December 2023 Texas Dental Journal

TDA

Texas Dental Journal DECEMBER 2023 584 TDA MEETING PREVIEW: HOW TO HAVE DIFFICULT CONVERSATIONS! SPEAKER: JUDY KAY MAUSOLF

588 OCCLUSAL CARIES DETECTION ON 3D MODELS OBTAINED WITH AN INTRAORAL SCANNER: A VALIDATION STUDY P. NTOVAS S. MICHOU A.R. BENETTI A. BAKHSHANDEH K. EKSTRAND C. RAHIOTIS A. KAKABOURA Originally printed in the Journal of Dentistry 131 (2023) 104457

599 TDA SMILES FOUNDATION ANNUAL REPORT

www.tda.org | December 2023

573

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(Insurance, Dental Benefits, & Marketing)

574 Texas Dental Journal | Vol 140 | No. 10

®

Anesthesia Education & Safety Foundation Two ways to register: Call us at 214-384-0796 or e-mail us at sedationce@aol.com Visit us on the web: www.sedationce.com

NOW Available: In-Office ACLS & PALS renewals; In-Office Emergency Program

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Two ways to Register for our Continuing Education Programs: e-mail us at sedationce@aol.com or call us at 214-384-0796

OUR GOAL: To teach safe and effective anesthesia techniques and management of medical emergencies in an understandable manner.

WHO WE ARE: We are licensed and practicing dentists in Texas who understand your needs, having provided anesthesia continuing education courses for 34 years. The new anesthesia guidelines were recently approved by the Texas State Board of Dental Examiners. As practicing dental anesthesiologists and educators, we have established continuing education programs to meet these needs.

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New TSBDE requirement of Pain Management Two programs available (satisfies rules 104.1 and 111.1) Live Webcast (counts as in-class CE) or Online (at your convenience)

All programs can be taken individually or with a special discount pricing (ask Dr. Canfield) for a bundle of 2 programs:

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Use and Abuse of Prescription Medications and Provider Prescription Program Fulfills rules 104.1 and 111.1

SEDATION & EMERGENCY PROGRAMS: Nitrous Oxide/Oxygen Conscious Sedation Course for Dentists:

Credit: 18 hours lecture/participation (you must complete the online portion prior to the clinical part)

Level 1 Initial Minimal Sedation Permit Courses:

*Hybrid program consisting of Live Lecture and online combination Credit: 20 hours lecture with 20 clinical experiences

SEDATION REPERMIT PROGRAMS: LEVELS 1 and 2 (ONLINE, LIVE WEBCAST AND IN CLASS) ONLINE LEVEL 3 AND 4 SEDATION REPERMIT AVAILABLE!

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WEBCASTING and ONLINE RENEWALS AVAILABLE! Live and archived webcasting to your computer in the comfort of your home.

Here are the distinct advantages of the webcast (contact us at 214-384-0796 to see which courses are available for webcast): 1. You can receive continuing education credit for simultaneous live lecture CE hours.

2. There is no need to travel to the program location. You can stay at home or in your office to view and listen to the course.

3. There may be a post-test after the online course concludes, so you will receive immediate CE credit for attendance 4. With the webcast, you can enjoy real-time interaction with the course instructor, utilizing a question and answer format

OUR MISSION STATEMENT: To provide affordable, quality anesthesia education with knowledgeable and experienced instructors, both in a clinical and academic manner while being a valuable resource to the practitioner after the programs. Courses are designed to meet the needs of the dental profession at all levels.

Our continuing education programs fulfill the TSBDE Rule 110 practitioner requirement in the process to obtain selected Sedation permits.

AGD Codes for all programs: 341 Anesthesia & Pain Control; 342 Conscious Sedation; 343 Oral Sedation This is only a partial listing of sedation courses. Please consult our www.sedationce.com for updates and new programs.

Two ways to Register: e-mail us at sedationce@aol.com or call us at 214-384-0796 www.tda.org | December 2023

575

contents FEATURES

HIGHLIGHTS

584 TDA MEETING PREVIEW

580

Official Call for Nominations

582

TDA Grant Availability

610

Oral and Maxillofacial Pathology: Case of the Month

HOW TO HAVE DIFFICULT CONVERSATIONS! SPEAKER: JUDY KAY MAUSOLF

588 OCCLUSAL CARIES DETECTION ON 3D MODELS OBTAINED WITH AN INTRAORAL SCANNER: A VALIDATION STUDY

612

Jacqueline M. Plemons, DDS, MS, Editor Juliana Robledo, DDS, Associate Editor Nicole Scott, Managing Editor Barbara Donovan, Art Director Lee Ann Johnson, CAE, Director of Member Services

Editorial Advisory Board Ronald C. Auvenshine, DDS, PhD Barry K. Bartee, DDS, MD Patricia L. Blanton, DDS, PhD William C. Bone, DDS Phillip M. Campbell, DDS, MSD Michaell A. Huber, DDS Arthur H. Jeske, DMD, PhD Larry D. Jones, DDS Paul A. Kennedy, Jr., DDS, MS Scott R. Makins, DDS, MS Daniel Perez, DDS William F. Wathen, DMD

614

P. Ntovas, S. Michou, A.R. Benetti, A. Bakhshandeh, K. Ekstrand, C. Rahiotis, A. Kakaboura

Value for Your Profession: Thinking of Transitioning to Practice Ownership? Here are

Robert C. White, DDS Leighton A. Wier, DDS Douglas B. Willingham, DDS

Good Reasons to Choose This Path.

Originally printed in the Journal of Dentistry 131 (2023) 104457

599 TDA SMILES FOUNDATION ANNUAL REPORT

Oral and Maxillofacial Pathology: Case of the Month Diagnosis and Management

Editorial Staff

The Texas Dental Journal is a peer-reviewed publication.

Established February 1883 • Vol 140 | No. 10

616

Classifieds

622

Index to Advertisers

Texas Dental Association 1946 S IH-35 Ste 400, Austin, TX 78704-3698 Phone: 512-443-3675 • FAX: 512-443-3031 Email: tda@tda.org • Website: www.tda.org Texas Dental Journal (ISSN 0040-4284) is published monthly except January-February and August-September, which are combined issues, by the Texas Dental Association, 1946 S IH-35, Austin, TX,

About the Cover The History of Cuetlaxochitl (Commonly known as the Poinsettia) La Cuetlaxochitl was originally sacred to the Nahuati-speaking and Aztec cultures, and it’s still used in decorative and medicinal ways today among the Teenek Indians in southeastern Mexico.

It holds seasonal religious significance as well because it blooms during the winter solstice, the birthday of Huitzilopochtli, the god of sun and war.

“The Aztecs found many uses for the plant,” horticulture educator Jennifer Fishburn wrote in an article for the University of Illinois Urbana-Champaign Extension program.

“The cuetlaxochitl was a symbol of the new life earned by warriors who died in battle. They also used the plant’s red bracts to make a reddish-purple dye used in textiles and cosmetics. They crushed and applied the plant to skin infections, or placed plant parts on a person’s chest to stimulate circulation.”

In the 16th century, Spanish Franciscan friars began using it in nativity processions, calling it la flor de la nochebuena, or Flower of the Holy Night. Many new legends began around the plant and Indigenous celebrations gave way to Christmas, but the plant’s seasonal significance remained.

How To Say “Cuetlaxochitl” Cuetlaxochitl is pronounced, roughly, kwet-la-sho-she. Pronunciation sites provide variations.

Source: https://www.familyhandyman.com/article/history-of-the-cuetlaxochitl-poinsetta/

576 Texas Dental Journal | Vol 140 | No. 10

78704-3698, 512-443-3675. PeriodicalsPostage Paid at Austin, Texas and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S IH 35 Ste 400, Austin, TX 78704. Copyright 2023 Texas Dental Association. All rights reserved.

Annual subscriptions: Texas Dental Association members $17. Instate ADA Affiliated $49.50 + tax, Out-of-state ADA Affiliated $49.50.

In-state Non-ADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA Affiliated, $17 Non-ADA Affiliated. For in-state orders, add 8.25% sales tax.

Contributions: Manuscripts and news items of interest to the membership of the society are solicited. Electronic submissions are required. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. For more information, please refer to the Instructions for Contributors statement included in the online September Annual Membership Directory or on the TDA website: tda.org. All statements of opinion and of supposed facts are published on authority of the writer under whose name they appear and are not to be regarded as the views of the Texas Dental Association, unless such statements have been adopted by the Association. Articles are accepted with the understanding that they have not been published previously. Authors must disclose any financial or other interests they may have in products or services described in their articles.

Advertisements: Publication of advertisements in this journal does not constitute a guarantee or endorsement by the Association of the quality of value of such product or of the claims made.

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www.tda.org | December 2023

577

Board of Directors Texas Dental Association PRESIDENT Cody C. Graves, DDS 325-648-2251, drc@centex.net PRESIDENT-ELECT Georganne P. McCandless, DDS 281-516-2700, gmccandl@yahoo.com PAST PRESIDENT Duc “Duke” M. Ho, DDS 281-395-2112, ducmho@sbcglobal.net VICE PRESIDENT, SOUTHWEST Richard M. Potter, DDS 210-673-9051, rnpotter@att.net

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SENIOR DIRECTOR, NORTHWEST Stephen A. Sperry, DDS 806-794-8124, stephenasperry@gmail.com SENIOR DIRECTOR, NORTHEAST Mark A. Camp, DDS 903-757-8890, macamp1970@yahoo.com SENIOR DIRECTOR, SOUTHEAST Laji J. James, DDS 281-870-9270, lajijames@yahoo.com DIRECTOR, SOUTHWEST Melissa Uriegas, DDS 956-369-9235, meluriegas@gmail.com DIRECTOR, NORTHWEST Adam S. Awtrey, DDS 314-503-4457, awtrey.adam@gmail.com DIRECTOR, NORTHEAST Drew M. Vanderbrook, DDS 214-821-5200, vanderbrookdds@gmail.com DIRECTOR, SOUTHEAST Matthew J. Heck, DDS 210-393-6606, matthewjheckdds@gmail.com SECRETARY-TREASURER* Carmen P. Smith, DDS 214-503-6776, drprincele@gmail.com SPEAKER OF THE HOUSE* John W. Baucum III, DDS 361-855-3900, jbaucum3@gmail.com PARLIAMENTARIAN** Glen D. Hall, DDS 325-698-7560, abdent78@gmail.com EDITOR** Jacqueline M. Plemons, DDS, MS 214-369-8585, drplemons@yahoo.com LEGAL COUNSEL Carl R. Galant *Non-voting member **Non-voting

578 Texas Dental Journal | Vol 140 | No. 10

Terry Watson, D.D.S.

Jeremy Brown, J.D.

Frank Brown, J.D., LL.M.

Free Dental Practice Valuation Take the 1st step in selling your dental practice.

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469-222-3200 www.tda.org | December 2023

579

OFFICIAL CALL FOR NOMINATIONS OFFICIAL CALL FOR CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS: SPEAKER OF THE HOUSE, SECRETARY-TREASURER, AND EDITOR OFFICIAL CALL FOR SPEAKER OF THE HOUSE CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS

6.

To appoint members of reference committees in consultation with the president, president-elect, and the immediate past president by the Board of Directors’ first meeting of the calendar year.

7.

