May 2010

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Announcing the 2010-11 TDA Board of Directors President Dr. Ronald L. Rhea, Houston President-elect Dr. J. Preston Coleman, San Antonio Past President Dr. Matthew B. Roberts, Crockett

Vice Presidents Dr. R. Lee Clitheroe, Sugar Land (SE) Dr. John W. Baucum, III, Corpus Christi (SW) Dr. Kathleen Nichols, Lubbock (NW) Dr. Donna A. Miller, Waco (NE)

Senior Directors Dr. Karen E. Frazer, Austin (SE) Dr. Lisa B. Masters, San Antonio (SW) Dr. Robert E. Wiggins, Abilene (NW) Dr. Larry D. Herwig, Dallas (NE)

Directors Dr. Rita M. Cammarata, Houston (SE) Dr. T. Beth Vance, Weslaco (SW) Dr. Michael J. Goulding, Fort Worth (NW) Dr. Arthur C. Morchat, Kilgore (NE)

Secretary-Treasurer Dr. Ron Collins, Houston Speaker of the House Dr. Glen D. Hall, Abilene Parliamentarian Dr. Michael L. Stuart, Sunnyvale Editor Dr. Stephen R. Matteson, San Antonio Executive Director Ms. Mary Kay Linn Legal Counsel Mr. William H. Bingham

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Contents TEXAS DENTAL JOURNAL n Established February 1883 n Vol. 127, Number 5, May 2010

On The Cover: As dental professionals, we are charged with adequate pain control for our patients. For those undergoing cancer therapy, we are faced with a number of complications of head and neck radiation. Designed by Grady Basler, Dental Oncology Education Program.

NOTICE

484

Upcoming ADA Appointive / Elective Positions

ARTICLES

Oral Health in Cancer Therapy: Part II

463

Management of Oropharyngeal Mucositis Pain

Mark M. Schubert, D.D.S., M.S.D., and Daniel L. Jones, Ph.D., D.D.S.

The authors address supportive care for cancer and oropharyngeal mucositis, a debilitating oral side effect of aggressive cancer therapies.

487

Xerostomia Management in the Head and Neck Radiation Patient

Carl Haveman, D.D.S., M.S., and Michaell Huber, D.D.S.

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The authors provide a detailed guide to management of hyposalivation, a devastating and consistent complication of head and neck radiation.

MONTHLY FEATURES

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

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The President’s Message

454 456

The View From Austin

508 510 512 516 518

Oral and Maxillofacial Pathology Case of the Month

Diagnosis and Management

522 526 538

Calendar of Events

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

Advertising Briefs

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

Letters to the Editor

(713) 467-3458, rrhea@tda.org Immediate Past President Hilton Israelson, D.D.S.

(972) 669-9444, drisraelson@yahoo.com

In Memoriam / TDA Smiles Foundation

Vice President, Southeast Craig S. Armstrong, D.D.S.

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

Value for Your Profession

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

What’s on tda.org?

(915) 581-3391, endoman@att.net Vice President, Northwest J. Brad Loeffelholz, D.D.S.

Oral and Maxillofacial Pathology Case of the Month

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

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

Index to Advertisers EDITORIAL STAFF

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

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

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

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

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

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

Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, Out-of-state ADA Affiliated $49.50. In-state Non-ADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA Affiliated, $17 Non-ADA Affiliated, September issue $17 ADA Affiliated, $65 Non-ADA Affiliated. For in-state orders, add 8.25% sales tax.

Contributions: Manuscripts and news items of interest to the membership of the society are solicited. The Editor prefers electronic submissions although paper manuscripts are acceptable. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. For more information, please refer to the Instructions for Contributors statement printed in the September Annual Membership Directory or on the TDA website: www.tda.org. All statements of opinion and of supposed facts are published on authority of the writer under whose name they appear and are not to be regarded as the views of the Texas Dental Association, unless such statements have been adopted by the Association. Articles are accepted with the understanding that they have not been published previously.

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

aa de

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

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

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

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

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

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

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

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

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

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

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

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

(512) 495-6000 bbingham@mcginnislaw.com

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

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

451 403 139

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

One year ago I began working on the first of my 12 President’s Messages to appear on the pages of this journal. It has been, without a doubt, a very fast year. You cannot believe how rapidly time goes by when there is a deadline to write this Journal message by the 20th of each month and the TDA Today message by the 5th of each month. Not only that, you are writing for this publication at least one and a half to 2 months ahead of time. Try to be timely with that amount of lag time! Lest you think that I am complaining, let me say right now that it has been an enjoyable experience that I hope has contributed some degree of relevance to the readers.

A great deal of thanks must go to the staff that oversees this and all of our publications. They do a wonderful job editing my words to make me look as good as possible.

This will be my last official President’s Message, and it is not lost on me the legacy of leadership that has held this important post of Texas Dental Association President. The membership issue in February thoroughly explored that very idea, and I am humbled by the experiences and thankful to have been a part of it.

The just-completed House of Delegates meeting in San Antonio has given direction to your new Board of Directors, president and president-elect. We have clarified the legislative agenda for the 82nd Regular Session of the Texas Legislature next January and debated the many issues we hold dear in our hearts.

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My thanks go out to each of the component societies that hosted my visits and permitted me to be the face of the Texas Dental Association. While much remains to be accomplished and many challenges loom, I feel confident that the right people, at the right time, are in place to move this association forward.

This past year we have tackled problems relating to the unlicensed practice of dentistry and capping third-party fees. We have begun implementing the expanded functions of our dental assistants, and hosted a highly successful multi-state summit to look at the many dangers facing our profession and our patients.

Time will tell how successful we were in navigating the waters in which we sailed. Membership must remain a priority as we look for ways to retain and recruit the diverse student body into our Association. The economy remains unstable and Washington continues to struggle with many important issues. Through it all your Board has remained steadfast in attempting to carry out the wishes of the membership.

Many have asked what the experience as president of the Texas Dental Association has been like. While difficult to fully explain, perhaps you will allow me to use a saying from my Texas A&M past. It goes like this: “From the outside looking in, you cannot understand it, and from the inside looking out, you cannot explain it.”

To me it must be personally experienced to fully grasp what life as the president is like. So with that, thank you for allowing me this high honor and I look forward to once again seeing old friends from across this great state.

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

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

“Hey, Barb. Is your neck okay?” asked her husband Blair.

“You know, there’s kind of a knot in the side of my neck,” she replied, “I wonder what it is.”

A week later, the doctor calls about the biopsy report with the news that she has Hodgkin’s disease. She must come to his office to discuss treatment.

She is told that this is a cancer of the lymph nodes, but it is one of the more treatable cancers and schedules radiation therapy. Things go well for a year or so, but then the cancer recurs with lesions in her chest. After 2 years of additional treatments, Barb dies at age 41, leaving a bereaved husband and three young children.

Meanwhile, Barb’s father, Rod, who had smoked heavily for 40 years, discovers that he has laryngeal cancer and requires a radical neck dissection.

The family gathered in the hospital waiting for the ENT surgeon’s report on the surgery and saw the doctor coming down a long hallway with stooped shoulders and head hanging. He said he removed most of the tumor but could not get it all out because of the adjacent vital structures. The family members were discouraged by his report and his disappointed-looking body posture. At that time, the devices designed to help these patients’ speech were rudimentary and his ability to speak was significantly diminished. He died 3 years later at age 67, about 6 months before Barb’s death.

Several years later, Barb’s mom, Libby, experienced gastrointestinal symptoms and was diagnosed with colon cancer. She and Rod had moved to Florida at the advice of Rod’s ENT doctor who said the humid weather would be good for his throat. Her disease progressed and 5 years later, she died at age 79.

Years later, Barb’s sister, Sue, was diagnosed with breast cancer and her older brother, Dave, with prostate cancer. Sue’s treatment was success-

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ful and she is today free of cancer.

Dave’s cancer spread after unsuccessful surgery and radiation treatments but is managed medically and he has survived his disease.

This family was victimized by cancer; both parents and three of their four children experienced this disease.

This is the story of my family. We lived in northern New Jersey in an industrial region. I do not know if that was the basis of this cluster of cancers.

Thus this editor’s personal interest in cancer in general and professional interest in oral cancer. During my years as a dental school radiology instructor, an emphasis was placed on being sure that my students could distinguish benign lesions from malignant ones on radiographs. I found it was fairly easy for students to identify benign tumors, but the radiographic signs of malignant tumors seemed to be more difficult for them to master. I think this was because the malignancies destroyed tissues in place such as absent cortical plates and bony borders rather than the easier to detect displacements of teeth and bony features associated with benign lesions.

Oral cancer causes intense suffering and loss not only from the disease itself, but from painful and disabling side effects of the treatments. Dr. K. Vendrell Rankin at the Department of Public Health Sciences at the Baylor College of Dentistry and her distinguished colleagues have written an informative monograph about the various aspects oral cancer (1). This is the second of two issues (May 2009, May 2010) of the Texas Dental Journal that features republished portions of that document to enhance wider dissemination of these papers. Please also know that the Dental Oncology Education Program website contains the monograph in its The editor apologizes to any readers who found the cover of the April 2010 issue to be offensive.

entirety and a wealth of information on oral cancer: www.DOEP.org.

While discussing the topic of oral tumors, I also wish to thank Dr. Harvey Kessler at the Baylor College of Dentistry for organizing the Oral and Maxillofacial Case of the Month series in the Texas Dental Journal. He and his oral pathology colleagues in the state help keep all of us up to date on this important subject. Thanks, Harvey.

Reference 1. Oral Health in Cancer Therapy Monograph. A guide for health care professionals. ed 3. K V Rankin, Daniel L. Jones, Spencer Redding.

2009 Dental Oncology Education Program, Dallas, Texas. (Also available at: www.doep.org).

EDITOR’S CALL FOR COMMENTS FROM TDA MEMBERS This editor is interested in the experiences of Texas dentists who have encountered patients with oral cancer. I believe that we have much to learn from one another.

Questions for Texas dentists: • How many cancers have you seen per your years in practice?

• Have patients complied promptly with your recommendations for referral for treatment?

• What are the two most prevalent malignant tumors you have seen in your practice?

• Have you detected oral cancer in patients who were unaware of their disease?

• What is your experience with cancers caused by smokeless tobacco use?

If you wish, please e-mail your comments and provide your permission to publish them in the TDA Today newsletter, smatteson@satx.rr.com. Thanks so much.

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376 Texas Dental Journal l www.tda.org l April 2010 Texas Dental Journal l www.tda.org l May 2010 455 ARKANSAS • INDIANA • IOWA • KENTUCKY • LOUISIANA • OHIO • OKLAHOMA • TEXAS

Letters 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):271-278 Dear Dr. Overton: Your article recalled my G.P. days.

Depending on one’s exposure to dentistry, some things aren’t all that different.

About 1965, there were articles advocating indirect pulp capping by removing just the soft and leathery decay to avoid an exposure. Then, place a temporary. As I remember, the recommendation was to re-enter the tooth, carefully remove more of just the soft decay to avoid an exposure.

Interestingly, about that time, I was treating some patients from an 80-year-old retired dentist. X-rays of their teeth revealed decay under any restorations. After I replaced some, I became aware that the decay was dry, not active. His covering over the decay resulted in an indirect pulp cap.

My dilemma was if I didn’t replace the restorations and the patient went to another dentist, that dentist might

think they were my restorations.

Regarding the extension of the interproximal preparation of Class Two’s, I experimented with not extending the interproximal preparation to where I could check the margins visually or with an explorer.

I stopped when some patients developed decay on margins that I couldn’t see or check. Sometimes if the patient didn’t return for a year or so, the decay got fairly extensive. I concluded, if the patient had original decay interproximally, it was logical he or she would be prone to develop it again in the same area. It made sense to extend the edges to where they could be checked.

I like the retention grooves for slot amalgams and Class Two’s. Back about 1965, Will Eames advocated a groove on each side or the box of a Class Two preparation made with a 169L bur. He said that it would prevent the crack that occurs across the isthmus. Grooves also eliminated

the need for the large “key” on the occlusal.

As a result the extension for prevention could be made with burs the width of a 35. The challenge then was finding tiny condensers.

Some other influential clinicians that wrote and spoke on amalgams were Miles Markley (pins), Henry Tanner (Tanner Carvers), John Anderson and John Mosteller.

Early on I had the opportunity to try Kerr’s mechanical amalgam condenser. I believed it condensed amalgam better than I could by hand. I also noticed that after overfilling and condensing with the rubber tip that the amalgam immediately was hard enough to carve and remove the Matrix without damaging the restoration. I switched to Densco’s Condensaire when it became available.

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

Dear Dr. Speer: While I did not start practice until 1978 we have been to a lot of the same places. I too enjoyed using the Condensaire for my amalgams. I still have photographs of a Class 3 gold foil that Dr. Markley helped me create when I was a General Dentistry Resident in 1986. Dr. Markley even conceded that our TMS pins might not be as bad for teeth as he once thought.

In 2009 on the junior competency examinations (more than 200 preparations), only 15 percent of the preparations still had contact (always on the facial) at the time of the preparation photographs. This was a fact that I wish I had included in the original manuscript. In teeth with the most conservative of Class 2 lesions that need surgical intervention, about 85 percent of the time both the facial and lingual contacts will be open when the preparation is complete by our current standards.

Sincerely, J.D. Overton, D.D.S.

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Re: Tex Dent J; 127(3): 314-15.

Re: Tex Dent J; 127(2): 166-213.

Dear Editor: Reading Dr. Blair’s article in the March 2010 Texas Dental Journal, I noticed a couple of interesting statements. One point the article states is: “The E4D/Cerec 3D technology allows a percentage of the current composites to be converted to higher-fee crowns.” It appears to me that if our decision tree guides us to the conclusion that a tooth can be restored with a composite, we should refrain from doing a crown no matter what piece of equipment we have purchased for our office.

My second serendipitous finding in this article has to do with the diagnodent. In his article in the same issue, Dr Overton states: “The enamel is only cavitated 40 percent of the time when the radiograph is at the D1 stage so the majority of lesions that are just visible in dentin could still be arrested or reversed without a restoration (1).” I have a sneaking suspicion that there are not very many dentists who purchase a diagnodent so they can sell more bottles of fluoride.

I realize that many of us are having a hard time right now. However, padding our bottom line by doing unnecessary dentistry will only hurt our public image. When we cause the public to be suspicious of our intentions, it will hurt treatment acceptance in the long run.

Sincerely, Saskia C. Vaughan, D.D.S., FAGD Reference 1. Overton, JD. What is Different in Operative Dentistry? Tex Dent J; 127 (3); 271-278.

Dear Dr. Vaughan: My thanks to Dr. Vaughan for his comments regarding my article, “Technologies Impact on Practice Busyness”. Dr. Vaughan states, “It appears to me that if our decision tree guides us to the conclusion that a tooth can be restored with a composite, we should refrain from doing a crown no matter what piece of equipment we have purchased for our office.”

Most dentists’ decision tree involves the clinical decision to treatment plan either a composite or full crown coverage, with no place for an intermediate restoration. My experience, looking at pre- and post-clinical procedure mixes reveals that some of the purchasers of CAD/CAD do discover and provide the more clinically conservative onlay and partial crown. No doubt, when patients are given a choice, some will opt for a higher-fee ceramic restoration versus a composite restoration. I often see this result from implementing CAD/CAM technology.

Dr. Vaughan further cites Dr J. D. Overton’s excellent article which appeared in the same issue, “‘The enamel is only cavitated 40 percent of the time when the radiograph is at the D1 stage so the majority of lesions that are just visible in dentin could still be arrested or reversed without a restoration (1).’ I have a sneaking suspicion that there are not very many dentists who purchase a Diagnodent so they can sell more bottles of fluoride.”

While I have been away from clinical dentistry for some time, it broke my heart to open up a child’s first or second molar, finding extensive decay with little radiographic evidence of it. In that day and time, I sure wish I had technologies such as today’s Diagnodent, Spectra, and other devices that could provide an adjunct to clinical diagnosis. A conservative approach with the Diagnodent does provide “watching” a lesion to see if it progresses.

Let’s get to the bottom line of Dr. Vaughan’s comments — technology is abused by some dentists’ overtreatment. Unfortunately, overtreatment does go on in the marketplace, regardless of the impact of technology. The flip side is that many dentists don’t properly invest in their practice with modern technology — they and their patients lose.

Dear Editor: I wish to congratulate you on the February issue of the Texas Dental Journal which carried the theme, “Legacy of Leadership”. This is a delicate time for health care on many levels, and this issue was very timely. Leadership and the examples set by the featured leaders are crucial to the ongoing health of the dental profession and the public it serves.

On a personal level, I very much enjoyed reading the individual accounts and memories of many of our colleagues — what brought them into dentistry, the key moments in which they saw and activated opportunities to further their profession through leadership, and the special people in their lives who made a difference for them.

Thank you to those who contributed their thoughts and memories to making this one of the most enjoyable reads ever.

Very sincerely, Douglas B. Willingham, D.D.S. Texas Dental Journal Editor (1986-93)

In summary, my article points out “Technology drives the doctor’s busyness and plays a key role in diminishing the need to advertise or participate in PPO plans. Bottom line, technology increases profitability while vastly improving patient care.” Let’s all agree with Dr. Vaughan’s observation, “don’t abuse technology with overtreatment.”

Sincerely, Charles Blair, D.D.S. Reference 1. Overton, JD. What is Different in Operative Dentistry? Tex Dent J; 127 (3); 271-278.

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Oral Health in Cancer Therapy Part II: Management of Xerostomia and Pain in Cancer Patients K. Vendrell Rankin, D.D.S. Professor, Department of Public Health Sciences Baylor College of Dentistry–Texas A&M Health Science Center, Dallas, TX; Dental Director, Dental Oncology Education Program, Cancer Prevention and Research Institute of Texas

Background the May 2009 issue of the Texas Dental Journal addressed oral complications in cancer therapy in hematopioetic stem cell transplant, chemotherapy and radiation of the head and neck. these manuscripts were derived from the monograph Oral Health in Cancer Therapy. the content of the current issue is devoted to the management of xerostomia and pain in patients undergoing cancer therapy and are derived from the same source.

Hyposalivation is a devastating and consistent complication of head and neck radiation. the condition disrupts virtually all the functions of the oral cavity and the overall health of the patient. this article goes well beyond a discussion of the condition to provide a detailed guide to the management and specific agents available to minimize the discomfort, decrease the risks of rampant caries, increase remineralization, treat carious lesions based on the degree of hyposalivation and treat secondary mucosal and salivary gland infections.

