June 2010

June 2010

Journal TEXAS DENTAL

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

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Contents

TEXAS DENTAL JOURNAL n Established February 1883 n Vol. 127, Number 6, June 2010

NOTICES

559

ADA Appointive/Elective Positions

ARTICLES

Addresses to the Texas Dental Association House of Delegates:

562 Outgoing President’s Address,

May 6, 2010

Matthew B. Roberts, D.D.S.

568 American Dental Association 15th District

Trustee’s Address, May 6, 2010 S. Jerry Long, D.D.S.

576 Incoming President’s Address,

May 9, 2010

Ronald L. Rhea, D.D.S.

583 El Paso Dental Conference

The 48th Annual El Paso Dental Conference will be September 23-24, 2010, at the El Paso Convention Center in El Paso, Texas.

589 Smokeless Tobacco: Challenges, Products, and Cessation

K. Vendrell Rankin, D.D.S., C.T.T.S.; Daniel L. Jones, Ph.D., D.D.S.; Elain Benton, R.D.H., B.S., C.T.T.S.

The authors weigh the risks of smokeless tobacco and compare the various products

on the market.

599 Orthognathic Correction of a Craniofacial Deformity in a

Patient with a Mutilated Dentition: A Case Report

The authors present a case report of a patient who underwent orthognathic surgery to repair a craniofacial deformity.

Jason N. Stamboulieh, D.D.S.; Jack M. Neagle, D.D.S.; Roger Throndson, D.D.S.

ACKNOWLEDGEMENT

In the April 2010 Issue of the Texas Dental Journal, the authors of “Removable Partial Dentures — Treatment Now and for the Future” would like to express sincere appreciation for the contributions of Dr. David Bohnenkamp to the article and acknowledge his photographs Figures 3 and 4 on page 368. We regret this acknowledgement was not incorporated within the article.

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MONTHLY FEATURES

552 556 558

The View From Austin

605 606 608 610 613 614

What’s on tda.org?

616 630

Advertising Briefs

BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION

Letter to the Editor Guest Editorial, Dr. Kurt Loveless, Chair, TDA Smiles Foundation Board of Trustees

Oral and Maxillofacial Pathology Case of the Month Value for Your Profession Calendar of Events In Memoriam / TDA Smiles Foundation Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management

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.

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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

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Texas Texas DentalTexas Journal l Journal www.tda.org l June 2010 Dental l May 2009 Dental Journal l February

551 403 139

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

“Grandpa, your cell phone is a fourth grade phone; you can’t get e-mails, see your Google calendar, or actually hear incoming phone calls well.”

My teenage granddaughter has been after me to buy a smart phone for about a year, and I did finally upgrade to an iPhone a few weeks ago. She has been busy downloading “apps” to bring me up to date.

Seems backwards that the young people are teaching the older ones amongst us how to function in today’s high-tech environment. Being behind in technology is perhaps a symptom of being a senior, but at least I am not alone. At a recent Board of Directors meeting in Austin, a lunch-and-learn session was held by TDA staff to teach the older ones of us how set up and use Facebook. They have also done a wonderful job on our website and it hosts Facebook, LinkedIN, and Twitter communication options.

Keeping in touch with one another is so essential in these times of turmoil in healthcare delivery. The website, newsletter, and journal are our means of dissemination of news and new clinical science.

The explosion of new scientific information contributes to the difficulty

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for practitioners to keep up with current developments. One estimate states that clinicians would need to read six journals per week, 52 weeks per year to keep up with published randomized clinical trials, an almost impossible task for the busy healthcare worker (1). Online access to systematic reviews done by experts relieves this obstacle and collections of these reviews such as those on the Cochrane Library have become very useful tools. One other interesting library of summaries is emergency medicine’s bestbets.org.

This collection was originated for emergency medicine physicians but has expanded to other areas and several dental subjects are listed.

I find it helpful as a general site for information about health care topics and that it is rapidly available. Just around the house, current first aid subjects can be helpful such as burns, trauma, and indications for antibiotics for dog or snake bites (especially in Texas).

The Texas Dental Journal has been available online since 2001, but the new EZ Flip format has been available since January 2010 and is accessed by 10 percent of TDA members each month. I am told this is a good start for online access when print journals offer online version

in addition to the traditional paper issues. The EZ Flip application lets the reader “flip” through the pages quickly or to skip to selected items.

Readers may also “click” on any display advertisement and be taken directly to the advertiser’s website or print any items of interest in the issue. Advertisers are also offered the option of online inclusion. It will be interesting to see how the online version of the Journal is used as time goes by. My guess is that as younger dentists come into the profession, utilization of the online version will increase. We plan to continue publishing both the online and print issues of the Journal indefinitely. Other dental editors in the country confirm that print journals continue to be well received and that they also plan to continue this practice. The TDA Today newsletter is also available on the TDA website.

Uh oh! Got to go. I am getting a text message from my granddaughter.

References 1. Niederman R, Chen L, Murzyn L, et al. Benchmarking the dental randomized controlled literature on MEDLINE. Evid Based Med. 2002; 3:5-9.

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

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

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

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

Home

Current Issues

Membership Info UPDATE PROFILE Change your home or office address, phone, fax or e-mail.

CONTACTS Member Directory TDA Contacts Components Personal Web Pages Dental Websites

Special Events

Peer Review Sign

Check out the TDA Express

Amalgam Fillings

Exhibits

HIPAA and TMPA info

Travel

How to Obtain an NPI

Contact Us

Internet Portal!

Course Now Available!!

Professional Recovery Network Medicaid

FEATURES

CHIP Dental

Calendar of Events

Recall - Firm Press Releases Dental Student Info

TDA Publications Member Discussion References Online Classifieds Job Placement Center

DENTAL STUDENT INFO

Educations

TDA 2009

TDA Dental Assistant PAY DUES Pay 2008 dues online.

Resources

General Info

To go to a specific page on an affiliate website, simply mouseover the website name and a menu will appear.

You can always get back to the homepage, by clicking on “Home” under each menu.

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

In Memoriam

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

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

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

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

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

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

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ARKANSAS INDIANA • IOWA • KENTUCKY • LOUISIANA • OHIO • OKLAHOMA • TEXAS 554 Texas• Dental Journal l www.tda.org l June 2010

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Letter to the Editor The Texas Dental Journal welcomes letters to the editor on the various manuscripts and articles published in the Journal. The ideas and comments expressed in the letters and responses herein are not endorsed by the Texas Dental Association and do not necessarily reflect the opinion of the Association.

Re: Tex Dent J; 127(3):295-300 Dear Editor: RE: Are Routine Sterilization Procedures Effective?”

After reading the article, it seemed unusual that so many files and burs could still harbor viable bacteria after wiping, placing them in the ultrasonic with a disinfectantcleaner then autoclaving.

Could there be something wrong with their procedure or equipment?

Did they use a biologic control?

Something seems out of line.

Microbiology labs and hospitals

routinely sterilize contaminated material. Why are dentists having difficulty with a few small instruments? What are they doing that dentists are not?

On the bright side, a single study is only presumptive. It needs to be corroborated by another identical study done by an independent researcher.

In their study, the specific kind of bacteria cultured was not identified. Only a gram stain was used and only a gram positive coccus was cultured. The author “identified” it as being consistant with a staphylo-

coccus morphology.

It seemed “curious” that, of all the micro-organisms in the mouth, that only a staphylococcus albus is cultured in labs, and is considered a contaminant, so it would be nice to know what the organism is on the gram stain.

The study was interesting; but I am not ready to concede that all dental offices are hopelessly trying to sterilize their instruments.

I’ll wait for another study.

Dear Dr. Speer: Thank you for your interest in

our article and your comments and questions. I will hopefully address those for you. This study was to investigate how ‘sterile’ multi-use items actually became when ‘sterilized’ in the usual fashion in our offices. As a hospital-based OMF surgeon, we have been told in recent years that certain items were ‘single use’ because the manufacturers couldn’t guarantee sterility following routine cleansing and sterilization.

So one of my residents conducted a project similar to this one except with various surgical instruments, drill points and saw blades in a hospital OR environment. The findings were somewhat similar to this study as

well. It seems that high quality steel instruments do not pose much difficulty to sterilize and stay sterile. But several drill points and other items that appeared more corroded to the naked eye after sterilization did not.

Our belief is that micro corrosion of the surface and etching of the metal provides crevices to house bacteria that may not be adequately eliminated even with strict sterilization protocol.

Remember in this study we did use a control — new unused instruments out of their unsterile packages that were then sterilized. These remained sterile and showed no growth in the broth. All sterilizers used were acceptable based on the biologic indicators testing.

Our goal was not to speciate the bacteria cultured but rather just to show that some items were not ‘sterile’ as we would presume them to be after routine sterilization procedures.

Personally I don’t feel this should alarm anyone; with all of the discussion of microbes and super bugs and ‘sterility’ that we hear about these days, this study may shed some light on the fact that the sense of security that we get from ‘sterilizing’ everything may not be as solidly founded as we think.

W. Braden Speer, D.D.S., M.S.D.

Archie Morrison, D.D.S., M.S., F.R.C.D. Assoc Prof OMF Surgery, Dalhousie University Halifax, Nova Scotia, Canada

Editor’s Comment: The article referred to above was originally published in the Journal of the Canadian Dental Assocation (JCDA, February 2009, Vol. 75, No.1). The Editor thanks Dr. John O’Keefe, Editor of the Journal of the Canadian Dental Association, for his assistance in obtaining the letter from Dr. Morrison.

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Guest Editorial Dr. Kurt Loveless, Chair, TDA Smiles Foundation Board of Trustees the texas Dental Association smiles Foundation (tDAsF) was formed 4 years ago from the merger of texas Dentists For Healthy smiles and the texas Dental Foundation. Both of these former organizations were born out of necessity, but as the texas Dental Association (tDA) grew, their initial purposes were also outgrown. today’s Foundation delivers a much better end-result organization, which is a hybrid of the prior groups’ missions and strengths — plus a little bit more.

Dr. Kurt Loveless

As we have evolved over these last 4 years, our role in the overall strategic plan of the tDA has also evolved. we are an important piece of the future of the tDA, providing access to care initiatives, invaluable opportunities for membership recruitment and retention, educational programs and finally, promotion of the positive image of texas dentists. i want to highlight each of these contributions in a series of guest editorials. Because, after all, the tDAsF is the tDA. This first article in this series of guest editorials will cover “Access to Care.” tDAsF is tackling this problem with our mission programs — texas Missions of Mercy (tMoM) and smiles on wheels — and our comprehensive care program for the aged and disabled, texas Donated Dental services (txDDs). All of the access to care initiatives of the tDAsF target those in texas who have no other means to take care of their dental needs, with tMoMs geared toward larger metropolitan areas and smiles on wheels aimed at rural underserved areas. lubbock is my home town, and we are in an area that has consistently been considered one of the underserved parts of our state. there are several counties nearby that do not have a dentist, and some that have just one or two serving an entire population. An enormously successful tMoM was held here last november, setting a record for the number of patients receiving care. the event spawned a movement in the local community to continue to provide services on an ongoing basis with dental offices providing charity care at community Health clinics of lubbock once or twice a year on Fridays. in the williamson county area (which is just north of Austin), there have been four

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TMOMs, with the fifth planned this month in Taylor.

The events have set the community on fire, resulting in the creation of a fully-staffed clinic for the underserved members of their population. The events have immediate results, but a lasting impact. To date, TMOM has visited a dozen cities for 20 events, and future visits are planned for Waco, Dallas, and Amarillo during the remainder of 2010 and 2011.

Smiles on Wheels is the youngest program of the TDASF funded through a grant from the Meadows Foundation. This dental mission is smaller, utilizing 10-12 chairs verses the 40-50 chairs typical for a TMOM. After already visiting Rockdale, Crockett, Los Fresnos, Mt. Pleasant, Atlanta (twice!), Marlin, Rocksprings, Mineral Wells, and Lampasas since the program’s inception in December 2008, we are planning more events in Goliad, Mason, Cactus, and Hondo before 2010 comes to a close. In Rocksprings (Edwards County), we were presented with a patient base from a population of 2,200 stretched over 2,100 square miles without a single dentist in the entire county. The nearest dental office was an 85-mile drive away! What a great way to show the generosity of our profession; taking the time out of our practices to travel to a town like Rocksprings and help their remote community.

Rounding out our access to care offerings is TXDDS, continuing as a cornerstone of the TDASF. Based on the National Foundation for Dentistry for the Handicapped’s system, TXDDS accepts applications from those over the age of 55 or with a permanent disability providing comprehensive, in-office care to those who have no other means. This program allows a personal relationship to be developed between the practitioner and patient as the treatment plan is completed, resulting in a rewarding experience for all those involved.

Access to care is certainly a real hot topic today, but I am encouraged by the support for our programs shown by the members of our association. I most certainly want to thank all of our supporters: dentists and dental students, hygienists and hygiene students, community volunteers and community leaders, those who give time and those who give money.

Without you we are but an idea … you are the hands and hearts of the Texas Dental Association Smiles Foundation.

Thank you, Kurt Loveless, D.D.S.

Notice:

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

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

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

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

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

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

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TDA Annual Session 2010 Dr. Matthew B. Roberts, President Outgoing President’s Address to the Texas Dental Association House of Delegates, May 6, 2010

Mr. speaker, tDA Board, House of Delegates, and distinguished guests. what an honor to stand before you this morning and bring this president’s message. My father often remarked, “if you don’t think time flies, sign a 90-day note.” Truer words were never spoken. one short, yes very short year ago, i was standing before you to lay out my thoughts about the future of dentistry and of our Texas Dental Association. How time does fly! With that passing of time came the successes and failures, the hopes and disappointments, but more importantly the continued commitment to the betterment of this great profession.

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As i traveled across this state these last 12 months, i made a promise to update you, the member, and do so with relevant and current information. i also promised myself that i would hold tightly to the two key guiding principles that i laid out before you last year. First, i believe in the sanctity of the dentist/patient relationship. the dentist must make the decisions on treatment needs and options that will best fit the desires of the public we serve. second, i believe that the diversity of this great state is one of its strengths, but that diversity must never be a reason for ill advised legislation or change that will weaken the quality of care we provide for our patients. i believe we have been successful in holding to those two principles this year.

