November 2010

AL IC UE I EC ATR ISS P S I RY D PE IST rt 1 T Pa N DE

November 2010

TEXAS DENTAL

Journal

Texas Dental Association’s Gold Medal Winner Dr. John S. Findley

/ rg ns o . o a td ati nic al sit blic ectro ourn i V pu el l J a e a td r th ent fo s D xa Te

Peer Review: Process Snapshot Peer review is organized dentistry’s dispute resolution process that generally handles complaints from patients against dentists regarding the quality or appropriateness of clinical dental treatment received.

Need a peer review sign for your office?

You may print a copy of the peer review sign from the Resources section of the members homepage on the TDA Website (tda.org).

For more information about peer review please contact the Council on Peer Review via Cassidy Neal at 512-443-3675 ext. 152.

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

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

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

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

Contents

TEXAS DENTAL JOURNAL n Established February 1883 n Vol. 127, Number 11, November 2010

ON THE COVER

1156 The 2010 Gold Medal for Distinguished Service —

Dr. John S. Findley Nicole Scott

The Gold Medal for Distinguished Service is the highest honor one can achieve in the Texas

Dental Association. The criteria involves service in TDA leadership positions, ADA service,

local society contributions that affected state concerns, commitment to organized dentistry

through other organizations including teaching, and service to the community.

Photo courtesy of Paul H. Schlesinger.

ARTICLES This issue is the first of two special issues on pediatric dentistry. The authors present advances in restorative procedures, care for primary dentition, and the introduction of the First Dental Home for our youngest patients.

1165 Restorative Dentistry for the Pediatric Patient

Steven P. Hackmyer, D.D.S.; Kevin J. Donly, D.D.S., M.S.

The authors review updates to the consensus statements that were issued as a result of the Pediatric Restorative Dentistry Consensus Conference in 2002.

1175 Indirect Pulp Therapy: An Alternative to Pulpotomy

in Primary Teeth

The manuscript describes the use of an alternative to the pulpotomy, indirect pulp therapy, for the treatment of primary teeth with carious involvement approaching the pulp.

N. Sue Seale, D.D.S., M.S.D.

1187 Comprehensive Oral Rehabilitation with General Anesthesia

and Prosthetic Care in the Primary Dentition: A Case Report

Gisela M. Velasquez, D.D.S., M.S.; Sanford J. Fenton, D.D.S., M.D.S. Laura Camacho-Castro, C.D., D.M.D.; Bhavini S. Acharya, B.D.S., M.P.H.; Aaron Sheinfeld, D.D.S., D.M.D.

The case report discusses the oral rehabilitation and treatment plan of a 5-year-old male with extensive dental caries.

1195 Infant Oral Exam and First Dental Home

1148

Kavitha Viswanathan, D.D.S., M.S., Ph.D.

The article encourages general practitioners to actively participate in providing care for young children under the age of 3 and provides details of the components of the First Dental Home initiative.

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

MONTHLY FEATURES

1152 1153 1162 1208 1213

President’s Message

TDA Smiles Foundation

1214 1216 1220 1222 1225

1228 1246

Notice of Grant Availability Guest Editorial TEXAS Meeting Preview In Memoriam /

Errata The staff of the Texas Dental Journal regrets the inadvertent inclusion of Dr. Thomas Graves in the October issue’s Memorials and Honorariums for the Texas Dental Association Smiles Foundation. The correct name included should have been Dr. Thomas Grams.

What’s on tda.org?

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

EDITORIAL STAFF

Texas Dental Journal (ISSN 0040-4284) is published monthly, one issue will be a directory issue, by the Stephen R. Matteson, D.D.S., Editor Texas Dental Association, 1946 S. IH-35, Austin, Texas, 78704-3698, (512) 443-3675. Periodicals Nicole Scott, Managing Editor Postage Paid at Austin, Texas and at additional mailBarbara S. Donovan, Art Director ing offices. POSTMASTER: Send address changes Paul H. Schlesinger, Consultant to TEXAS DENTAL JOURNAL, 1946 S. Interregional Highway, Austin, TX 78704.

EDITORIAL Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, ADVISORY BOARD Out-of-state ADA Affiliated $49.50. In-state NonRonald C. Auvenshine, D.D.S., Ph.D. ADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA AffiliBarry K. Bartee, D.D.S., M.D. ated, $17 Non-ADA Affiliated, September issue $17 Patricia L. Blanton, D.D.S., Ph.D. ADA Affiliated, $65 Non-ADA Affiliated. For in-state William C. Bone, D.D.S. orders, add 8.25% sales tax.

Phillip M. Campbell, D.D.S., M.S.D. Contributions: Manuscripts and news items of interest to the membership of the society are solicited. The Tommy W. Gage, D.D.S., Ph.D. Editor prefers electronic submissions although paper Arthur H. Jeske, D.M.D., Ph.D. manuscripts are acceptable. Manuscripts should be Larry D. Jones, D.D.S. typewritten, double spaced, and the original copy Paul A. Kennedy, Jr., D.D.S., M.S. should be submitted. For more information, please refer to the Instructions for Contributors statement Scott R. Makins, D.D.S. printed in the September Annual Membership DirecRobert V. Walker, D.D.S. tory or on the TDA website: www.tda.org. All statements of opinion and of supposed facts are published William F. Wathen, D.M.D. on authority of the writer under whose name they Robert C. White, D.D.S. appear and are not to be regarded as the views of the Leighton A. Wier, D.D.S. Texas Dental Association, unless such statements Douglas B. Willingham, D.D.S. have been adopted by the Association. Articles are accepted with the understanding that they have not The Texas Dental Journal is a been published previously. Authors must disclose any financial or other interests they may have in products peer-reviewed publication. or services described in their articles.

Advertisements: Publication of advertisements Texas Dental Association in this journal does not constitute a guarantee or 1946 South IH-35, Suite 400 endorsement by the Association of the quality of Austin, TX 78704-3698 value of such product or of the claims made of it by Phone: (512) 443-3675 its manufacturer.

FAX: (512) 443-3031 E-Mail: tda@tda.org Texas Dental Journal is a member of the aa Website: www.tda.org American Association of Dental Editors.

de

BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION PRESIDENT Ronald L. Rhea, D.D.S. (713) 467-3458, rrhea@tda.org PRESIDENT-ELECT J. Preston Coleman, D.D.S. (210) 656-3301, drjpc@sbcglobal.net IMMEDIATE PAST PRESIDENT Matthew B. Roberts, D.D.S. (936) 544-3790, crockettdental@gmail.com VICE PRESIDENT, SOUTHEAST R. Lee Clitheroe, D.D.S. (281) 265-9393, rlcdds@windstream.net VICE PRESIDENT, SOUTHWEST John W. Baucum III, D.D.S. (361) 855-3900, jbaucum3@msn.com VICE PRESIDENT, NORTHWEST Kathleen M. Nichols, D.D.S. (806) 698-6684, toothmom@kathleennicholsdds.com VICE PRESIDENT, NORTHEAST Donna G. Miller, D.D.S. (254) 772-3632, dmiller.2thdoc@grandecom.net SENIOR DIRECTOR, SOUTHEAST Karen E. Frazer, D.D.S. (512) 442-2295, drkefrazer@att.net SENIOR DIRECTOR, SOUTHWEST Lisa B. Masters, D.D.S. (210) 349-4424, mastersdds@mdgteam.com SENIOR DIRECTOR, NORTHWEST Robert E. Wiggins, D.D.S. (325) 677-1041, robwigg@suddenlink.net SENIOR DIRECTOR, NORTHEAST Larry D. Herwig, D.D.S. (214) 361-1845, ldherwig@sbcglobal.net DIRECTOR, SOUTHEAST Rita M. Cammarata, D.D.S. (713) 666-7884, rmcdds@sbcglobal.net DIRECTOR, SOUTHWEST T. Beth Vance, D.D.S. (956) 968-9762, tbeth55@yahoo.com DIRECTOR, NORTHWEST Michael J. Goulding, D.D.S. (817) 737-3536, mjgdds@sbcglobal.net DIRECTOR, NORTHEAST Arthur C. Morchat, D.D.S. (903) 983-1919, amorchat@suddenlink.net SECRETARY-TREASURER Ron Collins, D.D.S. (281) 983-5677, roncollinsdds@hotmail.com SPEAKER OF THE HOUSE Glen D. Hall, D.D.S. (325) 698-7560, abdent78@sbcglobal.net PARLIAMENTARIAN Michael L. Stuart, D.D.S. (972) 226-6655, mstuartdds@sbcglobal.net EDITOR Stephen R. Matteson, D.D.S. (210) 277-8595, smatteson@satx.rr.com EXECUTIVE DIRECTOR Ms. Mary Kay Linn (512) 443-3675, marykay@tda.org LEGAL COUNSEL Mr. William H. Bingham (512) 495-6000, bbingham@mcginnislaw.com

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

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Texas Dental Association 140th Annual Session 2010 TEXAS Meeting Photo Contest 2011 Category: Natural Wonders • Award: 3rd Place Photographer: Dr. Roy L. Tiemeyer of Corpus Christi Title: “Marsh Lights”

STAR OF THE SOUTH DENTAL MEETING

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

February 3-5, 2011 George R. Brown Convention Center Houston, Texas We invite you to the 40th Star of the South Dental Meeting. Come help us celebrate 40 Years of Education, Achievement, Recognition and Service. Not only will we have outstanding, well-known speakers covering every topic, but you will enjoy the festive atmosphere. Make it a must to attend our 40th Birthday Extravaganza on Friday night. Registration begins in October. Visit www.starofthesouth.org. for more information.

FEATURED CLINICIANS Dr. Roger Alexander Emergencies / Oral Surgery

Dr. Greg Folse Geriatrics

Dr. Robert Margeas Cosmetic / Restorative

Ms. Lois Banta Insurance/ Scheduling

Dr. Paul Feuerstein Technology

Dr. Steven Bender Sleep Medicine

Ms. Mary Govoni Hygiene

Dr. Jaimee Morgan / Dr. Stanley Presley Orthodontics / Cosmetic / Restorative

Dr. Jonathan Bregman Oral Cancer Detection

Dr. Gary Glassman Endodontics

Ms. Shannon Pace-Brinker Dental Assistant CE

Dr. Raymond Bertolotti Cosmetics / Restorative

Dr. Mark Hyman Practice Management

Dr. Maria Ryan Women’s Health / Periodontics

Dr. Joe Camp Endodontics

Dr. Arthur Jeske Pharmacology

Dr. Bruce Small Cosmetic / Restorative

Dr. Anthony Cardoza Forensics

Dr. Robert Kerstein / Dr. Mark Montgomery Occlusion

Ms. Pam Smith Nutrition

Dr. Bernard Costello Pediatric Oral Surgery / Trauma Dr. Catherine Flaitz Oral Pathology

Dr. Rod Kurthy Bleaching

Dr. Charles Wakefield Cosmetic / Restorative and many more . . .

Star of the South Dental Meeting • February 3-5, 2011 • George R. Brown Convention Center • Houston, Texas For more information, visit our website at www.starofthesouth.org.

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

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1151 1043

ARKANSAS • INDIANA • IOWA • KENTUCKY • LOUISIANA • OHIO • OKLAHOMA • TEXAS

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

By the time you receive this issue of the Texas Dental Journal, your 15th Trustee District Delegation to the American Dental Association (ADA) will have returned from the 151st Annual Session of the House of Delegates. The policies of the ADA on workforce and governance of the association have been decided.

The way dentistry is practiced in each state is governed, not by the policies of the ADA, but by the legislative bodies of each individual state.

However, the policies of the ADA are critical components in each of our legislative efforts.

The pressure exerted by access to care problems drives many of the policies of the ADA and the TDA. One of the most critical access problems is the availability and quality of care provided to children from economically challenged families. The prevention of dental disease in these children and the delivery of care to those in need is not a problem that we can ethically and conscientiously ignore. No child in Texas should have to cry himself to sleep with a toothache because of the lack of access.

Though we all labor diligently in the repair of the ravages of dental disease, we know the ultimate solution lies in prevention.

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

Unique to Texas is the First Dental Home initiative. This program centers around the child’s first dental visit between the age of 6 months and 3 years. Significant to this visit is the establishment of a relationship with a dentist, lap exam, caries risk assessment, preventive treatment, ageappropriate anticipatory guidance, and perhaps most important, parent education.

This issue and a second issue in December are devoted to pediatric dentistry. While not all of us are pediatric dentists, we must all be dedicated to the reduction of dental disease in this vulnerable population.

In this issue you will find articles on the infant oral exam and the First Dental Home initiative, a review of the current restorative modalities for children, indirect pulp therapy in primary teeth, and a case report of prosthetic restoration of the pediatric patient.

For your inspiration, please also read the article about Dr. John Findley, the 2010 winner of the TDA Gold Medal for Distinguished Service.

Enjoy your issue!

NOT JUST A PRACTICE BROKER CONSULTING TEXAS DENTISTS “37 YEARS” Texas Dental Association Notice of Grant Availability 501(c)(3) Non-Profit Dental Organizations

T

he Texas Dental Association (TDA) announces availability of financial assistance for qualifying 501(c)(3) non-profit organization affiliated with dentistry. The monies are derived from TDA Relief Fund interest income earned over the previous fiscal year.

Grantees will be determined by the TDA Board of Directors.

Eligibility: Grantees must be 501(c)(3) nonprofit organizations affiliated with dentistry.

Application: Letters of interest detailing the proposed project(s) and including a budget(s) should be mailed to: TDA Board of Directors Attn.: Mr. Terry Cornwell 1946 S. IH 35, Ste. 400, Austin, TX 78704 Deadline: Letters of Interest must be received no later than January 31, 2011.

Approval: Letters of Interest will be reviewed and considered by the TDA Board of Directors at its April 2011 meeting.

Notification: All applicants will be notified in writing by May 15, 2011.

Previous Recipients: In 2010, grants were awarded to Christian Community Action in Lewisville, Community Health Center of Lubbock, Dentists Who Care in the Rio Grande Valley, and the HOPE Clinic in Alvin.

For more information, please contact Mr. Terry Cornwell, TDA, (512) 443-3675 or terry@tda.org.

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

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Dr. Frank Boyar, a Fortress Dentist.

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

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

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

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

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

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

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

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

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3. Your current contract must be expired or expiring. When your contract expires, you can join other TDA members who qualify for a lower-tier rate, and have substantial savings per year. If your office uses up to 250,000 kilowatt hours (kW-h) per year, it can sign a new contract to pay the same rate as those using 1 million kW-h per year, OR choose 100% renewable energy at the lowest group pricing in Texas. Your new rate should effectively give you a savings equal to free electricity for the last two months of every year or more.

The 2010 Gold Medal for Distinguished Service — Dr. John S. Findley

By Nicole Scott, TDA Managing Editor About the Honor

By Paul H. Schlesinger

The Gold Medal for Distinguished Service is the highest honor one can achieve in the Texas Dental Association.

Nominations are submitted to the awards committee by the Board of Directors, component society presidents, and component executive staff.

Only one person per year may receive the award, and that is only if the awards committee believes one of the nominees successfully meets the criteria. The criteria involves service in TDA leadership positions, ADA service, local society contributions that affected state concerns, commitment to organized dentistry through other organizations including teaching, and service to the community.

About the Gold Medal Presentation

Owing to its stature, the TDA president presents the award before the House of Delegates. The name of the recipient is not revealed to anyone, including the recipient, until the actual presentation takes place.

The awards committee works behind the scenes with the recipient’s family members to make sure they are in attendance without alerting the recipient.

In 2006 the TDA commissioned a nationally renowned Texas artist, Ronadró, to design a unique award piece to represent the Association. The result is a beautiful, bronze relief depicting a dentist caring for a patient. This sculpture was adopted for the Gold Medal award in 2008. Inset into the shadowbox are two custom designed medallions: the TDA seal and the gold medal.

About the Past Recipients

To date, there have been 13 recipients of the Gold Medal: Drs. John D. Wilbanks, Michael D. Vaclav, O.V. Cartwright, H.M. “Mit” Sorrels, Jack H. Harris, James E. Bauerle, Robert V. Walker, Frank K. Eggleston, Robert M. Anderton, Rene M. Rosas, Richard M. Smith, Sam W. Rogers, Jr., and Stephen F. Schwartz. By the judgment of their colleagues, they represent the best of the TDA; dentists who have dedicated their lives to the Association and profession, and have advanced both through their commitment, strength, and vision.

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Texas l November 2010 2009 TexasDental DentalJournal Journall www.tda.org l www.tda.org l November

“I was one of many in TDA who believed that Texas dentists by education, training, service, and commitment were entitled to determine the course of the profession of dentistry in Texas.”

Dr. John S. Findley — Plano (2010)

Many distinguishable professional titles have preceded Dr. John S. Findley’s name over the years: dentist, president, mayor, council member, board member, and mentor. He also has some pretty remarkable personal designations: father, pilot, and hunter.

The 2010 winner of the TDA Gold Medal for Distinguished Service wears many hats in his professional and personal lives.

John was born in 1942 in Bryan. His mother was a schoolteacher, and his father worked as a terminal trainmaster for the Southern Pacific and Cotton Belt Railroads. When he was 12, the family moved from Hearne to Ennis. Before graduating from Ennis High School, he earned the prestigious title of Eagle Scout.

He attended the United States Air Force Academy and North Texas State University and served in the U.S. Air Force/U.S. Air Force Reserve from 1961 to 1968.

With his father’s encouragement and the influence of dentists Drs. Crawford A. McMurray and Walter C. Stout, both of Ennis, John established an interest in the dental profession. He graduated with a Doctor of Dental Surgery from Baylor University College of Dentistry in 1970.

He planned to attend graduate school, but an acquaintance from the Air Force, a dentist in Plano, urged him to experience general dentistry before specializing. “I came to Plano intending to stay for 1 year, but somehow that turned into 40,” John says.

Reflecting on his participation in organized dentistry, he remembers that he joined the Texas Dental Association the same year he graduated from Baylor because that was the expected and usual thing to do. Although he was always a member of organized dentistry, building a practice in Plano took a great deal of time, and regular attendance and participation in organized dentistry took a

back seat to other issues.

“I once loved to complain about the sad state of things in the community and in the practice environment, berating those who had put us in a particular bind,” he says. “Then, I realized that I was not participating in my local dental society … at all. I could complain, but did not want to work to find a solution to the problems — I wanted to let someone else do the work!”

John says this realization changed his commitment and determination to work for the profession and his community.

He began attending the Dallas County Dental Society (DCDS) meetings. In 1988, he was the mayor of Cross Roads in Denton County, and he served on the boards of directors for the United Way of Plano, the Plano Chamber of Commerce, and the Plano Family YMCA. He was chair of his church Board of Trustees. He began his dental service as DCDS president in 1993, then, in 1997 he was elected as TDA president.

He lists the “reformation” of TDA legislative activity as one of his most significant contributions in dentistry. “I was one of many in TDA who believed that Texas dentists by education, training, service, and commitment were entitled to determine the course of the

John delivers the graduation commencement address at Baylor College of Dentistry —Texas A&M Health Science Center.

John and his staff treat a young patient at his Plano office during the ADA’s Give Kids a Smile Day.

profession of dentistry in Texas.”

He and a committed group of TDA members rallied behind a restructuring and a fundraising effort called “For Dentistry I Will.”

With a new structure, adequate funds available, and a lobby team in place, the group set a determined legislative course for TDA.

“We began to see that Texas dentists had more than the basic ability to practice,” he says. “We had the ability to effect change to the benefit of patient and profession. I am exceptionally proud of those legislative members who followed me. They built an even better and stronger program … we are capable and successful in Austin, and that is one of our most important responsibilities for our practicing member dentists.”

John served as American Dental Association president-elect in 2008 and president in 2009.

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2010 Gold Medal

John attends a class reunion at the U.S. Air Force Academy in Colorado Springs, Colorado. He attended the Academy in the 1960’s.

In 2009, he began his most challenging role as the president of the American Dental Association (ADA). When he was elected to the position of president-elect at ADA, the association was “riding high,” as John describes it. In fact, however, there were tremendous lapses in organizational and financial integrity, a complication most members did not know and most did not want to imagine. The situation was compounded at the time by the loss of key people in Chicago.

“When faced with the extraordinary challenges of war, General Robert E. Lee remarked that you cannot do more than your duty, and you should never wish to do less,” John says, reflecting on the fact that the position of ADA president required much and would have been easier had these complications not been in place.

“It was duty, simply a job to be done, but it was much more than I ever imagined!”

He says he is indebted to his friends in Texas dentistry who supported him in efforts and campaigns for office and while in office. “I hope in some way, the small amount we all did will strengthen and support the profession for many years to come.”

As would be expected, his dental practice took a hit from his absence. But, he says dental patients are loyal and the prac-

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tice is still busy. “What I remember most is that in March and April of last year I practiced only 2 days! My typical workday in Chicago began at 6:00 AM and ended about 10:00 PM, usually 4 or 5 days a week.”

Now, John is serving as a mentor in the “Great Expectations: Mentoring Professionalism” program at Baylor College of Dentistry – Texas A&M Health Science Center (BCD). The program, established by BCD, the Texas Section of the International College of Dentists and DCDS, uses a small group approach to match faculty mentors to students.

