersensitivity The most widely accepted theory of dentinal hypersensitivity is that it is a result of hydrodynamics which is the outward fluid movement within the pulp that creates pressure on the nerves causing pain.

This condition has been estimated to effect between 14 and 30 percent of the population and is ever increasing with the aging population and the use of whitening agents (36). Fluorides have been shown to form a layer of CaF2 on the exposed cervical dentin surface blocking the tubules and reducing hypersensitivity (37,38). Fluoride varnishes have ADA approval for dentinal hypersensitivity and have the advantage over fluoride gels, rinses, and foams due to their retention on the tooth surface for extended time periods. They have been shown to be effective in reducing sen-

sitivity to air and cold for up to 34 weeks after application (39).

The procedure for application is the same as outlined previously.

The Role of the Dental Team As with all dental procedures, the safe use of evidence based practices and products should be the first concern of the dentist, dental hygienist, and dental assistant. Fluoride varnish is recommended by the ADA for caries prevention, and it is the only professionally applied fluoride product recommended for children under age 6. In addition to assessing patient caries risk level and prescribing an appropriate professional fluoride regimen according to ADA recommendations, the dentist should assure that his/ her auxiliaries are properly educated and trained in the correct use of all fluoride products, including varnishes. The dental auxiliary responsible for administering fluoride should update his/her knowledge of fluorides frequently and follow appropriate procedures to ensure efficacy and safety.

In conclusion, fluoride varnishes are recommended by the ADA for prevention of caries in moderate to high risk patients of any age group — this is a unique distinction. Efficacy, safety, ease of administration, and patient acceptability contribute to this winning combination. Thus, when considering professionally applied fluoride, think fluoride varnish!

Texas Dental Journal l www.tda.org l August

757

Fluoride Varnish References 1. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General – Executive Summary.

Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

2. Center for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR 2001;50(No. RR-14) 2.

3. American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. Journal of the American Dental Association 2006; 137(8):11511159.

4. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride gels for preventing dental caries in children and adolescents. The Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD002280.

DOI: 10.1002/14651858.

CD002280.

5. Chu CH, Mei ML, Lo EC. Use of fluorides in dental caries management. General Dentistry 2010 JanFeb; 58(1)37-43.

6. Miller EK, Vann WF. The use of fluoride varnish in children: a critical review

758

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

with treatment recommendations. The Jounral of Clinical Pediatric Dentistry 2008; 32(4):259-264.

7. Petersson LG, Twetman S, Dahlgren H, Norlund A, Holm A-K, Nordenram G, Lagerlof F, Soder B, Kallestal C, Mejare I, Axelsson S, Lingstrom P. Professonal fluoride varnish treatment for caries control: a systematic review of clinical trials. Acta Odontol Scand 2004; 62:170-176.

8. Hawkins R, Noble J, Locker D, Wiebe D, Murray H, Wiebe P, Frosina C, Clarke M. A comparison of the costs and patient acceptability of professionally applied topical fluoride foam and varnish. Journal of Public Health Dentistry 2004; 64(2):106-110.

9. Tinanoff N, Douglass JM. Clinical decision-making for caries management in primary teeth. Journal of Dental Education 2001; 65(10):1133-1142.

10. Autio-Gold J. Recommendations for fluoride varnish use in caries management.

Dentistry Today 2008; 27(1):64-67.

11. Autio-Gold JT, Courts F. Assessing the effect of fluoride varnish on early enamel carious lesions in the primary dentition.

Journal of the American Dental Association 2001; 132(9):1247-1253.

12. Singh KA, Spencer AJ, Brennan DS. Effects of water fluoride exposure

at crown completion and maturation on caries of permanent first molars. Caries Res 2007; 41:34-42.

13. Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing caries in adults. J Dent Res 2007; 86(5):410415.

14. Tatevossian A. Fluoride in dental plaque and its effects. Journal of Dental Research 1990; 69(special issue):645-652.

15. Featherstone JDB. Prevention and reversal of dental caries: role of low level fluoride. Community Dentistry and Oral Epidemiology 1999; 27:31-40.

16. Chow LC. Tooth-bound fluoride and dental caries. Journal of Dental Research 1990; 69(special issue):595-600.

17. Rolla G, Ekstrand J. Fluoride in oral fluids and dental plaque. In: Fejerskov O, Ekstrand J, Burt BA, eds. Fluoride in dentistry.

2nd ed. Copenhagen: Munksgaard, 1996; 215229.

18. Beltran-Aguilar ED, Goldstein JW, Lockwood SA. Fluoride varnishes: a review of their clinical use, cariostatic mechanism, efficacy and safety. Journal of the American Dental Association 2000; 131(5):589596.

19. Eakle WS, Featherstone JDB, Weintraub JA, Shain SG, Gansky SA. Salivary fluoride levels following ap-

plication of fluoride varnish or fluoride rinse. Community Dent Oral Epidemiol 2004; 32:462-469.

20. Strohmenger L, Brambilla E. The use of fluoride varnishes in the prevention of dental caries: a short review. Oral Diseases 2001; 7:71-80.

21. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride varnishes for preventing dental caries in children and adolescents. The Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD002279.

DOI: 10.1002/14651858.

CD002279 22. Marinho VCC, Higgins JPT, Sheiham A, Logan S. One topical fluoride (toothpastes, or mouthrinses, or gels, or varnishes) versus another for preventing dental caries in children and adolescents. The Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002780.pub2.

DOI: 10.1002/14651858.

CD002780.pub2.

23. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents. The Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.:CD002782.

DOI: 10.1002/14651858.

CD002782.

24. Kallestal C. The effect of five years’ implementation of caries-preventive methods in Swedish high-risk adolescents. Caries Research 2005; 39:20-26.

25. Skold UM, Petersson LG, Lith A, Birkhed D. Effect of school-based fluoride varnish programmes on approximal caries in adolescents from different caries risk areas. Caries Research 2005; 39:273-279.

26. Dohnke-Hohrmann S, Zimmer S. Change in caries prevalence after implementation of a fluoride varnish program. Journal of Public Health Dentistry 2004 Spring; 64(2):96-100.

27. Stecksen-Blicks C, Renfors G, Oscarson ND, Bergstrand F, Twetman S. Caries-preventive effectiveness of a fluoride varnish: a randomized controlled trial in adolescents with fixed orthodontic appliances. Caries Research 2007; 41:455-459.

28. Innes N, Evans D. Caries prevention for older people in residential care homes.

Evidence Based Dentistry 2009; 10(3):83-87.

29. $750,000 Given in child’s death in fluoride Case: boy, 3, was in city clinic for routine cleaning. New York Times January 20, 1979.

30. Ekstand J, Koch G, Petersson LG. Plasma fluoride concentration and urinary fluoride excretion in children following application of fluoride-containing varnish. Caries Research 1980; 14:185-189.

31. Ekstrand J, Koch G, Petersson LG. Plasma fluoride concentration in pre-school children after ingestion of fluoride tablets and toothpaste. Caries Research 1983; 17:379-384.

32. Sharma PR. Allergic contact stomatitis from coloph-

ony. Dental Update 2006; Sep;33(7):440-442.

33. Isaksson M, Bruze M, Björkner B, Niklasson B. Contact allergy to Duraphat. Scandinavian Journal of Dental Research 1993; Feb;101(1): 49-51.

34. Warren DP, Henson HA, Chan JT. Dental hygienist and patient comparisons of fluoride varnishes to fluoride gels. Journal of Dental Hygiene 2000 Spring; 74(2):94-101.

35. Koch G, Hakeberg M, Petersson LG. Fluoride uptake on dry versus water-saliva wetted human enamel surfaces in vitro after topical application of a varnish (Duraphat) containing fluoride. Swed Dent J 1988; 12:221-225.

36. Chabanski MB, Gillam DG. Aetiology, prevalence and clinical features of cervical dentine sensitivity. J Oral Rehab 1997; 24:15-9.

37. Gangarosa LP Sr. Current strategies for dentistapplied treatment in the management of hypersensitive dentine. Arch Oral Biol 1994; 39:101S-6S. 38. Ehrlich J, Hochman H, Gedalia I, Tal M. Residual fluoride concentrations and scanning electron microscopic examination of root surfaces of human teeth after topical application of fluoride in vivo. J Dent Res 1975; 54:897-900.

39. Ritter AV, de L. Dias W, Miguez P, Caplan DJ, Swift EJ. Treating cervical dentin hypersensitivity with fluoride varnish. Journal of the American Dental Association 2006; 137:10131030.

Texas Dental Journal l www.tda.org l August

759

EXPRESS

The Texas Dental Association has integrated the existing TDA website (www.tda.org) into the “TDA Express” Internet portal. The TDA Express portal allows members to customize their homepage to show only the content in which they're interested.

Members can choose from existing links or add their own. TDA Express now includes a video library showcasing TDA videos and podcasts. Be sure to view the “Welcome” video by Mary Kay Linn, TDA Executive Director.

EXPRESS

Google

Cargo plane crashes in Uganda's Lake Victoria (AP) Yahoo News Dental News & Videos

Stefanie’s Desktop My Account

Sign-Out

Set as Home

RSS News Center Calculators

News & Publications

More News...

Dental

Personal

My Links

•

How to Reduce Stress Dr. Ben Bernstein has created a stress reduction m...

11/14/2008 10:00:00 AM

•

Understanding, Planning and Funding My Retirement This podcast addresses topics related to retiremen...

11/14/2008 10:00:00 AM

•

Revive, Refresh, Renew — Creating Balance for the Dental Has your get up and go, got up and left? This uniq...

11/14/2008 10:00:00 AM

•

Dental Professional Liability 101 This podcast addresses topics related to professio...

11/14/2008 10:00:00 AM

•

More Headlines...

Announcement Click HERE - TDA Express Feedback TDA Express has been enhanced! Along with a new look, TDA Express now has its very own TDA video library.

Events Calendar 2009 2007

Su

M

T

W

Th

F

Sa

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

1

2

3

4

Welcome to the TDA Video Library Introduction to the new TDA video library

by Mary Kay Linn, TDA Executive Director

Endodontics

TDA News TDA Committee on the New Dentist Podcast: Starting a New Practice The second installment of the TDA Committe on the New Dentist podacst series, conducted by Dr, Josh Austin.