Pictured are Dr. Debrah J. Worsham of Center, Rep. Charles L. Hopson (D-Jacksonville), House Committee on Public Health, and Dr. Matthew B. Roberts at the 2009 TDA Legislative Day in Austin.

shortly after taking over as president, your leadership, under the direction of Dr. rick Black, successfully passed our expanded function dental assistant’s bill, sB455. the help of two key legislators, Florence shapiro in the texas senate and chuck Hopson in the texas House, along with a very strong lobby team, ensured that the pitfalls that face all legislation did not derail this bill. i believe this legislative success sets the stage for future expansion of our assistant’s duties; however, only this House of Delegates can determine the scope and breadth that that expansion might take. in the coming days, you will consider resolutions that will make up the legislative agenda for the upcoming 82nd legislative session that begins next January. it is an ambitious agenda and i must caution that this will be a very difficult legislative year. The two overriding issues facing your elected officials are redistricting and

Drs. Steven T. Cutbirth of Waco, Matthew B. Roberts, and Larry W. Spradley of Keller attend the 2009 TDA Legislative Day at the Texas Capitol.

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Dr. Matthew B. Roberts, TDA Outgoing President

the budget shortfall. To even begin to appreciate the enormous complexity of passing legislation in times like these would take more words than I care to expend. Suffice it to say that your Council on Legislative and Regulatory Affairs (CLRA) will work until the last gavel falls to pass legislation this House deems appropriate.

During the 81st Legislative Session, Rep. Diane Patrick (R-Arlington) filed HB 2611 establishing an interim committee to study the advisability and feasibility of requiring dental examinations for public school students who are entering the first grade. Ultimately, the bill never received a hearing in the House Committee on Public Education yet Rep. Patrick intends to file the bill again during this next legislative session. CLRA and your Board of Directors reviewed the issue and have determined that the Texas Dental Association, if this House directs, should pursue legislation requiring a mandatory dental exam for children entering public school. Another bill from the 81st Legislative Session that is sure to be refiled requires dental support for a child under a court order — SB 1048. Senator Carlos Uresti (D-San Antonio) and Rep. Roberto Alonzo (D-Dallas) filed this legislation during the 81st Legislative Session. It would have required dental insurance to be included with health insurance in a child support order mandated in court. SB1048 passed the senate but failed to pass the house due to the late-session “chubbing” by democrats that killed many bills.

Perhaps no one issue has caused more anxiety for not only our member dentists, but also dentists across this country, than insurance fee limitations for non-

The TDA has policy in support of this legislation, and Senator Uresti’s office has indicated interest in again pursuing this legislation next session.

covered services.

Perhaps no one issue has caused more anxiety for not only our member dentists, but also dentists across this country, than insurance fee limitations for non-covered services. To date, 28 states have filed bills that, if passed, will prevent dental plans from capping non-covered services. However, those bills only affect state regulated insurance plans and do not affect insurance plans governed by the Employee Retirement Income Security Act — better known as ERISA — which exempts single employer self-funded plans from state laws, including state insurance laws. Self-funded plans are plans that pay health benefits for an employer’s own employees, rather than through insurance contracts. In February 2010, the Council on Dental Economics (CODE) reported to the TDA Board of Directors regarding resolution 49-2010-B concerning capping fees for non-covered services. In response to CODE’s report, your Board of Directors approved resolution 101-2010-B directing the TDA to “seek legislation and/or regulation prohibiting the inclusion of language in contracts with dentists that requires providers to restrict fees on services which are non-covered, or nullifying the requirement that they comply with such contract language.” With this House’s approval we will do just that this next session. It must be said, however,

To date, 28 states

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have filed bills that, if passed, will prevent dental plans from capping non-covered services.

that we have had with the texas state Board of Dental Examiners (tsBDE). without a doubt one major goal of this Association has always been to have open communication between the tsBDE and the tDA. this House of Delegates last year requested a stakeholders meeting between interested parties to discuss rules pertaining to Botox and Dermafillers. As presiding officer of the TSBDE, Dr. Bill Purifoy facilitated this request and helped clarify existing rules related to this subject. we will continue to work with the state Board on such vital issues as the unlicensed practice of dentistry and anesthesia rules that can and will impact our members.

Seventh District Dental Society president Dr. Stephen Wright of College Station presents Dr. Roberts with the district’s outgoing president’s gift, a Berretta Silver Pigeon II 12-gauge shotgun, at the 2010 TDA House of Delegates.

that if the texas legislature passes this legislation, it will affect only about one-third of the insurance plans in texas as some two-thirds are covered by ErisA laws and would require passage of federal legislation to be completely successful. there are several other potential legislative initiatives including a Medicaid deferred compensation proposal, a bill requiring that the oral Health Program be led by a texas licensed dentist, and a charitable dental license bill. As you can see, this is an aggressive legislative package and one that very well may see limited success during the 82nd legislative session.

Before leaving the legislative arena, i would be remiss if i did not mention the interaction

the budget crisis looming this biennium has the potential to cause a rollback of recently raised Medicaid provider fees. your Association will do all that it can to defend the rates that have not only benefited you the provider but have also led to an increase in the actual number of Medicaid providers. this previous fee increase has proven what we all knew and believed — with adequate fee structures comes increasing numbers of providers and that translates to more services for our most needy populations. so there you have it, an ambitious legislative agenda that needs your support for implementation and success. with your approval we will put in motion the strategy and make the contacts necessary to be winners in Austin next year. our councils and committees continue to work and produce results that give value to your dues dollars. one such bright spot in these challenging times is membership. our membership numbers were up this past year and i for one am grateful for the effort that the council on Membership and the Department of Member services & Administration has put forth. Another ongoing success story is this annual session. it continues to be a shining example of member value across many areas — from vendor support to world class speakers. From support for our allied organizations to revenue generated which helps keep your dues reasonable. once again, the council on Annual session and the council on Membership are two examples of organizational excellence at its best. i am extremely excited about the direction our communications committee is heading under the direction of Dr. Bill wathen of Dallas. with new focus and direction, he is working at putting together online continuing educational courses that will bring the texas Dental Association into the 21st century. our young dentists demand and utilize technology to a far higher degree than those of my generation. one critical way to recruit and retain this Texas Dental Journal l www.tda.org l June 2010

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TDA president Dr. Matthew B. Roberts discusses TDA’s strategic plan at the August 2008 strategic planning session in Austin.

valuable generation is through these technological advances. while speaking of technology i must mention our website and the online publication of the EZ Flip Texas Dental Journal. the ability for you, the member, to keep up with tDA happenings not only through this website but also on Facebook and twitter has never been easier. while i could talk for quite awhile about what has happened this past year, i will close by discussing what i believe could be the greatest threat and perhaps the greatest victory for organized dentistry in my lifetime. one year ago when i addressed this House, i talked about my graduation from dental school in 1981. the economy was in turmoil then. interest

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rates were in the 20 percent range. An uncertain future had each of us cautious about our chances of success. i said last year, “Here we are, 28 years later, still in a challenging economy facing increasing government regulation with others all about who want to practice our profession with little or no education. Protecting our ability to practice dentistry with the dentist in control, protecting our patients, educating future dentists, and increasing membership from the ever expanding diverse population are just a few of the pressing issues we must face and have answers for. while these may not be new challenges they are becoming more critical to each of us here today.” so what is this growing threat that i alluded to earlier? this

past year as i traveled, i told each component that the drumbeat you hear moving ever closer and closer was the encroachment by mid-level providers, or what many of us now call “nonprofessional providers.” this threat is very real and must be challenged head on. you no doubt have heard of the state strategy conference held in Austin during early March. let me bring this House up to date on not only why this meeting took place but also what may transpire going forward. Each year the American Dental Association (ADA) convenes what is called the ADA lobby conference. last December i attended this conference along with our outside lobby team, public affairs staff, and clrA chair Dr. rick Black. During the numerous states’ updates, one theme continually became apparent — non-professional providers had made a beachhead in many states and we should all be prepared for the same fate in our states. tDA lead lobbyist Dr. David sibley and lobbyists nora DelBosque and susan ross commented that this was the same news they had heard for the past several years. i was honestly quite shocked that there appeared to be no strategy to counter this movement and more shocked when told this train had left the station so get used to it. As Dr. Black and i connected with other attendees, it became apparent that we were not alone in our dismay. it seemed to

me, if strategy was to be developed and plans be made to stop non-professional providers, we must look within our own state and to other like-minded states for help. that realization of like-minded states defending state practice acts from those who want to perform dentistry without going to dental school was what set in motion the states strategy conference, now better known as the Austin Group. your texas Dental Association Board was approached and asked to support with money and staff the hosting of this event. i cannot tell you how proud i am of the work and effort that your staff played in making this conference a huge success. with the help of four core states — north carolina, Georgia, Delaware, and louisiana — an agenda was developed and 20 additional states were invited to convene. in early March, 50 representatives from 15 states arrived in Austin to discuss and develop strategy for dealing with non-professional providers. our group subsequently learned that many more states across this country want to be included in any future events. From this initial meeting, three policy statements were developed, and each state’s representative was asked to return to his or her respective trustee districts with these statements for study and possible action. while all three statements asked for action by the ADA, one in my opinion stands out above the rest. It specifically asks that current ADA policy be maintained and that irreversible procedures by anyone other than the dentist not be allowed. this very message was delivered just last month to the trustees, president, and president elect of the ADA. so what now? it is up to each ADA delegate to determine how loud they want this drumbeat to sound. this issue of irreversible procedures by non-professional providers in my mind will be what ultimately distinguishes us as a profession or as a trade. Each state must determine its own fate, but i submit to you that texas is ready, willing, and able to slam the door and silence the drumbeat of non-professional providers performing irreversible procedures.

you may ask how can i help? Dig deep and give to DEnPAc. Meet with and get to know personally your state representative and state senator. we can and must protect this profession for the citizens of texas and future generations of caring hard working dental professionals.

As my time draws to a close, i am reminded once again of these words spoken by teddy roosevelt: “it is the doer of deeds who actually counts in the battle for life, and not the man who looks on and says how the fight ought to be fought, without himself sharing the stress and the danger.” i am honored to have served with a Board that has lived these very words. they have waged the battles and fought the good fight on your behalf. To this House, thank you for this once-in-a-lifetime opportunity. And finally, to my wife, who lovingly spent many a quiet night alone while the business of this Association took precedence. thank you, nancy, and God bless the tDA.

Dr. Matthew B. Roberts gives his outgoing address to the 2010 House of Delegates in San Antonio.

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TDA Annual Session 2010

Dr. S. Jerry Long, ADA 15th District Trustee Address to the Texas Dental Association House of Delegates, May 6, 2010

this is my third 15th District trustee’s update to the tDA House of Delegates as i continue to serve out the third year of my 4-year term. And once again, it is a tremendous honor to represent the dentists of texas on the American Dental Association Board of trustees. since ADA President Dr. ron tankersley will be here saturday to update you on the activities of ADA…and there is much to talk about…i want to focus my presentation this year on three critical issues facing our profession as we enter the second decade of this millennium-membership, advocacy, and non-government thirdparty interference. the cooperation of the entire tripartite is critical in addressing these immediate challenges to our profession.

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2009 was the 150th anniversary of the world’s oldest and largest national dental organization, the American Dental Association(ADA). Because of my Trustee position during this celebration year, I have had the opportunity to participate in many activities celebrating ADA’s milestone birthday. And quite frankly, I learned more about this profession in 1 year than the previous 40 combined.

In the earliest years of our American colonies, there were no trained dentists and the barber/ surgeons performed their limited repertoire of services (extractions and more extractions)...that is, if they were not applying their surgical skills (mainly bloodletting) to cure our founding fathers of their ailments in the 1600’s. It was documented in the celebration coffee table book, “150 Years of the American Dental Association,” that the average colonist had a life expectancy of somewhere in their 30s, and their deaths could not have come soon enough, since most had lost their teeth during their 20s. Correspondence back to Europe by these early Americans documented the suffering and pain that resulted from dental maladies that were epidemic to the New World.

Every dentist in America should own a copy of this book. After reading the entire work, it became obvious to me that we are honored members of a very “new” profession, in that dentistry did not make many steps to even basic respectability, until the formation of the American Dental Association…just 150 years ago.

Once ADA was up and running, it only took 26 years for Harvard University to establish the first university-affiliated dental school.

For someone who’s been practicing as long as I have, it seems like yesterday!

ADA 15th District Trustee Dr. S. Jerry Long of Houston addresses the 2010 House of Delegates at TDA’s 140th annual session in San Antonio.

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“Evidence-based” history tells us: No ADA, No profession!

And to carry that analogy a step further: No Members, No ADA, No Profession!

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Membership is the “mother’s milk” of professional associations. Again…No Members, No ADA, No Profession! I can’t say that enough.

Here are some vital membership statistics that should be of great interest to TDA and your local components. Some good, and some discouraging: • ADA membership in 2009 increased by 42 total members.

• However, in the first decade of this millennium, ADA increased its total members by 11,670. There was a huge decline of total members in the last year of the decade.

• 80.5 percent of all specialists are members of ADA. • Only 54 percent of all Blacks, Hispanics, Asians, Native Americans, and women dentists are members. Diversity is our greatest asset and can be our worst enemy if we don’t get a handle on that vital issue.

• The segment of dentists that represents the greatest market share and loyalty in renewing their memberships, the Traditionalists and Baby Boomers, are in the process of retiring from

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the profession.

As would probably be expected, recent graduates dominate the largest group of new members. However, their total numbers are slightly below, or at best stable, when compared to previous years. Considering that there are more new graduates than ever, this means that ADA is attracting a smaller slice of a supersized pie!

In 2009, ADA market share among dentists fell from 70.4 percent to 69.1 percent. This number is a true indicator of political power of the ADA or TDA — just how influential we are. In my opinion, unless we truly dedicate our efforts to plowing back above 70 percent, our market share will steadily sink deeper into the 60+ percentile.

Caucasian males remain the most consistent group in joining and maintaining ADA membership.

And here’s a stat that should get the attention of every Texas dentist: When it comes to graduates of the three Texas dental schools in transitioning from complimentary ADA dues to partially paying dues members, the 2008 Texas graduates of the three Texas schools (our newest colleagues) ranked in the

bottom half of the other 53 US dental schools when it comes to their graduates sending in their first dues payment Of the three, UT San Antonio graduates headed the list with a conversion rate of 68.2 percent, Baylor 63.5 percent, with UT Houston (UTHB) converting only 53.3 percent to full ADA membership. As a UTDB graduate, all I can say is: “Houston, we have a problem!”

In comparison, the University of Minnesota graduates converted 88.8 percent and Medical College of Georgia was 86.9 percent.

The challenges are clear, and the stakes are high. As you might expect, the membership numbers are weakest in the metropolitan areas, while many of the mid-range and small components routinely turn in market share numbers in the 80-90 percent ranges.

