February 2022 Texas Dental Journal

February 2022

TEXAS DENTAL

INSIDE:

Combination Therapy: How Dentistry Can Assist the Medical Community www.tda.org | February 2022

53

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Texas Dental Journal | Vol 139 | No. 2

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www.tda.org | February 2022

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Contents February 2022 Established February 1883 n Vol 139, No. 2

FEATURES 72 | Combination Therapy: How Dentistry Can Assist the Medical Community Martin Denbar, DDS, D.ABDSM Aaron Glick, DDS, D.ABDSM A patient with poor dentition as the foundation for the oral appliance can provide a particularly complicated management strategy for the medical and dental practitioner.

Ideally, patients seeking oral appliance therapy will present with healthy periodontium and perioral

DEPARTMENTS

82 | Oral and Maxillofacial

60 | President’s Message

Month Diagnosis and

structures, but that is not always

61 | TDA Governance:

the case.

86 | Value for Your

64 | TDA Governance:

in an Era of Stagnant

Texas Dental Association House of Delegates 66 | Oral and Maxillofacial

56

Management

Officia Call for Nominations

Official Call to the 2022

TDA members, use your smartphone to scan this QR Code and access the online Texas Dental Journal.

Pathology Case of the

Pathology Case of the Month

Texas Dental Journal | Vol 139 | No. 2

Profession: How to Thrive or Declining Insurance Reimbursements 90 | Advertising Briefs 98 | Calendar of Events 99 | Index to Advertisers

Editorial Staff Daniel L. Jones, DDS, PhD, Editor Paras B. Patel, 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 Robert C. White, DDS Leighton A. Wier, DDS Douglas B. Willingham, DDS

The Texas Dental Journal is a peer-reviewed publication.

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 (one issue will be a directory issue), by the Texas Dental Association, 1946 S IH-35, Austin, TX, 787043698, 512-443-3675. Periodicals Postage Paid at Austin, Texas and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S IH 35, Austin, TX 78704. Copyright 2018 Texas Dental Association. All rights reserved.

Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, Out-of-state ADA Affiliated $49.50. In-state Non-ADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA Affiliated, $17 Non-ADA Affiliated, September issue $17 ADA Affiliated, $65 NonADA 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 printed in the 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 Association of the quality of value of Dental Editors and such product or of the claims made of Journalists. it by its manufacturer.

Board of Directors PRESIDENT Debrah J. Worsham, DDS 936-598-2626, worshamdds@sbcglobal.net PRESIDENT-ELECT Duc “Duke” M. Ho, DDS 281-395-2112, ducmho@sbcglobal.net PAST PRESIDENT Jacqueline M. Plemons, DDS, MS 214-369-8585, drplemons@yahoo.com VICE PRESIDENT, NORTHEAST Carmen P. Smith, DDS 214-503-6776, drprincele@gmail.com VICE PRESIDENT, SOUTHEAST Georganne P. McCandless, DDS 281-516-2700, gmccandl@yahoo.com VICE PRESIDENT, SOUTHWEST J. Ted Thompson, DDS 361-242-3151, tedito@aol.com 817-238-6450, pdalw@yahoo.com VICE PRESIDENT, NORTHWEST E. Dale Martin, DDS SENIOR DIRECTOR, NORTHEAST Elizabeth S. Goldman, DDS 214-585-0268, texasredbuddental@gmail.com SENIOR DIRECTOR, SOUTHEAST Glenda G. Owen, DDS 713-622-2248, dr.owen@owendds.com SENIOR DIRECTOR, SOUTHWEST Carlos Cruz, DDS 956-627-3556, ccruzdds@hotmail.com SENIOR DIRECTOR, NORTHWEST Teri B. Lovelace, DDS 325-695-1131, lovelace27@icloud.com DIRECTOR, NORTHEAST Jodi D. Danna, DDS 972-377-7800, jodidds1@gmail.com DIRECTOR, SOUTHEAST Shailee J. Gupta, DDS 512-879-6225, sgupta@stdavidsfoundation.org DIRECTOR, SOUTHWEST Richard M. Potter, DDS 210-673-9051, rnpotter@att.net DIRECTOR, NORTHWEST Summer Ketron Roark, DDS 806-793-3556, summerketron@gmail.com SECRETARY-TREASURER* Cody C. Graves, DDS 325-648-2251, drc@centex.net 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** Daniel L. Jones, DDS, PhD 214-828-8350, editor@tda.org LEGAL COUNSEL Carl R. Galant William H. Bingham, Advisor *Non-voting member **Non-voting attendee

www.tda.org | February 2022

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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

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

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

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

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

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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

Combined ACLS-PALS-BLS and Level 2, 3 and 4 Program

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

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Texas Dental Journal | Vol 139 | No. 2

CELEBRATING 30 YEARS

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| February 2022

59

Chewon this Man Plans, and God Laughs.

Despite our most careful planning, sometimes life and Mother Nature can be highly unpredictable. If you’re living in Texas in February, you know how true that statement is. The TDA’s plan for the February leadership conference was to bring leaders from component societies across the state to Austin for fellowship, to provide updates on TDA’s advocacy efforts, council activities, membership trends and initiatives, and to hear from components how TDA can better meet their needs. Since our conference didn’t happen as planned here is a report on some of those topics that impact your profession and your Association.

TDA’s Council members work diligently each year to accomplish goals outlined in TDA’s strategic plan.

The Council on Membership, New Dentists and Students is hosting their second “Diversity in Dentistry” Town Hall Webinar on March 10, 2022 at 6:30 p.m. Look for information on all social media platforms and in an upcoming email. TDA Presidentelect, Dr Duc “Duke” Ho will be the facilitator for the event. The Council held its first Local Leaders Forum on March 2, providing component leaders the opportunity to collaborate on issues impacting membership statewide.

CLRA met on January 28, 2022 and discussed numerous topics including the primary election held on March 1, 2022 and its potential impact on the Texas House of Representatives and the Texas Senate, the TDA’s legislative agenda for the 88th session which begins in January, 2023, dental insurance legislation addressing network leasing, retroactive denials, and disallowables, and Medicaid dental reimbursement rate increases.

The TDA and CLRA are also currently working closely with the Texas State Board of Dental Examiners on rules associated with teledentistry legislation that TDA helped pass through the legislature last session.

Texas Dental Journal | Vol 139

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The DENPAC Board recently approved a slate of campaign contributions which were given to candidates before the March 1st Primary Election. Many of those contributions were hand delivered by “key contact dentists.” Key contacts are TDA member dentists who are committed to the advancement of TDA issues and who serve as liaisons to one or more elected state officials. If you have personal or political ties to an elected official, or are interested in developing connections, and would like to serve as a key contact dentist, please email Staci Rives at srives@ tda.org.

TDA’s Council on Professions and Trends is tasked with monitoring economic issues affecting dentistry, emerging trends, and practice innovations. CPT recently examined insurance-related pain points affecting Texas dentists and recommended CLRA look at addressing disallowables legislatively.

CPT is also in the process of updating The Navigator, TDA’s in-depth practice resource guidebook.

The Council on Public Health and Access to Care recently submitted recommendations to the Texas Health and Human Services Commission’s (HHSC) Rider 26 Workgroup on Medicaid diagnostic dental services.

The workgroup, authorized by HHSC Budget Rider 26 during the 87th Regular Legislative Session, is completing a comprehensive review of all dental codes in the Medicaid dental program and making recommendations to HHSC about Medicaid dental codes at higher risk of fraud, waste, and abuse along with proposals to ameliorate that risk.

The Council on Dental Licensing, Standards and Education is working on reports to the Texas Dental Association’s leadership about licensure and clinical considerations when using Botox and dermalfillers in dentistry. Additionally, the council continues work on teledentistry and changes | No. 2 to the Texas State Board

TDA President Debrah J. Worsham, DDS of Dental Examiners’ regulation governing the minimum standard of dental care in Texas.

The Council on Governance meets on March 11-12, 2022 to discuss and make any governance-related recommendations to the Board at its last meeting prior to the 2022 TDA House of Delegates. Such recommendations may include Board and Council proposed changes to TDA Bylaws and other governing documents and manuals of the Association.

TDA ended 2021 at over 8,800 members, but with only 46.7% market share. That number is up slightly from 2020 which was a year of loss for most all professional membership associations. It’s up to us to create opportunities for growth, especially among our new dentist members. Remember what it was like when you first started practice?

You needed a mentor, you needed someone to share an experience with, and you needed a smile from a friendly face when you walked into a local meeting.

My continual message has been to reach out to colleagues and invite them to a meeting, and I encourage each of you to accept this challenge.

New dentists need mentors and dialogue with peers Everyone needs relationships with those experiencing similar life events and practice issues.

Make an effort to connect with those dentists around you, make yourself available as a resource for those needing assistance, and make an impact by being a positive influence along the way!