Although the recommendations are offered in the context of the management of cancer patients, the content is well suited to the treatment of patients suffering xerostomia due to other causes.

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Adequate pain control is central to the overall health and psychological well being of patients in cancer therapy. Alleviating patients’ fear of pain is as much a part of pain management as the modalities used to treat the pain. Patients experience pain on a personal level. Therefore scaling pain based on the individuals’ perception is essential to effective management. A stepped approach to pain management and its treatment is an effective tool. Although this section addresses pain management specific to cancer therapy, dentists face the constant challenge of pain management in a variety of circumstances. The concepts and regimes presented are useful in the treatment of oral pain related to multiple etiologies.

About the Editors Editors Oral Health in Cancer Therapy, Third edition K. Vendrell Rankin, D.D.S. Professor, Department of Public Health Sciences, Baylor College of Dentistry — Texas A&M Health Science Center, Dallas, Texas

Daniel L. Jones, Ph.D., D.D.S. Professor and Chair, Department of Public Health Sciences, Baylor College of Dentistry — Texas A&M Health Science Center Dallas, Texas

Spencer W. Redding, M.Ed., D.D.S. Professor and Chair, Department of Dental Diagnostic Science, University of Texas Health Science Center at San Antonio Dental School

We are indebted to the speakers, authors, and conference participants in the Oral Health and Cancer Therapy Conference, 2009.

The monograph was published in its entirety in August 2009. To obtain a printed copy of the monograph Oral Health in Cancer Therapy, contact Mr. Grady Basler at grady@doep.org. The monograph is also available for download in Adobe Acrobat format on the Dental Oncology Education Program website, doep.org.

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Management of Oropharyngeal Mucositis Pain Mark M. Schubert, D.D.S., M.S.D., and Daniel L. Jones, Ph.D., D.D.S.

Introduction one of the central fears of all cancer patients is pain — both pain caused by cancer and pain arising from cancer therapy. Patients can present with tumor pain involving various sites of the body, including the head and neck and oropharynx, treatment-related pain, and preexisting pain complaints such as low back pain or other chronic pain problems. All these are intertwined in the patient’s ongoing pain experience, and must be addressed if the patient’s pain is to be successfully managed.

Schubert

Jones

Mark M. Schubert, D.D.S., M.S.D., director, Oral Medicine, Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, Seattle, Washington Daniel L. Jones, Ph.D., D.D.S., professor and chair, Department of Public Health Sciences, Baylor College of Dentistry, TAMHSC, Dallas, Texas

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Management of Oropharyngeal Mucositis Pain Severe OPM significantly affects the cancer patient’s psychological state, producing mood disturbances, specifically increased depression and anger.

While significant advances continue to be made in the field of supportive care for cancer, oropharyngeal mucositis (OPM) continues to be a frequent and debilitating oral side effect of aggressive cancer therapies. However, mucositis is much more than just mouth and throat pain. Chemotherapy and radiation can cause significant mucosal damage but can also have a marked effect on oral function and the patient’s psychological well-being.

From a patient’s perspective, the pain and disability from oral mucositis can be all consuming, and represent the worst experience that the patient remembers from their cancer treatment.

Studies have shown that the mucositis associated with myeloablative treatments for hematopoietic stem cell transplant can be the most frequently reported cause of pain and is rated as the most debilitating side effect and, in fact, as the worst transplant-related experience by patients. Severe OPM significantly affects the cancer patient’s psychological state, producing mood disturbances, specifically increased depression and anger.

The impact of mucositis on the patient’s physical and psychological well-being is pervasive and profound, since mucositis and the pain it causes can: • • • • • •

Interfere with therapy by necessitating treatment delays and dose reductions that can interfere with cancer cures.

Increase risk of other complications including infections and bleeding.

Increase the cost of care.

Interfere with oral function, making it difficult or impossible to eat, swallow or drink.

Affect mood and behavior.

Dramatically diminish quality of life.

Advancements in the field of supportive care relative to the prevention and management of OPM continue to be made. Evidencebased guidelines, such as those produced by the Multinational Association of Supportive Care in Cancer (MASCC), have identified mucositis prevention and treatment strategies that can be beneficial for patient care based on level II and III evidence.

Unfortunately, only a relatively small number of treatments met criteria for inclusion in the guidelines. Examples of effective treatments include the use of palifermin (a mucosal growth factor) that has been shown to be able to significantly reduce the frequency and severity of OPM in patients undergoing autologous hematopoietic cell transplants (HCT) and oral cryotherapy (so called “ice chip therapy”) that has been shown to reduce the frequency and severity of oral mucositis in patients treated with high dose 5-FU, melphalan, and edatrexate. But these treatments, while effective for specific cancer therapy protocols, cannot be used with all patients at risk for OPM, leaving significant numbers of patients to potentially suffer. Considerably more research is clearly needed. In

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most instances, current strategies focus on palliation of pain symptoms until the oral tissues involved can recover and heal.

Currently, management of mucositis pain continues to rely on a multidimensional approach to pain and symptom management. Evidence-based guidelines suffer from the lack of sufficient evidence to manage OPM across the scope of cancer patients and there still is a need for an organized and cogent approach to oral mucositis pain management that allows a comprehensive approach to patient care in the face of major gaps in scientific evidence. The oral mucositis management guidelines recently published by the National Cancer Care Network (NCCN) represent an attempt to utilize a reasonable combination of levels of evidence that combines “evidencebased guidelines” with lesser levels of evidence in a manner that allows for more comprehensive mucositis management where gaps in evidence occur.

One major clinical cause of ineffective mucositis pain management is simply under-treatment. In general, the under-treatment of cancer and cancer therapy-related pain is a recognized problem throughout oncology, for a number of reasons. Clinician-related factors in the under-treatment of pain can include inadequate knowledge of pain management, poor assessment of pain, and concerns about prescribing controlled substances, especially opioids with the potential for patient tolerance, addiction and side effects. Patient-related factors include reluctance to report pain, fear that pain means the primary treatment is failing, concern about being perceived as a “complainer”, reluctance to take pain medications, fear of addiction/dependence and concerns about side-effects. Factors such as gender, culture, education, occupation, economic status, and experience with medical care systems also contribute to differences in response to treatment and the incidence of side effects.

All of these factors must be considered, not only for the treatment of pain, but also in the approach of medicine and care of patients from diverse cultural and educational backgrounds. Delivery of individually appropriate pain control requires more than knowledge of pathobiology and pharmacology, and must extend to an understanding of cultural and ethnic values, linguistic influences on pain expression and description of pain quality, patients’ reaction to the pain experience (seeking healthcare), coping styles and adopting disability status, the patient/provider relationship and finally, the patient’s receptivity to treatment and compliance.

One major clinical cause of ineffective mucositis pain management is simply under-treatment. In general, the undertreatment of cancer and cancer therapy-related pain is a recognized problem throughout oncology, for a number of reasons.

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Management of Oropharyngeal Mucositis Pain

Pain Management for Mucositis: General Principles OPM pain can be generally classified as an acute cancer treatmentrelated pain although it clearly has several unique qualities and the management of oral mucositis pain can generally follow the basic principles used for acute pain management. OPM pain results from direct local injury to tissues and inflammation that activates nociceptive receptors at the site of injury. The pain lasts for a relatively limited time, as short as 1-2 weeks for chemotherapy-related mucositis and usually less than 3 months for head and neck radiation-induced mucositis. Mucositis pain will usually resolve once the underlying mucosal tissue damage resolves. A possible exception is mucositis resulting from radiotherapy, which may produce chronic pain. For effective management of mucositis pain, a multidimensional approach to patient care, with a supporting pain management framework and mucositis pain management guidelines is required for more comprehensive management, increased success, and patient comfort.

The basic tenets of a standard acute pain management model are as follows: • The basis of acute pain management does not relate to pain intensity, but rather to responses to rising levels of pain and the provision of adequate pain control. The clinician should escalate pain management to the next level when pain control becomes inadequate.

• Start with pain management with strategies that are appropriate for the patient. Start with local topical treatments and escalate as needed.

• The objective of analgesic drug use, especially for opioids, is to achieve the minimum effective analgesic concentration, (i.e., the lowest blood level that results in consistent patient report of complete analgesia.) Research shows that this level may vary by a factor of 5 across patients. There is no “standard dose” for opioids, as efficacy varies across individuals.

• Once a steady state of adequate pain relief has been achieved, dosing should remain stable until pain assessments show increasing background pain.

• Breakthrough OPM pain should be addressed immediately, usually with aggressive strategies that provide immediate pain relief.

This can involve the application of topical anesthetics in combination with a rapid onset short-acting opioids.

• Adjuvant drugs and non-pharmacologic pain management strategies are used at all levels, to enhance pain relief and to treat adverse effects of analgesic medications and to treat concomitant psychological and physiological disturbances such as anxiety, depression and insomnia.

• The drugs recommended for mild-to-moderate pain have dose limits, not because they contain opioids, but primarily because they are combined with acetaminophen or non-steroidal anti-inflammatory drugs that require dose ceilings to avoid toxicity.

• Regular assessment of analgesic adequacy and the adverse effects of analgesic drugs are necessary.

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Improving Management Success There are several common principles that can improve overall management success: •

•

•

•

• •

Anticipate pain problems — be prepared for mucositis pain and commence management at the first recognition of a discomfort.

Deliver pain medication via the simplest and most convenient manner possible (usually by mouth).

Dose pain medication on a time-contingent basis, not a pain-contingent basis.

Utilize a pain management strategy with escalating strength and complexity of pain medications (e.g., the World Health Organization (WHO) “Pain Ladder”).

Customize pain strategies for the individual.

Manage the patient’s pain with an attention to detail.

Ideally, patients should be assessed prior to therapy as to their level of understanding about mucositis which should be followed up with appropriate education and training.

Questions to ask should include the following: • • •

Do you know what mucositis is?

Have you had mucositis in the past?

How was it managed? How successfully was it managed?

If patient has had no experience with mucositis, patient education should include: • • • •

What causes mucositis.

What it feels like.

How long it lasts.

What can be done to prevent it and/or manage it.

Stepped Oral Mucositis Pain Management Model This stepped oral mucositis pain management model is based on principles of ascending aggressiveness of pain management strategies in response to the patient’s increasing OPM pain and integrates the basics of oral oncology and dental care with a medical model for managing pain. While based on the principles of the World Health Organization (WHO) analgesic ladder, the integration of a basic oral care foundation step and the consistent use of topical management strategies across steps are unique. This approach initially utilizes a wide variety of oral pain management strategies, including bland rinses and mild analgesic agents (topical anesthetics, non-steroidal anti-inflammatory agents and opioids), but also recommends the use of non analgesic agents (benzodiazepines, antidepressants, etc) and non-pharmacologic pain management strategies (relaxation techniques, TENS, acupuncture and psychological therapy management strategies) when appropriate. An important note to make about this approach to pain management is that when a patient’s care is stepped up to the next level, the strategies utilized from the previous step(s) should be continued — for example, bland rinses and topical anesthetics used for mild mucositis pain management should continue to be used after the patient is started on opioids.

Table 1. Oral Mucositis Pain Control Model Elements of Stepped Model for Management of Oral Mucositis Pain Pre Cancer Treatment: Oral Health Stabilization

Elimination / prevention of oral infection and trauma Dental health stabilization: dental decay, periodontal disease, endodontic disease, potential sources of trauma Mucosal health stabilization: elimination of oral infection Patient education and training

Step 1 Foundations of Care

Maintenance of dental and oral health stabilization Routine oral hygiene Bland oral rinses / ice chips Trauma / irritation prevention / diet modifications Multidisciplinary team: frequent oral assessments

Step 2

Mild oropharyngeal mucositis pain / oral dysfunction Basic oral hygiene Topical oral pain management Mild analgesics Adjuvant drugs Non-pharmacologic pain control Trauma / irritation prevention Frequent assessments

Step 3

Moderate oral mucositis pain / oral dysfunction Basic oral hygiene (modification as needed) Topical oral pain management Moderate strength opioids Breakthrough pain management Non-pharmacologic pain control Adjuvant drugs Frequent oral assessments of mucositis and oral pain Diet modifications: Nasogastric tube / hyperalimentation Frequent assessments: oral mucositis and pain

Step 4

Severe oral mucositis pain / oral dysfunction Basic oral hygiene Topical oral pain management Strong opioids: Sustained release / patient-controlled analgesia Breakthrough pain management Non-pharmacologic pain control Adjuvant drugs Frequent oral assessments of mucositis and oral pain Diet modifications: Nasogastric tube / hyperalimentation Frequent assessments: oral mucositis and pain Texas Dental Journal l www.tda.org l May 2010

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Oral Mucositis Pain Control: Pre Cancer Therapy Oral and Dental Health Stabilization The goals for this level are essentially to stabilize oral health, eliminate factors that could complicate the course of cancer therapy, and educate and motivate patients relative to oral self-care. It is very important to ensure that patients understand the relationship between oral/dental health and systemic health during cancer treatment. Additionally, strategies to reduce the risk of oral trauma from normal oral function (eating, oral hygiene, etc.) should be reviewed with patients. Basic oral care protocols include plaque control measures (tooth brushing, flossing, etc.), the use of bland oral rinses (normal saline and/or sodium bicarbonate rinses), and the consideration of viral and fungal prophylaxis if patients are at risk for immunosuppression. Potential sources of mucosal irritation from sharp or fractured teeth, broken restorations, or poor fitting dentures should also be identified and eliminated.

Finally, patients should be educated as to what oral complications could be associated with the upcoming cancer therapy and how these problems are managed. Patient education should always be instituted prior to initiation of therapy and the onset of symptoms. Information on oral mucositis management should be provided regarding available pain control therapies, including non-pharmacologic options, with the rationale for their use. It is important to discuss the duration and course of symptoms and side-effects. The patient care team should have protocols in place for assessment of mucositis and mucositis management strategies. The patient needs to understand that: 1) it is easier to prevent pain than to reduce it once it has begun, 2) to tell care providers if their pain is not adequately controlled, and 3) to factually report pain, while avoiding stoicism or exaggeration.

Table 2. Foundations of Care Oral Hygiene: Bacterial Plaque Control

Tooth brushing (twice a day) Flossing (once a day) Antibiotic rinses (when indicated)

Mucosal Moisturizing and Lubrication

Saline rinses Sodium bicarbonate rinses Artificial salivas / oral moisturizing products

Chapped Lips

Lip balms Lip moisturizing agents Lanolin products

Oral Mucosal and Pain Assessment

Routine mucositis assessment with validated mucosal scoring instrument Oral pain and oral function assessment

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Oral Mucositis Pain Control Model level

1: foundations of care

Basic Oral Hygiene The foundation of oral care for cancer patients centers on maintaining basic dental and gingival health and mucosal integrity throughout cancer treatment periods. Patients should continue oral hygiene protocols to remove bacterial dental plaque with tooth brushing and flossing regimens.

Oral bacteria can negatively influence ulcerative mucositis and periodontal infections (gingivitis, periodontitis, etc.) and can lead to both local and systemic infection problems for patients, especially if they become immunosuppressed. Antibiotic oral rinses (e.g., chlorhexidine oral rinses) can be used to control bacterial plaque when brushing or flossing is compromised.

As mouth pain increases, oral hygiene protocols may need to be modified, (e.g., having patients discontinue the use of toothpaste if it causes stinging, encouraging the use of floss holders for patients with mucositis or if flossing with hands is associated with nausea and vomiting).

Bland Oral Rinses Bland rinses are useful for moisturizing the mouth, reducing mucosal irritation, and reducing discomfort. Numerous rinses containing various combinations of ingredients have been recommended. Recent evidence indicates, however, that perhaps normal saline solution (0.9 percent) is the best. Dodd, et al. (2001), found that normal saline solution was as effective as “magic mouthwash” (lidocaine, diphenhydramine, antacid solutions and nystatin) in reducing mucositis pain and was also better than chlorhexidine. The conclusion was that the least expensive, safest and easiest to use compound — normal saline solution — was the treatment of choice.

Examples of bland oral rinses include: • 0.9 percent saline solution (0.9 gm NaCl in 100 ml water — approximately ¼ tsp in 8 oz water). In most instances, sterile saline is not necessary unless there is concern for the safety of water supply. Rinse containers should be changed daily or thoroughly cleaned. Ice can be added to the saline solution immediately before rinsing if the coolness is more comfortable for the patient. Sucking on ice chips can also be of benefit for many patients due to their “counter stimulation” effect.

• Sodium bicarbonate rinses (1-2 Tbls in 32 oz water) — especially recommended after emesis, to neutralize gastric acid and buffer oral pH. • 0.9 percent saline + sodium bicarbonate rinses — (0.9 percent saline has a pH of 5.2, adding sodium bicarbonate will increase the pH to a more neutral to slightly basic pH. Oral Rinsing Instructions: • Swish and gargle solution for 12-30 seconds per mouthful.

• Use a total of 12-16 oz every 6 hours or as often as every 15-30 minutes as necessary to provide for patient comfort.

• Use rinses prior to application of medicated rinses or topical medications, to remove mucus saliva and debris.

Oral Moisturizing and Lubrication Since salivary gland dysfunction is frequently noted with cancer chemotherapy and head and neck radiation, bland rinses can be instituted

Antibiotic oral rinses (e.g., chlorhexidine oral rinses) can be used to control bacterial plaque when brushing or flossing is compromised. As mouth pain increases, oral hygiene protocols may need to be modified, (e.g., having patients discontinue the use of toothpaste if it causes stinging).

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Management of Oropharyngeal Mucositis Pain when this occurs to help moisturizing mucosal surfaces, keeping the mouth clear of debris and stimulating salivary function to maintain oral comfort. Artificial salivas and oral moisturizing products can help patients remain more comfortable. The swishing and expectorating of antacid solutions (e.g., Amphojel®) to coat oral tissues have not been adequately studied to determine efficacy, but could be hypothetically of benefit, especially in instances of emesis.

Chapped Lip Management Chapped lips are also a common complication of intensive cancer chemotherapy protocols. The use of lip balms and moisturizing agents should be encouraged early on to prevent potential cracking and splitting of the patient’s lips. Lanolin cream or ointment can often provide for better lip protection than petroleumbased products.

Oral Mucositis and Mucositis Pain Assessment Oral assessments for mucositis should begin early after the start of cancer treatment protocols and be repeated on a regular basis. A multidisciplinary team approach to assessing and managing oral care is strongly recommended to assure continuity and completeness of care.