When it comes to membership, I have a simple solution that seems to come naturally to the rural areas and among the ethnic groups, but difficult for the large diverse societies: Offer dentists opportunities to work and socialize together because this profession works best when dentists are actually friends!

our fellow professionals as close personal friends, that competition will just naturally be elevated to its highest form — the professional level.

TDA president Dr. Matthew B. Roberts welcomes ADA 15th District trustee Dr. S. Jerry Long to the podium at the TDA House of Delegates in May 2010.

Dentistry in 2010 remains primarily a cottage industry.

Physicians interact with their colleagues on a daily basis at the hospitals. Attorneys have the courthouses as their meeting places. Most dentists must, however, make a conscious effort to make contact with their fellow professionals. I truly believe there are dentists throughout the United States who go months without any form of communication with one of their peers. Again using my home society as an example, there are monthly meetings when Greater Houston Dental Society has trouble attracting 100 dentists.

Think back to dental school with its many challenges and the stress that resulted from navigating that mine field known as dental education.

One of first thoughts that comes to mind is about the camaraderie that was so essential to the entire process. That camaraderie should be no less important to us today as practicing dentists.

As Americans, we necessarily work in a free enterprise system. Dentists must compete with their professional colleagues. But if we know and socialize with one another more often, actually counting some

Organized society gatherings with a very real social function should, in my opinion, be offered at every level of the profession. To quote a leading credit card company, “Membership has its rewards.” There is much at stake. Remember: No members, No ADA, No Profession!

That brings me to my second and third concerns: advocacy and third-party interferences.

At TDA, we have a Texas-size pride in DENPAC and our consistent successes in dealing with our elected officials. Up until now, political decisions affecting regulation of the profession, licensure, workforce, scope of practice, insurance companies, a myriad of other issues, and even dental education have primarily been made in Austin by the Texas Legislature. However, with the recent passage of the federal Healthcare Reform Act, the balance of power and influence made a meteoric shift away from Austin to Washington. Although 2014 is the “bewitching hour” for Texas Dental Journal l www.tda.org l June 2010

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Our president, Dr. Ron Tankersley, has often said that the ADA’s most important mission is to maintain the standards of the profession. From ethics to education to clinical decisions to regulation, no organization influences the public standing of our profession more than the American Dental Association. most of the implementation of the provisions of this bill, many changes will be felt from this year on.

God Bless the TDA! Our association never takes a lazy step when it comes to dealing with the state legislature. That cannot change. Unfortunately, the Constitutional authority that has traditionally limited the power of the federal government is being eroded more and more, and the influence of the feds is gradually usurping the power of individual states to regulate healthcare delivery within their jurisdictions.

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TDA must never let down its guard. But what we must realize is that the individual dentist has to also understand and appreciate the importance of the ADA, its Washington staff, and ADPAC to the future of our profession and businesses. If you are not an ADPAC donor, start today. Demand as much accountability from your ADA officers, delegates, and staff as you do from TDA officers and staff.

All four candidates for ADA President-elect will be here tomorrow at our Candidates Forum to ask for your support in their campaigns. Be there and listen! They are all dedi-

cated, hardworking dentists like you and I, and they are offering up their talents and energies for the opportunity to lead your profession. All four value the support of Texas dentists. Listen closely to their presentations, be respectful of their dedication and sacrifices, but ask them questions. ADA can afford nothing less than the best. These times are really critical for our profession and families.

As I mentioned earlier, Federal Healthcare Reform is now the law of the land. Dr. John Findley outlined in a letter to President Obama our Association’s needs and concerns that should be addressed by any new legislation. If ADA’s recommendations had been adopted, the Board was convinced that access to oral health care for most Americans would have been greatly improved — and all of our recommendations were consistent with ADA policy as established by our House of Delegates. Unfortunately, only one of ADA’s recommendations was included in the final bill, which resulted in the ADA not endorsing the President’s legislation. As far as I know, and for better or worse, the ADA is the largest healthcare organization that did not publicly support the final version of the Healthcare Reform Act.

I want to close with a story about my father that I have told before at a TDA Legislative Day, but I think it is very appropriate to illustrate the importance of the public debate on oral health care and how ADA’s legislative positions must mirror Association policy to the letter.

My father was a contractor from 1920 into the 1960’s and built private roads for oil companies during the East Texas oil boom, transitioned to the railroad, and finished his career building farm-to-market roads from Texarkana to Beaumont.

For the first 20 years of his career, he worked with mules and at one time owned more than 200 head of mules before transitioning to motorized power equipment. As you can imagine, Dad was a mule expert.

I remember as a boy, people coming by our house to talk with him about mules…even up to 1984 when he passed away.

I learned a lot about these animals by just being around him.

For instance, relative to the weight differentials of the two animals, mules are faster than horses, and in many cases, they can jump higher than most horses, no matter their large size. He always said that you should always build a little higher fence around a pasture where there are mules.

He also said that mules, despite their reputations of being stubborn, are extremely smart animals. That was hard to believe then, as it is now. But according to him, a horse can be trained to jump off a cliff even if it means its destruction, or even made to work until it collapses and dies if it was being driven to do so.

On the other hand, a mule will work or take direction from sun up until sundown — it’s truly a beast of burden. But if it gets tired or is put in a situation where it fears personal danger, a mule will stop in its tracks.

Yes mules can be stubborn, but only when it senses danger or its very existence is threatened. With that story, I think you’ll agree that “stubborn as a mule” takes on a whole new light.

The TDA and ADA have, over the years, been accused of being stubborn when it comes to our associations being “handcuffed” by House of Delegates policy when articulating their positions on all aspects of oral health care. Healthcare reform, mid-level providers, and irreversible procedures are issues that have been recent examples of outside interests labeling our associations of being “stubborn”.

In the past that criticism has come from members of special

interest groups, certain legislators, and third party payors.

But recently, several large foundations have mounted serious challenges to our core beliefs about the dental home, dentists as leaders of the team, and that irreversible and surgical procedures should only be performed by a doctor.

If the ADA and TDA Houses of Delegates refuse to alter policies or compromise many of the core values of the profession, it’s only because our governing bodies sense imminent dangers and threats to our profession.

Acting like a bunch of mules?

You bet!

Our president, Dr. Ron Tankersley, has often said that the ADA’s most important mission is to maintain the standards of the profession. From ethics to education to clinical decisions to regulation, no organization influences the public standing of our profession more than the American Dental Association.

And each piece of the tripartite is essential in maintaining the prestige, the power, the influence — and oh yes — the standards of our great profession.

And it all starts with you ... the individual member.

And by the way, don’t ever forget: No Members, No ADA, No Profession!

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TDA Annual Session 2010

Dr. Ronald L. Rhea, President-Elect Incoming President’s Address to the Texas Dental Association House of Delegates, May 9, 2010

Mr. speaker, tDA Board of Directors, House of Delegates, and distinguished guests. thank you for this great honor and this wonderful job you have allowed me to accept. in ancient china there was a saying: “May you live in interesting times.” it was intended as a curse. But sometimes the most difficult times are the most interesting and the most rewarding too. they challenge us, they test us, and occasionally they can even bring out the best in us. so the saying is truly as much a blessing as a curse. the times in which we are now living are nothing if not interesting.

For those things that are “interesting” to dentistry and the tDA, we have developed a strategic plan, the latest version of which is tDA 2014. i would like to discuss four of the areas of this plan, Access

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(L-R) Dr. Rhea’s family, May 2010: Anna Ayzenshtat, wife of son Darren Rhea, both of Austin, TX; wife Kay Rhea and Dr. Ron Rhea, both of Houston, TX; son Dr. Sean Rhea of San Francisco, CA, and New York City, NY, and Lucy Almers of New York City, NY.

to Oral Healthcare, Workforce, Advocacy and Public Image.

These goals are, as you might expect, greatly intertwined.

First let me remind you least there is even an outside chance you might have forgotten, “Dentistry is healthcare that works”. For many decades the dental profession in the United States has provided the highest quality of care in the world.

Throughout the world, Americans can be recognized by the brightness, beauty, and health of their smiles. Yet forces both within our profession and without are challenging the way

dental care is delivered and who will be allowed to deliver it in our nation. There are those who would have us adopt care delivery models of nations whose citizens have far poorer dental health than our citizens.

The driving force, indeed the battle cry of these groups is “Access to Care” or in our case, “Access to Oral Healthcare”. Yet no two of these groups agree on what “Access to Care” means.

All would agree, however, that poverty and geography are involved.

Certainly, there are people in Texas that, through no fault of their own, are truly indigent. According to the Texas Education Agency, for the 2008-09 school year, 56.6 percent of all Texas school aged children were economically disadvantaged.

As for geography, we all know, Texas is a very vast state. If you drive from Orange, Texas, to El Paso you are more than half way to Los Angeles! You might drive for miles in some areas and find no one living.

The Texas Department of State Health Services tells us that by Texas Dental Journal l www.tda.org l June 2010

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Dr. Ronald L. Rhea, TDA President-Elect

2011, seven counties of the 254 in Texas will still have less than 1,000 residents. One county will have only 65 residents! We are challenged to make dental care readily available to these people. If your nearest neighbor is 15 miles away, is it reasonable to demand that he will be a dentist?

Nevertheless, from these realities of indigence and geography emerges the concept of Access to Care. Organized dentistry has stepped up and accepted the challenge to provide this access. The TDA has made it one of our seven major goals.

We have worked diligently to enroll our members as Medicaid providers. Since 2006, the number of Texas active dental Medicaid providers increased 26.2 percent. As a result, Texas was third in the nation for the highest percentage of Medicaid eligible children who received care in 2009. Yet, we still demand that quality of care not be sacrificed on the altar of access to care. “One standard for all” remains our mantra!

The Texas Dental Association’s charitable foundation, the Smiles Foundation, is also involved in providing access. The Foundation’s Texas Mission of Mercy projects and our Smiles on Wheels projects in 2008 and 2009 saw almost 4,400 Tex-

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ans and delivered to them $2.1 million dollars worth of dental care. Through our members, TDASF’s Texas Donated Dental Services projects delivered another $1.35 million in dentistry to needy Texans. A grand total of almost $3.5 million in dental treatments in 2 years! Additionally, free clinics in many of our cities, staffed by TDA volunteers, delivered millions more in dental care for those in need.

Let’s give ourselves and our Smiles Foundation staff a hand!

During the last legislative session, a TDA sponsored-bill expanded the duties of our dental assistants so under direct supervision of a dentist, they might aid in delivering more quality care for Texans. We have passed loan repayment programs for young dentists burdened with debt from their professional school training, if they would agree to work in underserved areas for a period of time. And we have lobbied to increase funding for the public health system to establish stable treatment centers where most needed. The American Dental Association (ADA) is testing a model for an additional dental team member who would be trained from within an underserved area to address

the educational needs and encourage these populations to seek preventive care rather than only emergency services.

TDA 2014’s second goal, Workforce, is tied closely to Access to Oral Healthcare. Some entities from outside the practicing dental community would have us believe that Access to Care can only be improved by radical changes in Workforce. The PEW Foundation or the offshoot of sugary cereal for kids, the Kellogg Foundation, would redesign the dental profession and yet they have not a single practicing dentist on their boards. This is like redesigning the cockpit instrumentation of a 747 aircraft without getting the opinion of a pilot! A sure recipe for a crash!

These foundations would force the creation of what they term a “mid-level provider”. The term “mid-level provider” has been forced upon us from medicine where they exist as “nurse practitioners”, “physician’s assistants”, etc. These medical providers who are allowed to perform irreversible procedures, such as surgery, have the equivalent of a master’s degree-level of training.

The proposed dental version, however, the Dental Health Aid Therapist or DHAT, has no equivalent in medicine. These

technicians, which I choose to call “non-professional providers” would have a high school education and 20 months of vocational school training and be allowed to give local anesthetic injections, clean, drill and fill teeth and do extractions while under minimal or no supervision. Picture in your mind’s eye an overgrown teenager, coming at you with a scalpel in his hand! Or a dental drill!

Even within organized dentistry groups, individuals exist who would have us believe the “train has already left the station” and the trends toward nonprofessional providers cannot be changed. We in Texas do not accept this. Indeed, on March 5th and 6th, with approval and funding from the TDA Board of Directors, Texas hosted a conference of like-minded states in Austin. This conference of states, now known as The Austin Group, began to design strategies for dental care delivery which would maintain the dentist as the head of the dental team and the only one to perform irreversible surgical procedures. To maintain manageability the size of this conference was limited to 15 states, although requests could have easily have expanded it to 30 or 35 states.

…the Dental Health Aid Therapist or DHAT, has no equivalent in medicine. These technicians, which I choose to call “non-professional providers” would have a high school education and 20 months of vocational school training and be allowed to give local anesthetic injections, clean, drill, and fill teeth and do extractions while under minimal or no supervision. Picture in your mind’s eye an overgrown teenager, coming at you with a scalpel in his hand! Or a dental drill!

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Dr. Ronald L. Rhea, TDA President-Elect

Resolutions from The Austin Group will be presented to the ADA House of Delegates in Orlando in October that will, among other things, require the ADA to maintain its current policies that only a dentist is responsible for examination, evaluation, diagnosis, and development of the patient’s treatment plan, and only the dentist can perform irreversible procedures.

With hard work, we can get the ADA House of Delegates to pass these resolutions.

As a licensed profession we are controlled, indeed, allowed to exist by rule of our Texas Legislature and the enforcement body, the Texas State Board of Dental Examiners or TSBDE. The Access to Oral Healthcare goal, and the Workforce goals of the TDA and other aspects of practicing dentistry in Texas, can only be effectively addressed through Advocacy.

The Texas State Legislature is in session every 2 years for 140 days. The next session begins this coming January! It will be a very busy session in which redistricting and a probable revisiting of the voter ID legislation and a large budget deficit may impair the passage of any other legislation. Nevertheless, the Texas Dental Association

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…the TDA’s Council on Legislative and Regulatory affairs must expect to face challenges from those who would alter the very successful dental care delivery model in Texas. We will be ready!

will have an agenda to expand the jurisdiction of the Texas State Board of Dental Examiners to cover those individuals who practice dentistry without a license at make-shift offices along the Texas border and at a kiosk in a mall near you.

Secondly, we will propose legislation to prohibit insurance companies from setting fees for procedures which they do not cover. And finally, the TDA’s Council on Legislative and Regulatory affairs must expect to face challenges from those who would alter the very successful dental care delivery model in Texas. We will be ready!