“I believe strongly in preparing today’s young dentists for the future practice of dentistry,” says John. “It is an obligation we incur as professionals.”

During his downtime, John enjoys spending it with his sons, Brett, who is a lobbyist in Austin, and Alan, who is attending school in Austin.

A pilot for 38 years, John considers flying enjoyable, rewarding work. “There is no experience on Earth like being alone up there and realizing that it’s up to you to get back on the ground safely … it is up to you alone,” he says.

“Breaking out of the clouds a few hundred feet from the runway and being right at the runway lights was always an exhilarating

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

experience, an expected surprise!

I doubt there is another situation where you must be so right, so exact every time … or suffer some untoward consequences.”

When not visiting his children, riding his Harley Davidson motorcycle, or flying, you’ll find John on a hunting lease with good hunting dogs and good friends.

He says hunting brings together some unique experiences that are a huge part of life.

Two honors came to John this past year. He was named an Honorary Member of the AIO (Italian Dental Association) a year ago, and he received notification on October 5, 2010, that he will be made an Honorary Member in the APCD (Associacao Paulista de Cirugioes-Dentistas) (Brasil) at its 100th Anniversary Meeting in Sao Paulo in January. “I have a tremendous respect and feeling for those in the APCD with whom I have worked over the last few years,” John stated. “Brazil has one of the best economies in the world, the country is progressive in the dental sense and the dentists of the APCD are well ahead in an effort to place modern dentistry and oral healthcare in a position that favors patient and dentist alike in their country. As the first international recipient of this award in their 100-year history, I am both humbled and deeply appreciative.”

However, one other life experience stands out for John.

He was named the recipient of the TDA Gold Medal for Distinguished Service in May 2010 at the TDA House of Delegates.

“There are quite a few good people on that list, and to be included in that company is significant,” he remarks. “I have to say being honored by your own people is a huge honor.”

Knowing and working with

the people of dentistry in Texas, he says, is one of the greatest rewards of service to the profession.

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2011 SPEAKERS Dr. Scott Benjamin Dr. Lee Ann Brady Ms. Rosemary Bray Dr. Lynne Brock Dr. Steve Buckley Dr. Alan Budenz Ms. Debbie Castagna Mr. Bruce Christopher Dr. Gary DeWood Dr. M. Franklin Dolwick Dr. James Fondriest Dr. Henry Gremillion Dr. Timothy Hempton Dr. Maria Howell Dr. Randy Huffines Dr. Richard Hunt Dr. Peter Jacobsen

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Component Peer Review Committee and Judicial Committee 2010-2011 Training Dates Friday, September 24, 2010 El Paso Dental Conference El Paso, Texas Friday, October 8, 2010 Beaumont, Texas Friday, January 14, 2011 Southwest Dental Conference Dallas, Texas Friday, February 4, 2011 Star of the South Dental Conference Houston, Texas Friday, May 6, 2011 The TEXAS Meeting San Antonio, Texas

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Guest Editorial

Access To Care Kevin J. Donly, D.D.S., M.S.

Dr. Matteson asked me if I would like to prepare an editorial

concerning “access to care”. This seemed like a reasonable request for this special Texas Dental Journal issue devoted

to children.

The words “Access to Care” have become a focus point when discussing dental care to our population, including children. The US Surgeon General’s first report on Oral Health clearly identified that dental caries remains a significant health concern for children, particularly children that represent underserved minority populations (1). Texas now has a population that is approximately 50 percent Hispanic and has a significant African-American population which has also been identified as a dentally underserved population. Comprehensive dental care must be provided to all children; therefore the concept of creating a dental home for every

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child by their first birthday seems like an excellent start.

The dental home is, as defined by the American Academy of Pediatric Dentistry, “The ongoing relationship between the dentist who is the Primary Dental Care Provider and the patient, and includes comprehensive oral health care, beginning no later than age one.” Establishment of the dental home can create an environment of patient/parent education, with a strong focus on prevention of disease.

Studies have indicated that early intervention can be very cost-effective (2).

Knowing that the establishment of a dental home at an early age can be an effective way of preventing dental disease, it becomes important to understand why it is difficult for all children to access care. The report entitled “Building Better Oral Health: A Dental Home for All Texans,” which was commissioned by the Texas Dental Association in 2008, identifies barriers to access dental care. These barriers included financial barriers, structural barriers (individuals with limited mobility, individuals that live in rural areas where dentists are not near by and lowincome individuals that live in communities with limited public transportation), and cultural barriers (language barriers, and lack of education on importance of oral health).

All of these barriers can impact access to dental care for children.

So, what recommendations were made that could help children access dental care?

1.

Identify a “dental home” for every Texan.

This would include all children in the state of Texas. All Texas dentists can provide a dental home to children.

2. Strengthen the Texas Department of State Health

Services (DSHS) Oral Health Program.

Strengthening the Oral Health Program by providing adequate funding to sponsor an effective staff, as well as providing funding necessary to develop/implement a comprehensive oral health education and prevention campaign, would further enhance public awareness to seek care. Outcome data could be analyzed so that oral health needs are apparent and care strategies can be evaluated for effectiveness.

3. Create new programs to encourage general

dentists and specialists to practice in underserved

areas and to treat underserved populations.

The DSHS has certainly made an excellent start in this area, the development of the First Dental Home Initiative.

As dentists, we can all make sure that we complete the training session so that the First Dental Home visit can be implemented in each dental practice, whether it be private or public. Likewise, a student loan repayment program was developed to give graduating students that have created a significant debt from attending college and dental school the ability to incorporate underserved patients within their dental practice while receiving aid to reduce student loan debt. Dental schools are active in recruiting students that represent underserved populations and wish to return to medically/dentally underserved communities. We can all encourage students from underserved areas to pursue dental careers. These efforts in conjunction with the student loan repayment program can be beneficial in encouraging graduates to practice in underserved areas.

4. Develop a comprehensive oral health public

awareness and education program.

This comprehensive oral health public awareness and education program can ensure that the appropriate level of communication is developed for the appropriate audiences, including being culturally sensitive and containing critical information targeted towards achieving the desired outcome of improved oral health, whether it be at the political level, professional level, or general public level.

All of these recommendations focus on the improvement of oral health and pertain to the children of the State of Texas. So many dentists, politicians, and participants in advocacy for children have already “stepped up to the plate” to improve the oral health of children. The dental profession has always been a strong advocate for children, including the support of water fluoridation, community sealants programs, school-based fluoride rinse programs, prevention beginning by the first birthday, and the renowned “Give Kids a Smile Day”. Increased awareness and implementation of programs discussed in this editorial will surely give kids a healthy smile for much more than a day.

References l. Building Better Oral Health: A Dental Home for All Texans. A Report Commissioned by the Texas Dental Association. Winter 2008.

2. Savage M, Lee J, Kotch J, and Vann WF Jr. Early Preventive Dental Visits: Effects on Subsequent Utilization and Costs. Pediatrics 2004; 114:e418-e423.

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Texas Dental Association 140th Annual Session 2010 TEXAS Meeting Photo Contest Award: Best of Show Photographer: Dr. Roy Tiemeyer Title: “Skimmers” For information on entering your photo in the 2011 TEXAS Meeting Photo Contest, please visit texasmeeting.com.

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Restorative Dentistry for the Pediatric Patient Steven P. Hackmyer, D.D.S. Kevin J. Donly, D.D.S., M.S.

Introduction In April, 2002, the American Academy of Pediatric Dentistry (AAPD) sponsored a Pediatric Restorative Dentistry Consensus Conference (1). The purpose of

Abstract The American Academy of Pediatric Dentistry sponsored the Pediatric Restorative Dentistry Consensus Conference in 2002. This paper will review the consensus statements that were issued as a result of the conference. Since the conference there have been advances in procedures, materials, and techniques

the conference was to bring together experts in eight

that need to be considered in

recognized areas (risk assessment, sealants, glass

terms of some of the consensus

ionomer cements, amalgam, dentin/enamel adhe-

statements. The introduction

sives, resin-based composites, stainless steel crowns,

of the First Dental Home, in-

and anterior restorations) to provide literature re-

terim therapeutic restoration and

views to aid in the development of evidence-based, scientifically supported position papers supporting pediatric restorative techniques and approaches.

The purpose of this paper is to revisit those findings and recommendations in terms of current pediatric restorative techniques.

nanotechnology are examples of some of the materials and techniques that are now part of everyday pediatric dentistry. This paper will discuss the updates as it relates to each of the 2002 consensus statements.

Key worDS: Pediatric, restorative dentistry, risk assessment, sealants, amalgam, resinbased composite, glass ionomer Hackmyer

Donly

Dr. Hackmyer is a clinical associate professor, Department of Developmental Dentistry, University of Texas Health Science Center at San Antonio Dental School, San Antonio, Texas.

Dr. Donly is a professor and chair, Department of Developmental Dentistry, University of Texas Health Science Center at San Antonio Dental School, San Antonio, Texas.

cement, stainless steel crowns, bonding adhesives Tex Dent J;127(11):1165–1171.

Corresponding Author: Steven Hackmyer, D.D.S., Clinical Associate Professor, Department of Developmental Dentistry, University of Texas Health Science Center at San Antonio Dental School, 7703 Floyd Curl Drive, San Antonio, Texas 78229-3900; Phone: (210) 567-3535; Fax: (210) 567-3526; E-mail: hackmyer@uthscsa.edu.

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

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Pediatric Restorative Dentistry The following were the 2002 consensus statements (2): Epidemiology, risk assessment and clinical decision making (3, 4) The dental literature supports: 1. The goal of caries risk assessment is to deliver patient specific diagnostic, preventive, and restorative services.

2. The following caries risk factors need to be considered: present and past caries activity; socioeconomic status; sealant status; mutans streptococci levels; fluoride exposure; sugar consumption; special needs; and parent/ sibling caries activity.

3. Dental caries management includes individualized prevention and restorative therapy based on an individual patient’s needs.

Sealants (5, 6) The dental literature supports: 1. Bonded resin sealants, placed by appropriately trained dental personnel, are safe, effective, and underused in preventing pit and fissure caries on at-risk surfaces. Effectiveness is increased with good technique, appropriate follow-up and resealing as necessary.

2. Sealant benefit is increased by placement on surfaces judged to be at high risk or surfaces that already exhibit incipient carious lesions. Placing sealant over minimal enamel caries has been shown to be effective at inhibiting lesion progression.

Appropriate follow-up care,

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3.

4.

5.

6.

7.

8.

as with all dental treatment, is recommended.

Presently, the best evaluation of risk is done by an experienced clinician using indicators of tooth morphology, clinical diagnostics, past caries history, past fluoride history, and present oral hygiene.

Caries risk and, therefore, potential sealant benefit, may exist in any tooth with a pit or fissure at any age, including primary teeth of children and permanent teeth of children and adults.

Sealant placement methods should include careful cleaning of the pits and fissures without removal of any appreciable enamel. Some circumstances may indicate use of a minimal enameloplasty technique.

A low-viscosity, hydrophilic material bonding layer, as part of or under the actual sealant, has been shown to enhance the long-term retention and effectiveness.

Glass ionomer materials have not been shown to be effective as pit and fissure sealants, but could be used as transitional sealants.

The profession must be alert

to new preventive methods effective against pit and fissure caries. These may include changes in dental materials or technology.

retention, minimize microleakage, and reduce sensitivity.

Amalgam (7, 8) The dental literature supports the safety and efficacy of dental amalgam in all segments of the population. Furthermore, the dental literature supports the use of dental amalgam in the following situations: 1. Class I restorations in primary and permanent teeth; 2. Two-surface Class II restorations in primary molars where the preparation does not extend beyond the proximal line angles; 3. Class II restorations in permanent molars and premolars; 4. Class V restorations in primary and permanent posterior teeth.

Tooth-bonding adhesives (9, 10) The dental literature supports: 1. Tooth-bonding adhesives, when used according to the manufacturer’s instructions unique for each product, are effective in primary and permanent teeth to enhance

Figure 1A. Pre-operative radiograph indicating tooth S is in need of a Class II restoration.

Glass ionomer materials (11, 12) The dental literature supports the use of glass ionomer cement systems in the following situations: 1. Luting cement: a. stainless steel crowns, b. orthodontic bands, c. orthodontic brackets (limited).

2. Cavity base/liner.

3. Class I restorations in primary teeth.

4. Class II restorations in primary teeth (Figure 1).

5. Class III restorations in primary teeth.

6. Class III restorations in permanent teeth in high-risk patients or teeth that cannot be isolated.

7. Class V restorations in primary teeth.

8. Class V restorations in permanent teeth in high-risk patients or teeth that cannot be isolated.

9. Caries control: a. high-risk patients, b. restoration repair, c. atraumatic restorative treatment (now termed

Interim Therapeutic Restoration).

Figure 1B. A distocclusal Class II resin-modified glass ionomer cement restoration on tooth S at 3 years.

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Pediatric Restorative Dentistry Resin-based composite (13, 14) For all resin-based composite restorations, teeth must be adequately isolated to prevent saliva contamination. The dental literature supports the use of highly filled resin-based composites in the following situations: 1. Small pit and fissure caries where conservative preventive resin restorations are indicated in both the primary and permanent dentition; 2. Occlusal surface caries extending into dentin; 3. Class II restorations in primary teeth that do not

4.

5.

6.

7.

8.

extend beyond the proximal line angles; Class II restorations in permanent teeth that extend approximately one-third to one-half the buccolingual intercuspal width of the tooth; Class V restorations in primary and permanent teeth; Class III restorations in primary and permanent teeth; Class IV restorations in primary and permanent teeth; Strip crowns in the primary and permanent dentitions.

Stainless steel crowns (15, 16) The dental literature supports the use of stainless steel crowns in the following situations: 1. Children at high risk exhibiting anterior tooth decay and/or molar caries may be treated with stainless steel crowns to protect the remaining at-risk tooth surfaces.

2. Children with extensive decay, large lesions, or multiple surface lesions in primary molars should be treated with stainless steel crowns (Figure 2).

Figures 2A and 2B. Bitewing radiographs illustrating proximal caries on posterior teeth.

Figure 2C. Stainless steel crowns on the mandibular molars.

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Figure 2D. Stainless steel crowns on the maxillary molars.

3. Strong consideration should be given to the use of stainless steel crowns in children who require general anesthesia.

Anterior restorations (17, 18) The dental literature supports the following recommendations for anterior restorations: 1. Resin-based composites may be used for: a. Class III restorations in

the primary and permanent dentitions; b. Class V restorations in

the primary and permanent dentitions; c. Strip crowns in the pri mary anterior dentition; d. Class IV restorations in

the primary and permanent dentition.

2. Although minimal clinical data is available, glass ionomer cement or resin-modified glass ionomer cement may be used for Class III and V restorations for primary teeth that cannot be isolated.

3. Full-coverage crowns for primary anterior teeth may be recommended for teeth with: a. multiple carious surfaces; b. incisal edge involvement; c. extensive cervical decalcification; d. pulpal therapy; e. hypoplasia; f. poor moisture or hemorrhage control.

Discussion Since the 2002 Pediatric Restorative Dentistry Consensus Conference, numerous articles in the literature have addressed directly or indirectly some of the consensus statements. Despite advances in materials and procedures, the vast majority of the consensus statements are still

considered indicative of current standards of care.

However, there has been the introduction of the term “Interim Therapeutic Restoration (ITR)” to replace the existing term “Alternative/Atraumatic Restorative Technique (ART).” The ITR is important for patient care as the AAPD recognizes ITR as a beneficial provisional restorative technique in contemporary pediatric dentistry (19). The ITR is a part of the comprehensive care in the dental home (19). ITR can be used for caries control, when necessary, prior to definitive restorative treatment (19).

Risk assessment is critical for clinical decision making. Each child must be evaluated on an individual basis so that preventive and restorative dental care can be implemented that is appropriate for the best anticipated long-term outcomes.

First introduced in 2002 (20), the dental home was introduced to provide comprehensive and continual dental care, including preventive care, to many children at an earlier age than they would have received years ago.

The dental home helps to introduce important concepts such as prevention, nutritional counseling and anticipatory guidance for children no later than 12 months of age. In time, this should help generations of individuals see a reduction in extensive dental care needs (20).

In May 2008, a Scientific Committee of the European Commission concluded that “dental amalgams are effective and safe, both for patients and dental personnel” and also noted that “alternative materials are not

without clinical limitations and toxicological hazards” (22). In July 2009 the American Dental Association Council on Scientific Affairs, after a comprehensive review of the literature over a 5year period, reaffirmed the position on amalgam. “The scientific evidence supports the position that amalgam is a valuable, viable and safe choice for dental patients (23).” The U.S. Food and Drug Administration (FDA) also reaffirmed the agency’s position that the material is a safe and effective restorative option for patients (24). Thus, both the literature and recognized organizations and agencies separately have reaffirmed, after extensive investigation, the safe use of amalgam as a restorative material.

The introduction of nanotechnology has created a new group of resin-based composites that provides a material that essentially combines the strengths of both microfills and hybrids. Despite the smaller particle size which is characteristic of microfills, the new resin exhibits less shrinkage and less surface roughness as a result of toothbrush abrasion. In addition, wear is less than both hybrids and microfills.

Flexural modulus and strengths were both better than microfills, but comparable to many hybrids.

Therefore, these new nano filled materials offer a composite that displays the polish and polish retention of a microfill, while maintaining the strength and wear properties of a modern hybrid (25).

Some newer resins contain longer resin chemical structures to aid in the reduction of polymerization shrinkage. An example would be Z 250 (3M ESPE, St. Paul, MN, USA). This resin-

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Pediatric Restorative Dentistry based composite has replaced the traditional Bis-GMA molecule with Bis-EMA. This larger chemical chain reduces polymerization shrinkage by approximately 25 percent.

Self-etching sealants appears to be on the horizon. Early formulations may not be ideal in etching enamel to prevent microleakage, but surely more research and product development will result in self-etching sealant availability in the marketplace (26).

A resin infiltrate material, ICON (DMG, Hamburg, Germany) has been introduced to the profession. This material is intended to infiltrate subsurface incipient enamel lesions and inhibit lesion progression. Early clinical outcomes appear to be promising and more research has been initiated which will provide further information on the clinical success of such a product (28). The enamel is etched with hydrochloric acid and the resin is delivered facially, lingually, or proximally with delivery systems provided by the manufacturer with the resin product (Figure 3).

When placing stainless steel crowns, the cement of choice is primarily glass ionomer and not poly carboxylate, which was the cement of choice prior to the introduction of glass ionomer cement. Chemical bonding to both enamel and dentin is seen with glass ionomer cements. Thermal expansion of glass ionomer cements is similar to that of tooth

1170

Figure 3. Photograph of the ICON resin infiltrate system with the proximal resin placement attachment.

structure. Thus improved retention and less post-treatment sensitivity is seen in vital teeth as a complication, which frequently was seen with other cements.

Success of the stainless steel crown is enhanced, as previously noted, with the use of glass ionomer cement during crown placement.

The goal for those practitioners who treat children routinely is to render high quality care at all times. Prevention and appropriate treatment are key components of this approach.

In terms of clinical practice standards, quality patient care is enhanced by utilization of techniques that can positively impact or influence treatment. An example of this is the use of rubber dams, whenever clinically possible, something that is universally viewed as an integral part of providing optimal pediatric restorative dentistry care. Routine use of the rubber dam offers multiple benefits simultaneously.

Some of these benefits are: • Helps improve child management by reducing or eliminating annoying water and debris from the oral cavity.

• Improved visibility and working conditions for the practitioner.

• Offers protection to patients from possible trauma to their soft tissues.

• Helps protect and thus prevent the patients from acci-

The integration of anticipatory guidance and caries risk assessment are fundamentals of prevention.

Caries risk serves as an aid for the practitioner to address each patient’s individual treatment needs. A very young child with numerous posterior interproximal carious lesions should be treated with stainless steel crowns as opposed to resin or amalgam restorations. The stainless steel crown functions as a full coverage restoration which offers greater long-term longevity. This fact is well documented in the dental literature (15, 16).

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

•

•

dental ingestion or aspiration during the procedure.

When performing pulp therapy of any kind provides an “Aseptic Field,” reducing contamination of the pulp.

Overall, offers the opportunity for increased efficiency by the practitioner. This helps reduce treatment time for the patient.

In conclusion, the consensus standards that were developed at the 2002 Pediatric Restorative Dentistry Consensus Conference, in addition to techniques and materials noted in this manuscript, have established an evidencebased standard of care (27).

Acknowledgment We would like to thank the American Academy of Pediatric Dentistry for allowing us to republish portions of the Pediatric Restorative Dentistry Consensus Conference paper.

Financial Interest Disclosure Dr. Kevin J. Donly has received grants or research support from the National Institute of Dental and Craniofacial Research, Health Resources and Services Administration, 3M ESPE, Premier, Bisco, GC, Dentsply, Ivoclar, Kerr, Procter and Gamble, Church and Dwight, Philips, Optiva, Oral-B, Enamelon, Atrix Laboratories, and Guidor companies.

Although he has received grants or research support from these entities, he has no personal financial interests.

References

l.

Pediatric restorative dentistry consensus conference. Pediatr Dent 2002; 24(5):373516.