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 Candidacy announcements for the statewide elective office of Texas Dental Association (TDA) Speaker of the House may be submitted to TDA Secretary-Treasurer Dr Cody C Graves for the upcoming 2021 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 statement. Nominations are in order at the first meeting of the House of Delegates and remain open until the close 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 of the House of Delegates. Please see the Manual on Caucus, Campaigns, Nominations and Elections at tda.org for full details.

Duties of the Speaker of the House are enumerated in the Bylaws and include the following: 1. To serve as an ex-officio member of the Board of Directors without vote or the privilege of proposing resolutions.

2. To serve as an ex-officio member of the Executive Committee without vote or the privilege of proposing resolutions.

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.

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, the number of delegates and alternates necessary to constitute a quorum.

8. To meet with the divisional officers prior to the meeting of the divisional caucuses at the annual session to review the Rules for Caucus Procedures, Nominations, And Elections.

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.

10. To serve as presiding officer of the TDA Candidates Forum, unless the Speaker is in a contested race, at which time the Speaker Pro-tem will preside.

11. To be a certified parliamentarian or be in the process of certification Candidacy announcements are to be mailed to TDA Secretary-Treasurer Dr Cody C Graves, Texas Dental Association, 1946 S IH-35 Ste 400, Austin, Texas 78704; or, emailed to TDA Executive Director Linda Brady: lbrady@tda.org.

(See TDA Bylaws, Chapter IV, House of Delegates—Sections 100 (Officers), 110A (Duties), 150C(3), 150D, Chapter V, Board of Directors—Sections 10 (Composition); TDA House Manual; Speaker Manual).

www.tda.org | February 2022

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OFFICIAL CALL FOR SECRETARY-TREASURER CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS Candidacy announcements for the statewide elective office of Texas Dental Association (TDA) Secretary-Treasurer may be submitted to TDA Secretary-Treasurer Dr Cody C Graves for the upcoming 2021 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 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 of the House of Delegates. Please see the Manual on Caucus, Campaigns, Nominations and Elections at tda. org for full details.

Duties of the TDA Secretary-Treasurer are enumerated in the Bylaws and include the following: 1. Serve as chair, without vote, of the Budget, Assets and Finance Committee.

2. Examine the income and expenses of this Association and report at each meeting of the Board of Directors.

3. Ensure that the minutes of the House of Delegates and the Board of Directors be maintained.

4. To be responsible and perform such other duties as shall be specified by the Board of Directors and the Bylaws.

Other duties as Secretary include the following: • 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 the right to vote.

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Texas Dental Journal | Vol 139 | No. 2

• •

Serve as secretary to the House of Delegates.

Serve as the secretary of the American Dental Association Fifteenth Trustee District Delegation.

Candidacy announcements are to be mailed to TDA Secretary-Treasurer Dr Cody C Graves, 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 70A-B (Notice and Publication—Official Call & Publication of Actions, 110B (Duties); Chapter V, Board of Directors —Sections 10 (Composition), 80B (OfficersSecretary); 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).

OFFICIAL CALL FOR EDITOR CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS Candidacy announcements for the statewide elective office of Texas Dental Association (TDA) Editor may be submitted to TDA SecretaryTreasurer Dr Cody C Graves for the upcoming 2021 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 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 of the House of Delegates. Please see the Manual on Caucus,

Campaigns, Nominations and Elections at tda. org for full details.

Duties of the editor are enumerated in the Bylaws and include the following: 1. To be editor-in-chief of all journals and publications of the Association and exercise full editorial control over such publications, subject only to policies established by the House of Delegates, Board of Directors, and these Bylaws and provided such content is not in conflict with 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 editor may appoint associate editors, with the concurrence of the Board of Directors, to gather and/or review material for publication. Such associate editors shall serve as long as the editor deems necessary; but never longer than the term of the editor.

3. To attend all open meetings of the Board of Directors and the House of Delegates of this association, and the annual session of the American Dental Association.

4. To hold no other elective 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 ADA House of Delegates from his/her respective division.

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

Should the position of Editor become vacant ad interim, the Board of Directors shall appoint an Editor to act in the vacated position until such time as an Editor is nominated and elected in accordance with Chapter V, Sections 40B,b and Chapter IV, Sections 30B,b and 150 of these Bylaws.

Candidacy announcements are to be mailed to TDA Secretary-Treasurer Dr Cody C Graves, Texas Dental Association, 1946 S IH-35 Ste 400, Austin, Texas 78704; or, emailed to TDA Executive Director Linda Brady: lbrady@tda.org.

JKJ Pathology Oral Pathology Laboratory

John E Kacher, DDS • Available for consultation by phone or email • Color histology images on all reports • Expedited specimen shipping with tracking numbers • Reports available online through secure web interface

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Call or email for free kits or consultation. jkjpathology.com 281-292-7954 (T) 281-292-7372 (F) johnkacher@jkjpathology.com

Protecting your patients, limiting your liability

(Ref. TDA Bylaws, Chapter VI, Elective Officers —Section 90I (Duties); Policy Manual). www.tda.org | February 2022

63

OFFICIAL CALL TO THE 2022 TEXAS DENTAL ASSOCIATION HOUSE OF DELEGATES HOUSE OF DELEGATES:

REFERENCE COMMITTEE HEARINGS:

In accordance with Chapter IV, Section 70, paragraph

Reference Committee

A-1 of the Texas Dental

hearings will be facilitated

Association (TDA) Bylaws,

on Thursday, May 5, 2022

this is the official call for the

open to all members who

152nd Annual Session of

are present (any changes

the Texas Dental Association

to committee start times

House of Delegates. All

will be posted on the TDA

sessions of the House

website and announced

will be in the Lost Pines

at the first meeting of the

Ballroom of the Hyatt

House of Delegates):

Regency Lost Pines,

10:00 AM

Bastrop, Texas. The opening session of the House will convene at 8:00 a.m. on Thursday, May 5, 2022. The second meeting of the House will be at 1:30

REFERENCE COMMITTEES A & B (COMBINED) LOST PINES 1

p.m. on Friday, May 6, 2022. The third meeting of

COMMITTEE A:

the House will be at 8:00

Administration, Budget,

a.m. on Saturday, May 7,

Building, House of

2022, followed by the fourth

Delegates, Membership

meeting at 1:30 p.m. until

Processing

close of business.

Component Societies are urged to certify an accurate list of Delegates and Alternates to fill each of their seats on the floor of the TDA House of

COMMITTEE B: President’s Address, Miscellaneous Matters, Component Societies, Subsidiaries, Strategic Planning, Annual Session

Delegates.

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Texas Dental Journal | Vol 139 | No. 2

1:00 PM REFERENCE COMMITTEES C & D (COMBINED) LOST PINES 2 COMMITTEE C: Dental Education, Dental Economics, Health and Dental Care Programs COMMITTEE D: Legislative, Legal and Governmental Affairs

3:30 PM REFERENCE COMMITTEE E: Constitution, Bylaws, Ethics & Peer Review LOST PINES 3 The agendas for these committee meetings will be included in the Reference Committee section of the Delegate materials and sent to the Delegates and Alternate Delegates at least 30 days in advance of the meetings.

REFERENCE COMMITTEE REPORTS: Reference Committee Reports will be posted on the TDA website and

participation by candidates

electronically at least 30

for ADA elected offices, the

days prior to the Annual

Candidates Forum will not

Session. The supplements

be held.

to the House Documents,

DIVISIONAL CAUCUSES:

containing the agenda and subsequent reports, will be sent after the March 2022 TDA Board of Directors

emailed in PDF format to the members of the House

Divisional Caucuses

meeting. The minutes of the

of Delegates (reports may

(Northwest, Northeast,

TDA Board shall be posted

be downloaded from any

Southwest, Southeast)

on the members’ side of

location with Internet

will be facilitated entirely

the TDA website and made

access). Printed copies will

through electronic virtual

available to the general

not be provided.

means at 6:00 p.m. CDT as

TDA membership once the

follows:

minutes are approved by

FINANCIAL FORUM:

the TDA Board of Directors •

Monday, April 25, 2022

in accordance with Policy

Northeast Division

26-2018-H. Delegates and alternates will receive all

The TDA SecretaryTreasurer will facilitate

•

a 1-hour questions and

Tuesday, April 26, 2022

House Documents in PDF

Southeast Division

format. Printed copies of the House Documents will not

answer financial forum open to all members who are

•

Wednesday, April 27, 2022

be provided.

Southwest Division

present at 9:30 a.m. on Thursday, May 5, 2022 in the same meeting room as Reference Committee A & B

•

Thursday, April 28, 2022

Wireless internet

Northwest Division

access will not be provided in the House

(Lost Pines 1).

Registration is required

of Delegates meeting

CANDIDATES FORUM:

and open to all current

room—please download

The ADA and TDA

additional information.

Candidates Forums will be held in Lost Pines 1 and 2 of the hotel on Friday, May

members—please see the

all House materials on

TDA website for details and

a fully-charged laptop

DELEGATE MATERIALS:

or device prior to attendance (charging stations will be centrally located in the meeting rooms).