Lastly, this year we will address the goal of Public Image. When our members are asked what service they would most like for the TDA to perform for them, promotion of the public image of dentistry usually tops the

list. Dr. Matt Roberts has appointed, and I will re-appoint, a task force to research public relationship firms with a view toward using electronic media such as Facebook and Twitter to enhance the already robust public image of dentistry and TDA dentists.

By working toward these goals that the Texas Dental Association has established, dentistry in Texas will remain “Healthcare that Works!” The access to care problem cannot only be solved by institutionalized, corporate and public health care dentistry, nor must we sacrifice quality of care for quantity. We are dentists. We are the oral healthcare providers in Texas.

And with the help of our skilled and loyal staffs, we will provide!

I look forward to serving you and the people of Texas.

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On behalf of the El Paso District Dental Society, it is a pleasure to welcome the members of the Texas Dental Association to the 48th Annual El Paso Dental Conference, September 23 – 24, 2010, at the El Paso Convention Center.

Surrounded by the Chihuahuan Desert, El Paso is situated in the westernmost corner of the state. The only major Texas city on Mountain Time, it’s flanked by the Rio Grande River and the Franklin Mountains that extend north into New Mexico.

When the conference is over, make a short trip to our neighboring state to participate in the 6th Annual El Paso Dental Conference Charity Golf Tournament at the Santa Teresa Country Club in Santa Teresa, New Mexico, on September 25, 2010. Proceeds will benefit charities in the El Paso area.

Come see our lovely city and enjoy our sunny weather! Experience the hospitality of this unique area of Texas while partaking in the world-class CE offered at this year’s conference. For more information about the conference and the golf tournament, please visit www.elpasodentalconference.org or call Yoli Corella, (915) 540-1705.

Thomas Hilton, DMD, MS — September 23, 2010 (All Day) Composites: The Key to Success with Posterior Composites and Bridging the Gap — Adhesives Update Thursday, 8:30 a.m.-11:30 a.m., 1:30 p.m.-4:30 p.m.

Course Code: T01 • CE: 6 Hours

T01

584

The objective of this seminar is to update the attendee with the latest information on composite technology. Adhesive systems have undergone considerable changes in recent years. We will review how modern adhesive systems work, what the differences are among them, the advantages and disadvantages of the various systems, as well as how they should be used clinically. Practitioners are faced with a myriad of questions regarding light curing dental composites: 1) what should I be curing with? Halogen? LED? PAC? Laser? 2) How should I cure composites? High intensity? Low intensity? Ramp? Pulse-delay? 3) How long should I cure? 4) How should I maintain my light curing unit? This presentation will address these issues, review light curing principles, compare the advantages and disadvantages of different light-curing units, and provide clinical guidelines for light curing and curing unit maintenance.

Also to be discussed are the keys to success with posterior composites.

Intended Audience: Dentists, Hygienists, Dental Assistants

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

Kaneta R. Lott, DDS — September 23, 2010 (All Day) Pediatric Dentistry: Success and Profit: Understanding the Child Patient Thursday, 8:30 a.m.-11:30 a.m., 1:30 p.m.-4:30 p.m.

Course Code: T02 • CE: 6 Hours This lecture will explore, discuss, and teach techniques that you will use as soon as you return to your office. You will have a new appreciation for the dental health of children and be equipped with the knowledge to educate your patients and parents about pediatric dentistry. This knowledge will protect children from further pain and suffering.

Subsequently, you will enjoy the practice of dentistry for children and will see the profits of the office increase. This interactive lecture asks each person to bring with them a question regarding the treatment of children that they struggle with on a regular basis.

Those who do not bring a question will be given one when they enter the room. Together we will develop the appropriate responses. The participant will be able to: Learn to listen and know the appropriate responses to lower the parents and patients stress; develop a keen understanding of the verbal and non-verbal language of the child while staying connected; formulate a plan of action with the staff.

Intended Audience: Dentists, Hygienists, Dental Assistants

T02

Kathi Carlson, CDA — September 23, 2010 (All Day) Discovering Your Contribution — The Power of Appreciation Thursday, 8:30 a.m.-11:30 a.m., 1:30 p.m.-4:30 p.m.

Course Code: T03** • CE: 6 Hours (** non-technical course — may not qualify for State Board CE hours) The objective of this seminar is to help each member of the dental team understand, appreciate, and identify their talents and gifts they have to offer to themselves, the patients, and dentistry. Once we have identified within ourselves these talents and gifts, how can we use them to better the lives of our team mates and our patient’s wellbeing? A program like this can truly change the personal perspective of the dental team. It is a powerful and rewarding experience to be privileged with the life changing experiences we have within the walls of our dental practices. Please join us as we take this time to see who we really are.

Intended Audience: Dentists, Hygienists, Dental Assistants, Office Personnel

T03

Terry Tanaka, DDS — September 23, 2010 (All Day) Treatment Planning Guidelines for Restorative and Prosthodontic Problems Thursday, 8:30 a.m.-11:30 a.m., 1:30 p.m.-4:30 p.m.

Course Code: T04 • CE: 6 Hours Important diagnostic criteria for the restoration of everyday restorative problems will be presented in this interactive program that is critical to the success of all restorations. New guidelines will be presented on how age, gender, facial morphology, and oral habits affect the dentition and the overall well being of our patients. Dental assistants and dental hygienists will learn guidelines to identify who are the “high-risk patients,” the clenchers, the bruxers, the high-stress patients with muscle related malocclusions that are contributing to face pain and temporomandibular disorders, and the patients who will be more likely to fracture your new restorations and complain about your fees. In addition, videos on how to fabricate splints in your own office and how to adjust the splints in the mouth in 5 minutes will be presented. Come prepared with pen and paper, this is an “interactive workshop.”

Intended Audience: Dentists, Hygienists, Dental Assistants, Lab Technicians Texas Dental Journal l

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Richard Winter, DDS, MAGD — September 24, 2010 (All Day) Upgradeable Dentistry Friday, 8:30 a.m.-11:30 a.m., 1:30 p.m.-4:30 p.m.

Course Code: F01 • CE: 6 Hours

F01

This course is designed to teach the integration of many facets of modern dentistry into a program that will allow patients to accept ideal dentistry without objection.

The concept of Upgradeable Dentistry highlights the dynamic nature of dentistry as it relates to occlusal rehabilitation. Patients should be given treatment options with endpoints to be determined mutually. A patient cannot choose what is not presented.

Often a dentist will present only what they feel a patient will accept and can afford.

In today’s dental environment, patient retention and “Upgrading” can result in economic stability of the practice and greater patient satisfaction. Some topics include: Denture dentistry can be enjoyable and rewarding; step-by-step discussions of how to achieve accurate fitting; pain-free dentures; impressions, tooth selection, gorgeous smiles will be discussed; partial dentures are designed for long-term failure, would you want to wear these for 5 years or longer?; upgrade paths: overdentures, mini-implants, implant supported bridges.

Intended Audience: Dentists, Hygienists, Dental Assistants, Lab Technicians

C. Mark Nichols, DDS — September 24, 2010 (All Day) Oral Manifestations of HIV/AIDS and Current Treatment Modalities Friday, 8:30 a.m.-11:30 a.m., 1:30 p.m.-4:30 p.m.

Course Code: F02 • CE: 6 Hours

F02

586

Most AIDS-related opportunistic infections and neoplasms can present in the oral cavity, such as: candida, oral hairy leukoplakia, Kaposi’s sarcoma, lymphoma, and various bacterial, fungal, and viral infections. This course will describe the clinical characteristics for these lesions and the diagnostic methods utilized. Current treatment modalities for these lesions will be explored, including: CO2 laser ablation, surgical excision, intralesional injections (alpha interferon, cidofovir, dexamethasone, vinblastine sulfate), and other pharmacotherapeutics. Objectives: 1) To identify and describe HIV-related oral lesions; 2) To review diagnostic techniques: cytology, biopsy and empirical treatment; 3) To learn various treatment methods for these oral lesions and importance of post-treatment follow-up.

Intended Audience: Dentists, Hygienists, Dental Assistants, Lab Technicians

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

F03 Caldwell

Dimmitt

Feuille

C. Stephen Caldwell, DDS, Walter Dimmitt, DDS, and Frank Feuille V, DDS, MS — September 24, 2010 (All Day) Potpourri of Periodontal and Implant Surgery Friday, 8:30 a.m.-11:30 a.m., 1:30 p.m.-4:30 p.m.

Course Code: F03 • CE: 6 Hours This program will lead participants through a series of discussions on the exciting changes and advances in the treatment of periodontal disease and in the replacement of teeth with implant supported restorations. Understanding ideal applications of new technology today is critical for success in the use of these new methods in clinical practice. Topics will include visits to the subjects of diagnosis, bone grafting, implant breakthroughs, laser surgery, tissue grafting, and more.

Intended Audience: Dentists, Hygienists, Dental Assistants, Lab Technicians

Joy Millis, CSP — September 24, 2010 (All Day) Stimulating Practice Growth, Even In This Economy Friday, 8:30 a.m.-11:30 a.m., 1:30 p.m.-4:30 p.m.

Course Code: F04** • CE: 6 Hours (** non-technical course — may not qualify for State Board CE hours) In an exciting full-day program, Joy Millis will engage the entire team in creating a “Stimulus Plan” that could propel your practice into unprecedented growth. Joy will show you how to boost treatment acceptance by involving every member of the team in communicating the value of quality care and the urgency of receiving treatment. You will also learn how to get paid using Joy’s unsurpassed system for making financial arrangements — twelve critical steps that increase the likelihood that patients will pay for the value they receive, without insurance interfering with their decision about care. As a bonus, Joy will show you how to stimulate practice growth by tapping into your existing patient base. Could there be $7,200,000 hidden in your office waiting to be found? Joy will show you how to find, keep, and stop losing patients —reviving your spirit in dentistry!

Intended Audience: Dentists, Hygienists, Dental Assistants, Office Personnel

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Legal Representation for Texas Dentists

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

Attorney at Law

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

Not Certified by the Texas Board of Legal Specialization

www.legaldental.com

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

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Smokeless Tobacco: Challenges, Products and, Cessation K. Vendrell Rankin, D.D.S., C.T.T.S. Daniel L. Jones, Ph.D., D.D.S. Elain Benton, R.D.H., B.S., C.T.T.S.

Health Risks The primary carcinogens in smokeless tobacco (ST) are the tobacco-speciďŹ c N-nitrosamines. The Nnitrosamine content varies by a factor of 18 across brands. The primary target organ for smokeless tobacco-related cancer is the pancreas. Localized oral lesions are common in smokeless tobacco users and there is an increased risk for development of oral cancer. Users are also at increased risk for cancer of the larynx, stomach, and pancreas (1-3).

There is some evidence that ST users, particularly younger males, are at increased risk of fatal myocardial infarction (4).

Rankin

Jones

Benton

Dr. Rankin is a professor, associate chair, and director of Baylor Tobacco Treatment Services, Department of Public Health Sciences, Baylor College of Dentistry TAMHSC, Dallas, Texas Dr. Jones is a professor and chair, Department of Public Health Sciences, Baylor College of Dentistry TAMHSC, Dallas, Texas

Abstract Tobacco companies continue to develop and aggressively market new products for oral use. Most new products are intended to dissolve in the mouth and swallow rather than spit out the juices.

These products effectively circumvent smoke-free policies, decrease tobacco cessation efforts, and create individuals who use both smokeless tobacco (ST) and cigarettes.

All ST products contain nicotine, carcinogens, and pose multiple health risks. The cancer and health risks associated with ST use extend well beyond the changes in the oral cavity and the risk of oral cancer. Unlike cigarettes, the contents of ST vary widely by brand and product posing difďŹ culty in the use of the available pharmacotherapy for cessation. Although no uniform guidelines exist for the use of pharmacotherapy for smokeless tobacco cessation, research suggests that use of these drugs is effective. The most important motivator for quitting ST cessation remains in the hands of the dentist.

KEY WORDS:

smokeless tobacco, tobacco cessation Tex Dent J;127(6):589-94.

Ms. Elain Benton is an assistant professor and counselor at Baylor Tobacco Treatment Services, Department of Public Health Sciences, Baylor College of Dentistry TAMHSC, Dallas, Texas

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Smokeless Tobacco: Challenges, Products, and Cessation

The concept of reduced harm through the replacement of cigarette use with ST thwarts smoking cessation efforts and encourages All smokeless tobacco products contain nicotine, a potent addictive substance. Despite the more rapid delivery of nicotine from a cigarette, nicotine dependence in ST users is nonetheless equivalent to that of a cigarette (5). The availability of un-ionized (free) nicotine differs widely by brand posing a significant challenge for dosing nicotine replacement therapy in individuals ready to quit ST use. According to an extensive list compiled by the Massachusetts Department of Health, the percentage of free nicotine for 80 brands and sub-brands available in the U.S. ranges from 7.88 mg/g to 0.05 mg/g.

Some of the more common brands, Copenhagen速 fine cut

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and Grizzly速 fine cut contain 5.56 mg/gram and 6.42 mg/g of free nicotine, respectively (6).

The variation in nicotine available for absorption is largely a function of the differences in the size of the tobacco cuttings, moisture content and manipulation of the tobacco pH through ammonia technology.

According to reports, the intent is to attract youth with lower nicotine content brands with the expectation that they will progress to brands with higher nicotine content (7).

The wide variability in nicotine and carcinogen content across the various brands is exacerbated by aggressive marketing and the introduction of new

dual use of both products. The prevention of youth initiation, education of current users as well as effective strategies and medications for ST cessation all pose significant challenges for dental practitioners.

ST products. The concept of reduced harm through the replacement of cigarette use with ST thwarts smoking cessation efforts and encourages dual use of both products. The prevention of youth initiation, education of current users as well as effective strategies and medications for ST cessation all pose significant challenges for dental practitioners.

New ST Products The term “smokeless tobacco” has been used interchangeably with the term “spit tobacco”. A more appropriate term at this point in time might be oral or non-combustible tobacco. Tobacco companies continue to develop and aggressively market new products.

These products, as well as the traditional ST forms, are not

intended to reduce harm but to expand the tobacco market, circumvent smoke-free policies, decrease tobacco cessation efforts, and create dual use of ST and cigarettes.

One new products is generically referred to as snus, a form of oral tobacco predominately used in Sweden. Well known U.S. tobacco companies as well as several lesser-known companies currently produce and market snus in the U.S. (8,9).

Snus is available in a variety of flavors. New FDA regulations, which will ban the use of flavoring in cigarettes, do not prohibit flavorings in traditional ST or the emerging new forms. Because the tobacco in snus is pasteurized rather than fire-cured and is intended to be refrigerated, the nicotine and carcinogen concentration in traditional fire-cured ST increases over the time from production to consumption.