A number of instruments have been developed to assess clinical oral status and range from simple scales such as the WHO Mucositis Scale, to more complicated research orientated instruments such as the Oral Mucositis Index; the choice of which instrument to use is primarily based on the intended use of gathered scores and the practicality of who will be assessing the patient where training and issues of interrater reliability are the primary issues.

Oral Infection Prophylaxis Though technically not part of a mucositis prevention or management protocol, patients at risk for significant myelosuppression from cancer therapies and thus oral viral and fungal infections, will often be placed on infection prevention protocols that include antiviral, antifungal and antibacterial agents. Oral infections, especially herpes simplex infections in this setting, can significantly amplify mucosal breakdown and oral pain. If patients are not treated with infection prophylaxis protocols, they should be carefully monitored for the possible occurrence of infection, the presence of which can be masked by the “expected” mucositis.

Oral Mucositis Pain Control Model levels

2-4: mild to severe oral mucositis pain and oral

dysfunction Oral mucositis related discomfort and pain often is first noted as pharyngeal discomfort (“sore throat”) and then progresses to oral symptoms. Patients should increase their frequency of rinsing with bland rinses and be started on topical anesthetics and, when medically possible, mild non-opioid analgesics. The use of the NSAIDs is contraindicated where concerns for bleeding due to anticoagulation

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or low platelet counts are present. The addition of mucosal protectants, adjuvant drugs, and non-pharmacologic pain control measures should also be considered. Additionally, modifications to the patient’s diet should be encouraged that include softer and moister foods. Oral examinations and subjective assessments should document the extent of mucosal damage, level and direction of pain, and overall patient comfort and satisfaction with current management strategies.

With increasing pain, oral mucositis pain management efforts should become more focused on the use of opioids.

Initially mild opioids are used, but should be quickly escalated to the use of stronger opioids, often with continuous dosing with timerelease formulations, patches, intravenous, intramuscular or subcutaneous parenteral dosing. The use of patient-controlled analgesia (PCA) requires a specific computerized infusion pump apparatus, and though techni-

cally more complicated to set up, provides an excellent strategy for pain medication delivery; studies have shown patients to use a lower total opioid dose with better pain control and fewer opioid side-effects.

Basic oral hygiene should be continued. If toothpaste becomes irritating, patients should be switched to non-mint flavored toothpastes or instructed to brush with saline or water only.

Topical Management of Mucositis Pain Topical management of oral mucositis pain utilizes bland oral rinses, mucosal protectants and bland coating and moisturizing agents.

Bland Rinses The frequency of bland rinses should be increased as oral discomfort increases. Rinses should be made available bedside so that they can be used ad lib. A cup of saline should be easily available at bedside to be swished and

spit should the patient wake with mouth discomfort. The soothing effect can help the patient go back to sleep more readily.

Topical Anesthetics The use of topical anesthetics is recommended early in the evolution of mucositis, to manage mild to moderate mucositis pain. The anesthetic should be applied directly to painful tissues in sufficient concentrations, and held in the mouth for a long enough time, to allow penetration to reach nerve endings and provide for significant anesthesia.

Frequency of subsequent applications depends on which anesthetic is being used, how it is applied, and the severity of mucositis.

As mucositis worsens, the effective duration of anesthesia will become shorter. However, use should continue as the patient moves up the pain control ladder.

As there are relatively few comparative trials of topical efficacy, the clinician will have to rely on clinical experience and patient acceptance when choosing which drug to use and how to apply it.

Table 3. Topical Anesthetics for Management of Mucositis Pain Agent

Formulations

True Topical Anesthetics Lidocaine

Viscous gel, jelly, ointment, solution, patches

Benzocaine

Gel, ointment, spray

Tetracaine/Chirocaine

Anesthetic tabs

EMLA

Cream

“Magic Mouth Rinses”

Compounded rinse (lidocaine, diphenhydramine, Amphojel, +/- nystatin)

Antihistamines Diphenhydramine

Elixir, IV solution

Other Agents Doxepin

Elixir

Benzydamine

Rinse (not available in US)

Benzonatate

Gel caps (open and coat mouth)

Cocaine

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Management of Oropharyngeal Mucositis Pain Probably one of the most frequently prescribed treatments for oral mucositis are the so-called “Magic Mouth Washes.” These rinses represent an empiric combination of a number of agents including anesthetics (lidocaine and diphenhydramine) together with an antacid “coating” agent (e.g., Amphojel®), an antifungal (e.g., Nystatin), and occasionally a steroid. While these compounded rinses can clearly provide for palliative pain control due to the topical anesthetics, their efficacy remains equivocal and there is insufficient evidence to suggest that they are any more effective than topical anesthetic agents used signally.

Additionally, the efficacy of antacid coating agents, nystatin and steroids in this setting has never been proven, especially in the more common concentrations. It is worth noting that topical nystatin rinses have been definitively shown to be ineffective in preventing oral Candida infection in oncology settings, so there is even less reason to believe nystatin provides any benefit in the setting of this mucositis treatment.

When considering the use of such compounds, the following questions should be asked: • Are all the agents in the rinse indicated for the situation and are they efficacious?

• Does the combination provide any more benefit than a single agent?

• Are all the agents in the compound accepted by the patient? Many patients find the taste and/or consistency of these combination rinses

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• •

unacceptable.

Is the best formulation of the drug being used?

What is the cost/benefit ratio for these rinses, given that compounding is more expensive?

When doxepin, an antidepressant, is applied topically in liquid form, it initially causes anesthesia, but as the anesthesia wears off there can be a persistent analgesic effect. This is a phenomenon that is similarly noted for benzydamine rinses (benzydamine is not available in the US, but is marketed in Canada, Europe, and South America).

Both diphenhydramine solutions and doxepin elixir can produce some degree of sedation and oral dryness if swallowed. Cocaine is a powerful topical anesthetic, which has not been prescribed very much in recent years due to its reputation as a drug of abuse, but which nonetheless is potentially useful in this setting.

In addition to producing rapid anesthesia, it is also a strong vasoconstrictor, which makes it useful for mucositis patients with mucosal bleeding problems. There can be some central effects from topical oral mucosal application, although the mild euphoria experienced can be beneficial for patient mood and the potential for abuse in mucositis patients is generally not an issue.

Warning: Mucositis patients being treated with topical anesthetics should be cautioned to: • Avoid accidental mucosal trauma when tissues are numb.

• Not to eat or perform oral

• •

•

hygiene while oral tissues are anesthetized.

Not to wear removable oral appliances.

Be especially careful not to gargle or swallow anesthetics — anesthesia of the soft palate/ oropharynx can diminish the patient’s gag reflex and increase the risk of aspiration.

Do not swallow topical anesthetics unless they are safe relative to potential systemic effects and they are deemed acceptable.

Mucosal Surface Protectants A number of proprietary agents with mucosal covering or mucoadherent effects are marketed to help with the management of oral mucositis, some with “prophylactic use” protocols. While these products have been approved as “devices” by the FDA (e.g., Gel Clair®, Mucotrol™, MuGard™, CAPHOSOL®); unfortunately there is minimal or no scientific evidence to demonstrate clinical efficacy for these products, and until there is adequate supportive research, they cannot be recommended. Filmforming agents (e.g., hydroxypropylcellulose gels and 2-octyl cyanoacrylate products) provide a thin adherent barrier over ulcerated tissue, thereby reducing some of the stimulation and reducing pain.

Pharmacologic Pain Control Systemic pharmacotherapy currently provides the foundation

for treating moderate or severe oral mucositis, as it is low risk, cost effective, dependable and easily administered. The value in starting with and maintaining topical and non-pharmacological therapies along with cognitive and behavior interventions lies in the ability to provide the dual benefits of pain control and coping strategies. A multimodal approach maximizes the effectiveness of pain control and reduces the need for otherwise more aggressive single modality pain therapies. Treatment must be individualized, as patients vary in acceptance of, and responses to, specific analgesics and adjuvants as well as different behavioral strategies.

Systemic Analgesics The major classes of analgesic drugs used in treatment of cancer-related pain include the nonsteroidal anti-inflammatory drugs (NSAIDS), opioids and adjuvant analgesics. The various routes of drug delivery used include both enteral (oral, transdermal, transmucosal) and parenteral (intramuscular, subcutaneous and intravenous) routes.

enhanced analgesia when used with opioids, as the resultant effect is more than simply an additive effect. The advantages of the NSAIDS include the fact that many are available OTC, making them relatively inexpensive, and that they do not produce tolerance or dependence. There is, however, a ceiling effect on both analgesic potential and toxicity and thus maximum safe dose limits must be adhered to — a factor that is critical to consider when they are combined with opioids. The safe maximum dose for the NSAID component of the combination agents can often be reached well before reaching the maximum dose of the opioid agent. While technically not an NSAID, acetaminophen is included in this group due to its analgesic action and general safety level.

Non-opioid Analgesia: NSAIDS The major class of analgesics recommended for mild oral mucositis pain are the non-steroidal antiinflammatory drugs. They are effective when used alone or when combined with opioids. These drugs bind to different receptors than do the opioids and affect the tissue damage and pain caused by inflammation. They provide

Table 4. Non-Steroidal Anti-Inflammatory Drugs Paracetaol

Acetaminophen

Propionic acids

Ibuprofen, Naproxen, Naproxen sodium, Fenoprofen, Ketoprofen, Flurbiprofen, Oxaprozin

Meclofenamic acid

Meclomen

Acetic Acids

Diclofenac potassium, Sulindac, Ketoralac, Etodolac

Nonselective COX-1 and COX-2 Inhibitors

Aspirin, Diflunisal, Choline magnesium trisalicylate

Selective COX-2 Inhibitors

Celecoxib (see FDA alert)

Cox / Lox Inhibitor

Llicofelone (under development)

Oxicams

Piroxicam, Tenoxicam, Droxicam, Lomoxicam, Meloxicam

Spectrum of NSAID Toxicity Platelet dysfunction is the most problematic side effect of NSAIDS, and they should not be given to patients at risk for bleeding problems, (e.g., thrombocytopenic patients or patients with a history of bleeding gastric or duodenal ulcers, etc.) The side-effect of greatest

concern, however, is renal and hepatic toxicity, especially with extended use. NSAIDS bind to plasma proteins and may displace other protein-bound drugs, thus altering the availability and effectiveness of drugs such as warfarin, methotrexate, digoxin, cyclosporin, oral anti-diabetic agents, and sulfa drugs. NSAIDS

are typically available in a variety of dosing forms, including tablets, caplets, capsules, oral liquids, and rectal suppositories.

Choice of drug and dosage may be based on patient response and titrated to effect.

Opioids The opioids are the cornerstone Texas Dental Journal l www.tda.org l May 2010

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Management of Oropharyngeal Mucositis Pain for moderate to severe mucositis pain management. These drugs are effective, easy to titrate and have a favorable risk/benefit ratio. There is no ceiling to their analgesic efficacy. There are two major categories of opioid drugs: those used for control of mild to moderate pain and those used for control of moderate to severe pain. The efficacy and potency of these drugs is dependent upon the delivery system, and when they are formulated with NSAIDs, the latter agent can limit their dosage.

Opioids: Formulations The oral dose of these drugs can provide for immediate, intermediate and extended release. The latter are often the most popular formulations, as they can provide longer periods of sustained pain relief, and can also result in better compliance with “by the clock� dosing. While oral is generally the preferred route of analgesia administration, other routes (transdermal, transmucosal or parenteral) may be considered.

By utilizing different routes and formulations of agents throughout the day, an effective pain relief protocol can often be developed to keep a patient comfortable while both awake and during sleep.

Recent studies have established the benefit of transdermal Fentanyl in managing severe oral mucositis. Additionally, the rapid uptake of oral transmucosal fentanyl makes it a reasonable consideration for use for breakthrough oral mucositis pain; combination with other opioids requires careful adjustment of doses and monitoring for sideeffects.

Dosage of Opioid Analgesics Patients vary greatly in analgesic dose requirements and responses to opioids, thus the recommended protocol specifies standard starting doses, followed by titration of subsequent doses, as the analgesic and side effects are monitored.

Addiction is a term that is often mistakenly applied to physical dependence side-effects associated with opioid use for pain control.

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For many opioids, it is may be possible to reduce the amount of opioid needed to control oral mucositis pain by combining the opioid with a medication with analgesic-sparing properties, also referred to as a potentiator. Hydroxyzine is probably the most effective and safest opioid potentiator. Orphenadrine and other antihistamines, nefopam (a non-opioid analgesic available in Europe), and the muscle relaxant carisoprodol, and antihistamines can also be used to potentiate most opioids. It is extremely important that the titration of opioids and addition of the potentiator be very carefully supervised, especially in the case of carisoprodol.

Table 5.Oral Mucositis Pain Control: Level III and IV Opioid Medications for Oral Mucositis: Steps 2 - 4 Mucositis Management Step

Standard Starting Dose / Route1

Steps 2 and 3: Opioids for Mild to Moderate Mucositis Pain Codeine phosphate2 Codeine sufphate2 Oxycodone2 Oxycodone extended release tabs2 Hydrocodone2

15 – 60 mg PO/SC/IM q4-6 hr 15 – 60 mg PO q4-6hr 15 – 30 mg PO q4hr 10 – 160 mg PO q12hr 5 – 10 mg PO q4-6 hr

Steps 3 and 4: Opioids for Moderate to Severe Mucositis Pain Morphine oral Morphine extended release Morphine IV, IM

10-60 mg PO 15-30 mg PO q8-12 hr Intravenous doses can vary from1-7 mg/hour (IV direct: 1-5 mg given over at least 1 minute, titrated every 6-10 minutes until analgesia is achieved (usual maximum 12 mg per hour), then give IM, SC, IV intermittent or IV/SC infusion: IM, SC: 5-10 mg q3-4h IV intermittent: 5-10mg given over 15-30 minutes q3-4h IV, SC infusion: 0.5-4 mg/hr titrated to effect; there is no maximum dose

Hydromorphone

2-8 mg PO q3-4 hr; 1-4 mg SC / IM / IV

Oxycodone2a Oxycodone extended release2

15-30 mg PO q4 hr 10-160 mg PO q12 hr

Oxymorphone2 Oxymorphone extended release2 Oxymorphone2

10-20 mg PO q4-6 h 5 – 40 mg PO q12hr 1 – 1 .5 mg SC / 2.5-5 mg SC/ IM /IV q8-12 hr

Methadone

2.5-10 mg PO bid or t.i.d. / 10 mg IM 2 mg PO / 2 mg IM

Levorphanol

2 mg PO q6-8hr

Fentanyl transdermal patch Fentanyl Intravenous Fentanyl transmucosal3 Fentanyl buccal tablet l3

12-1000 mcg/h patch q72hr100 μg 50-100 mcg/kg IV q1-2hr or 0.5-1.5 mcg/kg/IV 100 - 200 mcg per dose (titrate q15 minutes p.r.n.)

100 – 800 mcg applied to buccal gingiva

Not recommended: These drugs are either antagonists or agonist drugs with poor profiles for extended use

Not recommended:

Meperidine Propoxyphene Tramadol Talwin Pentazocine

Buprenophine Pentazocine Butorphanol Dezocine Mereridine Nalbuphine

1 Adult dosing schedules. Doses need to be adjusted depending on renal and/or hepatic status 2 Are combined with acetaminophen, aspirin, or ibuprohen which can be dose-limiting 3 Transmucosal and buccal fentanyl are used for breakthrough pain, doses can vary and are customized by prescribing clinician

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Management of Oropharyngeal Mucositis Pain Side-Effects of Opioids One of the major drawbacks to the use of opioid drugs for pain control is the potential development of tolerance, which is a physiologic state in which the patient requires increased doses of the drug to achieve the same analgesic effect. Fortunately, tolerance is more of a consideration for long-term use of these drugs and not usually a problem for opioid-naïve mucositis patients.

Physical dependence is an expected state of adaptation, not an adverse side-effect to opioid analgesics that can develop and is due to the pharmacologic properties of opioids, producing an “abstinence syndrome”. It occurs when a patient becomes adapted to an agent that when withdrawn can cause distinct side effects.

Physical dependence is often confused with addiction.

The signs and symptoms of physical dependence include: • Anxiety • Lacrimation • Abdominal cramps • Irritability • Rhinorrhea • Vomiting • Chills and hot flashes • Diaphoresis • Diarrhea • Joint pain • Nausea Dependence tends to occur after 2 weeks of opioid therapy, and withdrawal symptoms may be avoided by gradually decreasing the scheduled frequency of the opioid.

Addiction is a term that is often mistakenly applied to physical

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dependence side-effects associated with opioid use for pain control. Addiction involves a psychological dependence, characterized by overwhelming involvement with drug use, compulsive use and behavior directed toward securing a supply of drug. In addicted individuals, there is a high tendency to relapse into drug abuse, despite the obvious harm and social consequences that result. In contrast to true addiction, what is more commonly encountered in patients using opioids for pain control is pseudo-addiction, which is the result of inadequate opioid dosage, leading to increased sympathetic nervous system activity and a need for increased medication.

Management of Side Effects of Opioid Therapy When prescribing opioids, sideeffects should be anticipated.

The most common side-effects that interfere with opioid dosing are constipation, nausea, pruritus, and sedation. Other side effects that are encountered include fatigue, vomiting, confusion, urinary retention, myoclonus, dysphoria, euphoria, sleep disturbance, sexual dysfunction, respiratory depression, and endocrine abnormalities.

Persistent respiratory depression is rare in opioid-tolerant individuals. Generally, most side-effects will occur in the first few hours of treatment and then will gradually disappear. If side-effects persist, the clinician may choose to switch a patient’s pain medication to make sure the patient gets maximum pain

control with a minimum of sideeffects. Dehydration can accentuate the side-effects of opioids, so patients should be encouraged to drink adequate fluid volumes or these should be provided intravenously when necessary.

Strategies to manage side effects of opioid therapy can include: • Change the dosing regimen or route of the same drug – aim for constant blood levels and avoiding high serum peak levels.

• Try another opioid that may have a different propensity for producing a specific sideeffect.

• Add drugs to regimen to counteract specific adverse effects.

• Constipation: Anticipate this very common problem caused by opioids. Prevention revolves around the following:

n Encouraging patients to

drink plenty of fluids.

n Use of high fiber diets.

n Administering bowel

stimulants and stool

softeners on a regular

basis.

If constipation develops, treatment usually requires the use of enemas and/or suppositories.