2. Consensus statements. Pediatric restorative dentistry consensus conference. Pediatr Dent 2002; 24(5):374-376.

3. Anderson M. Risk assessment and epidemiology of dental caries: review of the literature. Pediatr Dent 2002; 24(5):377-385.

4. Tinanoff N, Douglass JM. Clinical decision making for caries management in children. Pediatr Dent 2002; 24(5):386 392.

5. Simonsen R. Pit and ‘fissure sealant: review of the literature. Pediatr Dent 2002; 24(5):393-414.

6. Feigal RJ. The use of pit and fissure sealants. Pediatr Dent 2002; 24(5):415-422.

7. Osborne JW, Summitt JB, Roberts HW. The use of dental amalgam in pediatric dentistry: review of the literature. Pediatr Dent 2002; 24(5):439-447.

8. Fuks AB. The use of amalgam in pediatric dentistry. Pediatr Dent 2002; 24(5):448455.

9. Swift EJ, Dentin/enamel adhesives: review of the literature. Pediatr Dent 2002; 24(5):456-461.

10. Garcia-Godoy F, Donly KJ. Dentin/Enamel Adhesives in Pediatric Dentistry. Pediatr Dent 2002; 24(5):462-464.

11. Croll TP, Nicholson JW. Glass ionomer cements in pediatric dentistry: review of the literature. Pediatr Dent 2002; 24(5):423-429.

12. Berg JH. Glass ionomer cements. Pediatr Dent 2002; 24(5):430-438.

13. Burgess JO, Walker R, Davidson JM. Posterior resin-based composite: review of the literature. Pediatr Dent 2002; 24(5):465-479.

14. Donly KJ, Garcia-Godoy F. The use of resin-based composite in children. Pediatr Dent 2002; 24(5):480-488.

15. Randall RC. Preformed metal crowns for primary and permanent molar teeth: review of the literature. Pediatr Dent 2002; 24(5):489-500.

16. Seale NS. The use of stainless steel crowns. Pediatr Dent 2002; 24(5):501-505.

17. Lee JK. Restoration of primary anterior teeth: review of the literature. Pediatr Dent 2002; 24(5):506-510.

18. Waggoner WF. Restoring primary anterior teeth. Pediatr Dent 2002; 24(5):511-516.

19. American Academy of Pediatric Dentistry. Policy on Interim Therapeutic Restorations. Pediatr Dent 2009:31(suppl): 38-9 20. Nowak AJ, Casamassimo PS. The dental home: A primary oral health concept. J Am Dent Assoc 2002;133 (1):93-8.

21. American Academy of Pediatric Dentistry. Policy on the Dental Home. Pediatr Dent 2009;31(suppl):22-3.

22. European Commission: Scientific Committee on Emerging and Newly Identified Health Risks. The Safety of Dental Amalgam and Alternative Dental Restoration Materials for Patients and Users May 8, 2008 (accessed March 27, 2010) 23. The ADA Council on Scientific Affairs http://www.ada.org/prof/resources/positions/statements/amalgam.asp, July 2009, (accessed March 27, 2010).

24. US Food and Drug Administration http://www.fda.gov/NewsEvents/Newsroom/ PressAnnouncements/ucm173992.htm, July 28,2009, (accessed March 27, 2010) 25. 3M Filtek technical report, (accessed March 27, 2010) 26. Wadenya RO, etc. Strength and microleakage of a new self-etch sealant. Quintessence Int. 2009 Jul-Aug;40(7):559-63.

27. Graskemper JP. The standard of care in dentistry: Where did it come from? How has it evolved? J Am Dent Assoc, 2004 October , Vol 135, No 10, 1449-1455.

28. Ekstrand KR, Bakhshandeh A, Martignon S. Treatment of Proximal Superficial Caries Lesions on Primary Molar Teeth with Resin Infiltration and Fluoride Varnish versus Fluoride Varnish only: Efficacy after 1 year. Caries Res 2010;44:41-46.

Dr. Steven P. Hackmyer reports no personal financial interests.

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Masters OF Alternative to Pulpotomy

Indirect Pulp Therapy: An

Abstract

Aesthetic excellence

in Primary Teeth N. Sue Seale, D.D.S., M.S.D.

Introduction Preservation of the primary teeth is of paramount importance in maintaining the integrity of the dental arch and supporting normal growth and development of the face of the child. The tooth is the best space maintainer and best contributes to normal function and growth. Therefore, the primary tooth with a large carious lesion approximating the pulp presents the challenge of managing the lesion with the intent of maintaining the tooth until normal exfoliation. To meet this challenge, several pulp therapy techniques have been advocated. Among the earliest recommendations was indirect pulp therapy (IPT), then called indirect pulp capping. As far back as the 1950’s, IPT was recommended for primary teeth with large carious lesions in which complete caries removal would expose the pulp (1-8).

JW MARRIott San Antonio hill Country ReSoRt & SpA Seale Dr. N. Sue Seale, Department of Pediatric Dentistry, Baylor College of Dentistry – Texas A&M Health Science Center, Dallas, Texas.

Correspondence to: N. Sue Seale, D.D.S., M.S.D., 3302 Gaston Avenue, Dallas, Texas 22 Dental CE Hours 75246; Phone: (214) 828-8241; Fax: (214) 874-4562; E-mail: sseale@bcd.tamhsc.edu.

Approved For The author has no declared financial interests. This article has been peer reviewed.

Preservation of the primary teeth until their normal exfoliation is essential for normal oral function and facial growth of the child. To that end, treatment of primary teeth with large carious lesions approximating the pulp should be aimed at preserving the tooth. Currently, the pulpotomy is the most frequently used pulp treatment for cariously involved primary teeth. The purpose of this manuscript is to describe the use of an alternative to the pulpotomy, indirect pulp therapy (IPT), for the treatment of vital, primary teeth with carious involvement approaching the pulp.

Accurate diagnosis of the vitality status of the pulp is critical to the success of IPT and involves careful radiographic and clinical assessment of the teeth to be sure they are healthy or at worst, reversibly inflamed. The indications for IPT are the same as for pulpotomy. The technique involves one appointment, requires that some carious dentin be left to avoid pulp exposure and requires the placement of a biologically sealing base and sealing final restoration.

Teeth treated with IPT have success rates at least as good as those treated with pulpotomies, and IPT offers an acceptable alternative to pulpotomy as a treatment for vital, asymptomatic, cariously involved primary teeth.

Key worDS:

Indirect pulp therapy, Register primary teeth, pulp therapy

at www.asdatoday.com Tex Dent J 2010;127(11): 1175-1183. or call 1-888-988-ASDA for more information Texas Dental Journal l www.tda.org l November 2010

1175

Indirect Pulp Therapy However, the formocresol primary tooth pulpotomy, first introduced in the 1930’s, surpassed IPT as the recommended approach to management of teeth with large carious lesions and is currently the most recommended treatment approach (9-12). Recently, however, there has been a resurgence of interest in IPT as an alternative to pulpotomy in primary teeth (13-21). This new interest has come about as a result of attempts to replace the 5-minute formocresol pulpotomy due to the increasing controversy over adverse features of formocresol.

Ferric sulfate (FS) and mineral trioxide aggregate (MTA) have been the major contenders to replace formocresol as the pulpotomy medicament, but both have problems. Ferric sulfate, while having similar success rates to formocresol, has inconsistent outcomes with respect to internal resorption (22-30).

MTA, a very expensive alternative, has been shown to actually be more successful than formocresol when used as a primary tooth pulpotomy agent (31-36).

However, the high costs associated with its use may slow its acceptance as a pulpotomy agent. Therefore, the resurgence of interest in and investigations of indirect pulp therapy (IPT) as a viable pulp therapy alternative to pulpotomy has been encouraging.

An investigation comparing IPT with formocresol pulpotomy for primary tooth pulp therapy appeared in 2000 and reported

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success rates superior to pulpotomy (13). Since then additional investigations have produced evidence supporting the use of IPT in primary teeth and these investigations all report successes at least as good as those for pulpotomy studies (14-21). Therefore, it is the purpose of this manuscript to advocate that serious consideration be given to the technique of IPT as an alternative to pulpotomy for primary tooth vital pulp therapy.

Diagnosis The indications for performing an IPT are exactly the same as for a pulpotomy, which makes it the ideal alternative. The tooth must be vital with no clinical or radiographic signs of irreversible pulpitis or loss of vitality. The diagnostic work up for teeth being considered for IPT must be very stringent, because there is no opportunity to confirm the vitality of the tooth as is found in the pulpotomy technique by viewing the pulp tissue when the coronal pulp is amputated. Therefore the first step in deciding to perform an IPT is to gather clinical and radiographic diagnostic data aimed at determining the vitality status of the primary tooth in question.

Clinical Data Clinical parameters that must be examined to determine tooth vitality status are soft tissue changes, pathologic mobility and history of pain. The first component of a clinical examination of a tooth with a large carious lesion with suspected pulpal involvement, is to evaluate the Figure 1. Large carious lesion in first primary molar.

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Figure 2. Sinus tract associated with necrotic pulp in tooth S.

soft tissue around the involved tooth to rule out the presence of a sinus tract or parulis (Figures 1 and 2). Nonvital primary tooth pulps often establish drainage through the thin buccal bone. The presence of a parulis or a sinus tract indicates a pulp that is necrotic and is a direct contraindication to IPT; in such cases, extraction or pulpectomy would be appropriate.

Mobility beyond that expected as normal is a contraindication to IPT, as it indicates that the inflammatory process in the pulp has begun to destroy supporting bone and/or pathologically cause resorption of the primary tooth’s roots.

In young children pulp testing (such as cold and hot testing and electric pulp testing to determine pulp vitality) is not appropriate because pain is the only response one can elicit from a vital pulp. Intentionally causing pain during these tests can scare a young child and affect future cooperation. Thus we are left with the more subjective method of obtaining a pain history about the presence or absence, cause, and duration of pain associated with the tooth in question. Young children are not reliable historians; therefore, one must ask both the child and his/her caretaker about the child’s pain

history. Type and duration of pain are important components of the history. A history of spontaneous non-provoked pain (such as pain that awakens the child in the middle of the night) may indicate an irreversible pulpitis and/or a partially necrotic tooth. Such teeth are not indicated for IPT. Provoked or elicited pain are more complicated to interpret. Pain on chewing may be the result of food compressing into the occlusal aspect of a large carious lesion or food impaction in a proximal carious lesion rather than the result of percussive pain, which is a more ominous sign. Percussive pain can be ruled out by placing a tongue blade on an uninvolved cusp of the tooth in question and having the child bite down, watching for signs of discomfort that would be consistent with percussive pain. If percussive pain is identified, the tooth is contraindicated for IPT. Elicited pain of short duration from sweets, hot or cold foods, and drinks do not contraindicate vital pulp therapy but should be recorded in the data collection sheet.

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Indirect Pulp Therapy Figure 3.

Bitewing and periapical radiograph of first primary molar with carious lesion approximating the pulp.

Radiographic Data Both a bitewing and a periapical radiograph are necessary to assess the pulpal status of a primary molar with a large carious lesion (Figure 3). The bitewing, because it offers the least amount of distortion concerning the depth of decay, provides the best assessment of the carious lesion’s proximity to the pulp. It is also the best film for viewing the furcation of the primary tooth, where the first signs of a necrotic pulp in primary molars appear. A radiographically demonstrable lesion that is equal to or greater than three-quarters of the way encroaching on the pulp chamber would be the carious lesion considered for IPT. Accessory canals present in the floor of pulp chambers of primary molar’s allow the toxins from the necrotic pulp in the chamber to travel to the bone in the furcation and affect that bone first. Thus decreased radiopacity and loss of lamina dura of the bone in the furcation are the first signs of a dead or dying primary molar pulp. IPT would not be appropriate for teeth that demonstrate these radiographic changes.

The superimposition of the furcation of the maxillary molars on the palatal root makes accurate reading for radiolucency in the earliest stages difficult in maxillary molars. Primary anterior

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teeth demonstrate periapical changes such a loss of lamina dura, widening of the periodontal ligament space or external root resorption as signs of pulp degeneration. In addition, teeth nearing exfoliation are not candidates for IPT. The hallmark of an IPT is that the operator intentionally leaves caries in the tooth; not all caries is removed. The decision to leave caries is made when the decision to treatment plan the tooth for IPC has been made, i.e. following a careful diagnostic decision that the tooth is vital and not irreversibly inflamed, not during the procedure. In other words, one begins the procedure with the intent to leave caries and to not expose the pulp. The IPT technique recommended for primary teeth is one in which the tooth is definitively treated in the first appointment, and the tooth is not re-entered for the purpose of removing the residual caries. The purpose it to avoid pulp exposure and maintain pulp vitality.

Technique of IPT Local anesthesia must be administered before performing any invasive procedure that could result in pain. IPT requires a well-fitted rubber dam that controls salivary contamination.

The first step in IPT is removal of the superficial undermined enamel and peripheral caries and can be performed by using a high-speed bur with water coolant. All peripheral walls must be cleaned to sound dentin using a slow-speed (No. 4 or No. 6) round bur, so that the caries over the pulp is surrounded by sound peripheral dentin. The caries over the pulp should be removed very carefully using the same slow speed round bur. Spoon excavators should be avoided, as they can remove large chunks of dentin and inadvertently expose the pulp. The slow-speed round bur allows the operator to precisely control how much affected dentin is removed and when to stop. Using a slow-speed hand piece with a large round bur, carefully remove the softened, infected dentin over the pulp. Caries removal should stop when the operator still sees decay but is nearing the pulp. The dentin will appear leathery (though still soft) and should be left in place, regardless of the color of the remaining dentin. This is “affected dentin.� Affected dentin is not infected with large numbers of micro-organisms and it has the ability to remineralize, provided it has a biological seal (21, 37, 38). As a result, it is acceptable to leave 1 mm over the pulp (Figure 4). Do not be overzealous when removing caries; doing so increases the risk of pulp exposure.

Remaining affected dentin must be covered with a base that extends onto sound dentin and provides a biological seal over the caries that is left. As long as the seal is maintained, any bacteria in the affected dentin will die or become inactive and the dentin will remineralize and become harder (21, 37, 38). The two materials recommended as a base for IPTs are reinforced ZOE products like Caulk IRM Intermediate Restorative Material (Dentsply International), or resin modified glass ionomer (RMGI). Recent studies on IPT in primary teeth have shown no improvement in outcome when calcium hydroxide was used between the sealing base and the remaining carious dentin (14, 17, 21). Therefore, its use is at the discretion of the operator. The tooth should be restored with an SSC at that same visit, to ensure that the biological seal is maintained.

Figure 4. Removal of infected dentin, leaving discolored, affected dentin to avoid a pulp exposure.

Courtesy of J Coll, York, PA.

Follow-up Teeth treated with vital pulp therapy techniques must be followed to determine the success of the outcome. Six months is the recommended follow-up time.

There should be no post treatment signs or symptoms such as sensitivity, pain, or swelling (39). Bitewing and periapical radiographs of the treated teeth should to be taken and read and compared with the preoperative radiographs to observe for changes over time. Obviously, there should be no change between the preoperative and follow-up radiographs; however, many primary teeth that receive vital pulp therapy will show changes over time. Uniform narrowing of the canals (known as calcific metamorphosis) is common and indicates an attempt on the part of the pulp to heal (Figure 5). Over time, in observing the tooth until exfoTexas Dental Journal l www.tda.org l November 2010

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Indirect Pulp Therapy Figure 5. Radiograph of pulpotomized tooth (K) demonstrating calcific metamorphosis (arrow).

liation on a 6-month basis, the entire pulp canal may be obliterated. These teeth rarely progress to failure, and calcific metamorphosis is considered a success. Internal resorption is another change in the root canals, which appears less frequently than calcific metamorphosis. Recent studies have reported that many teeth that demonstrate internal resorption do not progress to failure over time, and some reverse and heal; as a result, minor resorption that is confined to the canal can be watched but may not require action (Figure 6) (22, 40). However, these changes indicate a chronically inflamed, vital pulp with the potential to progress and develop perforating internal resorption. If it continues and perforates the root and involves supporting bone, the tooth will require extraction, as the IPT has failed (Figure 7). Any osseous radiolucencies or evidence of external root resorption not associated with normal exfoliation indicate pulpal death and treatment failure (Figure 8). These teeth

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Figure 6. Radiograph of pulpotomized tooth (T) demonstrating contained internal resorption (distal root).

must be extracted and space management must be considered, depending on the child’s age and eruption patterns.

Barriers to the use of IPT as an alternative to pulpotomy in primary teeth must be acknowledged. The procedure is frequently inadequately reimbursed by third-party payers, and at this time a pulpotomy is a more financially rewarding procedure to perform. However, lobbying third-party payers to explain that higher reimbursement rates for IPTs would actually save them money as they pay for fewer pulpotomies could incentivize them to adjust their reimbursement rates for IPT. IPT requires a very careful and thorough diagnostic work up to ensure the tooth’s vitality status, because the clinician does not have the same opportunity to verify that the pulp is vital as in pulpotomy, where one is actually able to view the pulp during the access and amputation steps. Additionally, there is still a reluctance by practitioners to leave decay in teeth in spite of strong evidence that the caries is arrested so long as a biological seal is maintained over the caries (21, 37, 38, 41-43). Finally, practitioners are reluctant to give up the traditional pulpotomy that they have used with good success for greater than 80 years.

Figure 7. Radiograph of pulpotomized tooth (L) demonstrating both contained (mesial root) and perforating internal resorption (distal root).

Summary IPT has many advantages over pulpotomy techniques. Because the pulp is not entered and the coronal pulp is not amputated, there is no pulpal wound to absorb medicament and allow for the potential of systemic absorption and distribution of the medicament. In addition, IPT results in less chair time, which is a valuable adjunct with young children with sort attention spans. In summary, many primary teeth with large carious lesions approximating the pulp can be saved until normal exfoliation through careful diagnostic assessment to determine the appropriateness of vital pulp therapy and attention to the

Figure 8. Radiograph of pulpotomized tooth (S) demonstrating furcation radiolucency and external root resorption.

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Indirect Pulp Therapy details of technique and followup. Currently the pulpotomy is the most commonly used technique for vital pulp therapy in primary teeth. The technique of IPT has recently begun to reappear in the literature as an alternative to pulpotomy and has the potential to simplify the process of maintaining primary teeth with large lesions approximating the pulp. Current best evidence indicates that IPT has similar success rates to pulpotomy. It was the intent of this manuscript to describe the technique of IPT and to encourage readers to try IPT in place of pulpotomy in cariously involved primary teeth.

References

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2. Law DB, Lewis TM. The effect of calcium hydroxide on deep carious lesions. Oral Surg Oral Med Oral Pathol 1961;14:1130-7.

3. King JB, Crawford BA, Lindahl RY. Indirect pulp capping: A bacteriologic study of deep carious dentine in human teeth. Oral Surg Oral Med Oral Path 1965; 20:663-71.

4. Aponte AJ, Hartsook JT, Crowley MC: Indirect pulp capping success verified. J Dent Child 1966;15: 164-6.

5. Kerkhove BC Jr, Herman SC, Klein AI, McDonald RE: A clinical and television densitometric evaluation of the indirect pulp capping technique. J Child Dent 1967;34: 192-201.

6. Ehrenreich DW. A comparison of the effects of zinc-oxide eugenol and calcium hydroxide on carios dentin in human primary molars.

J Child Dent 1968; 35:451-6.

7. Magnusson BO, Sundell SO: Stepwise excavation of deep carious lesions in primary molars. J

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8. Massler M. Treatment of profound caries to prevent pulpal damage. J Pedod 1978; 2:99105.

9. Sweet, CA. Procedure for treatment of exposed and pulpless decidious teeth. Jour ADA 1930; 6:1150-3.

10. McDonald RE, Avery DR, Dean J. Treatment of deep caries, vital pulp exposures and pulpless teeth. In: McDonald RE, Avery DR, Dean J, eds. Dentistry for the Child and Adolescent. 7th ed. St Louis: Mosby-Year Book, Inc; 2000:413-439.

11. Fuks AB. Pulp therapy for the primary dentition. In: Pinkham JR, Casamassimo PS, Fields HW, McTigue DJ and Nowak AJ, eds. Pediatric Dentistry: Infancy Through Adolescence. 4th ed.

St. Louis: Elsevier Saunders Co, 2005:375-93.

12. Camp JH and Fuks AB. Pediatric Endodontics: Endodontic Treatment for the Primary and Young Permanent Dentition. In: Cohen S and Hargreaves KM eds.

Pathways of the Pulp: 9th ed St. Louis, CV Mosby co;19--:822-82.

13. Farooq NS, Coll JA, Kuwabara A, and Shelton P. Success rates of formocresol pulpotomy and indirect pulp therapy in the treatment of deep dentinal caries in primary teeth. Pediatr Dent 2000; 22:278-86.

14. Falster CA, Araujo FB, Straffon LH, Nor JE. Indirect pulp treatment: in vivo outcomes of an adhesive resin system vs calcium hydoxide for protection of the dentin-pulp complex. Pediatr Dent 2002; 24:241-48.

15. Al-Zayer MA, Straffon LH, Feigal RJ, Welch KB. Indirect pulp treatment of primary posterior teeth: a retrospective study. Pediatr Dent 2003; 25:29-36.