To notify the divisional officers and the Committee on Credentials, Rules and Order, prior to the annual session,

Candidacy announcements for the statewide elective office

the number of delegates and alternates necessary to

of Texas Dental Association (TDA) Speaker of the House may

constitute a quorum.

be submitted to TDA Secretary-Treasurer Dr Carmen P Smith

8.

To meet with the divisional officers prior to the meeting

for the upcoming 2024 House elections. Only an active, life,

of the divisional caucuses at the annual session to review

or retired member in good standing of this Association shall

the Rules for Caucus Procedures, Nominations, And

be eligible. A curriculum vitae (CV) must be submitted, and

Elections.

the candidate will also have to sign a conflict of interest statement. Nominations are in order at the first meeting of the House of Delegates and remain open until the close of

9.

To appoint a parliamentarian pro tem, should it become necessary for the parliamentarian to be absent during a session of the House of Delegates.

the second meeting of the House of Delegates; however,

10. To serve as presiding officer of the TDA Candidates

announcements of candidacy should be made as early as

Forum, unless the Speaker is in a contested race, at

possible so that membership eligibility may be verified. To

which time the Speaker Pro-tem will preside.

become a nominee, a delegate must place the name of the candidate in nomination at the first meeting of the House

11. To be a certified parliamentarian or be in the process of certification

of Delegates. Please see the Manual on Caucus, Campaigns, Nominations and Elections at tda.org for full details.

Candidacy announcements are to be mailed to TDA Secretary-Treasurer Dr Carmen P Smith, Texas Dental

Duties of the Speaker of the House are enumerated in the

Association, 1946 S IH-35 Ste 400, Austin, Texas 78704; or,

Bylaws and include the following (excerpt):

emailed to TDA Executive Director Linda Brady: lbrady@

1.

tda.org.

To serve as an ex-officio member of the Board of Directors without vote or the privilege of proposing

2.

resolutions.

(See TDA Bylaws, Chapter IV, House of Delegates—Sections

To serve as an ex-officio member of the Executive

100 (Officers), 110A (Duties), 150C(3), 150D, Chapter V, Board

Committee without vote or the privilege of proposing

of Directors—Sections 10 (Composition); TDA House Manual;

resolutions.

Speaker Manual).

3.

To preside at all meetings of the House of Delegates.

4.

To determine the order of business for all meetings, subject to the approval of the House of Delegates, in accordance with Section 140B of this chapter.

5.

To appoint tellers to assist him/her in determining the result of any action taken by vote.

580 Texas Dental Journal | Vol 140 | No. 10

OFFICIAL CALL FOR SECRETARY-TREASURER CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS

Candidacy announcements are to be mailed to TDA

Candidacy announcements for the statewide elective office

70A-B (Notice and Publication-Official Call & Publication of

of Texas Dental Association (TDA) Secretary-Treasurer may be submitted to TDA Secretary-Treasurer Dr Carmen P Smith for the upcoming 2024 House elections. Only an active, life, or retired member in good standing of this Association shall be eligible. A curriculum vitae (CV) must be submitted, and the candidate will also have to sign a conflict of interest

Secretary-Treasurer Dr Carmen P Smith, Texas Dental Association, 1946 S IH-35 Ste 400, Austin, Texas 78704; or, emailed to TDA Executive Director Linda Brady: lbrady@ tda.org.

(Ref. TDA Bylaws, Chapter IV, House of Delegates—Sections Actions, 110B (Duties); Chapter V, Board of Directors—Sections 10 (Composition), 80B (Officers-Secretary); Chapter VI, Elective Officers—Section 90G (Duties); Chapter VIII, Fifteenth Trustee District American Dental Association Delegates and Alternate Delegates—Section 80 (Delegation Secretary); Board Manual; Secretary-Treasurer Manual).

statement. Nominations are in order at the first meeting of the House of Delegates and remain open until the close of nominations at the end of the second meeting of the House of Delegates; however, announcements of candidacy should be made as early as possible so that membership eligibility can be verified. To become a nominee, a delegate must place the name of the candidate in nomination at the first meeting

OFFICIAL CALL FOR EDITOR CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS

of the House of Delegates. Please see the Manual on Caucus, Campaigns, Nominations and Elections at tda.org for full

Candidacy announcements for the statewide elective office

details.

of Texas Dental Association (TDA) Editor may be submitted to TDA Secretary-Treasurer Dr Carmen P Smith for the

Duties of the TDA Secretary-Treasurer are enumerated in the

upcoming 2024 House elections. Only an active, life, or

Bylaws and include the following (excerpt):

retired member in good standing of this Association shall

1.

To serve without vote as member of the Board of

be eligible. A curriculum vitae (CV) must be submitted, and

Directors and the House of Delegates.

the candidate will also have to sign a conflict of interest

2.

To serve without vote as chair of the Budget Committee.

statement. Nominations are in order at the first meeting of

3.

To examine the income and expenses of this Association

the House of Delegates and remain open until the close of

and report at each meeting of the Board of Directors.

nominations at the end of the second meeting of the House

To ensure that the minutes of the House of Delegates

of Delegates; however, announcements of candidacy should

and the Board of Directors be maintained.

be made as early as possible so that membership eligibility

To be responsible and perform such other duties as shall

can be verified. To become a nominee, a delegate must place

be specified by the Board of Directors and the Bylaws.

the name of the candidate in nomination at the first meeting

4.

5.

of the House of Delegates. Please see the Manual on Caucus, Other duties as Secretary include the following:

Campaigns, Nominations and Elections at tda.org for full

•

details.

Serve as recording officer and custodian of the records of the House of Delegates and the Board of Directors.

Serve as secretary to the Executive Committee, without

Duties of the editor are enumerated in the Bylaws and include

the right to vote.

the following (excerpt):

•

Serve as secretary to the House of Delegates.

1.

•

Serve as the secretary of the American Dental Association

the Association and exercise full editorial control over

Fifteenth Trustee District Delegation.

such publications, subject only to policies established by

•

To be editor-in-chief of all journals and publications of

the House of Delegates, Board of Directors, and these Bylaws and provided such content is not in conflict with

www.tda.org | December 2023

581

or contrary to the TDA’s established policies, legislative agenda, or advocacy efforts.

2.

To control the selection of scientific material published in the Journal. The

TEXAS DENTAL ASSOCIATION NOTICE OF GRANT AVAILABILITY 501(C)(3) NONPROFIT DENTAL ORGANIZATIONS

editor may appoint associate editors, with the concurrence of the Board

The Texas Dental Association (TDA) announces availability

of Directors, to gather and/or review

of financial assistance for qualifying 501(c)(3) non-profit

material for publication. Such associate

organizations affiliated with dentistry. The monies are derived

editors shall serve as long as the editor deems necessary; but never longer than the term of the editor.

3.

from TDA Relief Fund interest income earned over the 2023 fiscal year. Grantees will be determined by the TDA Board of Directors.

To attend all open meetings of the Board of Directors and the House of

Eligibility: Grantees must be 501(c)(3) non-profit organizations

Delegates of this association, and the

affiliated with dentistry.

annual session of the American Dental Association.

4.

To hold no other office in this association or the American Dental Association while serving as editor, except the editor may be elected as delegate or alternate delegate to the

5.

Application: Letters of interest detailing the proposed project(s), including a budget, should be mailed to: TDA Board of Directors C/O Mr Terry Cornwell

ADA House of Delegates from his/her

1946 S. IH 35, Ste. 400

respective division.

Austin, TX 78704

To cooperate with his/her successor upon termination of the Editor’s term

Deadline: Letters of Interest must be postmarked or emailed

of office.

(tcornwell@tda.org) no later than January 31, 2024.

Candidacy announcements are to be mailed to TDA Secretary-Treasurer Dr Carmen P Smith, Texas Dental Association, 1946 S IH-35 Ste 400,

Approval: All letters of Interest will be reviewed by the TDA Relief Committee and considered by the TDA Board of Directors.

Austin, Texas 78704; or, emailed to TDA

Notification: All recipients will be notified in writing on or before

Executive Director Linda Brady: lbrady@

May 15, 2024.

tda.org.

Previous Recipients: In 2023, grants totaling $14,200 were (Ref. TDA Bylaws, Chapter VI, Elective Officers—Section 90I (Duties); Policy Manual).

awarded to the following organizations in Texas for charitable patient care: Capital Area Dental Foundation (Austin), The Family Place (Dallas), Greater Killeen Community Clinic (Killeen), Network of Community Ministries (Richardson), Rotary Club of Grand Prairie Saving Smiles Program (Grand Prairie), and San Jose Clinic (Houston).

For more information, please contact Mr Terry Cornwell, TDA Governance Manager, 512-443-3675, Ext. 146, or email tcornwell@tda.org.

582 Texas Dental Journal | Vol 140 | No. 10

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LAW OFFICES OF MARK J. HANNA EXPERIENCED LEGAL REPRESENTATION FOR TEXAS DENTISTS •

Representation Before the Texas State Board of Dental Examiners

•

Medicaid Audits and Administrative Hearings

•

Employment Issues—Texas Workforce Commission Hearings

Mark J. Hanna JD Former General Counsel, Texas Dental Association

•

Administrative (SOAH) Hearings and Counsel

•

Professional Recovery Network (PRN) Compliance

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Employment/Associateship Contract Reviews

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Practice Acquisition and Sales

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www.tda.org | December 2023

583

TDA Meeting Preview How to Have Difficult Conversations!

By Judy Kay Mausolf

Speaker: Judy Kay Mausolf

T

here are hundreds of moving parts in a dental practice’s dayto-day activities. Stuff happens even in the most successful

Event:

R.I.S.E to Success

Date:

Thursday, May 16

Time:

1:30 PM - 4:00 PM

Event:

Delivering W.O.W. Service

Date:

Friday, May 17

conversations. I love the quote: “Short-term discomfort prevents

Time:

8:30 AM – 11:00 AM

long-term dysfunction!” Avoiding short-term discomfort of difficult

Event:

Communication Solutions

Date:

Friday, May 17

we don’t address issues as they happen, they will spiral out of control.

Time:

1:00 PM – 3:30 PM

We have all experienced something little grow into something big.

practices. It is vital that the entire team is empowered to discuss

and resolve issues. However, the fear of confrontation and conflict can often prevent many team members from having necessary difficult

conversations often causes long-term dysfunction in behaviors. When

584 Texas Dental Journal | Vol 140 | No. 10

It’s time to have difficult conversations to sustain a happier, healthier, and higher performing service culture. The conversation includes 2 roles: The Approacher(s) and Approachee(s).

The Approacher(s) is the person conveying and

about the Speaker Judy Kay Mausolf

inquiring, and the Approachee it the person

is an inspirational

receiving and responding.

speaker, published author, and dental

The Approacher’s Role A difficult conversation is always in private and starts with positive communication from the

practice culture specialist with expertise in helping

Approacher. The Approacher shares what they

others get happier

appreciate about the other person. They build

and more successful!

up instead of tearing down by focusing on the

She coaches dental

other person’s strengths. A positive conversation

teams who want to

has a minimum of a 3-1 ratio. Three positives for each growth opportunity. Research shows that exceptional relationships have a 5-1 ratio. You may be thinking, “What if I can’t find 5 positives?”

be better leaders, work together better, deliver service

Every person has at least 5 strengths you can

with more focus,

highlight! We will discover their strengths when

and passion and

we shift our focus from their weaknesses to their

ultimately grow their

strengths. How ironic that our strengths are just

practice.

taken for granted and minimized whereas our weaknesses are highlighted.

