January/February 2023 Texas Dental Journal

TDA Texas Dental Journal

January/February 2023

10 2023 TDA MEETING

MAY 4-6

SAN ANTONIO

Preliminary Program Advance Your Knowledge. Advance Your Career.

28

TDA MEETING PREVIEW

PARADOXICAL MASSETERIC BULGING

SPEAKER: GIGI MEINECKE, DMD, FAGD

A potential side effect unique to Masseter treatment is Paradoxical Masseteric Bulging (PMB). Although this adverse event is not dangerous, it is very alarming to the patient and occasionally presents with localized discomfort.

36

LOCATION TRULY IS EVERYTHING

KATIE E. STUCHLIK, DDS, FAGD

Many of us use commutes to listen to podcasts, audio books, or catch up with family. Then some of us, like myself, just spend time sitting in traffic thinking about everything I could be doing if I wasn’t sitting in traffic.

5

EDITOR’S NOTE

If there was ever a year for self- or professional-improvement, 2023 is it! Opportunities abound at TDA.

7

PRESIDENT’S MESSAGE

While the Association may not have a formal New Year’s resolution, it has an ever-living mission—to bring value to every member; but we need members to conquer our goals.

Almost

of

the TDA members working

with

ERC Specialists

are scheduled to receive refund checks greater than $50,000.

Did your accountant tell you your practice didn’t qualify for the Employee Retention Credit (ERC)?

You should know IRS rules have changed and most dental practices now qualify even if they received Paycheck Protection Program (PPP) funding.

The ERC allows qualified small businesses to receive a refund of up to $26,000 per employee as a fully forgiven tax credit.

Generally, if your practiced experienced revenue reduction, supply chain disruptions, or a full or partial shutdown, it qualifies for the refund.

281-229-4918

Because the ERC has confusing qualifications and a complex tax code, an accountant may not know how to maximize the credit or only partially understand its complexities.

ERC Specialists, a specialty tax service, is exclusively dedicated to simplifying the complex process of filing for ERC and helping businesses maximize their credit.

There’s no fee to work with ERC Specialists until your refund is collected from the Treasury. At that time, 15% will be put into escrow, and the the rest is yours.

*As of late November 2022

40%

FEATURES

10 2023 TDA MEETING

MAY 4-6

SAN ANTONIO

Preliminary Program

Advance Your Knowledge. Advance Your Career.

28 TDA MEETING PREVIEW PARADOXICAL MASSETERIC BULGING SPEAKER: GIGI MEINECKE, DMD, FAGD

Treatment of the Masseter muscle for myogenic-related parafunction with neurotoxins (Botulinum Toxin A) has become a common treatment modality. A potential side effect unique to Masseter treatment is Paradoxical Masseteric Bulging (PMB). Although this adverse event is not dangerous, it is very alarming to the patient and occasionally presents with localized discomfort.

36 LOCATION TRULY IS EVERYTHING

KATIE E. STUCHLIK, DDS, FAGD

If you live in a large city in Texas, which a great number of Texas Dental Association members do, then you understand my frustration with spending hours of my life in traffic. Many of us use commutes to listen to podcasts, audio books, or catching up with family. Then some of us, like myself, just spend time sitting in traffic thinking about everything I could be doing if I wasn’t sitting in traffic.

Editorial Staff

Jacqueline M. Plemons, DDS, MS, 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. Established February 1883 • Vol 139 | No. 8

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 July-August, which are combined issues, by the Texas Dental Association, 1946 S IH-35, Austin, TX, 78704-3698, 512443-3675. Periodicals Postage 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.

editor’s note

We’ve all done it, set resolutions that we likely won’t keep. Or, maybe you’re more disciplined than most, and your “new year, new you” mantra stays steady January through December. Sometimes, I find it’s easier to make small improvements, bite off small pieces at a time to help increase the likelihood of success. So let’s break down a few of the many “smaller pieces” that make up TDA’s “bold and steady” resolutions or really commitment to help all member dentists succeed. If there was ever a year for self- or professional-improvement, I believe 2023 is it. Opportunities abound and your TDA is ready for the challenge.

patients and the dentists who care for them. Worried you don’t know the details? Information is currently out in many forms including the TDA, TDAT and the legislative publication of the TDA, The Root. Oh, and watch for information in Dr Duke Ho’s videos on multiple social media sites. In addition, the issues will be discussed in detail before we walk or ride to the capital. And, you won’t be alone! We visit legislators in small groups!

Jacqueline Plemons, DDS, MS

For starters, next month is Legislative Day which requires all-hands-on-deck. We have great captains at the helm—our legislative team and lobbyists already have their boots on the ground in Austin. But, on February 15, it’s your turn to walk the steps of the capitol.

Spend the day talking with legislators and staff regarding issues such as increasing Medicaid funding to today’s dollars what was initially appropriated in 2008-09. We need you there to remind them of ways to strengthen the Texas dental public health safety net for patients with unmet and sometimes emergent dental needs. Share with them opportunities for insurance reform that ensure fair practices for

Another effort in achieving TDA’s 2023 resolution of helping all members succeed happens in May at the Annual TDA Meeting. Join us in San Antonio for an amazing opportunity to learn the latest in all that is dentistry. From science to technology, practice management, ideas for personal growth and more. The TDA Meeting program is truly incredible this year and registration is available online right now! Bring your staff and knock out everyone’s CE requirements at one event, meet peers from other cities, and visit vendors at the exhibit hall to explore your office needs. There is something special for new dentists and entertainment is provided as well!

Mark your calendar. Add to your list of resolutions and let your TDA help you succeed! And, let’s get to work, on ourselves and our profession.

FreeWill x TDA Smiles Foundation

A new resource to secure your future

The TDA Smiles Foundation wants to help our supporters protect what matters most. To thank you for supporting our future, we want to introduce a resource to secure your own: an online tool to write your legal will at no personal cost.

happy healthy smiles... that’s our mission!

Through our exciting new partnership with FreeWill, estate planning is now free and accessible to every single member of our community. We share this resource as an easy way to protect your family — and the causes you care about. With this resource, you can also create a planned gift that will leave a legacy of accessible dental care in underserved communities for years to come.

Visit FreeWill.com/TDASmilesFoundation to get started.