6, 2022, from 10:30 a.m. to 12:00 p.m. In the event

In accordance with

there are no contested TDA

TDA Bylaws, the House

statewide elections and no

documents will be sent

www.tda.org | February 2022

65

ORAL

and maxillofacial pathology

Clinical History

A 53-year-old Hispanic male was referred to the predoctoral urgent care dental clinic at UT Health San Antonio with a chief complaint of, “I have been having some pain in my upper right gums near where I had a tooth extracted.” He reported having #1 extracted 4 months prior to presentation. Since the extraction, the patient experienced discomfort in the surrounding soft tissue. The pain described was continuous but fluctuated in severity. His discomfort at the time of presentation was 1/10, but he reported it had periodically increased to 7/10. He noticed the affected area was enlarged, and the distalmost tooth, #3, was loose.

case of the month AUTHORS Amanda Jean Wilson, BS Third-year dental student, School of Dentistry, UT Health San Antonio, San Antonio, Texas

Anne Cale Jones, DDS Distinguished Teaching Professor, School of Medicine, Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, Texas

Juliana Robledo, DDS Assistant Professor, School of Medicine, Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, Texas

Figure 1.

Clinical photograph demonstrating slight expansion of the buccal vestibule in the area of #6 and slight expansion of the alveolar ridge distal to #3.

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Numbness in the upper right posterior region, pain in the right periorbital area, mild changes in eyesight in the right eye, and pain in the right ear were reported. The patient’s past medical history was significant for hypertension, hyperlipidemia, and fatty liver; the fatty liver was treated for 3 months and no longer required medication. His social history included occasionally smoking cigars and a 6-year period of smoking cigarettes 20 years ago. He denied taking any medications besides ibuprofen for pain management and did not experience any fever, chills, nausea, or vomiting.

Intraoral examination revealed slight expansion of the buccal vestibule in the area of #6 and slight expansion of the alveolar ridge distal to #3 (Figure 1). Subtle expansion of the right palate extending to midline was also observed.

The areas of expansion were tender to palpation.

No discomfort was associated with #3 when tested with percussion and palpation, and it did not respond to pulpal testing.

Tooth #3 demonstrated class II mobility, grade I

furcation involvement, and sulcular probing depths of 3 mm or less. Teeth #4 and #5 did not respond to pulpal testing but teeth #6 and #7 responded normally.

The patient provided a panoramic radiograph taken at an outside clinic prior to the extraction of #1.

It revealed an ill-defined radiolucent lesion in the right maxilla extending from the distal of #1 to the anterior segment of the upper right quadrant.

The anterior extent was difficult to delineate due to the shadow from the airway. The panoramic radiograph confirmed the patient was missing #2 prior to the extraction of #1. He also provided two upper right molar periapical radiographs. The pre-extraction periapical radiograph showed a destructive radiolucent lesion extending from the distal of #1 to the distal root of #3. The mesial root of #1 and the apex of the distal root of #3 demonstrated external root resorption. The postextraction periapical radiograph showed irregular root apices of #3 and an expansile radiolucency extending from the

edentulous area distal of #3 to its mesial root. A new panoramic radiograph was obtained in the predoctoral urgent care dental clinic.

This radiograph revealed a destructive radiolucency involving the right maxilla distal and apical to #3 with destruction of the inferior wall of the maxillary sinus (Figure 2).

Based upon the clinical and radiographic presentation, the patient was scheduled in the graduate oral and maxillofacial surgery clinic for an incisional biopsy of the radiolucent lesion of the right posterior maxilla. A needle aspiration was performed which did not generate any aspirate. Tooth #3 was extracted, and the soft tissue from the region was excised and submitted for histopathologic examination.

Pathologic Findings The specimen was received in a container of formalin and contained four graytan irregularly shaped fragments of soft tissue measuring 2.2 x 1.6 x 0.7 cm in aggregate.

Histopathologic examination revealed a malignant www.tda.org | February 2022

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and maxillofacial pathology, continued

Figure 2. Panoramic radiograph revealed a destructive radiolucency involving the maxilla distal and apical to #3 with destruction of the inferior wall of the maxillary sinus.

epithelial glandular neoplasm invading the surrounding fibrous connective tissue. The neoplasm demonstrated two growth patterns: solid aggregates of neoplastic cells exhibiting tumor cell necrosis (comedo necrosis) and neoplastic cells arranged in a cribriform pattern (Figures 3 and 4).

Scattered small ducts with tiny lumina were noted in the solid areas. In the cribriform areas, cystic and pseudocystic spaces were evident, some of

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which contained a central basophilic material. A homogenous eosinophilic material, consistent with basal lamina, was noted surrounding some of the cribriform islands. The individual tumor cells contained round to oval shaped lightly basophilic nuclei with prominent nucleoli and pale eosinophilic cytoplasm. Scattered mitotic figures were noted in the neoplastic cells. Although extensive sampling was performed,

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no perineural invasion was identified. The neoplastic cells transected all surgical margins. Additional immunohistochemical stains were performed for phenotypic analysis and to rule out other malignant glandular neoplasms.

What is the most likely diagnosis?

See page 82 for the answer and discussion.

Figure 3. Malignant glandular neoplasm exhibiting solid islands of tumor cells and focal cystic areas (center and lower right) (H&E: original magnification 4x).

Figure 4. Malignant glandular neoplasm exhibiting a focal cribriform pattern (center), cystic and pseudocystic spaces, and solid islands of neoplastic cells (far right)(H&E: original magnification 10x).

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COMBINATION THERAPY: How Dentistry Can Assist the Medical Community Martin Denbar, DDS, D.ABDSM Aaron Glick, DDS, D.ABDSM

AUTHORS Martin Denbar, DDS, D.ABDSM, Adjunct Assistant Professor (Non-Principal Faculty), Department of Internal Medicine, Texas A&M School of Medicine, and Private Practice, Austin, Texas Aaron Glick, DDS, D.ABDSM, Clinical Assistant Professor, UTHealth School of Dentistry at Houston and Sam Houston State University College of Osteopathic Medicine Address correspondence to: Martin Denbar, dr.denbar@austinapnea.com

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A patient with poor dentition as the foundation for the oral appliance can provide a particularly complicated management strategy for the medical and dental practitioner. Ideally, patients seeking oral appliance therapy will present with healthy periodontium and perioral structures, but that is not always the case.

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Abstract Continuous positive airway pressure (CPAP) non-compliance with multiple co-morbidities can be a challenge for medical providers to manage. Combination therapy (PAP therapy with an oral appliance) can aid in managing a severe case of obstructive sleep apnea (OSA).

However, a patient with poor oral dentition as the foundation for the oral appliance can provide a particularly complicated management strategy for both the medical and dental practitioner. This case will review the successful management of a severe OSA patient with damaged dentition, bilateral artificial temporal mandibular jaw joint (TMJ) replacement, and limited opening with the use of combination therapy.

A 68-year-old female presented with uncontrolled hypertension, fibromyalgia, nasal allergies, severe sleep apnea, thyroid disorder, and severe claustrophobia. She had bilateral total TMJ joint replacement in 1980 with subsequent surgeries to remove the left and right auricular fossa. In addition, the patient had an implant supported lower denture with the remaining maxillary teeth heavily restored. The patient had limited opening of 29mm at the initial visit. She was treated in coordination with her cardiologist, primary care provider, and dentist. Her initial diagnosis of sleep apnea revealed an apnea-hypopnea index (AHI) of 43.3 and nadir of 55%. Due to claustrophobia, headgear discomfort, sleep interruption, and ineffectiveness of her treatment, she was unable to tolerate her CPAP and therefore was non-compliant with therapy. Jaw stretching exercises were completed allowing for an increased vertical and horizontal movement. After completing

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Continuous positive airway pressure (CPAP) non-compliance with multiple co-morbidities can be a challenge for medical providers to manage.

her simple physical therapy she was able to translate 3.25mm past centric occlusion and comfortably wear the oral appliance (TAP 3 TL). Drastic improvement occurred through the use of the oral appliance alone. Her time above 90% SpO2 (CT90) was 97.2% with elevated desaturation indices of 11.1 (4% oxygen desaturation) and 23 (3% oxygen desaturation), a significant improvement, but not total management. After completion of her titration protocol and attachment of the oral appliance to the CPAP nasal mask (Phillips Respironics DreamWear), the patient showed an AHI of 2.8 with median pressures of 7.3 cmH2O and a time of usage at 5 hours and 29 minutes. The field of Oral Appliance Therapy goes far beyond the “simple” cases of mild/moderate sleep apnea. When patients present for treatment there needs to be available therapies that are cost effective and yet still comprehensive enough to offer the patient. Compromised dental management is a necessity in many cases in order to meet the patient’s needs. This case is a classic example of the patient not having an ideal or adequate dental condition, yet full management was obtained within the confines of basic dentistry with minimal cost and overall excellent results.