TDA Perks Program TDA Members Website TDA Public Website DENPAC Website TDA Smiles Website

ADA News

Dental Plans Website

Pediatric Dentistry

TDA Perks Program Website TEXAS Meeting Website

7278.38

-122.42

S&P 500

768.54

-15.50

NASDAQ

457.27

-26.21

S&P/TSX

8506.35

-184.14

•

Five-year follow-up of a root canal filling material in the Oral Surgery, Oral Medicine, Oral Pathology, Oral ...

3/20/2009 10:21:05 AM

•

A longitudinal study of dental caries risk among very Community Dentistry and Oral Epidemiology 3/20/2009 10:21:05 AM

•

Putative signaling action of amelogenin utilizes the Journal of Periodontal Research 3/19/2009 10:25:15 AM

•

Silver Diamine Fluoride: A Caries Silver-Fluoride Bullet Journal of Dental Research 3/19/2009 10:25:15 AM

Orofacial Pain/TMJ News •

Patient Image Selection Criteria for Cone Beam Computed Seminars in Orthodontics 3/19/2009 10:25:14 AM

•

Current Diagnostic Tests to Assess Pulp Vitality Journal of the Canadian Dental Association 3/19/2009 10:25:15 AM

•

Likelihood ratio methodology to identify predictors of Oral Surgery, Oral Medicine, Oral Pathology, Oral ...

3/18/2009 11:15:34 AM

•

More Headlines...

•

Effects of a Liquid Diet on Temporomandibular Joint Journal of Dental Research

World Indices DOW JONES

Tools

ADA Podcast Network

Meetings/Planners Weather Center

March

Austin Weather: Overcast 70

Finance

TDA Videos

GO

Implantology

Top Section: Google search box (top-right corner), Helpful Tips, Contact Info (top-left), News scroll of top headlines, Local weather update Left-hand margin: RSS News Center, Calculators, Meetings/Planners, Weather Center, Announcements from TDA, Events Calendar, TDA News and TDA Perks Program highlights, List of TDA and affiliate websites, and World Indices Middle section (portlets) - Content divided into 7 sections: • Dental News & Videos: TDA video library, ADA Podcast Network, and dental specialty news.

• News & Publications: Business and personal news, magazines, television, and Internet links.

• Dental: Links related to the profession and dental office needs.

• Personal: Links to travel, weather, people, sports, and other leisure interests.

• Finance: Banking and finance related links, including investment, retirement, and bankruptcy.

• Tools: Variety of helpful links such as office and tech tools, research, demographic, and people searches.

• My Links: Links and categories created by the user.

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

Masters OF

Aesthetic excellence October 20-23, 2010

34th Annual International Conference on Dental Aesthetics

MENTORING WORld-RENOWNEd SpEakERS luNch & lEaRN daIlY l haNdS-ON WORkShOpS lY

JW MARRIott San Antonio hill Country ReSoRt & SpA 22 Dental CE Hours Approved For

Register at www.asdatoday.com or call 1-888-988-ASDA for more information Texas Dental Journal l www.tda.org l August

761

Texas Dental Association 140th Annual Session 2010 TEXAS Meeting Photo Contest Award: 3rd Place, Sports/Human Endeavor Photographer: Dr. C. Doug Foster of El Paso Title: “Dad and Daughter Having a Blast�

For information on entering your photo in the 2011 TEXAS Meeting Photo Contest, please visit texasmeeting.com.

762

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

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.

Texas Dental Journal l www.tda.org l August

763

TX-JUN-2010.pdf

6/21/10

8:47:56 AM

C

M

Y

CM

MY

CY

CMY

K

764

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

Free CE Credits Are Just a Click Away.

Now you can choose the time and place to take the courses you need and want. We’ve made it easy to take free CE courses online. Dentists and dental hygienists can get free continuing education (CE) credits for the First Dental Home and the Oral Health Examination by Dental Professionals courses. Learn more about Texas Health Steps (Medicaid for children) and other health-care services with Texas Health Steps Online Provider Education.

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

Taking New Steps

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

766

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

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

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

Texas Medicaid… TDA Dentists Making a Difference William D. Steinhauer, D.D.S.

The 2000 U.S. Surgeon General’s report, Oral Health in America: A Report of the Surgeon General, raised awareness about the oral health disparities that persist in the United States, despite the many improvements in the nation’s overall oral health. Included in the report is information that we in dentistry have known for many years — there are serious oral health disparities for those segments of the child population that come from indigent, low income, and uninsured families (1).

Steinhauer Dr. Steinhauer is a pediatric dentist in private practice in San Antonio. He is the 2010-11 chair of the TDA Committee on Access, Medicaid, and CHIP.

Texas Dental Journal l www.tda.org l August

767

Medicaid In Texas, public health programs such as Medicaid, the Children’s Health Insurance Program, and Head Start have requirements designed to provide a full range of health services for at-risk children.

Specifically, Medicaid services, including dental, are provided to eligible children under 21 through the Early and Periodic Screening, Diagnosis, and Treatment program (EPSDT), also known as Texas Health Steps (THSteps).

In the first 6 months of implementation, a total of 161 individual OEFV providers billed 5,733 THSteps claims.

This means that, most likely, an additional 5,733 children were referred by THSteps Medical providers into a waiting dental home.

Although Medicaid includes a wide range of preventive and therapeutic services, historically low reimbursement rates and administrative hassles have discouraged many dentists from participating in the program.

In 2007, the TDA played an important role in the State of Texas’ successful effort to settle the long-running Frew v Suehs (formerly Frew v Hawkins) lawsuit, which alleged that children enrolled in THSteps were not adequately receiving the preventive and therapeutic services (including dental care) legally available to them through the EPSDT program.

Although the TDA was not a party to the lawsuit, state officials consulted with the Association’s leadership during negotiations that led to the settlement agreement. Rep. Warren Chisum (RPampa), chair of the 80th Legislative Session House Committee on Appropriations, and Sen. Steve Ogden (R-Bryan), chair of the 80th Legislative Session Senate Committee on Finance, requested and obtained the Association’s support for various proposals to boost fees for dental services in an effort to increase the number of dentists participating in the Medicaid program.

Under the Frew settlement, the state Medicaid program received a total of $1.8 billion in new funding, including more than $700 million in state funds. State funds equaling $259 million were used to increase fees for dental services, with another $150 million budgeted for “strategic dental and medical initiatives” to increase access to care, including dental treatment, in underserved areas (2).

While the Frew reimbursement rate increases directly contributed to more dentists participating in the program, the TDA’s deliberate and systematic efforts to recruit and retain Medicaid dental providers also played a significant role. Texas now has approximately 2,260 Medicaid dental providers actively treating eligible children (3). Since 2006, the number of active dental Medicaid providers increased 26.2 percent. As a result, Texas is now third in the nation for the highest percentage of Medicaid eligible children receiving dental care in 2009 (4).

768

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

The Department of State Health Services Oral Health Program (OHP) administers two Frew dental-related initiatives — the “First Dental Home (FDH)” and the Oral Evaluation and Fluoride Varnish in the Medical Home (OEFV).”

The FDH provides training and enhanced reimbursements for pediatric and general dentists who agree to provide exams and other care for very young children (i.e., those aged 6 months to 3 years) enrolled in the Medicaid. A separate but related project, the OEFV, reimburses pediatric physicians who provide oral evaluations and fluoride varnish to very young children enrolled in Medicaid with the goal of transitioning the patients into a dental home.

In the first 6 months of implementation, a total of 161 individual OEFV providers billed 5,733 THSteps claims. This means that, most likely, an additional 5,733 children were referred by THSteps Medical providers into a waiting dental home (5).

reduced school lunch, and 3) not enrolled in Medicaid or the free/reduced lunch program.

The report showed that Medicaid enrolled children had better dental outcomes than those not enrolled in Medicaid regardless of whether the children received free school lunch.

TDA member dentists also improved the dental health of Medicaid children overall. A 2010 OHP report studied the following three groups of third grade children; 1) enrolled in Medicaid; 2) not enrolled in Medicaid but receiving free/

The Frew settlement agreement also included funding to create a Children’s Medicaid Loan Repayment Program (CMLRP) which provides student loan repayment assistance to physicians and dentists who provide services to children enrolled in

Initial data from the FDH and OEFV projects strongly indicates that dentists are interested and actively participating in both of these programs. The TDA’s FDH marketing efforts, along with those by the OHP, have resulted in dentists actively providing FDH services as indicated by the high proportion (82.6 percent) of FDH trained dentists billing for FDH services during the report’s evaluation period (5).

OEFV implementation was delayed until September 2008 so that an adequate FDH network of dental providers were available to accept dental referrals from THSteps medical checkup providers for THSteps children ages 6 months through 35 months.

Texas Dental Journal l www.tda.org l August

769

Medicaid Medicaid. Award recipients must provide eligible services for 4 consecutive years and meet the target number of Medicaid visits by children under the age of 21 for each 12-month period as stated in the program requirements.

To date, 101 of the entire 300 loan repayment awards went to dentists and those dentists are now practicing in underserved communities treating Medicaid children that might otherwise go without dental care (7).

As evidenced above, the TDA is diligently working to improve access to dental care for children in Texas by encouraging its members to meaningfully participate in public health programs and support initiatives designed to improve the oral health of the state’s most vulnerable children. The TDA looks forward to continuing to work with legislators and other state officials to provide needed oral health services, which will make a real difference in the lives of thousands of Texas children.

Resources 1. U.S. Department of Health and Human Services. National Call to Action to Promote Oral Health. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental and Craniofacial Research. NIH Publication No. 03-5303, Spring 2003.

2. Texas Health and Human Services Commission. House Bill 15 Frew Expenditure Plan, September 2007.

3. Texas Health and Human Services Commission. THSteps Active Provider Participation Report 1996-2010. Case 3:93-cv-00065RAS Document 762, April 2010.

4. Electronic communication from the Texas Department of State Health Services Oral Health Program, July 22, 2010.

770

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

5. Texas Department of State Health Services Division of Family and Community Health Office of Program Decision Support. Evaluation of Dental Strategic Initiatives: First Dental Home and Oral Evaluation and Fluoride, July 13, 2010.

6. Texas Department of State Health Services Division of Family and Community Health Office of Program Decision Support. Assessment of Child Dental Services As Required

by Frew v. Suehs, December 2009.