16. Vij R, Coll JA, Shelton P and Farooq NS. Caries control and other variables associated with success of primary molar vital pulp therapy. Pediatr Dent 2004; 26:214-20.

17. Marchi JJ, Araujo FB, Froner

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AM, Straffon LH, Nor JE. Indirect pulp capping in the primary dentition : a 4 year follow-up study. J Clin Pediatr Dent 2006; 31:68-71.

18. Fuks AB. Vital pulp therapy with new materials for primary teeth: New directions and treatment perspectives. Pediatr Dent 2008; 30:211-19.

19. Coll JA. Indirect pulp capping and primary teeth: Is the primary tooth pupotomy out of date?

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20. Casagrande L, Falster CA, Di Hipolito V, et al. Effect of adhesive restorations over incomplete dentin caries removal: 5-year follow-up study in primary teeth.

J Dent Child 2009; 76:117-22 21. Franzon R, Gomes M, Pitoni CM, Bergmann CP, Araujo FB. Dentin rehardening after indirect pulp treatment in primary teeth.

J Dent Child 2009; 76:223-8.

22. Smith NL, Seale NS, Nunn ME. Ferric sulfate pulpotomy in primary molars; a retrospective study. Pediatr Dent 2000; 22:192-9.

23. Fei AL, Udin RD, Johnson R. A clinical study of ferric sulfate as a pulpotomy agent in primary teeth. Pediatr Dent 1991;13:327-32.

24. Fuks AB, Holan G, Davis JM, Eidelman E. Ferric sulfate vs dilute formocresol in pulpotomized primary molars; long-term follow-up. Pediatr Dent 1997; 19:327-30.

25. Papagiannoulis L. Clinical studies on ferric sulphate as a pulpotomy medicament in primary molars. Eur J Paediatr Dent 2002; 3:126-32.

26. Ibricevic H, Al-Jame Q. Ferric sulfate as pulpotomy agent in primary teeth; twenty-month clinical follow-up. J Clin Pediatr Dent 2000; 24:269-72.

27. Huth KC, Paschos E, Hajek-AlKhatar N et al. Effectiveness of 4 pulpotomy techniques: Randomized controlled trail. J Dent Res 2005; 84:1144-8.

28. Markovic D, Zibojinovic V, Bucetic M. Evaluation of three pulpotomy medicaments in pri-

mary teeth. Eur J Paediatr Dent 2005; 6:133-8.

29. Peng L, Ye L, Guo X, et al.

Evaluation of formocresol versus ferric sulphate primary molar pulpotomy: a systematic review and meta-analysis. Int Endod J 2007; 10;751-7.

30. Loh A, O’Hoy P, Tran X, et al.

Evidence-based assessment: Evaluation of the formocresol versus ferric sulfate pulpotomy.

Pediatr Dent 2004; 26:401-9.

31. Agamy HA, Bakry NS, Mounir MMF, Avery DR. Comparison of mineral trioxide aggregate and formocresol as pulp-capping agents in pulpotomized primary teeth. Pediatr Dent 2004; 26:302-9.

32. Jabbarifar SE, Khademi DD, Ghasemi DD. Successs rates of formocresol pulpotomy vs mineral trioxide aggregate in human primary molar tooth. J Res Med Sci 2004; 6:304-7 33. Farsi N, Alamoudi N, Balto K, Mushayt A. Success of mineral trioxide aggregate in pulpoto-

mized primary molars. J Clin Pediatr Dent 2005; 29:307-12.

34. Holan G, Eidelman E, Fuks AB. Long-term evaluation of pulpotomy in primary molars using mineral trioxide aggregate and formocresol. Pediatr Dent 2005; 27:129-36.

35. Naik S, Hedge AH. Mineral trioxide aggregate as a pulpotomy agent in primary molars: an in vivo study. J Indian Soc Pedo Prev Dent 2005; 23:13-6.

36. Ng FK and Messer LB. Mineral trioxide aggregate as a pulpotomy medicament: An evidencebased assessment. Europ Archives Paediatr Dent. 2008; 9:58-73.

37. Bjorndal L, Larsen T. Thylsrup A. A clinical and microbiological study of deep carious lesions during stepwise excavation using long treatment intervals.

Caries Res 1997; 31:411-17.

38. Bjorndal L, Larsen T. Changes in the cultivable flora in deep carious lesions following a stepwise excavation procedure. Caries

Res 2000; 34:502-8.

39. AAPD Reference Manual.

Pediatr Dent 2009;31(6 Spec Issue):79-188.

40. Zurn D, Seale NS. Light-cured calcium hydroxide vs formocresol in human primary molar pulpotomy: A randomized controlled trial. Pediatr Dent 2008; 30:34-41.

41. Maltz M, de Oliveira EF, Fontanella V Bianchi R. A clinical, miracobiologic, and radipgraphic study of dep caries lesions after incomplete careis removal. Quintessence Int 2002; 33:151-9.

42. Oliveira EF, Carminatti G, Fontanella V, Maltz M. The monitoring of deep caries lesions after incomplete dentine caries removal: results after 14-18 months. Clin Oral Invest 2006; 10:134-9.

43. Maltz M, Oliveira EF, Fontanella V, Caarminaatti G. Deep caries lesions after incomplete dentine caries removal: 40-month followup study. Caries Res 2007; 41:493-6.

HOUSTON — Enteral Sedation Initial Permit and Renewal Programs The University of Texas Dental Branch at Houston Continuing Dental Education

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

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

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

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Read Before You Sign Use ADA’s Contract Analysis Service!!

The ADA offers the Contract Analysis Service which analyzes dental provider contracts between dentists and insurance carriers. This service is free when submitted through state dental societies.

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Comprehensive Oral Rehabilitation with General Anesthesia and Prosthetic Care in the Primary Dentition: A Case Report Gisela M Velasquez, D.D.S., M.S.; Sanford J. Fenton, D.D.S., M.D.S.; Laura Camacho-Castro, C.D., D.M.D.; Bhavini S. Acharya, B.D.S., M.P.H.; Aaron Sheinfeld, D.D.S., D.M.D.

Abstract This case report describes the oral rehabilitation of a 5year-old male referred by a general dentist to a pediatric dentist due to acute psychological

Introduction Pediatric dentists seldom consider removable prosthesis in children after loss of multiple primary teeth due to dental caries or trauma because it is often thought unrealistic to expect a child to be compliant with this type of treatment (1). However, it is important to consider not only esthetics but also the psychological and emotional development of the child as an individual (2, 3). General anesthesia is one of the many procedures that pediatric dentists use to treat patients with extensive dental caries associated with psychological or emotional maturity or physical or mental disabilities where there is no expectation of behavior improvement over time (4, 5).

The following case report describes the prosthetic rehabilitation of a 5-year-old male whose pre-treatment behavior might have discouraged a practitioner from considering a removable prosthesis. However, not only was the patient compliant with treatment, he was very happy with the results.

stress to dental treatment and extensive dental caries. The patient’s dental restorations and extractions were completed under general anesthesia.

Maxillary and mandibular prostheses were completed in the outpatient clinical setting.

The treatment plan for this child provided options to improve appearance, self-image and oral function.

Key worDS: Dr. Gisela M. Velasquez is an assistant professor, Department of Pediatric Dentistry, University of Texas at Houston Dental Branch, Houston, Texas.

Dr. Sanford J. Fenton is a professor and chair, Department of Pediatric Dentistry, University of Texas at Houston Dental Branch, Houston, Texas.

Dr. Laura Camacho-Castro is a clinical assistant professor, Department of Pediatric Dentistry, Tuft University School of Dental Medicine, Boston, Massachusetts.

Dr. Bhavini S. Acharya is an assistant professor, Department of Pediatric Dentistry, University of Texas at Houston Dental Branch, Houston, Texas.

Dr. Aaron Sheinfeld is a prosthodontist, private office, Boca Raton, Florida.

General anesthesia, pediatric, primary dentition, removable prosthesis Tex Dent J 2010; 127(11): 1187-1192.

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Comprehensive Oral Rehabilitation Case Report

Clinical Case A 5 year-old male was referred to the Pediatric Dentistry Department of Tufts University School of Dental Medicine, Boston, Massachusetts, for comprehensive oral rehabilitation in the operating room under general anesthesia. The patient presented to the dental clinic with a previous history of acute stress to dental treatment and his pre-cooperative behavior at our clinic was consistent with that diagnosis.

Figure 1. Frontal profile, 5-year-old male.

At the preoperative appointment, consent forms for treatment and authorization for the use of general anesthesia in the operating room were signed by the mother and all available treatment procedures and outcomes were explained. A medical health update form was completed by the patient’s pediatrician and returned 1 week prior to the date of surgery. All appropriate forms were submitted to the hospital a week before the scheduled procedure and the patient was evaluated by the anesthesiologist.

The patient’s medical history revealed that he had asthma and was taking Albuterol only when needed. He weighed 42 lbs and his height was 3’6’’. His dental history included unsuccessful treatment appointments at a private dentist due to pre-cooperative behavior.

The extraoral evaluation revealed a frontal profile that demonstrated parallel eyes and ears, allergic shiners (Dennie’s line), and his right shoulder was higher than his left shoulder (Figure 1). His lateral profile included a straight head posture, with upper and lower face height being 60 percent and 40 percent respectively. His nasolabial angle was obtuse and his facial profile was straight (Figure 2).

The intraoral evaluation revealed poor oral hygiene, generalized marginal gingivitis, an overjet of 3mm, and an overbite of 50 percent. The mandibular midline was shifted to the right by 3mm (functional shift) with a unilateral left posterior crossbite. The maxillary arch was “U” shaped with a missing tooth I, which was previously extracted.

The mandibular arch was also “U” shaped with multiple teeth showing extensive dental caries (Figure 3).

Figure 2. Lateral profile, 5-year-old male.

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In the operating room, after the patient was under general anesthesia, the following diagnostic procedures were

Figure 3. Intraoral preoperative photographs.

completed; a set of radiographs (two occlusal films, two bitewing films, and four periapical films) were made and a dental prophylaxis was completed with a rubber cup and paste. After completing these initial procedures, a dental treatment plan was developed.

The clinical and radiographic exam revealed multiple teeth with extensive dental caries (Figure 4). The sub-gingival extent of the caries made most of the teeth non-restorable even with full coverage restorations.

Also, considering the risks versus benefits associated with prolonged treatment under general anesthesia, an appropriate treatment for this patient was achieved.

The treatment included extraction of almost all primary teeth with the exception of teeth A, H, J, and K, which were treated with stainless steel crowns and pulpotomies, and a

Figure 4. Radiographic survey: two bitewing films, four periapical films, two occlusal films.

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Comprehensive Oral Rehabilitation Case Report

Figure 5. Postoperative photographs.

compomer restoration that was placed on the facial surface of tooth H (Figure 5).

be monitored every 2 months until fixed space maintainers could be placed.

In order to address his mother’s concern about her child’s esthetic appearance, a removable prosthesis was recommended for both the maxillary and mandibular arches. These dentures would serve as an interim treatment to improve esthetics and function and maintain his developing emotional and psychological profile. The mother was informed that the patient would

After evaluating the patient and taking into consideration his esthetics and phonetics, it was necessary to restore the patient’s vertical dimension with prosthetic replacement of his posterior teeth. Maxillary and mandibular impressions were made using an irreversible hydrocolloid impression material and diagnostic casts were mounted on an articulator with

Figure 6. Maxillary and mandibular removable prostheses.

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the use of a face-bow and centric relation records were noted.

A diagnostic wax-up was completed incorporating the teeth that had been extracted and it was tried-in to evaluate the patient’s capability to tolerate the appliances. The wax try-in was sent to the laboratory, with instructions for fabrication of removable pediatric partial dentures utilizing shade A1 for the tooth color and Adams clasps for the posterior molars A, J, K, with a “C” clasp on tooth H for appliance retention (Figure 6).

Figure 7. Prosthetic appliances in child’s mouth.

Minor adjustments of the appliances were made on the day of delivery. Postoperative instructions were given to the patient and mother regarding the care of the appliances and periodic appointments were made to evaluate the patient’s compliance. The prosthetic intervention significantly improved the patient’s appearance and speech. Eventually the appliances would be replaced by fixed space maintainers as the permanent teeth start to erupt (Figure 7, 8).

Discussion Dental caries is one of the most common diseases present in children and is considered to be five times more common than asthma. It is also the chief cause of premature loss of primary teeth (6). In this case report, the primary purpose of the treatment rendered was to stabilize the patient’s den-

tal health while enhancing his esthetic appearance.

The diagnoses and treatment for this patient were determined from the clinical and radiographic findings. Clearly, the preferred treatment option was to extract the non-restorable primary teeth, restore the remaining primary molars with stainless steel crowns, and esthetically restore the primary canine. However in this case, the severity of the sub-gingival dental caries did not allow for more conservative restorative procedures to be performed.

Dental treatment performed under general anesthesia allowed total dental treatment in a single treatment appointment.

The use of prostheses has been recommended by some authors as early as the age of 5 years (9). In cooperative patients it can be placed at early ages from 3 to 4 years. Prosthetic rehabilitation has been used in patients

encountering problems associated with the development of tooth structures, such as congenital absence of teeth, severe dental caries or trauma. Continuous monitoring of prostheses by the mother and pediatric dentist is necessary due to the growth and development, and eruption of permanent teeth.

In this case, prosthetic rehabilitation improved the patient’s esthetics, phonetics, and mastication, and the patient will be monitored periodically at the Pediatric Dentistry Clinic.

After the complete eruption of the permanent incisors and first permanent molar teeth, the patient will be scheduled for orthodontic evaluation and dental arch space management.

Summary Comprehensive oral rehabilitation under general anesthesia is often considered to be

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Comprehensive Oral Rehabilitation Case Report

the option to treat young patients with Severe Early Childhood Caries between the ages of 3 to 5. Sometimes the extraction of primary teeth is inevitable and should be combined with restoration of the patient’s oral cavity to improve function and esthetics.

References

Figure 8. Before and after photographs.

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1. Waggoner WF, Kupietzky A. Anterior esthetic fixed appliances for the preschooler: considerations and a technique for placement. Pediatr Dent 2001; 23:147-150.

2. Barcelos R, Pomarico I. Oral rehabilitation in pediatric dentistry — profile of Brazilian dentistry. J Dent Res 2001; 80:973, abst 192.

3. van Wass MAJ. The influence of psychologic factors on patient satisfaction with complete dentures. J Prosth Dent 1998; 63:545-548.

4. Enger DJ, Mourin AP. A survey of 200 pediatric dental general anesthesia cases. ASDC J Dent Child 1985; 5:36-41.

5. Bohary B, Spencer P. Trend in dental treatment rendered under general anesthesia, 1978 to 1990 J Clin Pediatric Dent 1992; 16:222-224.

6. U.S. Department of Health and Human Services (HHS). Oral Health in America: A Report of the Surgeon General. 2000Rockville, MD: HHS, National Institutes of Health, National Institute of Dental and Craniofacial Research.

7. Kisling E, Hoffding J. Premature loss of primary teeth: part V, treatment planning with due respect to the significance of drifting patterns. J Dent Child 1979;46: 300-306.

8. Rodd HD, Atkin JN. Denture satisfaction and clinical performance in a paediatric population. Int J Paediatr Dent 2000; 10: 27-37.

9. Tarjan I, Gabris K, Rozsa N. Early prosthetic treatment of patient s with ectodermal dysplasia: a clinical report. J Prosthet Dent 2005; 93:419-424.

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Infant Oral Exam and First Dental Home

Abstract

Kavitha Viswanathan, D.D.S., M.S., Ph.D.

Introduction Early Childhood Caries (ECC), also known as ‘baby bottle caries’ or ‘nursing bottle decay’ is a severe form of childhood dental caries that is chronic, rampant and infectious in young children under 6, most commonly seen in poor and minority populations (1, 2 ). ECC (Figure 1) is defined as “the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries) or filled tooth surfaces in any primary tooth in a preschoolage child between birth and 71 months of age (3).” ECC usually affects maxillary primary incisors but when severe, can progress to involve primary molars and cuspids. ECC, like caries has a multi-factorial etiology but its high prevalence in poor minority children is attributed to improper feeding practices, familial socioeconomic background, lack of parental education and dental knowledge, and lack of access to dental care (1). ECC is a disease that, when severe, can affect growth, cause pain and infection and have lasting detrimental effects on the quality of life of patients and parents. Even though ECC is preventable through parental education, early and regular checkups, topical fluoride treatments, appropriate diet control and proper oral hygiene practices, it is still the most common chronic childhood disease in America. The prevalence of ECC is alarming — 40 percent of children are affected by the time they reach kindergarten; 70 percent of these carious lesions are found in approximately 20 percent of our nation’s children (4). Approximately, 51 million school hours are lost due to dental-related illness (5, 6).

The purpose of this article is to familiarize general practitioners with the components of a dental home including an infant oral exam, and to the First Dental Home initiative, which is unique to the State of Texas.

This article encourages the general practitioners to actively participate in providing care for young children under the age of 3. Components of an infant oral examination are described here with emphasis on knee-toknee or lap exam, caries risk assessment, preventive treatment, ageappropriate anticipatory guidance, and parent education. The First Dental Home is uniquely designed to help pediatric clients 6 months through 35 months of age to establish a dental home.

The objectives, goal and components of FDH are discussed in detail.

Key worDS:

Viswanathan Dr. Viswanathan is an assistant professor, Department of Pediatric Dentistry, Baylor College of Dentistry – Texas A&M Health Science Center, Dallas Texas.

Requests for reprints should be sent to Kavitha Viswanathan, D.D.S., M.S., Ph.D., Assistant Professor, Pediatric Dentistry, Baylor College of Dentistry, #207, 3302 Gaston Ave., Dallas, Texas 75246, USA; Phone: (214) 828-8317; Fax: (214) 874-4562; E-mail: kviswanathan@bcd.tamhsc.edu.

dental home, Texas Health Steps, knee-toknee exam, prevention, early childhood caries Tex Dent J 2010; 127(11): 1195-1205.

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Infant Oral Exam and First Dental Home

Figure 1. Examples of Early Childhood Caries Few examples of early childhood caries in young children. The maxillary anteriors are the first to be affected by the carious process.

Research has shown that parents and caretakers have a vital role to play in the prevention of ECC (1, 7). To do so, parents and caregivers must be educated about the disease and must receive an individualized preventative plan, dietary counseling and home oral care instructions so that they can prevent caries in their children (1, 7, 8). For these reasons, the American Academy of Pediatric Dentistry (AAPD) recommends that every child must have been evaluated by a dentist (hence, have a “dental home” established) within 6 months of eruption of the first tooth or by

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one year of age, whichever comes first (9). The idea is simple and is adapted by the AAPD from the American Academy of Pediatrics’ (AAP) “medical home” which states that pediatric primary health care is best delivered where comprehensive, continuously accessible, family-centered, coordinated, compassionate, and culturally-effective care is available and delivered or supervised by qualified child health specialists (10).

Children who have a dental home are more likely to receive appropriate preventive and routine oral

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care. Care in this environment is more effective and less costly in comparison to emergency care facilities or hospitals (10).

The timing is critical because it allows for early dietary and oral hygiene practice counseling, much before the possible incidence of dental caries. Moreover, this timing also provides opportunity for age-based anticipatory guidance — such as non-nutritive suckling habits specifically about pacifier or thumb habits to parents of infants and oral injury prevention to parents of toddlers.

The dental home can be a private dental clinic, community dental

Table 1. Components of a Dental Home The dental home should provide: 1

Comprehensive oral care including acute care and preventive services.

2

Comprehensive assessment for oral diseases and conditions.

3

Individualized preventive dental health programs based on caries and periodontal disease risk assessment.

4

Anticipatory guidance about growth and development.

5

Plan for managing acute dental trauma.

6

Information about proper care of the child’s teeth and gums.

7

Dietary counseling.

8

Referral to specialists when care cannot be provided in the dental home.

9

Education regarding future referral to a dentist knowledgeable and comfortable with adult oral health issues when the time is right for the patient, parent, and dentist.

clinic, or hospital-based dental clinic, depending on the child’s circumstances. Since most of the services that children need involve education and prevention (see Table 1), a dental home need not necessary be limited to a pediatric dental practice.

It cannot be limited to pediatric dental practices alone for practical reasons based on supply versus demand. In Texas, there are only 350 pediatric dental specialists in total to care for the entire 6 million children, 1.9 million of whom are below the age of 5. The bulk of this pediatric population naturally will need to be cared for by general dentists, and the general dentists do have a professional obligation to do so, in order to serve all members of the community. The good news is that in Texas, most of the pediatric dental care for children older than 4 is already being provided by general practitioners.

While most general dental practices accept older children, many general dentists have limited experience or interest in providing care for very young children and therefore are reluctant in providing a dental home for infants and toddlers younger than 3 years of age (11). In a survey of approximately 5000 general practitioners, it was shown that 90 percent of them treated children in their practices; however, only a few accepted children under age 4, with extensive caries and with Medicaid coverage. This survey also showed that many general practitioners did not know about or did not agree with the AAPD’s guidelines for first dental visit. Not surprisingly,

general practitioners surveyed in this study also did not perform infant oral examinations (12).