Keywords obstructive sleep apnea (OSA), mandibular advancement, continuous positive airway pressure (CPAP), temporomandibular joint disorders, cumulative above 90% SpO2 (CT90), positive airway pressure (PAP), apnea hypopnea index (AHI), mandibular advancing device (MAD), central apnea (CA), high resolution pulse oximetry (HRPO)

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INTRODUCTION Oral appliance therapy (OAT) treats Obstructive Sleep Apnea (OSA) through repositioning the mandible in an anterior position during sleep.

This anterior movement elevates the hyoid, expands the posterior airway space particularly in a lateral direction, and increases muscle tone in the genioglossus.1 Oral appliances alone can sufficiently treat mild to moderate OSA in many cases and significantly reduce if not control severe OSA in rare cases.

OSA is in epidemic proportions globally in most of developed countries.

Continuous positive airway pressure (CPAP), although considered the gold standard of therapy, has been in question as a first line therapy due to poor long-term compliance rates.2,3 Patients that are untreated or undertreated that continue to suffer from OSA have a higher likelihood of hypertension, stroke, depression, and mortality, among other medical risks.4 Either partial or total CPAP non-compliance when seen

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in patients with significant multiple co-morbidities can be a challenge for medical providers to manage.

Combination Therapy (CT) combines positive airway pressure (PAP) therapy with an oral appliance (with or without an interface) to aid in managing a severe case of obstructive sleep apnea.

Traditionally the severity of OSA is measured by the Apnea Hypopnea Index (AHI), which is the number of times that patients partially or fully stop breathing per hour of sleep. Currently in the field of sleep medicine, there is criticism of using only the AHI as a measure of

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OSA severity, particularly since the metric does not adequately capture all clinical impacts of the disease and thus may potentially misrepresent the true severity.5 Other metrics that can also be used to assess the comprehensive impact of OSA are the Respiratory Disturbance Index (RDI), time spent below 90% SpO2 (CT90), and the lowest oxygen level reached when the patient is sleeping (nadir). These metrics are important when considering the complex nature of OSA. In addition, a patient with poor dentition as the

Her claustrophobia, not from the Interface or oral appliance, but from the mouth to nasal breathing caused panic attacks during the delivery phase.

The obtainable anterior translation of 3.25 mm from centric occlusion was enough to prevent mouth venting making the use of the Phillips Respironics Dream Wear nasal cushions effective without creating any claustrophobia.

foundation for the oral appliance can provide a particularly complicated management strategy for the medical and dental practitioner. Ideally, patients seeking oral appliance therapy will present with healthy periodontium and perioral structures, but that is not always the case. Patients with cardiovascular disease or other significant comorbidities will often present with major dental challenges when using an oral appliance. The healthcare provider, either medical or dental, will need to modify the patient’s therapy to obtain the

best treatment outcome personalized to those individual needs.

This case will review the successful management of a severe OSA patient with damaged dentition, minimal teeth, bilateral artificial temporomandibular jaw (TMJ) joint replacement, obligate mouth breathing, severe claustrophobia and limited opening using Combination Therapy with an Interface and adjustable mandibular advancing device (MAD).

CASE REPORT A 68-year-old female presented with uncontrolled hypertension, fibromyalgia, nasal allergies, severe sleep apnea, thyroid disorder, and severe claustrophobia.

She had been using nasal cushions with her CPAP but was not able to fully control her OSA with this treatment alone, due to exceptionally severe claustrophobia.

The patient had bilateral total TMJ joint replacement in 1980 with subsequent surgeries to remove the left and right auricular fossa due to infection.

This created a significant issue with her opening capability resulting in a limited opening of 29mm at the initial visit. In addition, she presented with an implant supported lower denture with remaining maxillary teeth 1, 2, 5, 7, 9, 13 (implant), 15, and 16 (Figure 1). The remaining maxillary teeth were heavily restored with existing decay and significant periodontal disease. During the impression phase for the master impression, the anterior bridge containing the teeth came out with the alginate impression.

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ill review A patient eral t re ombination

of 7.3 cmH2O and time of usage at 5 hours and 29 minutes. At her six-month follow-up examination her AHI is below 3 with time of usage six plus hours/night. Her general dentist is restoring her remaining dentition and treating her periodontal condition conservatively.

Figure 1. After completion of the titration protocol, the patient showed an AHI of 2.8 with median pressures of 7.3 cmH2O and time of usage at 5 hours and 29 minutes. At her 6-month followup examination her AHI is below 3 with time of usage 6 plus hours/night. Her general dentist is restoring her remaining dentition and treating her periodontal condition conservatively. corresponding inadequate oral hygiene habits.7-9 Her initial diagnosis of sleep apnea showed an AHI of 43.3 and nadir of 55%. Without the ability to utilize the conventional CPAP headgear to allow for the higher than normal air pressures required to control her OSA, therapy was minimally efficacious when it was used. Care was coordinated with her general dentist, cardiologist, and primary care provider. The treatment outline was developed and agreed upon. The patient was an obligate mouth breather with a low resting tongue level. A low resting tongue level can complicate CPAP

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and oral appliance therapy since it increases the chance of mouth venting.

In this case, due to the severity of claustrophobia, a lip guard could not be used to prevent mouth venting. A lip guard is a soft silicone barrier that fits on the TAP-PAP Interface stem covering the mouth and preventing air venting while breathing.

After an extensive consultation with the patient and with a close friend being present, the decision to proceed with treatment was made.

Due to the severity and complexity of this case, additional steps were completed to ensure treatment. Treatment

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began with simple jaw stretching exercises that the patient performed at home as often as she comfortably could. The patient was instructed to simulate the position of her hand as if she was going to snap her fingers. She placed her fingers between her upper and lower anterior teeth and slowly made the snapping motion stretching her jaw open, but only with comfort.

At the impression appointment approximately 2 weeks later, significant progress was achieved with maximum opening.

Both upper and lower impressions using Kerr metal trays and a highly refined alginate were taken

without any discomfort.

The patient continued her jaw stretching exercises during the initial treatment phase. This allowed for an increased vertical and horizontal movement.

Upon completion of initial treatment the patient was able to translate 3.25mm past centric occlusion and comfortably wear the oral appliance (TAP 3 Triple Laminate). The lower oral appliance was fitted over her existing implant supported denture and the upper appliance was made over the remaining teeth.

An innovative technique was utilized in the fabrication of the upper appliance allowing for the triple laminate (TL) material to be used around the remaining teeth and hard denture acrylic to be used for the remaining appliance. The SR Ivocap Injection System (Ivoclar Vivadent Inc., Amherst, NY) was used to produce an appliance base that could be modified with chairside or laboratory relines or rebases for stability purposes. This injection system controls the heat/ pressure polymerization and regulates the exact amount of material flowing into the flask to

compensate for acrylic shrinkage, allowing for a highly accurate fit with minimal appliance adjustment when seated.

As the ridge anatomy changes with age and use, the appliance’s inner lining can be easily readapted with chair-side relines (soft or hard) for the partially edentulous patient and with chair-side or laboratory rebase and relines for the fully edentulous individual.

The patient had significant improvement through treatment with the oral

appliance alone. Her time above 90% SpO2 (CT90) was 97.2% with elevated desaturation indices of 11.1 (4% oxygen desaturation scoring) and 23 (3% oxygen desaturation scoring). Initially the TAPPAP (CS) Interface was utilized. Her claustrophobia, not from the Interface or oral appliance, but from the mouth to nasal breathing caused panic attacks during the delivery phase.

The obtainable anterior translation of 3.25 mm from centric occlusion was enough to prevent mouth

TAP 3 Triple Laminate

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venting making the use of the Phillips Respironics Dream Wear nasal cushions effective without creating any claustrophobia. After completion of the titration protocol, the patient showed an AHI of 2.8 with median pressures of 7.3 cmH2O and time of usage at 5 hours and 29 minutes/ night. At her 6-month follow-up examination her AHI was still below 3 and time of usage had increased to more than 6 hours/night.

Her general dentist restored her remaining dentition to work in conjunction with her airway therapy and treated her periodontal condition conservatively.

DISCUSSION Oral appliances in the form of mandibular advancing devices (MAD) are becoming an important treatment modality that the medical profession is beginning to increasingly utilize for the treatment of OSA. There are still significant numbers of patients that are unable to use conventional CPAP while at the same time oral appliance therapy on its own is unable to fully manage the patient’s airway issue. In these cases, CT can become a

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useful tool for managing severe OSA. Combination therapy can be in the form of simply putting a conventional CPAP apparatus over an oral appliance, using a monoblock appliance with an approximate jaw position, or ideally CPAP connected to an adjustable oral appliance or MAD. Surgical options can be performed at any time as an adjunct therapy. A particular benefit of CT is its reversibility and more conservative therapeutic approach. The underlying principle of CPAP is to provide sufficient air pressure using positive airflow through the mouth and/or nose to create a pneumatic splint opening the upper airway. PAP pressures need to be high enough to continuously push the tongue and other soft tissues out of the airway and thereby maintain airway patency.