7. Electronic communication from the Texas Health and Human Services Commission, September 16, 2009.

Ad Number: OT050937 Publication: Tx Dntl assoc Due Date: 7/20/09 Color or BW: BW Publisher Size Designation: 1/2 Page Horiz Non Bleed (framed) Size: 7 x 4.5 Bleed Size: Live Area: n/a With Bleed: n/a Page Trim Size: 8.5 x 11 Art: PDF (300), New: Yes Pick Up From: n/a Notes: Publication Contact email & Phone Number: Nicole Scott, Publications Coordinator, Texas Dental Association Tel: 512-443-3675, ext. 124 <nicole@tda.org> Upload Instructions: email to nicole

Texas Dental Journal l www.tda.org l August

771

Restore with Confidence Clinician's #1 Choice for Esthetic Crowns More dentists choose NuSmile® Crowns for esthetic restoration with full coverage protection in cases of early childhood caries (ECC). NuSmile® Crowns have become the #1 Restoration of Choice by proving their quality and value to thousands of doctors worldwide. If you are looking for an easy, rapid and durable Before treatment solution for cases of ECC, you'll want to restore with NuSmile.

After

Two million crowns now in use around the globe!

Survey Results For Esthetic Crown Preferences ANTERIOR & POSTERIOR ESTHETIC CROWNS COMBINED

31%

Use NuSmile® Crowns

14%

#1 BRAND CHOICE

18%

Use Crowns X

Use Crowns Y

H Oueis / S Atwan / B Pajtas / P Casamassimo University of Detroit Mercy School of Dentistry – 2008

POSTERIOR ESTHETIC CROWNS

55%

Shepherd

got consent?

Use NuSmile® Crowns Use 12% Crowns X

15%

Use Crowns Y

E Jacobsen DDS / C Smith DDS / N Kakanantadilok DMD Albert Einstein College of Medicine – 2008

on TDA CD

texdentlaw.com Informed Consent Forms & Other Legal Forms for Texas Dentists from Boyd W. Shepherd, D.D.S., J.D. © 2007 Boyd W. Shepherd, P.C. – Boyd W. Shepherd, D.D.S., J.D. – Not Certified by the Texas Board of Legal Specialization

772

Order Yours Today

800-346-5133 www.nusmilecrowns.com Email NuSmile® Clinical Questions Directly to an Experienced Clinician

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

Ad Number: NS031029 Publication: Texas Denta

Thinking of Getting On-Hold Messaging? aceOnHold.com delivers 50+ polished, professionally recorded and personalized on-hold messages, music and digital equipment at very reasonable prices, and has received excellent reviews from TDA members.

There are no contracts or monthly fees, and aceOnHold.com offers a 100% satisfaction guarantee.

TDA members save $80 on their initial purchaseâ&#x20AC;&#x201D;which includes digital playback equipment thatâ&#x20AC;&#x2122;s theirs to keep.

(800) 892-9179

www.aceonhold.com/tdaperks

Texas Dental Journal l www.tda.org l August

773

EXPRESS Customize your homepage to show only the content you’re interested in. PLUS:

-

Check out the NEW! TDA Video library Add your own links Hide links you’re not interested in Select text size Personalize your weather center Make TDA Express your homepage Choose news headlines to display Search TDA’s interactive calendar Check stocks Perform MedLine, Google, WebMD, or Answers.com searches Utilize tools such as conversion, business, time zone, and deadline calculators Access reference and meeting planner

Start your day with TDA Express!

Log in at tda.org to get started today!

774

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

SPDDS

Employees Benefit Trust

Group Health Care Plans Designed for Dental Offices Health Care Coverage is our business ... we’ve been providing it exclusively to the dental industry since 1996!

Three distinct plans now available: Freedom Plan

PPO Plan

HSA High Deductible Health Plan

• Multiple deductibles available for all plans • May choose different plans and deductibles within the dental office • Employer determines the amount of employee contribution and waiting periods

To obtain rates or more information, please call 1-800-658-6810 or visit us on the Web at www.spddsebt.com SPPDS Employee Benefit Trust is a Texas licensed, multiple employer welfare arrangement, governed by ERISA, providing self-funded health coverage for dentists, their employees, and dependents.

Texas Dental Journal l www.tda.org l August

AD-9

775

Stefanie Clegg, TDA Web & 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.

If you do not have a Facebook, LinkedIn, or Twitter account, you can set one up in minutes!

The View From Austin article on page 734 asks for Letters to the Editor describing the great teachers in your experience. Join the Texas Dental Association group on Facebook and post your experience on the group wall. The first five posts will receive a FREE personal web page or link to an existing website on tda.org for 1 year!!

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.

For more information or 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 & new media manager, at stefanie@tda.org.

776

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

JKJ Pathology Oral Pathology Laboratory

John E Kacher, DDS • Available for consultation by phone or email • Color histology images on all reports • Expedited specimen shipping with tracking numbers • Reports available online through secure web interface

Professional, reliable service with hightechnology solutions so that you can better serve your patients.

Call or email for free kits or consultation. jkjpathology.com 713-598-9284 (T) 281-292-7372 (F) johnkacher@jkjpathology.com

Protecting your patients, limiting your liability

Texas Dental Journal l www.tda.org l August

777

Provided by TDA Perks Program

value for your

profession Sound Advice

How to Leverage Your Telephone’s On-Hold Feature to Build Loyalty and Enhance Patient Experience

By Ron Schott, aceOnHold.com Impressions, impressions, impressions! Making multiple dental impressions in a given day is pretty normal, but can the same be said about the number of advertising impressions you make? Professionally produced on-hold messages can help on both accounts.

Every day, we’re presented with opportunities. Some we make the most of, others we miss. If you are running a business, you are probably aware of something called “opportunity cost,” the monetary value associated with missed opportunities. An often overlooked, disregarded, or under-rated opportunity is the time your patients spend on-hold when calling your practice. Your telephone system’s on-hold feature is tantamount to your own private radio station, which provides an opportunity to inform, educate, entertain and communicate—in other words, it’s an opportunity to advertise for your practice!

778

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

Using professionally produced on-hold messages dramatically increases the number of advertising impressions you make with your existing and prospective patients.

On-hold messages work tirelessly as a dedicated spokesperson, conveying relevant practice information that subtly reinforces patient loyalty and enhances professionalism. And with a small amount of research, it doesn’t have to take a big bite out of your marketing budget.

Cost Considerations Messages on hold (MOH) run the gamut when it comes to pricing. You can scrimp and defeat your efforts to portray professionalism, or overpay for unnecessary licensing and service fees. As with any purchase, cheaper options aren’t always the best. Solutions under $200 typically include generic messages on a compact disc or e-mailed in MP3 format. Then they leave it up to you to provide the playback solution and lower-priced options rarely offer technical support. On the flip-side, high-priced options can run $1,000-$1,500 annually. Of course, you’re offered custom message programs, writing assistance, digital playback equipment, technical support, and unlimited updates. While these are truly helpful in certain business circumstances, it’s probably overkill for a dental practice.

If you’re like me, researching options, no matter what the topic, feels overly time consuming, so I put it off. For evaluating message on-hold options, I recommend answering three questions to help clarify your real needs: 1. “Am I okay using a CD player, which is likely to require daily attention, or would I prefer a device designed for 24/7 playback?”

2. “When it comes to frequency of updating on-hold messages, do I prefer a ‘one and done’ solution, or a ‘keep it fresh’ approach?”

3. “With regard to my time, am I available to write messages to keep the content current or is it worth having it done for me?”

Depending on your answers to the above questions, you should be able to find a satisfactory MOH solution in the $400-$700 range with frequency options for updates that match your needs. Once you are set up with equipment, annual charges should be substantially lower or non-existent depending on whether you continue receiving update options, and the music licensing approach used by your on-hold message supplier.

There are plenty of payment options that include onetime, monthly and all sorts of combinations thereof. Be clear about whether you will own or lease equipment and understand the consequences of terminating or discontinuing the use of your on-hold message system. Contracts and licensing and/or termination fees can cause

By The Numbers*…

10 20 40 70

Minutes per day the average person spends on hold Percent of people who made a decision based on something they heard while on hold.

Seconds before callers with “silence-on-hold” hang up.

Percent of small business callers put on hold

*Survey results from AT&T, North American Telecom Association and CNN Studies

you plenty of tribulations. As with any service, few people enjoy dealing with contracts that lock them into rules and regulations they don’t feel they signed up for; nor do they enjoy paying a hefty sum if they decide to cancel the service. Today, there are plenty of options that don’t require a contract or monthly fees — nonetheless, make sure to read all of the fine print!

Quality Makes a Difference It’s easy for callers to tune out when they are put on hold.

That’s why the quality of your on-hold production matters.

It should include an upbeat music background, with professional voice talent (preferably a combination of male and female), delivering well-written messages that talk about products, services, upcoming events or pertinent practice information. Updating your message content on a regular basis creates a feeling that there’s something “new and exciting” to talk about.

Some business owners try and take the easy way out by playing the radio or music CD they own. DON’T DO THAT! First of all, it’s illegal without proper licensing (organizations such as ASCAP, BMI, CCLI, and SESAC handle music licensing), which costs hundreds of dollars per year. Secondly, playing the radio creates the opportunity for information to be presented that you wouldn’t Texas Dental Journal l www.tda.org l August

779

want your callers to hear, such as advertisements for competitors or content of which you may not approve.

Not to mention, using the radio or just music means you still miss the opportunity to brand your own professional image.

Closely related to the quality of your on-hold production is the quality of your phone support staff. The care with which they place calls on-hold and resume them has a huge impact on the impression left with your callers. It’s imperative to train all members of your team to use genuine politeness and permissionbased hold techniques.

Simply put, ask, “May I put you on-hold for a moment?” and then WAIT FOR A RESPONSE! Upon retrieving a holding caller, be sure to say, “Thank you for holding, how may I help you?”

Table of Phone Systems and Message On-Hold Options Hardware PBX

Virtual PBX

Description Two- and four-line phones purchased at office supply stores and electronics retailers.

Phones connect to a central onsite “brain” that manages incoming calls, transfers, holds and other features.

Manages incoming calls, transfers, holds, and features through a webbased internet service.

Popular Brands

AT&T 944, 974, 984, 1040, 1070 RCA Executive Series Panasonic KX Series

Nortel Norstar (CICS and MICS), Samsung, Toshiba, NEC, Mitel, Avaya, Allworx, InterTel, and many others.