Magnesium citrate is used for impaction in the proximal colon.

Opioid-induced ileus is managed with continuous infusion of metoclopramide.

Nausea and vomiting: Normally, these side effects occur a day or two after first taking a par-

ticular medicine and correlate to high serum peak levels.

Consequently, aiming for relatively constant blood levels can help reduce nausea. Different opioids in different patients can cause variable degrees of nausea – therefore consider an alternative opioid. The prophylactic use of antiemetics can reduce or prevent this side-effect.

Transdermal scopolamine, hydroxyzine or phenothiazine can be used until tolerance to nausea develops.

Sedation: When first taking opioids, some patients may feel drowsy or sleepy; however, it is usually only transient and for most patients will disappear in a day or two. If this is a serious problem, several strategies can be employed: • Decreasing the dose and increasing the frequency of administration; • Switching to an opioid with a shorter half-life; • Opioid rotation; or • Administration of centrally acting stimulants such as caffeine, methylphenidate, or amphetamines.

Pruritus (itching): Changing opioids can usually help eliminate this problem. Oxymorphone and fentanyl have little propensity to release histamine, which often causes itching or urticaria.

Additionally, antihistamines can be used to manage this side effect of opioid administration.

Antihistamines can also augment analgesia and help reduce anxiety.

Respiratory depression: Respiratory depression is probably the best example of a serious adverse pharmacological effect that is only rarely encountered clinically, but which generates concern sufficient to cause under-treatment. The occurrence of respiratory depression is extremely uncommon in patients who undergo gradually escalating doses. It can however, occur in opioid-naïve patients who receive high doses of opioid analgesics. Opioid-induced respiratory depression, if not caused by a massive overdose, is always heralded by the gradual onset of obtunded and/or slowed respiratory rate, signs that signal an impending problem that needs to be managed appropriately. Monitoring drug effects by assessing the level of consciousness and respiratory rate can greatly diminish the risk of serious respiratory depression.

Adjuvant Drugs Adjuvant pharmacotherapy is used to augment analgesia, to treat psychological disturbances and distress and to treat the adverse effects of primary analgesic drugs. This is a diverse group

of drugs and often utilizes antidepressants and anti-anxiety agents, and can be more difficult to use without some level of experience.

Adjuvant analgesia frequently utilizes low-dose tricyclic antidepressants (TCAs). While the most recognized pain management arena for these agents is for chronic pain, they can also be used advantageously for short-term pain situations, too, especially where mucositis is a recurrent problem with successive rounds of cancer treatment.

The value of these drugs for patients with mucositis is clearly not in providing an antidepressant effect but rather to aid with sleep dysfunction and relaxation.

These drugs bind centrally to non-opioid receptors and in this situation it is accepted that they have no antidepressive effect per se. Due to their “anticholinergiclike” effect, TCAs may produce adverse side effects such as xerostomia, sedation and occasionally constipation. Although rare, there also is a risk for marrow suppression.

The other major group of drugs in this category are anti-anxiety agents with such agents as lorazepam, diazepam, and alprazolam. Standard precautions relative to the use of these agents definitely need to be followed in this setting.

Table 6. Adjuvant Drugs Tricyclic antidepressants

Favored because of weaker anticholinergic effect

Selective serotonin re-uptake inhibitors

Can be used, but have not been adequately researched, and generally do not help with sleep

Antihistamines

Enhance opioid analgesia Help manage anxiety Provide sedation Reduce opioid-related itching

Benodiazepines

Useful to relax patients when anxiety contributes to mucositis pain experience Texas Dental Journal l www.tda.org l May 2010

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Oral Health in Cancer Therapy

Management of Oropharyngeal Mucositis Pain Non-pharmacologic Management of Pain Non-pharmacologic techniques for pain management represent a wide range in supportive care pain management strategies. Several of these techniques require specific training prior to the onset of pain and ongoing supervision and support can increase their effectiveness.

Strategies include: • Exercise • Counter-stimulation — ice packs, massage, and heat applied to perioral/head and neck areas • Pediatric patients — holding, stroking, and rubbing • Transcutaneous electrical nerve stimulation (TENS) • Acupuncture • Cognitive-behavioral strategies • Distraction and reframing • Relaxation and guided imagery • Hypnosis • Psychosocial interventions • Peer support groups — particularly if pain is of longer duration • Pastoral counseling — spiritual care and support system for patients and family • Pediatric patients need more help — the parents must also be educated and involved.

Special Considerations: Elderly Patients The clinician must be cognizant of the fact that the elderly often have many chronic problems, and be aware of patient confusion and/or difficulty with comprehension. While there are misconceptions about aging and pain, the clinician must learn to recognize symptoms of hearing or vision changes, as well as cognitive impairment, delirium, or dementia that may be present in older patients. By recognizing these problems and making appropriate modifications to analgesic regimens, both NSAIDs and opioids can be used safely in a geriatric population.

Special Considerations: Pediatric Patients There are a number of important misconceptions about pain and pain management in children:

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•

• •

•

• •

Children of all ages experience pain just as adults do, and they do remember the pain.

Children can communicate and describe their pain.

Pain in children is multidimensional, just as it is in adults — emotion, cultural and spiritual beliefs, environmental factors, behaviors, cognition, and development can all influence the pain experience for the child.

Behavioral and expressive aspects of pain may not be as evident in children, especially when the pain is chronic — you need to ask the child how and what they are feeling.

It is no surprise to dentists: pain can affect a child’s future development.

Pediatric pain management principles are very similar to those used for adults. Pain management protocols should look to treat with the least invasive route possible and utilize appropriate combinations of opioids plus non-opioids and adjunctive therapy. When pain is anticipated and/or ongoing, medication should be given around the clock to provide steady-state analgesia. Appropriate analgesic therapy should be available for any breakthrough pain.

When determining dosage levels of analgesics, titrate pain medications to effect — use as much as needed, not as little as possible.

Involve child-life specialists in customizing the care approach for the child. Educate the patient and family to know that pain is to be treated, not tolerated.

Children can suffer from the side effects of pain management protocols and these should be anticipated and managed quickly — constipation, nausea, vomiting, itching, and sedation. Non-pharmacologic management strategies can help relieve pain — relaxation (including a soothing environment with less noise and light), imagery, distraction, massage, etc. all help. Involve child-life specialists in customizing the care approach for the child. Educate the Texas Dental Journal l www.tda.org l May 2010

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Oral Health in Cancer Therapy

Management of Oropharyngeal Mucositis Pain patient and family to know that pain is to be treated, not tolerated. Both patient and family are essential for pain assessment and determining the success of pain management strategies.

3.

Summary Effective pain control for mucositis requires constant attention and willingness on the part of managing clinicians to evaluate and adapt pain-relieving strategies throughout the period of risk for oral mucositis. By utilizing the principles of an individualized, tiered approach to pain management that addresses the multidimensional components of a patient’s pain, maximum comfort can be consistently provided while reducing the risk for side effects.

4.

5.

6.

References 1. Rubenstein EB, Peterson DE, Schubert M, Keefe D, McGuire D, Epstein J, Elting L, Fox PC, Cooksley C, Sonis ST. Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral and gastrointestinal mucositis.

Cancer 100 (S9): 2026-2046, 2004.

2. Keefe DM, Schubert MM, Elting LS, Sonis ST, Epstein JB, Raber-Durlacher JE, Migliorati C, McGuire DB, Hutchins R, Peterson DE and Mucositis Study Section of the Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology. Updated

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Clinical Practice Guidelines for the Prevention and Treatment of Mucositis. Cancer, 109:820-831, 2007.

Barasch A, Elad S, Altman A, Damato K, Epstein J. Antimicrobials, mucosal coating agents, anesthetics, analgesics, and nutritional supplements for alimentary tract mucositis, 14:528-532, 2006.

Bensinger W, Schubert M, Ang KK, Brizel D, Brown E, Eilers JG, Elting L, Mittal BB, Schattner MA, Spielberger R, Treister NS, Trotti AM. NCCN task force report: Prevention and management of mucositis in cancer care. JNCCN 6 (supp 1):s1-24), 2008.

Niscola P, Scaramucci, L, Romani C, Biovannini M, Maurillo L, Del Poeta G, Cartoni C, Arcuri E, Amadori S, De Fabritiiis. Opioids in pain management of bloodrelated malignancies. Ann Hematol 85:489-501, 2006 Kim JG, Sohn SK, Kim DH, Baek JH, Chae YS, Bae NY, Kim SY, Lee KB. Effectiveness of transdermal fentanyl patch for treatment of acute pain due to oral mucositis in patients receiving stem cell transplantation.

Transplantation Proceedings 37:4488-4491, 2005.

Darwish M, Kirby M, Robertson P, Tracewell W, Jian JG. Absorption of fentanyl from fentanyl buccal tablet in cancer patients with or without oral mucositis. Clin Drug Invest 17:605-611, 2007.

Rosati J, Gallagher M, Shook B, Luwisch E, Favis G, Deveras R, Sorathia A, Conley S. Evaluation of an oral patientcontrolled analgesia device for pain management in oncology inpatients. J Support Oncol,

5:443-448, 2007.

9. McCann S, Schwenklenks , Bacon P, Einsele H, D’Addio A, Maertens J, Niederwieser D, Rabitsch W, Roosaar A, Ruutu T, Schouten H, Stone R, Vorkurka S, Quinn B, Blijlevens N. The prospective oral mucositis audit: relationship of severe oral mucositis with clinical and medical resource use outcomes in patients receiving highdose melphalan or BEAMconditioning chemotherapy and autologous SCT. Bone Marrow Transplant, Epub, 2008.

10. McCann S, Schwenkglenks M, Bacon P, Einsele H, D’Addio A, Maertens J, Niederwieser D, Rabitsch W, Roosaar A, Ruutu T, Schouten H, Stone R, Vorkurka S, Quinn B, Blijlevens N. Prospective oral mucositis audit: oral mucositis in patients receiving highdose melphalan or BEAM conditioning chemotherapyEuropean Blood and Marrow Transplantation Mucositis Advisory Group. 26:1519-25, 2008 11. Shaiova L, Berger A, Blinderman C, Bruera E, Davis MP, Derby S, Inturrisi C, Kalman J, Metha D, Pappagallio M, Perlov E. Consensus guideline on parenteral methadone use in pain and palliative care. Palliative and Supportive Care 6, 165– 176, 2008.

12. Jost L, Roila F. Management of cancer pain: ESMO Clinical Recommendations. Annals Oncolog 19(supp2):1119-1121, 2008.

13. Epstein JB, Schubert MM. Managing pain in mucositis.

Semin Oncol Nurs. 20(1):30-7, 2004.

14. Miaskowski C, Cleary J, Burney R, Coyne P, Finley R, Foster R, Grossman S, Janjan NA, Ray J, Syrjala K, Weisman S, Zahbrock C. Guideline for the management of cancer pain in adults and children.

American Pain Society 2005. (http://www.ampainsoc.org/).

15. Ashby MA, Martin P, Jackson KA. Opioid substitution to reduce adverse effects in cancer pain management. Med J Aust. 18;170(2):68-71, 1999.

16. Bellm LA, Epstein JB, RosePed A, Martin P, Fuchs HJ. Patient reports of complications of bone marrow transplantation. Support Care Cancer, 8:33-39, 2000.

17. Bruera E, Belzile M, Pituskin E, Fainsinger R, Darke A, Harsanyi Z, Babul N, Ford I. Randomized, double-blind, cross-over trial comparing safety and efficacy of oral controlled-release oxycodone with controlled-release morphine in patients with cancer pain. J Clin Oncol. 17(2):738, 1999.

18. Cerchietti LC, Navigante AH, Bonomi MR, Zaderajko MA, Menendez PR, Pogany CE, Roth BM. Effect of topical morphine for mucositis-associated pain following concomitant chemo-radiotherapy for head and neck carcinoma. Cancer, 95:2230-6, 2002.

19. Chapman CR, Hill HF. Prolonged morphine selfadministration and addiction liability. Evaluation of two theories in a bone marrow transplant unit. Cancer 63:163644,1989.

20. Chapman CR, Donaldson GW, Jacobson RC, Hautman B. Differences among patients in opioid self-administration during bone marrow transplantation. Pain. 71:213-23 1997.

21. Dodd MJ, Dibble SL, Miaskowski C, MacPhail L, Greenspan D, Paul SM, Shiba G, Larson P. Randomized clinical trial of the effectiveness of 3 commonly used mouthwashes to treat chemotherapy-

induced mucositis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 90:39-47, 2000.

22. Ehrnrooth E, Grau C, Zachariae R, Andersen J. Denmark. Randomized trial of opioids versus tricyclic antidepressants for radiationinduced mucositis pain in head and neck cancer. Acta Oncol, 40:745-50, 2001.

23. Epstein JB, Truelove EL, Oien H, Allison C, Le ND, Epstein MS. Oral topical doxepin rinse: analgesic effect in patients with oral mucosal pain due to cancer or cancer therapy. Oral Oncol, 37:632-7, 2001.

24. Fitzgibbon DR, Richard CR. Cancer pain: Assessment and diagnosis. In: Bonica’s Management of Pain. JD Loeser, SH Butler, CR Chapman, Turk DC (eds), Lippincott Williams & Wilkins.

Philadelphia. pp. 623- 658, 2001.

25. Hill, H. F., Mackie, A. M., Coda, B. A. et al. Patientcontrolled analgesic administration. A comparison of steady-state morphine infusions with bolus doses. Cancer 67: 873–82, 1991.

26. Jacox A, Carr DB, Payne R, et al. Management of cancer pain. Clinical Practice Guideline (no 9). U.S. Department of Health and Human Services. AHCPR Publication No. 94-0592, 1994.

27. Mackie AM, Coda BC, Hill HF. Adolescents use patient-controlled analgesia effectively for relief from prolonged oropharyngeal mucositis pain. Pain, 46:265-9, 1991.

28. Max MG, Payne R, Edwards WT, Sunshine A, Inturrisi CE. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. American Pain Society. Glenview, Illinois.

1999.

29. Narang U. Cyanoacrylate medical adhesives--a new era Colgate ORABASE Soothe.N.Seal Liquid

Protectant for canker sore relief .Compend Contin Educ Dent Suppl;(32):7-11; 2001.

30. Oguchi M, Shikama N, Sasaki S, Gomi K, Katsuyama Y, Ohta S, Hori M, Takei K, Arakawa K, Sone S. Mucosa-adhesive water-soluble polymer film for treatment of acute radiationinduced oral mucositis. Int J Radiat Oncol Biol Phys.

40:1033-7, 1998.

31. Payne R, Coluzzi P, Hart L, Simmonds M, Lyss A, Rauck R, Berris R, Busch MA, Nordbrook E, Loseth DB, Portenoy RK Long-term safety of oral transmucosal fentanyl citrate for breakthrough cancer pain. J Pain Symptom Manage 22: 575-83 2001.

32. Redding SW, Haveman CW. Treating the discomfort of oral ulceration resulting from cancer chemotherapy. Compend Contin Educ Dent, 20:389-96, 1999.

33. Rubenstein EB. Evaluating cost-effectiveness in outpatient management of medical complications in cancer patients. Curr Opin Oncol July 10(4):297-301, 1998.

34. Schulz-Kindermann F, Hennings U, Ramm G, Zander AR, Hasenbring M. The role of biomedical and psychosocial factors for the prediction of pain and distress in patients undergoing high-dose therapy and BMT/PBSCT. Bone Marrow Transplant, 29:34151, 2002.

35. Yamamura K, Ohta S, Yano K, Yotsuyanagi T, Okamura T, Nabeshima T. Oral mucosal adhesive film containing local anesthetics: in vitro and clinical evaluation. J Biomed Mater Res, 43(3):313-7, 1998.

36. Yamamura K, Yotsuyanagi T, Okamoto T, Nabeshima T. Pain relief of oral ulcer by dibucaine-film. Pain, 83:625-6 199

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NOT JUST A PRACTICE BROKER CONSULTING TEXAS DENTISTS “37 YEARS”

GARY CLINTON PMA CERTIFIED PRACTICE APPRAISALS (Over 2,200 Dental Practice Sales for Comparison) OUR FEES LOW AS 3.75% IF YOU HAVE ASSOCIATE BUYER • PMA MARKETING NETWORK • 100% NON-OWNER FUNDING • NO DUAL REPRESENTATION • NEGOTIATE FAIR PRICE • PROCESS COMPLETE CLOSING • TAX STRATEGY • TRANSITION PLANNING

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Surf's Up in San Diego!

ADA 24th New Dentist Conference June 24-26, 2010 San Diego Catamaran Resort Hotel & Spa A new full day of Leadership Development, 15 hours of spectacular CE, unique networking opportunities, and social events. Don't miss out!

Register now!

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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EXPRESS

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

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

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Xerostomia Management in the Head and Neck Radiation Patient Carl Haveman, D.D.S., M.S., and Michaell Huber, D.D.S.

INTRODUCTION Hyposalivation is a devastating and consistent complication of head and neck radiation. A detailed description of the management of this condition is presented here. Much of this material would also apply to any patient experiencing xerostomia.

Ionizing radiation that includes the salivary glands results in acinar damage and cell death and affects the vascular elements of the glands with subsequent fibrosis of the salivary glands. Decreased salivary flow has been reported at doses of 10 Gy, while permanent hyposalivation may occur at doses greater than 25 Gy. A loss or significant reduction of

Haveman

Huber

Dr. Haveman, associate professor, Department of General Dentistry, University of Texas Health Science Center at San Antonio Dental School, San Antonio, Texas Dr. Huber, associate professor, Department of Dental Diagnostic Science, Division of Oral Medicine, University of Texas Health Science Center at San Antonio Dental School, San Antonio, Texas

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Oral Health in Cancer Therapy Xerostomia Management in the Head and Neck Radiation Patient salivary function is one of the most unpleasant and problematic side-effects of radiation therapy involving the head and neck. The major salivary glands produce approximately 1 liter of saliva per day. The average unstimulated flow rate is 0.4 ml/ min and the average stimulated flow rate is 2.0 ml/min. The commonly accepted values for lower limits of normal salivary function are 0.1 – 0.2 ml/min unstimulated flow rate and 0.7 ml/min stimulated flow rate, although the definition of adequate salivary volume to prevent oral/dental disease and maintain comfort is not clearly defined.

In addition to loss of salivary volume, changes in the constituents of saliva and changes in viscosity impact salivary function. When salivary production is compromised most individuals experience the sensation of a dry mouth, which is termed xerostomia. Loss of salivary function leads to a plethora of adverse sequelae, including: • • • • •

•

488

Alteration/reduction in taste function.