Snus is advertised as an alternative to cigarettes for use in situations where smoking is prohibited or restricted to select areas: ball games, bars, etc. The advertising for snus claims “No smoke, no guilt, no blame.” Other slogans state that snus is “Back-stage friendly, inning friendly, club friendly, work friendly.”

The newest additions to the ST market are intended to dissolve in the mouth, thereby avoiding the need to spit out the juices (10). As these products do contain tobacco, they should not be confused with nicotine replacement products used for tobacco cessation. They provide an easy way to conceal tobacco use in tobacco-free environments. This is of particular concern in youth, who can easily circumvent the restrictions on tobacco use on school property. A number of different nicotine delivery systems offer

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dissolvable products, including Orbs, Sticks and Strips, all of which are made with tobacco.

Strips (which resemble breath freshener strips) come in a package of 20 that are placed on the tongue and dissolve within 2 to 3 minutes.

Sticks that resemble toothpicks (10 sticks per package) can be placed in the mouth like a toothpick or broken into pieces that can be placed between the upper lip and gum. Sticks last between 20 and 30 minutes before dissolving completely. Orbs and similar candy-like products with a variety of names resemble a small mint and dissolve over a period of 30 to 45 minutes.

Marketing While a decline in cigarette advertising has been observed since the implementation of the Master Settlement Agreement, the same cannot be said for advertisement of ST products.

A full-page advertisement for one popular ST product states that on their 75th anniversary, the celebration is all about the consumer. The

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slogan for the campaign proclaims, “Dippers created a Brotherhood — Guys who share a love of quality dip, and we’re honored to be part of it.

2009 is the Year of the Dipper. So keep an eye out, and a pinch ready.”

The traditional association between ST and the sport of rodeo are reinforced by advertisements featuring Ty Murray, seven-time world champion all-around cowboy, who is quoted as saying, “The three priorities in my life are my horse, my rope, and my Copenhagen. I never walk when I can ride and I never ride without my Cope.” ST is also advertised as perfect for “road tripping, girlfriend listening, best-man being, airplane flying, and line waiting.” Current advertising campaigns are designed to capture a market beyond those not previously associated with ST use. Promotions suggest that ST is “Made for the great Indoors,” offering the satisfaction and convenience of nicotine whenever you want and wherever you go.

Images in ST advertising feature young males riding motorcycles, working construction and young men fishing, as well as lumberjacks, firefighters, and fishermen on the high sea. (Advertising images are archived at www.trinkets&trash.org).

Trends in Smokeless Smokeless Tobacco Tobacco Initiation and Use Cessation An average of 1.1 million persons in the US start using ST each year. In males aged 12 to 17, ST use increased significantly, from 3.4 percent to 4.4 percent, in the 5-year period 2002-07 (11).

Researchers have found that adolescent boys who use smokeless tobacco products are highly likely to become cigarette smokers within four years. After a number of years of decline in ST use in youth, this increase is troubling. Smokeless tobacco is also not a viable nicotine replacement therapy to help cigarette smokers quit. It is instead a “gateway drug” that can lead users to a lifetime of cigarette smoking (12).

Nearly half (47 percent) of ST users are former cigarette users. Some initiates of smokeless tobacco substitute ST for cigarettes as a way to quit smoking. Testimony to the failure of this approach to tobacco cessation is the 88.1 percent of smokers who initiated ST use but were using ST and still smoking daily 6 months later (13).

Nicotine Dependence in Smokeless Tobacco Nicotine from ST is absorbed more slowly through the oral mucosa than through inhalation of smoke. However, the blood level of nicotine in ST users is sustained for a longer period of time.

Withdrawal symptoms from ST use are similar to those associated with quitting smoking. The degree of withdrawal depends not only on the individual and the amount used per day but also the nicotine content of the brand of ST. The brands capable of delivering a large dose of nicotine are generally associated with more severe withdrawal symptoms and more challenging quit attempts.

Smokeless tobacco users who dip or chew 8 to 10 times a day may be exposed to the same amount of nicotine as persons who smoke 30 to 40 cigarettes a day (14). This variability in nicotine not only alters the perception of nicotine dependence by the user but also complicates treatment for cessation.

Assessing nicotine dependence in ST users continues to be problematic due to the variation in nicotine delivery across products and the absence of guidelines specific to ST cessation.

Ebbert, et al., 2006 described a scale that can be useful in assessing nicotine dependence in ST users, which mitigates some of the difficulty associated with rating ST brand nicotine content (15). The strongest measures of high nicotine dependence are related to: 1) using ST within 30 minutes of awakening; 2) intentionally swallowing the juice; 3) difficulty giving up use in the morning; and 4) more frequent use during the first hours of the day.

According to the 2008 update of Treating Tobacco Use and Dependence, sufficient evidencebased studies are not yet available to make definitive recommendations on the use of pharmacotherapy for ST cessation (16). However, preliminary studies have reported some success.

One randomized, placebo-controlled clinical trial concluded that the use of 42 mg/day nicotine patch therapy (two 21 mg nicotine patches) is safe and should be considered as initial therapy for individual who use ≥3 cans/week (17). The use of the 4 mg nicotine lozenge also appears promising for the clinical treatment of withdrawal symptoms and craving associated with tobacco abstinence in ST users (18). It has been suggested that placing the lozenge in the mouth where ST was traditionally held might be helpful. Bupropion SR (Zyban®) has not been found to significantly increase tobacco abstinence rates among ST users, but does significantly decrease craving and weight gain over the treatment period (19). Currently there are no studies describing their use of Chantix® for ST cessation.

What is abundantly clear is that oral health professionals play a major role in assisting ST users to quit. Studies have repeatedly demonstrated that the single most important factor in ST cessation is feedback on oral findings related to ST use (20). Cessation is likewise reinforced with the gradual resolution of ST related oral lesions.

Nicotine replacement therapy (nicotine patch, gum, lozenge) can be used to lessen nicotine Texas Dental Journal l www.tda.org l June 2010

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Smokeless Tobacco: Challenges, Products and Cessation withdrawal symptoms. the oral examination and follow-up can have a significant impact on smokeless tobacco quit rates.

The Culture of Spit Tobacco to experience the youth culture of spit tobacco, go to: www. youtube.com and search: “throw a D in ya lip.”

References 1.

2.

3.

4.

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Health Effects of smokeless tobacco Products Scientific Committee on Emerging and newly Identified Health Risks June 2007. us Department of Health and Human services. the health consequences of using smokeless tobacco: a report of the advisory committee to the surgeon General. Bethesda, Maryland: us Department of Health and Human services, Public Health service, 1986 world Health organization, international Agency for research on cancer, “smokeless tobacco and some Tobacco-specific Nnitrosamines. iArc Monographs on the Evaluation of carcinogenic risks to Humans 89(2007)”, http://monographs.iarc.fr/ EnG/Monographs/vol89/index. php, Accessed september 25, 2009. http://monographs.iarc. fr/EnG/Monographs/vol89/index.php teo, K. K., ounpuu, s., Hawken, s., Pandey, M. r., Valentin, V., Hunt, D., et al. (2006). tobacco use and risk of myocardial

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infarction in 52 countries in the intErHEArt study: A case-control study. lancet, 368, 647-658.

5. Richter P, Hodge K, Stanfill S, Zhang l, watson c. surveillance of moist snuff: total nicotine, moisture, pH, un-ionized nicotine, and tobacco-specific nitrosamines. nicotine tob res. 2008 nov;10(11):1645-52.

6. world Health organization, international Agency for research on cancer. (2007). smokeless tobacco and some tobacco-specific n-nitrosamines (iArc Monographs on the Evaluation of carcinogenic risks to Humans, Vol. 89). lyon, France pages 67-69.

7. Alpert, Hr, Koh H, connolly Gn, Free nicotine content and strategic marketing of moist snuff tobacco products in the united states: 2000-2006..

8. Adkins B, Anderson rH snus, a new oral smokeless tobacco. w V Med J. 2009 Jan-Feb;105(1):7 9. stepanov i, Jensen J, Hatsukami D, Hecht ss. new and traditional smokeless tobacco: comparison of toxicant and carcinogen levels. nicotine tob res. 2008 Dec;10(12):1773-82 10. new tobacco Product Alert Massachusetts Department of Public Health tobacco control Program (617) 624-5900 www.makesmokinghistory.org updated 3/6/09 11. substance Abuse and Mental Health services Administration, Office of Applied Studies. (February 19, 2009). the nsDuH report: smokeless tobacco use, initiation, and relationship to cigarette smoking: 2002 to 2007. rockville, MD. 12. s. tomar, “is use of smokeless tobacco a risk factor for cigarette smoking? the u.s. experience,” nicotine & tobacco research 5(4):561-569, August 2003.

13. H.H. severson, K.K. Forrester, and A. Biglan, “use of smokeless tobacco is a risk factor for cigarette smoking,” nicotine tob res. 2007 Dec;9(12):1331-7.

14. Determination of nicotine, pH, and Moisture content of six u.s. commercial Moist snuff Products -- Florida, January-February 1999 MMwr May 21, 1999 / 48(19);398-401.

15. Ebbert Jo, Patten cA, schroeder Dr. the Fagerström test for nicotine Dependence-smokeless tobacco (FtnD-st). Addict Behav. 2006 sep;31(9):1716-21.

Epub 2006 Jan 31 16. Fiore Mc, Jaen cr, Baker tB, et al. treating tobacco use and dependence: 2008 update. clinical practice guideline. rockville, MD: u.s. Department of Health and Human services, Public Health service; 2008.

17. Ebbert Jo, Post JA, Moyer tP, Dale lc, schroeder Dr, Hurt rD. nicotine percentage replacement among smokeless tobacco users with nicotine patch. Drug and Alcohol Dependence 89 (2007) 223–226.

18. Ebbert Jo, Dale lc, severson H, croghan it, rasmussen DF, schroeder Dr, Vander weg Mw, Hurt rD. nicotine lozenges for the treatment of smokeless tobacco use. nicotine tob res.

2007 Feb;9(2):233-40 19. Dale lc, Ebbert Jo, Glover ED, croghan it, schroeder Dr, severson HH, Hurt rD. Bupropion sr for the treatment of smokeless tobacco use. Drug Alcohol Depend. 2007 sep 6;90(1):56-63.

20. carr AB, Ebbert Jo. interventions for tobacco cessation in the dental setting. cochrane Database syst rev. 2006 Jan 25;(1):cD005084.

Is your team on the right path? Let us help you create a specific process that will guide you and your staff down the path you have chosen for your practice.

Dental Practice Specialists Growth and Transition Consulting Services helps dentists to grow, sell or buy practices with plans created just for your practice. Find out how our 33 years of experience and unique plans can benefit your practice.

Clyde C Dollens, DDS (281) 639-4703

Shepherd got consent? on TDA CD

texdentlaw.com Informed Consent Forms & Other Legal Forms for Texas Dentists from Boyd W. Shepherd, D.D.S., J.D.

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© 2007 Boyd W. Shepherd, P.C. – Boyd W. Shepherd, D.D.S., J.D. – Not Certified by the Texas Board of Legal Specialization

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

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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

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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

Orthognathic Correction of a Craniofacial Deformity in a Patient with a Mutilated Dentition: A Case Report Jason N. Stamboulieh, D.D.S., Jack M. Neagle, D.D.S., Roger Throndson, D.D.S.

Report of a Case our patient is a 24-year-old African-American female referred to the oral and maxillofacial surgery service by her prosthodontist for removal of her remaining carious dentition and to address her skeletal deformity in order to reconstruct a functioning occlusion. Her pre-extraction deformity was consistent with: 1) Anterior skeletal open bite; 2) Maxillary posterior alveolar hyperplasia; 3) Mandibular horizontal hyperplasia; 4) Mutilated dentition; and 5) unrealized low self-esteem. the patient was not aware of her deformity or reason as to why her teeth could not come together in a normal bite due to patient’s low dental iQ. this patient’s evaluation, preoperative planning, and surgical execution shows the close working relationship between surgeon

Stamboulieh

Neagle

Throndson

Dr. Stamboulieh is in private practice, Oral and Maxillofacial Surgery, PC, dba Legacy Oral and Maxillofacial Surgery, Frisco, Texas.

Dr. Neagle is in private practice, Oral and Maxillofacial Surgery, Conroe, Texas.

Dr. Throndson is Professor and Chief, Department of Surgery, Division of Oral and Maxillofacial Surgery, University of Texas Medical Branch, Galveston, Texas.

Address correspondence and reprint requests to Dr. Stamboulieh: Legacy Oral and Maxillofacial Surgery, 2500 Legacy Drive, Suite 230, Frisco, Texas 75034; email: drstamboulieh@legacyoralsurgery.com

Abstract

Orthognathic surgery is routinely performed for patients with dentofacial deformity and has been conducted for more than 100 years (1). Orthognathic Surgery is a functional and esthetic surgery that affects patients self perception. Patients have noted an improvement in their facial appearance after orthognathic surgery that was associated with improvement in psychosocial adjustments (2). When the decision to move both the maxilla and the mandible is made, there are numerous variables to be considered. Among these variables are the stability of double jaw surgery, improving the masticatory function of the patient and lastly, the esthetic result.

Past studies have also looked at patient concerns including temporomandibular joint symptoms, speech difficulties and problems with mastication. In one study by Rivera and colleagues who studied 143 patients pre-operatively found 71 pecent with esthetic concerns (3), 47 percent had functional concerns and 28 percent had temporomandibular joint concerns.

Traditional treatment planning for two-jaw surgery uses the condyle as the point of rotation with the mandibular occlusal plane being used as a template for setting the maxillary teeth (4). This approach, which allows clockwise and counterclockwise rotation of the mandible gives stable skeletal results. Recent studies appear to indicate that long term stability is achieved mainly when rigid fixation is employed.

Orthognathic surgery is only one part of the process to correct a dentofacial deformity.

The process starts with the initial diagnosis, followed by a treatment plan and then patient consent. Treatment generally begins with a dental assessment to correct decay, followed by orthodontic decompensation in preparation for surgical intervention. Orthognathic surgery is followed by postoperative orthodontia to maximize the occlusal relationship. This process underscores the skill and detailed communication between orthodontist and oral surgeon, and emphasizes the crucial aspect of team approach in such complex surgical cases.

We present here a report on a patient who had a mutilated dentition both in the maxilla and mandible along with a craniofacial deformity.

KEY WORDS: Orthognathic surgery mandibular prognathism, maxillary hypoplasia, gunning splints, apertognathia, meth mouth, cranial base of jaw anomaly.