Packet 8 (8x8), Fonality, Asterisk, Aptela, RingCentral, Thinking Phones and many others.

On-Hold Message Option

Requires adapter to “emulate” the on-hold feature and allow MOH to play through phone lines. Often includes pressing

Seamless integration of MOH by connecting a playback source (CD or digital on-hold player).

Connects with a single audio cable from ( * * Hold) to engage playback source to music.

MOH input on main NOTE: Still requires PBX unit. a playback source connected to adapter Continuous loop (such as a CD player playback provides best rotation of or digital on-hold device). Some digital messages. players have analog adapters built-in.

Does not require hardware playback device. Upload digital files (.mp3 or .wav) or email to provider for placement.

No PBX (KSU-less)

What about Compatibility?

Most phone systems provide a message-on-hold feature as part of its basic setup. This usually consists of a MOH input, normally located on the main unit (PBX). A simple audio cable connects your on-hold player to your phone system. Of course, not all businesses use actual business-grade phone systems.

Some opt for simple multi-line business phones available from office-supply and electronics retailers, or Voice over Internet (VoIP). Still, there are on-hold solutions available depending on your particular setup. The chart to the right represents some of the more popular phone systems and their MOH options.

780

NOTE: Messages typically play from the beginning each time “hold” is initiated, which limits the rotation of what is heard by callers.

Final Notes When it comes to running a business, it pays to advertise and inform whenever possible. Every company that uses the telephone as an integral part of daily business should utilize on-hold messages because it enables regular communication with an audience that is already established as clients—your patients. It lets them know you respect their “waiting” and realize that their time is valuable. And instead of sitting in silence wondering if they are still connected, patients can be informed and educated. Keep in mind, according to a Telemarketing magazine survey, 20 percent of callers have actually made a purchase or a decision based on information heard while they were on hold.

So the next time you call a small business and you’re put on hold, tune your ears to whether it’s missing opportunities, or maximizing the moment to make a great on-hold impression. aceOnHold is a TDA Perks Program partner that delivers personalized and professional on-hold messaging with no contracts or monthly fees. aceOnHold offers a 100 percent satisfaction guarantee. For more information, contact aceOnHold at: (800) 892-9179, or visit: https://www.aceonhold.com/home/tda/. For more information regarding other TDA Perks Programs, visit tdaperks.com, or call (512) 443-3675.

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

Place a classified ad in the Journal!

It’s a member benefit! Reach more than 8,000 of your colleagues!

Cost: Deadline:

$35 for the first 30 words 20th, 2 months prior

Managing Editor nicole@tda.org

Calendar of Events 782

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) 4402599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org.

23 & 24 The El Paso District Dental Society will hold its 48th annual El Paso Dental Conference at the El Paso Convention Center in El Paso, Texas. For more information, please contact El Paso Dental Conference, 8815 Dyer, Suite 210, El Paso, TX 79904. Phone: (915) 581-6688; Web: elpasodentalconference.org.

25 The TDA Smiles Foundation will hold a Smiles on Wheels in Cactus. 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.

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) 678-6286; Web: aamos.org.

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 113735159. 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) 454-2732; 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: (312) 787-3670; E-mail: susan@perio.org; Web: perio.org.

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

3–6 The Dental Trade Alliance will hold its annual meeting at the Hyatt Grand Champions Resort in Indian Wells, CA. For more information, please contact Ms. Mary Dolan, Dental Trade Alliance, 2300 Clarendon Road, Suite 1003, Arlington, VA 22201. Phone: (703) 379-7755; FAX: (703) 931-9429; E-mail: info@dentaltradealliance.org; Web: dentaltradealliance.org.

3–6 The American College of Prosthodontists will hold its 40th annual session at the Hyatt Grand Cypress in Orlando, FL. For more information, please contact Ms. Melissa Kabadian, ACP, 211 E. Chicago Ave., Suite 1000, Chicago, IL 60611. Phone: (312) 573-1260; FAX: (312) 573-1257; E-mail: mkabadian@prosthodontics.org; Web: prosthodontics.org.

4–9 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.

7 – 13 The US Dental Tennis Association will hold its meeting at the Grand Wailea Resort in Maui, HI. More than 16 continuing education AGD/PACE-approved opportunities available. Phone: (800) 445-2524; E-mail: dentaltennis@gmail.com; Web: dentaltennis.org.

December 2010

6&7 The ADA Institute for Diversity in Leadership will hold its meeting at the ADA in Chicago, IL. For more information, please contact Ms. Stephanie Starsiak, 211 E. Chicago, Ave., Chicago, IL 60611. Phone: (312) 440-4699; FAX: (312) 440-2883; E-mail: starsiaks@ada.org; Web: ada.org.

January 2011

13 – 15 The Dallas County Dental Society will hold the Southwest Dental Conference at the Dallas County Convention Center in Dallas, Texas. For more information, please contact Ms. Jane Evans, DCDS, 13633 Omega Drive, Dallas, TX 75244. Phone: (972) 386-5741; FAX: (972) 233-8636; E-mail: jane@dcds.org; Web: dcds.org 23 – 25 The American Dental Association will hold its Presidents Elect Conference in Chicago, IL. 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.

February 2011

4 The American Dental Association’s Give Kids a Smile Day occurs nationwide. For more information, please contact Ms. Lynne Mangan, ADA, 211 East Chicago Ave, Chicago, IL 60611-2678. Phone: (312) 440-2500; FAX (312) 440-7494; E-mail: online@ada.org; Web: ada.org.

24 The American Equilibration Society will hold its 55th annual meeting at the Chicago Downtown Marriott in Chicago, IL. For more information, please contact Mr. Kenneth Cleveland, AES, 207 E. Ohio St., Ste. 399, Chicago, IL 60611. Phone: (847) 965-2888; FAX (609) 573-5064; E-mail: exec@aes-tmj.org; Web: aes-tmj-org.

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

Calendar of Events

November 2010

Texas Dental Journal l www.tda.org l August

783

In Memoriam Those in the dental community who have recently passed

Appleton, F. George Haltom City, Texas July 21, 1924 – June 15, 2010 Good Fellow, 1993 • Life, 1989 • Fifty Year, 2007

to the Texas Dental Association Smiles Foundation

Bird, Albert D. McKinney, Texas June 15, 1926 – June 15, 2010 Good Fellow, 1978 • Life, 1991 • Fifty Year, 2002

Dr. John Hammerick

By Ralph Martin, D.D.S.

Jones, Mackin L. Bryan, Texas November 20, 1920 – September 14, 2009 Good Fellow, 1973 • Life, 1985 • Fifty Year, 1998 McNutt, John Howard Austin, Texas October 1, 1923 – June 16, 2010 Good Fellow, 1982 • Life, 1988 • Fifty Year, 2007 Moore, John George Corpus Christi, Texas February 12, 1934 – August 11, 2008 Good Fellow, 1990 • Life, 2000 Oliver, Victor T. Staunton, Virginia February 28, 1913 – May 8, 2010 Good Fellow, 1960 • Life, 1978 • Fifty Year, 1984 Rhodes, William H. Frisco, Texas January 30, 1927 – April 13, 2010 Good Fellow, 1978 • Life, 1992 • Fifty Year, 2003 Robnett, James Hulen Lubbock, Texas September 19, 1922 – May 3, 2010 Good Fellow, 1977 • Life, 1987 • Fifty Year, 2002 Smith, Robert F. March 19, 1928 – October 4, 2010 Good Fellow, 1980 • Life, 1993 Tipton, Talmage H. Lubbock, Texas February 25, 1922 – August 1, 2009 Good Fellow, 1979 • Life, 1987 Wester, Bill G. Weatherford, Texas August 7, 1928 – June 3, 2010 Good Fellow, 1980 • Life, 1984 • Fifty Year, 2005 Zernial, Gerald Allen Brenham, Texas August 21, 1937 – December 23, 2009 Life, 2003

784

Memorial and Honorarium Donors

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

In Memory of:

Dixie McCutcheon

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

Please make your check payable to:

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

TDA Video Highlights on tda.org Due to the positive feedback and overall success with the TDA New Dentist Committee podcast series and the TDA Video Library on TDA Express, TDA has added a new TDA Video Highlights section on the homepage of tda.org. Members can browse through dozens of videos from TDA events, like the TEXAS Meeting.

Listen to TDA members share their opinions on issues such as, “Why Join TDA” and “The Value of Membership.” Watch shout-outs from various events at the TEXAS Meeting like the House of Delegates, TDA GOLD reception or exhibit hall.

Thank you to all the participants! We hope to include more footage in the future and welcome any feedback.

Questions? Contact Stefanie Clegg, TDA Web & New Media Manager at (512) 443-3675 or stefanie@tda.org

Oral and Maxillofacial Pathology Case of the Month Clinical History A 49-year-old African American female was referred for evaluation of erythema and edema limited to the maxillary facial gingiva. Her chief complaint was the pain in the maxillary region that had lasted the past 6 months and failed to resolve after conventional periodontal treatment.

The patient reported some improvement in her gingival inflammation when she used a chlorhexidine oral rinse prescribed by her periodontist.

However, the improvement was limited and she was unable to use this mouth rinse consistently because it caused a burning sensation in her gums. She also complained that her mouth felt dry. The patient denied skin or other mucosal lesions. No specific triggers or inciting medications for this gingival lesion could be elicited from history.

The patientâ&#x20AC;&#x2122;s medical history was significant for sarcoidosis affecting the brain (neurosarcoidosis), diabetes insipidus, chronic sinusitis, anemia, and depression. The patient also reported loss of vision in the right eye and compromised vision on the left due to the neurosarcoidosis.

She underwent multiple imaging studies that showed sarcoidosis was limited to her brain only; there was no history of involvement of the lung, bone, or any other internal organs.

Her current medications included IV dexamethasone 200 mg, every 3 weeks for neurosarcoidosis, Carimune (IV immunoglobulin) given to prevent infection due to long-term corticosteroid treatment, desmopres-

786

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

Kavitha Parthasarathy, B.D.S., M.S.; Jessica Wu, B.S.; Nadarajah Vigneswaran, D.M.D., Dr. Med. Dent.

The University of Texas Dental Branch at Houston

Parthasarathy

Wu

Vigneswaran

sin acetate nasal spray for diabetes insipidus, levothyroxine for hypothyroidism and Prozac (fluoxetine) for depression.