The purpose of this article is to familiarize readers with the components of a dental home including an infant oral exam, and to discuss the Texas First Dental Home initiative (13).

Infant Oral Exam An infant oral examination consists of these five components: 1. Review of medical and dental history 2. Oral examination 3. Caries risk assessment 4. Preventive counseling and treatment, and 5. Anticipatory guidance and parent/patient education.

1. Review of medical and dental history Review of the child’s medical history should include:

A. Systemic, neurological, and developmental

complications during pregnancy, time of

delivery, or thereafter.

B. Current medical conditions including immunization status, known allergies,

medications, and hospitalizations.

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Infant Oral Exam and First Dental Home Review of dental history should include: A. B. C. D.

History of dental trauma, Oral home care routine and dietary habits, Non-nutritive oral habits, and Access to topical and systemic fluoride and prior dental visits if any.

It is important to address the chief complaint, if any present before proceeding with the oral examination.

2. Oral examination Infant oral examination is often thought to be the main focus of the visit, yet it often takes the least amount of time, depending on the age of the child, for there may only be a few teeth present and sometimes none. This can surprise dentists who are used to examining older children in full primary dentition. A general knowledge of the eruption pattern and timing of eruption of primary teeth will come in handy and be necessary.

Most infants and toddlers will be restless and fussy when a stranger tries to examine their mouth. A safe, convenient and preferred method to do an exam is in a knee-to-knee (or lap) position (Figure 2). The parent is an important team player who, while immobilizing the child for the exam is actively observing and learning from the dentist. The dentist should not only demonstrate where plaque and caries (if present) are, but will also need to teach proper oral hygiene measures that can be easily mimicked at home.

An infant oral examination is different from the regular dental examination in many ways. First, the armamentarium is simple, consisting of a toothbrush (with a smear of toothpaste), mouth mirrorexplorer kit, topical fluoride (varnish preferred) and some gauze (Figure 2 a,b). Second, the child patient sits on the parent’s lap, not on the dental chair.

Before starting to do the exam, the dentist should take time to explain the knee-to-knee position because the closeness of the parent and dentist may concern some parents, especially with a male

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dentist and a mother. The dentist should also explain to the parent that their child will probably cry and importantly enough, reassure the parents that crying is a normal response from the child to strange environments and strangers touching their mouth, and not because they are hurting. Crying will also facilitate a quick and easy examination and prophylaxis. The overall goal is to assess the infant’s overall growth and development, and extraoral and intra-oral hard and soft tissues. Special attention is given to the presence of developmental dental anomalies, dental plaque, gingivitis, decalcifications and caries, and evidence suggestive of dental trauma in the past.

3. Caries risk assessment Caries risk assessment is a crucial part of the management of dental caries in contemporary practice.

Caries risk assessment can help identify subjects who require extra caries control measures, guide in treatment planning decisions, and determine the timing of recall appointments. In the past, dentistry focused on repairing damaged tooth structure via a surgical approach. Now we are focused on fighting an infectious disease, not just the cavitated lesion. To effectively treat and prevent caries, we need to identify the specific variables that directly contribute to the disease onset like exposure to fermentable carbohydrates. We also need to identify specific variables that have been shown useful in predicting a risk for caries like lower socioeconomic status. These variables are known as risk factors and they indicate the level of risk the particular child may be at for developing caries. Risk factors may vary with race, culture, and ethnicity.

The AAPD’s Caries Risk Assessment Tool (CAT, Table 2) can be used to determine the patient’s relative risk for caries (14). The primary thrust of early risk assessment is to screen for parent–infant groups who are at risk for caries, particularly ECC and who would benefit from early intervention.

The ultimate goal of early caries risk assessment is timely delivery of educational information to population at risk for developing caries to prevent the need for later surgical intervention.

Figure 2. Infant Oral Exam (IOE) 2a. Armamentarium for Infant Oral Exam (IOE) includes a soft-tufted infant toothbrush with a smear of toothpaste, mouth

mirror and explorer, topical fluoride, patient bib, and gauze.

2b. Close up of the amount of toothpaste require for IOE. 2c. Knee-to-knee exam: The dentist should instruct the parent to hug the child initially, with the child’s legs encircling the

parent’s waist. Later, the parent should hold the child’s hands in theirs, and child’s feet using their elbows. The parent

then should recline their child gently cradling the head on to the dentist’s lap. A dental assistant will be needed to record

findings, pass instruments and materials, and aim the light source at the child’s mouth.

2d. Occasionally, a child may try to close their mouth and in these circumstances, a finger may need to be placed distal to the most posterior tooth on the gum pad. The dentist should not force the mouth open with fingers. The end of a soft

handled toothbrush can be used instead to gently prop the mouth open. IOE includes a toothbrush prophylaxis, and

fluoride treatment. The dentist must deliver the oral health initiative while demonstrating toothbrush prophylaxis to the

parent. Excess toothpaste and fluoride can be wiped away with gauze. If using hand instruments such as an explorer and

mirror, care should be taken to have a finger rest so that the child’s mouth is open. Otherwise they might bite down hard on the instrument(s) and injure themselves. When the IOE is completed, the dentist must gently return the child to the

parent’s arms and should allow some time for the child to settle down and relax before proceeding to address any

concern the parent may have.

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Table 2. Caries Risk Assessment Tool (CAT)

AAPD Caries-Risk Assessment Tool (CAT)* Caries-risk Indicators Clinical conditions

Low Risk No carious teeth in past 24 mos. � No enamel demineralization �

�

Environmental characteristics

�

No visible plaque; no gingivitis

Optimal systemic and topical fluoride exposure

Consumption of simple sugars or foods strongly associated with caries initiation primarily at meal times. � High caregiver socioeconomic status �

Moderate Risk Carious teeth in past 24 mos. � 1 area of enamel demineralization �

�

�

�

Gingivitis

Suboptimal systemic fluoride exposure with optimal topical exposure Occasional (i.e., 1-2) between-meal exposures to simple sugars or foods strongly associated with caries

Midlevel caregiver socioeconomic status (i.e. eligible for school lunch program or SCHIP) � Regular use of dental � Irregular use of care in an established dental services dental home General health conditions

�

High Risk �

Carious teeth in past 12 mos.

� More than 1 area enamel � Demineralization (enamel

caries “white-spot lesion”)

Visible plaque on anterior (front) teeth � Radiographic enamel caries � High titers of mutans Streptococci � Wearing dental or orthodontic appliances � Enamel hypoplasia � Suboptimal topical fluoride exposure �

�

�

Frequent (i.e., 3 or more) between meal exposures to simple sugars or foods strongly associated with caries.

Low-level caregiver socioeconomic status (i.e., eligible for Medicaid)

� No

usual source of dental care � Active caries present in the mother � Children with special health care needs � Conditions impairing saliva composition / flow

Risk Category �

�

�

High Risk: The presence of a single risk indicator in any area of the “high-risk” category is sufficient to classify a child as being at “high risk”.

Moderate Risk: The presence of at least 1 “moderate risk” indicator and no “high risk” indicators present results in a “moderate risk” classification.

Low Risk: The child does not have “moderate risk” or “high risk” indicators.

*AAPD, Council on Clinical Affairs, www.aapd.org

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2-OH-013 (5/06)

Depending on the findings on CAT, a child may be placed in a low, moderate or high risk category. Presence of a single risk indicator in any area of the high risk category is sufficient to classify the child as being at high risk. Most children, particularly those from poor families are naturally at high risk for caries. This helps to implement aggressive treatment and preventative plans for these children. The practitioner will have to remember that caries risk assessment needs to be performed constantly. The risk status of a child may change, especially with successful interventions.

4. Preventive strategies ECC can progress with great rapidity suggesting that aggressive preventive measures beyond traditional community water fluoridation and topical fluoride treatment are required. Preventive measures should treat ECC as a communicable, carbohydrate-modified, microbial disease and should place emphasis on controlling the disease process before it occurs. Preventive strategies should include: A. Minimizing vertical and horizontal transmission of cariogenic

bacteria, by educating parents and siblings about the infectious nature of this disease, by encouraging them to take care of their dental needs and to discourage habits such as pre-chewing and kissing in the mouth.

B. Reducing exposure to fermentable carbohydrates, by explaining the biochemistry of caries process in laymen terms and offering diet counseling. It must also be reinforced that the frequency of exposure to, and not the quantity of fermentable carbohydrates is attributable to disease onset.

C. Regular topical in-office fluoride treatment such as topical varnish or gel.

D. Developing safe and effective antibacterial approaches to reducing the number of acidogenic (acid-producing) oral bacteria in children. For example, cotton tips soaked in xylitol and chlorhexidine rinses can be painted on to teeth of susceptible children (15).

Timing of preventive treatment is crucial, and this should start within 6 months following the eruption of the first tooth. As the window of opportunity for inoculation and infection with cariogenic bacteria starts even early, steps to prevent caries should ideally start prenatally with the parents, and then continue with the primary care giver (mother) and young child (16).

5. Anticipatory guidance and parent/patient education Anticipatory guidance is defined as “proactive counseling of parents and patients about developmental changes that will occur in the interval between health supervision visits that includes information about daily caretaking specific to that upcoming interval (17).� It allows for specific dental education that can be tailored to the individual patient’s developmental stage. It also complements risk assessment and often goes hand-in-hand. General anticipatory guidance for the young patients between 0 to 5 years of age include oral hygiene, diet counseling, fluoride treatments, injury prevention and oral habits (17, 18).

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Infant Oral Exam and First Dental Home

First Dental Home Initiative

When the US Surgeon General David Satcher issued his report titled Oral Health in America in 2000, he called for prompt action to promote access to oral health care for all Americans, especially the disadvantaged and minority children, who were found to be at greatest risk for severe medical complications resulting from minimal oral care and treatment.

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When the US Surgeon General David Satcher issued his report titled “Oral Health in America” in 2000, he called for prompt action to promote access to oral health care for all Americans, especially the disadvantaged and minority children, who were found to be at greatest risk for severe medical complications resulting from minimal oral care and treatment (5). While this report discussed the prevalence of oral health problems and the connection between dental health and overall well-being of an individual, it highlighted the disparities seen in oral health care system and its prejudice against certain underprivileged sections of the population, particularly children, from lower income families and children, as a minority group (19, 20). About 15 million children, one out of every four, live below the federal poverty level (21).

Poor children suffer twice as much dental caries, and their disease is more likely to be untreated than children from wealthy families (5, 20).

About 26 million American children lack dental insurance and these uninsured children are 2.5 times less likely to receive dental care than insured children. Children living in homes with income below the federal poverty level have twice the number of visits for pain relief but far fewer total dental visits, particularly preventative and maintenance compared with children from families with higher incomes (22). Childhood caries, particularly ECC affects children in general, but is 32 times more likely to occur in infants who are of low socioeconomic status, whose mothers have a low education level, and who consume sugary foods. For example, 90 percent of children enrolled in the US Head Start program (ages 3 to 5 years) were affected by ECC (23). Unfortunately, children affected by ECC will never have the same oral health experience when compared with healthy children who have not suffered this disease. The affected children suffer from a reduced oral healthrelated quality of life (24). Multiple state and federal programs like the Women, Infants and Children (WIC), Medicaid, and Children’s Health Insurance Plan (CHIP) have been instituted to offer poor children access to dental care that would otherwise be unavailable to them.

In 2007, a class action lawsuit was filed and won against Texas officials to improve children’s access to health care through the state’s Medicaid program (25). Funds were allocated to support several special health care initiatives. One such initiative is the First Dental Home (FDH), which is unique to the State of Texas Medicaid Program.

FDH is a legislatively supported dental initiative developed by both pediatric and general dental practitioners, aimed specifically at improving the oral health of children 6-35 months of age, who are covered by Medicaid (13). It is unique because this is the first and only program instituted to provide dental checkup visits for infants 6 months of age, prior to eruption of teeth and onset of caries. The dental checkups are recommended every 3 months, starting at 6 months of age, which will

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account for four periodic recall visits a year. The idea is to provide infant oral examinations and preventive dental services to the child patient, and deliver consistent, simple and easy oral health care education and anticipatory guidance during each of these visits to parents/caregivers (13). The goals of FDH are: A.

B.

C.

D.

To start early, way before the disease process is established.

To deliver important information tailored to the individual child and parent in small, divided, and digestible doses.

To teach parents about the infectious nature of caries, and ways to prevent spreading of cariogenic bacteria between parents and children.

To teach proper diet and oral hygiene practices in order o prevent childhood caries.

These regularly timed dental visits are a critical component of the FDH; each visit focuses on familiarizing these young children and their parents with dental health care education in small increments.

The rationale behind these frequent dental recalls is that it would result in fewer carious teeth and higher dental awareness. Topics that will be important to discuss with the parents will be: A.

B.

C.

Dental caries prevention and oral hygiene techniques — Parents should brush their child’s teeth twice a day and use the kneeto-knee or lap exam posture with another adult to brush teeth of young toddlers who tend to fight it.

Cariogenic and non-cariogenic diet and their frequency — Parents should be given alternatives to cariogenic, high sucrose snacks like cheese and fresh fruits. They must be reminded that the frequency of exposure to fermentable carbohydrates should be kept to a minimum as possible.

Access to fluoride: information about fluoridated water and toothpaste use — Parents of young infants who are formula fed need to advised to use bottled, nonfluoridated water to mix formula in. Even though the AAPD recommends using nonfluoridated toothpaste for children under 2, for children under 3 years enrolled in FDH, just a smear of fluoridated children’s tooth paste is recommended. For children under age 6, a pea-sized amount of fluoridated children’s toothpaste is recommended.

D. Age-appropriate anticipatory guidance — Parents must be counseled about teething, dental trauma prevention and non-nutritive oral habits depending on the age of the child.

E. Importance of regular dental visits — Parents need to understand that the will have to return to the dental clinic for a recall visit every 3 months. That way we can access the progress made in improving their child’s oral hygiene, access growth and development, and check for caries or gum diseases.

Prior to the FDH initiative in the State of Texas, for children covered by Medicaid, the minimum age limit for preventive dental services such as periodic exams, dental cleaning, and topical fluoride applications was 1 year. These dental services were also underutilized — only one out five Medicaid-covered children between ages of 6 to 36 months sought dental treatment or dental services. The ones that did were already affected by childhood caries or had experienced other medical conditions like cellulitis due to untreated dental infections (26). These children required extensive dental restorative and surgical treatment, often requiring multiple dental appointments with conscious sedations or a 1-2 hour treatment under general anesthesia. The first line of defense against ECC is prevention, and according to the CAT, the presence of caries already puts a child at a high risk for future caries (14). In support of this, Galganny-Almeida et al reported that a startling 79 percent of Medicaid-covered children who had been previously treated in an operating room under general anesthesia had developed additional tooth decay in less than 2 years, compared with 29 percent of children without cavities at the onset (27). The financial implications of treating childhood caries, particularly ECC are noteworthy.

Treatment costs for ECC can range from few hundred dollars per visit adding to several thousands of dollars per case (15, 28, 29). Prevention of the disease is the answer to reducing these costs. Savage et al found that when proper diet and oral hygiene instructions were followed during early childhood, caries incidence was reduced significantly.

In their study, Medicaid-covered children, who had their first preventive dental visit by age 1 incurred dental costs almost 40 percent lower than children whose first preventive visit was after 3 years of age (30). Another study found that preschool Medicaid covered children who had an early preventive dental visit by age 1 were more likely to use periodic Texas Dental Journal l www.tda.org l November 2010

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Infant Oral Exam and First Dental Home preventive services and therefore, had less dental invasive treatment needs and were cost effective (31). As a result of these studies, Texas State Health and Human Services Commission proposed to include preventive dental services to children less than 1 year of age via the FDH initiative (13).

With these facts in mind, general dentists are encouraged to participate in the First Dental Home Program for all children in order to treat the backlog of untreated early childhood caries in Texas.

In addition, programs directed towards examinations of children should be accompanied by processes that include treating the disease that is detected. Even for those who do not favor or endorse federally-aided dental healthcare programs, this initiative should spark an interest because the ‘taxpayer dollars’ allocated to the FDH program is possibly one of the most well spent dollars in recent times. The success of the FDH program lies in the hands of Texas dental practitioners. As the number of providers goes up, there will be less access to care issues and more children can benefit from this initiative.

In order to be a provider of FDH, dentists must currently serve as Medicaid dental care providers and be enrolled in Texas Health Steps and complete the FDH provider training. FDH provider educational materials and parent/patient educational materials in English and Spanish are available at no cost to the dental

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practitioner. More information on FDH and how to become a provider can be obtained from visiting http://www.dshs.state. tx.us/dental/FDH.shtm (13).

References 1. Chu, S. Early Childhood Caries: Risk and Prevention in Underserved Populations.

The Journal of Young Investigators 2006; 14 (5). http:// www.jyi.org/research/ re.php?id=717. Access May 13, 2010.

2. Flores G, Tomany-Korman SC. Racial and ethnic disparities in medical and dental health, access to care, and use of services in US children. Pediatrics.

2008;121(2):e286-98. Epub 2008 Jan 14.

3. American Academy of Pediatric Dentistry. 2009-10 Definitions, Oral Health Policies, and Clinical Guidelines. Policy on Early Childhood Caries (ECC): Unique Challenges and Treatment Options. http://www.aapd.org/media/Policies_Guidelines/P_ ECCUniqueChallenges.pdf 4. American Academy of Pediatric Dentistry. 2009-10 Definitions, Oral Health Policies, and Clinical Guidelines. Guideline on Infant Oral Healthcare. http:// www.aapd.org/media/Policies_Guidelines/G_InfantOralHealthCare.pdf 5. US Department of Health and Human Services. US Public Health Service. Oral health

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in America: a report of the surgeon general. Rockville, MD: National Institutes of Health, 2000. http://www. surgeongeneral.gov/library/ oralhealth/. Accessed May 11, 2010.

6. Gift He. Oral health outcomes research: Challenges and opportunities. ln Slade GD, ed., Measuring Oral Health and Quality of Life.

Chapel Hill, NC: Department of Dental Ecology, University of North Carolina,1997;pp. 7.

25-46.

7. Weinstein, P. Public health issues in early childhood caries. Community Dentistry and Oral Epidemiology 1998; (26) 84-90.

8. Ismail, AI. Determinants of health in children and the problem of early childhood caries. Ped Dent 2003;(25) 328-33.

9. American Academy of Pediatric Dentistry. 2009-10 Definitions, Oral Health Policies, and Clinical Guidelines.

Definition of Dental Home. http://www.aapd.org/media/Policies_Guidelines/P_ DentalHome.pdf 10. Nowak AJ, Casamassimo PS. The dental home: a primary care oral health concept. J Am Dent Assoc 2002;133(1):93-8.

11. Dosani FZ, Nguyen TD, Farkouh DR. The Infant Oral Exam. Oral Health and Dental Practice. Jan 2010. www.oralhealthjournal.com/issues/story. aspx?aid=1000353810. Ac-

cessed May 13, 2010.

12. Seale NS, Casamassimo PS. Access to dental care for children in the United States: a survey of general practitioners. J Am Dent Assoc 2003;134(12):1630-40.

13. Texas Department of State Health Services. Oral health group. Texas health Steps. http://www.dshs.state. tx.us/dental/FDH.shtm 14. American Academy of Pediatric Dentistry. 2009-10 Definitions, Oral Health Policies, and Clinical Guidelines. Policy on Use of Caries Risk Assessment for Infants, Children and Adolescents. http://www.aapd.org/media/Policies_Guidelines/P_ CariesRiskAssess.pdf 15. Den Besten PK, Berkowitz RJ, Early childhood caries: an overview with reference to our experience in California. J Cal Dent Assoc 2003; 31(2):13943. www.cdafoundation. org/.../February_E_2003_ CDA_127CCF.pdf 16. Caufield PW, Griffen AL. Dental caries: An infectious and transmissible disease.

Pediatric Clinics of North America, 2000;47(5):100119.

17. American Academy of Pediatric Dentistry. 2009-10 Definitions, Oral Health Policies, and Clinical Guidelines.

Guideline on periodicity of examination, preventative dental services, anticipatory guidance/counseling; and oral treatment for infants, children and adolescents. http://www.aapd.org/media/Policies_Guidelines/G_ Periodicity.pdf

18. New York State. Department of Health. Information for a healthy New York. http:// www.health.state.ny.us/prevention/dental/birth_oral_ health.htm 19. Mouradian, WE, Wehr E, Crall JJ. Disparities in children’s oral health and access to dental care. JAMA, 2000; 284:2625-31.

20. Mouradian WE. The face of a child: children’s oral health and dental education. J Dent Educ 2001;65(9):821-31.

21. Hearts and Minds, Children in poverty, America’s Ongoing War. http://www.heartsandminds.org/articles/ childpov.htm. Accessed May 13, 2010.

22. Edelstein, BL. Disparities in oral health and access to care: findings of national surveys. Ambul Pediatr 2002;2(2 suppl):141-7.

23. Tinanoff, N. and D.M. O’Sullivan. Early childhood caries: overview and recent findings. American Academy of Pediatric Dentistry, 1997;19:12-5.

24. Low W, Tan S, Schwartz S. The effect of severe caries on the quality of life in young children. Pediatr Dent 1999;21:325-26.