Be specific instead of generalizing. Focus more

She does this by developing

on objective points than subjective opinions. Just

leadership,

saying “I don’t like it or you’re doing this wrong”

broadening mindsets, elevating attitude, strengthening

is not helpful. On the other hand, stating the

communication and developing skills to build high-performing

specific strengths or skills you would like to see

doctor/team/patient relationships!

developed is helpful.

Don’t make it personal. Talk about the issue not the person. Avoid saying, “You need to.” Start the

Judy Kay is past president of the National Speakers Association Minnesota Chapter, a member of the National Speakers Association

conversation with the word “I” instead of saying

and Academy of Dental Management Consultants, and director of

“you.” For example, “I noticed,” “I have seen,” “I

Sponsoring Partners for the Speaking Consulting Network.

observed,” or use sharing feedback from others, “I have had reported to me.” “I” conversations are issue-focused instead of person-focused. Always consider how your words may impact the other person. Ask yourself, “How can I say what I need to say and be respectful of how they may feel?”

She is author of 3 books: Delivering W.O.W. Service! People Will Forget Everything Except How You Made Them Feel!; TA-DAH! Get Happy in 5 Seconds or Less and Rise & Shine; An Evolutionary Journey to Get Out of Your Way and On Your Way to Success, and a contributing author for many dental publications.

Keep your energy neutral and come with a mindset of care, curiosity, and concern instead of judgment and criticism. Never have a

www.tda.org | December 2023

585

conversation when you are angry or frustrated or your emotions will rule the conversation. Instead take a few minutes to process and get calm. Start out by making eye contact with the other person. Be mindful of tone and

Keep your energy neutral and come with a mindset of care, curiosity, and

body language as well as words. A tone

concern instead

of care and concern communicates a sense of importance and provides the appropriate level of sincerity to the conversation. Avoid using sarcasm or derogatory words or the content of the conversation will get lost in the harshness. Once you say something it cannot be taken back. An apology doesn’t mean we forget. The old nursery rhyme that goes “sticks and stones may break my bones, but words will never hurt me”, is not true. Words can destroy even the best of relationships.

of judgment and

Acknowledge you heard and understand them. Never assume. If you are unsure, ask questions until you clearly understand. If you are thinking, “I think they mean this,” then ask more questions.

Don’t take it personally. If the issue pertains to the patients, the practice, or the team, it is necessary to address. It

criticism. Never have

can be difficult to hear when we are not

a conversation when

However, it is necessary to address to

you are angry or frustrated or your emotions will rule the conversation.

meeting the standards or expectations. create and sustain a happier, healthier and higher performing culture.

Take it seriously. It may not seem important or be a priority to you, but it is for the other person.

Control your emotions. If you are

Break your feedback down into key

upset, don’t just walk off in anger or

points. Don’t give your feedback as one

frustration. Instead, let them know that

big lump. Break it down into various key points, then give your feedback point

Ask the other person what they need

by point.

from you (communication, support,

Give examples of each point. What

the desired results. Together, discuss

are the exact issues, situations, or examples where the person exhibits the behaviors you highlighted? There is no need to highlight every single one—just

training, practice) to be able to achieve and agree on a resolution.

The Approachee’s Role

you need a little time to process the information they shared, and you will respond later that day. Try to respond within 24 hours.

If you are on the receiving end of anger or frustration, ask the person if they are okay. This is their cue to reset their energy to calm and neutral. A response of frustration, sigh, or rolling of the

disclosing a couple of examples per point will be sufficient. The purpose

The Approachee is to start out by

eyes, may actually be inward focused

is to bring the person’s awareness to

just listening and not taking offense.

and yet can feel directed outward. If you

things which he/she may not be aware

The team must be able to talk about

are feeling attacked or uncomfortable

of and clearly illustrate what you mean.

what’s not working to resolve issues.

let them know. For example, “You seem

It is important to recognize that the

frustrated or angry. Is that directed

Be timely! Try to address issues/

Approacher’s intent is good and to

toward me?”

concerns as they happen or within

realize that it is not easy to approach

24 hours of the occurrence. I have

someone.

Share what you need (communication, support, training, practice) to be able

actually seen employers make a list of everything an employee has done

Listen intently before responding. Make

achieve the desired results. Together,

wrong or needs to improve on for the

eye contact with the other person.

discuss and agree on a solution and

year and go over it at their annual

Instead of defending, deflecting, or

make a commitment.

review. It reminds me of Santa Claus’s

blaming someone else consider how

naughty list! It’s no wonder why reviews

your actions or lack of actions affected

Have difficult conversations to sustain

get a bad rap!

the outcome. Be honest with your

a happier, healthier, and higher

response.

performing service culture!

586 Texas Dental Journal | Vol 140 | No. 10

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www.tda.org | December 2023

587

Occlusal caries detection on 3D models obtained with an intraoral scanner

A validation study

By P. Ntovas, S. Michou, A.R. Benetti, A. Bakhshandeh, K. Ekstrand, C. Rahiotis, A. Kakaboura Originally printed in the Journal of Dentistry 131 (2023) 104457. P. Ntovas, S. Michou, A.R. Benetti, A. Bakhshandeh, K. Ekstrand, C. Rahiotis, A. Kakaboura. Occlusal caries detection on 3D models obtained with an intraoral scanner: A validation study. Journal of Dentistry, Volume 131, 2023, 104457, ISSN 0300-5712, https://doi.org/10.1016/j.jdent.2023.104457. (https:// www.sciencedirect.com/science/article/pii/S0300571223000441).

Introduction Visual examination remains the primary and most efficient method employed for occlusal caries detection.1 However, this technique presents limitations due to the examiner’s subjective assessment and the relatively low reproducibility.2 In addition, the detection of occlusal caries is impaired by various factors, including dental plaque, non-carious lesions (e.g., developmental defects), and obstacles during the examination process (e.g., insufficient light, presence of saliva).2,3 Thus, diagnosing and managing occlusal dental caries is still a challenge for general practitioners. Additionally, the inability to conduct blind examination on the subjects and the grading inconsistencies make visual examination fall short in large-scale epidemiological oral surveys, particularly considering expenses related to travel and working hours.1,4 Dental photographs obtained with intraoral or extraoral cameras using white light or other light sources such as blue and near-infrared have been proposed for caries detection and monitoring, as well as remote assessment purposes.5 Going one step

588 Texas Dental Journal | Vol 140 | No. 10

Abstract Objectives

further from the two-dimensional (2D) cameras, the three-dimensional (3D) intraoral scanner (IOS) has recently been introduced as a tool

To evaluate the diagnostic performance of visual caries assessment on 3D

to support caries detection utilizing

dental models obtained using an intraoral scanner and to compare it with the

different optical caries detection

performance of the clinical visual inspection.

methods.6-9 Fluorescence using

Methods Fifty-three permanent posterior teeth scheduled for extraction were randomly selected and included in this study. One to three independent examination sites on the occlusal surface of each tooth were clinically inspected using International Caries Detection and Assessment System (ICDAS) criteria. Afterwards, the examined teeth were scanned intraorally with a 3D intraoral scanner (TRIOS 4, 3Shape TRIOS A/S, Copenhagen, Denmark) using white and blue-violet light (415 nm wavelength) to capture the colour and fluorescence signal from the tissues. Six months after the clinical examination, the same examiner conducted the on-screen assessment of the obtained 3D digital dental models at the selected examination sites using modified ICDAS criteria. Both tooth colour and fluorescence texture with high resolution were assessed. Lastly, an independent examiner conducted the histological examination of all teeth after extraction.

Using histology as the reference test, Sensitivity (SE), Specificity (SP), Accuracy (ACC), area under the Receiver Operating Characteristic (ROC) curve, and

blue light excitation is one of the most promising technologies for detecting the earliest stages of enamel demineralization on occlusal and smooth surfaces. Fluorescence has recently been employed on a 3D intraoral scanner (TRIOS 4, 3Shape TRIOS A/S, Denmark) to aid caries detection and monitoring, presenting good results in vitro and in vivo.6,7,9 Additionally, the near-infrared reflectance and transillumination methods have recently been implemented in commercial and prototype intraoral scanners for

Spearman’s correlation coefficient were calculated for the clinical and on-screen ICDAS assessments.

Results The ACC values of the evaluated methods varied between 0.59-0.79 for initial caries lesions and 0.77-0.99 for moderate-extensive caries lesions. Apart from SE values corresponding to caries in the inner half of enamel, no significant difference was observed between clinical visual inspection and on-screen assessment. In addition, no difference was found in the assessment of 3D models with tooth colour alone or supplemented with fluorescence for all the evaluated diagnostic measures.

Conclusions On-screen visual assessment of 3D digital dental models with tooth colour or fluorescence showed a similar diagnostic performance to the clinical visual inspection when detecting and classifying occlusal caries lesions on permanent teeth.

Clinical significance 3D intraoral scanning can aid the detection and classification of occlusal caries as part of patient screening and can potentially be used in remote caries assessment for clinical and research purposes.

Keywords Dental caries, quantitative light-induced fluorescence, tooth demineralization, three-dimensional imaging

about the Authors P. Ntovas

Operative Dentistry Department, School of Dentistry, National and Kapodistrian University of Athens, Greece

S. Michou

Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark, 3Shape TRIOS A/S, Copenhagen, Denmark

A.R. Benetti

Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark

A. Bakhshandeh

Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark

K. Ekstrand

Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark

C. Rahiotis

Operative Dentistry Department, School of Dentistry, National and Kapodistrian University of Athens, Greece

A. Kakaboura

Operative Dentistry Department, School of Dentistry, National and Kapodistrian University of Athens, Greece

www.tda.org | December 2023

589

potential application both in proximal

automated scoring systems (e.g., Caries

employing ICDAS criteria, as derived by

and occlusal caries detection showing

indication provided by TRIOS Patient

a previous study and using the formula

good diagnostic performance.2,3,10

Monitoring software, 3Shape TRIOS A/S,

described by Buderer et al.7,13 More

Despite the widespread use of intraoral

Denmark) can potentially contribute

specifically, the following parameters

scanners in daily dental practice in

towards more reliable and objective

were employed: Sensitivity (SE) at 0.93,

developed countries, their application

caries assessment compared to direct

Specificity (SP) at 0.88, absolute error

for diagnostic purposes such as caries

clinical visual examination.6,7,9

at 0.1, confidence interval at 95%, and

detection and monitoring is still limited.

prevalence at 60%. Based on the above,

This is partially due to the limited

Thus, this study aims to evaluate the

a minimum of 101 examination sites

literature assessing their diagnostic

diagnostic performance of on-screen

on permanent molars and premolars

performance.2,3,6,7,9,10

visual caries assessment on 3D dental

should be included in the study.

models obtained using an intraoral Some of the limitations observed for

scanner and to compare it with the

Teeth scheduled for extraction due to

the direct clinical visual examination or

performance of the clinical visual

therapeutic reasons at the Department

the use of digital photographs for caries

inspection. The null hypothesis of the

of Oral Surgery and Periodontology

assessment could be overcome by using

present study was that there is no

of the School of Dentistry, National

intraoral scanner systems for detection

difference in diagnostic performance

and Kapodistrian University of Athens

and monitoring of caries lesions

between conventional clinical visual

were included in the study. Only adult

and other oral diseases.2,3,7-11 More

caries detection and on-screen caries

participants ranging from 18 to 60

specifically, the image acquisition angle,

detection on 3D digital models.

years old were included. The sample

which can significantly affect the size of the lesion depicted in photographs, is not expected to influence the assessment on 3D models. Therefore, the intraoral scanners can potentially enable the acquisition of reproducible images at different points in time for caries monitoring while eliminating the problems associated with the acquisition angle on 2D images.

distribution according to tooth type

Materials and methods The STAndard Reporting of CAries Detection and Diagnostic Studies (STARCARDDS) was followed as closely as possible to report this article’s methods and results.12

was the following: 15 premolars (12 mandibular and 3 maxillary), and 43 molars (18 mandibular, 25 maxillary).