Board of Directors Texas Dental Association

PRESIDENT Duc “Duke” M. Ho, DDS 281-395-2112, ducmho@sbcglobal.net

PRESIDENT-ELECT

Cody C. Graves, DDS 325-648-2251, drc@centex.net

PAST PRESIDENT Debrah J. Worsham, DDS 936-598-2626, worshamdds@sbcglobal.net

VICE PRESIDENT, SOUTHEAST Glenda G. Owen, DDS 713-622-2248, Dr.owen@owendds.com

VICE PRESIDENT, SOUTHWEST Carlos Cruz, DDS 956-627-3556, ccruzdds@hotmail.com

VICE PRESIDENT, NORTHWEST Teri B. Lovelace, DDS 325-695-1131, lovelace27@icloud.com

VICE PRESIDENT, NORTHEAST Elizabeth S. Goldman, DDS 214-585-0268, texasredbuddental@gmail.com

SENIOR DIRECTOR, SOUTHEAST Shailee J. Gupta, DDS 512-879-6225, sgupta@stdavidsfoundation.org

SENIOR DIRECTOR, SOUTHWEST Richard M. Potter, DDS 210-673-9051, rnpotter@att.net

SENIOR DIRECTOR, NORTHWEST Summer Ketron Roark, DDS 806-793-3556, summerketron@gmail.com

SENIOR DIRECTOR, NORTHEAST Jodi D. Danna, DDS 972-377-7800, jodidds1@gmail.com

DIRECTOR, SOUTHEAST Laji J. James, DDS 281-870-9270, lajijames@yahoo.com

DIRECTOR, SOUTHWEST Krystelle Anaya, DDS 915-855-1000, krystelle.barrera@gmail.com

DIRECTOR, NORTHWEST

Stephen A. Sperry, DDS 806-794-8124, stephenasperry@gmail.com

DIRECTOR, NORTHEAST Mark A. Camp, DDS 903-757-8890, macamp1970@yahoo.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

DENTIST to DENTIST

RELATIONSHIP. MENTORSHIP. COMMUNICATION.

Happy New Year!

It’s a new year and your Texas Dental Association’s Membership Drive is now in full swing. We all know the common New Year resolutions: get in shape, eat healthy, learn a new hobby, or break the addiction to a smartphone.

While the Association may not have a formal New Year’s resolution, it has an ever-living mission—to bring value to every member; but we need members to conquer our goals. The more members, the more effective our association becomes, fulfilling our pledge by:

• Focusing on the upcoming Legislative session with an agenda that includes insurance reform, better reimbursements for Medicaid, and dental education loan repayment programs, just to mention a few.

• Improving tangible, member value to include all dentists (owner and employee).

• Expanding how education, both in dentistry and beyond, gets to you.

Moreover, our volunteer leaders on the national level continue to represent your concerns —including 2 members who now serve on an American Dental Association (ADA) Task Force that will examine how we can make meaningful change in the Employment Retirement Income Security Act (ERISA) and specifically, how it is applied to dentistry and dental insurance.

However, as we peek into the future, let’s also take a moment to “stop and look around once in a while” at what we are doing now to make your membership valuable.

• Personalized Help—our “Ask Diane” site (https://www.tda.org/askdiane/questionsubmission) offers direct, personalized assistance with dental insurance and compliance issues, from our State Board of Dental Examiners, the Drug Enforcement Agency, and other regulatory agencies.

• Continuing Education—discounts on CE courses highlighted on the TDA Dental Concierge App including new Pankey courses, team-specific courses and a free Human Trafficking course.

• Advocacy—a focused legislative agenda and an advocacy team with strong, grassroots ties to key legislators and stakeholders.

Of course, there’s so much more but always know that our driver is to serve you and bring value to your membership, your practice, and your patients. Most importantly, we need you, so consider joining or renewing at https://www.tda.org/member-center/ join-renew.

Taking another line from the same movie, “The question isn’t, ‘What are we going to do?’ The question is, ‘What aren’t we going to do?’”

“Life moves pretty fast. If you don’t stop and look around once in a while, you could miss it.”

Ferris Bueller (Matthew Broderick), Ferris Bueller’s Day Off

Duc “Duke” M. Ho, DDS, FAGD TDA President

Anesthesia Education & Safety Foundation

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.

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 RE PERMIT 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 cou rse.

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 Sedat ion 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

Dr. Canfield

Terry Watson, D.D.S. Jeremy Brown, J.D. Frank Brown, J.D., LL.M.

023 Annual Meeting of the Texas Dental Association!

dentists and team members to this office-centric meeting on May 4 - 6, 2023 in the Henry B Gonzalez Convention Center in downtown San Antonio The Council on the eting and Continuing Education Programs and the professional staff of the TDA have rd to bring you an eventful, fun, and educational learning experience among the best on

terrific lineup of continuing education courses and speakers, some popular at the TDA or years and others new to the conference

ate, pertinent presentations geared toward the front office, dental hygienists, dental entire office will benefit and is encouraged to attend as a team Some required or A, Infection Control, Sedation, Opioid Prescribing, and Human Trafficking will be available We also have a number of workshops/hands-on experiences which combine and n applied practice procedures that assistants, hygienists and dentists can take back to meeting!

g center at the meeting, with hundreds of exhibitors showing equipment and supplies, nse research TDA Perks staff and many vendors whom you are familiar with be there as port, and expertise The Exhibit Hall will have two CE Express areas that feature onstrations for your listening and learning pleasure Please join us for the “Lone Star – 6:30 pm for live music, food, and fun! We will also feature an interactive “ scavenger n and around the Exhibit Hall Follow us on social media to learn more details

our guide for timely information, show specials, tracking of CE credits and pairs well with Please visit tdameeting com for registration and schedule information Take advantage of Early Bird discounts by registering before March 31

Beautiful, historic downtown San Antonio offers top-notch hotels, terrific restaurants, and activities all within walking distance of the Henry B Gonzalez Convention Center and the TDA Meeting Bring the entire office team to the TDA Annual Meeting, we look forward to enjoying yo !

Robert Beatty, DDS 2023 Scientific Chair

Thank you to our TDA Meeting Sponsors. Their generous support and donations help us provide you with cutting edge education and one of the best dental meetings in the country.