Joining the oral appliance and CPAP together provides an improved dual set of therapeutic principles maximizing the benefit to the patient. Combination Therapy balances the inspiratory pressure of the CPAP and the amount of mandibular advancement

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to be effective but with minimal air pressures and jaw movement. This reduces the overall number of complications for both therapies.

Additionally, lower PAP pressures and reduced mandibular protrusion improves overall patient comfort and therefore their compliance improves.6,7 The standard PAP headgear does not need to be used thereby improving patient mobility during sleep and reducing air leaks.

CT therapy must be performed with a physician’s written order and in conjunction with the physician’s office.

CPAP downloads should be monitored on a regular basis. Depending on the severity of disease, CPAP induced central apneas (CA) will potentially become evident during the course of treatment and should be continuously monitored.

Over time CAs typically will dissipate, however in some cases, particularly with traumatic brain injuries, more advanced PAP devices such as a BiPAP ST or an Adaptive Servo-Ventilation (ASV) system may be needed for management.

The use of high resolution pulse oximetry (HRPO) is important as a tool during titration. This non-diagnostic test can reveal the presence of residual OSA that the CPAP machine alone will not detect. The HRPO will provide the cumulative time above 90% oxygen (CT90) level along with the desaturation indices and pulse rate. Patients with COPD, asthma, emphysema or other lung issues can have a normal AHI but abnormally low CT90. The patient’s CT90 may be normal but still have elevated desaturation indices. Occasionally patients can have leakage through the lacrimal duct causing eye dryness along with potentially other issues that can affect treatment outcome. Close communication between the dentist and the physician is important as the final treatment outcome may precipitate the need for discovered additional medical issues.

Once the most therapeutic analytics and comfort is achieved, the patient must be sent back to their physician for re-evaluation.

Depending on the severity of disease, medical co-

morbidities, and ability to control OSA with CT, the physician may order an in-lab titration or continue treatment based on CPAP download and HRPO results.

CONCLUSIONS The field of Oral Appliance Therapy goes far beyond the “simple” cases of mild/ moderate sleep apnea.

When patients present for treatment there is a need for available therapies that are cost effective and yet still comprehensive enough to offer the patient.

Compromised dental management is a necessity in many cases in order to meet the patient’s needs.

This case is a classic example of the patient not having an ideal or adequate dental condition for treatment, yet full management was obtained within the confines of basic dentistry with minimal cost and overall excellent results. As a result, her physicians have a much better chance to manage her cardiovascular issues and her stroke risk is significantly minimized.

References 1.

2.

3.

4.

5.

6.

7.

Sutherland K, Vanderveken OM, Tsuda H, Marklund M, Gagnadoux F, Kushida CA, Cistulli PA. Oral appliance treatment for obstructive sleep apnea: an update. Journal of Clinical Sleep Medicine.

2014;10(2):215-27.

Rotenberg BW, Vicini C, Pang EB, Pang KP. Reconsidering firstline treatment for obstructive sleep apnea: a systematic review of the literature. Journal of Otolaryngology-Head & Neck Surgery. 2016;45(1):1-9.

Sutherland K, Phillips CL, Cistulli PA. Efficacy versus effectiveness in the treatment of obstructive sleep apnea: CPAP and oral appliances. J Dent Sleep Med. 2015;2(4):175-81.

Young T, Palta M, Dempsey J, Peppard PE, Nieto FJ, Hla KM. Burden of sleep apnea: rationale, design, and major findings of the Wisconsin Sleep Cohort study. WMJ: official publication of the State Medical Society of Wisconsin.

2009;108(5):246.

Pevernagie DA, GnidovecStrazisar B, Grote L, Heinzer R, McNicholas WT, Penzel T, Randerath W, Schiza S, Verbraecken J, Arnardottir ES. On the rise and fall of the apnea—hypopnea index: A historical review and critical appraisal. Journal of sleep research. 2020;29(4):e13066.

Tong BK, Tran C, Ricciardiello A, Donegan M, Chiang AK, Szollosi I, Amatoury J, Carberry JC, Eckert DJ. CPAP combined with oral appliance therapy reduces CPAP requirements and pharyngeal pressure swings in obstructive sleep apnea.

Journal of Applied Physiology.

2020;129(5):1085-91.

Liu HW, Chen YJ, Lai YC, Huang CY, Huang YL, Lin MT, Han SY, Chen CL, Yu CJ, Lee PL. Combining MAD and CPAP as an effective strategy for treating patients with severe sleep apnea intolerant to high-pressure PAP and unresponsive to MAD. PloS one.

2017;12(10):e0187032.

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and maxillofacial pathology diagnosis and management—from page 68

Adenoid cystic carcinoma, cribriform and solid type Based upon the patient’s clinical and radiographic findings, our differential diagnosis included: nonHodgkin lymphoma, osteosarcoma, squamous cell carcinoma, or a malignant salivary gland neoplasm. Non-Hodgkin lymphoma is a malignancy of hematopoetic cells, typically of B-lymphocyte lineage. This neoplasm often arises in a lymph node where it presents as a slowly growing, firm mass.

Occasional cases may present in an extranodal location in which case, a slowly growing, nontender mass is noted.

Non-Hodgkin lymphoma predominately affect adults.

When this neoplasm occurs in children, it is often more aggressive. Intraorally, non-Hodgkin lymphoma most frequently arises on the hard palate or posterior lateral tongue. It presents as diffuse boggy swelling which may be ulcerated or erythematous. Palatal examples may cause

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palatal perforation. NonHodgkin lymphoma may also arise centrally in bone, including the mandible or the maxilla. Intraosseous examples present as an ill-defined, destructive radiolucency.1

exhibits aggressive radiographic features including spiking root resorption, widening of the periodontal ligament space, ill-defined borders, and extension through cortical bone.1

Osteosarcoma is a malignant mesenchymal neoplasm in which the neoplastic cells produce immature bone or osteoid.

It is the second most common malignancy to originate in bone after hematopoietic neoplasms.

Osteosarcoma may occur as a primary malignancy or secondary to Paget disease or radiation therapy.

Approximately 6% of osteosarcomas arise in the jaws, where it may present as either a destructive radiolucent, radiopaque, or mixed lesion. Occasionally, a sunburst pattern may be visualized on a radiograph, but this is often difficult to visualize when osteosarcoma arises in the jaws. An osteosarcoma

Squamous cell carcinoma (SCC) is a malignancy that arises from stratified squamous epithelium. It accounts for approximately 95% of all oral cancers.1,2 Intraorally, it most commonly occurs on the ventrolateral tongue, floor of the mouth, lower lip, soft palate, gingiva, and in the oropharynx.2 The etiology of SCC is multifactorial, and its clinical presentation is varied. It may present as a leukoplakia, erythroplakia, or an ulcerated to papillary exophytic or endophytic mass. When it arises on the gingiva or alveolar mucosa, it may extend into the underlying bone. In these cases, it will present as an ill-defined, destructive radiolucency. A wide range

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of symptoms have been reported including pain and paresthesia.1 Malignant salivary gland neoplasms may arise centrally within the mandible or maxilla.

The most common malignant salivary gland neoplasm to arise in bone is a mucoepidermoid carcinoma.1 This neoplasm typically arises in the posterior mandible and presents as a unilocular or multilocular radiolucency.

Affected patients may complain of pain and paresthesia. Other salivary gland neoplasms have been reported to occur centrally in the mandible and maxilla, one of which is an adenoid cystic carcinoma. An adenoid cystic carcinoma, previously referred to as “cylindroma,” is a malignant salivary gland neoplasm of unknown etiology composed of a mixture of myoepithelial cells and ductal cells.3 It accounts for 1% of malignant tumors in the head and neck area and 10% of malignant salivary gland tumors.4 With 3 to 4.5 cases per million diagnosed each year, this malignancy is relatively uncommon.5 Adenoid cystic

carcinoma demonstrates a slight female predilection and typically occurs between 40-69 years of age. It is rarely found in individuals younger than 20 years of age.3 Most tumors involving minor salivary glands arise in the palate whereas major gland tumors arise in the parotid and submandibular glands.

Indeed, adenoid cystic carcinoma is the most common malignant salivary gland tumor to occur in the submandibular gland.1 This neoplasm typically presents as a slowly growing mass.

Tumors arising on the palate may extend into the underlying bone or maxillary sinus. Neoplasms that arise centrally within bone lead to an ill-defined, destructive radiolucent lesion. A unique clinical feature of an adenoid cystic carcinoma is a dull ache or pain in the affected or adjacent areas. These symptoms are associated with the tendency for this neoplasm to spread along nerves as the tumor cells wrap around nerve fascicles.1 Histopathologic examination of an adenoid cystic carcinoma reveals a malignant glandular

neoplasm composed of myoepithelial cells and ductal cells arranged in a cribriform (Swiss cheese) pattern. The spaces within the tumor islands may contain a basophilic material while the islands are often surrounded by homogenous eosinophilic material thought to represent basal lamina. The tumor cells are typically small with darkly staining nuclei, little cytoplasm, and rare mitoses. A characteristic feature of an adenoid cystic carcinoma is its propensity to surround and invade nerve fascicles.