Thus, 58 posterior teeth without calculus on their occlusal surfaces nor restorations, severe developmental defects, or visible extensive caries on other surfaces than the occlusal were used.

Additionally, proper lighting and magnification of the examined area

2.1. Study design

The workflow of the study is presented

that usually affect the visual clinical

This was a cross-sectional in vivo

in Figure 1.

examination are not expected to affect

study with in vitro validation. First,

the assessment on 3D models, as long

visual examination of teeth for caries

2.3. Clinical visual examination

as the intraoral scanner manufacturers’

detection and 3D intraoral scanning

(ICDAS)

instructions are followed during

(3Shape TRIOS 4 A/S, Denmark) were

The clinical examiner (P.N.) was

scanning. Furthermore, the obtained

conducted, and subsequently, the

calibrated according to the

3D models can be shared and assessed

teeth were extracted. The 3D models

recommendations from the ICDAS

remotely by multiple dental experts,

of the teeth were examined on a

Committee.14,15 Firstly, the examiner

allowing proper blinding of examiners

digital monitor after tooth extraction.

was trained to use these criteria

in epidemiological surveys while at

Finally, the histological assessment was

on an educational software (ICDAS

the same time reducing travel-related

performed as the reference test.

training software), and further training was accomplished with a second

time and costs. Lastly, the optical caries detection methods (e.g., fluorescence

2.2. Study sample

examiner (C.R.) trained and validated

and NIR reflection) implemented in

Prior to the study’s onset, the estimated

for using ICDAS criteria.14,15 Initially,

modern intraoral scanners (TRIOS 4,

required sample size was defined

the 2 examiners scored 10 teeth

3Shape TRIOS A/S and iTero Element 5D,

based on the expected diagnostic

independently and then discussed the

Align Technologies) and corresponding

performance for visual assessment

scores presenting disagreement until

590 Texas Dental Journal | Vol 140 | No. 10

they could reach an agreement. One

the occlusal surfaces of the examined

were assessed visually under proper

week later, 10 more teeth were scored.

teeth using prophy brushes on a

illumination of a dental lamp before and

Again, the 2 examiners conducted the

low-speed handpiece (Kavo Intra 20k,

after air-drying.

assessment independently and came to

Italy). Afterwards, the clinical examiner

an almost perfect agreement (weighted

(P.N.) defined 1 to 3 examination sites

2.4. 3D intraoral scanning

kappa=0.92).

on the occlusal surface of each tooth

At the same appointment, following

(Figure 1,i). Finally, the same examiner

the visual examination and before

Clinical oral examination of the patients

examined all the assigned sites

tooth extraction, intraoral scanning was

was conducted prior to tooth extraction.

clinically using the visual ICDAS criteria

performed with a 3D intraoral scanner

Firstly, the plaque was removed from

as presented in Table 1. The teeth

(TRIOS 4, 3Shape TRIOS A/S, Denmark)

Figure 1 i

Clinical

ii

(Before Tooth Extraction)

Tooth Colour

Sample 1.

Histological Score (E1, E2) = Enamel Demineralization Enamel Thickness

Histological Score (D1, D2, D3) Sample 2.

(53 teeth, 118 examination sites)

iii

Histology

Fluorescence

Will clean up this text

Sample 1.

Intraoral Scanning and Site Selection

(6 Months After)

Sample 2.

(ICDAS)

(58 teeth, 129 examination sites)

Visual Examination

Clinical Examination

On-Screen

= Dentin Demineralization Dentin Thickness

Figure 1. Overview of study’s methods (i-iii). Two representative teeth (sample 1, sample 2) from the study’s sample are shown.

On the histological sections, the red measurement lines correspond to the demineralization depth in enamel or in dentin, and the blue measurement lines correspond to the enamel or dentin thickness respectively. For the histological assessment, multiple histological sections were obtained corresponding to the different examination sites (a,b,c).

www.tda.org | December 2023

591

aided by commercial software

dental tissues. This fluorescence signal

were examined under standardized

(TRIOS vers. 1.18.2.11 and Dental

was applied to the previously created

light conditions by the clinical examiner

Desktop vers.1.6.8.1, 3Shape TRIOS

3D model (Figure 1ii). The intraoral

(P.N.) on a laptop computer with a

A/S, Denmark). The manufacturer’s

scanning procedure was considered

15-inch monitor (VPCF1, Sony Vaio)

recommendations were followed

adequate when the software obtained

and a custom-designed software

throughout the scanning. The dental

sufficient tooth colour and fluorescence

(not commercially available software,

lamp was switched off during intraoral

information on the examined tooth by

3Shape A/S, Denmark) (Figure 1ii). This

scanning, and the teeth were air-dried

using a specific algorithm developed

software visualized the post-processed

thoroughly.

by the manufacturer and visualized as

3D models with high resolution as they

a blue overlay on the 3D model (TRIOS

appear on the commercial software

software, 3Shape TRIOS A/S, Denmark).

(TRIOS vers. 1.18.4.0 or higher, 3Shape

All teeth were first scanned with the

Dental Desktop, 3Shape). For the on-

intraoral scanner using the standard white light to obtain a 3D model with

2.5. On-screen assessment on 3D

screen assessment of the 3D models

tooth colour texture (Figure 1i, ii), and

dental models

(i.e. with tooth colour and fluorescence),

thereafter with light at 415 nm to obtain

Six months after the clinical

modified ICDAS criteria described by

fluorescence signal from the hard

examination, the 3D models of the teeth

Ferreira-Zandona et al. were used (Table

Table 1. Criteria used for histological assessment and corresponding scores used for clinical visual examination (ICDAS) and on-screen assessments.

SOUND

HISTOLOGY

HISTOLOGY

CLINICAL VISUAL

ON-SCREEN

ON-SCREEN

Lesion Depth

Score

ICDAS Score

Tooth colour 3D Model

Fluorescence 3D Model

Sound

E0

0: Sound tooth surface with no visible

0: Sound tooth surface

0: Sound tooth surface

1: Slight fluorescence change

1: Slight fluorescence change

evidence of caries, when viewed after cleaning and 5 seconds of air-drying ENAMEL

Outer half of

E1

enamel Inner half of

1: First visual change in enamel, seen after 5 seconds of air-drying

E2

2: Distinct visual change in enamel

2: Distinct visual change in

2: Distinct fluorescence

enamel, including

visible when both wet and dry, with

enamel

change

the DEJ

no evidence of surface breakdown or

3: White or brown spot lesion with

3: Localized enamel

3: Visible enamel breakdown

localized enamel breakdown, without

breakdown due to caries with

with a distinct fluorescence

visible dentin exposure

no visible dentin

change

4: Non-cavitated surface with an

4: Surface with underlying

4: Poorly delineated distinct

underlying dentin shadow, which

dark shadow from dentin

fluorescence change with or

obviously originated on the surface

with or without enamel

without enamel breakdown

being evaluated

breakdown

5: Visually distinct cavity in opaque

5: Distinct cavity with visible

5: Caviation visible with

or discoloured enamel and exposed

dentin (less than half of the

distinct fluorenscence change

dentin (less than half of the surface)

surface)

(less than half of the surface)

6: Extensive and visually distinct cavity

6: Extensive distinct cavity

6: Extensive caviation visible

with exposed dentin (more than half of

with visible dentin (more than

with distinct fluorescence

the surface)

half of the surface)

change (more than half of the

underlying dentin shadowing DENTIN

Outer third of

D1

dentin Middle third of

D2

dentin

Inner third of dentin

D3

surface)

592 Texas Dental Journal | Vol 140 | No. 10

1).16 Firstly, only the 3D models with

2.7. Outcome variables

Az comparisons were performed using

tooth colour texture were assessed,

The outcome variables in this study

MedCalc statistical software (Version

and afterwards, the models with

consisted of a correlation (rs) between

19.6.4, MedCalc Software Ltd, Belgium).

the fluorescence texture. The same

the histological scores and the scores

Other calculations, i.e., SE, SP, ACC,

examination procedure was repeated 2

from the index tests, as well as

were done in Excel (Microsoft Office

months later under the same conditions

diagnostic accuracy metrics for the

2016) based on the cross-tabulations

to evaluate the intra-examiner reliability.

index tests at the different histological

exported from SPSS.

cut-offs. Additionally, the intra-examiner 2.6. Reference test—histology

reliability for the on-screen visual

The confidence level was defined as

An independent examiner (S.M.)

assessment. was also calculated.

95% for all statistical tests.

as the reference standard. This

2.8. Data analysis

examiner was blinded to both the

The rs was used to evaluate the

Results

clinical and on-screen scores given

correlation between the clinical visual

Fifty-eight teeth met the inclusion

by the clinical examiner (P.N). The

and on-screen assessments and the

criteria and were evaluated but five

histological analysis was conducted

histological scores. ROC curves (Figure

teeth were destroyed during the

using multiple buccolingual cuts

2) and contingency tables were made

preparation for histological analysis.

(obtained using Accutom, Struers A/S,

using histology as the reference

Finally, 53 teeth with 118 examination

Denmark with diamond disc thickness

standard (Appendix tables A1, A2,

sites were histologically assessed and

~0.4 mm, Buehler, Illinois) on each tooth

A3). The diagnostic performance of

included in the present study. The

and consecutive manual grinding.8,11

the index tests (clinical and on-screen

distribution of examination sites into

The absolute depth of the caries

assessments) was expressed using the

the different histological levels was: 17

lesion and its corresponding enamel

area under the ROC curve (Az), SE, SP,

sound sites, 25 E1, 54 E2, 8 D1, 9 D2 and

or dentin thickness was registered

and ACC at the different histological

5 D3 sites. Due to insufficient colour or

for each examination site using a

cut-offs. The SE and SP were the

fluorescence data on some 3D models,

stereomicroscope (SteREO discovery V8;

true positive and true negative rates

the final number of examination sites

Zeiss, Germany) and the accompanying

respectively when considering the

included for the on-screen assessments

software (DeltaPix InSight V 5.2.6,

histological scores as reference. The

was 112. Cross tabulations are provided

DeltaPix, Denmark; precision 0.01 mm)

ACC was given as the sum of true

in the Appendix (Tables A1, A2, A3).

without staining (Fig. 1iii).

positive and true negative scores

conducted the histological assessment

obtained from the clinical and on-

The intra-examiner reliability expressed

Six different histological scores (E0, E1,

screen assessments divided by the

by quadratic weighted kappa was 0.86

E2, D1, D2, D3), as presented in Table 1,

total number of scores. The weighted

(Std. Error 0.04) for the assessments

were assigned to each examination site

Cohen’s kappa coefficient (k) with

on tooth-colour models, and 0.80 (Std.

according to the result from the fraction

quadratic weights was calculated for

Error 0.06) for the model assessments

between the caries lesion’s depth and

the intra-examiner reliability for the on-

combining colour and fluorescence

the total enamel or dentin thickness.

screen visual assessment.

information.

enamel was divided by the total enamel

Nonparametric test (McNemar’s) was

The rS as well as the descriptive results

thickness; likewise, the depth of the

used to compare the SE and SP values

(Az, SE, SP, ACC) at each histological level

lesion extending into dentin was divided

of the index tests. The Az from the

are presented in Table 2. In addition,

by the total dentin thickness.

investigated methods were compared

ROC curves for each evaluated method

pairwise using DeLong’s algorithm.17

are shown in Figure 2.