25. Frew v Suehs, Civil Action 3:93CV65, United States District Court for the Eastern District of Texas.

26. Health and Human Services Commission, FREW Medical and Dental Strategic Initiatives. http://www.hhsc. state.tx.us/about_hhsc/ AdvisoryCommittees/docs/ Briefing%20Paper_First%20 Dental%20Home.doc. Accessed October 22, 2010.

27. Galganny-Almeida A. Future Caries Susceptibility in Children with Early Childhood Caries Following Treatment under General Anesthesia.

Paediatr Dent 2000; 22:3026.

28. Savanheimo N, Vehkalahti MM, Pihakari A, et al. Reasons for and parental satisfaction with children’s dental care under general anaesthesia. Int J Paediatr Dent 2005;15:448-54.

29. Duperon D. Early childhood caries: a continuing dilemma.

J Calif Dent Assoc,1995; 23:15-25.

30. Savage M et al, Early Preventive Dental Visits: Effects on Subsequent Utilization and Costs, Pediatrics, October 2004; 418-23.

31. Lee JY, Bouwens TJ, Savage MF, Vann WF Jr. Examining the cost-effectiveness of early dental visits. Paediatr Dent 2006; 28: 102–5.

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900 Congress Avenue, Suite 250 Austin, Texas 78701

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

Three distinct plans now available: Freedom Plan

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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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AD-9

r P

w e i v e

Dental Implants Lee Ann Brady, D.M.D.

Not many years ago, dental implants were new, fascinating, and experimental procedures that could restore patients to a higher level of function. Times are changing. It is becoming increasingly common in my practice for patients to already be familiar with

Brady Designing An Occlusion — Occlusion In Everyday Dentistry Lee Ann Brady, D.M.D., and Gary DeWood, D.D.S., M.S. Thursday, May 5 8:30 AM ─ 11:30 AM Course Code: # T15 Creating An Organized Occlusion Workshop Lee Ann Brady, D.M.D., and Gary DeWood, D.D.S., M.S. Thursday, May 5 1:30 PM ─ 4:30 PM Course Code: # T16 Esthetic Techniques and Materials Lee Ann Brady, D.M.D., and Gary DeWood, D.D.S., M.S. Friday, May 6 8:30 AM ─ 11:30 AM Course Code: # F13 Esthetic Case Planning Lee Ann Brady, DMD Friday, May 6 1:30 PM ─ 4:30 PM Course Code: # F14

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dental implants. They ask me to help them understand what role implants might play in replacing missing teeth or allowing them to transition away from removable prosthetics.

As implant technology and surgical techniques advance, our criteria for success needs to advance as well. The days are gone when successful integration of a fixture measured success. We need to add obtaining optimal esthetics and functional results to our criteria for satisfaction. Obtaining naturally beautiful esthetics, optimal function, and predictable long-term results starts with a comprehensive evaluation. I begin by getting to know my patients so I can understand how dental implants will help accomplish their goals for dental health. Then I discover the technical components of their dental conditions.

Dental breakdowns result when two factors become out of balance with a patient’s adaptive capabilities and forces. Dental implants and teeth respond differently in the presence of these two factors. For each patient, achieving success begins with understanding present risk factors and their susceptibility to both. Optimal survival rates for dental implants occur when the fixtures are placed in environments free of inflammation and infection. As part of a comprehensive evaluation, I complete a thorough periodontal examination, including full-mouth sulcus depths, furcation involvements, attachment loss, mobility, tissue character, and home-care evaluation. The team’s goal is to assist patients in getting their mouths healthy and clean in a maintainable

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

way, prior to implant placement and final restorative therapy.

Achieving an optimal esthetic result begins at the evaluation. I include a complete set of diagnostic digital photographs at every evaluation. I take several full-face and profile images to assess facial esthetics and their relationship to the appearance of the teeth. Close-up images allow the patient and me to discuss tooth display at rest and full smile, gingival discrepancies, gingival display, and smile appearance, in addition to shade and tooth position. When the restorative phase is complete, I want it to be difficult to discern natural teeth from the restorations. Often, changes such as periodontal surgery or orthodontic repositioning must be made prerestoratively.

Implant dentistry has evolved beyond placing the fixtures where there is existing bone without regard for the restorative and esthetic consequences. Now, understanding the anatomy of the soft and hard tissues as they affect implant placement is part of the preliminary information that must be gathered. Digital photographs, in addition to their use in esthetic evaluation and planning, are invaluable tools for evaluating soft-tissue contours. This information, along with the clinical soft-tissue exam and the models, give me a complete picture of the soft-tissue parameters that affect the implant-placement outcome.

I also need a clear picture of the hard-tissue anatomy, so during the past few years, I added CT imaging to the diagnostic data I collect for cases in which I contemplate implants. These images allow implant surgeons and me to gain thorough understandings of the bony architecture and anatomical factors, such as maxillary sinus and inferior alveolar nerve position in areas where we plan to place fixtures. We can then incorporate site-augmentation procedures if needed to achieve optimal results.

Implant dentistry is most often accomplished using a team of dentists who work together to accomplish the restorative and surgical treatment.

Part of planning for success means giving each member of the team (orthodontist,periodontist, implant surgeon) an opportunity to become familiar with patients’ conditions. Once this has been accomplished, team members discuss each case and how we can help one another accomplish the best results. The removal of teeth prior to implant placement is one of the many topics our team works out to optimize results. This can be critical in implant-site preservation and creation. The timing of this treatment and who will be responsible for extractions must not be overlooked.

Figure 1. Maxillary arch — implant placement based on existing bony architecture that resulted in fixture being buccal to restorative space.

Figure 2. Full smile photo — implant placed at No.10.

Figure 3. Retracted view of implant replacing No. 10 without proper site development.

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Figure 4. Implant fixture replacing tooth No. 4. Placed properly between adjacent teeth and within alveolar housing.

Figure 5. Implant crown replacing No. 4 where planned fixture placement allowed for proper restorative contours.

Figure 6. Duplicate model of wax-up to replace tooth No. 9 which had fractured off and was orthodontically extruded to develop the site for implant placement.

Another tool our team uses to create optimal implant placement sites is orthodontic extrusion of hopeless teeth prior to their removal. Sometimes this is in conjunction with other orthodontic therapies to align adjacent teeth, create space for implant fixtures, or correct gingival discrepancies. Or, it can be the reason for planned orthodontics. For treatment to proceed seamlessly, these issues and many others must be well coordinated by a team. Often, we invite patients to these planning sessions, or we come together following our planning sessions with patients to answer questions and present treatment.

The final piece of the diagnostic puzzle is the restorative work-up. The final prosthetic result is worked up on a set of mounted models, including soft- and hard-tissue augmentation, final tooth placement based on esthetic and functional parameters, and refinement of the occlusion.

This work-up then can be used to create surgical guides for site-augmentation surgery that is planned as a separate procedure from final implant placement. A copy of the proposed prosthetic result is fabricated and impregnated or coated with a radiopaque material so that the patient may have a CT image taken with the prosthetic mock-up in place. This image is then used to finalize planning for the implant placement and any necessary site-augmentation procedures not yet accomplished. The image is exported into a software program. Fixture placement is planned so that the abutments are contained within the restorative framework without compromising embrasure spaces or forcing the restorative too far to the buccal or lingual, while being able to see the bony architecture and choose the optimal fixture sites at the same time. We choose the implant length and diameters based on existing anatomy or augment the site to use the fixture of our choice. The image also allows us to analyze the crown-to-fixture ratio of the final result based on existing ridge, or optimize the long-term outcome by grafting the site and reducing this ratio.

This final piece is crucial in planning the timing and sequencing of surgical treatment, as well as making sure that the fixture placement supports the optimal restorative outcome. Understand the patient’s present condition, manage any risk factors, and thoroughly plan. These allow us to achieve the patient’s desired functional and esthetic results with predictable long-term success.

Figure 7. Duplicate model is used to create a temp-stent, which directs implant fixture placement based on final restorative contours.

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Figure 8.Temp-stent following traumatic root removal. Photo © Dr. Brian Young

JKJ Pathology Oral Pathology Laboratory

John E Kacher, DDS • Available for consultation by phone or Figure 9. Radiograph, tooth root No. 9 after extrusion and implant fixture No. 9 after placement with tempstent. Surgery: Dr. Brian Young, Jacksonville, FL.

email • Color histology images on all reports • Expedited specimen shipping with tracking numbers • Reports available online through secure web interface

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

Figure 10. Cross sectional slices of mandible from CT scan showing measurement of potential implant site.

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

Protecting your patients, limiting your liability Figure 11. Implant planning for fixture.

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

Log in at tda.org to get started today!

In Memoriam Those in the dental community who have recently passed

Gaines, James Foster, Jr. San Angelo, Texas December 23, 1920 – September 3, 2010 Good Fellow, 1972 Life, 1985 Fifty Year, 1994 Goodwin, Joel F., Sr. Dallas, Texas September 9, 1924 – September 13, 2010 Good Fellow, 1977 Life, 1989

Memorial and Honorarium Donors to the Texas Dental Association Smiles Foundation

In Memory of: Carol Rogers

By Don and Kathy Lutes Peggy Hood Drs. Jamie and Jennifer Bone Your memorial contribution supports: • educating the public and profession about oral health; and • improving access to dental care for the people of Texas.

Please make your check payable to:

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

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

Save time, pay it online! Log in at tda.org and click on “Pay Dues” on the member homepage. Paying dues online is safe, quick, and easy.

Members should receive 2011 dues statements in the mail and be able to pay dues online early November.

Contact Lee Ann Johnson with any DUES questions at (512) 443-3675 or leeann@tda.org.

Contact Stefanie Clegg with any WEB questions at (512) 443-3675 or stefanie@tda.org.

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

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

Get both for only $35 a year.

For more information on TDA’s Personal Web Page, log in at www.tda.org click on “Personal Web Pages” under Membership Info -> CONTACTS. Here you can download the application or look at examples.

Questions? Contact Stefanie Clegg at (512) 443-3675 or stefanie@tda.org

Join us on Facebook groups.to/texasdental Follow us on twitter.com/theTDA Get LinkedIN at linked.com, search “Texas Dental Association”

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treatment plans” for practice transitions Creating “treatment for more than 23 years…

L. Norton Hindley III, A.S.A. Purchase/Sale of Practice • Negotiations and Closing Documents • Purchaser Representation Practice Mergers and Reformations • Associate Buy-in and Partnership Agreements Practice Valuations Leading to Merger and Acquisition • Banking: Loan Packages and Origination of Loans

The Hindley Group, L.L.C. 2202 Timberloch Place, Suite 218 • The Woodlands, Texas 77380 281-367-1955 • 800-856-1955 norton@thehindleygroup.com www.thehindleygroup.com

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

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Provided by TDA Perks Program

value for your

profession

A Better Freedom-of-Choice Plan,

and How your Patients and Practice Can Benefit From It Mark Deschenes and John Hawkins, DentalQUICK™

With the slowed economy and patients pinching pocketbooks, you may find it harder than ever to keep your chairs occupied. Identifying these patients, and then encouraging those who would benefit from dental insurance to obtain a good plan, will build your immediate revenues and position your practice for continued growth.

Until recently, if one wanted dental insurance, there were only two kinds of plans to choose from. The first are discount plans that require you to cut your fees.

This type of plan may fill chairs, but being busy and being profitable are two different things. The second are the traditional

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or PPO plans you’re forced to deal with to keep the lights on. Usually these require waiting periods, timeconsuming amounts of paperwork or pre-certification, or ambiguous 80-percent-of-something reimbursements that leave you wondering how much compensation you’re actually receiving.

Both types of plans have left a figurative bad taste in the mouth of many dental practices — to the point where they will accept cash only. Unfortunately many patients today are running short in cash, and as you know, fewer and fewer of them are being approved for credit.

A New Type of Freedom of Choice Plan The good news is: a new type of individual dental insurance is now available that can benefit your patients and enhance your bottom line. What could be “new” about dental insurance? Actually, quite a bit! I believe this new type of plan changes the playing field in dental insurance.

You can offer it in your own office and eliminate deductibles, hassles, and guesswork surrounding the benefits. Next-day coverage and individual dental insurance are also now available through this innovative type of plan.

Let’s take a look at five types of patients, and see how the new plan type could benefit patients that fall into these categories, as well as your practice. Each represents a challenge as well as an opportunity for your practice.

1) Patients who haven’t had a hygiene appointment

in at least 10 months These may be people who are pinching pennies and stretching time between hygiene visits. Improve their oral health and keep your chairs full by making it easier to see you semiannually. Suggest obtaining an economical “cleaning and cavity plan.” These are very affordable, with premiums ranging from $15 to $26 per month. The best plans will pay up to $100 to your office for each visit, and require no network affiliation or agreements. With such low premiums, every person who visits your practice could be insured. If a patient is paid an insurance benefit twice a year, he’ll be more inclined to use it, and less likely to cancel appointments because of dips in his income. These plans often include an amount for basic-restorative treatments as well. Run-of-the-mill plans normally have a 6-month

waiting period, but the new type of plan provides an immediate benefit, and pays up to $1,000/year/person — substituting the waiting period with a 50 percent benefit (half the full benefit) the first year. Both patient and practice would see a significant and immediate benefit. For example, at the immediate 50 percent level, the newly-available plan would reimburse $95 per three surface posterior resin (02393), and $190 at the full-benefit level.

2) Patients with evident disease or decay who need

an extensive treatment plan These patients are long overdue for an office visit, or require emergency treatment. It’s likely they came in because they couldn’t stand the pain or discomfort any longer. Often, the treatments these patients need are the most profitable ones for the practice. However, these patients are often not financially able to begin the treatment. Short of keeping these patients’ accounts in your books as receivables, suggest a dental insurance plan to them that provides immediate or next-day major-treatment coverage. The new type of plan, as it does with the “cleaning and cavity” plan, also provides immediate half coverage of a fee schedule. For individual plans, it will provide up to $1,500 for treatment, and $200 for wellness care, annually. Patients can often utilize the plan to take care of most-needed treatments first, and later schedule other procedures as their funds become available.

As the new plans don’t require pre-certification, they come as close to you being paid in cash as you can get, while allowing you to charge your regular fees and bill your patients for the balance. For an oral exam, molar root canal, and crown with cast, a patient may receive $587 that will post toward your actual fees.

The premium for this type of plan begins at $36/month, and does not require the patient to undergo a credit check. After 12 months, this plan provides patients the full benefit. In other words, the plan would pay your office, or reimburse the patient, $1,075 for the same treatment. Encourage your staff to mention this type of insurance when they are going over the treatment plan and your fees (with patients) as a way to help cover the immediate cost, as well as for scheduled follow-up appointments. Ask your staff to remind these patients that they need to visit your office for hygiene appointments at least twice a year to maintain the results of their newly-completed treatment.

3) Patients enrolled in discount dental plans Some dentists have resigned themselves to accepting discount plans as a way of doing business. I suggest you stop giving away your services! If you don’t acTexas Dental Journal l www.tda.org l November 2010

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cept discount plans, you can avoid driving your patients (such as those with a cracked tooth), toward them. Let them know about “next-day” dental insurance. Ask your staff to suggest this plan, and place a postcard in each patient’s hygiene bag. Keep freedom alive by letting your patients know they can purchase true insurance at reasonable rates, either through your office, or by contacting someone at a number you provide them. They’ll appreciate the information. In my opinion, once they learn about the new type of plan, a good percentage of patients and dental practices will be ready to drop their participation in discount plans as soon as their contracts expire. Tapping into this resource can change low-paying plans into well-paying accounts.

ceive a quote, predict their benefits, and apply for coverage with a unique, online benefit planner. Three benefit levels are available, with rates starting at $15.50/month. Adults age 19-64 may apply, and children may be covered with a qualifying adult. Visit www.DentalQUICK.com for information or to enroll or call (888) 350-2416.

4) Patients whose dental-insurance coverage

has waiting periods or low limits

For more information on other TDA Perks Program, visit tdaperks.com, or call (512) 443-3675.

You can see exactly how simple the plan is, a brief overview of the program, and get brief training for you and your staff at: www.paymydentist.com. Upon registering at the site, your office will receive printed material, a window cling, and access to PDF files and presentations for video screens. You may choose to get fully involved, or simply to recommend the program by distributing information to your patients. DentalQUICK™ is underwritten and administered by Assurant Health policy, form 8079.

When patients discover they don’t have enough coverage, or learn that the plan they have has a waiting period, you can come to their rescue by offering them a next-day coverage plan. The best plans pay up to $1,500 for treatment, include immediate basic and major coverage, and don’t have coordination of benefits. This way, both insurers will pay their full benefit. Have your staff suggest the additional coverage when there is a shortfall, and turn a patient’s “no” into a “yes”.

5) Patients who have no dental insurance information on file Benefit packages everywhere are changing with the economy. Whenever your staff sees a gap in a patient’s coverage appear, ask them to suggest a quality next-day coverage dental plan that includes immediate basic and major restorative benefits, and help prevent patients from delaying appointments or joining discount dental plans.

Where to Find More Information The new type of freedom-of-choice, next-day coverage individual dental insurance covered in this article is available through DentalQUICK™, a TDA Perks Program partner. This insurance is directly available to your patients; they can re-

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When patients discover they don’t have enough coverage, or learn that the plan they have has a waiting period, you can come to their rescue by offering them a next-day coverage plan.

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Oral and Maxillofacial Pathology Case of the Month Clinical History

Anne Cale Jones, D.D.S.,

A 58-year-old Hispanic male was evaluated by an oral and maxillofacial surgeon because of a 2-month history of bleeding ulcers involving the perioral skin and entire oral mucosa (Figure 1). The patient also demonstrated generalized cutaneous pruritic and blistering lesions, and exhibited periorbital erythema and edema.

The patient’s past medical history was significant for insulin dependent diabetes mellitus and chronic lymphocytic leukemia (CLL) diagnosed in 2006.

The University of Texas

Two biopsies from the left buccal mucosa were obtained. One was submitted in formalin for routine histologic examination while the other was submitted in Michel’s solution for direct immunofluoresence. Both specimens demonstrated fibrous connective tissue with no overlying surface epithelium. The superficial connective tissue exhibited a band-like mixed inflammatory cell infiltrate.

In the deeper connective tissue this inflammatory infiltrate was located in a perivascular pattern. Direct immunofluoresence was deferred since no surface epithelium was present.

What is the most likely diagnosis?

See page 1225 for the answer and discussion.

Department of Pathology, Health Science Center at San Antonio, Texas

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

Jones

Department of Pathology, The University of Texas Health Science Center at San Antonio, Texas James E. Franco, D.D.S.,

McGuff

M.D., private practice, Alamo Maxillofacial Surgical Associates, San Antonio, Texas Franco

Figure 1. Hemorrhagic crusting and ulceration involving the vermilion of the upper and lower lips, nasal mucosa, and perioral and perinasal skin.

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Texas Dental Journal l www.tda.org l November 2010 4970_TX_bw_Ads_02.indd 1

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11/18/08 9:42:28 AM

Calendar of Events 1222

December 2010

6&7 The ADA Institute for Diversity in Leadership will hold its meeting at the ADA in Chicago, IL. For more information, please contact Ms. Stephanie Starsiak, 211 E. Chicago Ave., Chicago, IL 60611.

Phone: (312) 440-4699; FAX: (312) 440-2883; E-mail: starsiaks@ada.org; Web: ada.org.

January 2011

13 – 15 The Dallas County Dental Society will hold the Southwest Dental Conference at the Dallas County Convention Center in Dallas, Texas. For more information, please contact Ms. Jane Evans, DCDS, 13633 Omega Drive, Dallas, TX 75244. Phone: (972) 386-5741; FAX: (972) 233-8636; E-mail: jane@dcds.org; Web: dcds.org 23 – 25 The American Dental Association will hold its Presidents Elect Conference in Chicago, IL. For more information, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org.

February 2011

4 The American Dental Association’s Give Kids a Smile Day occurs nationwide. For more information, please contact Ms. Lynne Mangan, ADA, 211 E. Chicago Ave., Chicago, IL 60611-2678.

Phone: (312) 440-2500; FAX (312) 440-7494; E-mail: online@ada.org; Web: ada.org.

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

March 2011

2–5 The Alliance of the American Dental Association will hold a conference in Richmond, VA. For more information, please contact Ms. Patricia Rubik-Rothstein, AADA, 211 E. Chicago Ave., Ste. 730, Chicago, IL 60611-2678. Phone: (312) 440-2865; FAX: (312) 440-2587; E-mail: manager@ allianceada.org; Web: ada.org.

2–9 The American Academy of Dental Practice Administration will hold its annual meeting at the JW Marriott Resort in San Antonio, TX. For more information, please contact Ms. Kathy S. Uebel, AADPA, 1063 Whippoorwill Lane, Palatine, IL 60067. Phone: (847) 934-4404; FAX: (847) 9344410; E-mail: executivedirector@aadpa.org; Web: aadpa.org.

2–5 The Academy of Laser Dentistry will hold its 18th annual conference and exhibition at the Loews Coronado Bay Resort in San Diego, CA. For more information, please contact Ms. Gail Siminovsky, ALD, 3300 University Dr., Ste. 704, Coral Springs, FL 33075. Phone: (954) 346-3776; FAX: (954) 757-2598; E-mail: laserexec@laserdentistry.org; Web: lasterdentistry.org.