In some cases, an adenoid cystic carcinoma may demonstrate a tubular or a solid growth pattern. In the tubular pattern, the tumor cells are arranged in small tubules/ducts without an evident cribriform pattern. The solid type of adenoid cystic carcinoma is composed of solid islands of tumor cells with little to no duct or tubule formation.

In this variant, mitotic activity, and tumor cell necrosis (comedonecrosis) are more common. Our case is interesting since two growth patterns were identified: solid and cribriform. The solid pattern was more pronounced while

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and maxillofacial pathology, continued

the cribriform pattern was limited to small areas of the tumor.

Based upon our patient’s clinical symptoms of fluctuating pain in the right posterior maxilla,

discomfort in the right ear, right periorbital pain with eyesight changes, mobile teeth, and marked bone destruction, it is proposed that this tumor arose in either glandular epithelium in the wall of the maxillary

sinus or within the minor salivary glands of the palate. In either case the neoplasm extended into adjacent soft tissue, bone, and sinuses and, ultimately, into the right ear, eye, and periorbital areas.

Our patient was referred to an otolaryngologist who facilitated urgent referrals. A positron emission tomography scan revealed a 3 mm node in the right upper lobe of the lung. A computed tomography scan was obtained with the primary tumor measuring 3.77 x 4.7 x 5.8 cm. Magnetic resonance imaging revealed a destructive lesion involving the right maxillary sinus with extension into adjacent structures, including the hard palate and orbital floor (Figure 5).

Based upon these findings, the patient was classified as T4bN0M1, Stage IV.

Figure 5. Coronal magnetic resonance imaging reveals a destructive lesion involving the right maxillary sinus, hard palate, and orbital floor.

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When the size and location of adenoid cystic carcinoma allows, local surgical excision with or without postoperative radiotherapy, is the treatment of choice.1

Radiation therapy may help with local recurrence, but its ability to affect survival is questionable.6 The benefit of chemotherapy as treatment has not been proven, but it is sometimes used for palliative care.3 To date, no targeted biologic agent has been identified that shows encouraging activity for routine treatment.6 Ultimately, death occurs from local recurrence and tumor extension, and/or from distant metastases.

Metastases occurs in 35% of cases and is often found in bone, lungs, and/or the brain. The prognosis varies widely based upon the location and size of the neoplasm, and the presence or absence of metastases. Adenoid cystic carcinoma has an overall 5-year survival rate of 77-82% which decreases to 35-52% at 20 years.

Poor prognostic factors include a solid growth pattern and involvement of the maxillary sinus and submandibular glands.1 In our case, the patient is not a candidate for surgical treatment.

The plan is for him to receive systemic therapy, followed by reevaluation for consideration of

palliative radiation therapy, depending on the results of the systemic treatment.

Our patient’s prognosis is poor due to the extensive involvement of soft and hard tissues, including the maxillary sinus, clinical symptoms of pain and paresthesia, and solid growth pattern noted on microscopic examination.

5. Coca-Pelaz A, Rodrigo JP, Bradley PJ, Vander Poorten V, Triantafyllou A, Hunt JL, Strojan P, Rinaldo A, Haigentz M Jr, Takes RP, Mondin V, Teymoortash A, Thompson LD, Ferlito A. Adenoid cystic carcinoma of the head and neck--an update.

Oral Oncol. 2015 Jul;51(7):652-61.

References 1. Neville BW, Damm DD, Allen CM, Chi AC. Oral and Maxillofacial Pathology, 4th Ed. Elsevier, 2016, 374389,462-464, 555-558, 614-618.

6. Dillon PM, Chakraborty S, Moskaluk CA, Joshi PJ, Thomas CY. Adenoid cystic carcinoma: A review of recent advances, molecular targets, and clinical trials. Head Neck. 2016 Apr;38(4):620-7.

2. Kumar V, Abbas AK, Aster JC. Robbins Basic Pathology, 10th Ed. Elsevier, 2018, 586-87.

3. Wenig BM, Atlas of Head and Neck Pathology, 3rd Ed. Elsevier, 2016, 953964.

4. Uraizee I, Cipriani NA, Ginat, DT. Adenoid Cystic Carcinoma of the Oral Cavity: RadiologyPathology Correlation.

Head and Neck Pathol.

2018;12:562-566.

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VALUE

for your

profession

HOW TO THRIVE IN AN ERA OF STAGNANT OR DECLINING INSURANCE REIMBURSEMENTS

By Nicholas Partridge, President; Five Lakes Dental Practice Solutions

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Provided by:

S

ince the advent of preferred provider organizations (PPOs) in the mid-1990s,

dental networks focused on one thing—getting bigger. Today, Metlife advertises more than 146,000 providers in-network; Delta Dental 144,000; and Cigna boasts 153,500 providers in their PPO networks.

MOST DENTISTS PARTICIPATE IN AT LEAST ONE NETWORK From 2007–2011, the number of providers participating in at least one network increased a whopping 72%—from 91,781 to 158,079. By 2015, the number increased by 34% to over 211,000. But since then, it grew a paltry 3%. Why the sudden and dramatic slow-down? The data suggests in-network providers are participating in more and more networks (28.3 per provider on average), but insurance companies have been less successful convincing out-of-network providers to join the fray.

The National Association of Dental Plans (NADP) reports 218,075 dentists are innetwork, though ADA reported that as of 2020, there were 201,117 professionally active dentists. Despite the discrepancy in data, I think we can all agree a vast majority of dentists participate in at least one network.

In summary, there just aren’t that many providers left to recruit.

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THE NETWORKS ARE VERY SIMILAR WHICH ONE IS THE BEST? In addition to directly recruiting providers, dental network leasing resulted in providers participating in significantly more plans. Nearly every dental network utilizes leasing agreements as a tool to provide access to more providers. Guess which network has the most participating providers in Texas? Principal—and the company has leasing agreements with many other networks.

Herein lies the problem. Network leasing created too much parity. Many of these dental networks now look very similar comparatively. For example, fewer than 10% of United Healthcare (UHC)’s PPO providers in Texas are not in-network with Principal. This means that over 90% of UHC’s network is exactly the same as Principal’s. Moving forward, the competitive difference is cost. I.e., if dentists are going to participate so broadly, the best network will be the most cost effective.

As evidence of this new reality, many Texas providers received contract amendments in 2021 reducing reimbursements. Many of the proposed changes represented significant decreases for providers. The climate has changed so quickly that the ADA Council on Dental Benefit Programs recently announced it would communicate with payers on behalf of providers, articulating the financial impact of COVID-19. The communications include data illustrating how practice costs increased, though patient volume has not yet returned to pre-COVID levels.

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WHY NOT JUST GO FEE-FOR-SERVICE? So what are we to do? The common answer found in forums and chats is to leave every network and go fee-forservice. However, this is not realistic for most practices.

Dental networks continue to grow because PPO participation status plays a meaningful role in patients’ decision making. 85% of patients visit an innetwork dentist, according to a study published in 2020 by Guardian Life. There are simply not enough patients willing to go to out-of-network providers.

Additionally, employee benefits are the avenue by which most Americans receive their dental benefit. Employers grappling with skyrocketing health care premiums are looking for large networks to provide their employees with broad access to care and affordable premiums.

As a result, dental networks continue to work on bringing more dentists innetwork, thereby reducing claims costs.

HOW TO FIGHT STAGNANT AND DECLINING REIMBURSEMENTS Focus on your business. The best place of leverage in negotiating with payers is to not need to be in-network. Healthy businesses have freedom to make decisions from a position of strength. In addition to engaging a strategic partner to assist, the best way to combat stagnant and declining reimbursements is to build a vibrant business.

It’s increasingly important for you and your team to master the business of dentistry—especially with the COVID situation, tight labor markets, inflation, and consolidation. To thrive as a PPO provider, practices need to measure and evaluate key business metrics and understand how insurance participation affects these metrics.

And specifically, practices should allocate their resources to more actively manage PPO participation. Every business manager should build a file for each network consisting of the following: 1. Copy of the insurance contract 2. Copy of the current fee schedule 3. Key contacts and notes, logged from correspondence 4. Dates of events like re-credentialing and last successful fee negotiation (These should be logged.)

5. Patients by insurance plan. (Track and report this monthly and look for trends.)

Further, each team member should maintain a working knowledge of insurance participation. For example, each member should develop the discipline to: •

•

Document when claims are paid under different fee schedules, such as through network leasing arrangements.

Document benefit breakdowns at the network level. For example, document a patient as having either Delta Premier and Delta PPO, not just Delta Dental.

Focusing on your business and allocating internal resources to actively managing insurance participation will position your practice to be able to make sound decisions as networks become increasingly focused on managing costs.

TDA Perks Program-endorsed Five Lakes Dental Practice Solutions can help your practice maximize reimbursements and manage your entire credentialing process.