0 2 3

The TDA regrets the omission of any sponsors or donors due to print deadlines

2 0 2 4 TDA MEETING

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SCHEDULE OF EVENTS

T H U R S D A Y , M A Y 4

7

: 0

R e g i s t r a t i o n H o u r s

T D A H o u s e o f D e l e g a t e s

C o n t i n u i n g E d u c a t i o n C o u r s e s

A l l i a n c e o f t h e T D A P r o g r a m , G r a n d H y a t t

E x h i b i t H a l l H o u r s

R e f e r e n c e C o m m i t t e e s

7 : 0 0 A M – 5 : 0 0 P M 8 : 0 0 A M – 7 : 0 0 P M 8 : 0 0 A M – 4 : 3 0 P M 8 : 3 0 A M – 4 : 3 0 P M 9 : 3 0 A M – 5 : 0 0 P M 1 : 3 0 P M – 4 : 3 0 P M 5 : 3 0 P M

R e g i s t r a t i o n H o u r s

T D A A P r o g r a m , M a r r i o t t R i v e r w a l k H o t e l C o n t i n u i n g E d u c a t i o n C o u r s e s

A l l i a n c e o f t h e T D A P r o g r a m , G r a n d H y a t t

E x h i b i t H a l l H o u r s

H o u s e o f D e l e g a t e s

T D A P a s t P r e s i d e n t s B r e a k f a s t

T D A P a s t V i c e - P r e s i d e n t s B r e a k f a s t

T D A H o u s e o f D e l e g a t e s

C o n t i n u i n g E d u c a t i o n C o u r s e s

T D A A P r o g r a m , M a r r i o t t R i v e r w a l k H o t e l

T D A H o u s e o f D e l e g a t e s

T D A B o a r d M e e t i n g

7 : 0 0 A M – 8 : 3 0 A M 7 : 0 0 A M – 8 : 3 0 A M 8 : 0 0 A M – 1 2 : 0 0 P M 8 : 0 0 A M – 5 : 0 0 P M 8 : 0 0 A M – 5 : 0 0 P M 1 : 3 0 P M 5 : 0 0 P M A l l e v e n t s w i l l b e h e l d a t t h e H e n r y B . G o n z a l e z C o n v e n t i o n C e n t e r u n l e s s o t h e r w i s e n o t e d .

C A N C

Registration Opens January 10, 2023

Register by March 31, 2023, to save with Early Bird registration fees!

Register Online at www tdameeting com Online registration will be available January 10 through May 6, 2023 Seats in continuing education courses are available on a first-come, first-served basis Additional fees may apply

Q U E S T I O N S A B O U T R E G I S T R A T I O N ?

Eleventh & Gather is our official registration provider They will manage preregistration and onsite registration of attendees and exhibitors Beware of fraudulent companies who may reach out to you to book registration or sell attendee lists

Questions regarding registration can be directed to Eleventh & Gather at:

Hours: Mon-Fri: 9:00 am – 4:00 pm EST

By Phone: 678-341-3039

By Email: tda@prereg net

A full refund (less a 20% administrative fee) will be issued if cancelled on or before March 31, 2023 No refunds will be approved after this date In the event of an emergency or death, cancellations will be reviewed on an individual basis

Dentists may not register under any category other than “dentist”

You must be registered under a dentist or team member registration category in order to earn CE credits

You must register on or before April 17 in order to receive your badge in the mail After this date, registration materials can be picked up onsite

The deadline for early bird discounted registration is March 31, 2023

Photo identification is required for onsite registration

By registering for the meeting, you authorize the TDA to add you to their email marketing list to receive convention updates for 2023 and subsequent years You can opt-out at any time, but you will not receive pertinent information regarding your registration

GUESTS

Family Member of TDA Member Dentist G Free $50

* Registration fee can be applied toward active membership if you join within 30 days after the meeting Contact rdaigle@tda org for more details 2023 TDA dues must be paid before you can attend the meeting at the member rate

TDA Member Benefit: Free registration for you and your team! Register early and SAVE!

For questions regarding your registration, contact Eleventh & Gather at 678-341-3039 or via email at tda@prereg.net

TDA Meeting Hotels

Support TDA by booking your room within the annual session hotel room block. TDA has secured special rates with these official hotels

Eleventh & Gather is the official housing provider for the 2023 TDA Meeting.

6840 Meadowridge Court, Alpharetta, GA 3005 678-341-3039

tda@prereg net

prereg net/2023/tda

9:00 am – 4:00 pm, Monday thru Friday (ET)

Beware of fraudulent companies who may reach out to you to reserve hotel rooms or sell attendee lists

Housing reservations open on Tuesday, January 10

Online Reservations: https://www prereg net/2023/tda

Phone Reservations: 678-341-3039

All rates are per room and are subject to a 16 75% occupancy tax

La

Thursday, May 4 8:00 am

Saturday, May 6 8:00 am

am Friday, May 5 1:30 pm – 4:30 pm

am |

- close of business

T D A M E M B E R S – G E T I N V O L V E D

The House of Delegates is the legislative and supreme governing body of the TDA The 2023 House of Delegates is composed of 132 voting members, which includes duly elected and installed delegates from each of the 26 components of the Texas Dental Association and the 15 voting members of the Board of Directors The Speaker of the House of Delegates is the presiding officer and is without vote The TDA secretary-treasurer is also a non-voting office of the House of Delegates and serves as the Secretary of the House Finally, there are four student delegates, each elected and installed by their respective dental school; student delegates have full privilege and access to the floor of the House of Delegates but are without the right to vote and may not introduce resolutions

H O U S E M A T E R I A L S

Delegates and alternates will receive their House book in a searchable PDF format Reference committee reports will be emailed in PDF format to all participants and these reports can be downloaded from any location with internet access

For more information, contact TDA Governance Manager Mr Terry Cornwell at 512-443-3675, or tcornwell@tda org A

Friday, May 5 10:30 am – 12:00 pm

In the event there are no contested TDA statewide elections and no participation by candidates for ADA elected offices, the candidate’s forum will not be held

R

E F E R E N C E C O M M I T T E E S

Reference committee hearings offer an opportunity for any member to participate in the TDA policy-making process All members are encouraged to attend the hearings scheduled on Thursday, May 4 All 2022-2023 resolutions will be discussed before presentation to the 2023 TDA House of Delegates for policy-making decisions Starting times are:

President’s Address, Miscellaneous Matters, Component Societies, Subsidiaries, Strategic Planning, Annual Session R

Dental Education, Dental Economics, Health and Dental Care Programs

Legislative, Legal and Governmental Affairs

Get involved by attending divisional caucus meetings and selecting your representatives on the state and national levels ADA delegates and alternates from your division and the divisional directors of the TDA Board of Directors are nominated in this forum

R E F E R E N C E C O M M I T T E E E : 3 : 3 0 P M

Constitution, Bylaws, Ethics & Peer Review

*Times subject to change, please visit www tdameeting com for the latest information

The House of Delegates convenes meetings during the Annual Session of the Texas Dental Association.

Exhibit Hall Hours:

Join us in the Exhibit Hall to visit with your favorite dental reps and discover new products and services for your practice Stop by the 600 aisle featuring our TDA Perks Program partners to learn more about discounts available to you as a TDA member and access resources with compliance and supplies; insurance and dental benefits; marketing; finance; real estate and more!