The depth of the lesion extending into

An independent score was assigned

IBM SPSS Statistics (Version 26, IBM

to each examination site from

Corporation, IL, USA) was used to

Both assessment methods showed

each method: direct clinical visual

calculate Spearman’s correlation

moderate correlation with the histology

examination, on-screen assessment

coefficient (rs), the Az and the k, create

(rs), ranging from 0.49 to 0.54. At the

on 3D dental models, and histological

the cross-tabulations, and conduct the

pre-defined histological levels, both

assessment.

nonparametric statistical analyses. The

methods (clinical visual examination

www.tda.org | December 2023

593

Figure 2

Figure 2. Receiver operating characteristic (ROC) curves for clinical and on-screen visual assessments at different histological levels. and on-screen visual assessment)

There was no significant difference in

SE at the E2 histological level, in which

showed no significant difference in

the results (SE, SP, Az) from the on-

the clinical visual examination resulted

Az (Az>0.65, p>0.05). Regarding initial

screen visual assessment conducted

in a significantly higher value (p<0.05).

caries lesion stages (E1-E2 histological

on the 3D models with tooth colour or

No other significant difference was

scores), the diagnostic accuracy (ACC)

when tooth colour and fluorescence

observed among the different methods.

ranged from sufficient (0.59) to good

texture were combined (p>0.05).

SE was higher for initial caries lesions in

(0.79). For the moderate-extensive

When comparing the clinical visual

enamel (E1) than deeper enamel lesions

caries lesions, diagnostic accuracy

examination results to those from

(E2).

ranged from good (0.77) to excellent

the on-screen assessments, the only

(0.99).

significant difference was observed for

594 Texas Dental Journal | Vol 140 | No. 10

Table 2.

The Az, SE, SP, ACC and the correlation with histology rS results for all methods assessed. The standard error is provided in parentheses. The standard errors for SE and SP are adjusted for clustered data. The different letters next to Az, SE, and SP values represent statistically significant differences in the same row (A > B , p < 0.05).

METHOD Histology

Measure

Clinical visual

(Std. Error)

E1

E2

D2

D3

On-screen—

On-screen— Fluorescence

Tooth Colour

and Tooth Colour

rS

0.54 (0.07)

0.49 (0.07)

0.50 (0.07)

Az

A

0.76 (0.06)

0.77 (0.05)

0.76 (0.05)A

SE

0.82 (0.03)A

0.75 (0.06)A

SP

0.59 (0.04)

0.71 (0.001)

0.65 (0.02)A

ACC

0.79

0.74

0.72

Az

0.71 (0.05)A

0.66 (0.05)A

0.68 (0.05)A

SE

0.72 (0.05)

A

B

0.57 (0.06)

0.61 (0.06)B

SP

0.60 (0.03)A

0.63 (0.03)A

0.60 (0.03)A

ACC

0.68

0.59

0.61

Az

0.90 (0.04)A

0.90 (0.05)A

0.91 (0.04)A

SE

0.93 (0.07)A

0.85 (0.09)A

0.85 (0.09)A

SP

0.75 (0.02)A

0.83 (0.04)A

0.80 (0.02)A

ACC

0.77

0.83

0.80

Az

1.00 (0.01)A

0.99 (0.01)A

0.99 (0.01)A

SE

1.00 (0.001)A

1.00 (0.001)A

1.00 (0.001)A

SP

0.99 (0.001)A

0.96 (0.002)A

0.96 (0.002)A

ACC

0.99

0.96

0.96

A

A

0.74 (0.05)A A

Discussion

Moving one step further from the

time and increasing the objectivity and

visual assessment of 3D dental

reproducibility of caries detection and

The present study showed that the

models, automated caries detection

monitoring on 3D models.5

3D digital dental models deriving

and classification on 3D models using

from intraoral scanning could be

specific software has previously been

In the current study, the ACC of both

used for occlusal caries detection and

investigated.4,5,7 Such automated system

evaluated methods was higher for more

classification. Furthermore, there was

was not included in the current paper.

extensive caries lesions than initial

no overall significant difference in the

However, previous investigations on the

lesions. The lower SE of the on-screen

diagnostic performance of direct clinical

same study sample or other samples

examination at the E2 level can be

visual examination and on-screen

have shown that the mentioned

explained by the fact that the ICDAS 2

visual examination of digital 3D models.

automated system results in similar

criterion could not be applied on-screen

Thus, digital 3D models displaying

diagnostic performance to the

like it is done in the clinical examination,

tooth colour and/or fluorescence can

conventional caries detection methods

where it is possible to observe the

be used to detect and, to some extent,

(visual, radiographic) of occlusal lesions

lesion wet and then dry.4,5 Additionally,

classify dental caries, even if there

using ICDAS criteria.

the current study results showed no

is no opportunity for a direct clinical

further assist the clinical examination

significant differences in the diagnostic

examination.

by potentially reducing the examination

performance when assessing models

4,7,13

The latter could

www.tda.org | December 2023

595

only with the tooth colour texture

by external dental experts and

or supplemented with fluorescence

update the knowledge of the local

information. This indicates that the high

dental staff in remote areas, as it

resolution and the reproduced tooth

can also serve as a distance learning

colour were sufficient for on-screen

tool.20 Other possibilities include

caries assessment, and fluorescence

assisting consultation among various

did not add important information.

specialities, and remote emergency

However, this result does not agree with

care screening.

the literature, where improved SE is

shows that besides the assessment

usually achieved when the fluorescence

of caries lesions, these 3D models

method is employed for initial caries

can be used to assess gingivitis and

detection due to the fluorescence

tooth wear. 4,5,7,9-11 By combining

method’s advantages in detecting

the 3D dental models and images

early enamel demineralization and the

with clinical and digital radiographic

presence of bacteria metabolites.16,18,19

assessments, the data can easily be

This can potentially be explained by

shared among dental practitioners and

the differences among the systems

assist in multidisciplinary diagnosis and

employing fluorescence method,

treatment planning without the need

such as differences in the wavelength

for the patient’s physical presence.22 For

used for fluorescence excitation,

this purpose, it is essential to deliver the

the fluorescence signal adjustment,

imaging devices to the areas where the

and the image processing before the

patients are located and to share the

visualization on the screen. On the

images with healthcare practitioners.

other hand, an increased number of

Although the intraoral scanners for 3D

false-positive indications is also often

dental model acquisition are relatively

reported for the fluorescence method

expensive and not yet implemented

due to image artefacts, surface defects

in the majority of dental clinics,

(e.g., developmental), and the presence

particularly in developing and rural

of plaque, which was not observed in

areas, it is expected that these devices

the current study.

will become more affordable and

5,7,16

We speculate

20,21

Literature also

that this study’s results might have

available worldwide. Additionally, such

been different if the sample either

intraoral scanners can be carried and

included a more significant number of

operated by non-dental personnel, e.g.,

initial lesions (E1) or if the assessment

nurses visiting patients in remote areas

of the fluorescence texture was

or elderly homes.

conducted independently rather than in conjunction with the tooth colour

Some limitations are identified in

assessment. These aspects can be

the current study. First, the teeth

considered for future work.

included in this study were scheduled for extraction due to different

The findings of this study support the

therapeutic reasons, which led to

use of intraoral scanning for patient

a sample not representative of the

screening for caries, for example,

general population. The sample was

as part of different remote patient

mainly formed by third molars, while

screening modalities, especially

a smaller number of teeth were

for disadvantaged remote living

extracted for orthodontic reasons or

populations.20 Digital technology

due to periodontal disease. In contrast,

could help perform well-documented

the teeth assessed and monitored in

diagnoses and treatment planning

daily clinical practice usually include

596 Texas Dental Journal | Vol 140 | No. 10

The findings of this study support the use of intraoral scanning for patient screening for caries, for example, as part of different remote patient screening modalities, especially for disadvantaged remote living populations.

premolars, and first and second

Funding acquisition. A Bakhshandeh:

and Kapodistrian University of Athens)

molars, with initial to moderate caries

Conceptualization, Methodology,

(protocol number 423/08.07.2019). The

lesions. Second, only primary occlusal

Resources, Writing—review & editing,

study was conducted according to the

caries lesions were assessed and thus,

Supervision, Funding acquisition.

declaration of Helsinki and the General

other types of caries lesions shall be

K Ekstrand: Conceptualization,

Data Protection Regulation (GDPR).

assessed, such as proximal caries,

Methodology, Resources, Writing—

All study participants gave informed

caries in the esthetic area and caries

review & editing, Supervision,

consent.

around restorations. Third, lesions

Funding acquisition. C Rahiotis:

in the outer third of dentin (D1 based

Conceptualization, Methodology,

Supplementary materials

on the histology), were not presented

Resources, Writing—review & editing,

Supplementary material associated

separately in the results of this study, as

Supervision, Project administration.

with this article can be found, in

D1 has no direct corresponding ICDAS

A Kakaboura: Conceptualization,

the online version, at doi:10.1016/j.

score within the visual examination to

Methodology, Resources, Writing—

jdent.2023.104457.

allow reliable discrimination between

review & editing, Supervision, Project

lesions located only in enamel or in the

administration.

9

outer third of dentin.17 Finally, our study evaluated only ICDAS scores without mentioning the caries activity, which

Conclusions

foundation’s guidelines for an industrial

visual inspection of caries lesions on 3D dental models obtained using an intraoral scanner can be used to aid the detection and classification of occlusal caries with an accuracy equivalent to that of the clinical visual inspection.

Further studies are required to assess the clinical reliability of the method and the diagnostic accuracy when assessing other types of caries lesions and tooth surfaces.

CRediT authorship contribution statement P. Ntovas: Conceptualization, Methodology, Investigation, Visualization, Writing—original draft. S. Michou: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Data curation, Funding acquisition,

Bakhshandeh, C. Fatturi-Parolo, M. Maltz. Occlusal caries: biological approach for its diagnosis and

no. 8053-00005B). Based on the

management, Caries. Res. 50 (2016) 527–542, https://doi.

PhD and the agreement between the industrial partner 3Shape TRIOS A/S and the University of Copenhagen,

J.C. Carvalho, I. Dige, V. Machiulskiene, V. Qvist, A.

The current study was funded by Innovation Fund Denmark (grant

study, we conclude that on-screen

1.

Declaration of Competing Interest

influences caries lesion management.

Within the limitations of the current

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H. Hintze, A. Wenzel, B. Danielsen, B. Nyvad, Reliability

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598 Texas Dental Journal | Vol 140 | No. 10

ANNUAL REPORT JANUARY - DECEMBER 2022

PHONE NUMBER: 512-448-2441 EMAIL: SMILES@TDA.ORG TDASF WEBSITE: TDASMILES.ORG TMOM WEBSITE: TMOMINC.ORG www.tda.org | December 2023

599

600 Texas Dental Journal | Vol 140 | No. 10

Our Year in Review “Our year in review is a testament to our progress and a compass for the journey ahead, reminding us that our greatest achievements often arise from our combined strength, resilience and determination to ensure we stay true to our mission -- serving our fellow Texans.”