3–5 The Academy of Osseointegration will hold its annual meeting, From Fundamentals to New Technologies for the next 25 Years, at the Washington DC Convention Center in Washington, DC. For more information, please contact Ms. Gina Seegers, 85 W. Algonquin Rd., Ste. 550, Arlington Heights, IL 60005-4422. Phone: (847) 439-1919; FAX: (847) 439-1569; E-mail: ginaseegers@ osseo.org; Web: osseo.org.

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11 – 16 The American Dental Education Association will hold its annual session and exhibition at the Manchester Grand Hyatt in San Diego, CA. For more information, please contact Ms. Michelle Allgauer, ADEA, 1400 K Street, NW, Ste. 1100, Washington, DC 20005. Phone: (202) 289-7201; FAX: (202) 289-7204; E-mail: allgauerm@adea.org; Web: adea.org.

April 2011

11 – 13 The American Association of Public Health Dentistry will hold its National Oral Health Conference at the Hilton Pittsburgh in Pittsburgh, PA. For more information, please contact Ms. Pamela J. Tolson, CAE, 3085 Stevenson Dr., Springfield, IL 62703. Phone: (217) 529-6941; FAX: (217) 529-9120; E-mail: natoff@aaphd.org; Web: aaphd.org.

13 – 16 The American Association of Endodontists will hold its annual session at the San Antonio Convention Center in San Antonio, TX. For more information, please contact Mr. James M. Drinan, AAE, 211 E. Chicago Ave., Ste. 1100, Chicago, IL 60611-2616. Phone: (312) 266-7255; FAX: (312) 266-9867; E-mail: jdrinan@aae.org; Web: aae.org.

28 – 30 The American Dental Society of Anesthesiology will hold its annual meeting at the Westin Keirland Resort & Spa in Scottsdale, AZ. For more information, please contact Ms. Barbra Josephson, ADSA, 211 E. Chicago Ave., Ste. 780, Chicago, IL 60611. Phone: (312) 664-8270; FAX: (312) 642-9713; E-mail: barbra.josephson@mac.com; Web: adsahome.org.

May 2011

9 – 11 The ADA will hold its Washington Leadership Conference in Washington, D.C. For more information, please contact Mr. Brian Sodergren, ADA, 1111 14th St., NW, Ste. 1100, Washington, DC 20005.

Phone: (202) 789-5168; FAX: (202) 789-2258; E-mail: sodergrenb@ada.org; Web: ada.org.

17 – 21 The American Academy of Cosmetic Dentistry will hold its annual scientific session at the Hynes Convention Center in Boston, MA. For more information, please contact Ms. Kelly Radcliff, AACD, 5401 World Dairy Dr., Madison, WI 53718. Phone: (800)543-9220; FAX: (608)222-9540; E-mail: kelly@aacd.com; Web: aacd.com.

26 – 29 The American Academy of Pediatric Dentistry will hold its 64th annual session at the Marriott Marquis New York in New York, NY. For more information, please contact Dr. John S. Rutkauskas, CAE, AAPD, 211 E. Chicago Ave., Ste. 1700, Chicago, IL 60611-2663. Phone: (312) 337-2169; FAX: (312) 337-6329; E-mail: jrutkauskas@aapd.org; Web: aapd.org.

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

Calendar of Events

11 – 16 The Omicron Kappa Upsilon will meet in San Diego, CA. For more information, please contact Dr. Jon B. Suzuki, OKU, Temple University Dentistry, 3223 North Broad St., Philadelphia, PA 19140.

Phone: (215) 707-7667; FAX: (215) 707-7669; E-mail: suzuki@dental.temple.edu; Web: oku.org.

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Oral and Maxillofacial Pathology Diagnosis and Management

Consistent with Paraneoplastic Pemphigus Oral and Maxillofacial Pathology Case of the Month (from page 1220)

Discussion At that time the patient was diagnosed with chronic lymphocytic leukemia (CLL) in 2006, he declined chemotherapy. In July 2010, he began to develop night sweats and cervical, abdominal, and inguinal lymphadenopathy. Three weeks prior to presentation to the oral and maxillofacial surgeon, the patient was admitted to the hospital due to significant cutaneous and mucosal pain, inability to eat, and weight loss. The patient was determined to be febrile and neutropenic. Treatment was begun with Famvir, Penicillin, and Zithromax but no clinical improvement was noted. Chemotherapy for his CLL, consisting of Rotuxin and Cytoxin, was initiated.

The patient was also given Solu-Medrol for treatment of the cutaneous and mucosal blisters and lymphadenopathy, and Pink Magic (Benadryl, Maalox, and viscous Lidocaine 2 percent) for oral pain control.

Based on the patient’s medical history of chronic lymphocytic leukemia and extensive cutaneous and mucosal hemorrhagic ulcerations, the clinical findings were felt to be most consistent with paraneoplastic pemphigus. However, in light of the nondiagnostic histologic and immunofluorescent findings, a differential diagnosis should also include erythema multiforme.

With the presumptive diagnosis of paraneoplastic pemphigus, the patient was placed on Prednisone 60 mg orally per day. Within 2 weeks, the lip lesions resolved and the conjunctival and periorbital lesions had significantly improved. The patient continues to have moderate to significant pain with slow resolution of the oral mucosal lesions, thus limiting his ability to eat. Due to his insulin dependent diabetes mellitus, the Prednisone dose was lowered to 40 mg per day.

Paraneoplastic pemphigus is an uncommon vesiculobullous disease that occurs in patients with a history of a benign or malignant lymphoproliferative neoplasm. Benign neoplasms associated with this disease include thymoma and angiofollicular lymphoid hyperplasia (Castleman disease); malignant neoplasms include chronic lymphocytic leukemia and non-Hodgkin lymphoma. The majority of patients have a known history of a lymphoproliferative disorder before the clinical features of paraneoplastic pemphigus develop.

In a minority of cases, the lymphoproliferative neoplasm is discovered after the diagnosis of paraneoplastic pemphigus has been established.

The immunologic basis of paraneoplastic pemphigus is complex and only partially understood. The disease is thought to involve either a cytotoxic T lymphocyte abnormal-

ity or the production of cytokines by host lymphocytes that generate unique antibodies. These antibodies are believed to cross react with antigenic components in the basement membrane area or with intercellular desmosomes in the surface epithelium.

Patients with paraneoplastic pemphigus demonstrate varied clinical manifestations that may involve any cutaneous or mucosal site. Cutaneous lesions present as vesicles or bullae, or as hemorrhagic crusted ulcerations. Occasionally, papular and pruritic involvement of the skin is noted. Mucosal lesions may arise in the ocular, oral, pharyngeal, respiratory, nasal, and vaginal regions.

These lesions are extremely painful and are characterized by diffuse areas of erythema, hemorrhage, and ulceration. The polymorphous clinical findings noted in paraneoplastic pemphigus mimic those associated with lichen planus, erythema multiforme, mucous membrane pemphigoid, or pemphigus vulgaris.

In order to establish a definitive diagnosis, a biopsy should be performed in an uninvolved area so that the overlying surface epithelium does not separate from the underlying connective tissue. Antibody deposition at the level of the basement membrane leads to subepithelial cleavage and a chronic inflamma-

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tory infiltrate in the superficial connective tissue. These histologic findings are similar to those seen in mucous membrane pemphigoid. Antibody deposition in the desmosomal complex area leads to intraepithelial separation (acantholysis) similar to the histologic findings noted in pemphigus vulgaris. In other cases, the histologic features may mimic those seen in lichen planus (necrotic eosinophilic keratinocytes and a band-like chronic inflammatory infiltrate in the superficial connective tissue) or erythema multiforme (necrotic keratinocytes, intraepithelial or subepithelial vesicles, and acute and chronic perivasculitis).

Direct immunofluorescence reveals the deposition of IgG and/or C3 either at the level of the basement membrane (similar to mucous membrane pemphigoid) or between the individual epithelial cells in the surface epithelium (similar to pemphigus vulgaris). Indirect immunofluorescence, utilizing the patient’s serum, may be useful when it is difficult to obtain an adequate biopsy.

The patient’s serum can be sent to a specialized laboratory that performs paraneoplastic pemphigus antibody screening. In order to establish a definitive diagnosis, these findings must be correlated with the patient’s clinical manifestations and medical history of a lymphoproliferative neoplasm.

In cases of paraneoplastic pemphigus caused by a benign lymphoproliferative neoplasm, treatment is easily accomplished by excision of the neoplasm. In cases associated with non-Hodgkin lymphoma or chronic lymphocytic leukemia, the patient should be managed by a hematology/oncology expert. The cutaneous and mucosal manifestations are treated with immunosuppressive drugs and prednisone. Unfortunately, paraneoplastic pemphigus is difficult to treat and the disease has a high morbidity and mortality.

Although the clinical features and medical history of our patient supported a diagnosis of paraneoplastic pemphigus, erythema multiforme should be considered in the differential diagnosis. Erythema multiforme is an acute vesiculobullous disease of unknown pathogenesis.

About half of the cases arise following a herpes simplex or Mycoplasma pneumoniae infection or after exposure to certain drugs, especially antibiotics. Patients typically present with prodromal symptoms of fever, headache, and sore throat before the onset of lesions. Most cases arise in young males before the age of 40.

The clinical severity of the disease varies markedly.

Most patients present with localized involvement of

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the skin and mucous membranes. Cutaneous lesions are erythematous and may be flat and round in shape, or bullous in nature. Target-like lesions are common and characteristic of this disease. Severe involvement may lead to sloughing off of large portions of the skin.

Mucosal lesions are also erythematous but erosions and ulcerations are more common than on the skin. Hemorrhagic crusting on the vermilion surface of the upper and lower lips is often seen. Erythema multiforme is a selflimiting disease that typically resolves in 2-6 weeks.

Despite two nondiagnostic biospy specimens, the clinical findings noted in our patient, along with his age and history of chronic lymphocytic leukemia, were most consistent with paraneoplastic pemphigus. Our patient had no previous history of herpetic or Mycoplasma pneumoniae infections so it is unlikely that his clinical findings were related to erythema multiforme. In addition, it is unlikely that Penicillin was responsible for his cutaneous and mucosal blisters and ulcerations since these symptoms arose 3 weeks before being placed on an antibiotic.

In order to improve the chances for establishing a definitive diagnosis in a case such as ours, it is essential that a biopsy be taken from noninvolved tissue adjacent to active disease. In our case, this was difficult to accomplish because of the marked oral mucosal involvement.

The severity of mucosal and cutaneous involvement in our case necessitated establishing a diagnosis based upon the clinical findings alone.

References 1. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology, 3rd Ed. St. Louis: Saunders/Elsevier, 2009: 769-71.

2. Billet SE, Grando SA, Pittelkow MR. Paraneoplastic autoimmune multiorgan syndrome: review of the literature and support for a cytotoxic role in pathogenesis. Autoimmunity. 2006; 36:617-30.

3. Allen CM, Camisa C. Paraneoplastic pemphigus: a review of the literature. Oral Dis. 2000; 6:208-14.

4. Anhalt GJ. Paraneoplastic pemphigus. J Investig Dermatol Symp Proc. 2004; 9(1):29-33.

5. Edgin WA, Pratt TC, Grimwood RE. Pemphigus vulgaris and paraneoplastic pemphigus. Oral Maxillofac Surg Clin North Am. 2008;20(4):577-84.

6. Zhu X, Zhang B. Paraneoplastic pemphigus. J Dermatol. 2007;34(8):503-11.

g n i rtis

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

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

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

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

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

Briefs

Practice Opportunities MCLERRAN AND ASSOCIATES: AUSTIN: Associate to purchase. High grossing, family practice located in retail center with seven operatories was recently remodeled. Near major freeway.

High growth area. Practice boast solid, well-established patient base. ID #108.

AUSTIN: North, high grossing, five operatory practice in free-standing building. Plenty of room to expand. Fee-forservice patient base, good equipment.

Owner wishes to sell and continue part-time as an associate. ID #115.

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

ID #107.

NEW! CENTRAL TEXAS HILL COUNTRY: Quality, family practice located in the heart of the beautiful hill country. Three op practice grossed mid-six figures. Practice and real estate for sale. Don’t miss out on the chance to live in this growing yet laid back hill country town. ID #117.

RIO GRANDE VALLEY: Excellent four operatory, 20-year-old general practice. Modern, new finish out in retail location with digital radiography. Fee-

for-service patient base and very good new patient count. Great numbers.

Super upside potential. ID #093.

SAN ANTONIO, NORTH WEST: Excellent four-chair general family practice in high traffic retail center across from busy mall location. Solid income on 30 hours a week. Ideal opportunity for doctor wanting a quick start in low overhead operation. ID #086.

SAN ANTONIO — Prosthodontic practice with almost new equipment and build out. Doctor wants to sell and continue to work as associate. Beautiful office! Perfect for stand alone or satellite office. ID #060.

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

ID #009.

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

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.

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

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

Almost new build out, great location, and excellent equipment. Good gross and net. Transition available. ID #113.

SAN ANTONIO, NORTH CENTRAL: Six operatory general practice located in high growth area. All operatories have large windows with great views. Very nice equipment, solid patient base, great hygiene program. Priced to sell. ID #112.

SAN ANTONIO, NORTH CENTRAL: Three operatory office in retail/office center with great visibility and access.

New equipment and nice build out.

Good solid numbers, very low overhead. ID #111.

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

WACO AREA: Modern and high-tech, three op general family practice grossing in mid-six figures with high net income. Large, loyal patient base. Office is well equipped for doctor seeking a modern office. ID #107.

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CORPUS CHRISTI: Doctor retiring, six op office with excellent visibility and access. Good numbers, excellent patient base, good upside potential.

Excellent practice for starting doctor.

Priced to sell. ID #023.

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

ID #106.

SAN ANTONIO: Medical center, four operatory family practice in very nice professional building. Great picture window views. Very nice, modern office, good patient base. Perfect size for starting doctor. ID #67.

NEW! SEGUIN: Three operatory, 30+-year-old practice with condo is priced very aggressively as doctor must sell. Call now to learn more about this great deal. ID #118.

SAN ANTONIO, NORTH CENTRAL: Very nice operatory office in retail center. Near freeway and large shopping areas. Good patient flow. Excellent pricing makes this attractive to starting doctor. ID #119.

HILL COUNTRY, near San Antonio: Five operatory office in high visibility retail center. Excellent equipment, digital pan. Very good gross and net. Doctor relocating for family reasons. Excellent opportunity. ID #120.

CORPUS CHRISTI: Three operatory, fee-for-service/crown and bridge oriented family practice in great location.

High grossing practice on 3-day week!

Doctor ready to retire. Make an offer.

ID #098.

Contact McLerran Practice Transitions, Inc.: statewide, Paul McLerran, DDS, (210) 737-0100 or (888) 6560290; in Austin, David McLerran, (512) 750-6778; in Houston, Tom Guglielmo and Patrick Johnston, (281) 362-1707.

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

ORAL SURGERY PRACTICE FOR SALE, HOUSTON AREA — GARY CLINTON, PMA: Fast growing location. Economy is strong in Texas.

Many referring dentists. Outright sale; seven-figure gross. Seller will work for buyer on limited basis. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation.

Authorized closing agent/escrow agent for numerous financial institutions.

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

GARY CLINTON / PMA BRYAN / COLLEGE STATION PRACTICE FOR SALE. Transition/outright sale. Retiring dentist. Beautiful office; Restorative practice. Well-established recall.

We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the 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 NORTHWEST OF DALLAS FARMERS BRANCH / CARROLLTON AREA PRACTICE FOR SALE: Well-established practice; exceptional recall; full general service practice with lots of crown and bridge. Retiring dentist. Will continue to work as needed 1 day per week. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation.

Authorized closing agent/escrow agent for numerous financial institutions.

Certified appraisals based upon the Texas Dental Journal l www.tda.org l November 2010

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

WE NEED SELLERS! GARY CLINTON / PMA: Serving the dental profession since 1973: I have buyers! Sell your practice and travel while you have your health. In many cases, you can stay on to work 1-2 days per week if you wish. I need practices to sell/transition as follows: Any practice in or near Austin, San Antonio, DFW area, and Houston. Have buyers for orthodontic, oral surgery, periodontic, pedodontic, and general dentistry practices. Values for practices have never been higher. One hundred percent funding available, even those valued at more than seven figures. Call me confidentially with any questions. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions.

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

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ORTHODONTIC PRACTICES FOR SALE / TRANSITION — GARY CLINTON / PMA TEXAS: O-1 West Central Texas mid-sized to larger community — Ideal transition; professional referral based; highly productive.

Gorgeous building with room for two in this planned 50/50 partnership; within 5 years complete buy-out with owner working 1-2 days as needed.

O-2 South Texas — Retiring orthodontist; 100 percent buy-out / transition; seller will stay 1-2 days per week as needed. Seven figure practice collections; 60 percent profits; lovely building. He is ready to spend time with his grandchildren. O-3 Houston/Clear Lake/ South of Houston area —Very nice medium sized practice; doctor retiring; will transition; excellent operating profit. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/ sale. No conflict of interest/dual representation. Authorized closing agent/ escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general).

Very confidential. DFW: (214) 5039696; WATS: (800) 583-7765.

GARY CLINTON / PMA HOUSTON GENERAL PRACTICE FOR SALE: BAYTOWN/CLEAR LAKE/NASA/BAY AREA: Well-established practice. Re-

tiring dentist will transition (limited).

Superb recall care program. Exceptional location with very good lease rate. Minimal PPO. Excellent operating profit after debt service. Facility on freeway frontage road; high visibility. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA MCKINNEY/ FRISCO AREA: MF-1 — Exceptional premier restorative practice; seven figure gross requiring experienced dentist. Newer equipment; attractive facility. MF-2 — Practice in the middle of high growth area off Dallas North Toll. Newer equipment. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation.

Authorized closing agent/escrow agent for numerous financial institutions.

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

GARY CLINTON / PMA ARLINGTON PRACTICE FOR SALE: The pace to be for young families. Well established practice. Excellent recare program.

Near seven figure gross. Garden style offices and operatories. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions.

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

GOLDEN TRIANGLE GENERAL DENTAL PRACTICE — SALE: Outstanding practice for sale developed by published mentor. Supported by outstanding staff and latest in dental equipment. Strong revenues and profit margin. Excellent new patient flow. Given high level of FFS revenues, doctor to transition to comfort level of purchaser. Come build your retirement in low competition community. Contact Texas Dental Journal l www.tda.org l November 2010

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Briefs

The Hindley Group at (800) 856-1955.

Visit us at www.thehindleygroup.com.

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

WEST HOUSTON GENERAL DENTAL PRACTICE — SALE: New, wellappointed office space in fast growing west Houston. Three fully-equipped operatories with two additional rooms plumbed for future use. Strong new patient flow, excellent staff, and highly qualified mentor. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

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

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

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competitiveness of the city, come see this practice. 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.

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

Limited competition and a large facility.

Ample room to grow in this community that is home to Baylor University. All ortho cases are being completed, unless purchaser would like to expand new cases. No Medicaid being seen, but good opportunity with enhanced state fee schedule. Experienced staff and steady new patient flow. Wonderful mentor. Building also available. Contact The Hindley Group at (800) 8561955. Visit us at www.thehindleygroup. com.

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

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

BRYAN/COLLEGE STATION GENERAL DENTAL PRACTICE — SALE: Wellestablished practice in mid-size town.

Four operatories. Healthy revenues, excellent profit margin, and strong new patient flow. Doctor must transition due to health reason. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

EAST TEXAS GENERAL DENTAL PRACTICE — SALE: Well-established practice in small town in hills in East Texas. Moderate revenues on 4 days per week; three operatories; excellent staff. Room to expand in adjusted space. Contact The Hindley Group, LLD, at (800) 856-1955. Visit us at www.thehindleygroup.com.

FORTH WORTH ORTHOTDONTIC PRACTICE — SALE: Excellent opportunity for satellite office; general dentist wanting to add ortho to services offered; female dentist desiring part-time position while children in school; or older dentist wanting to utilize ortho as less physically taxing exit strategy. Doctor will mentor or assist with transition. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

WEST TEXAS GENERAL DENTAL PRACTICE — SALE: Spacious office with five fully-equipped operatories; two additional spaces plumbed for future use. Strong revenues and profit margin. Excellent new patient flow. Eight hygiene days per week. 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. Predetermined purchase and partnership terms. Wonderful mentor looking for an “equally-yoked” individual. Excellent staff. SAN ANTONIO PERIODONTAL AND ENDODONTIST ASSOCIATESHIPS — Periodontal associateship with pre-determined buy-in for very active, multi-office periodontal practice. Endodontist associate also needed in this practice. Outstanding mentor and cohesive staff. If you are the right person, this is an outstanding opportunity. WEST TEXAS GENERAL DENTAL PRACTICE — Associateship with pre-determined buy-in and partnership terms. Nine operatories. Strong mentor and experienced staff. Excellent revenues and profit margin. Large Medicaid component. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

HOUSTON AREA PRACTICE FOR SALE: Profitable practice for sale.

Well-established. Call Jim Robertson at (713) 688-1749.

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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-ofthe-line Pelton and Crane equipment, digital X-rays, and intra-oral cameras.