Exhibit Hall Activities

M E M B E R L O U N G E

Relax, play or recharge at the TDA Member Lounge Plug-in your phone, then sit back and relax or play a quick game with fellow attendees. Visit with our DENPAC and TDA Smiles Foundation staff to discover additional ways to get involved and serve your dental community

C E E X P R E S S

Short on time? Have an extra hour open in your schedule? Register for our shorter education sessions in CE Express. We will have two classrooms available on Thursday and Friday. We will feature product demonstrations and commercials during the breaks between each session

T D A S C A V E N G E R H U N T !

Join in on the Scavenger Hunt and complete the missions for a chance to win prizes and earn bragging rights! Details on how to play will be available before the meeting

For dentists who graduated from dental school in 2012 or later

T H U R S D A Y , M A Y 4

D o m i n a t e Y o u r M a r k e t i n g O n l i n e

L e n T a u , D M D

1 : 0 0 p m – 3 : 3 0 p m

C o u r s e C o d e : T 2 4

P r e p a r i n g f o r P r a c t i c e O w n e r s h i p

B a n k o f A m e r i c a P a n e l

1 : 3 0 p m – 3 : 3 0 p m

C o u r s e C o d e : T 2 7

F R I D A Y , M A Y 5

U t i l i z i n g 3 D P r i n t i n g a n d O t h e r D i g i t a l

I n t e g r a t i o n i n G e n e r a l D e n t i s t r y

M a r k K l e i v e , D D S

8 : 0 0 a m – 1 0 : 3 0 a m

C o u r s e C o d e : F 1 4

P r a c t i c e P I Z Z A Z Z : P u t t i n g &

K e e p i n g P e p i n Y o u r D e n t a l S t e p

D e a n a Z o s t , F A A D O M

1 : 3 0 p m – 4 : 0 0 p m

C o u r s e C o d e : F 3 5

S A T U R D A Y , M A Y 6

P e r i o - P r o s I n t e g r a t i o n i n t h e D i g i t a l E r a

C e l i n A r c e , D D S , M S , F A C P

8 : 0 0 a m – 1 1 : 0 0 a m

C o u r s e C o d e : S 0 1

T h e r a p e u t i c B o t o x ( N e u r o m o d u l a t o r )

I n d i c a t i o n s w i t h L i v e P a t i e n t T r e a t m e n t

G i g i M e i n e c k e , R N , D M D

8 : 0 0 a m – 5 : 0 0 p m

C o u r s e C o d e : S 0 8

C h e c k o u t t h e C E E x p r e s s c o u r s e s o n T h u r s d a y a n d F r i d a y f e a t u r i n g

t o p i c s o n : P r a c t i c e T r a n s i t i o n s , P r a c t i c e A u t o m a t i o n, R e a l E s t a t e a n d

P r a c t i c e V a l u a t i o n , C y b e r s e c u r i t y , R i s k M a n a g e m e n t , a n d m o r e !

Let Envolve be the Jewel in your Crown

Practices For Sale

$778K EAST TEXAS - NEAR LOUISIANA BORDER: 4,400+ sq. ft. facility with 6 fully equipped ops and 2 additional plumbed. All digital with digital Pan (Sirona Galileos CBCT) and paperless with Eaglesoft. The practice has 1,250 active 100% FFS patients with an average of 50 new patients per month. The collections are over $778K on a 4-day work week. The seller would also like to sell the real estate, but is open to leasing to start. Opportunity ID: TX-7525

PRICE REDUCTION!!!! San Antonio GP located inside Loop 1604 in a medical complex with excellent street visibility and highway accessibility. The office is roughly 1,600 sq. ft. with 4 equipped ops, computerized with Easy Dental, and uses paper charts. There are approximately 1,350 active patients, 75% PPO/25% FFS. The seller has averaged $400K+ per year and currently refers out most surgery, endo, pedo, and implant placement, leaving ample opportunity for growth. Opportunity ID: TX-7437

$600K PRIME AUSTIN OPPORTUNITY: This practice collected $600K pre-Covid on a 4 doctor and 4 hygiene day workweek. Located in a busy retail center, with 5 ops in 1,700 sq. ft. the office is in excellent condition and has digital x-ray and pan. With over 1,350 active FFS 20%, PPO 80%, patients and an average of 25 new patients per month; this practice is primed for growth. Opportunity ID: TX-7183

$890K NEAR GALVESTON BAY: Exceptional 2000, 24-month count PPO/FFS patient base, 30 minutes south of downtown Houston. This 4 op, 2000 sq. ft. facility is located in a free-standing building on a major thoroughfare. It is currently a bread and butter practice focusing on restorations, crown & bridge and hygiene services. Tremendous opportunity for growth for the doctor with implant skills, who enjoys oral surgery, endo and perio, in addition to producing fine restorative dentistry. Opportunity ID: TX-7153

Go to our website or call to request information on other available practice opportunities!

We are pleased to announce...

Sateesh K. Ummareddy, D.D.S.

Niosha Edalat, D.M.D. has acquired the practice of

has acquired the practice of Kilgore, Texas Arlington, Texas

We are please to have represented all parties in these transitions.

Jeremiah R. Taylor, D.D.S.

Donald D. Landry, D.D.S.

TDA Meeting Preview

Paradoxical Masseteric Bulging

Event: Therapeutic Botox (Neuromodulator) Indications with Live Patient Treatment

Speaker: Gigi Meinecke, DMD, FAGD

Date: Saturday, May 6

Time: 8:00 am - 5:00 pm

Code: S08, S08a

Treatment of the Masseter muscle for myogenic-related parafunction with neurotoxins (Botulinum Toxin A) has become a common treatment modality. A potential side effect unique to Masseter treatment is Paradoxical Masseteric Bulging (PMB). Although this adverse event is not dangerous, it is very alarming to the patient and occasionally presents with localized discomfort. Dental practitioners, even those who do not administer neurotoxins, should have a basic understanding of the accepted etiology, classic presentation and management of PMB.

BACKGROUND

When traditional, reversible treatments for parafunction prove unsuccessful, Masseteric injection of Botulinum Toxin A (BONTA) such as Botox®, Xeomin®, Dysport®, is an acceptable treatment option.1 These injections are minimally invasive, have a low incidence of side effects and when appropriately dosed, act by decreasing the force of muscular contraction of the Masseter muscle. BONTA treatment for parafunction has been in use since the 1990’s.2

The preferred injection site for the Masseter is the lower third as opposed to a more rostral location due to multiple anatomical advantages:

1. The lower third constitutes the thickest portion of the muscular belly

2. Generally the lower third is not associated with Parotid tissue

3. Primary vascular supply of the Masseter is via the Masseteric artery. This vessel branches off the Maxillary Artery and passes through the mandibular notch to supply the Masseter. Its pathway is superior to a lower third injection site, decreasing bruising potential. Additionally, the Transverse Facial Artery passes superficial to the Masseter and can be located from 17mm to 26mm below the inferior border of the zygomatic arch.3 Even at its most inferior location, it remains out of range when injecting the Masseter lower third.