The extraoral exam was unremarkable and there was no cervical lymphadenopathy. The intraoral exam revealed a diffuse, inflamed and swollen gingiva with a granular red surface (Figure 1A). This gingival involvement was restricted to the maxillary facial region from tooth #5-13. The edema and redness involved the free gingiva as well as the attached gingiva (Figure 1A). There were no erosions or ulcerations in the affected gingiva. Pressure applied to this area failed to produce blisters (negative for Nikolskyâ&#x20AC;&#x2122;s sign).

Periodontal probing in this area exhibited no significant increase in probing depths, however bleeding on probing was elicited. The rest of the mucosa appeared within normal limits and no significant pathosis was detected. The patient demonstrated a moderate to severe degree of xerostomia. Incisional biopsies were obtained from the maxillary facial gingiva between teeth #11 and #12 and submitted for routine histopathologic and direct immunofluorescence studies.

Microscopic examination revealed mucosal fragments which were surfaced by parakeratinized stratified squamous epithelium. The underlying lamina propria exhibited an intense non-caseating chronic granulomatous inflammation consisting of a collection of histiocytes, lymphocytes, and multinucleated giant cells (Figure 1B). Microscopic examination revealed the presence of neither polarizable nor non-polarizable foreign body material. Special stains for deep fungal infections and acid-fast bacilli were negative. Direct immunofluorescence staining for IgG, IgA, IgM, c3 and fibrinogen were performed in freshfrozen tissue sections and were negative for lichen planus, mucous membrane pemphigoid and pemphigus vulgaris. The gingival lesions improved dramatically when treated with intralesional corticosteroid injection(s) (Figure 1C).

See page 788 for the answer and discussion.

Figure 1 (A-C).

Clinical picture of initial presentation reveals

erythematous enlargement

of the anterior maxillary facial gingiva (A).

Microscopic findings of the biopsy showing epithelioid granulomas (B).

Dramatic improvement of the gingival lesions after

intralesional corticosteroid injections (C).

Texas Dental Journal l www.tda.org l August

787

Oral and Maxillofacial Pathology Diagnosis and Management

Gingival Sarcoidosis Oral and Maxillofacial Pathology Case of the Month (from page 776)

Discussion The persistence of gingival inflammation after stringent plaque control with traditional periodontal therapy is a feature of non plaque-induced gingivitis (1, 2). Therefore, distinction hinges on good clinical history combined with histopathologic and direct immunofluorescence findings.

Non-plaque-associated gingival lesions include infectious diseases produced by specific bacterial (i.e., tuberculosis), viral (i.e., primary herpetic gingivostomatitis) and fungal (i.e., histoplasmosis) organisms (1, 3). Clinical history, the absence of cervical lymphadenopathy and the microscopic findings were not consistent with an infectious etiology for this case. Plasma cell gingivitis is an asymptomatic and distinct form of allergic gingival reaction which clinically presents as a diffuse red area that is sharply demarcated within the attached facial gingiva (4). Microscopic examination would reveal the presence of abundant plasma cells in the connective tissue beneath the epithelium. Cinnamon flavored chewing gum, herbal tooth paste, mint candy, and spices used in food preparations are the most common etiologic agents implicated in the development of plasma cell gingivitis (4). Other forms of allergic gingivitis commonly present localized or diffused swollen red gingiva triggered by constituents of mouthwashes, dentifrices, and dental restorative materials (4). A thorough clinical

788

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

examination and careful history are essential for the diagnosis of allergic gingivitis. An incisional biopsy of the affected gingiva is indicated to rule out other causes of non-plaqueassociated gingivitis.

Desquamative gingivitis is a manifestation of various mucocutaneous diseases which presents as diffuse and swollen red gingiva which spontaneously sloughs, leaving painful ulcerated or erosive gingival lesions (4, 5). The most common mucocutaneous disease that manifests as desquamative gingivitis is lichen planus, followed by mucous membrane pemphigoid (5, 6). Pemphigus vulgaris, linear IgA disease, bullous pemphigoid, and epidermolysis bullosa acquisita are less frequently associated with desquamative gingivitis (5, 6). Histopathologic and direct immunofluorescence findings in this case ruled out these mucocutaneous diseases.

Granulomatous gingivitis clinically presents as a localized or diffuse area of swollen and red gingiva that upon microscopic examination reveals chronic granulomatous inflammation (4, 7). A number of localized and systemic disorders may present as granulomatous gingivitis (4, 7, 8).

These include tuberculosis, deep fungal infections, foreign body reactions, Crohnâ&#x20AC;&#x2122;s disease, and sarcoidosis (4, 7, 8). Special stains excluded specific infections such as tuberculosis and systemic fungal infections in

this case. Microscopic examination failed to show exogenous material in the biopsy specimen. Hence, the diagnosis of granulomatous gingivitis associated with gingival sarcoidosis was made based on the clinical history and the microscopic findings.

Sarcoidosis is a multisystem disorder of unknown etiology that is characterized by the presence of noncaseating granulomas (9, 10). Sarcoidosis affects people of all racial and ethnic groups and usually develops before the age of 50 years (9, 10).

Women are affected more often than men and the adjusted annual incidence among African Americans is three times that among Caucasian Americans (9, 10). Moreover, sarcoidosis is more likely to be chronic and fatal in African Americans compared to other ethnic groups (9). Exposure to various environmental agents (i.e. insecticides, inorganic particles, and mold) has been implicated as triggers for the development of sarcoidosis because it most commonly involves the lungs, eyes, and skin (9). Currently, it is believed that sarcoidosis develops as an aberrant immune response to various ubiquitous environmental triggers (9). Susceptibility to sarcoidosis is determined by both genetic and environmental factors (9). Certain HLA class II alleles (i.e., HLA-DB1 and DQB1) are more prevalent in patients with sarcoidosis than in the general population (9).

The clinical presentation is often variable, with the lungs and bilat-

eral hilar lymph nodes being the most commonly involved organs (9, 10). However, the skin, eyes, liver, heart, central nervous, musculoskeletal, genitourinary, and endocrine systems are also frequently affected (9, 10). Gingival presentation and systemic symptoms of sarcoidosis share similarities with tuberculosis which include fatigue, night sweats, and weight loss (3). Acute presentation of sarcoidosis, known as Löfgren’s syndrome, consists of arthritis, erythema nodosum (tender erythematous nodules of the skin), and bilateral hilar lymphadenopathy (9). Sarcoidosis may also present with parotid enlargement, anterior uveitis of the eye, facial nerve paralysis and fever which is commonly known as uveoparotid fever (Heerfordt’s syndrome) (9).

Our patient had sarcoidosis involving the central nervous system, commonly known as neurosarcoidosis which occurs in 10 percent of all patients with sarcoidosis (11). Neurosarcoidosis is more common in African Americans, with a female predominance(11).

Patients with neurosarcoidosis may develop cranial nerve palsies, headache, ataxia, cognitive dysfunction, and seizures (11).

Moreover, neurosarcoidosis may affect the hypothalamus/pituitary axis and cause diabetes insipidus and panhypopituitarism (10, 11). It should be noted our patient had diabetes insipidus as a complication of neurosarcoidosis. In the head and neck area, sarcoidosis commonly involves the salivary glands causing dry mouth in affected patients (12). Oral manifestations of sarcoidosis are uncommon and may present as a submucosal mass or nodule rather than erythematous gingivitis (12). The buccal mucosa is the most commonly affected area followed by the gingiva, floor of the mouth, tongue and palate (12). Sarcoidosis may occur in an intraosseous location, frequently involving the anterior maxilla and posterior mandible (13).

Histopathologic findings of noncaseating granulomas in one or more organs in the absence of microorganisms and foreign body material are sufficient to make the diagnosis of sarcoidosis when the clinical and radiographic findings are compatible. Sarcoid granulomas produce angiotension-converting enzyme (ACE); hence, serum ACE levels are elevated in 60 percent of sarcoidosis patients (9). However, the diagnostic value of serum ACE levels in sarcoidosis remains inconclusive (9). Recently, 18Ffluordeoxyglucose position-emission tomography (18FDG-PET) has been used to evaluate the extent of sarcoid involvement in multiple organ systems (14). The initial therapy for sarcoidosis is corticosteroid therapy. The prognosis of sarcoidosis varies significantly among affected patients. Disease remission with few or no consequences is noted in two-thirds of patients with sarcoidosis (9). The remainder of the patients will have chronic sarcoidosis with episodic remission and recurrence. Approximately 5 percent of patients die of this disorder, usually due to pulmonary fibrosis leading to respiratory failure (9).

References: 1. Holmstrup P: Non-plaque-induced gingival lesions. Ann Periodontal 1999;4:20 2. Laskaris G, Scully C: Introduction. In Laskaris G, Scully C (eds): Periodontal manifestations of local and systemic diseases (ed. Berlin Heidelberg New York: SpringerVerlag, 2003:3.

3. Gill JS, Sandhu S, Gill S: Primary tuberculosis masquerading as gingival enlargement.

Br Dent J;208:343 4. Neville B, Damm D, Allen C, Bouquot J: Periodontal diseases. In Neville B, Damm D, Allen C, Bouquot J (eds): Oral & Maxillofacial Pathology, (ed. St. Louis, Missouri: SAUNDERS/ELSEVIER, 2009:154.

5. Lo Russo L, Fedele S, Guiglia R et al.: Diagnostic pathways and clinical significance of desquamative gingivitis. J Periodontal 2008;79:4 6. Yih WY, Maier T, Kratochvil FJ, Zieper MB: Analysis of desquamative gingivitis using direct immunofluorescence in conjunction with histology. J Periodontal 1998;69:678 7. Lourenco SV, Lobo AZ, Boggio P et al.: Gingival manifestations of orofacial granulomatosis. Arch Dermatol 2008;144:1627 8. Vigneswaran N, Morreti AJ, Braden WF: Oral and maxillofacial pathology case of the month. Foreign body gingivitis. Tex Dent J 2007;124:530 9. Iannuzzi MC, Rybicki BA, Teirstein AS: Sarcoidosis. N Engl J Med 2007;357:2153 10. Newman LS, Rose CS, Maier LA: Sarcoidosis. N Engl J Med 1997;336:1224 11. Delaney P: Neurologic manifestations in sarcoidosis: review of the literature, with a report of 23 cases. Ann Intern Med 1977;87:336 12. Blinder D, Yahatom R, Taicher S: Oral manifestations of sarcoidosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:458 13. Suresh L, Aguirre A, Buhite RJ, Radfar L: Intraosseous sarcoidosis of the jaws mimicking aggressive periodontitis: a case report and literature review. J Periodontal 2004; 75:478 14. Nunes H, Brillet PY, Valeyre D et al.: Imaging in sarcoidosis. Semin Respir Crit Care Med 2007;28:102

Texas Dental Journal l www.tda.org l August

789

g n i rtis

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

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

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

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

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

Briefs

Practice Opportunities MCLERRAN AND ASSOCIATES: AUSTIN: Associate to ownership opportunity. 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.