We are 70 percent PPO, 30 percent full fee. We take no managed care or Medicaid. We offer competitive salaries and benefits. To learn more about working for Dental One, please contact Rich Nicely at (972) 755-0836.

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

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) 3154584 or e-mail ycsongdds@yahoo.com.

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FOR SALE — BRENHAM DENTAL OFFICE: Attractive building in the center of three vacant, landscaped lots; 1,500 sq. ft., free-standing building with three large operatories, large lab, and storage area. Office is fully equipped with many amenities and in a high traffic, rapid growing area.

Building has been a dental office for many years. Ideal for a second dental location, a dentist who wants to slow down, or a dentist who wants a fulltime practice. For more information, call (979) 836-2880.

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

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

AUSTIN: Unique opportunity. Associateship and front-office position available for husband/wife team.

Southwest Austin, Monday through Thursday. Option to purchase practice in the future. Send resume and questions to newsmile@onr.com.

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

Practice references available from local specialists. Contact Dr. Richard Krumholz, (409) 762-4522.

EL PASO: FULL- OR PART-TIME ASSOCIATE NEEDED. Would be sole practitioner at location. Three opera-

tories 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@gmai1.com.

ASSOCIATE FOR LARGE GENERAL PRACTICE — NE SAN ANTONIO AREA: Motivated general dentist needed for expanding private practice.

Expansion to 10 operatories to be complete June 2009. Located in Universal City near Randolph AFB. Marketed as family practice, fee-for-service. Delivers Straight-wire Orthodontics / Invisalign, CEREC on site. Very large, active hygiene recall program. High new patient flow. Great opportunity for qualified candidate with future buy-in interest. Henslee Dental Team, established 1971. Contact Dr. Henslee at henslee@ satx.rr.com or (210) 658-3131.

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.

PRACTICE OWNER IN LUBBOCK is searching for a full-time associate dentist. Ideal candidate is comfortable performing extractions; interest in implants is a plus. No nights or weekends. Full-time package includes generous base salary, bonus potential and generous benefits plan to include free medical malpractice, CE and a 401K Texas Dental Journal l www.tda.org l November 2010

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plan with matching funds. Call or email Mike to learn more. Practice visit and working interviews are available.

The right dentist can start immediately. Call (800) 313-3863 x 2276.

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

TEXAS GULF COAST: Five blocks from the beach. Two operatory satellite office with no competition. Good income, low overhead, perfect starter or retirement office. Priced to sell, (361) 205-4360.

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 can-

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

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

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

GREAT OPPORTUNITY FOR A PEDIATRIC DENTIST OR GP to join our expanding practice. We are opening a new practice in the country (Paris, Texas), just 1 hour past the Dallas

suburbs and our original location.

The need for a pediatric dentist out there is tremendous, and we are the only pediatric office for 70 miles in any direction. We are looking for someone that is personable, caring, energetic, and loves a fast-paced working environment in a busy pediatric practice.

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

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

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

ASSOCIATE SUGAR LAND AND CYPRESS: Large well-established practice with very strong revenues is seeking an associate. Must have at least 2 years experience and be motivated to learn and succeed. FFS and PPO practice that ranks as one of the top practices in the nation. Great mentoring opportunity. Possible equity position in the future. Base salary guarantee with high income potential.

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

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

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

THRIVING PRACTICE IN GALVESTON providing the best of both worlds ... the great outdoors and a laid back lifestyle, yet quick access to metropolitan Houston. This 15-year-old practice has three fully equipped operatories, private office, 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.

LUBBOCK — GENERAL PRACTICE: Associate/partner. Growing group practice is looking for a motivated, long-term, career-minded dentist to provide quality care for our estab-

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lished and tremendous number of new patients. Experienced or new grad welcome. E-mail at dentist.lubbock@ gmail.com.

HOUSTON MEDICAL CENTER GENERAL PRACTICE: Practice dentistry the way you have always dreamed!

Incredible opportunity for general dentist to work as an associate and transition to partnership in this prestigious Texas Medical Center/Houston, four general dentists, LLP practice.

Doctor retiring in 2-4 years after a 40+year career, and wills stay for introductions and successful transition of a new dentist. Large number of loyal patients in recare. The office, located in Smith Tower of The Methodist Hospital, is convenient to the West University, Bellaire, River Oaks, and Mid-Town neighborhoods and is the beneficiary of referrals from physicians practicing in the Medical Center. State-of-the-art clinical and business systems throughout, including professional management, contemporary equipment, and an in-house dental laboratory staffed by three talented lab techs. See our website, www.ddsassociates.com, for more information, and direct any inquires to Ms. Sanders or Ms. Manovich at (713) 797-0846.

SAN ANGELO, ABILENE: Associates — outstanding earnings. Historically proven at over twice the national average for general dentists; future potential even greater. Thriving, established practice in great location. Bright and spacious facility. Experienced, effi-

cient, loyal staff. Best of all worlds; big city, earnings, small-town easy lifestyle, outstanding outdoor recreation.

Contact Dr. John Goodman at john@ goodman.net or (325) 277-7774.

ARLINGTON ORAL SURGERY PRACTICE — SALE: Oral and maxillofacial practice for sale in Arlington. It is located in a three unit professional office building and has two other dentists and an orthodontist. The building and office interior are very attractive and situated in a good area with a large referral base locally and the DFW area.

This would be a good opportunity if you are seriously considering purchasing your own practice at an attractive price. If you would like any further information, call (817) 917-4536 or email at aosapa2010@gmail.com.

A CASUAL COASTAL LIFESTYLE AND YEAR-ROUND GOLF, TENNIS, FISHING, AND OTHER WATER SPORTS are appealing parts of this compatible, quality-oriented group practice in Corpus Christ!. If you are a general dentist interested in hassle-free dentistry in a busy, growing organization, this is an excellent opportunity to prosper. Please call Cathy at (361) 993-9551 or e-mail resume to apple4ccassels@sbcglobal.net.

ASSOCIATE DENTIST NEEDED IN EULESS: Well-established general practice seeking full-time associate/ future partner. Cosmetic and full family practice. Please send resume to wendy.tcd@sbcglobal.net.

TWO-YEAR DENTAL ASSOCIATESHIP — EL PASO: We are a quality children’s dental office employing general dentists and dental anesthesiologists. Pay per year for 2-year agreement equals generous six-figure income. Salaries on percentage based commissions. Will train in oral sedation. Ownership opportunities available. Send resume to info@ txkidsdental.com. Call (915) 858-6868.

ESTABLISHED, SUCCESSFUL GENERAL PRACTICE AVAILABLE FOR OWNERSHIP with no personal financial investment. Niche market limited to removable prosthetics and related services. Guaranteed minimum salary plus unlimited potential from net profits. Full benefits package. Onsite lab. Monday through Friday, 8 a.m. to 5 p.m. Professional gratification, personal rewards. E-mail michele.cooke@ affordablecare.com.

GREAT OPPORTUNITY FOR ORTHODONTISTS AND GENERAL DENTISTS to join our busy practices providing orthodontic care in the Rio Grande Valley area. We are looking for orthodontists to oversee all aspects of patient care and general dentists to work in coordination with our orthdontists to be able to provide the highest quality care for our patients. Be a part of our exceptional team helping the children of Texas get great smiles.

Please contact Dr. Hal D. Lerman at (214) 789-4601 or e-mail to nflq21b@ swbell.net.

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AUSTIN — PEDIATRIC DENTISTS NEEDED FOR A VERY UNDERSERVED CITY. Established practice looking for associates leading to potential partnerships. Modern digital office. Please e-mail CV to cespilares@ sbcglobal.net.

ASSOCIATE/OWNERSHIP OPPORTUNITY: Why deal with the rat race of a big city? Come on out to east Texas and a superior way of life. Raise your kids in a community that cares for each other and has tremendous price.

Privately owned general dental practice in Sulphur Springs (80 miles east of Dallas) is searching for a dentist to join our team. We need an excellent, motivated doctor to add to our growing practice as we serve our loyal patients.

Completed just a year ago, our 5,400 sq. ft. office boasts nine operatories with state-of-the-art technology in order to do more dentistry than any city office can offer. We built “green” as well with solar, geothermal, and recycled glass, just to name a few. Fee-forserivce and select PPOs only, no DM0 or Medicaid. Please contact Todd at todd@tkeeter.com or (214) 679-5318.

KATY: Dr. Bui X. Dinh, D.D.S., M.S. is looking for a dentist right now with minimum 2 years experience. Please contact office manager Michelle, (832) 620-6982 or fax resume to (281) 5796045.

FOR SALE — GREAT 41-YEAR SUCCESSFUL PRACTICE IN SOUTH CENTRAL TEXAS. Owner retiring but will stay through transition period.

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Five operatories in beautiful building, Pan-0, digital X-ray. Experienced long-term dependable staff. Room for multiple dentists. Please mail letter of interest to Box 1, TDA, 1946 S. IH 35, Ste. 400, Austin, TX 78704.

SEEKING ASSOCIATE: Established general dental office in Brownsville (30 minutes away from South Padre Island) is seeking a caring, energetic associate. We are a busy office providing dental care for mostly children. Our know led gable staff will support and enhance growth and earning potential allowing the associate to focus on patient dental care. Interested candidates should call (956) 546-8397.

PRACTICE OF THE MONTH, DALLAS OPPORTUNITY OF A LIFETIME! This practice says you have made it.

No “spa dentistry” gimmick here! Just patient-centered focus and pampering to the extreme. Associate doctor is relocating, creating a lucrative void for a friendly, confident, and clinically qualified and capable GP. All the bells and whistles, including Laser and iTero. Associateship/partnership inti ti ally with full ownership in the future.

Your passion for patients, dedication to perfection, and “magic” hands will make you a strong candidate for consideration. Strong finances expected by seller if you join. Call (214) 893-0410.

FULL-TIME GENERAL DENTIST NEEDED FOR ESTABLISHED PRACTICE IN FLOWER MOUND. Residency or experience preferred. Buy-in opportunity if desired. Call (972) 381-1888.

HOUSTON PRACTICE IN HIGH TRAFFIC AREA. Established dental office for over 40 years. Incredible opportunity for general dentist to work as an associate and transition to partnership or just work full-time/part-time. Location is convenient to downtown and Medical Center. Please send resume to gonzalez_dental@yahoo.com. For more information, please call (713) 6440234.

OUR TWO-DOCTOR PARTNERSHIP IS SEEKING A FULL-TIME ASSOCIATE, rapidly leading to partnership/ ownership. Since 1976, we have had an excellent reputation in our community, 30 minutes east of downtown Houston. We offer oral sedation and anesthesiologist administered IV sedation. No HMOs, PPOs, or Medicaid.

Please e-mail resume to triptray@ gmail.com or fax to (281) 427-7127.

NEW, TYLER: Excellent opportunity, location, and lifestyle. Join an established doctor and share a 2-year-old, free-standing, award-winning building on busy south Tyler Street. Five of 10 ops and private office available. Share reception, lab, and sterilization. Equity position in property available or lease.

E-mail dburrow@suddenlinkmail.com.

Position Wanted

TEMPLE DENTAL CENTER IN TEMPLE TEXAS IS FOR SALE: Doctor changing professions. Firesale! Four operatories, tons of equipment and instruments, three wall X-rays (film just needs sensors to convert), Panorex (also easily converted) Velopex processor. Call (254) 791-0977 and leave message. E-mail doctorbrown80@ hotmail.com.

PEDIATRIC DENTAL OFFICE IN THE RIO GRANDE VALLEY IS SEEKING FULL-TIME GENERAL, PEDIATRIC, OR NEW GRADUATES to join our team. We offer a percentage on production, but negotiable. Please send resume to pwilcoxdent4kids@yahoo. com or contact Martha Wilcox at (956) 686-8611.

M.A.G.D.-TRAINED G.P. RELOCATING TO AMARILLO AFTER 28 YEARS OF PRIVATE PRACTICE IN HOUSTON. Extensive experience in all phases of general dentistry. Have enteral conscious sedation permit for oral surgery and implant placement. Seeking position as an associate equity partner and/ or purchase. Contact docjenk@netzero. com, (713) 981-7371 home, (281) 7770608 cell.

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

ORTHODONTIST NEEDED NEXT TO DENTIST IN HIGH GROWTH, HIGH TRAFFIC AREA IN ROUND ROCK, north of Austin in one of the fastestgrowing counties. Available at $155/ sq. ft. For more information, e-mail Texas Dental Journal l www.tda.org l November 2010

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john@herronpartners.com or call (512) 457-8206.

SHERMAN — 1,750 SQ. FT. DENTAL OFFICE. Building has established general dentist and perio/implant dentist. Plumbed and ready to go. High traffic and visibility with lots of parking. Sherman is beautiful and growing town 50 miles north of Dallas and near Lake Texoma, the second largest lake in Texas. It has great schools, a vibrant arts community, and is home to many, many Fortune 500 companies such as Texas Instruments and Tyson Foods. Call (760) 436-0446.

ALLEN — 1,885 SQ. FT. DENTAL OFFICE available September 2010. High traffic visibility with lots of parking.

Established dentist. Five treatment rooms plumbed and ready; reception, office, conference room, two bath. Alien is one of the top five growing cities in Texas. Affluent residential, average income $98,500 within 3 miles. Contact Levin Reality, (323) 954-1934.

ROUND ROCK — DENTAL SPACE AVAILABLE FOR LEASE: 323 Lake Creek, 2,032 sq. ft. Lease rate is $18 PSF + $6.50. PSF NNN. Existing air lines and plumbing. Call Darren Quick, (512) 255-3000.

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

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

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

ROCKWALL FOR LEASE: Three to 4 days per week, fully furnished and equipped orthodontic/pediatric office in one of the fastest growing counties in the country. High visibility location, call (469) 951-5554 or e-mail rcppersonal@sbcglobal.net.

CLEAR LAKE CITY — 2,000 SQ. FT. DENTAL SPACE AVAILABLE FOR LEASE: Relocate your existing practice for more space. Plumbing for dental with reception, private office, lab space and two bath. Call (281) 488-5815.

ARLINGTON DENTAL OFFICE FOR LEASE: Current doctor is only using 1 day a week. Has four up-to-date operatories with HD TVs in each op, assistant computer, doctor computer, Casey educational system, digital X-rays, digital panoramic machine, electric handpiece, sterilization room, laboratory, and Cerec CAD/CAM technology. Perfect for new practice start up. Visit our website to view our office.

Contact (817) 274-8667, info@docdds. com, www.docdds.com.

NORTHWEST AUSTIN ESTABLISHED DENTAL SPACE below market, busy main street, many schools, and Rooftops nearby. Good signage, four ops,

recently vacated, partially equipped, plumbed, and ready. Owner eager to lease, (512) 833-5300.

For Sale FOR SALE — FOUR USED WESTAR DENTAL CHAIR PACKAGES. Only used 1 year; $2,500 each. E-mail doctorbrown@hotmail.com for photos.

ESTABLISHED, FULLY EQUIPPED THREE OPERATORY LAB FOR SALE OR LEASE in Plainview. High visibility location. Seller retiring. Mentor to transition possible. Call (806) 2932686 or (806) 292-3156.

LARGE INVENTORY OF QUALITY REFURBISHED AIR DRIVEN DENTAL HANDPIECES. All have been repaired and tested by a qualified technician. All have new ceramic bearing turbines and all are fiberoptic. For sale — Star 430 SWL, $269; Kavo 640B, $279; Kavo 642B, $299; Kavo 647B, $299; Midwest Tradition push button or lever, $239; new Kavo multi-flex coupler five-hole, $249; new Kavo coupler six-hole, $149; new Star coupler fivehole, $145. Slow speed and implant handpieces available, too. Quality, discounts are possible. I have been a TDA member for 25 years. If what you are looking for is not on this list, we stock a wide variety at wonderful prices, just inquire. Call (877) 863-9938 or visit our website, www.truespindental.com.

USED GENDEX ORTHORALIX 8500 FILM-BASED PANORAMIC X-RAY machine with one Kodak Lanex cas-

sette. Only 5 years old. Was in excellent working order when stored, $7,995.

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

Short-notice coverage, personal, maternity, and disability leaves our specialty.

Free, no obligation quotes. Absolute confidentiality. Trusted integrity since 1996. Some of our team seek regular part-time, permanent, or buy-in opportunities. Always seeking new dentists to join the team. Bread and butter procedures. No cost, strings, or obligations —ever! Work only when you wish. Name your fee. Join online at www.doctorsperdiem.com. Phone: (800) 600-0963; e-mail: docs@doctorsperdiem.com.

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

Miscellaneous GALVESTON: The Division of Oral and Maxillofacial Surgery at The University of Texas Medical Branch-Galveston is accepting applications for full-time assistant professor/associate professor in The Department of Surgery. Position Texas Dental Journal l www.tda.org l November 2010

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includes supervision and teaching of graduate level residents, participation in faculty practice, and research. Candidate is to have full scope experience.

Candidates must have a dental degree, have completed an approved OMS residency, be eligible for licensure in Texas, and be board certified or an active candidate for certification. Salary and academic rank is to be commensurate with experience and qualifications. Please submit letter of application and current curriculum vitae to: Roger R. Throndson DDS, Associate Professor and Program Directory, Division of Oral and Maxillofacial Surgery,

Department of Surgery, The University of Texas Medical Branch-Galveston, 301 University Blvd., Galveston, TX 77555-0527. UTMB is an equal opportunity, affirmative action institution which proudly values diversity. Candidates of all backgrounds are encouraged to apply.

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

SEEKING BUSINESS-MINDED DENTISTS TO INVEST IN AN ONLINE MARKETPLACE that makes practice sales and staff placement no charge.

How’s that possible? It’s advertiser supported. That will change everything, won’t it? How would you compete against “no charge”? Here’s how to profit from practice sales and staff placement: eliminate all the other middlemen. Download the demo of this disruptive digital platform at acolleague.com and see this gamechanging idea. First dentistry, then medicine. Investors and questions welcome, (347) 746-0017; e-mail: jeff@ acolleague.com; or visit www.acolleague. com.

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AMARILLO: SEEKING FULL-TIME DENTIST TO WORK IN STATE CORRECTIONAL SETTING. We offer flexible work schedule, excellent state benefits, retirement, and a very competitive salary without the financial challenges faced in a private practice.

Contact the dental director at (806) 381-7080 x 8301; e-mail at mack. hughes@ttuhsc.edu; or visit the job site at http://jobs.texastech.edu.

TEXAS ASSOCIATESHIP PLACEMENT SERVICES — GP & SPECIALIST: You pick the compensation: salaries, compensation, earned equity to buy into practice. Convenient Friday and Saturday interviews in Dallas; no placement fees. Please outline your specific goals in a cover letter with your resume attached. Send to info@ officenetworkusa.com.

PER DIEM INC

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

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

Statewide Toll-free Helpline 800-727-5152 Emergency 24-hour Cell: 512-496-7247

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

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

Ace on Hold (TDA Perks) ....................................1219 ADS Watson, Brown & Associates ....................1219 AFTCO ..................................................................1221 A.J. Riggins Co ....................................................1244 American Academy of Dental Practice Administration ................................................1193 American Dental Association.............................1221 Anesthesia Education and Safety Foundation ...............................................1183/1194 Bright Now ...........................................................1161 Crown Dental Studio ...........................................1154 Dallas County Dental...........................................1224 DDR Dental Trust .................................................1207 Dental Practice Specialists.................................1212 Doctors Per Diem ................................................1245 Fortress Insurance ..............................................1154 Greater Houston Dental ......................................1186 Hanna, Mark — Attn. at Law ...............................1206 Henderson, Sherri L. & Associates....................1185 Hindley Group......................................................1215 Houston Academy of General Dentistry............1184 JKJ Pathology......................................................1211 JLT Energy Consultants .....................................1155 Kennedy, Thomas John, D.D.S., P.L.L.C............1221 Medical Protective ...............................................1147 Ocean Dental........................................................1151 Orthodontic Technologies ..................................1215 Paragon, Inc. ........................................................1207 Patterson Dental ..........................Inside Front Cover Practice Management Associates......................1153 Professional Recovery Network................1174/1246 Professional Solutions........................................1172 Robertson, James M ...........................................1160 Sharp & Cobos.....................................................1224 Shepherd, Boyd Wilson ......................................1219 Southern Dental Associates...............................1173 SPDDS ..................................................................1206 TDA Express ........................................................1213 TDA Financial Services Insurance Program........................................1159/Back Cover TDA Perks Program..................... Inside Back Cover Texas Dental Network .........................................1212 Texas Medical Insurance Company ...................1164 TEXAS Meeting ....................................................1159 TVMA ....................................................................1160 UTHSCSA .............................................................1160 Waller, Joe............................................................1213

Better Freedom-of-Choice, No-Network Dental Insurance for your Patients!  Immediate Preventative (up to $100, Twice Yearly)  Immediate Basic and/or Major (at 50% of Fee Schedule)  12 Months and Longer = 100% of Fee Schedule!

For more information, visit www.dentalquick.com or call: Dental Insurance from Assurant Health. Assurant Health is the brand name for products underwritten and issued by Time Insurance Company.

(888) 350-2416 Texas Dental Journal l www.tda.org l November 2010

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

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

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

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• Or visit a Liberty Mutual office near you

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

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