A Message from TDA Smiles Foundation and TMOM, Inc. Director Stacy Hill It is a privilege to serve as the new Director of both the Texas Dental Association Smiles Foundation (TDASF) and Texas Mission of Mercy, Inc. (TMOM).

In 2022, both organizations demonstrated exceptional resilience and adaptability, overcoming unprecedented challenges because of a global pandemic. Despite these unique circumstances, we achieved remarkable results in patient care, vendor collaboration, and partnership building, underscoring our unwavering commitment to our mission and long-term sustainability.

Stacy Hill Director of TDA Smiles Foundation and Texas Mission of Mercy, Inc.

Our gratitude goes to the communities of Houston, Texarkana, Luling, and Dallas for their invaluable support. We acknowledge that our continued success relies on the Texas Dental Association’s support and our dedicated Board members. Together, we will drive both organizations forward with innovation and sustainable growth as we embark on the upcoming year. We eagerly anticipate new opportunities to leave a lasting impact in the communities we serve. www.tda.org | December 2023

601

Doctor Barry J. Currey Chair of TDA Smiles Foundation

Dear Friends and Supporters of the Texas Dental Association Smiles Foundation, I am thrilled to share the remarkable progress and positive transformations that the TDA Smiles Foundation experienced in 2022. These strategic enhancements were meticulously designed to fortify our foundation, extend our outreach, and further our commitment to enhancing the oral health of Texans.

Throughout the year, we implemented several significant developments. These changes align with our mission “to improve the oral health of Texans.” We couldn't do it without your support: • •

We’ve welcomed new staff, Ms. Stacy Hill, Ms. Angie Benke and Ms. Mariana Calanda, to our team.

Dr. Wade Barker is our new Foundation Vice Chairman.

• • • • • •

Dr. Susan Jolliff leads our Finance Committee.

New sponsors support Texas Mission of Mercy events.

We’ve secured donated supplies and services for volunteers.

A thorough financial audit and recommendations are underway.

More funding for professional education and scholarships.

Approval for new fundraising initiatives in 2024.

These strategic initiatives were thoughtfully undertaken to strengthen our foundation’s governance, elevate our fundraising efforts, and promote ongoing education within our profession. As we look forward to 2022, we do so with great anticipation, driven by our mission to “improve the oral health of Texans.” We remain steadfast in our commitment to showcasing the incredible work accomplished by the TDA membership and its charitable foundation.

We express our heartfelt gratitude for your ongoing support and belief in our vision. Together, we will continue to make a meaningful impact on the oral health of Texans.

602 Texas Dental Journal | Vol 140 | No. 10

Doctor Doug Bogan Chair of Texas Mission of Mercy, Inc.

Greetings to all our valued supporters at the Texas Mission of Mercy, Inc. (In 2022) it feels like we have fully regained our stride. The onset of the COVID pandemic forced us to hit pause, but thanks to the unwavering dedication and creativity of several members of our leadership team, staff, and volunteers, we’ve navigated the challenges effectively and emerged even stronger. This year, we’ve provided care to a staggering 1,493 Texans, with a total value of care of $1.46 million.

Throughout this endeavor, the safety of our volunteers and patients has been our top priority.

The success of our events in Dallas, Houston, Luling and Texarkana can be attributed to the collective efforts of volunteer leadership, our dedicated staff, and the thousands of volunteers from all corners of Texas. It is this remarkable group of individuals who will continue to serve our fellow Texans in the years ahead.

As we look to the future, I’ve identified 3 key priorities: • • •

Expand our volunteer base.

Identify and nurture successors, equipping them with the tools to advance our mission to new heights.

Enhance our governance structure to better address current and future challenges and capitalize on emerging opportunities that lie ahead.

It is a great honor for me to be a part of preserving the vision of our founders, ensuring that all Texas dentists can take pride in our commitment to bringing smiles to the faces of more Texans.

www.tda.org | December 2023

603

TDA Smiles Foundation Board of Trustees NAME

POSITION

Dr Barry J. Currey

CHAIR

NAME

POSITION

Mrs Diane Bogan

MEMBER

Dr Wade Barker

VICE CHAIR

Dr Don Lutes

MEMBER

Dr Larry W. Spradley

PAST CHAIR

Dr Kent Macaulay

MEMBER

Dr Susan Jolliff

TREASURER

Mrs Paula Owens

MEMBER

Mrs Jane Evans

SECRETARY

Dr Michael Rainwater

MEMBER

Dr Jay Adkins

MEMBER

Mrs Beth Voorhees

MEMBER

Mrs Jen Banton

MEMBER

Dr Michael Wedin

MEMBER

Dr Michael L. Giesler

MEMBER

Dr Delton Yarbrough

MEMBER

Dr Doug Bogan

MEMBER

Texas Mission of Mercy, Inc. Board of Directors NAME Dr Doug Bogan

POSITION CHAIR

Mrs Paula Owens

1ST VICE PRESIDENT

Dr Barry J. Currey

TREASURER

Dr Delton Yarbrough

SECRETARY

Dr Kent Macaulay

604 Texas Dental Journal | Vol 140 | No. 10

2ND VICE PRESIDENT

TMOM, Inc. Mission “At Texas Mission of Mercy, Inc., giving back to the community is not just a mission, it’s our passion. We believe that by providing essential dental care to underserved Texans, we are making a profound difference in the heart of our great state.”

1,493 Patients Treated at TMOM Events during 2022

Texas Mission of Mercy, Inc., is dedicated to providing free, essential dental care to underserved Texans.

of those who need it most. It’s with this powerful sense of community that we were able to provide free dental care to over 1, 400 patients in 2022.

Our mission is to bridge the Our commitment to this gap in dental services, ensuring that all individuals, regardless of mission is unwavering, and we their circumstances, have the are driven by the belief that a opportunity to maintain their oral healthy smile can transform lives, fostering confidence, health, and health and overall well-being. hope within our Through our mobile clinics communities. and dedicated volunteers, we strive to make a tangible difference in the lives

www.tda.org | December 2023

605

TMOM 2022

Highlights

$1.46

40% Treated Male Patients

MILLION

60% Treated Female Patients

Total amount of care provided in 2022.

The patient average of treatment provided was $1,304.21.

21.3%

43.3%

24.6%

Hispanic

Black

White

Total amount donated in grants by businesses and foundations to Texas Mission of Mercy Events 2022.

$194,433.22

Total amount donated by individuals or households to Texas Mission of Mercy Events 2022.

$33,439.33

606 Texas Dental Journal | Vol 140 | No. 10

TEXARKANA DALLAS

387 PATIENTS

299 PATIENTS

LULING

274 PATIENTS

HOUSTON

534 PATIENTS

1,493

LIVES TOUCHED

1,233 VOLUNTEERS We are thrilled to share that, in 2022, we had the privilege of delivering free dental care to over 1,400 patients across Texarkana, Dallas, Houston, and Luling. The impact of our efforts extends far beyond the numbers, as each patient represents a life positively transformed through access to essential dental services.

In 2022, TMOM saw a 220% increase in volunteer attendence to events compared to that of the previous year.

The high level of attendence was due to staff efforts to communicate the events through social media and because of Covid-19 restrictions being lifted across the country.

www.tda.org | December 2023

607

TDA Smiles Foundation and Texas Mission of Mercy, Inc., Staff At

the

TDA

Smiles

Foundation

Our

team

is

a

dynamic

mix

and TMOM, Inc., we take immense

of professionals,

pride

to our mission of improving oral

in

the

compassionate

talented

and

individuals who form

each

committed

health and well-being.

the backbone of our organization.

STACY HILL Director

of

TDA

Smiles

Foundation and TMOM, Inc.

ANGIE BEHNKE

MARIANA CALANDA

Assistant

Director

Digital

Clinical

Programs

of

608 Texas Dental Journal | Vol 140 | No. 10

Solutions

and

Communications Manager

Renew now!

Scan here:

As a TDA member, you get access to valuable resources and a supportive community.

www.tda.org | December 2023

609

ORAL

AUTHORS Karan Dharia, BDS Maxradpath, Austin, Texas

and maxillofacial pathology case of the month

Case History

Sara A. Bender, DDS, MS Private practice, Frisco, Texas

A 59-year-old male presented to a dental office and an incidental finding was noted (see below).

The patient was asymptomatic, and the duration was unclear. The patient’s medical history was significant for diabetes. His medication list included Lunesta, ramipril, Lipitor, Ozempic, Jardiance, and Coq10.

Intraoral-examination revealed bilateral diffuse

Yi-Shing Lisa Cheng, DDS, MS, PhD Oral Pathology Associates, Dallas, Texas

white and wrinkled areas with fissures and folds in the posterior buccal mucosa, and it was more prominent in the left side (Figure 1). The

Figure 1. Clinical presentation revealed diffuse white, corrugated lesions in bilateral posterior buccal mucosa. Left side was more prominent and shown here. The lesions extended both superiorly and inferiorly beyond the occlusal plane.

610 Texas Dental Journal | Vol 140 | No. 10

lesions extended both superiorly and inferiorly beyond the occlusal plane, and stretching did not make the lesions go away. The lesions were first thought to be tobacco pouch keratosis. However, the patient denied smoking, alcohol, snuff or any lozenge use. There was no similar color or textural changes found in the mandibular vestibule, the common location for tobacco pouch keratosis (Figure 2). No family member that the patient knew of had similar lesions in the oral cavity.

Figure 2. The patient’s right mandibular buccal vestibule, the common site for tobacco pouch keratosis, showed no similar color or textural changes to that found in bilateral posterior buccal mucosa.

Figures 3a and 3b.

What is your differential diagnosis?

Follow Up Information The patient was asked if he ever had beef jerky or other type of bulky materials placed in the area. The patient admitted that he took beef jerky in the morning daily. The patient was asked to stop this habit for a month and came back to the clinic for follow up. Oral examination at the follow-up appointment revealed no diffuse white

A

rippled mucosa but prominent linea alba bilaterally (Figure 3A and B).

What is the most likely diagnosis?

See page 612 for the answer and discussion.

B Figure 3. Clinical presentation at the time of follow up appointment showed resolution of the lesions and prominent linea alba in left buccal mucosa (A) and right buccal mucosa (B).

www.tda.org | December 2023

611

ORAL

Although it is uncommon, when oral examination reveals a clinical

and maxillofacial pathology

presentation that is

diagnosis and management—from page 611

similar to tobacco

Final Diagnosis: Beef jerky-associated keratosis (keratosis associated with repeated, prolonged placement of bulky material)

Discussion The purpose of this report is to increase clinical awareness that repeated, prolonged placement of bulky materials other than smokeless tobacco, such as beef jerky, sunflower seed, and hard candy, can also produce diffuse white color changes with wrinkles or folds on mucosa that appear similar to the clinical presentation of tobacco pouch keratosis.1 Keratosis associated with those non-tobacco bulky material is not premalignant but represents a combined effect of chronic physical/ chemical irritation and tissue reaction. The reactive nature is evidenced by the fact that removal of the causative agent results in complete resolution of the lesion, as seen in the presenting case. Once the cause-effect relationship is demonstrated, the diagnosis is confirmed and biopsy is not needed.