Difficulty with chewing, bolus preparation and swallowing Esophageal dysfunction, including chronic esophagitis.

Nutritional compromises.

Higher frequency of intolerance to oral medications and oral care products (lack of buffering).

Increased incidence of local/ regional infection (glossitis, Texas Dental Journal l www.tda.org l May 2010

• •

•

• •

candidiasis, dental caries, halitosis, bacterial sialadenitis).

Loss of oral buffering capacity.

Reduction in remineralizing capacity leading to dental sensitivity and markedly increased susceptibility to dental caries.

Decreased resistance to loss of tooth structure due to attrition, abrasion and erosion (corrosion).

Increased susceptibility to mucosal injury.

Inability to wear dental prostheses.

The increased susceptibility to caries caused by hyposalivation and changes in saliva often results in rampant caries involving teeth both within and outside of the fields of radiation.

Rampant caries can result in an increased risk of osteoradionecrosis. Reduced saliva volume and increased viscosity of the secretion can also result in difficulty sleeping due to oral dryness waking the patient during the night.

The annoying problem of dealing with a constantly dry mouth can result in a loss of social and physical well-being. It can also become an emotional challenge with the possible result of withdrawal and clinical depression.

Managing the oral health of patients with radiation-induced xerostomia can be extremely challenging for the dentist. The following statement made by Dr. Ira Shannon in 1977 concerning these patients holds true today: “The maintenance of oral health in xerostomic patients is

demanding for both the patient and the dentist. It requires cooperation and compliance on the part of the patient, with a commitment of time and effort well beyond that required for normal oral care. The dentist must promote and inspire this cooperation, provide detailed instructions and guidance, and follow the patient meticulously.

Only in this way can the ravaging form of caries often found in these patients be prevented.”

The management of head and neck radiation therapy patients with xerostomia should begin prior to the patient receiving head and neck radiation therapy. The past performance of the patient regarding oral hygiene and the value placed on their dentition is a reliable predictor of future results. Patients who have not taken good care of their dentition prior to head and neck radiation therapy are unlikely to take good care of their dentition following radiation therapy.

When it is predictable that these patients will have very little salivary function remaining following head and neck radiation therapy, it is appropriate to extract teeth located within the high dose radiation volume prior to radiation therapy, and while all teeth will be at risk of dental disease in a patient with hyposalivation, teeth outside of the high dose radiation volume can be managed by extraction after cancer therapy.

However, preventive management should be instituted and reinforced to reduce the burden of dental disease.

The maintenance of oral health in xerostomic patients is demanding for both the patient and the dentist. It During radiation therapy, as normal meals become more difficult to ingest, patients may adopt a more cariogenic diet and sometimes use a cariogenic beverage to repeatedly moisten the mouth. When managing dentate patients with hyposalivation, it is very important to educate the patient regarding the effects radiation will have on their saliva and teeth. They must understand that reduced salivary flow places them at a greatly increased risk for dental caries, which cannot be controlled without their cooperation.

The provider must ensure that the patient understands the following requirements to maintain their dentition: •

• • • •

•

• •

Avoid moistening their mouth with cariogenic liquids such as soft drinks, citrus flavored or carbonated water, juices, punches, tea or any other liquid containing sugar.

Avoid using any liquid with an acidic pH as a mouth moistener.

Avoid using items containing sugar to stimulate salivary flow such as gums, mints, candies, lemon drops, etc.

Avoid frequent between-meal snacks that contain large amounts of sugar.

Understand the difference between sugar-free and sugar-less products. Only the former do not contain sugar and should be used by dry mouth patients. Sugar-less products do contain sugar — just less than a regular formulation.

Perform thorough oral hygiene measures using a soft toothbrush and floss or a Proxabrush® (if sufficient space exists), and a fluoridated toothpaste (1100 ppm fluoride ion) at least twice per day.

Brush teeth after every meal or snack.

Use a topical fluoride rinse or gel daily. Patients should understand that the best method of providing daily topical fluoride treatments to the teeth is with a fluoride tray and a 1–1.1 percent

requires cooperation and compliance on the part of the patient, with a commitment of time and effort well beyond that required for normal oral care.

The dentist must promote and inspire this cooperation, provide detailed instructions and guidance, and follow the patient meticulously.

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•

neutral sodium fluoride gel.

They must understand that over-the-counter fluoride rinses are much less effective than prescription fluoride gels and rinses.

Commit to follow-up dental examinations every 3 months during the first year and from every 3 to 6 months thereafter depending on their oral condition.

The provider must also ensure that the patient understands that, due to their decreased salivary flow, they have lost most or all of their saliva’s protective functions, which include: •

•

•

•

•

•

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The formation of a pellicle to act as a physical barrier to the invasion of microorganisms and as a moisturizing lubricant to prevent abrasive tooth wear and soft tissue trauma.

Potent antimicrobial effects, which help protect against bacteria, fungi, and viruses in the mouth.

A washing effect to help clear the oral cavity of microorganisms and food debris, especially sugars.

A hydrating effect that moistens the mouth and aids in chewing and swallowing.

The promotion of remineralization of the teeth because saliva is a saturated solution of calcium and phosphate ions.

A high buffering capacity, which protects the dentition against acids from both external and internal sources Texas Dental Journal l www.tda.org l May 2010

and aids in the control of the microorganisms that are responsible for dental decay and oral fungal infections.

Management Topical Management of Dry Mouth Discomfort Over-the-counter sugar-free gums and mints are safe to use to stimulate any remaining salivary function; however, xylitolcontaining gums and mints are preferable because xylitol inhibits the growth of cariogenic bacteria (mutans streptococci) that cause tooth decay (Table 3). There are several proprietary products that claim to increase salivary flow; however, they are more expensive than over-thecounter sugar-free gums and mints and evidence that they are more beneficial is lacking.

There are numerous commercial salivary substitutes available (Table 4), however these are used for palliation and stimulation of residual function should be considered prior to a palliative approach. There are few comparative trials of mouth-wetting agents, and several of these products have been found to have a pH below 5.1. Studies have found that saliva substitutes with a pH of 5.1 or less lead to demineralization and loss of tooth structure unless they contain calcium and phosphate ions and/or fluoride ions. Studies have found that carboxymethylcellulose-

based saliva substitutes with a saturation of 3.2 with respect to octacalciumphosphate and a pH of 6.5 enable the solution to remineralize bovine enamel in vitro. Presently there is no ideal salivary substitute commercially available. Because saliva substitutes are somewhat expensive, and have a short duration of action, many patients prefer to use water to moisten their mouth. Because of the confirmed topical benefit of fluoridated water, patients should use water known to contain approximately 1 ppm fluoride as a mouth moisturizer.

Commercially available bottled water does not usually contain significant amounts of fluoride and some home water purification systems remove the fluoride that is present in tap water.

Patients should be encouraged to use unfiltered fluoridated tap water as a mouth moistener.

The Biotene® products from Laclede are formulated for dry mouth patients and comparative trials have shown patient satisfaction with these products.

These products contain natural salivary enzymes and proteins as well as xylitol. The potential benefits of the presence of salivary enzymes in vivo are not well documented. Biotene® toothpaste does not contain sodium lauryl sulfate and Biotene® mouthwash does not contain alcohol, both of which can be irritating to dry mouth patients. Oralbalance Moisturizing Gel® is another Biotene® product that has met with patient acceptance. It is a

clear viscous water-soluble gel that contains xylitol as well as natural salivary enzymes and proteins. It can be used to coat oral soft tissues to protect and lubricate them. It has a longer duration of action than water and many patients find it beneficial to use when they need

something that lasts longer than fluoridated water, (e.g., in the evening prior to going to sleep).

molecule (poloxamer 407), which has an affinity for mucosa. It has a neutral pH and provides longer lasting relief from oral dryness than water. Some patients prefer to use it in place of Oralbalance Gel® prior to retiring in the evening as well as using it throughout the day.

TheraSpray® from Omni Preventive Care is another product that may be considered for symptomatic relief of a dry mouth. It contains a silicone

Table 1. Gums and Mints Products Containing Xylitol

Manufacturer

Telephone

B-Fresh® Xylitol Mints

B-Fresh Johnston, RI www.bfreshgum.com

800-555-1276

Biotene® Dry Mouth Gum

Laclede, Inc. Rancho Dominquez, CA www.laclede.com

800-922-5856

Smint® Gum

Perfete van Melle Lainati, Italy www.smint.com

34 93 495 2727

Smint® Mints

Perfete van Melle Lainati, Italy www.smint.com

34 93 495 2727

Spry™ Gum

Xlear Inc. Orem, UT www.xlear.com

877-599-5327

Spry™ Mints

Xlear Inc. Orem, UT www.xlear.com

877-599-5327

TheraGum®

Omni Preventive Care 3M ESPE Dental Products St. Paul, MN http://solutions.3m.com/

800-634-2249

TheraMints®

Omni Preventive Care 3M ESPE Dental Products St. Paul, MN http://solutions.3m.com/

800-634-2249

Trident® Gum (but not Trident White or Splash)

Cadbury Adams USA LLC Parsippany, NJ www.tridentgum.com

800-874-0013

Trident Xtra Care™ Gum Also contains Recaldent® (casein phosphopetideamorphous calcium phosphate for remineralization)

Cadbury Adams USA LLC Parsippany, NJ www.tridentgum.com

800-874-0013

Xponent® Xylitol Gum

Global Sweet Polyols LLC Rehoboth, MA www.globalsweet.com

800-601-0688

Xponent® Xylitol Mints

Global Sweet Polyols LLC Rehoboth, MA www.globalsweet.com

800-601-0688

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Oral Health in Cancer Therapy Xerostomia Management in the Head and Neck Radiation Patient Table 2. Mouth-wetting Agents Product

Manufacturer

Telephone

Biotene® Moisturizing Mouth Spray pH 7.0, Bio-active enzymes, amino acids, milk proteins

Laclede Inc. Rancho Dominquez, CA www.laclede.com

800-922-5856

BioXtra® Moisturizing Gel Milk proteins, salivary enzymes

Bio-X Healthcare Gembloux, Belgium www.bioxhealthcare.com

32 (0)81 72 34 65

BioXtra® Gel Mouthspray Milk proteins, salivary enzymes

Bio-X Healthcare Gembloux, Belgium www.bioxhealthcare.com

32 (0)81 72 34 65

Caphosol® (Rx) High concentration calcium and phosphate ions

Cytogen Corp Princeton, NJ www.cytogen.com

800-833-3353

Moi-Stir® Oral Spray pH 7.0 (carboxymethylcellulose), sorbitol, glycerin

Kingswood Laboratories Indianapolis, IN

800-968-7772

Numoisyn® Liquid Rx only – contains linseed extract, methylparaben and proplyparaben

Align Pharmaceuticals Cary, NC www.alignpharma.com

919-398-6225

Oasis® Mouthwash & Spray 35 percent glycerin oral demulcent

GlaxoSmithKline Brentford, United Kingdom www.gsk.com

888-825-5249

Oral Balance® Moisturizing Gel pH 6.0, Xylitol sweetener, Bio-active enzymes in a hydroxymethylcellulose base

Laclede Inc. Rancho Dominquez, CA www.laclede.com

800-922-5856

Oral Balance® Liquid pH 7.0, Xylitol, Bio-active enzymes, 8 amino acids, milk proteins

Laclede Inc. Rancho Dominquez, CA www.laclede.com

800-922-5856

Saliva Substitute® pH 6.5 (carboxymethylcellulose), sorbitol, mild mint flavor

Roxane Laboratories Inc. Columbus, OH www.roxane.com

800-962-8364

Salivart® Synthetic Saliva pH 6.0-7.0 (carboxymethylcellulose

Gebauer Company Cleveland, OH www.gebauerco.com

800-321-9348

Thayers® Dry Mouth Spray (Citrus)] pH 6.0, Glycerin, tris amino, lemon/lime flavor

Thayers Natural Pharmaceuticals Westport, CT www.thayers.com

888-842-9371

TheraSpray® pH 7.0, 1.2 percent poloxamer 407/dimeticone, xylitol

Omni Preventive Care 3M ESPE Dental Products St. Paul, MN http://solutions.3m.com/

800-634-2249

VA OraLube pH 7.0xylitol, 2 ppm F (carboxymethylcellulose)

Only available from VA Hospitals NDC 052859-005

Note: Oral moisturizers/artificial saliva having a pH < 5.5 are not recommended. Examples include MouthKote®, Stoppers 4 Dry Mouth Spray®.

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Systemic Management of Dry Mouth Discomfort Stimulation of saliva production should always be considered prior to palliation due to the critical role of salivary constituents in maintaining homeostasis in the oral environment. It is valuable to determine if residual salivary function remains by measuring the salivary flow rate, prior to prescribing a systemic sialogogue. If there is no measurable saliva following the collection of resting and stimulated saliva, systemic sialogogues are unlikely to be effective. If there is measurable saliva, sialogogues should be considered. Available agents in the United States are: Salagen® (pilocarpine), Evoxac® (cevimeline) and Bethanechol® (urecholine). These are acetylcholine analogues that stimulate exocrine glands via their actions as agonists at muscarinic receptor sites. Salagen® (pilocarpine) is a nonselective muscarinic agent which affects both the M3 receptors in the exocrine glands as well as the M2 receptors in the heart and has a duration of action of approximately 3 hours.

It is available in 5 and 7.5 mg tablets and the recommended dose is 5 -10 mg t.i.d. (not to exceed 30 mg per day). It has been approved by the FDA for relief of symptoms of dry mouth secondary to Sjögren’s syndrome and for dry mouth secondary to radiation therapy. Evoxac® (cevimeline) may have greater affinity for the M3 receptors in the glands and a lower affinity for the M2 receptors on the heart (fewer rhythmogenic cardiac effects), although this difference has not been proven in clinical trials. It has a longer duration of action due to plasma protein

Caution should be used in prescribing ophthalmic solution and dosing should be monitored closely, as overdosing has been reported.

binding capacity (approximately 5 hours.) It is available as a 30 mg tablet and the recommended dose is 30-60 mg t.i.d (not to exceed 180 mg per day). It has been approved by the FDA for symptoms of dry mouth secondary to Sjögren’s syndrome and for dry mouth secondary to radiation therapy. Bethanechol has been used off label and like cevimeline, may have a longer halflife. Doses range from 10-75 mg t.i.d., with most using 25 mg t.i.d. Comparative trials have been conducted of these agents.

Pilocarpine is also available as an ophthalmic solution. It is available in a variety of concentrations and comes in 15 ml dropper bottles. The 1 percent solution can be prescribed with instructions to place 1/2 ml - 1 ml on the tongue t.i.d. not to exceed 3 ml per day. Another option is a 4 percent solution,

which should be diluted to 600 ml with tap water to create a 1 mg/ml solution. The patient is instructed to take 5-10 ml (1-2 teaspoons) t.i.d. not to exceed 30 ml per day. The advantage of prescribing pilocarpine in a solution form is that it is much less expensive, however, the solution is rapidly absorbed and the dose taken more difficult to control.

Caution should be used in prescribing ophthalmic solution and dosing should be monitored closely, as overdosing has been reported.

All the sialogogues have similar unwanted side effects. The most common are: gastrointestinal upset, sweating, tachycardia, increased pulmonary secretions, increased smooth muscle tone and blurred vision, especially at night. Caution should be advised while driving at night or performing hazardous activities in reduced lighting. In addition, they have similar contraindications that include: gall bladder disease, narrow-angle glaucoma, acute iritis, uncontrolled asthma, known hypersensitivity to the drug, and renal colic.

Pilocarpine and cevimeline have similar warnings and precautions. Risks to the patient must be considered when administering either medication to individuals with cardiovascular disease, controlled asthma, angina pectoris, chronic bronchitis, chronic obstructive pulmonary disease, or a history of myocardial infarction, nephrolithiasis or cholelithiasis. Drug interactions may include: beta-blockers, other parasympathomimetic drugs, and medications that have a significant affect on the cytochrome P450 liver enzyme system.

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Oral Health in Cancer Therapy Xerostomia Management in the Head and Neck Radiation Patient Table 3. Rx Sialogogues Product

Manufacturer

Telephone

Bethanechol, 25 mg tablets (generic)

Global Pharmaceuticals Chalfont, PA www.globalphar.com

215-933-0323

Evoxac® (Cevimeline HCl) 30 mg capsules

Daiichi Sankyo Parsippany, NJ www.daiichius.com

877-437-7763

Pilocarpine Hydrochloride Tablets, 5 mg Equivalent to Salagen®

Roxane Laboratories Columbus, OH www.roxane.com

800-962-8364

Pilocarpine Ophthalmic solution 15 ml (4 percent solution – 40mg/ml) dilute to 600 ml to create 1 mg/ml.

Available from local pharmacies

Salagen® Tablets (Pilocarpine HCl) 5 mg tablets

MGI Pharma, Inc. Bloomington, MN www.mgipharma.com

Prevention and Treatment of Dental Caries In a dentate patient with hyposalivation, the lack of salivary oral clearance, remineralization action, buffering capacity and antibacterial activity may promote rampant dental caries.

Normal salivary pH is approximately 6.8 – 7.2. In patients with reduced saliva production, the oral pH can fall into the acidic range. Hyposalivation promotes the rapid growth of acidophilic organisms such as mutans streptococci, lactobacillus and candida. It is critical that the treatment of dental caries follow a medical model as described by Anderson, Bales and Omnell. Using this model, dental caries is primar-

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ily approached as an infection of the oral cavity with treatment directed at the causative organism. This medical model must include the following: • • • •

•

Manage hyposalivation.

Reinforce excellent oral hygiene.

Dietary instruction.

Eliminate existing mutans streptococci nidi of infection by removing caries from all cavitated caries lesions and obturating with glass ionomer interim restorations as well as sealing all carious pits and fissures.

Initiate antimicrobial therapy using a 0.12 percent chlorhexidine rinse (Table 6).

Instruct the patient to use ½ oz. oral rinse for one minute

800-562-5580

twice daily for 2 weeks. This will reduce the number of mutans streptococci below a pathological level for 12 – 36 weeks in non-cancer patients. However, studies in head and neck cancer patients document rapid recolonization when chlorhexidine is discontinued, which is in contrast to studies of noncancer patients and therefore continuing use and compliance is of increased importance in cancer patients.