4. With respect to innervation, data suggests the richest arborization of the Masseteric Nerve is most often found in the central lower third of the Masseter.4 Since BONTA targets the neuromuscular junction, placing neurotoxin within the densest nexus of neurons seems most efficient.

5. When present, Risorius is a fairly superficial muscle with variable sites of origin and anatomic presentations.

about the Speaker

Gigi Meinecke, DMD, FAGD received her DMD from Boston University School of Graduate Dentistry and is currently clinical faculty and course director of the Facial Injectables Program, Boston University School of Dental Medicine, Maryland. Her honors include the Fellowship Academy of General Dentistry, Fellowship International College of Dentists, and Fellowship American College of Dentists. She is a member of the American Dental Association, Academy of General Dentistry, Maryland Academy of General Dentistry, Maryland State Dental Association, and the American Nurses Association.

Her published articles include: Which is Safer for Dermal Filler Treatment—Cannula or Needle? July 29, 2020 Dentistry Today; Applications for Facial Injectables in Dentistry March 1, 2019 Decisions in Dentistry; Why Lip Injections Look Fake—And How You Can Create Natural Looking Lips January 2, 2018 Dentistry Today; Lower Face Influence on Total Facial Esthetics June 14, 2016 Dentistry Today; Should You Add Facial Injectables to Your Practice? January 9, 2017 Dentistry Today; When and How to Say No to Facial Injectable Patients September 29, 2016 Dentistry Today.

She has authored the book Start and Grow Your Cosmetic Injectable Practice January 2020

Inadvertent BONTA injection into Risorius can produce a smile asymmetry. Studies suggest the presence of a Risorius Muscle in 6% to 95% of individuals depending on race.5,6 Its appearance ranges from a few small muscular fascicles to a wide band of tissue.7 Even in its most inferior position, the superficial location of Risorius offers protection from the standard “on-periosteum” injections of the Masseter lower third.

ANATOMY AND ETIOLOGY

A brief anatomical review is helpful to understand the etiology of PMB. The Masseter is most often described as a quadrangular shaped muscle consisting of a superficial and deep layer. Various sources, both historical and recent, describe the existence of a 3rd layer (Middle Layer).8 This intermediate layer is not discussed here, as its presence or absence has no bearing on our present discussion. Of interest however, is the existence of a thick band of tissue located on the deep surface of the Superficial Masseter. Studies demonstrate several morphologic variations of this Deep Inferior Tendon (DIT). For the injecting practitioner, knowledge of patientspecific configuration of the DIT is not required. It is, however, vital for the injector to understand the potential impact the DIT may have on Masseteric BONTA injections and how to identify when it is in play.

Broadly speaking, arrangement of the DIT over the inferior aspect of the deep Masseter can appear in three configurations (Figure 1):

1. Covering distal half of lower third

2. Covering medial half of lower third

3. Covering entire lower third

When the tendon covers the entire lower third, diffusion of neurotoxin into the Superficial layer with a deep injection can be severely, if not completely, blocked (Figure 2). This provokes a compensatory response from unaffected Superficial fibers, leading to the appearance of an unnatural bulge when the muscle is contracted. It

Figure 1

should be noted that the reverse scenario is possible as well. When the initial dose is placed in the Superficial Layer, compensatory bulging may evolve from the Deep Layer. This speaks to the importance of consistent injection technique and accurate documentation.

As discussed, moving injections superiorly in an attempt to avoid PMB, has its own set of potential complications related to associated anatomy. These include, but are not limited to, smile asymmetry (Risorius) and xerostomia (Parotid). Moreover, from the pharmacological neurotoxin-target standpoint, the lower third appears to be most advantageous.

Conclusive data regarding how often PMB occurs after Masseter injections is not yet available. Current literature reports a wide incidence range, between 0.5-18.8%.9-11 With time, this data will narrow, revealing its true incidence.

Figure 2

Clinical exam alone cannot predict DIT fiber arrangement. Ultrasound and other imaging devices provide the only practical pre-treatment diagnosis. However, pre-treatment imaging creates an added expense for the patient and is not currently the standard of care. Therefore, prompt recognition of the problem and the ability to treat or refer for correction is necessary.

PRESENTATION AND MANAGEMENT

Typical pathogenesis of Paradoxical Bulging begins within days to a few weeks after a patient receives toxin for either parafunction or facial slimming. The patient suddenly notices an exaggerated Masseteric bulging when chewing. Most often, esthetics is the primary concern even when mild discomfort is present. Embarrassed and self-conscious, patients often avoid eating in public due to exaggerated masticatory bulging.

Untreated, visible bulging can last from a few weeks to 3 to 5 months depending on dose, technique and area.12 Detailed anatomical knowledge of the Masseter combined with a thorough patient treatment history allows the practitioner to make a prompt diagnosis. When indicated, treatment is simple and involves injecting the compensatory fibers, usually the superficial layer, with a moderate dose of neurotoxin. The patient is reassured and seen for re-evaluation in 2 weeks. Reduction in bulging can be seen in as little as 2 weeks.

As BONTA treatment for parafunction becomes more common, the number of patients presenting with side effects will increase proportionally. Understanding PMB, its presentation, etiology and management is essential for all dentists,

regardless of whether neuromodulator administration is a part of their professional practice.

REFERENCES

1. Thambar S, Kulkarni S, Armstrong S, Nikolarakos D. Botulinum toxin in the management of temporomandibular disorders: a systematic review. Br J Oral Maxillofac Surg. 2020 Jun;58(5):508519. Epub 2020 Mar 3. PMID: 32143934.

2. Ivanhoe CB, Lai JM, Francisco GE. Bruxism after brain injury: successful treatment with botulinum toxin-A. Arch Phys Med Rehabil. 1997 Nov;78(11):1272-3. PMID: 9365360

3. Koziej M, Polak J, Wnuk J, Trybus M, Walocha J, Chrapusta A, Brzegowy P, Mizia E, Popiela T, Hołda M. The transverse facial artery anatomy: Implications for plastic surgery procedures. PLoS One. 2019 Feb 7;14(2):e0211974. doi: 10.1371/ journal.pone.0211974. PMID: 30730953; PMCID: PMC6366864.

4. Kim DH, Hong HS, Won SY, Kim HJ, Hu KS, Choi JH, Kim HJ. Intramuscular nerve distribution of the masseter muscle as a basis for botulinum toxin injection. J Craniofac Surg. 2010 Mar;21(2):58891. PMID: 20489458.