AUSTIN: Well-established, FFS family practice in five op office located in growing community. Office has been recently updated, boasts a committed staff and strong hygiene program, and has seen increasing revenue in the high six figures the last 3 years. ID #1-0108.

CORPUS CHRISTI: Doctor retiring, six op office with excellent visibility and access. Good numbers, excellent patient base, good upside potential. Excellent practice for starting doctor. Priced to sell. ID #023.

CORPUS CHRISTI: Three operatory, feefor-service crown and bridge oriented family practice in a great location. High grossing practice on 3-day week. Doctor ready to retire. Make an offer! ID #098.

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.

790

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

NEW! AUSTIN NORTH: Beautiful five operatory (two equipped, all plumbed) family practice off busy thoroughfare grossing mid six figures. Digital X-ray, digital pano, floor-to-ceiling windows in all ops, solid patient base and cash flow at start-up price. Excellent opportunity.

ID #1-0107.

NEW! AUSTIN: North, high grossing, five operatory practice in free-standing building. Plenty of room to expand.

Fee-for-service patient base, good equipment. Owner wishes to sell and continue part-time as an associate. ID #1-0115.

NEW! AUSTIN: Very modern, newly built out, eight operatory family practice in highly visible location. Practice is underperforming and has tremendous upside potential. Grossed mid six figures with one doctor working limited schedule. ID #116.

NEW! CENTRAL TEXAS: Well-established, FFS family practice in five op office located in growing community.

Office has been recently updated, boasts a committed staff and strong hygiene program, and has seen increasing revenue in the high six figures the last three years. ID #1-109.

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

NEW! SAN ANTONIO: Oral surgery specialty practice. Very good referral base.

Almost new build out, great location, and excellent equipment. Good gross and net. Transition available. ID #0113.

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

Priced to sell. ID #1-0112.

NEW! SAN ANTONIO, NORTH CENTRAL: Three operatory office in retail/ office center with great visibility and access. New equipment and nice build out. Good solid numbers, very low overhead. ID #1-0111.

NEW! SAN ANTONIO, NORTH CENTRAL: Five operatory, state-of-the-art facility with new equipment. Located in a medical professional building in high growth, affluent area. Grossing seven figures with high net income. ID #106.

NEW! SAN ANTONIO, NORTH CENTRAL: Beautiful, almost new, stateof-the-art six operatory office. Terrific location, great signage, affluent patient base, beautiful decor. Owner has family issues, must sell. ID #1-0114.

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

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

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

SAN ANTONIO AREA: Three operatory office in small town with no competition. Very good income and low, low overhead. Priced to sell. ID #013.

SAN ANTONIO NORTH CENTRAL: High gross and net income general family practice located in high income area in very visible retail office 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.

SAN ANTONIO, NORTH WEST: 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.

SAN ANTONIO: Prosthodontic practice with almost new equipment and build out. Doctor wants to sell and continue to work as associate. Beautiful office!

Perfect for stand alone or satellite office. ID #060.

SAN ANTONIO: Three operatory general practice in condominium located in highly desirable 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.

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

SOUTH TEXAS BORDER: General practitioner with 100 percent ortho practice. Very high numbers, incredible net. ID #021.

Texas Dental Journal l www.tda.org l August

791

g

in s i t r e dv

A

Briefs

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. ID #105.

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

Very nice equipment and decor. Excellent opportunity. ID #003.

SAN ANTONIO: Six operatory practice with three chair ortho bay located in 3,400 sq. ft. building. Modern office with newer equipment. Free-standing building on busy thoroughfare. Practice has grossed in seven figures for last 3 years. Great location with super upside potential. ID #055.

SAN ANTONIO, NORTH SIDE: Eight operatory, high grossing, fee-for-service family practice in historic, free-standing building. Affluent neighborhood. Huge patient base and super hygiene program. ID #104.

SAN ANTONIO: Medical center, four operatory family practice in very nice professional building. Great picture window views. Very nice, modern office, good patient base. Perfect size for starting doctor. ID #1-0067.

WACO AREA: Modern and high-tech, three op general family practice grossing in mid-six figures with high net income. Large, loyal patient base. Office is well equipped for doctor seeking a modern office. ID -1-0106.

Contact McLerran Practice Transitions, Inc.: statewide, Paul McLerran, DDS, (210) 737-0100 or (888) 656-0290; in

792

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

Austin, David McLerran, (512) 7506778; in Houston, Tom Guglielmo and Patrick Johnston, (281) 362-1707.

Practice sales, appraisals, buyer representation, and lease negotiations. See www.dental-sales.com for pictures and more complete information.

HOUSTON AREA PRACTICE OPPORTUNITIES! MCLERRAN & ASSOCIATES: CONROE: ASSOCIATE BUY-IN grossing high six figures, six ops, great location on Loop 336 in exploding suburb north of Houston. Doctor wants to retire, looking for associate buy-in. Great opportunity for success now and well into the future. #H105.

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

HOUSTON: General family practice located southwest of Houston, high visibility, grossing mid-six figures. Five operatories, two ready for expansion.

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

GOLDEN TRIANGLE: Eight op general family practice grossing seven figures plus. Modern, open concept design in a highly residential area, strong new patient flow with high net. #H107.

HOUSTON: Established general and family practice inside 610 for transition. #H112.

HOUSTON: This general, 100 percent fee-for-service practice has been established for more than 25 years. Produced near mid-six figures with retiring doctor only working 2 days per week.

Spacious facility with three operatories, custom cabinetry throughout and great outside views can be expanded to four or five operatories. #H113.

NORTHWEST OF HOUSTON: General family practice, grossing mid six figures. Strong recall system with about 1,200 active patients, four operatories, equipment in very nice condition. PPO and fee-for-service, in thriving community. Low overhead means great cash flow. #H119.

Contact McLerran & Associates in Houston: Tom Guglielmo and Patrick Johnson, (800) 474-3049 or (281) 3621707. Practice sales, appraisals, buyer representation, and lease negotiations.

See www.dental-sales.com for more complete information.

ORAL SURGERY PRACTICE FOR SALE, HOUSTON AREA — GARY CLINTON, PMA: Economy is strong in Texas. Many referring dentists. Retiring surgeon; outright sale or transition; seven-figure gross. Seller will work for buyer on limited basis. We have the best sources for 100 percent buyer funding. Gary Clinton is 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) 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 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) 583-7765.

GARY CLINTON / PMA BRYAN / COLLEGE STATION PRACTICE FOR SALE. Transition/outright sale. Retiring dentist. Beautiful office; Restorative practice. Well-established recall. We have the best sources for 100 percent buyer funding. Gary Clinton is 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 compaTexas Dental Journal l www.tda.org l August

793

g

in s i t r e dv

A

Briefs

rables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA LUBBOCK / PANHANDLE AREA PRACTICE FOR SALE: P-l Four operatories, retiring dentist, high gross/net. Just over 1 hour away from large community. Near seven-figure gross. Profit from hygiene will pay debt service. P-2 Doctor will sell/transition. High collections/net; five operatories, full hygiene. We have the best sources for 100 percent buyer funding. Gary Clinton is 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) 583-7765.

GARY CLINTON / PMA NORTH DALLAS AREA PRACTICE FOR SALE: Well-established practice; exceptional recall; full general service practice with lots of crown and bridge. Retiring dentist. Will continue to work as needed 1 day per week. We have the best sources for 100 percent buyer funding. Gary Clinton is 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 institu-

794

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

tions. 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) 583-7765.

GARY CLINTON / PMA: Serving the dental profession since 1973: I have buyers! Sell your practice and travel while you have your health. In many cases, you can stay on to work 1-2 days per week if you wish. I need practices to sell/transition as follows: Austin, San Antonio, DFW area, and Houston. Have buyers for orthodontic, oral surgery, periodontic, pedodontic, and general dentistry practices. Values for practices have never been higher. One hundred percent funding available, even those valued at more than seven figures.

Call me confidentially with any questions. We have the best sources for 100 percent buyer funding. Gary Clinton is 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) 583-7765.

GARY CLINTON / PMA SAN ANGELO / ABILENE AREA PRACTICE FOR SALE: S-1 San Angelo area — Very sharp office. Plenty of patients to work 5 days a week; exceptional value. S-2 San Angelo — Excellent well-established restorative practice. Very nice equip-

ment. Dentist relocation. Transitional/ outright sale. We have the best sources for 100 percent buyer funding. Gary Clinton is 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) 583-7765.

ORTHODONTIC PRACTICES FOR SALE / TRANSITION — GARY CLINTON / PMA TEXAS: O1 North Dallas — Fast growing, highly desirable suburb; digital equipment; doctor relocating; will transition. O2 West Central Texas Mid-sized to larger community — Ideal transition; professional referral based; traditional fee-for-service, referral, highly productive. Gorgeous building with room for two in this planned 50/50 partnership; within 5 years complete buy-out with owner working 1-2 days as needed. O3 South Texas retiring orthodontist —100 percent buy-out / transition; seller will stay 1-2 days per week as needed. Seven figure practice collections; 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 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 clos-

ing 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) 583-7765.

SOUTH TEXAS CORPUS CHRISTI PERIODONTIC PRACTICE FOR SALE — GARY CLINTON / PMA: Doctor retiring for health reasons. Urgent sale.

Great value. Nice office close to beach.

Well-established practice. Staff will stay. We have the best sources for 100 percent buyer funding. Gary Clinton is 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) 583-7765.

GARY CLINTON ARLINGTON, TEXAS PRACTICE FOR SALE / TRANSITION: Seven figure gross; well-established cosmetic restorative practice. Arlington is one of the best places to be in Texas.