Tex Dent J;127(6):599-603.

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Figure 1. Pretreatment radiograph and photograph documenting patient’s condition: A. Preoperative panoramic radiograph. B. Preoperative intraoral clinical photograph. and prosthodontist to achieve the desired esthetic and functional result. The patient had a negative review of systems and denied any medical problems.

The patient reported that her teeth have been “broken” for several years and she is ready

to “fix” them. After obtaining panoramic radiographs and intraoral photographs (Figure 1), the patient was consented for full mouth extraction and alveoloplasty for all four quadrants. A total of 12 months was allowed to elapse after the pa-

tient’s full mouth extraction before the patient returned to our service for surgical correction of her craniofacial deformity.

Edentulous intra and extraoral photographs along with a cephalometric radiograph were obtained (Figure 2).

Figure 2. Presurgical clinical photographs and radiographs documenting patient’s condition after full mouth extraction: A. Profile. B. Full face with incompetent lip closure.

C. Intraoral with edentulous ridges post full mouth extraction. D. Cephalometric radiograph documenting patient’s jaw to cranial base anomaly.

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Clinical measurements were obtained along with a cephalometric analysis. Careful interpretation of the clinical and cephalometric measurements revealed excess lower 1/3 facial height, excess upper lip length from subnasale to stomion, excessive interlabial distance of 7 mm, a protrusive chin, excessive lower lip support, deficient maxillary projection to cranial base, excessive mandibular anterior projection to cranial base, (ANB revealed a Class III facial profile) and a mandibular plane angle of 32 degrees indicating a high angle with vertical excess and open bite. The patient’s pre-operative clinical/cephalometric measurements and chief complaint, after careful interpretation, revealed a problem list of: anterior open bite (Apertognathia), inability to chew food, craniofacial deformity, maxillary hypoplasia, mandibular prognathism, and submucous palatal cleft. The surgical plan was as follows: Le Fort I maxillary advancement of 7mm, a bilateral sagittal split osteotomy for 7mm of mandibular setback, and complete maxillary and mandibular full coverage dentures.

Maxillary and mandibular models were made and a facebow transfer was used to mount the patient’s models on a Hanau articulator.

Maxillary and mandibular wax occlusion rims were made by the prosthodontist and were used to make a bite registration. These rims were later processed into acrylic and were used at the time of surgery as Gunning Splints to position the maxilla and mandible in relation to the cranial base (Figure 3). Intermediate and final jigs were fabricated of jet acrylic for aligning the Gunning splints when positioning the maxilla and mandible respectively. Intra-operative findings during the horizontal osteotomy of

Figure 3. Gunning splints that were used intra-operatively to position the maxilla and mandible.

Figure 4. Le Fort 1 osteotomy showing atrophic maxillary sinus wall and thin zygomatico-maxillary buttresses.

the maxilla revealed an atrophic maxillary anterior sinus wall and thin zygmaticomaxillary buttresses (Figure 4). The Synthes Craniofacial titanium rigid fixation system was used with four 5 hole L-plates to stabilize the maxilla after downfracturing and anterior repositioning. The mandible was stabilized with six bicortical screws, three on each side of the mandible.

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Figure 5. Postsurgical clinical photographs and radiographs documenting patient’s successful outcome: A. Profile showing Class 1 facial profile. B. Full face with competent lip closure. C. Cephalometric radiograph documenting patient’s Class 1 skeletal relationship.

The patient was admitted as an in-patient to the hospital for 2 nights and was discharged on a clear liquid diet. The patient was able to open to 1.5 cm range of motion immediately postoperatively. The patient’s post operative course was uneventful with nausea being the patient’s only complaint during

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the first 5 hours immediately following surgery. Immediately after surgery the patient’s diet consisted of clear liquid for 5 days and then a full liquid diet for 2 weeks. At 2 weeks following surgery the patient’s diet was advanced to soft food. The patient continued to improve with edema decreasing at

each post op appointment at 2 weeks, 4 weeks, 3 months, 6 months, and then 1 year. The patient was released to the prosthodontist after 4 months and had full maxillary and mandibular dentures fabricated. At the 4-week follow up, the patient walked in the room and stated, “I had no idea how bad

I looked, you doctors have changed my life forever.” Such reactions from post-surgical orthognathic patients are not unusual, and in fact are more common than realized. As published by Pertschuk et al., “surgery produces sudden and often dramatic changes, thereby placing immediate demands on the patient’s adaptive skills. The literature supports the contention that improvement in appearance brought about by craniofacial surgery is associated with improvement in psychosocial adjustment (2, 5).” Due to the posterior maxillary denture flange on the right side, the patient returned to our service to have the right posterior titanium L plates removed because she was having mucosal irritation from the denture flange.

This was the only complication the patient presented at 5 months following surgery.

Discussion The patient’s first few appointments in our department consisted of visits to not only understand her chief complaint, but to educate the patient on her problems as well as benefits of how dentoalveolar, orthognathic surgery, and prosthetics could dramatically improve her function and appearance. A full mouth extraction without jaw surgery would not have allowed the patient to function with upper and lower prostheses due to a lack of interocclusal space as well as anterior incisal discrepancies resulting in approximately 1.5cm of overjet. The course of a Lefort I osteotomy and bilateral sagittal split osteotomies was therefore necessary to correct the patient’s hypoplastic maxilla, hyperplastic mandible, and prevent postoperative nonfunctional prosthetic appliances.

The patient’s bilateral mandibular anesthesia lasted approximately 2 weeks, and at 3 months the patient was able to sense two point discrimination on bilateral lower lips with points being greater than 7 mm apart on both sides. A post operative cephalometric radiograph revealed a more symmetrical appearing maxilla and mandible in relation to the cranial base with the ANB at 2 degrees (Figure 5). With the patient’s dentures in place, and a new vertical dimension established, the patient’s new mandibular angle was 24 degrees instead of her preoperative measurement of 32 degrees.

In conclusion, a mutilated dentition in a young patient requiring a combined maxillary and mandibular orthognathic surgery is not seen frequently. We have presented a case with an unusual set of factors that was treated with full mouth extraction, alveoloplasty, maxillary advancement, mandibular setback, and full maxillary and mandibular dentures. At 1 year follow up, the patient is pain free with an ideal denture occlusion, has full range of temporomandibular motion, and no permanent sensory disturbances. Our case further supports the study by Lazaridou-Terizoudi et al., in the fact that body image and self-concept do improve with orthognathic surgery (2).

References 1. Steinhauser EW: Historical development of orthognathic surgery. J Craniomaxillofacial Surgery 24:195, 1996.

2. Lazaridou-Terzoudi T, Kiyak HA, Moore R, et al.

Long term assessment of psychologic outcomes of orthognathic surgery. J Oral Maxillofacial Surgery 61:545-52, 2003.

3. Rivera SM, Hatch JP, Dolce C, et al. Patients own reasons and patient-perceived recommendations for orthognathic surgery. Am J Ortho Dentofacial Orthop 118:134-41, 2000.

4. Bell WH, Profitt WR. Maxillary excess. IN: Bell WH, Profitt WR, White RP, editors. Surgical correction dentofacial deformities.

Philadelphia: W.B Saunders Co.; p. 234-441, 1980.

5. Pertschuk M, Whitaker L: Social and psychological effects of craniofacial deformity and surgical reconstruction. Clinical Plastic Surgery 9:297, 1982.

6. Lee S.: Impact of orthognathic surgery on quality of life. J Oral Maxillofacial Surg 66:1194-1199, 2008.

7. Olson RE, Laskin DM: Expectation of patients from orthognathic surgery. J Oral Maxillofacial Surgery 38:283, 1980.

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

By Stefanie Clegg, Web and New Media Manager

Make TDA Express your homepage and start your day with TDA Express!

Make TDA Express your homepage and start your day with TDA Express!

The TDA Express internet portal for is aallone-stop-show for all your Internet The TDA Express internet portal is a one-stop-show your Internet needs.

Members can needs.

Members can personalize their TDA Express homepage personalize their TDA Express homepage to show only the content they’re interestedtoin.show Every only the content they're interested in. Every member who logs into TDA member who logs into TDA Express will have a different view of the system and its content.

Express will have a different view of the system and its content.

Members can add their own links with One-Click customization. One-Click allows you to add a button to your Links toolbar. Wherever you are on the Internet, if you find a link that you want to Members can add their own links with One-Click customization. One-Click allows you to add a button to add to your personal page links, simply click the “Quick Click” or “Manage Links” button in your your Links toolbar. Wherever you are on the Internet, if you find a link that you want to add to your (Clickclick on “User Manual” located in the lower-left margin thetoolbar. portal for moreondetails). personal pagetoolbar. links, simply the “Quick Click” or “Manage Links” button in of your (Click

"User Manual"The located in the lower-left margin of the portal forto more details). enhanced TDA Express gives members access their personal Facebook profile on

the “My Links” tab and includes a video library showcasing TDA videos and podcasts. Be The enhanced TDA Express gives members to access their personal Facebook profile on the “My sure to viewathe “Welcome”

by TDA TDA executive director Mary Kay Linn.

Other videos Links” tab and includes video library video showcasing videos and podcasts.

Be sure to view theinclude the by TDA Committee forTDA the New Dentist podcastOther series, Building Better news for report, “Welcome” video Mary Kay Linn, Executive Director. videos include theOral TDAHealth Committee and footageSeries, of the Texas Mission Mercy efforts across the state. the New Dentist Podcast Building BetterofOral Health News Report, and footage of the Texas Mission of Mercy efforts across the state.

FEATURES: FEATURES: • NEW! Access your Facebook profile • NEW! TDA video and podcast library  NEW! Accessyour yourhomepage Facebook profile TDA Express • Make  NEW! TDA video and podcast library • Add your own links  Make TDA Express your • Hide links you’re not interested homepage in  Add your own links • Select text size  Hide links you’re not interested in • Personalize your weather center  Select text size • Choose news headlines to display  Personalize your weather center • Search TDA’s news interactive calendar  Choose headlines to display • Check stocks TDA’s interactive calendar  Search • Perform MedLine,  Check stocksGoogle, WebMD, or Answers.com searches • Utilize tools such as conversion, business, time zone, and deadline calculators  Perform MedLine, Google, WebMD, • Access and meeting orreference Answers.com searchesplanner  Utilize tools such as conversion, business, time zone, deadline calculators To make TDA Express your homepage, log inand at tda.org and click on “TDA Express” on the  Express” Access reference meeting planner homepage. Click “Log in to TDA then “Setand as Homepage” in the top-right corner.

Questions? Contact Stefanie Clegg, TDA web and new media manager, stefanie@tda.org To make TDA Express your homepage, log in at tda.org and click on “TDA Express” on the homepage. Click “Log in to TDA Express” then “Set as Homepage” in the top-right corner.

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Questions? Contact Stefanie Clegg, TDA web and new media manager, stefanie@tda.org

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Oral and Maxillofacial Pathology Case of the Month Case History

A 4-year-old patient was brought to the dental office with a chief complaint of delayed tooth eruption in the upper right side. The patient did not have pain or any other symptoms. The patient’s past medical history revealed no significant findings. On clinical examination, it was noted that the primary maxillary right second molar (tooth J) was missing. The left primary upper second molar, however had erupted. There were no other significant clinical findings.

The erupted teeth were all of normal form and color. A review of the family history showed no relevant findings.

Periapical radiographs were taken. The radiograph revealed several poorly forming permanent teeth. The right permanent first molar (tooth 3), permanent first premolar (5), permanent second premolar (4) and tooth J were affected. These teeth displayed only a thin shell of enamel and dentin.

The pulp chamber was abnormally large and occupied most of the crown.

This was especially pronounced in teeth 4, 5, and J. Tooth 3 had a more

Pavithra Pugalagiri, B.D.S., Resident, Oral and Maxillofacial Pathology, Department of Diagnostic Sciences, Texas A&M Health Science Center, Baylor College of Dentistry, Dallas; and Harvey P. Kessler, D.D.S., M.S., Department of Diagnostic Sciences, Texas A&M Health Science Center, Baylor College of Dentistry, Dallas Kessler mixed radiopaque and radiolucent appearance. The radiographic distinction between enamel and dentin was lost and the teeth appeared to have a pale, wispy appearance on the radiograph.

The adjacent teeth and the developing teeth on the left, however exhibited normal tooth morphology in the radiographs.

The tissue covering tooth J was surgically excised and submitted for histopathological evaluation.

What is your differential diagnosis?

Microscopic Findings:

The specimen consisted of fragments of oral mucosa. Underlying the normal epithelium and lamina propria, there was a cellular fibrous stroma with scattered epithelial odontogenic rests. Also in this stroma were islands of irregular, small, ring-like calcifications.

What is the final diagnosis?

See page 614 for the answer and discussion.

Figure 1. Intraoral periapical radiograph of the right maxilla shows teeth 4, J, 5, and 3 exhibiting abnormally large pulps and severely thin dentin and enamel.

Figure 3.

A higher power (10 X) photomicrograph shows whorled, irregular calcifications (enameloid or type A calcification) in a fibrous cellular stroma.

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Figure 2. A low power (4 X) photomicrograph of a decalcified affected tooth showing dentin hypoplasia, increased interglobular dentin and amorphous immature dentin matrix.

Figure 4. A higher power (10 X) photomicrograph shows the larger type B calcifications.

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Provided by TDA Perks Program

value for your

profession

What You Should Know About Identity Theft Lindsey Sorenson, iSekurity

Because personal information is relatively easy to access today, and the probability of getting caught stealing it is low, identity theft has become the fastest-growing and most lucrative crime in America. Everyone is vulnerable to it.

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What is Identity Theft?

Identity theft is the crime of obtaining someone’s personal or financial information for the purpose of making transactions or purchases in his name.

Criminals can do a lot of damage very quickly once they’ve assumed someone’s identity; and the impact of identity theft can be devastating. Social security and credit card numbers, bank account codes, drivers licenses, or even health insurance cards can be used by criminals to commit fraud.

Do Detection & Deterrent Services Help?

Detection and deterrent services can be helpful, but they are insufficient in the overall fight against identity theft. I’m sure you’ve heard or seen advertising campaigns of companies claiming they can protect you from identity theft. Many people pay $10 per month or more for credit monitoring services.

The problem with credit monitoring is that once someone is notified, his identity has already been stolen. Additionally, it’s a service available free of charge to everyone.

Another anti-identity-theft service offered by companies is fraud alerts. Many people aren’t aware that fraud alerts, by law, are also free to all consumers.