5. Pessa JE, Zadoo VP, Adrian EK Jr, Yuan CH, et al. Variability of the midfacial muscles: analysis of 50 hemifacial cadaver dissections. Plast Reconstr Surg 1998;102:1888–93.

6. Bae JH, Choi DY, Lee JG, Seo KK, Tansatit T, Kim HJ. The risorius muscle: anatomic considerations with reference to botulinum neurotoxin injection for masseteric hypertrophy. Dermatol Surg. 2014 Dec;40(12):1334-9.

7. Jung-Hee Bae, BSDH, Joo-Heon Lee, MD, PhD, Kwan-Hyun Youn, PhD, Mi-Sun Hur, PhD, Kyung-Seok Hu, DDS, PhD, Tanvaa Tansatit, MD, MSc, Hee-Jin Kim, DDS, PhD, Surgical Consideration of the Anatomic Origin of the Risorius in Relation to Facial Planes, Aesthetic Surgery Journal, Volume 34, Issue 7, September 2014, Pages NP43–NP49,

8. Mezey SE, Müller-Gerbl M, Toranelli M, Türp JC. The human masseter muscle revisited: First description of its coronoid part. Ann Anat. 2022 Feb;240:151879.

9. eh Y.-T., Peng J.-H., Peng H.-L.P. Literature review of the adverse events associated with botulinum toxin injection for the masseter muscle hypertrophy. J. Cosmet. Dermatol. 2018;17:675–687.

10. Lee H.-J., Kim J.-S., Youn K.-H., Lee J., Kim D.H.-J. UltrasoundGuided Botulinum Neurotoxin Type A Injection for Correcting Asymmetrical Smiles. Aesthetic Surg. J. 2018;38:NP130–NP134.

11. Chang C.-S., Kang G.C.-W. Achieving Ideal Lower Face Aesthetic Contours: Combination of Tridimensional Fat Grafting to the Chin with Masseter Botulinum Toxin Injection. Aesthetic Surg. J. 2016;36:1093–1100.

12. Nestor MS, Arnold D, Fischer DL. The mechanisms of action and use of botulinum neurotoxin type A in aesthetics: Key Clinical Postulates II. J Cosmet Dermatol. 2020 Nov;19(11):2785-2804. Epub 2020 Sep 16. Erratum in: J Cosmet Dermatol. 2021 Apr 12;: PMID: 32866999; PMCID: PMC7693297.

DSOs: Fact vs. Fiction

EXCLUSIVE DSO WORKSHOP SERIES:

COMPREHENSIVE OVERVIEW

Uncover the truth about the current market. We’ll provide a comprehensive, unique and unbiased look at what is really going on in the DSO space.

EQUITABLE DEAL TERMS

Many practice owners make an uninformed decision based on intentionally misleading information. We aim to educate you on the true value of your practice.

UNBIASED PERSPECTIVE

We understand that it's essential to have access to accurate, unbiased information and we strive to be a valuable resource to those looking for guidance.

TRUSTED ADVISORS

Our team has been advising clients on DSO transactions long before their recent rise in popularity. Our experience has earned us a trusted and reliable reputation.

Our team of experts will provide an in-depth look at the world of DSOs, including how they operate, the benefits and drawbacks of joining one, and the key considerations to keep in mind when making the decision.

You may receive up to 6 CE hours by attending this course. Certificates will be emailed out at the conclusion of the seminar.

less chairside, more income

Are you a Dentist who is becoming tired of working chairside, near the end of your career, or merely looking for supplemental income? Dental Expert Witness work could be the answer for you!

Until now there have been no lectures and no instruction available on what it is, what it takes, and how to market yourself as an Expert Witness. Our exclusive workshop is the first ever of its kind!

Using their 30 years of experience, Dr. Boeke DDS & Dr. Krueger DDS/JD have created a 2 day workshop on the beautiful Texas A&M-Commerce campus, that will teach you the ins and outs of becoming an Expert Witness in a way that is informative, effective, and fun.

outside

as an

mock testimonies based on those trials, complete with testimony from a witness stand - end your day with a Texas BBQ experience on Dr. Boeke's Ranch

For an exclusive experience, our program is limited to 10 seats per sessio n!

Specializing in:

• Conventional biopsy testing

• Cytopathology

• Histochemistry

• Immunohistochemistry

Oral and Maxillofacial Radiology Interpretation Service

*Comprehensive, clinically oriented radiology reports

*Reassurance for exclusion of occult pathology

*Annotated images of relevant findings

*In-depth assessments aiding patient understanding

*Easy to use, HIPAA compliant image sharing portal

*2-4 day business day turn around time

346-221-0316

• Direct immunofluorescence testing

• Complimentary biopsy kits

• Delivery via FedEx, local courier or USPS

• Diagnosis within two business days of receiving most biopsy specimens.

• UT M.D. Anderson Cancer Center and UTHealth Medical School available for consultations as needed.

• Affiliated with UT School of Dentistry at Houston.

713.486.4411 go.uth.edu/Pathology

Our Pathologists:

Jerry E. Bouquot, DDS, MSD Ngozi N. Nwizu, BDS, MMSc, PhD

Kalu U.E. Ogbureke, BDS, DMSc, JD, MSc Nadarajah Vigneswaran, DMD, DrMedDent

Location Truly is EVERYTHING

Katie E. Stuchlik, DDS, FAGD

If you live in a large city in Texas, which a great number of Texas

Dental Association members do, then you understand my frustration with spending hours of my life in traffic. Many of us use commutes to listen to podcasts, audio books, or catching up with family. Then some of us, like myself, just spend time sitting in traffic thinking about everything I could be doing if I wasn’t sitting in traffic.

As previously mentioned in my last article, my first associateship straight out of school was nothing short of incredible. I had a chance to work with THE Dr Duc Ho at Welch Dental Group, current TDA president, and build the strong mentor/mentee relationship we have today. The biggest frustration with this associateship was the constant feeling I was going to be late to work because of an accident on I-10. Mind you, at this time I was an avid 5:00 AM CrossFitter, so I wasn’t afraid of oversleeping. I would hit the road at the same time every morning, giving plenty of time to make it to Katy by 8:00 AM, only to be regularly late. One might argue the commute home was even worse.

When the decision arose to start a practice, I knew exactly where I wanted to practice. I knew my husband and I didn’t want to move to Katy, so starting a practice close to my home was the best fit for my growing family. Of course, I was fortunate Dr Lindsey Wendt lived 2 streets behind me at the time. Lindsey and I visited with a practice real estate company on 2 separate occasions in the summer of 2017, to determine the feasibility of opening a dental practice in our community. After our meetings, we concluded we wanted to open a practice together. The real estate company was our first point of contact in determining how to open a dental practice. Our realty team showed us demographics for the target area and helped us to narrow down a specific location.