The clinical differential diagnoses include leukoedema, tobacco pouch keratosis or keratosis associated with other bulky materials, genodermatoses such as white sponge nevus, and multifocal leukoplakias.1,2,3 Leukoedema is a common oral condition most often seen in the black population.3 It is considered a variant of normal condition rather than an oral disease. It primarily presents bilaterally on the buccal mucosa as a diffuse, gray-white, milky opalescent area with folded areas appearing as wrinkles along the surface. The lesions disappear upon stretching the mucosa which help differentiate leukoedema from other white lesions.3 In the presenting case, stretching the mucosa did not make the lesions disappear, and this possibility was therefore excluded clinically.

Tobacco pouch keratosis corresponds to a characteristic gray or white plaque of the mucosa that is the result of contact with snuff (moist or dry) or chewing tobacco.

The development of the lesion is influenced by the tobacco brand, duration of habit, amount of tobacco used, length and amount of daily use, and number of sites placed. Clinically, the mucosa may appear thin and have an almost translucent appearance. There may be redness surrounding the affected area. The lesion may be soft and velvety and appears fissured. Stretching reveals a pouch caused by loss of

612 Texas Dental Journal | Vol 140 | No. 10

pouch keratosis, but the patient does not have a history of snuff use and leukoedema has been excluded clinically, keratosis caused by other bulky materials (beef jerky, hard candy or sunflower seed) may be considered in the clinical work-up plan.

References

tissue integrity in the area of placement.

biopsy material. Neither exfoliative

Due to the low malignant potential

cytology nor biopsy was performed for

comparing to that associated with

the presenting case. The patient’s age

cigarette smoking and alcohol abuse,

is very unusual for the age of onset for

and Chi AC. 2016. Chapter 10

biopsy is typically not required except

WSN, and absence of a family history

Epithelial Pathology in Oral and

for severe or atypical cases. Follow up is

also makes this diagnosis less likely for

Maxillofacial Pathology, 4th edi, St.

important as squamous cell carcinoma

this case.

Louis, Missouri: Elsevier.

1.

2.

can appear decades later. Cessation of

Neville BW, Damm DD, Allen CM

Müller S. Frictional Keratosis,

the chewing tobacco habit leads to a

Leukoplakia, a white plaque that cannot

Contact Keratosis and Smokeless

normal appearance within a few weeks

be characterized clinically as any

Tobacco Keratosis: Features of

in 98% of users.1 Chronically held bulky

other disease, is an oral premalignant

Reactive White Lesions of the Oral

materials such as hard candy, sunflower

lesion. Although it typically presents

Mucosa. Head Neck Pathol. 2019

seeds or beef jerky, as seen in this

as single isolated lesion in the oral

Mar;13(1):16-24.

report, has been known to cause similar

cavity, it is known that leukoplakia

alterations.1

sometimes may present as multifocal

CM and Chi AC. 2016. Chapter 1

1

3.

Neville BW, Damm DD, Allen

lesions, evidence supports the concept

Developmental Defects of the Oral

Genodermatosis is a group of rare

of “field cancerization” of the upper

and Maxillofacial Region in Oral

genetic diseases that affect skin, and

aerodigestive track. The irregular

and Maxillofacial Pathology, 4th edi,

many of these diseases also affect

surface texture seen in the presenting

St. Louis, Missouri: Elsevier.

oral mucosa. White sponge nevus

case also raises the possibility if it

(WSN) is an autosomal dominant

may represent proliferative verrucous

and Chi AC. 2016. Chapter 16

condition caused by mutations of the

leukoplakia, a subtype of leukoplakia

Dermatologic Diseases in Oral and

keratin 4 and 13 genes.4 The patient

that is characterized clinically by

Maxillofacial Pathology, 4th edi, St.

typically has a family history for this

multifocal white plaques which show

condition and the lesions are usually

rough or verrucous surfaces.6 However,

present from birth or are seen in

the surface textural change seen in

the oral cavity: clinical presentation,

childhood. It most often presents as

this case is predominantly wrinkle or

diagnosis, and treatment.

bilateral, thick, white plaques with a

ripple rather than verrucous in pattern.

Semin Cutan Med Surg. 2015

corrugated, spongy texture on the

Nevertheless, the possibility of multi-

Dec;34(4):161-70.

buccal mucosa; although labial mucosa,

focal leukoplakia cannot be completely

ventral tongue, and soft palate also

excluded. If the lesions persist after

Tumours of the oral cavity and

can be affected. Extraoral mucosal

discontinuation of the beef jerky habit,

mobile tongue - Oral potentially

sites are less commonly affected

then the lesions will be considered

malignant disorders and oral

but include the nasal, esophageal,

as multi-focal leukoplakias and a

epithelial dysplasia. In: El-Naggar

laryngeal and anogenital mucosa.5 The

biopsy will be necessary for definitive

AK, Chan JKC, Grandis JR, Takata

WSN lesions do not disappear upon

diagnosis.

T, Slootweg PJ, editors, WHO

4.

Neville BW, Damm DD, Allen CM

Louis, Missouri: Elsevier.

5.

6.

Jones KB, Jordan R. White lesions in

Takata T and Slootweg PJ. 2017.

Classification of Head and Neck

stretching. The diagnosis can be made by a combination of family history and

Although it is uncommon, when

Tumors, 4th edi, International

clinical evaluation, although exfoliative

oral examination reveals a clinical

Agency for Research on Cancer

cytology (oral smear) stained with

presentation that is similar to tobacco

(IARC), Lyon Cedex, France

Papanicolaou method or biopsy may

pouch keratosis, but the patient

provide more definitive diagnosis.

does not have a history of snuff use

Peri-nuclear eosinophilic condensation

and leukoedema has been excluded

in keratinocytes of the superficial

clinically, keratosis caused by other

spinous cell layer is a characteristic

bulky materials (beef jerky, hard candy

and diagnostic microscopic feature for

or sunflower seed) may be considered

WSN. This feature can be seen in both

in the clinical work-up plan.

Papanicolaou-stained oral smear and

www.tda.org | December 2023

613

value

for your profession Provided by:

PERKS

P R OG R A M

Thinking of Transitioning to Practice Ownership?

Here are Good Reasons to Choose This Path.

Provided by Xite Realty

614 Texas Dental Journal | Vol 140 | No. 10

For dental associates who’ve spent years refining their skills at someone else’s practice, transitioning to practice ownership could be the right move.

The Ability to Build Your Ideal Patient Base

opportunities that align with your budget and long-term financial goals.

You exercise full control over all financial decisions; and you can make choices that maximize profitability, ensuring

Choosing this path could have a significant impact on your career and

When you tailor your practice to reflect

the financial health and sustainability of

financial future.

your ideals, you’re able to set your

your practice from the outset.

practice apart and make it instantly If you’re an associate eyeing practice

recognizable.

good option, but there are potential

ownership, here are compelling benefits of choosing this entrepreneurial path.

Having Control Over your Practice Vision The significant opportunities that crafting your practice from the ground up offers can’t be overstated.

Starting fresh allows you to sculpt your practice according to your vision. You set the tone, design your distinctive culture, and align them with your preferences for the well-being of your patients.

For example, you’ll have the freedom to shape your office layout according to your vision. You can create a space

For example, outfitting your office

drawbacks. Acquiring an established

with state-of-the-art dental equipment

practice often comes with a substantial

and technology is a game-changer for

financial commitment upfront. You

patients seeking modern and efficient

may inherit existing debts or financial

care.

burdens, leaving you budgetary control and flexibility that start-ups offer.

If you build a strong local presence through local engagement and combine that with a well-crafted online presence (marketing your practice’s brand identity—a creative, dynamic opportunity you also have control over), this potent combination can attract patients who are drawn to your approach and values.

But this means you’ll need to form meaningful connections in your community and build a robust online presence.

Conclusion The advantages of launching a new dental office are clear: total control over your practice setup, a canvas for painting your unique vision, the ability to create a dynamic, technology-rich environment, and financial autonomy.

We encourage associates to contemplate the possibilities the entrepreneurial journey presents, weigh your options; and perhaps take the transformative step towards ownership

that functions seamlessly to deliver

Financial

the best patient care and design the

Autonomy and

environment where you and your

Buying an existing practice is another

of a practice that truly reflects their values and ambitions and offers a world of potential.

patients will spend substantial time.

Fiscal Management

Significantly, you’ll be able to embrace

Launching a new office grants you

offers services ranging from finding the

unparalleled financial autonomy. You’ll

best location for a practice to turnkey

be managing startup costs and tailoring

dental project management. Xite can

your budget to your financial situation,

also negotiate your lease and help with

so you can build your practice on a solid

building to suit. TDA members receive

financial foundation.

a free initial demographic analysis—

innovation and incorporate modern technology into your practice. With digital imaging and the latest dental tools, you have the power to provide cutting-edge care and enhance patient care and satisfaction.

TDA Perks Program-endorsed Xite Realty

both on existing space(s) as well as any Leasing a new practice space offers

new offices being considered. For more

an additional advantage by giving you

information, visit tdaperks.com (Financial

the ability to explore cost-effective

and Real Estate) or call 214-306-4555.

www.tda.org | December 2023

615

classifieds Opportunities Online at TDA.org and Printed in the

PRACTICE OPPORTUNITIES ALL TEXAS LISTINGS FOR MCLERRAN &

Texas Dental Journal

ASSOCIATES. AUSTIN-NORTH (ID #604):

CLASSIFIEDS INFORMATION

reputation located in a budding community

DEADLINE Copy text is due the 20th of the month, 2 months prior to publication (ie, January issue has a due date of November 20.)

MONTHLY RATES PRINT: First 30 words—$60 for ADA/TDA members & $100 for non-members. $0.10 each additional word.

Legacy FFS practice with an impeccable north of Austin. The office has relied solely on word-of-mouth referrals with very little marketing/advertising and refers out many specialty procedures leading to upside potential for an incoming buyer. The real estate is also available for purchase. AUSTIN (ID #636): Rare opportunity to purchase a turnkey, FFS/PPO general dentistry practice and real estate in Austin. This spacious 2,500 sq ft office features

ONLINE: $40 per month (no word limit). Online ads are circulated on the 1st business day of each month, however an ad can be placed

4 operatories, digital radiography, iTero, and paperless charts. The practice is situated in a

within 24 business hours for an additional fee

highly desirable Austin community. HOUSTON

of $60.

SUBURB (ID #610): GD practice plus real estate

SUBMISSION Ads must be submitted, and are only accepted,

just 45 minutes from downtown Houston.

Large PPO/FFS patient base, approx. 2,200

via www.tda.org/Member-Resources/TDA-

active patients, all perio, implants, and ortho

Classified-Ads-Terms. By official TDA resolution,

is being referred out. The owner is retiring

ads may not quote specific incomes or

and open to a transition period. HOUSTON-

revenues and must be stated in generic terms (ie “$315,000” should be “low-to-mid-6 figures”).