Originally created for individuals who want to monitor their activity because they believe fraud is imminent (for example, their wallet or purse was stolen), these alerts can help thwart attempts to fraudulently open new credit applications in someone else’s name. However, it’s up to the credit issuer to verify the applicant’s identity. You can easily set up alerts through one of the three major credit bureaus: Experian, TransUnion, and Equifax.

The Effects of Identity Theft It’s difficult to determine how long an identity-theft victim will suffer repercussions. Many factors can affect how time consuming a recovery will be, including: whether or not the stolen information was passed along or sold to another thief, if the criminal is caught, and whether or not your credit report is returned to its pre-fraud state. Unless the damage reaches a level the state or federal government decides is appropriate to take action, it’s likely that your case will never be investigated by law enforcement personnel.

The process of restoring one’s credit after an identity-theft incident is frustrating, expensive, and time-consuming. An individual without the proper insurance and support will spend approximately $20,000 and more than 350 hours completing paperwork, making calls, writing letters, and researching options.

Identity theft’s reach is not limited to credit. A thief can assume your identity to get medical procedures, gain employment, and worse, commit a crime. No detection or deterrent service can stop identity theft from occurring. The fact is that no matter what you do, or how careful you are, there are no guarantees that your identity will not be stolen.

Aside from taking sensible precautions to protect your information, the most effective way to combat identity theft is to try to prevent more incidents by pursuing, locating, and prosecuting the identity-theft criminal, and attacking the problem at its source.

iSekurity is a TDA Perks Program partner, and a national provider of identity-theft protection. The company employs the largest team of former federal agents from the United States Secret Service, FBI, DEA, ATF, IRS, Customs, and Postal Inspector agencies, and is committed to aggressively investigating identity-theft crimes against its members. iSekurity was formed to provide the most comprehensive identity theft and fraud protection service in the marketplace. If you become a victim of identity theft, iSekurity will launch an aggressive investigation to locate the criminal and assist authorities in his arrest and prosecution. For more information on iSekurity, please contact the company at: (877) 838-5734.

For information regarding other TDA Perks programs, please visit tdaperks.com, or call (512) 443-3675.

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Calendar of Events 610

July 2010 8 – 11 The Academy of General Dentistry will have its annual meeting at the Ernest Morial Convention Center in New Orleans, LA. For more information, please contact Ms. Rebecca Murray, AGD, 211 E. Chicago Avenue, Suite 900, Chicago, IL 60611-2616. Phone: (312) 440-3368; FAX: (312) 4400559; E-mail: agd@agd.org; Web: agd.org.

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

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

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

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

13 & 14 The TDA Smiles Foundation will hold a Texas Mission of Mercy in Waco. For more information, please contact the TDA Smiles Foundation, 1946 S. IH 35, Ste. 300, Austin, TX 78704.

Phone: (512) 448-2441; Web: tdasf.org.

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

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.

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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 11373-5159. Phone: (718) 639-0192; FAX: (718) 639-8122; E-mail: ngehani@aol.com; Web: ida-usa.org.

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

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

9 – 12 The American Dental Association will hold its 151st annual session at the Orange County Convention Center in Orlando, FL. Web: 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.

Calendar of Events

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) 4482441; Web: tdasf.org.

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Calendar of Events 612

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

November 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) 9319429; 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.

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.

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

In Memoriam Those in the dental community who have recently passed

Memorial and Honorarium Donors to the Texas Dental Association Smiles Foundation

Beal, Edward J. Shiner, Texas January 8, 1957 – April 13, 2010 Good Fellow, 2009

Wuensche, James Harold Temple, Texas August 22, 1933 – March 25, 2010 Good Fellow, 1991 Life, 1999

In Memory of: Billie Beyer

By Don R. Deaver, D.D.S. Roxy Linton

By Charles A. Robertson, D.D.S. Florence Meurer

By Charles A. Robertson, D.D.S. Bobbie J. Resendez

By Charles A. Robertson, D.D.S. Dr. Thomas Tennery

By Dr. and Mrs. Larry W. Spradley Claude “Corky” Cunningham

By Dr. Robert C. Cody Margie Schmidt

By Dr. Robert C. Cody Bertha Mae Wilson

By Charles A. Robertson, D.D.S.

In Honor of: Dr. Kent Macaulay

By Richard S. Will The Spouses of the TDA Board Members

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

Please make your check payable to:

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

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Oral and Maxillofacial Pathology Diagnosis and Management

Regional Odontodysplasia (Ghost Teeth) Oral and Maxillofacial Pathology Case of the Month (from page 606)

Discussion Regional odontodysplasia (RO) is a localized developmental anomaly that causes defects in enamel, dentin and pulp in the affected dentition.

The condition usually manifests as unerupted teeth or as discolored yellowish-brown teeth in a focal area. The defects in tooth structure often cause periapical infections.

Changes in tooth structure are revealed by radiographs, which show pale, fuzzy ‘ghost teeth’.

RO was first described in 1934 by Hitchin as a case of unerupted deciduous teeth (1). In subsequent years, it was also described by various names like odontogenic dysplasia, amelogenesis imperfecta non-hereditaria segmentalis, unilateral dental malformation, odontogenesis imperfecta, and ghost teeth (2, 3). Currently, the accepted terminology for this anomaly is regional odontodysplasia.

The term ‘odontodysplasia’ was proposed by Zegarelli and Kutscher, with the description ‘regional’ suggested later on by Pindborg.

Though various theories have been espoused, conclusive evidence as to etiology has not been demonstrated.

The theories proposed include local circulatory disorders, association with vascular nevi, trauma, latent virus in tooth germs, metabolic disturbance, genetic transmission, local infections, and somatic mutation (2).

There has not been much in the way of evidence to prove heredity, viral infections or local trauma as possible factors responsible for RO (3). However, the reported associations of RO with vascular nevi and animal experiments that show RO-like changes

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with artery ligation seem to point to a vascular etiology.

Another more plausible cause was proposed by Rohanizadeh et al (4).

They hypothesized that defective absorption of enamel matrix by proteases could lead to the hypomineralized enamel in RO. Later experiments

by Courson et al demonstrated an association between the odontodysplastic process and metalloproteinases (MMPs) and their inhibitors (TIMPs) (5). MMPs are a group of protease enzymes. These enzymes are responsible for cleaving extracellular matrix components like collagen and amelogenin, which are found in dentin and enamel respectively (1).

Regional odontodysplasia has also been reported in association with ectodermal dysplasia, epidermal nevi, hypophosphatasia, hydrocephalus, ipsilateral facial hypoplasia, neurofibromatosis, orbital coloboma, Rh factor incompatibility and vascular nevi (3).

The age of presentation of RO includes children, adolescents, and young adults. Reported cases range from 1-23 years old. A bimodal age distribution at time of diagnosis is present, with cases clustering at 4 and 10 years of age. This corresponds to the eruption of primary and permanent teeth. A definite predilection for the female sex has been noted. The maxilla was most frequently affected. According to SA Tervonen, 52.9 percent of cases with affected deciduous teeth also showed similar odontodysplastic changes in succedaneous teeth (1). Clinical examination shows the condition is often limited to one area in a single quadrant of a jaw. Cases

involving more than one quadrant have been reported. However, involvement of 3 or all 4 quadrants is exceedingly rare (1, 3).

The presenting complaint may be delayed eruption or a gingival swelling. Sometimes, it also presents as an abscess related to non-carious teeth or discolored, unaesthetic teeth. The affected teeth appear to be pitted, small and often with a yellow-brown color. There is an increased incidence of caries in these teeth. Radiographic findings show teeth that have lost most of their radiodensity and appear to be pale, fuzzy images compared to adjacent normal teeth. Loss of contrast between dentin and enamel is characteristically observed. The teeth have abnormally large pulp chambers, which sometimes has calcifications.

Affected teeth also often have short roots and open apices. Periapical radiolucencies are also often associated with these teeth.

Enamel is often lost subsequent to the decalcification procedure during the processing of tissue for histopathologic evaluation. However, ground sections of affected teeth reveal enamel hypoplasia and frequent clefts from the enamel surface into the dentin that are responsible for ingress of bacteria and increased reports of pulpitis. Decalcified sections show increased interglobular dentin, clefting of mantle dentin and irregularly oriented dentinal tubules (6). In addition, there are amorphous areas, which appear grey in the incisal or cuspal areas. These areas, which are immature dentin matrix, are regarded as pathognomonic for RO. Pulpal outline is also abnormal and the pulp often has pulp stones.

The dental follicle consists of whorled fibrous connective tissue and plump fibroblasts with odontogenic epithelial rests and foci of calcification. Two types of calcification have been described: type A calcification (also referred to as enameloid) and type B calcifications. Type A calcifications were defined by Gardner and Sapp as small whorled irregular structures with a stronger staining periphery and lightly staining centers. Type B calcifications were larger structures than type A and were more fibrillar in nature.

Often type A calcifications are found embedded within the larger type B calcifications (3, 7-9).

Clinical differential diagnosis includes amelogenesis imperfecta, dentinogenesis imperfecta, dentinal dysplasia and hypophosphatasia. However, all these conditions affect the entire dentition and are not localized to one segment as in RO. Trauma to primary teeth could lead to changes in the predecessor that resembles RO. Nevertheless, microscopic analysis of afflicted teeth shows deposition of normal dentin and enamel at least initially.

The current principle of treatment for RO advocates retention of affected teeth for as long as possible to ensure adequate growth of the associated alveolar process.

Unrestorable teeth are extracted and temporary prosthetic dentures can be placed (10). Successful endodontic therapy in such teeth has also been reported.

References

1. Tervonen, S.A., et al., Regional odontodysplasia: a review of the literature and report of four cases. Clin Oral Investig, 2004. 8(2): p. 45-51.

2. Neupert, E.A., 3rd and J.M. Wright, Regional odontodysplasia presenting as a soft tissue swelling. Oral Surg Oral Med Oral Pathol, 1989. 67(2): p. 193-6.

3. Crawford, P.J. and M.J. Aldred, Regional odontodysplasia: a bibliography. J Oral Pathol Med, 1989. 18(5): p. 251-63.

4. Rohanizadeh, R., et al., Ultrastructural organization and microanalysis studies of deciduous enamel crystallites in regional odontodysplasia (RO). J Oral Pathol Med, 1998.

27(10): p. 501-7.

5. Courson, F., et al., Regional odontodysplasia: expression of matrix metalloproteinases and their natural inhibitors. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2003. 95(1): p. 60-6.

6. Gardner, D.G., The dentinal changes in regional odontodysplasia. Oral Surg Oral Med Oral Pathol, 1974. 38(6): p.

887-97.

7. Gardner, D.G. and J.P. Sapp, Regional odontodysplasia.

Oral Surg Oral Med Oral Pathol, 1973. 35(3): p. 351-65.

8. Gardner, D.G. and J.P. Sapp, Ultrastructural, electron-probe, and microhardness studies of the controversial amorphous areas in the dentin of regional odontodysplasia. Oral Surg Oral Med Oral Pathol, 1977. 44(4): p. 549-59.

9. Sapp, J.P. and D.G. Gardner, Regional odontodysplasia: an ultrastructural and histochemical study of the soft-tissue calcifications. Oral Surg Oral Med Oral Pathol, 1973. 36(3): p. 383-92.

10. Kahn, M.A. and R.L. Hinson, Regional odontodysplasia.

Case report with etiologic and treatment considerations. Oral Surg Oral Med Oral Pathol, 1991. 72(4): p. 462-7.

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

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

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

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

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

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

Briefs

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

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

ID #1-0110.

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

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.

RIO GRANDE VALLEY: Excellent four operatory, 20-year-old general practice. Modern, new finish out in retail location with digital radiography. Fee-for-service patient base and very good new patient count.

Great numbers. Super upside potential. ID #093.

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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 offices in small town with no competition.

Very good income and low, low overhead.

Priced to sell. ID #013.

SAN ANTONIO: 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: 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: Small, 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.

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.

NEW! 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.

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! 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 3 years. ID -1-0108.

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.

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

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.

RIO GRANDE VALLEY: Excellent four operatory, 20-year-old general practice. Modern, new finish out in retail location with digital radiography. Fee-for-service patient base and very good new patient count.

Great numbers. Super upside potential. ID #093.

NEW! SAN ANTONIO: Five operatory, stateof-the-art facility with new equipment. Located in a medical professional building in high growth, affluent area. Grossing seven figures with high net income.

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

GARY CLINTON / PMA ORAL SURGERY PRACTICE FOR SALE, HOUSTON AREA: Fast-growing northwest Houston. Many referring dentists. Retiring surgeon; outright sale or transition; seven-figure gross. Seller will work 1-2 days 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.

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Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables.

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

GARY CLINTON / PMA 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 will 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. Retiring dentist. Beautiful office; will transition as needed. Restorative practice. Well-established recall. We have the best sources for 100 percent buyer funding. Gary Clinton is 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

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confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA SAN ANGELO PRACTICES FOR SALE: S1 San Angelo area — Very sharp office. Plenty of patients to work 5 days a week; exceptional value.

S2 San Angelo — Excellent well-established restorative practice. Very nice equipment.

Dentist relocation. Transitional / outright sale. We have the best sources for 100 percent buyer funding. Gary Clinton is 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 / ORTHODONTIC PRACTICES ASSOCIATE / TRANSITION OR OUTRIGHT SALES: O1 Within 90 miles of Austin — Flexible, will transition; seven-figure practice; planned practice value from the beginning. Beautiful office. O2 West Central Texas mid-sized to larger community —Professional referral based, traditional fee-for-service, referral, highly productive. Gorgeous building with room for two in this 50/50 partnership.

O3 South Texas — Retiring orthodontist; 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

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 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 WEST CENTRAL TEXAS: Excellent mid-size practice. Wellestablished quality practice; excellent location; great recall and new patient flow. 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 ORTHODONTIC NORTH DALLAS SUBURB: Highly desirable area. Great high traffic location; near schools; mid-size practice; latest digital equipment. Expandable to more than 4,800 sq. ft. Work 3-4 days per week; staff to stay with the practice. Outright sale/ transition. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/ transition/sale. No conflict of interest/dual representation. Authorized closing agent/ escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential.

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

GARY CLINTON / PMA 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 institutions. Certified appraisals based upon the comparables.

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

GARY CLINTON / PMA: 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

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wish. I need practices to sell/transition as follows: Austin, San Antonio, DFW area, and Houston. Have buyers for orthodontic, 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.