There are 2 theories of thought when interviewing practice owners on location: 1) grow a practice in your community that you live and want to be completely invested in; 2) practice far from home so you don’t see your patients at the grocery store. There are benefits to both options. For one, you become your own marketing tool in your community, whether it’s through your kids’ schools or just hanging out at the local brewery. On the other hand, practicing far from home can help you separate work from play more easily.

We settled on a new shopping center that was still under construction in Fall 2017. Simultaneously, we worked with a dental equipment company to fully understand

Drs Katie Stuchlik and Lindsey Wendt visit the space to their new practice before construction began.

the size of the space we needed to build our practice. As associates, we never fully paid attention to the sizes of our operatories. I also knew Welch Dental Group was one of a kind in terms of staff lounge space.

There are important questions to ask when looking for a space:

• Does this space fit the practice I envision?

• Does this location serve the practice model I imagine?

• Can I afford to equip this space?

• Is there room for growth?

• Are there any obstructions in this space to make construction difficult?

• Is there enough parking for my patients?

• Is this space easily accessible?

• How important is street visibility to me?

We knew we wanted a space that allowed us to grow, but we understood that we may outgrow the space during our 10-year lease. We also knew that the location of our dental practice was extremely important. With high rent in our area of Houston, it was imperative our practice was located at a busy intersection to allow for plenty of organic patients. Our intention was to initially accept majority PPO plans based on the demographics of our area. Decisions like these are important to consider before signing a lease or starting new construction.

Our realty team worked to help us through the Letter of Intent phase. This phase lasted about 2 months prior to beginning lease negotiations. During this time, the team helped us to determine a fair rent price, locking down certain perks like parking spots, and helped to increase our tenant improvement allowance.

Negotiating our lease took the expertise of multiple lawyers. During this process, we also used those attorneys to set up our individual entity and our personal entities, a process laid out for us by a CPA whom we met at the Greater Houston Dental Society Star of the South meeting. In March 2018, we officially signed our lease and continued down the road to practice ownership. Our goal was to say no to traffic and open our practice in October 2018.

To date, over 30% of patients in our practice find us from driving by or visiting the UPS store next door. Location truly is everything.

Drs Stuchlik and Wendt’s Dentistry of the Oaks practice opened in 2018 in Houston.

ORAL

and maxillofacial pathology case of the month

AUTHORS

Allison M. Lee, DDS

Department of Diagnostic Sciences

School of Dentistry, Texas A&M University

Dallas, TX

Todd A. Kovach, DDS, MD Private Practice

Trinity River Oral Surgery and Dental Implant Center Willow Park, TX

John M. Wright, DDS, MS

Department of Diagnostic Sciences

School of Dentistry, Texas A&M University

Dallas, TX

Disclosures: There are no financial, economic, or professional interest disclosures for this study.

Clinical History

A 56 –year-old Caucasian male was referred to an oral surgeon for evaluation of an asymptomatic, ulcerated lesion, located proximal to his left nasolabial fold, of approximately 9 months’ duration. His medical history was significant for GERD, depression, and seasonal allergies. He was not taking any medications and reported no known allergies. The lesion had been previously treated with topical fluorouracil; however, it had not resolved.

On clinical examination, the lesion measured 7-8mm in diameter and was located between the left ala and left nasolabial fold. The lesion was nodular, firm on palpation, and ulcerated in the center. It had a well-defined and rolled border with arborizing telangiectasia around the periphery (Figure 1).

Figure 1. Clinical image of a pearly nodule with a central ulceration surrounded by telangiectasias located on the left nasolabial fold.

Based on the clinical presentation of the lesion, the surgeon elected to perform an excisional biopsy for histopathological examination (Figures 2A and B).

Pathologic Findings

Histopathologic examination of the excised lesion revealed a soft tissue specimen surfaced by orthokeratinized stratified squamous epithelium with focal areas of parakeratosis and ulceration. Within the underlying papillary and reticular dermis, variably sized islands of basaloid cells were seen (Figure 3A). At the periphery of the islands, prominent palisading of the tumor cells was noted (Figure 3B). The interface between the tumor nests and connective tissue showed myxoid change with occasional areas of clefting. The tumor cells had hyperchromatic nuclei with relatively little cytoplasm. Numerous mitotic figures were seen throughout.

Figure 2. Clinical image immediately after excision of the lesion (A); The surgical site immediately after wound closure (B).

Follow-up

The healing of the biopsy site was uneventful with minimal scarring. There was no evidence of recurrence at a 1 month follow-up visit (Figure 2C) and 3 months after surgery.

What is the most likely diagnosis?

See page 50 for the answer and discussion.

Figure 3. Histopathologic examination of the excised lesion revealed a soft tissue specimen surfaced by orthokeratinized stratified squamous epithelium with focal areas of parakeratosis and ulceration. Variably sized islands of basaloid cells were seen within the reticular dermis (A); Prominent palisading of the tumor cells is seen at the periphery of the tumor islands (B). (A, Hematoxylin and eosin [H&E], original magnification x 20; B, H&E x 100).

Figure 2C. Clinical presentation at 1 month follow-up visit.

Calendar of Events

TDA Legislative Day Wednesday, February 15, 2023

Amplify Austin: March 1-2, 2023

TDA Meeting May 4-6, 2023 • San Antonio (tdameeting.com)

TMOM 2023 Events

TMOM Marble Falls: February 24-25, 2023

TMOM Bonham: April 14-15, 2023

TMOM Abilene: July 14-15, 2023

TMOM Edinburg: September 15-16, 2023

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

Those in the dental community who have recently passed

Ottie Eugene Barrett Jr

Huntsville

May 19, 1934–December 21, 2022

Good Fellow: 1985 • Life: 2000 • Fifty Year: 2009

Christopher E Edmondson

Argyle

November 19, 1969–July 6, 2022

Joe Thomas Highnote

Wimberley

November 27, 1933–January 2, 2023

Good Fellow: 1989 • Life: 2000 • Fifty Year: 2014

Stephen B Hutchings

Copperas Cove

June 8, 1947–September 30, 2022

Life: 2012

Eugene M Kouri

Fort Worth

January 5, 1936–December 30, 2022

Good Fellow: 1985 • Life: 2001 • Fifty Year: 2011

James Gordon Miller Tyler

March 30, 1932–December 5, 2022

Good Fellow: 1988 • Life: 1997 • Fifty Year: 2012

Scott P Musslewhite Houston

February 3, 1958–November 25, 2022

Good Fellow: 2016 • Life: 2021

John Lynn Porter Denison

July 30, 1938–January 7, 2023

Good Fellow: 1996 • Life: 2003 • Fifty Year: 2016

Fred Flinn Simmons Jr

San Marcos

July 14, 1933–December 12, 2022

Good Fellow: 1982 • Life: 1998 • Fifty Year: 2008

Nearing the end of the procedure, Dr N lost control of the implant driver she was using when Mr J coughed without warning. She last saw the driver at the back of the tongue, before losing sight of it.