Five Lakes can also help you optimize your revenue and improve your patients’ experience. Learn more about Five Lakes at tdaperks.com (Insurance, Dental Benefits, and Marketing) or call Five Lakes at 440-490-3118.

References:

https://www.metlife.com/business-and-brokers/employeebenefits/dental-insurance/ https://deltadentalma.com/Employers/The-Delta-DentalDifference https://www.cigna.com/employers-brokers/dental-andvision/dental https://www.ada.org/resources/research/health-policyinstitute/dentist-workforce https://www.ada.org/publications/ada-news/2021/ december/ada-requests-payers-take-current-trends-intoaccount-when-negotiating-fees-with-individual-dentists

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ADVERTISING BRIEFS PRACTICE OPPORTUNITIES ALL TEXAS LISTINGS FOR MCLERRAN & ASSOCIATES: To request more information on our listings, please register at www.dentaltransitions.com

or contact us at 512-900-7989 or info@ dentaltransitions.com. AUSTIN (ID #T521): This highly productive, implantfocused, general dentistry practice located in a growing community approx.

30 miles from the Austin metro area.

Current annual revenue is 7 figures with

Opportunities Online at TDA.org and Printed in the

net cash flow in excess of 6 figures. The

Texas Dental Journal

and equipped with 6 operatories, CBCT,

ADVERTISING BRIEF INFORMATION 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.

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 within 24 business hours for an additional fee of $60.

SUBMISSION Ads must be submitted, and are only accepted, via www.tda.org/Member-Resources/TDAClassified-Ads-Terms. By official TDA resolution, ads may not quote specific incomes or revenues and must be stated in generic terms (ie “$315,000” should be “low-to-mid-6 figures”). Journal editors reserve the right to edit and/or deny copy.

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modern facility is located in a retail space and paperless charts. The ideal buyer would be 1-2 high producing doctor(s) who are well versed in placing implants.

NORTH OF AUSTIN (ID #T515): GD Practice + Real Estate. Excellent location situated in a rapidly growing community north of Austin. The practice is located in a free-standing building, contains 4 fully equipped operatories, digital X-ray units, and CBCT. This 100% fee-forservice practice boasts a strong hygiene recall program, which produces a third of practice revenue and a fantastic online reputation. EAST TEXAS (ID #H486): Located in a growing east Texas community, this general practice caters to a dedicated multi-generational active

patient base. The well-appointed 2,500

occupies an attractive free-standing

sq ft space contains 5 fully equipped

building situated on a high traffic street

operatories, digital pano, plumbed

in a desirable community in the heart

nitrous, and computers throughout.

of east Texas. The practice has realized

EAST TEXAS (ID #H489): This highly

annual revenue of seven figures with

profitable, general dentistry practice &

exceptional profitability. The office

real estate is located in an east Texas

features a 4-chair ortho bay, 2 exam

town. The practice serves a large FFS/

rooms, and digital Pan/Ceph unit. The

PPO patient base and is on pace to

real estate is also available for purchase.

exceed seven figures in revenue in

HOUSTON-EAST (ID #H483):

2021 while maintaining a 45%+ profit

100% FFS GD practice + Real Estate.

margin. The office has 3 fully equipped

Situated in a 2,200 square foot, free-

operatories with possible room for

standing building with 5 fully equipped

expansion, digital radiography, and

operatories. Hygiene production is very

computers throughout. HOUSTON (ID

healthy and the practice has seen 1,700+

#H472): This established, boutique

active patients in the last 24 months with

practice is located in a highly desirable

a steady new patient flow. HOUSTON-

area of central Houston. The practice

NORTH (ID #H487): 100% FFS practice

provides general, implant, and cosmetic

in The Woodlands/Spring area. Modern

dentistry services to a 100% FFS patient

facility with 4 equipped ops, digital

base and has an excellent reputation

X-ray sensors, an iTero, and paperless

in the local community. The beautiful

charts. This practice checks all of the

facility features high-end finishes/décor,

boxes—strong profitability, an excellent

3 fully equipped operatories, digital

hygiene program, and further upside via

radiography, and a CBCT. HOUSTON,

numerous specialty procedures being

ORTHODONTICS (ID #H480): This

referred out. HOUSTON-NORTHEAST

productive, FFS orthodontic practice

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91

ADVERTISING BRIEFS (ID #H488): FFS/PPO practice + Real

referred out and little to no marketing,

Estate. Growing suburb 45 minutes

this practice offers a tremendous level

NE of Houston. 1,800 total patients,

of upside potential. SAN ANTONIO—

steady flow of new patients, solid

WEST (ID #T454): GD Practice + Real

hygiene recall, and consistent revenue

Estate. Located in a rural community

of high 6 figures per year. The office

approximately 75 miles west of San

contains 6 fully equipped operatories,

Antonio. Serves a PPO/FFS patient base,

plumbed nitrous, digital X-rays, CBCT,

sees approximately 30+ new patients

and computers throughout. HOUSTON

per month, and offers consistent annual

(ID #H490): General/cosmetic practice

revenue with substantial upside potential

located West of Houston in the highly

through expanding the procedures

desirable Memorial area. With roughly

offered in-house. The turn-key office

40% of the production being generated

features 3 fully equipped operatories,

from the hygiene program and numerous

digital sensors, intra-oral cameras, and

specialty procedures being referred out,

a digital pano. SAN ANTONIO (ID

there is immediate upside potential to

#T501): Located in a highly sought-

be discovered. The office occupies 1,700

after area along Loop 1604 in north San

sq ft, has 3 equipped operatories with

Antonio. The practice serves a large

room for a 4th, digital radiography, and

PPO/FFS patient base and is located

computers throughout. HOUSTON-

in a spacious office condo with 6 fully

SOUTHEAST (ID #H491): 100% FFS

equipped operatories, digital pano, digital

practice in a growing suburb southeast

X-rays, and digital sensors. SOUTH

of Houston. The 1,685 sq ft facility

TEXAS (ID #T460): GD Practice and

contains 3 fully equipped operatories

free-standing building, located in a

with room for expansion, digital

charming south Texas town. The office

radiography, and computers throughout.

is located in a 2 story, free-standing

With most specialty procedures being

building and has a spacious layout that

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Texas Dental Journal | Vol 139 | No. 2

ADVERTISING BRIEFS includes 6 fully equipped operatories

area. Majority of patients are 30 to

(one additional plumbed for expansion,

65 years old. Practice has operated at

digital sensors, a digital pano, CBCT,

this location for over 38 years. Practice

and computers throughout. To request

sees patients about 16 days a month.

more information on our listings, please

Collection ratio of 100%. The practice

register at www.dentaltransitions.com

is a fee-for-service practice. Building is

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

owned by dentist and is available for

dentaltransitions.com.

sale. Contact Christopher Dunn at 800930-8017 or Christopher@DDRDental.

AUSTIN: Associate to buy, planning on

com. HOUSTON (SHARPSTOWN AREA)

long transition. Prefer GP interested in

—GENERAL (REFERENCE “SHARPSTOWN

orthodontics. Fee-for-service practice,

GENERAL”). Motivated seller. Well

43 years same location, long standing staff, beautiful view. Email Info@ AustinSkylineDental.com.

BEAUMONT—GENERAL (REFERENCE “BEAUMONT”): Small town practice near a main thoroughfare. 80 miles East of Houston. Collections in 7 figures.

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.

P RAC T I C E S AL E S DS O T RAN S ACT I O N S

P RAC T I C E AP P RAISA LS ASSOCIATE PLACEMENT

Country living, close enough to Houston for small commute. Practice in a standalone building built in 1970. The office is 1,675 sq ft with 4 total operatories, 2 operatories for hygiene and 2 operatories for dentistry. Contains, reception area,

Austin

512-900-7989

DFW

214-960-4451

Houston

281-362-1707

San Antonio 210-737-0100 South Texas 361-221-1990 Emai l : t ex as@ den t al t r an si t i o n s.co m www.dentaltransitions.com

dentist office, sterilization area, lab

www.tda.org | February 2022

93

ADVERTISING BRIEFS Established general dentist with high-6

Christopher Dunn at 800-930-8017 or

figure gross production. Comprehensive

Christopher@DDRDental.com.

general dentistry in the southwest Houston area focused on children

DALLAS: Don’t waste time and money

(Medicaid). Very, very high profitability.

on buildouts when you can have a great

1,300 sq ft, 4 operatories in single

practice today. Great opportunity to start

building. 95% collection ratio. Over 1,200

your dental practice without having to

active patients. 20% Medicaid, 45%

pay a big loan and interest. Flexible lease

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

options are available for well-qualified

patients younger than 30. Office open

dentists with no down payments and no

6 days a week and accepts Medicaid.

interest for up to two years. Don’t waste

Contact Christopher Dunn at 800-930-

time and money on buildouts when you

8017 or Christopher@DDRDental.com.

can have a great practice today. Turnkey

HOUSTON (BAYTOWN AREA)—GENERAL

dental offices for sale in the Dallas Fort

(REFERENCE “BAYTOWN GENERAL”).