Attempts to reduce the exposure to chlorhexidine (i.e., ½ oz.) for 1 minute twice daily 1 or 2 days per week) must be undertaken with caution and closely monitored.

Table 4. Rx Chlorhexidine Mouthrinses — 0.12 Percent Chlorhexidine Gluconate, 11.6 Percent Alcohol Product

Manufacturer

Telephone

Denti-Care® Oral Rinse

Medicom USA, Tonawanda, NY www.medicom.ca

800-308-6589

Peridex®

Omni Preventive Care 3M ESPE Dental Products, St. Paul, MN http://solutions.3m.com/

800-634-2249

PerioGard®

Colgate Oral Pharmaceuticals, New York, NY www.colgateprofessional.com

800-372-4346

PerioRx®

Discus Dental, Culver City, CA www.discusdental.com

800-422-9448

Pro-DenRx® 0.12 Percent Chlorhexidine Rinse

Pro-Dentec, Batesville, AK www.prodentec.com

800-228-5595

Table 5. Fluoride Varnishes — 5 Percent Sodium Fluoride — 22.6 mg/ml F, 22.600 ppm F Product

Manufacturer

Telephone

CariFree® — Single dose syringes volume not specified

Oral BioTech, Albany, OR www.carifree.com/dentists

866-928-4445

CavityShield® — Unit dose 0.25ml and 0.4 ml

Omni Preventive Care 3M ESPE Dental Products, St. Paul, MN http://solutions.3m.com/

800-634-2249

Duraflor® — 10ml Tube

Medicom USA, Tonawanda, NY www.medicom.ca

800-308-6589

Duraflor® — Unit dose 0.25ml and 0.4ml

Medicom USA, Tonawanda, NY www.medicom.ca

800-308-6589

Duraflor® Halo White Varnish Unit dose – 0.5ml

Medicom USA, Tonawanda, NY www.medicom.ca

800-308-6589

Duraphat® — 10ml Tube Prevident® Varnish — Unit dose — 0.4ml Transparent on teeth

Colgate Oral Pharmaceuticals, Inc.,Canton, MA www.colgateprofessional.com/

800-372-4346

DuraShield® — Unit dose – 0.4ml

Sultan Healthcare, Englewood, NJ www.sultanintl.com

800-637-8582

Enamel Pro® Varnish —Unit dose 0.25ml and 0.4ml — Dries white Contains Amorphous Calcium Phosphate

Premier Dental, Plymouth Meeting, PA www.premusa.com/dental

888-670-6100

Flor-Opal® — Unit dose 0.5ml Syringes Contains Xylitol

Ultradent, South Jordan, UT www.ultradent.com

888-230-1420

FluoroDose® — Unit dose — 0.3ml Translucent A-2 shade

Centrix, Shelton, CT www.centrixdental.com

800-235-5862

Fluorilaq — 10ml Tube

Pascal Company, Inc., Bellevue, WA www.pascaldental.com

800-426-8051

Nupro® 5 Percent Sodium Fluoride Varnish Unit dose - volume not specified

Dentsply International, York, PA www.dentsply.com

800-877-0020

Varnishamerica™ — Unit dose 0.25ml and 0.4ml Contains Xylitol — Dries to a natural tooth color

Medical Products Laboratories, Philadelphia, PA www.medicalproductslaboratories.com/publichealth/varnishamerica.html

800-523-0191

*Unit dose packaging preferred; content per dose may vary with tube packaging.

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Oral Health in Cancer Therapy Xerostomia Management in the Head and Neck Radiation Patient While the effect of fluoride varnish has not been studied in cancer patients, (Table 7) it may be reasonable to consider the use of 1 percent neutral sodium fluoride gel such as FluoriSHIELD® or Prevident® in medication trays or when not possible as a brush-on (Tables 7 & 8) to protect the teeth against demineralization and promote remineralization. Consideration should be given to use of calcium and phosphate products, as remineralization requires their presence in the environment in order to reduce demineralization and promote remineralization.

Fabricate fluoride trays for the application of the neutral sodium fluoride gel (ideally this should be done prior to radiation therapy). Both 1-1.1 percent neutral sodium fluoride and 0.4 percent stannous fluoride gels have proven effective. However, stannous fluoride is highly acidic and may affect certain types of restorations, especially glass ionomers. Neutral sodium fluoride is the agent of choice for patients with glass ionomer restorations.

Instruct the patient on the daily use of the trays as follows: • Place a ribbon of 1–1.1 percent neutral fluoride

• •

• •

• •

gel in the carriers.

Insert both the upper and lower carrier.

Gently bite several times to “pump” gel between the teeth.

Leave the carriers in place for 5 to 10 minutes.

Remove carriers and expectorate the gel but do not rinse.

Rinse the carriers and allow to air dry.

Do not eat or brush for at least 30 minutes (optimal time to use is prior to bedtime).

Table 6. Fluoride Gels — 1.1 Percent Sodium Fluoride, 5000 ppm, pH 7.0 Product

Manufacturer

Telephone

ControlRx™

Omni Preventive Care 3M ESPE Dental Products, St. Paul, MN http://solutions.3m.com/

800-634-2249

Denti-Care® Sodium fluoride Gel

Medicom USA, Tonawanda, NY www.medicom.ca

800-308-6589

FluorideX®

Discus Dental, Culver City, CA www.discusdental.com

800-422-9448

FluoriSHIELD®

Medical Products Laboratories, Philadelphia, PA www.medicalproductslaboratories.com

800-523-0191

NeutraCare®

P & G, Cincinnati, OH www.oralbprofessional.com

800-543-2577

NeutraGard® Home Care Gel

Pascal Company, Inc., Bellevue, WA www.pascaldental.com

800-426-8051

Prevident®

Colgate Oral Pharmaceuticals, New York, NY www.colgateprofessional.com

800-372-4346

Pro-DenRx® Neutral Sodium Brush-On Gel

Pro-Dentec, Batesville, AK www.prodentec.com

800-228-5595

Topex® Take Home Care®

Sultan Dental Products, Englewood, NJ www.sultandental.com

800-637-8582

*The 0.4 SnF2 gels such Gel-Kam® and Omni-Gel® are not recommended because of their acidity (pH 2.4-4.7) and lower fluoride concentration (1000 ppm) vs. 1-1.1% NaF (pH 7.0, 5000 ppm F).

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Table 7. Fluoride Toothpastes — 1.1 Percent Sodium Fluoride, 5000 ppm, pH 7.0 Product

Manufacturer

Telephone

ControlRx™

Omni Preventive Care 3M ESPE Dental Products, St. Paul, MN http://solutions.3m.com/

800-634-2249

ContolRX™ Sodium fluoride Dentifrice

Omni Preventive Care 3M ESPE Dental Products, St. Paul, MN http://solutions.3m.com/

800-634-2249

FluorideX Daily Defense®

Discus Dental, Culver City, CA www.discusdental.com

800-422-9448

NeutraGard® Advanced Home Care Gel with Dentifrice

Pascal Company, Inc., Bellevue, WA www.pascaldental.com

800-426-8051

Prevident 5000 Plus®

Colgate Oral Pharmaceuticals, New York, NY www.colgateprofessional.com

800-372-4346

Prevident 5000 Booster®

Colgate Oral Pharmaceuticals, New York, NY www.colgateprofessional.com

800-372-4346

Prevident® 5000 Dry Mouth

SLS free formulation, Colgate Oral Pharmaceuticals, New York, NY www.colgateprofessional.com

800-372-4346

Prevident® 5000 Sensitive 5 percent potassium nitrate

Colgate Oral Pharmaceuticals, New York, NY www.colgateprofessional.com

800-372-4346

Pro-DenRx® Plus Neutral Brush-On Dentifrice

Pro-Dentec, Batesville, AK www.prodentec.com

800-228-5595

Table 8. Fluoride Mouthrinses Rx Products — Neutral pH, 0.2%, NaF, 900 ppm

Manufacturer

Telephone

CaviRinse®

Omni Preventive Care 3M ESPE Dental Products, St. Paul, MN http://solutions.3m.com/

800-634-2249

Dental Resources Neutral Gel

Dental Resources, Inc., Delano, MN www.dentalresourcesinc.com

800-328-1276

Oral-B® Fluorinse®

P & G, Cincinnatti, OH www.oralbprofessional.com

800-543-2577

Prevident® Dental Rinse

Colgate Oral Pharmaceuticals, New York, NY www.colgateprofessional.com

800-372-4346

Pro-DenRx® Neutral Rinse

Pro-Dentec, Batesville, AK www.prodentec.com

800-228-5595

The 0.2 percent NaF rinses (900 ppm F) are an acceptable alternative for patients who will not use the 1.0-1.1 percent NaF gels, although more expensive and not as effective.

OTC Products — 0.5%, NaF, 225 ppm

Manufacturer

Telephone

Act® Fluoride Rinse pH 5.8 – 6.6, 0.05%, Alcohol Free

Chattem, Inc, Chattanooga, TN www.actfluoride.com

866-228-7467

Fluorigard®

Colgate Oral Pharmaceuticals, New York, NY www.colgateprofessional.com

800-372-4346

Oral-B® Anti-Cavity Rinse Alcohol Free

P & G, Cincinnati, OH www.theessentials.com

800-924-4950

The 0.05 percent NaF rinses do not equally replace the daily use 1.0-1.1 percent NaF gels because of their much lower fluoride concentration (225 ppm F). If these low concentration rinses are used, they should be alcohol free. The 0.63 percent SnF2 rinses such as PerioMed® or Gel-Kam Rinse® are not recommended because their fluoride concentration is low (dilute to 0.1 percent SnF2 = 250 ppm F) and they are very acidic (pH - 2.8-3.5). The APF rinses such as Phos-Flur® are not recommended because of their acidic pH 4.0.

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Oral Health in Cancer Therapy Xerostomia Management in the Head and Neck Radiation Patient Low concentration products such as 0.05 percent (250 ppm) sodium fluoride rinses (Table 10) and 0.63 percent stannous fluoride rinses (diluted 1:8 - 250 ppm) have not been shown to be effective in dry mouth patients.

The most effective products are those containing 5000 ppm such as the 1-1.1 percent sodium fluoride gels and toothpastes.

The recommended technique is a 1-1.1 percent sodium fluoride gel in fluoride trays, together with the twice-daily use of a conventional 1100 ppm sodium fluoride toothpaste. The next most favorable protocol is to brush on the sodium fluoride gel, together with the twice-daily use of a conventional 1100 ppm sodium fluoride toothpaste.

Begin definitive restorative therapy when the above approaches to dental demineralization have been addressed, with direct restorative materials. Resin modified glass ionomer restorations are the materials of choice to restore class 3 and class 5 preparations due to their antibacterial surface properties and their proven ability to afford some protection from recurrent caries at the cavosurface restorative margins. In higher stress areas, such occlusal and incisal surfaces, either composite resin or amalgam can be used.

Compomer materials are not recommended because of their need to be replaced more frequently due to recurrent caries, as well as their inferior physical proper-

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ties as compared to amalgam or composite resin. Consideration should be given to using an “open sandwich” technique when placing either amalgam or composite resin on the root surfaces of these patients. Restorative recommendations are as follows: Patients Compliant with the Use of Topical Fluorides Class 1 or 2 Direct Restorations • Either amalgam or

microhybrid composite Class 3 Direct Restorations • Either microhybrid

composite or resin modified

glass ionomer Class 5 Direct Restorations • Either amalgam, microhybrid

composite or resin modified

glass ionomer Laboratory Fabricated In-direct Restorations • Only after caries free for at

least 6 months Enamel “White Spot” or Noncavitated Dentin Lesions • Apply a fluoride varnish 2-3

times in one week, if possible • Daily topical 1.0–1.1 percent neutral sodium fluoride in

trays 5-10 minutes Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) is a non-fluoride agent developed at Melbourne University in Australia, which in some studies has been found

to suppress tooth demineralization while enhancing tooth remineralization. These studies have shown that this material buffered plaque pH by stabilizing and localizing amorphous calcium phosphate within the plaque, thereby helping to maintain a state of supersaturation with respect to tooth enamel. In one study the buffering of the plaque resulted in a depression of demineralization and enhancement of remineralization as much as 63.9 percent (+/- 20 percent). Another study demonstrated that sugar-free gum is a safe and effective way to deliver CPP-ACP in order to promote remineralization of enamel in subsurface lesions. CCP-ACP is marketed as Recaldent® and in the United States it is commercially available in paste form as MI Paste™ and MI Paste Plus™ (CPP-ACP plus 0.2 percent NaF, 900 ppm) from GC America (Table 9). In other global markets it is marketed as GC Tooth Mousse. In addition to being marketed as a remineralizing agent it is also marketed as a desensitizing agent for exposed roots. In the United States Recaldent® is also available in Trident® Xtra Care™ chewing gum (in other global markets it is available as Recaldent® Chewing Gum). The artificial saliva product CAPHOSOL®, available by prescription, also contains calcium and phosphate solution.

Table 9. Remineralizing Products Product

Manufacturer

Telephone

CAPHOSOL® (Rx) High concentration calcium and phosphate ions

Cytogen Corp, Princeton, NJ www.cytogen.com

800-833-3353

MI Paste™ Contains Recaldent™ (CPP-ACP), pH 7.

GC America, Alsip, IL www.gcamerica.com

800-323-7063

MI Paste Plus™ Contains Recaldent™ (CPP-ACP) plus 0.2 percent NaF, 900 ppm, neutral pH

GC America, Alsip, IL www.gcamerica.com

800-323-7063

Patients Not Compliant with the Use of Topical Fluorides

Prevention and Treatment of Candidiasis

Provide dental care to control dental damage:

In patients with hyposalivation, the oral mucosa often becomes dry, sticky, rough, may bleed easily and is more susceptible to infection. The most frequently encountered mucosal infection associated with hyposalivation is candidiasis. A significant correlation between hyposalivation and Candida has been confirmed

by Navazesh, et al. and shown in head and neck cancer patients with colonization and infection increasing during and following radiation therapy. RamirezAmador, et al. found that in this group of patients, candida colonization significantly increased from the initiation of therapy (43 percent) to the completion (62 percent) and continued to increase during follow-up visits to a prevalence of 75 percent. A shift in the species of the candida organisms from 85 percent Candida albicans at the beginning of radiation treatment to 65 percent at the termination of treatment was also noted, as was an increase in populations of other candidal species, including C. glabrata, C. tropicalis, C. parapsilosis, C. cerevisae, and C. krusei.

Class 1 and 2 Direct Restorations • Amalgam — glass ionomer

liner may be beneficial • Composites not recommended Class 3 and 5 Direct Restorations • Resin modified (dual cure)

glass-ionomer or packable

(chemical cure) glass-ionomer • Composites not recommended Laboratory Fabricated In-direct Restorations — Not recommended Enamel “White Spot” or noncavitated dentin lesion • Place a topical fluoride

varnish as often as possible,

but expect to restore early.

• Initially, close follow-up every

3 months assessing for

caries.

• Careful examination and

bite-wing radiographs until

at least 6 months without

lesions, may then extend

time between follow-up

appointments.

• Reinforce oral hygiene

instructions and use of

topical fluorides, chlorhexi dine rinses and salivary

stimulating agents.

Candida organisms have been found to colonize 67.9 percent of patients with self-reported xerostomia, of which 58 percent were found to have hyposalivation. The dry mouth patient’s oral mucosa should be carefully examined for the infection. It may present as a pseudomembranous form (thrush), as an atrophic (erythematous) form (often associated with a removable dental appliance) or, less commonly, as a hypertrophic (white) form. It should also be suspected when dry mouth patients complain of a burning mouth or tongue. At times this infection may spread to involve the commissures of the mouth, a condition described as angular cheilitis or cheilosis.

A clinical diagnosis of Candida may be supported by performing a Gram stain or potassium hydroxide (KOH) preparation from oral scrapings, especially with the pseudomembranous form, or confirmed with a fungal culture. There are several antifungal agents effective against Candida albicans as topical preparations and systemic medications (Table 10). Nystatin solutions contain large amounts of sucrose (approximately 50 percent), and should be avoided in dentate dry mouth patients. Dry

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

499

Oral Health in Cancer Therapy Xerostomia Management in the Head and Neck Radiation Patient cant problem when treating patients for fungal infections.

Hyposalivation is thought to be a factor in response to fluconazole because its salivary concentration is equal to its plasma concentration and systemic use may lead to both systemic and topical exposure in those with saliva production. However, fluconazole has been found to be effective in dry mouth patients.

Fluconazole, because of its efficacy and excellent safety profile, is the recommended systemic therapy for oral candidiasis. However, development of resistance to fluconzaole is a

recognized problem and other species may have greater resistance. Itraconazole solution is a good alternative if this occurs.

Itraconazole is also available as a solution and acts both as a topical and systemic medication.

It has the advantage of containing no sugar (sweetened with sorbitol and saccharin), however, it has more liver toxicity than does fluconazole. Chlorhexidine gluconate also inhibits the growth of Candida, and may be useful in prevention and assist in reducing colonization, but is not recommended as a primary treatment against clinical infection.

Generic

Proprietary

Directions

Clotrimazole cream

Lotrimin®, Mycelex® (1 percent)

Apply to affected area q.i.d.

Clotrimazole oral troches

Mycelex® Troches 10 mg

Let one troche dissolve in mouth 5 x / day

Fluconazole tablets*

Diflucan® 100 mg tabs

200 mg stat p.o., then 100 mg q.d. p.o.

Ketoconazole cream

Nizoral® 2 percent

Apply to affected area q.i.d.

Miconazole cream, powder

Monistat® 2 percent

Apply to affected area q.i.d.

Nystatin cream, ointment, powder

Mycostatin® cream, powder 100,000 units/gram

Apply to affected area q.i.d.

Nystatin solution**

Mycostatin® 100,000 units/ml

4-6 ml swish x 2 min & swallow q.i.d.

Nystatin oral pastilles

Mycostatin® 200 mg pastilles

Let one pastille dissolve in mouth 4 x day

Itraconazole solution*

Sporanox® Oral Solution 100 mg/10ml

10 ml swish and swallow bid

mouth patients are often poorly compliant in the use of troches and pastilles because they lack sufficient saliva to dissolve them, which may also cause mucosal abrasion. Topical medications can be applied in creams applied to denture surfaces or lozenges or rinses. Systemic treatment may be more convenient. Systemic agents include ketoconazole (Nizoral®), fluconazole (Diflucan®) and itraconazole (Sporanox®). They are effective and do not require as frequent dosing as topical agents. Dosing frequency is important because compliance can be a signifi-

Table 10. Antifungal Products

* Caution with drug interactions when using the azoles systemically. Check drug reference. ** Not recommended because of the high sucrose content and need to use at least 4X day

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

Systemic Treatment of Oral Candidiasis in Dry Mouth Patients Treat risk factors for candidiasis if possible: manage dry mouth, evaluate systemic medications and modify if possible (e.g., discontinue steroid inhalers if other asthma management is possible; evaluate and manage diabetes); treat oral prostheses.

