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
Live Programs Available Throughout Texas
Approved PACE Program Provider FAGD/MAGD Credit. Approval does not imply acceptance by a state of provincial board of dentistry or AGD endorsement. 8/1/2018 to 7/31/2022. Provider ID# 217924
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.
Dr. Canfield
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:
Principles of Pain Management Fulfills rule 104.1 for all practitioners
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!
(Parenteral Review) Level 3 or Level 4 Anesthesia Programs (In Class, Webcast and Online available): American Heart Association Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) Initial and Renewal Programs NOTE: ACLS or PALS Renewal can be completed by itself at any combined program
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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
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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. Contact us to receive a free practice valuation.
WBpracticesales.com *
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 •
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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
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Professional Recovery Network (PRN) Compliance
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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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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
References
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H. Hintze, A. Wenzel, B. Danielsen, B. Nyvad, Reliability
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covered her salary. The other co-
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authors, Panagiotis Ntovas, Ana R.
direct visual examination
Benetti, Azam Bakhshandeh, Kim R.
following tooth separation for
Ekstrand, Christos Rahiotis, and Afrodite
the identification of cavitated carious lesions in contacting
Kakampoura declare that they have no
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32 (1998) 204–209, https://doi.
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org/10.1159/000016454. 3.
Huang, et al. Comparison of a smartphone-based photographic
Acknowledgements
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assessment: A mobile teledentistry
technician Liselotte Larsen for her
model, Telemed. J. E. Health.
assistance with the sample storage and
23 (2017) 435–440, https://doi.
preparation for histological assessment, the development teams at 3Shape TRIOS A/S for technical support, and
M. Estai, Y. Kanagasingam, B.
org/10.1089/tmj.2016.0122. 4.
S. Michou, A.R. Benetti, C. Vannahme, P.G. Hermannsson,
Innovation Fund Denmark for financial
A. Bakhshandeh, K. R. Ekstrand.
support (grant no. 8053-00005B).
Development of a fluorescence-
Visualization, Writing—review &
Ethics
editing. AR Benetti: Conceptualization,
This study received ethical approval
Methodology, Resources, Writing—
from the Research Ethics Committee
review & editing, Supervision,
of the School of Dentistry (National
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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
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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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Visit us online www.txprn.com
622 Texas Dental Journal | Vol 140 | No. 10
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624 Texas Dental Journal | Vol 140 | No. 10 m Ipsum