SOUTHWEST (ID #625): Modern GD practice

Journal editors reserve the right to edit and/or

in a high-visibility retail location in a desirable

deny copy.

suburb in southwest Houston. Large, 2,800 sq ft office that features 6 fully equipped

616 Texas Dental Journal | Vol 140 | No. 10

operatories, computers in operatories, intra

figures in revenue and strong net income. The

oral cameras, a digital scanner, and CBCT. The

turn-key practice features 4 fully equipped

practice is on track to collect over 7 figures

operatories with digital radiography, intra

in 2023 with strong historical year over year

oral cameras, paperless charts, CBCT, and a

growth. The office serves a primarily FFS patient

digital scanner. SAN ANTONIO (ID #635):

base with a limited number of patients in-

Established general dentistry practice in San

network, has over 1,450 active patients, and

Antonio. Large 2,500 sq ft office space, 8

has added 25+ new patients per month over

total operatories, with computers in the ops,

the last 12 months. HOUSTON-SOUTHWEST

digital sensors, and intra oral cameras. The

(ID #627): Legacy GD practice with majority FFS

practice has realized revenue of over 7 figures

patient base in a growing southwest Houston

consistently over the past several years and has

suburb. Located in a retail center on a busy

exceptional cash flow. The office serves a large,

intersection, this 1,200 sq ft office features

multi-generational patient base, sees 20+ new

4 fully equipped ops plumbed for nitrous,

patients per month, and has approximately 40%

computers throughout, digital radiography,

of total production coming from the hygiene

a digital scanner, intraoral cameras, and

department on an annual basis. TEXAS HILL

paperless charts. HOUSTON-NORTH (ID #618):

COUNTRY, ORTHO (ID #616): Rare opportunity

100% FFS, legacy office located in a high traffic

to purchase an orthodontic practice located

retail shopping center in a highly desirable

in a serene, rapidly growing community in the

suburb north of Houston. 4 fully equipped

Texas Hill Country (Austin, San Antonio, and the

ops with digital sensors, intraoral cameras,

Texas wine country all available within a short

computers in ops, and paperless charts. This

drive). State-of-the-art facility with extensive,

is a rare opportunity to own an established,

modern upgrades and top-of-the-line digital

legacy practice in a sought-out community that

technology. The buyer will have the option

is sure to move quickly! NORTHEAST TEXAS

of purchasing or leasing the real estate. The

(ID #584): 100% FFS general dentistry practice

current owner will be retiring but is available

in a desirable town in northeast Texas with 7

to provide a transition period to the incoming

www.tda.org | December 2023

617

classifieds buyer. TO REQUEST MORE INFORMATION

area. Majority of patients are 30 to 65 years

ON MCLERRAN & ASSOCIATESí LISTINGS:

old. Practice has operated at this location for

Please register at www.dentaltransitions.

over 38 years. Practice sees patients about 16

com or contact us at 512-900-7989 or info@

days a month. Collection ratio of 100%. The

dentaltransitions.com.

practice is a fee-for-service practice. Building is owned by dentist and is available for sale.

AUSTIN: Fee-for-service private practice,

Contact Christopher Dunn at 800-930-8017

45 years same location with a 10-15 mile

or christopher@ddrdental.com. HOUSTON

panoramic view over downtown Austin

(SHARPSTOWN AREA): GENERAL (REFERENCE

skyline. Associate to buy with a preferred long

“SHARPSTOWN GENERAL”). Motivated seller.

transition for the senior doctor. Nine years

Well-established general dentist with high-

remaining current lease. Tremendous amount

6 figure gross production. Comprehensive

of residential growth immediately outside

general dentistry in the southwest Houston

our huge windows. Ideally a GP interested in

area focused on children (Medicaid). Very, very

learning full scale orthodontics. Please email for

high profitability. 1,300 sq ft, 4 operatories

information, info@austinskylinedental.com.

in single building. 95% collection ratio. Over 1,200 active patients. 20% Medicaid, 45%

BEAUMONT: GENERAL (REFERENCE

PPO, and 35% fee-for-service. 30% of patients

“BEAUMONT”). Small town practice near a

younger than 30. Office open 6 days a week and

main thoroughfare. 80 miles east of Houston.

accepts Medicaid. Contact Christopher Dunn

Collections in 7 figures. Country living, close

at 800-930-8017 or christopher@ddrdental.

enough to Houston for small commute.

com. HOUSTON (BAYTOWN AREA): GENERAL

Practice in a stand-alone building built in

(REFERENCE “BAYTOWN GENERAL”). Motivated

1970. The office is 1,675 sq ft with 4 total

seller. Well-established general practice with

operatories, 2 operatories for hygiene and 2

mid-6 figure gross production. Comprehensive

operatories for dentistry. Contains reception

general dentistry in Baytown on the east side of

area, dentist office, sterilization area, lab

Houston. Great opportunity for growth! 1,400

618 Texas Dental Journal | Vol 140 | No. 10

sq ft, 4 operatories in single story building.

Located within a beautiful single-story, free-

100% collection ratio. 100% fee for service.

standing building, built in 1996 and is ALSO

Practice focuses on restorative, cosmetic and

available for purchase. Natural light from large

implant dental procedures. Office open 3.5 days

windows within 2,300 sq ft with 4 operatories

a week. Practice area is owned by dentist and

(2 hygiene and 2 dental). Includes a reception

is available for sale. Contact Christopher Dunn

area, dentist office, a sterilization area, lab

at 800-930-8017 or christopher@ddrdental.

area, and break room. All operatories fully

com. WEST OF AUSTIN: ORTHODONTIC

equipped. Does not have a pano but does

(REFERENCE “HILL COUNTRY ORTHO”). Located

have digital X-ray. Production is 50% FFS and

in a rapidly growing small town, this practice

50% PPO (no Medicaid), with collection ratio

is in the heart of the Texas Hill Country. This practice serves the youth of the area. There are 4 operatories in the practice. The practice is 100% fee-for-service. Orthodontic care is the only service provided at this office. 1300 sq ft Open 4 days per week. Digital X-rays and pano and Cloud9Ortho software. The practice has excellent visibility and is located near a hospital.

McLerran & Associates is the largest dental practice brokerage firm in Texas.

When it’s time to buy or sell a practice, we’ve got you covered.

Contact Christopher Dunn at 800-930-8017 or christopher@ddrdental.com.

HOUSTON, COLLEGE STATION, AND LUFKIN

DS O

P RAC T I C E S AL E S C S

Austin

512-900-7989

DFW

214-960-4451

for other DDR Dental listings and visit www.

Houston

281-362-1707

DDRDental.com for full details. LUFKIN: General

San Antonio 210-737-0100

(DDR DENTAL Listings). (See also AUSTIN

practice on a high visibility outer loop highway near mall, hospital and mature neighborhoods.

P RAC T I C E AP P RA ISA LS

South Texas 361-221-1990 E m ai l : t ex as@ den t al t r an si t i o n s.co m www.dentaltransitions.com

www.tda.org | December 2023

619

classifieds above 95%. Providing general dental and

plumbed for 5 operatories. Digital pano and

cosmetic procedures, producing mid-6 figure

digital X-ray. Contact Christopher Dunn at

gross collections. Contact Christopher Dunn

800-930-8017 or christopher@ddrdental.com

at 800-930-8017 or Christopher@DDRDental.

and reference “Pearland General or TX#538”.

com and reference “Lufkin General or TX#540”.

HOUSTON: PEDIATRIC (NORTH HOUSTON).

HOUSTON: GENERAL (SHARPSTOWN). Well

This practice is located in a highly sought-

established general dentist with high-6 figure

after upscale neighborhood. It is on a major

gross production. Comprehensive general

thoroughfare with high visibility in a strip

dentistry in the southwest Houston area

shopping center. The practice has 3 operatories

focused on children (Medicaid). Very, very

for hygiene and 2 for dentistry. Nitrous is

high profitability. 1,300 sq ft, 4 operatories

plumbed for all operatories. The practice has

in single building. 95% collection ratio. Over

digital X-rays and is fully computerized. The

1,200 active patients. 20% Medicaid, 45%

practice was completely renovated in 2018.

PPO, and 35% fee-for-service. 30% of patients

The practice is only open 3.5 days per week.

younger than 30. Office open 6 days a week

Contact Christopher Dunn at 800-930-8017

and accepts Medicaid. Contact Chrissy Dunn

or christopher@ddrdental.com and reference

at 800-930-8017 or chrissy@ddrdental.

“North Houston or TX#562”. WEST HOUSTON:

com and reference “Sharpstown General or

MOTIVATED SELLER. Medicaid practice with

TX#548”. HOUSTON: GENERAL (PEARLAND

production over 6 figures. Three operatories

AREA). General located in southeast Houston

in 1,200 sq ft in a strip shopping center.

near Beltway 8. It is in a freestanding building.

Equipment is within 10 years of age. Has a pano

Dentist has ownership in the building and

and digital X-ray. Great location. If interested

would like to sell the ownership in the building

contact chrissy@ddrdental.com. Reference

with the practice. One office currently in use

“West Houston General or TX#559”.

by seller. A 60% of patients age 31 to 80 and 20% 80 and above. Four operatories in use,

620 Texas Dental Journal | Vol 140 | No. 10

PORTLAND, TEXAS: Seeking full time associate

WATSON BROWN PRACTICES FOR SALE:

in an established, fee-for-service, high

Practices for sale in Texas and surrounding

quality dental practice. This is an exceptional

states, For more information and current

opportunity to move into partnership after

listings please visit our website at www.

a successful initial employment phase. Must

adstexas.com or call us at 469-222-3200 to

be committed to providing optimal patient

speak with Frank or Jeremy.

care with exceptional technical skills, strong people skills and a passion for excellence. This practice has a dynamic, experienced team

INTERIM SERVICES

and a strong emphasis on CE and professional growth. Please send CV and a letter outlining

HAVE MIRROR AND EXPLORER, WILL TRAVEL:

your future objectives and goals to pam@

Sick leave, maternity leave, vacation, or death, I

lifetransitions.com.

will cover your general or pediatric practice. Call Robert Zoch, DDS, MAGD, at 512-517-2826 or

ROCKPORT: Practice for sale in Rockport.

drzoch@yahoo.com.

Two chairs, plumbed for 3. Currently being worked 3 days a week producing near mid6 figures. Fee-for-service, no DMO, HMO or PPO contracts. Hygienist 3 days a week and will stay, been with practice since 2019. Digital X-rays, paperless, Newtom 3D/Panorex, (3) X-ray sensors. Practice is in older house, which can be leased or purchased. Great starter practice or for someone slowing down and wants to live on the coast. Send inquires to jim@jlongdds.com or call: 281-726-1812, leave message.

www.tda.org | December 2023

621

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WHO CAN YOU TRUST?

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If you or a dental colleague are experiencing impairment due to substance use or mental illness, The Professional Recovery Network is here

Law Offices of Mark J. Hanna......................................583 McLerran & Associates.................................................619 Princess Dental Staffing..................................Back Cover

to provide support and an opportunity for confidential recovery.

Professional Recovery Network..................................622 TDA Perks............................................. Inside Front Cover Texas A&M School of Dentistry...................................587 Texas Health Steps.......................................................577 UTHSC SA/South Texas Pathology Lab.......................583 Watson Brown...............................................................579

PRN Helpline (800) 727-5152

Visit us online www.txprn.com

622 Texas Dental Journal | Vol 140 | No. 10

Since 1996, our team of experts have provided successful transition services exclusively to dentists. Choice prides itself on its reputation for integrity, service and results.

Considering selling to a DSO? Scan the QR code to watch a brief and informative video to help you decide.

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624 Texas Dental Journal | Vol 140 | No. 10 m Ipsum