Worth metro and surrounding areas, the

Motivated seller. Well established

offices are strategically located in areas

general practice with mid-6 figure gross

for high production with ample parking.

production. Comprehensive general

Locations are ideal for Emergency Dental

dentistry in Baytown on the east side of

services, Medicaid, Insurance and FFS.

Houston. Great opportunity for growth!

Can be sold separately or as a package.

1,400 sq ft, 4 operatories in single

Requirements Dentists need to have at

story building. 100% collection ratio.

least 2 years of experience in private

100% fee for service. Practice focuses

practice/corporate dentistry; credit and

on restorative, cosmetic and implant

background check. For more information,

dental procedures. Office open 3 1/2

please email Txpracticesales@gmail.com

days a week. Practice area is owned by

or call/text 214-995-0806.

dentist and is available for sale. Contact

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Texas Dental Journal | Vol 139 | No. 2

ADVERTISING BRIEFS FORT WORTH: Practice for sale in the

and 2 dental). Includes a reception

fast growing southwest area. Average

area, dentist office, a sterilization

gross; 6 operatories; Excellent lease.

area, lab area, and break room. All

Seller is relocating. Need to move quickly

operatories fully equipped. Does not

on this one. DFW 214-503-9696. WATS

have a pano but does have digital X-ray.

800-583-7765.

Production is 50% FFS and 50% PPO (no Medicaid), with collection ratio

HOUSTON AREA: Several acquisition

above 95%. Providing general dental

opportunities in the greater

and cosmetic procedures, producing

Houston area. General, ortho, pedo

mid-6 figure gross collections. Contact

practices available for sale. Visit

Christopher Dunn at 800-930-8017

lonestarpracticesales.com or email

or Christopher@DDRDental.com and

houstondentist2019@gmail.com.

reference “Lufkin General or TX#540”.

HOUSTON—GENERAL (SHARPSTOWN).

HOUSTON, COLLEGE STATION, AND

Well established general dentist

LUFKIN (DDR DENTAL Listings). (See

with high-6 figure gross production.

also AUSTIN for other DDR Dental listings

Comprehensive general dentistry in

and visit www.DDRDental.com for full

the southwest Houston area focused

details. LUFKIN—GENERAL practice on

on children (Medicaid). Very, very high

a high visibility outer loop highway near

profitability. 1,300 sq ft, 4 operatories

mall, hospital and mature neighborhoods.

in single building. 95% collection

Located within a beautiful single-story,

ratio. Over 1,200 active patients. 20%

free-standing building, built in 1996 and

Medicaid, 45% PPO, and 35% fee-for-

is ALSO available for purchase. Natural

service. 30% of patients younger than

light from large windows within 2,300

30. Office open 6 days a week and

sq ft with 4 operatories (2 hygiene

accepts Medicaid. Contact Chrissy Dunn

www.tda.org | February 2022

95

ADVERTISING BRIEFS at 800-930-8017 or chrissy@ddrdental.

2018. The practice is only open 3 1/2

com and reference “Sharpstown General

days per week. Contact Christopher

or TX#548”. HOUSTON—GENERAL

Dunn at 800-930-8017 or christopher@

(PEARLAND AREA). GENERAL Located

ddrdental.com and reference “North

in southeast Houston near Beltway

Houston or TX#562”. WEST HOUSTON­—

8. It is in a freestanding building.

MOTIVATED SELLER. Medicaid practice

Dentist has ownership in the building

with production in 6 figures. Three

and would like to sell the ownership

operatories in 1200 sq ft in a strip

in the building with the practice. One

shopping center. Equipment is within

office currently in use by seller. 60%

10 years of age. Has a pano and digital

of patients age 31 to 80 and 20% 80

X-ray. Great location. If interested

and above. Four operatories in use,

contact chrissy@ddrdental.com.

plumbed for 5 operatories. Digital pano

Reference “West Houston General or

and digital X-ray. Contact Christopher

TX#559”.

Dunn at 800-930-8017 or christopher@ ddrdental.com and reference “Pearland

HOUSTON: Established general practice

General or TX#538”. HOUSTON—

located in the Galleria/Memorial Villages

PEDIATRIC (NORTH HOUSTON). This

area of Houston for sale. The 4,000

practice is located in a highly sought-

sq ft leased space has 8 operatories,

after upscale neighborhood. It is on a

2 dental labs, 2 sterilization areas, a

major thoroughfare with high visibility

private consultation room, 2 offices,

in a strip shopping center. The practice

a breakroom, and storage. This FFS

has 3 operatories for hygiene and two

practice collects in the high-6 figures

for dentistry. Nitrous is plumbed for all

annually. Current dentist will participate

operatories. The practice has digital

in a 3- to 5-year transition. Contact 713-

X-rays and is fully computerized. The

781-3599 or email bkkpallen@gmail.com.

practice was completely renovated in

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Texas Dental Journal | Vol 139 | No. 2

ADVERTISING BRIEFS KATY: Now is the time to join Grand

you won’t have to spend your career

Lakes Dental Group and Orthodontics.

navigating practice administration.

You will have opportunities to learn new

Instead, you’ll focus on your patients

skills from our team of experienced

and your well-being. Add on excellent

professionals. If you’re ready to take your

benefits, including malpractice insurance,

career to the next level and gain valuable

medical, dental and vision insurance,

experience, apply today! You’ve invested

retirement plans and much more and

the time to become a great dentist,

you’ll feel well taken care of throughout

now let us help you take your career

your career. The average full-time PDS-

further with more opportunity, excellent

supported associate dentist earns low-6

clinical leadership and one of the best

figures in their first year. The average

practice models in modern dentistry. In

income for a PDS-supported owner

working with our practice you will have

dentist, whose practice has been open

the autonomy to provide your patients

at least 2 years, is mid-6 figures. As

the care they deserve. In addition, you’ll

an associate dentist, you will receive

enjoy the opportunity to earn excellent

ongoing training to keep you informed

income and have great work-life balance

and utilizing the latest technologies and

without the worries of running a practice.

dentistry practices. If you are interested

You became a dentist to provide excellent

in a path to ownership, our proven

patient care and have a career that will

model will provide you with the training

serve you for a lifetime. With us, you

needed to become an owner of your own

will have a balanced lifestyle, fantastic

office. PDS is one of the fastest growing

income opportunities, and you’ll work for

companies in the US which means we

an office that cares about their people,

will need excellent dentists like you

their patients and their community. Our

to continue to lead our growth in the

practice is an office supported by Pacific

future. Apply now or contact a recruiter

Dental Services (PDS), which means

anytime. We’d love to chat, get to know

www.tda.org | February 2022

97

ADVERTISING BRIEFS you and share more about us. Pacific

INTERIM SERVICES

Dental Services is an equal opportunity employer and does not discriminate

HAVE MIRROR AND EXPLORER, WILL

against any employee or applicant

TRAVEL: Sick leave, maternity leave,

for employment based on race, color,

vacation, or death, I will cover your

religion, national origin, age, gender, sex,

general or pediatric practice. Call Robert

ancestry, citizenship status, mental or

Zoch, DDS, MAGD, at 512-517-2826 or

physical disability, genetic information,

drzoch@yahoo.com.

sexual orientation, veteran status, or military status. Apply here:http://www.

Click2Apply.net/gwy6pkn22knbzwzx PI106822492.

WATSON BROWN PRACTICES FOR SALE: Practices for sale in Texas and surrounding states, For more information and current listings please visit our website at www.adstexas.com or call us at 469-222-3200 to speak with Frank or Jeremy.

Calendar

of events

TMOM 2022 SCHEDULE Luling—March 4-5 Houston—April 22-23 Dallas—November 4-5

SMILECON

Houston—October 13-15, 2022 House of Delegates, October 15-18 Due to COVID-19, please check each meeting’s website for up-to-date information related to cancellations or rescheduling.

THE TEXAS DENTAL JOURNAL’S CALENDAR will include only meetings, symposia, etc., of statewide, national, and international interest to Texas dentists. Because of space limitations, individual continuing education courses will not be listed.

Readers are directed to the monthly advertisements of courses that appear elsewhere in the Journal.

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Texas Dental Journal | Vol 139 | No. 2

YOUR PATIENTS TRUST YOU.

WHO CAN YOU TRUST?

ADVERTISERS Anesthesia Education & Safety Foundation..... 58

E-VAC, Inc....................................................... 71

JKJ Pathology.................................................. 63

If you or a dental colleague are experiencing impairment

Law Offices of Hanna & Anderton.......................70

due to substance use or mental illness, The Professional

McLerran & Associates.................................... 93

Recovery Network is here to provide support and an

Professional Recovery Network....................... 99

opportunity for confidential recovery.

Southwest Sedation Education........................ 71

TDA Perks.............................. Inside Front Cover

Texas Health Steps.......................................... 55

UTHealth Houston Pathology........................... 70

PRN Helpline (800) 727-5152

Visit us online www.txprn.com

Watson Brown Practice Sales & Appraisals...... 59

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