Home of the Dallas Cowboys, Texas Rangers, Six Flags, and more. We have the best sources for 100 percent buyer funding. Gary Clinton is 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 closTexas Dental Journal l www.tda.org l August

795

g

in s i t r e dv

A

Briefs

ing 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) 583-7765.

GARY CLINTON / PMA HOUSTON GENERAL PRACTICE FOR SALE: CLEAR LAKE/NASA/BAY AREA: Wellestablished practice. Retiring dentist will transition (limited). Superb recall care program. Exceptional location with very good lease rate. Facility on freeway frontage road; high visibility. We have the best sources for 100 percent buyer funding. Gary Clinton is 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) 583-7765.

GARY CLINTON / PMA MCKINNEY/ FRISCO AREA: Exceptional premier restorative practice; seven figure gross requiring experienced dentist. Newer equipment; attractive facility. We have the best sources for 100 percent buyer funding. Gary Clinton is 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

796

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

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) 583-7765.

GARY CLINTON / PMA FORT WORTH AREA SOUTH GENERAL RESTORATIVE PRACTICE FOR SALE: Still an excellent rate of growth with new schools. Very nice office and equipment. We have the best sources for 100 percent buyer funding. Gary Clinton is 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) 583-7765.

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 want to practice in a less competitive more relaxed environment, this is a must-see opportunity. Contact The Hindley Group at (800) 856-1955. Visit us at www. thehindleygroup.com.

NORTH CENTRAL TEXAS GENERAL DENTAL PRACTICE — SALE: Wonderful opportunity in small town that is 1 hour north of DFW metroplex. Four operatories. Good new patient flow.

Excellent staff. Building also for sale.

Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www. thehindleygroup.com.

HOUSTON GENERAL DENTAL PRACTICE — SALE: Small practice in attractive office in southwest Houston professional building. Four treatment rooms.

Affordable terms. Wonderful mentor.

Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www. thehindleygroup.com.

NORTH TEXAS GENERAL DENTAL PRACTICE — SALE: Small, well-established practice in mid-sized community in north Texas. Three fully-equipped operatories. Experienced staff with excellent skills. Doctor will assist with transition. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

WEST HOUSTON GENERAL DENTAL PRACTICE — SALE: Outstanding opportunity in rapidly growing community west of Houston. Excellent revenues and profit margin. Four operatories.

Some Medicaid. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

SOUTH HOUSTON GENERAL DENTAL PRACTICE — SALE: Most attractive office located on busy thoroughfare in rapidly growing south Houston suburb. Six treatment rooms, five fully equipped. Two additional spaces plumbed. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

WEST HOUSTON GENERAL DENTAL PRACTICE — SALE: new, wellappointed office space in fast growing west Houston. Strong new patient flow, excellent staff, and highly qualified mentor. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

NORTHWEST TEXAS GENERAL DENTAL PRACTICE — SALE: Established practice located across from large shopping mall. Wonderful staff and strong new patient flow. Digital X-rays. Ten operatories. Doctor to facilitate transition. Contact The Hindley Group, LLC, 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) 8561955. Visit us at www.thehindleygroup. com.

SOUTHEAST HOUSTON GENERAL DENTAL PRACTICE — SALE: Incredible general dental practice with six operatories in new facility. High revTexas Dental Journal l www.tda.org l August

797

g

in s i t r e dv

A

Briefs

enues with excellent profit margin. Doctor relocating but is most interested in smooth transition. This is a wonderful opportunity to accumulate a substantial retirement nest egg with a low level of risk. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

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

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.

WACO PEDIATRIC DENTAL PRACTICE — SALE: Well-established practice with moderate revenues and high profit margin on 4 days per week.

Limited competition and a large facility.

Ample room to grow in this community that is home to Baylor University. 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.

798

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

ASSOCIATESHIPS: EAST TEXAS GENERAL DENTAL PRACTICE — Small but busy practice generating mid-range revenues on 4 days per week. Located in quaint small town with excellent access to forests and lakes for hunting, fishing, and boating. Excellent opportunity for dentists looking ahead to separation from the military. Pre-determined buy-in terms. SOUTH CENTRAL TEXAS PERIODONTAL — Wonderful practice completing periodontal treatment seeks long-term associate who desires to be a partner within 1-2 years. Great location with strong new patient flow. Pre-determined purchase and partnership terms.

Wonderful mentor looking for an “equally-yoked” individual. Excellent staff.

SAN ANTONIO PERIODONTAL AND ENDODONTIST ASSOCIATESHIPS — Periodontal associateship with pre-determined buy-in for very active, multioffice periodontal practice. Endodontist associate also needed in this practice.

Outstanding mentor and cohesive staff.

If you are the right person, this is an outstanding opportunity. DWF METROPLEX AND ORAL AND MAXILLOFACIAL SURGERY — Parkland trained surgeon seeking an “equally yoked” associate desiring to acquire the entirety of his practice within the next 3-5 years. Wellestablished practice enjoying 2008 revenues exceeding seven figures from two locations. Wonderful opportunity for a resident who has recently completed their program and who wish to transition into practice ownership. You could not find a superior partner. Contact The Hindley Group, LLC, at (800) 856-1955.

Visit us at www.thehindleygroup.com.

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

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

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

EAST TEXAS AREA — Two general dentistry practices and one pedo practice.

WEST TEXAS — Three general dentistry practices (El Paso and West Texas).

NEW MEXICO — Two general dentistry practices (Sante Fe, Albuquerque).

For more information and current listings, please visit our website at www. adstexas.com or call ADS Watson, Brown & Associates at (469) 222-3200.

SAN ANGELO: For sale — general practice, 100 percent fee-for-service.

Well-established practice in a growing community of over 100,000. Excellent patient-to-dentist ratio; many dentists in community are nearing retirement so patient-to-dentist ratio expected to get even better. Five operatories — four equipped, fifth is plumbed and ready to equip. All operatories are computerized using Dentrix software. Highly productive practice with excellent collections.

Staff is young, friendly, energetic and loyal with excellent clinical and managerial skills. Continued growth each year with minimal advertising, low overhead. Full-time CDT in office produces crown and bridge as well as removable

prosthodontics. All lab equipment included with practice. Owner moving out of state; priced to sell. Please inquire by e-mail at sanangelodds@hotmail.com.

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 X-rays, and intraoral 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.

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’ Texas Dental Journal l www.tda.org l August

799

g

in s i t r e dv

A

Briefs

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

SUGAR CREEK / SUGAR LAND: General dentist looking for periodontist, endo, ortho specialist to lease or sell.

Suite is 1,500 sq. ft. with four fullyequipped treatment rooms, lab, business office, telephone system, computers, reception and playroom; 5 days per week. If seriously interested, please call (281) 342-6565.

TOP OF THE HILL COUNTRY GENERAL PRACTICE FOR SALE. Beautiful free-standing 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 is the opportunity you’ve been looking for. Call (254) 6753518 or e-mail dnicholsdds@earthlink. net.

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-forservice, 100 percent quality-oriented practice looking for a quality oriented

800

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

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.

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 five figures per week. No administrative responsibilities. Call (702) 510-7795 or e-mail drartbejarano@gmail.com.

DALLAS / FT. 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 50 offices have its own, individual name. Our latest office to open is Park Lakes Dental Care in Humble. All our offices have top-of-the-line Pelton and Crane equipment, digital X-rays, and intra-oral cameras. We are 100 percent FFS with some PPO plans. We offer competitive salaries, benefits, and equity buy-in opportunities. To learn more about working for Dental One, please call Rich Nicely at (972) 755-0836.

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.

HOUSTON: General dentist with pediatric experience needed. Full-time posi-

tion available. Excellent compensation.

Please send CV to cvanalfen@yahoo. com.

ASSOCIATE FOR TYLER GENERAL DENTISTRY PRACTICE: Well-established general dentist in Tyler with 30+ years experience seeks a caring and motivated associate for his busy practice. This practice provides exceptional dental care for the entire family.

The professional staff allows a doctor to focus on the needs of their patients.

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

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

HOUSTON: Retiring dentist is seeking his successor. Located in the Heights area of Houston, this two operatory practice consistently generates revenue in the low six figures because the owner wanted it that way. Whatâ&#x20AC;&#x2122;s really remarkable about this practice is the number of active patients. A maintenance practice like this will usually have a high active patient count but relatively low revenue, which makes this acquisition a dream come true for the dentist that appreciates value and growth. The potential for this practice will only be limited by you, so open your mind and let your eyes see. Inquire to practiceinfo@comcast.net.

ASSOCIATE NEEDED FOR NURSING HOME DENTAL PRACTICE. This is a non-traditional practice dedicated to delivering care onsite to residents of long term care facilities. This practice is centered in Austin but visits homes in the central Texas area. Portable and mobile equipment and facilities are used, as well as some fixed office visits.

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

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

PEDIATRIC DENTIST: Pediatric Dental Wellness is growing and needs a dynamic 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 willing 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 fastpaced working environment in a busy pediatric practice. We are willing to Texas Dental Journal l www.tda.org l August

801

g

in s i t r e dv

A

Briefs

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

Please e-mail CV to allenpl2345@yahoo. com.

SOUTHWEST FT. WORTH â&#x20AC;&#x201D; 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 immediately 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 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.

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

802

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

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. Email CV to Dr. Mike Kesner, drkesner@ madeyasmile.com.

SEEKING ASSOCIATE DENTISTS. Dental Republic is a well-established general dental practice with various successful locations throughout the Dallas Metroplex. A brand new state-ofthe-art facility in a bustling location will be opening soon. Join our outstanding and professional team in creating beautiful healthy smiles for all. Let us give you the opportunity to enhance your professional career with excellent hours, competitive salary/benefits, and by forming long-lasting friendships with our patients and staff members. Please contact Phong at (214) 466-8450 or email CV to phong@dentalrepublic.com.

CARE FOR KIDS, A PEDIATRIC FOCUSED PRACTICE, is opening new practices in the San Antonio and Houston area. We are looking for energetic full-time general dentists and pediatric dentists to join our team. We offer a comprehensive compensation and benefits package including medical, life, long- and short-term disability insurance, flexible spending, and 401(K) with employer contribution. New graduates and dentists with experience are welcome. Be a part of our outstanding team, providing care for Texasâ&#x20AC;&#x2122; kids.

Please contact Anna Robinson at (913) 322-1447; e-mail: arobinson@amdpi. com; FAX: (913) 322-1459.