SOUTHEAST HOUSTON GENERAL DENTAL PRACTICE — SALE: Incredible general dental practice with six operatories in a new facility. High revenues with excellent profit margin. Doctor relocating but is most interested in smooth transition. This is a wonderful opportunity to accumulate a substantial retirement “nest egg” with a low level of risk. Contact The Hindley Group at (800) 856-1955. Visit us at www. thehindleygroup.com.

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

EAST TEXAS ORAL & MAXILLOFACIAL SURGERY PRACTICE — SALE: Beautiful

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and spacious facility located in the heart of a rapidly growing Texas metropolis. Great opportunity for highly qualified surgeon with desire to assume responsibility for a wide spectrum of OMS procedures, expand surgical treatment, and dramatically increase income. Strong revenues and high profit margins; flexible acquisition terms!

Must see opportunity! Contact The Hindley Group at (800) 856-1955. Visit us at www. thehindleygroup.com.

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

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

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

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

GOLDEN TRIANGLE GENERAL DENTAL PRACTICE — SALE: Outstanding practice for sale developed by published mentor.

Supported by outstanding staff and latest in dental equipment. Strong revenues and profit margin. Excellent new patient flow.

Given high level of FFS revenues, doctor to transition to comfort level of purchaser.

Come build your retirement in low com-

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

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

If you are an older doctor who needs to recomplete his retirement package after the stock market drop, and want to practice in a less competitive more relaxed environment, this is a must-see opportunity. Contact The Hindley Group at (800) 856-1955.

Visit us at www.thehindleygroup.com.

NORTHWEST SAN ANTONIO GENERAL DENTAL PRACTICE — SALE: General dentistry practice with strong revenues and excellent new patient flow. Practice is located in highly visible location on well-traveled road. Four treatment rooms. Doctor is most anxious to facilitate strong transition. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

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

SOUTH OF HOUSTON GENERAL DENTAL PRACTICE — SALE: Outstanding practice with very high growth potential experiencing a strong new patient flow. Moderate revenues with a healthy profit margin on 4 days per week. Building also for sale. Contact The Hindley Group at (800) 856-1955.

Visit us at www.thehindleygroup.com.

WEST HOUSTON GENERAL DENTAL PRACTICE — SALE: Wonderful opportunity in rapidly growing west Houston com-

munity. Strong revenue and profit margin.

Wonderful staff. Practice has ortho emphasis, but seller will stay on to complete cases if necessary. Building also for sale.

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

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

Visit us at www.thehindleygroup.com.

NORTHWEST HOUSTON GENERAL DENTAL PRACTICE — SALE: New practice in growing area located near well-traveled Highway 290 and Jones Road. Two fully equipped treatment rooms with three others plumbed for expansion. Digital X-rays. Moderate revenues on 2.5 days / week. If you want to be in the rapidly growing northwest quadrant, this practice is for you. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

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.

ASSOCIATESHIPS: EAST TEXAS GENERAL DENTAL PRACTICE: Small but busy practice generating mid-range revenues on 4 days per week. Located in quaint small

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town with excellent access to forests and lakes for hunting, fishing, and boating.

Excellent opportunity for dentists looking ahead to separation from the military. Predetermined 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 “equallyyoked” individual. Excellent Staff. DFW METROPLEX 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. Well-established practice enjoying 2008 revenues exceeding seven figures from two locations. Wonderful opportunity for a resident who has recently completed their program and who desires transition into practice ownership. You could not find a more superior partner! MIDLAND GENERAL DENTAL PRACTICE — Well established and growing practice with strong revenues and healthy profit margin on 4 days per week.

Wonderful mentor with plenty of room to grow. SAN ANTONIO PERIODONTAL AND ENDODONTIST ASSOCIATESHIPS —Associateship with pre-determined buy-in for very active, multi-office periodontal practice. Outstanding mentor and cohesive staff. If you are the right person, this is an outstanding opportunity. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

HOUSTON AREA PRACTICE FOR SALE: Profitable practice for sale. Well-established.

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

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(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 Pel ton 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) 7550836.

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

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

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

TOP OF THE HILL COUNTRY GENERAL PRACTICE FOR SALE. Beautiful freestanding building in growing Clifton medical/arts district. Well established, quality oriented, five ops, FFS. Easy proximity to Dallas, Austin, and Lake Whitney. Doctor relocating but willing to provide flexible transition terms. If you are tired of patient turnover and want to make a difference in patients’ lives, this is the opportunity you’ve been looking for. Call (254) 6753518 or e-mail dnicholsdds@earthlink.net.

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

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.

TEXAS PANHANDLE: Well-established 100 percent fee-for-service dental practice for immediate transition or complete sale at below market price by retiring dentist.

Relaxed work schedule with community centrally located within 1 hour of three major cities. The office building can be leased or purchased separately and is spaciously designed with four operatories, doctors’ private office and separate office rental space. This is an excellent and profitable opportunity for a new dentist, a dentist desiring to own a practice, or a satellite practice expansion. Contact C. Vandiver at (713) 205-2005 or clv@tauruscapitalcorp. com.

GALVESTON ISLAND: Unique opportunity to live and practice on the Texas Gulf coast. Well-established fee-for-service, 100 percent quality-oriented practice looking for a quality oriented associate. Ideal for a new graduate or for an experienced dentist wanting to relocate and become part of an established practice with a reputation for providing comprehensive, quality dental care with a personable approach. Practice references available from local specialists.

Contact Dr. Richard Krumholz, (409) 7624522.

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

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responsibilities. Call (702) 510-7795 or email drartbejarano@gmail.com.

ASSOCIATE NEEDED — NE TEXAS: Pittsburg is surrounded by beautiful lakes and piney woods. Well-established, qualityoriented, busy cosmetic and family practice. Associate to partnership opportunity.

Call Dr. Richardson at (903) 856-6688.

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

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

ASSOCIATE PARTNER, SOUTHEAST HOUSTON — WEBSTER: Excellent opportunity for a highly energetic, enthusiastic, hard working general dentist. Beautiful high-tech family practice is seeking an exceptional well rounded individual to take over existing adult patient base. Individual must be self motivated, experienced, and willing to work hard to obtain goals. Office is in great location with state-of-the-art equipment with the latest technology. The general dentist area has five treatment rooms with high production potential. Call (281) 488-2483 or fax resume (281) 4883416.

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

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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. What’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.

NEEDED: BOARD CERTIFIED ORTHODONTIST FOR CLINICAL DIRECTOR POSITION IN EDINBURG MEDICAID PRACTICE. Duties include formulating and implementing procedures for operation of orthodontic services, determining equipment, materials, and personnel required for performance of treatment and construction of corrective appliances, coordinating orthodontic services with other dental and medical services, preparing diagnostic and treatment records, examining, diagnosing, and treating irregularities, and malocclusions of teeth and malrelations of jaws, examining patients and interpreting and evaluating radiographis, models, and clinical photographs to determine nature and extent of deficiencies caused by irregularly positioned teeth and

relationships, and instructing assistants and other auxiliary personnel in orthodontic procedures and techniques. Requirements: 24 months training for orthodontic specialty. Board Certified Orthodontist, Texas Dental license, 150 hours continuing education in orthodontics, license to practice dentistry in the state of Texas.

If interested, please e-mail resume to N&W Ortho, LLC, c/o Dr. Hal D. Lerman, nflq21b@swbell.net.

ASSOCIATE NEEDED FOR NURSING HOME DENTAL PRACTICE. This is a nontraditional 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) 2389250; 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 fast-paced working environment in a busy pediatric practice. We are willing to train the right individual if working with children is your ambition. This position is part-time initially, and after a short training period will lead to full-time. If you join our team, you will be mentored by a Board certified pediatric dentist and will develop experience in all facets of pediatric dentistry including behavior management using oral conscious sedation as well as IV sedation. For more information, please visit our websites at www.wyliechildrensdentistry. com and www.parischildrensdentistry. com. Please e-mail CV to allenpl2345@ yahoo.com.

SOUTHWEST FT. WORTH — GENERAL DENTAL PRACTICE WITH BUILDING FOR SALE OR LEASE: This very successful, well-established practice has an excellent patient base with referrals from near and far. The seller is retiring 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.

CENTRAL TEXAS SPECIALIST SERVICES NEEDED to provide endodontic, primarily, but also periodontal and oral surgery services to a 30-year-old general and cosmetic dentistry practice on Fridays

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and other times negotiable. Perfect satellite or start-up office. Exclusive use of a beautiful and well-equipped three-operatory office, less than 1 hour from Austin with great visibility and surroundings in an historic, affluent community. An assistant is available on request. Please send CV to TDA, Attn.: TDA Box #1, 1946 S. IH35, Ste. 400, Austin, TX, 78704.

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

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

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

SEEKING ASSOCIATE DENTISTS. Dental Republic is a well-established general dental practice with various successful locations throughout the Dallas Metroplex.

A brand new state-of-the-art facility in a bustling location will be opening soon.

Join our outstanding and professional team in creating beautiful healthy smiles for all. Let us give you the opportunity to enhance your professional career with excellent hours, competitive salary/benefits, and by forming long-lasting friendships with our patients and staff members.

Please contact Phong at (214) 466-8450 or e-mail CV to phong@dentalrepublic.com.

CARE FOR KIDS, A PEDIATRIC FOCUSED PRACTICE, is opening new practices in the San Antonio and Houston area. We are looking for energetic full-time general dentists and pediatric dentists to join our team. We offer a comprehensive compensation and benefits package including medical, life, long- and short-term disability insurance, flexible spending, and

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401(K) with employer contribution. New graduates and dentists with experience are welcome. Be a part of our outstanding team, providing care for Texas’ kids. Please contact Anna Robinson at (913) 322-1447; e-mail: arobinson@amdpi.com; FAX: (913) 322-1459.

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, fulltime 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-of-town practice and must sell.

Call Jim Dunn at (800) 930-8017.

DALLAS / ROCKWALL: Seeking full- and part-time endodontists. Expanding a busy, TEAM-oriented, modern practice with a well-established referral base. Must have strong clinical and people skills. E-mail endo.dr.888@gmail.com.

MCALLEN — LOOKING FOR ASSOCIATE in a busy, growing, and well-established cosmetic and family practice with stateof-the-art equipment. Call Zonia Lopez at (956) 630-6130.

LUBBOCK — GENERAL PRACTICE: Associate/partner. Growing group practice is looking for a motivated, long-term, careerminded 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 oppor-

tunity 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. Stateof-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 information, and direct any inquires to Ms. Sanders or Ms. Manovich at (713) 797-0846.

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.

LUBBOCK: Established pediatric dental practice (not corporate) offers excellent opportunity for pediatric dentist or general dentist with interest in treating children.

Must be Texas Medicaid provider, restorative, sedation, preventive dentistry. First Dental Home. Send resume to lkd79401@ gmail.com.

FAST-GROWING BASTROP: Experienced dentist needed for FFS practice. Part-time

into full-time; potential partnership. Excellent patient and clinical skills a must. Fax resume to (512) 321-7300 or e-mail office@ thedentists.us.

DENTIST FOR JCAHO-ACCREDITED COMMUNITY HEALTH CENTER IN SOUTH TEXAS. Texas licence 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) 787-2021; Email: 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.

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

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

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

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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.

LINDALE (TYLER) DENTAL OFFICE BUILDING FOR SALE. Present use: general dentistry. Across from middle school and junior high (great opportunity for ortho, pedo). Lindale ISD has been rated as one of the top ten systems in the state.

Lindale adjoins Tyler to the north. Includes one reception, three offices, one lab, seven op rooms, one courtyard; 4,045 sq. ft. ideal for new or experienced dentist wanting a “small town feel”. Appraisal available.

Contact John Williams at (903) 520-5147.

Serious offers considered.

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. Allen 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.

ROUND ROCK — ORTHODONTIST SPACE FOR LEASE: On IH-35, between FM 620 and Hwy. 79. 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.

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

TWENTY STAR 430 SWL HANDPIECES freshly refurbished with brand new turbines, very good fiberoptics and clean, like new appearance. Will sell as a lot or individually — $279 for one, $2,590 for 10, or $5,000 for 20. I have new OEM Star swivel/couplers, too, for $125 each. Please call (512) 363-9938.

Interim Services TEMPORARY PROFESSIONAL COVERAGE (Locum Tenens): Let one of our distinguished docs keep your overhead covered, your revenue-flow open wide, your staff busy, your patients treated and booked for recall, all for a flat daily rate not a percent of production. Nation’s largest, most 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) 600-0963; e-mail: docs@doctorsperdiem.com.

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

Miscellaneous ESTABLISHED DENTAL ASSISTING SCHOOL searching for general dental office to lease on 1 weekend day and 1 weeknight in Plano and Austin. Ongoing 12-week course. Lease payments of $1000$1500/month for minimal light use of the office. Please call Dr. Peter Najim, (800) 509-2864, pnajim@dentalassist.org.

LOOKING TO HIRE A TRAINED DENTAL ASSISTANT? We have dental assistants graduating every 3 months in Dallas and Houston. To hire or to host a 32-hour

externship, please call the National School of Dental Assisting at (800) 383-3408. Visit www.schoolofdentalassisting-plano.com.

FANTASTIC OPPORTUNITY FOR GENERAL DENTIST to learn and incorporate orthodontics into career; no experience required. Become a partner/owner, full-time or part-time while building your general dental practice concurrently. All training and business support provided. Easy and affordable financing. Call now, (469) 2323100.

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Your Patients Trust You. Who can YOU Trust?

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

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

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

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A Real-Estate Firm that Specializes in Helping Dentists The Reynolds Company specializes in helping dental professionals across Texas secure the best space for their practice. It’s completed hundreds of projects for dental professionals in the last several years. The entire fee for its services is paid by the building owner; there’s no cost to you.

The Reynolds Company: •Analyzes demographic information and competition to determine the best location for you.

•Locates the best real estate options that will support the goals and objectives of your practice.

•Negotiates the best economic terms, as it exclusively represents the interests of its dental clients in the process.

•Reviews and negotiates all contract terms.

•Manages and coordinates the entire real-estate process.

•Does not have a contract or retainer; only a simple agreement either party can terminate at any time.

For more information, contact Evan Reynolds at: E: evan.reynolds@thereynoldscompany.com T: 972.231.8900 www.thereynoldscompany.com

Dallas/Fort Worth Office 6380 LBJ Freeway, Suite 280 Dallas, Texas 75240 Houston Office 2100 West Loop S., Suite 900 Houston, Texas 77027

Austin/San Antonio Office 401 Congress Avenue, Suite 1540 Austin, Texas 78701

See what other great Perks programs are available to you at: www.tdaperks.com

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

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

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

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

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