Fluconazole (Diflucan®) 100 mg tablets

Dispense: 8-15 tablets Sig; Take two tablets on day 1 and then one tab per day for

6-13 days Itraconazole (Sporonox®) solution 100 mg/10ml

Dispense: 140 ml – 280 ml Sig: Swish and swallow 10 ml bid for 7 to 14 days If Systemic Agents Cannot be Used — Recommended Topical Treatment Alternatives Clotrimazole (Mycelex®) 10 mg troches

Disp: 70 troches

Sig: Dissolve one troche in the mouth five times per day for 14 days Nystatin (Mycostatin®) 200 mg oral pastilles

Disp: 56 pastilles

Sig: Dissolve one pastille in the mouth four times per day for 14 days Xerostomia and Removable Prosthodontic Therapy Hyposalivation is often associated with reduced denture retention and generalized denture intolerance. It has long been recognized that the surface tension developed as a result of the layer of saliva interposed between the denture base and the supporting tissues is important for effective prosthesis retention. To achieve optimal surface tension between the denture (especially the maxillary) and the tissue, the intervening saliva must be thin and effectively wet the opposing surfaces. This allows the saliva to maximize contact between the surfaces, creating an adhesive force between saliva and the denture base. Maximum extension of the denture base within the physiologic limits of the supporting tissue and a bilaterally balanced occlusion are important for adequate denture retention in dry mouth patients.

Denture adhesive may augment retention. A properly applied wellhydrated adhesive functions to enhance the surface tension between the denture and tissue. This replaces the otherwise saliva-deficient film layer thereby improving adhesion, eliminating voids between the denture and the mucosa, providing a cushioning or lubricating effect which helps to reduce mucosal irritation due to friction and prevents additional tissue dehydration. A properly applied adhesive will reduce food impaction between the denture and tissue, improve chewing efficiency and bite force, improve functional load distribution and facilitate the psychological well-being of the patient. For best results, these materials should be spread across the entire surface of the denture and firmly seated against the tissues.

To achieve optimal surface tension between the denture (especially the maxillary) and the tissue, the intervening saliva must be thin and effectively wet the opposing surfaces.

This allows the saliva to maximize contact between the surfaces, creating an adhesive force between saliva and the denture base.

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

501

Oral Health in Cancer Therapy Xerostomia Management in the Head and Neck Radiation Patient Dry mouth denture wearers are also more prone to recurrent Candida infections. When the infection is confined to removable denture supporting tissues, treatment of the tissues can be effectively accomplished by placing an antifungal cream (e.g., nystatin or clotrimazole cream) or nystatin powder on the surface of the denture prior to placement. This should be done daily until the tissue appears clinically healthy and then for an additional 2 weeks. When the candidal infection involves other oral or pharyngeal soft tissues, a systemic agent may be considered. Additionally, the denture should be treated with one of the following protocols over the course of treatment.

Topical Treatment for Infected Dental Appliances Daily 30 minute soak in 0.12 percent chlorhexidine solution Daily 30 minute soak in diluted sodium hypochlorite solution (10 ml

or 2 teaspoons of 5.25 percent bleach, e.g., Clorox®, in 250 ml or

1 cup of water).

Decreased salivary output has a direct correlation with increased difficulty with denture function. Clinicians may consider implant-borne prostheses for dry mouth edentulous patients (Massad and Cagna).

Bacterial Sialadenitis When salivary flow rates are diminished, secretions frequently become viscous and may block flow through the ductal system resulting in glandular swelling. This should be distinguished from swelling caused by an infection of the gland. A diminished flow rate may also result in retrograde bacterial infection of the duct system and the gland (bacterial sialadenitis). Swelling due to blockage may be relieved by glandular massage, whereas infection should be treated with antibiotics and, if possible, stimulation of salivary flow.

Appropriate antibiotics are Penicillin VK® clindamycin or amoxicillin.

Antibiotic Treatment of Bacterial Sialadenitis Penicillin VK® 500 mg tablets

Dispense: 40 tablets Sig: two tablets initially then one q 6 hrs for 10 days Clindamycin 300 mg tablets

Dispense: 40 tablets Sig: two initially then one q 6 hrs for 10 days Amoxicillin 500 mg tablets

Dispense: 30 tablets Sig: two tablets initially then one q 8 hrs for 10 days

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

NOTE ON PRODUCT TABLES: In the preparation of this manuscript, every effort has been taken to ensure the product information provided is accurate and up to date. However, the development, marketing and availability of products used in the management of xerostomia is constantly changing.

Practitioners are advised to routinely check the literature, product suppliers and manufacturers.

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504

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Texas Dental Journal l www.tda.org l May 2010 Ad Number: OT050937

505

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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

SPDDS

Employees Benefit Trust

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Three distinct plans now available: Freedom Plan

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

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

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Oral and Maxillofacial Pathology Case of the Month

Clinical History

H. Stan McGuff, D.D.S., Daniel

This 47-year-old-male presented with a 3-year history of a right posterior palatal swelling. The lesion was painless and slow growing. However, over the last several months the patient had developed dysphagia. Examination revealed a firm 3.7 x 2.8 x 2.7 cm non-ulcerated mass involving the right hard and soft palate (Figure 1). A computed tomography scan showed no evidence of osseous destruction or erosion (Figure 2). There was no associated palpable lymphadenopathy.

D.D.S., M.D., Anne Cale Jones,

E. Perez, D.D.S, Travis W. Kern, D.D.S., Departments of Pathology and Oral & Maxillofacial

Surgery, The University of Texas Health Science Center at San Antonio

McGuff

Jones

The patientâ&#x20AC;&#x2122;s past medical history was significant for obesity and hypertension. His medications included Metoprolol and he had no known drug allergies. He was a non-smoker and drank beer on the weekends.

The differential diagnosis for this palatal mass included salivary gland neoplasms and soft tissue tumors. An incisional biopsy was performed under local anesthesia. Histologic examination revealed a circumscribed, partially encapsulated glandular neoplasm composed of bland ductal epithelial cells, myoepithelial cells and myxoid to fibrohyaline stroma.

Rare mitotic figures were seen.

Figure 1 (above).

Large non-ulcerated right palatal mass.

What is the most likely diagnosis?

Figure 2.

CT scan showing welldelineated mass without osseous involvement.

See page 518 for the answer and discussion.

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In Memoriam Those in the dental community who have recently passed

Ellis, Clay Edward Arlington, Texas September 9, 1953 – April 12, 2010 Good Fellow, 2004

Petrovich, George J. Garland, Texas March 22, 1926 – March 31, 2010 Good Fellow, 1980 • Life, 1991 • Fifty Year, 2006

Riddle, Hal Gene Amarillo, Texas April 20, 1930 – March 19, 2010 Good Fellow, 1982 • Life, 1995 • Fifty Year, 2006

Memorial and Honorarium Donors to the Texas Dental Association Smiles Foundation

In Memory of: Shanna Olson

By Dr. Robert C. Cody Peggy Moore

By Dr. Robert C. Cody Dr. Brady Cox

By The Seventeenth District Dental Society Dr. Leo Valentine “Hoey” Selz, Jr.

By Dr. and Mrs. Paul G. Kooi Your memorial contribution supports: • educating the public and profession about oral health; and • improving access to dental care for the people of Texas.

Tennery, Thomas N. Colleyville, Texas November 1, 1942 – April 11, 2010 Good Fellow, 1997 • Life, 2008

Please make your check payable to:

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

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. © 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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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.

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Provided by TDA Perks Program

value for your

profession

Why Using Tape Backups is a Risky Practice And Why Reliable Patient-Data Backup is So Important

By David Post, MBS Managed Backup Solutions

Losing critical business records such as accounts receivable, patient records, or transaction histories could be a death

blow to your practice. If your office had

to re-enter all its data manually, the cost would be astronomical.

But the reality is that many dentists have not kept up with technology when it comes to data backup and safeguarding.

Alarmingly, some donâ&#x20AC;&#x2122;t even follow a regular backup routine of any kind. A backup method should be dependable, secure, scalable, and ideally, economical. Not only do you need to protect yourself from damagingly-costly losses of data, but also to abide by State board requirements pertaining to the retention and handling of patient data, federal legislation such as HIPAA, and newer e-discovery requirements related to the backup, archiving and recovery of files, which hone in on how practices store their data. With numerous backup and recovery solutions available today, businesses should not take the risk of losing irretrievable data or allowing private information to be accessible to non-authorized individuals.

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The Drawbacks of Tape Backups Many in the dental community are still relying on tape backups to protect their data. While this method is generally considered low-tech and fairly inexpensive, tape backups and restores require management and administration. It’s a time-consuming, often unreliable and complex task that typically falls on the office manager, who may or may not be technically oriented. Over the last 15 years in the dental IT and security business, I’ve found tape backups to be a risky proposition. Human error (e.g. forgetting to back up or change tapes, losing tapes), technical or tape failures, and the resulting inability to recover data are real dangers. New technologies and the migration toward paperless offices are rapidly expanding the amount and type of data dentists need to capture and store electronically. And as dental offices see the need to store 50, 150, or even 200 gigabytes of data at a time, tape becomes an increasingly expensive backup method with greater liabilities.

The Cost of Recovering Data The cost of recovering data can vary widely. It depends on the data-loss incident, and most critically, the amount of data lost. For example, in an instance where all the data lost could be re-keyed in a short period of time, the cost of data recovery would be relatively low. In another case, it could take hundreds of man-hours and several weeks to recover or reconstruct data. Such an effort could cost a practice thousands, or even hundreds of thousands of dollars.

Though some types of data are more valuable than others, according to a Gallup poll, most businesses value 100 megabytes (MB) of data at approximately $1 million dollars; or $10,000 for each MB of lost data (1). In my experience, an average incident results in a loss of about 2 MB of data. Using the Gallup poll’s findings, we can estimate that it would cost $20,000 to recover the 2MB of data. In the average incident I encounter, about 17 percent of the data lost cannot be recovered. Again using the Gallup’s findings as a guide, this would be a loss of approximately $3,400 worth of data. If you factor in the costs of technical services and lost productivity with the value of the lost data, the expected value of the loss of the 17 percent of data would be $3,957. I’ve found the average incident has a much lower data-recovery cost. However, in cases where data is permanently lost, the costs are estimated to be much higher. In any case, these figures show how valuable your data is to your practice.

Not If, But When Disaster Strikes Data protection, or a serious examination of data-backup options, is often neglected until a disaster strikes. Consider

the high-stakes risks associated with natural disasters, such as fire, flood, or hurricane; and it’s obvious that a good data-backup plan is virtually useless without a robust recovery plan in place. A tape backup—even a current one with an off-site copy—would be futile in a postdisaster scenario. Imagine you’re standing outside your flattened or burned-out building holding a tape in your hand. Among other things, you would have to buy a server compatible with your software, make sure it has a tape drive compatible with your tape, load the server software, and set up your users with the correct security rights.

Then you’d need to install your application programs and reload your data. It could take days or weeks to return to the point of being fully operational. In the meantime, you may or may not be conducting business. The growing dependence of dental practices on information technology to operate and remain profitable dictates that they be able to recover from data loss in near real time.

Bottom Line An effective backup strategy is essential if your practice is to be protected against data loss. Today, advances in data security technology and the plummeting price of disk-based backups make server-based local and off-site backup available at about the same price as tape backups or external hard drives, but with much greater security.

In short, these options are dependable, secure, scalable, and economical. But whether you opt for a traditional tape backup, external hard drive, or an off-site backup solution, do something rather than nothing. It took years to build your successful dental practice and you owe it to your patients and yourself.

MBS is a TDA Perks Program partner and a Texas-based company with more than 15 years of experience dedicated exclusively to the dental industry. Its data security experts are knowledgeable in all of the major practice management software packages, and the management team at MBS has more than a decade of experience in managing large scale technology implementations and data security solutions at Fortune 50 companies. The MBS team brings its experience and expertise to TDA members through the Perks program. For more information, or answers to questions you may have, contact David Post, TDA Perks Program’s MBS representative, at (877) MBS-0787. For more information regarding other TDA Perks Programs, visit tdaperks.com, or call (512) 443-3675.

Reference 1. Smith DM, PhD. The Cost of Lost Data: The Importance of Investing in that “Ounce of Prevention” Graziado Business Report, A Journal of Relevant Information and Analysis. Available from: URL: http:// gbr.pepperdine.edu/033/dataloss.html.

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

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

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

Join us on facebook.com/texasdental or groups.to/texasdental Follow us on twitter.com/theTDA Get LinkedIN at linkedin.com, search â&#x20AC;&#x153;Texas Dental Associationâ&#x20AC;?

May 2010 What’s on tda.org? Stefanie Clegg, TDA Web and New Media Manager

Department of Member Services & Administration

Members can now access their personal Facebook account from their TDA Express homepage.

Click on “My Links” to view your account.

Members can now access theirTDA personal account from their TDA Express homepage. Click on “My Links” Check out groupsFacebook on Facebook, LinkedIN and Twitto view your account. ter by clicking on the icons at the top of TDA Express.

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Click “Set as homepage” in top-right corner of the page.

Make TDA Express your homepage: Log in at tda.org and click on “TDA Express” on the member homepage. Click “Set as homepage” in top-right corner of the page.

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Check it out online!

Log in at tda.org and click on “2010 TEXAS Meeting” on the member homepage to access:

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PHOTOS Flip through photos from social events, courses, exhibit hall, and more Log in at tda.org and click on “2010 TEXAS Meeting” on the member homepage to access: VIDEO PHOTOS Watch video highlights of daily activities.

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ONLINE CE VERIFICATION FEEDBACK CEShare Verification will be available for up toMeeting six months after the 2010 TEXAS Meeting. You will need your your thoughts on your online 2010 TEXAS experience. badge number and the four-digit completion code for each course attended.

The One Hundred & Forty-First Annual Session will be held in San Antonio May 5-8. 2011. Check back with Thetexasmeeting.com 141st Annual Session will be held in San Antonio May 5-8, 2011. Check back with texasmeeting.com for for details. details.

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Cost: Deadline:

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

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Oral and Maxillofacial Pathology Diagnosis and Management

Pleomorphic Adenoma (Benign Mixed Tumor) Oral and Maxillofacial Pathology Case of the Month (from page 508)

Discussion Pleomorphic adenoma (PA) is a benign salivary gland neoplasm of epithelial origin (1-4). PA is a relatively common tumor with an annual incidence of 2.4 to 3.0 per 100,000 persons (1). It represents the most common salivary gland tumor, accounting for 40-70 percent of these lesions (1). There are no well defined risk factors for PA, and familial occurrence is unusual. PA occurs across a wide age range with a peak incidence in the 3rd and 4th decades of life (1). There is a female gender predilection of 2:1.1 PA most frequently develops in the superficial lobe of the parotid gland, the lateral

palate and the submandibular gland.

The upper lip and buccal mucosa represent other common sites of occurrence in intraoral minor salivary glands. PA is usually a solitary lesion; however it may occasionally be associated with other salivary gland tumors, most often Warthin tumor.

PA presents as a firm slow growing painless mass lesion. Untreated lesions may reach a large size and become bosselated. While most lesions have some degree of mobility, palatal tumors are often bound to the underlying periosteum. Pain, ulceration, and infarction usually do not occur unless the tumor is secondarily traumatized. PAs arising

Figure 3. Histologic section revealing a circumscribed glandular neoplasm (original magnification 4x).

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in the parotid gland may rarely cause facial nerve dysfunction secondary to compression.

Gross pathologic examination of PA reveals a circumscribed nodular mass with a firm tan-white to translucent blue-grey cut surface. Cystic areas may be present. Histologically, PA is composed of a mixture of ductal epithelial cells, myoepithelial cells and stromal elements â&#x20AC;&#x201D; hence it is also referred to as â&#x20AC;&#x153;mixed tumor.â&#x20AC;? These tumors may show a variety of growth patterns including ductal, tubular, trabecular, solid and cystic. The cellular components may include cuboidal, basaloid and squamous epithelial cells; as well as

Figure 4. Histologic section demonstrating a tumor composed of ductal epithelial cells, myoepithelial cells and fibromyxoid stroma (original magnification 20x).

Figure 5. Wide local excision of the palatal mass. spindled, clear, and hyaline plasmacytoid myoepithelial cells. Focal mucous, sebaceous and oncocytic cells may also be present. Areas of keratinization may be seen. The stroma is derived from the myoepithelial cells and includes fibrous, hyaline, myxoid, and chondroid elements. Rarely, bone and adipose tissue may be present. PA may occasionally contain tyrosine, collagen and oxalate crystalloids. All of these diverse cellular and stromal components may be present in varying proportions from tumor to tumor and from area to area within the same tumor — hence the term “pleomorphic (many forms) adenoma”. PA is typically incompletely encapsulated and lobules of tumor may bulge through the capsule to abut adjacent normal parenchyma. Areas of increased cellularity and foci of mild cytologic atypia may be present. Mitotic activity is typically low. Fine needle aspiration cytology is often helpful in the preoperative assessment of PA, and will demonstrate a characteristic mixture of the epithelial and stromal elements. However, other salivary gland

Figure 6. Gross surgical specimen.

tumors may have similar cytologic characteristics. Secondary trauma, including fine needle aspiration, may induce necrosis, hemorrhage, inflammation and reactive atypia which can complicate histologic evaluation.

Extensive hyalinization, spontaneous necrosis, marked cytologic atypia, increased mitotic activity and infiltrative growth are features concerning for malignancy. Tumors that display worrisome features that are not definitively diagnostic of malignancy may be termed “atypical pleomorphic adenoma”.

PA may harbor genetic abnormalities in up to 70 percent of cases. These include translocations involving the PLAG1 gene on chromosome 8q12 and the HMGA2 gene on chromosome 12q14-15 (3).