THRIVING PRACTICE IN GALVESTON providing the best of both worlds ... the great outdoors and a laid back lifestyle, yet quick access to metropolitan

Houston. This 15-year-old practice has three fully equipped operatories, private office, full-time hygienist, and a great staff. Ownership of free-standing building is available. Generating mid-six figure gross collections on only 3 days per week. Earn a six-figure income as the owner of one of the most well-known, well-respected practices in Galveston.

Owner currently splits time with out-oftown practice and must sell. Call Jim Dunn at (800) 930-8017.

LUBBOCK â&#x20AC;&#x201D; GENERAL PRACTICE: Associate/partner. Growing group practice is looking for a motivated, longterm, career-minded dentist to provide quality care for our established and tremendous number of new patients.

Experienced or new grad welcome. Contact at dentist.lubbock@gmail.com.

HOUSTON MEDICAL CENTER GENERAL PRACTICE: Practice dentistry the way you have always dreamed! Incredible opportunity for general dentist to work as an associate and transition to partnership in this prestigious Texas Medical Center/Houston, four general dentists, LLP practice. Doctor retiring in 2-4 years after a 40+-year career, and will stay for introductions and successful transition of a new dentist. Large number of loyal patients in recare. The office, located in Smith Tower of The Methodist Hospital, is convenient to the West University, Bellaire, River Oaks, and Mid-Town neighborhoods and is the beneficiary of referrals from physicians practicing in the Medical Center.

State-of-the-art clinical and business systems throughout, including professional management, contemporary equipment, and an in-house dental laboratory staffed by three talented lab techs. See our website, www. ddsassociates.com, for more informa-

tion, and direct any inquires to Ms. Sanders or Ms. Manovich at (713) 7970846.

HILL COUNTRY AUSTIN AREA: This is an exceptional opportunity for a general dentist to share a beautiful new office building in the Lakeway area; 3,250 sq. ft., seven ops, paperless, three existing staff members. Minimum investment for a start-up/finish out two to four ops and personal office. Sub-lease space for satellite location. Relocate your existing practice for more space. Great opportunity for a general dentist who surgically places implants. Opportunity to become a partner. Location pictures are available. Call Sherri, (972) 562-1072 or (214) 697-6152.

DENTIST FOR JCAHO-ACCREDITED COMMUNITY HEALTH CENTER IN SOUTH TEXAS. Texas license or eligible. Full-time or part-time. Competitive compensation package, and great working hours. Contact Nuestra Clinica del Valle, PO Box 1689, Pharr, TX 78577; Phone: (956) 787-8915; FAX: (956) 7872021; E-mail: hchcc@hiline.net. EOE. 6 DAY DENTAL & ORTHODONTICS is an established group practice model, providing all dental services to our patients under one roof. Our general dentists and specialists work together to provide the most convenient and quality dental care possible. We have a 25 percent earned equity (no money down) opportunity for a general dentist to prosthodontist. Contact Dr. John Bond at jbond@6daydental.com and Jody Hardy at jhardy@6daydental.com.

SAN ANGELO, ABILENE: Associates â&#x20AC;&#x201D; outstanding earnings. Historically proven at over twice the national average for general dentists; future potenTexas Dental Journal l www.tda.org l August

803

g

in s i t r e dv

A

Briefs

tial even greater. Thriving, established practice in great location. Bright and spacious facility. Experienced, efficient, loyal staff. Best of all worlds; big city, earnings, small-town easy lifestyle, outstanding outdoor recreation. Contact Dr. John Goodman at john@goodman. net or (325) 277-7774.

EXPERIENCED DENTIST IS NEEDED FOR AN ESTABLISHED PRIVATE GROUP PRACTICE located in Katy.

General dentistry practice with a comfortable and friendly atmosphere without administrative responsibilities. Full- and part-time positions with competitive compensation, benefits, and flexible schedule. Great opportunity for a quality oriented person. Please call Dr. Akerman at (832) 934-2044 or email at yourhappydentist@aol.com.

BUSY PRACTICE SEEKING ASSOCIATE/PARTNER close to Texas Panhandle in Northwest Oklahoma. Seven ops, Cerec, digital Schick, Casey lasers.

Seven figures production in 2009.

Call (580) 938-2566 or e-mail kabdds@ hotmail.com.

ARLINGTON ORAL SURGERY PRACTICE — SALE: Oral and maxillofacial practice for sale in Arlington. It is located in a three unit professional office building and has two other dentists and an orthodontist. The building and office interior are very attractive and situated in a good area with a large referral base locally and the DFW area. This would be a good opportunity if you are seriously considering purchasing your own practice at an attractive price. If you would like any further information, call (817) 917-4536 or e-mail at aosapa2010@gmail.com.

804

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

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) 3264098.

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.

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.

ALLEN — 1,885 SQ. FT. DENTAL OFFICE available September 2010. High traffic visibility with lots of parking. Established dentist. Five treatment rooms plumbed and ready; reception, office, conference room, two bath. Alien is one of the top five growing cities in Texas.

Affluent residential, average income $98,500 within 3-miles. Contact Levin Reality, (323) 954-1934.

ROUND ROCK — DENTAL SPACE AVAILABLE FOR LEASE: 323 Lake Creek, 2,032 sq. ft. Lease rate is $18 PSF + $6.50. PSF NNN. Existing air

lines and plumbing. Call Darren Quick, (512) 255-3000.

BUILT-OUT DENTAL OFFICE SPACE FOR LEASE in Northwest Houston close to 1-45 and FM 1960; 2,527 sq. ft. and 4,357 sw. ft. available. Across street from elementary school opening in August. Jay, (713) 304-0033, jsurles@cbcingram.com.

TURNKEY, FULLY-EQUIPPED DENTAL OFFICE OPPORTUNITY FOR LEASE IN KATY: Modern 2,400 sq. ft., six operatory refurbished office now available. Call (281) 414-8870 or e-mail rwhdds@sbcglobal.net for more information.

INGLESIDE DENTAL BUILDING FOR SALE! 1,700 sq. ft., two chairs plumbed. Rental side, near Corpus Christi. Busy main street location.

Vacant, no equipment. Landscaping, parking, owner/dentist, $124,900; financing, photographs. E-mail mbtex@ aol.com or call (702) 480-2236.

ROUND ROCK — ORTHODONTIST SPACE FOR LEASE: On IH-35, between FM 620 and Hwy. 79. Call Darren Quick, (512) 255-3000.

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.

Interim Services TEMPORARY PROFESSIONAL COVERAGE (Locum Tenens): Let one of our

distinguished docs keep your overhead covered, your revenue-flow open wide, your staff busy, your patients treated and booked for recall, all for a flat daily rate not a percent of production. Nation’s largest, most distinguished team.

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 DOCTORSCHOICEGOLDEXCHANGE. COM: Try our high prices for dental scrap. Check sent 24 hours after you approve our quote. See why we have so many repeat customers. Visit www.

DoctorsChoiceGoldExchange.com.

STATE FAIR OF TEXAS, DALLAS: Texas licensed dentists needed to visit with public during Texas State Fair in Dallas, September 24 through October 17. Have an enjoyable time and earn money, too. Work as many or few hours as you wish: days, evenings, weekends, or weekdays. Contact Dr. Duane Taylor at (214) 330-7771, ext. 109.

Texas Dental Journal l www.tda.org l August

805

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

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

806

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

Better Freedom-of-Choice, No-Network Dental Insurance for your Patients!

NOW

 Immediate Preventative (up to $100, Twice Yearly)  Immediate Basic and/or Major (at 50% of Fee Schedule)  12 Months and Longer = 100% of Fee Schedule!

New Features as of Sept. 1** 

  

 

Three affordable and convenient plans to choose from: Basic, Intermediate, and Plus.

Rates from: $15/month/adult; $42/family (Level I) No underwriting; it’s easy to apply.

Benefits available immediately: the day after coverage is purchased.

Immediate wellness benefits (all plans) In-house claims administration and customer service. No thirdparty administrators.

Assurant Health fee-for-service plans continue to offer coverage that’s:   

For more information Learn how you can share this information with your patients. Contact Mark Deschenes at:

Guaranteed issue Guaranteed renewable Portable. Patients can visit any dentist. No network restrictions

(888) 350-2416

The plans also continue to provide benefit-payment choice.

Payment can be sent directly to the insured, or to insured’s provider

NO Precertification, Narratives or X-Rays Needed!

Type of Coverage

Includes

Basic Plan (Level I)

Intermediate Plan (Level II)

Plus Plan (Level III)

Preventative (2 visits/year)

Preventative care, cleanings, X-rays

$75 per visit

$100 per visit

$100 per visit

Basic Services

Fillings, Tooth Extractions

$25 - $200 Based on procedure

$50 - $400 Based on procedure

$50 - $400 Based on procedure

Major Services

Crowns, root canals, oral surgery

None

None

$20 - $1,000 Based on procedure

$500

$1,000

$1,500*

$1500*

*Maximum for combined basic and major services **New plans available in states where approved. Dental Insurance from Assurant Health. Assurant Health is the brand name for products underwritten and issued by Time Insurance Company.

Texas Dental Journal l www.tda.org l August

807

Did you know that TDA members could save up to $327.96 or more a year on auto insurance?

You may already know that you can enjoy competitive auto insurance rates and special money-saving discounts through the Liberty Mutual Advantage® program.* But did you know that Liberty Mutual offers many other discounts on both auto and home insurance?* In fact, you could save hundreds of dollars a year on auto insurance alone. And you could save even more by insuring your home, as well.

AUTO

Contact us for your FREE no-obligation quote: • Call 1-800-524-9400 and mention client #110024 • Go to www.libertymutual.com/tda

HOME

• Or visit a Liberty Mutual office near you

*Discounts and savings are available where state laws and regulations allow, and may vary by state. Certain discounts apply to specific coverages only. **Figure based on a February 2008 sample of auto policyholder savings when comparing their former premium with those of the Liberty Mutual Advantage program. Individual premiums and savings will vary. Coverage provided and underwritten by Liberty County Mutual Insurance Company and its affiliates, 2100 Walnut Hill Lane, Irving, TX. A consumer report from a consumer reporting agency and/or a motor vehicle report, on all drivers listed on your policy, Journal l www.tda.org may be obtained whereTexas stateDental laws and regulations allow. l August 2010 © 2009 Liberty Mutual Insurance Company. All Rights Reserved.

808