The treatment for PA is complete surgical excision with a margin of normal tissue. Since these tumors are incompletely encapsulated, enucleation results in a high recurrence rate. Tumors with a prominently loose myxoid stroma may be more

easily spilled to contaminate the surgical field. Parotid recurrences are typically multifocal and are difficult to manage, often resulting in considerable morbidity, including loss of facial nerve function. At times, radiation therapy may be necessary to control benign recurrent disease. Tumors of the minor salivary glands have less potential for recurrence. With appropriate therapy, the prognosis for PA is good with a greater than 95 percent cure rate (4). PA does carry a 5 percent risk of malignant degeneration with development of a carcinoma ex pleomorphic adenoma (4). The risk for this complication increases with the duration of the tumor. The malignant component is most often a poorly differentiated adenocarcinoma. Rarely, benign PA may metastasize to lung or bone, most often following multiple recurrences and surgical manipulations which allow tumor access to vascular channels.

In this case, the tumor was excised with a 1 cm margin of normal tissue including the underlying periosteum, Texas Dental Journal l www.tda.org l May 2010

519

Figure 7. Surgical defect requiring reconstruction.

the adjacent muscular fascia and portions of the tensor and levator palatini muscles (Figures 5-6). In order to prevent contracture of the soft palate and velopharyngeal insufficiency, the large surgical defect was closed with a pedicled tongue-based flap (Figures 7-9). The surgical margins were negative for tumor. The patient recovered without complications and is being followed closely.

Figure 8. Dissection of tongue-based flap.

Dental practitioners should be aware that any intraoral submucosal mass may represent a salivary gland neoplasm â&#x20AC;&#x201D; with the palate representing the most common location for these tumors. Prompt recognition and diagnosis are essential as the overall incidence of malignancy in minor salivary gland tumors is 50 percent (4).

References 1. Gnepp DR. Diagnostic Surgical Pathology of the Head and Neck, 2nd Ed. Saunders/Elsevier, Philadelphia, 2009: 438-449.

2. Ellis GL, Auclair PL. Tumors of the Salivary Glands, AFIP Atlas of Tumor Pathology, Fourth Series, Fascicle 9, ARP Press, Silver Springs, Maryland, 2008: 49-71.

3. Wenig BM. Atlas of Head and Neck Pathology, 2nd Ed. Saunders/ Elsevier, Philadelphia, 2008: 584-591.

4. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology, 3rd Ed. Saunders/Elsevier, St. Louis, 2009: 473-480.

Figure 9. Pedicled tongue flap following closure of the donor site.

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

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Calendar of Events 522

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

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

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

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

Phone: (210) 653-7174; FAX (210) 653-8204.

24 – 26 The ADA will hold its 24th New Dentist Conference in San Diego, CA. For more information, please contact Mr. Ron Polaniecki, ADA, 211 East Chicago Avenue, Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org.

24 – 26 The American Association of Women Dentists will hold its annual meeting, A Taste of Dentistry in Chicago, in Chicago, IL. For more information, please contact Ms. Deborah Gidley, AAWD, 216 W. Jackson Road, Ste. 625, Chicago, IL 60606. Phone: (800) 920-2293; Fax: (312) 750-1203; E-mail: info@aawd.org; Web: aawd.org.

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: lhenderson@ndaonline.org; Web: ndaonline.org.

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

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.

25 The TDA Smiles Foundation will hold a Smiles on Wheels in Cactus. For more information, please contact the TDA Smiles Foundation, 1946 S. IH 35, Ste. 300, Austin, TX 78704. Phone: (512) 448-2441; Web: tdasf.org.

27 – October 2 The American Association of Oral Maxillofacial Surgeons will hold its 92nd annual meeting at McCormick Place in Chicago, IL. For more information, please contact Dr. Robert C. Rinaldi, AAOMS, 9700 W. Bryn Mawr, Rosemont, IL 60018. Phone: (847) 678-6200; FAX: (847) 678-6286; Web: aamos.org.

October 2010

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

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

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

Calendar of Events

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) 8851272; FAX: (847) 885-8393; E-mail: central@aacfp.org; Web: aacfp.org.

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Calendar of Events 524

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

20 – 23 The American Society of Dental Aesthetics will hold the 34th Annual American Society of Dental Aesthetics International Conference in San Antonio, TX. For more information, please contact Dr. Dan Lambert, ASDA, 635 Madison Ave., New York, NY 10022. Phone: (800) 454-2732; E-mail: ddssmile@aol.com; Web: asdatoday.com.

20 – 24 The American Academy of Implant Dentistry will hold its 59th annual meeting at the Boston Marriott Copley Place in Boston, MA. For more information, please contact Ms. Sara May, AAID, 211 East Chicago Ave., Suite 750, Chicago, IL 60611-2637. Phone: (312) 335-1550; FAX (312) 3359090; E-mail: info@aaid.com; Web: aaid.com.

28 – 30 The Hispanic Dental Association will hold its annual meeting in Chicago, IL. For more information, please contact Ms. Rita Brummett, HDA, 3085 Stevenson Drive, Suite 200, Springfield, IL 62703.

Phone: (217) 529-6517; FAX: (217) 529-9120; E-mail: hispanicdental@hdassoc.org; Web: hdassoc.org.

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

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) 931-9429; E-mail: info@dentaltradealliance.org; Web: dentaltradealliance.org.

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

4–9 The ADA will hold its Kellogg Executive Management Program (ADAKEMP) in Chicago, IL. For more information, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org.

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

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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: 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. ID #1-0109.

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

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with digital radiography. Fee-for-service patient base and very good new patient count. Great numbers. Super upside potential. ID #093.

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

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

Very good income and low, low overhead.

Priced to sell. ID #013.

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

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 2,400 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 -10108.

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 startup price. Excellent opportunity. ID #10107.

WACO AREA: Modern and high-tech, three op general family practice grossing in mid-six fiturs 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.

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

NEW! HOUSTON: Established, crown and bridge/removable practice with digital Xrays, great new patient flow, production

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in high six figures. PPO and fee-for-service only. Tremendous cash flow. #H109.

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

HOUSTON — General family practice located southwest of Houston, high visibility, grossing mid-six figures. Five operatories, two ready for expansion. Building and up to four acres of real estate ready for development included in sale. #H108.

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

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

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

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

NEW! HOUSTON —Six operatory general practice located in southwest Houston; very recent, elegant buildout; digital Xrays, new equipment (two rooms). Grossing near mid-six figures for 2009, poised for growth. #H119.

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

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Austin, David McLerran, (512) 7506778; in Houston, Tom Guglielmo and Patrick Johnston, (281) 362-1707. Practice sales, appraisals, buyer representation, and lease negotiations. See www. dental-sales.com for pictures and more complete information.

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

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

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

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

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

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

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

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 a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale.

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

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

GARY CLINTON / PMA 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 wellestablished restorative practice. Very nice equipment. Dentist relocation. Transitional / outright sale. We have the best sources for 100 percent buyer funding.

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

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

GARY CLINTON / PMA ABILENE: Retiring dentist outright sale / PRN transition; great location southside of Abilene.

Well-established practice; three operatories; excellent full recall and new patient flow. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of

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. 03 South Texas — Retiring ortho-

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dontist. Transition flexible. Seven-figure practice collections; over 60 percent profits; lovely building. He is ready to spend time with his grandchildren. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale.

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

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

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

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

GARY CLINTON / PMA LUBBOCK / PANHANDLE AREA PRACTICE FOR SALE: Well-established practices. Doctor will sell/transition. High collections/net.

Five operatories; full hygiene. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/ sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential.

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

GARY CLINTON / PMA NORTH TEXAS PRACTICE FOR SALE: Small community 1.5 hours away from Dallas. Seven-figure gross with very high operating profits. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general).

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

GARY CLINTON / PMA ORTHODONTIC NORTH DALLAS AREA: Highly desirable

SOUTHEAST HOUSTON GENERAL DENTAL PRACTICE — SALE: Incredible

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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 and spacious facility located in the heart of a rapidly growing Texas metropolis. Great opportunity for highly qualified surgeon with desire to assume responsibility for a wide spectrum of OMS procedures, expand surgical treatment, and dramatically increase income.

Strong revenues and high profit margins; flexible acquisition terms! Must see opportunity! Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

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

treatment rooms with new equipment.

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

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

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

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

Contact The Hindley Group at (800) 8561955. 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 envi-

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ronment, this is a must-see opportunity.

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

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

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

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

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

WEST HOUSTON GENERAL DENTAL PRACTICE — SALE: Wonderful opportunity in rapidly growing west Houston community. Strong revenue and profit margin. Wonderful staff. Practice has ortho emphasis, but seller will stay on to complete cases if necessary. Building also for sale. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

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WACO PEDIATRIC DENTAL PRACTICE — SALE: Well-established practice with moderate revenues and high profit margin on 4 days per week. Due to limited competition and a large facility, there is ample room to grow in this community that is home to Baylor University. All ortho cases are being completed, unless purchaser would like to expand new cases.

No Medicaid being seen, but good opportunity with enhanced state fee schedule.

Experienced staff and steady new patient flow. Wonderful mentor. Building also available. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

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

Two fully equipped treatment rooms with three others plumbed for expansion.

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

CENTRAL TEXAS GENERAL DENTAL PRACTICE — SALE: Healthy practice generating strong revenues. Five fully equipped treatment rooms and 12 hygiene days per week. Excellent staff and strong new patient flow. Most capable doctor to facilitate transition. Building also for sale. 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 town with excellent access to forests and lakes for hunting, fishing, and boating. Excellent opportunity for dentists looking ahead to separation from the military. Pre-determined buy-in terms.

SOUTH CENTRAL TEXAS PERIODONTAL — Wonderful practice completing periodontal treatment seeks long-term associate who desires to be a partner within 1-2 years. Great location with strong new patient flow. Pre-determined purchase and partnership terms. Wonderful mentor looking for an “equally-yoked” individual. Excellent staff. 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-estab-

lished. Call Jim Robertson at (713) 6881749.

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

DALLAS / FORT WORTH: Dental One is opening new offices in the upscale suburbs of Dallas and Fort Worth. Dental One is unique in that each office of our 60 offices has its own, individual name such as Riverchase Dental Care and Preston Hollow Dental Care. All our offices have top-of-the-line Pelton and Crane equipment, digital X-rays, and intra-oral cameras. We are 70 percent PPO, 30 percent full fee. We take no managed care or Medicaid. We offer competitive salaries and benefits. To learn more about working for Dental One, please contact Rich Nicely at (972) 755-0836.

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

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

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

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

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

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

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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) 3426565.

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.

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

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

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

EL PASO: FULL- OR PART-TIME ASSOCIATE NEEDED. Would be sole practitio-

ner at location. Three operatories for DDS plus one for hygienist, equipment less than 1 year old. Past compensations up to five figures per week. No administrative responsibilities. Call (702) 510-7795 or e-mail drartbejarano@gmail.com.

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

HOUSTON: 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) 488-3416.

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

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

The practice offers a tremendous opportunity to grow a solid foundation with the doctor. The practice offers excellent production and earning potential with a possible future equity position available. Our knowledgeable staff will support and enhance your growth and earning potential while helping create a smooth transition.

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

HOUSTON: Retiring dentist is seeking his successor. Located in the Heights area of Houston, this two operatory practice consistently generates revenue in the low six figures because the owner wanted it that way. 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.

EXPERIENCED RESTORATIVE DENTIST (PANKEY/LVI TYPE) who enjoys

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aesthetics and full-mouth rehab needed to lead a first-class, full service practice. Unique practice model affords the opportunity to earn high income doing big cases and coordinating patient care with our specialty teams. Practice with the support of a veteran team in a beautiful practice. Contact Dr. John Bond at jbond@6daydental.com.

6 DAY DENTAL & ORTHODONTICS is an established group practice model, providing all dental services to our patients under one roof. Our general dentists and specialists work together to provide the most convenient and quality dental care possible. We are growing and have an immediate opportunity for a general dentist or prosthodontist with future partnership/equity opportunity. 6 Day Dental & Orthodontics just may be the premier feefor-service alliance of dental practices in the country. Our doctors earn more, see fewer patients, and have plenty of time off to enjoy a rich and healthy lifestyle.

New grads and experienced dentists/ prosthodontists welcomed. Our dentists earn in the top 10 percent of extractions, as well as performing all types of dentistry. Please send CV or contact Dr. John Bond at jbond@6daydental.com. Visit www.6daydental.com.

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

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

PEDIATRIC DENTIST: Pediatric Dental Wellness is growing and needs a dynamic dentist to work full time in our pediatric practice. The perfect complement to our dedicated staff would be someone who is compassionate, goal oriented, and has a genuine love for working with children. If you are a motivated self-starter that is willing to give us a long-term commitment, please apply. Salary plus benefits. Looking to fill position immediately. Send resumes and cover letters to candice-n.moore@ gmail.com.

GREAT OPPORTUNITY FOR A PEDIATRIC DENTIST OR GP to join our expanding practice. We are opening a new practice in the country (Paris, Texas), just 1 hour past the Dallas suburbs and our original location. The need for a pediatric dentist out there is tremendous, and we are the only pediatric office for 70 miles in any direction. We are looking for someone that is personable, caring, energetic, and loves a 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 parttime initially, and after a short training period will lead to full-time. If you join our team, you will be mentored by a Board certified pediatric dentist and will develop experience in all facets of pediatric dentistry including behavior management using oral conscious sedation as well as IV sedation. For more information, please visit our websites at www.wyliechildrensdentistry.com and www.parischildrensdentistry.com.

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

SOUTHWEST FT. WORTH â&#x20AC;&#x201D; GENERAL DENTAL PRACTICE WITH BUILDING FOR SALE OR LEASE: This very successful, well-established practice has an excellent patient base with referrals from near and far. The seller is retiring immediately or will negotiate a comfortable transition. With a low overhead and excellent profit margin, this practice makes a great investment for just the right person. Five treatment rooms, 3,200 sq. ft. plus 800 sq. ft. for additional expansion or rental space.

The practice is located in a high visibility and stable economic community.

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

ASSOCIATE â&#x20AC;&#x201D; CORPUS CHRISTI: 25-year-old family practice providing quality care in modern operatory office.

Great supportive team, excellent compensation history. Associate to partnership opportunity. Contact Dr. Boss for more information, (361) 774-5410 or e-mail abossjr@aol.com.

MEMORIAL DENTISTS currently seeking part-time associate to join our practice. Minimum 5 years experience. Please send your CV to info@memorialdentists. com.

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

on Fridays and other times negotiable. Perfect satellite or start-up office.

Exclusive use of a beautiful and wellequipped 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. Email CV to Dr. Mike Kesner, drkesner@ madeyasmile.com.

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

SAN ANGELO GENERAL PRACTICE FOR SALE. Well-established (35+ years). Prosperous and well located building in central area with exceptionally high traffic flow two blocks from Shannon Hospital. The building is approximately 3,000 sq. ft. Only 1,600 sq. ft. being used at present with three fully equipped operatories, three X-ray units, auto developer, and perfectly maintained autoclave and compressor.

All equipment to be included. Ample parking and easy in-out to traffic. All records will be given to doctor who is Texas Dental Journal l www.tda.org l May 2010

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interested and the current practitioner will be available for transition. Will entertain a purchase, lease with option to purchase, or lease only. Wonderful opportunity for new practitioner or one who desires to own his/her own building/practice. Call (325) 653-6816 M-F, 8 AM-Noon.

SEEKING ASSOCIATE DENTISTS. Dental Republic is a well-established general dental practice with various successful locations throughout the Dallas Metroplex. A brand new stateof-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 401(K) with employer contribution. New graduates and dentists with experience are welcome. Be a part of our outstanding team, providing care for Texasâ&#x20AC;&#x2122; kids.

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

THRIVING PRACTICE IN GALVESTON providing the best of both worlds

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... the great outdoors and a laid back lifestyle, yet quick access to metropolitan Houston. This 15-year-old practice has three fully equipped operatories, private office, full-time hygienist, and a great staff. Ownership of free-standing building is available. Generating midsix 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 fulland 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 AN ASSOCIATE in a busy, growing, and well-established cosmetic and family practice with state-of-the-art equipment. Call Zonia Lopez at (956) 630-6130.

LUBBOCK GENERAL PRACTICE: Associate/partner. Growing group practice is looking for a motivated, longterm, career-minded dentist to provide quality care to our established and tremendous number of new patients. Experienced or new grad welcome. Contact at dentist.lubbock@gmail.com.

Office Space FOR SALE OR LEASE, READY TO MOVE IN: Facility and equipment with three to five ops in far North Dallas, just south of Piano between Addison and Richardson. Office is fully equipped including handpieces, instruments, and supplies. Lease hold improvements

already in place. Furnishings in great shape. space is 1,800 sq.ft. with a 5-year lease at $16-$18 per square foot and excellent net. Exceptional rate that is well below market. Fantastic value.

For additional details and complete equipment list, please call (972) 9784832 or e-mail jkg@grinallday.com.

MEDICAID FACILITY FOR SALE OR LEASE/PURCHASE: ideal situation to get started for little cost. Please call (214) 794-0975 or e-mail jkg@grinallday.com.

SPACE AVAILABLE FOR SPECIALIST. new professional building located

southwest of Fort worth in Granbury between elementary and junior high schools off of a state highway with high visibility and traffic. Call (817) 3264098.

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

DENTAL / MEDICAL OFFICE in Medical Center area. Nicely finished out;

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move-in ready; all bills paid. Up to 3,509 sq. ft. (1,608 sq. ft. and 1,892 sq. ft.) for $5,800 / month. Call Shannan Schnittger, broker, (210) 930-3700.

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

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

Call (760) 436-0446.

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) 5205147. Serious offers considered.

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

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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 buyin 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 Austin. Ongoing 12-week course. Please call Dr. Peter Najim,

(800) 509-2864, pnajim@dentalassist. org.

TEXAS LICENSED DENTIST needed to teach RDA course in North Dallas area Dental Assisting School; one Saturday every 3 months; $500 / day. No teaching experience necessary. E-mail inquiry to pnajim@dentalassist.org.

corporate orthdontics 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) 232-3100.

FANTASTIC OPPORTUNITY FOR GENERAL DENTIST to learn and in-

Thomas John Kennedy of Texas, D.D.S., P.L.L.C.

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Your Patients Trust You. Who can YOU Trust?

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

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

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

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

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

• SUV costs less than other surface disinfectants.

• Spray bottles are provided FREE with your order.

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

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

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

© 2009 OSHA Review, Inc.

Texas Dental Journal l www.tda.org l May 2010 543 Call 1-800-555-6248 to place your order or request more information www.oshareview.com

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

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

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

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

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