Implant Placement Leads to Appendectomy and Colonoscopy

Marc Leffler, DDS, Esq.

Background Facts

A 73-year-old man, whose medical history consisted of diabetes and hypertension, both well-controlled with medication, diet, and weight management presented to an oral surgeon on referral from the patient’s general dentist. Mr J had been edentulous in the posterior lower left quadrant for a number of years, with the distal-most tooth in that area being #20; otherwise, he had an essentially complete dentition in good repair. At the consultation visit with the OMS, a CBCT was taken in conjunction with a clinical examination: there was adequate buccolingual width of the mandible and approximately 15mm of available bone superior to the inferior alveolar canal. Dr N explained the entirety of the implant procedure, to be performed with local anesthesia, and involving the placement of two 11mm endosseous implants, which would ultimately be restored by the referring dentist. A thorough back-and-forth discussion about risks, benefits and alternatives took place, with Mr J signing an “implant consent form” that day. Surgery was planned for the following week.

On the day of surgery, Mr J came to the office alone, ready to proceed. Dr N again asked if her patient had any further questions before injecting local anesthesia, but he did not. After the patient became anesthetized, Dr N performed the implant osteotomies as she had done so many times before, with a dental assistant employing a high-speed suction and retracting the tongue toward the right side of the mouth. Nearing the end of the procedure, Dr N lost control of the implant driver

she was using when Mr J coughed without warning. She last saw the driver at the back of the tongue, before losing sight of it. Unsure of where it had gone, she closed the surgical site and instructed Mr J to immediately go to a free-standing medical clinic in close proximity to the OMS’s office, which Dr N called to alert the physician as to what had happened.

There, the physician ordered radiographs, which revealed that the driver had made its way into the stomach. With the patient in no distress, the physician advised Mr J that the driver would very likely pass in his stool within a few days without any intervention; however, if it did not pass within 4 days, or if he began to have any abdominal pain or other symptoms,

Mr J should return or seek hospital care immediately. Mr J did, in fact, begin to have lower right abdominal discomfort on the third post-procedure day, in conjunction with the lack of a bowel movement since the prior day and a total lack of appetite, so his friend drove him to a local hospital emergency department.

At the ED, a CT scan was promptly performed, showing that the driver was located in the appendix. Mr J was told that he would need an appendectomy, and a surgeon was called. Because the surgeon had 2 scheduled procedures for the day, the first of which was then ongoing, he was not able to attend to Mr J for more than 4 hours. Later that afternoon, Mr J was in the operating room, having

a laparoscopic appendectomy under general anesthesia. Upon removal of the appendix, the driver was not located in it. When Mr J arrived in PACU, abdominal flat films were ordered and performed.

The driver had, between the time of the CT and surgery, made its way out of the appendix and was radiographically found in the hepatic flexure of the colon. The following morning, a gastroenterologist performed a colonoscopy, locating and removing the driver. Mr J remained in the hospital for another night, receiving IV fluids and medications. He was then discharged and followed an uncomplicated course to recovery.

value for your profession

Legal Action

In less than a month, Dr N received a letter from Mr J’s attorney, requesting a complete copy of her records for this patient; she complied with the request and immediately contacted her malpractice insurer. The attorney then assigned to the case by the carrier immediately reached out to Mr J’s attorney, who forwarded on all of the medical records. When Dr N and her new attorney met, they reviewed all of the records together.

Dr N acknowledged the events that took place during the implant procedure, expressed how badly she felt about all that happened, which she believed was her fault, and told her attorney that she wished to try to resolve things with Mr J as soon as possible.

The 2 attorneys spoke, with Mr J’s counsel saying that his client would be willing to resolve the situation if he was reimbursed for all of the medical expenses for which he was responsible and for unrecoverable costs for a scheduled vacation which had to be cancelled, as well as an amount for emotional distress and the pain which followed the appendectomy, which limited his activity for some time. With the approval of the insurance carrier, after a review from an expert, the case was settled prior to a lawsuit having been filed.

Takeaways

It is not uncommon for foreign objects to be swallowed or aspirated during the course of dental treatment, either because of a patient’s sudden move, or a simple loss of grip of a wet instrument, or an errant piece of a tooth in the process of sectioning for removal. For some dental procedures, a rubber dam can be applied, and it creates the best shield against such events; in other situations, a piece of dental floss can be tied to small instruments so that, even if grip is lost, the instrument can be retrieved by simply pulling on the floss; in still other situations, placing a protective gauze drape behind the treatment field can help to “catch” a foreign object; and an attentive dental assistant with suction always serves as the final back-up measure. Whatever methods are used, standard of care dictates that it is the surgeon’s obligation to protect the patient from foreign objects being swallowed or aspirated.

The series of events within the intestinal tract here might seem odd and unlikely, with the general legal principle that practitioners are potentially liable for only the foreseeable consequences which result from negligent acts.

The series of events within the intestinal tract here might seem odd and unlikely, with the general legal principle that practitioners are potentially liable for only the foreseeable consequences which result from negligent acts. While it can be argued that it was not specifically foreseeable that the driver would have made its way into the appendix in the first place, and then back out again, it was certainly generally foreseeable that a swallowed driver would end up in the colon and potentially cause damage to the patient and/or the need for interventional treatment, so that would fulfill the legal requirement.

Once again on the issue of foreseeability, but here in the context of informed consent, patients must be advised of foreseeable risks, as well as benefits and alternatives. The fact that most consent discussions and most consent forms do not include the potential for swallowing and/or aspiration of a foreign body may again serve as an argument that liability should not lie when such an event happens. But that argument is not legally sound because informed consent protects practitioners from risks which occur in the absence of negligence, not because of negligence; patients cannot “sign away” the right to have treatment performed upon them in a non-negligent fashion. (In contrast, for example, is the risk of a patient suffering an inferior alveolar nerve injury from the extraction of a tooth which has roots in direct proximity to that nerve, such that, no matter how ideally the extraction was performed, that injury might well be expected to result.) Some untoward events cannot be protected against, but some can, and a swallowing/aspiration event is among the latter.

If this case were to have proceeded beyond where it did, a defense strategy might have included that the ED physician should have asked a gastroenterologist to perform an endoscopy—which, if successful, would have spared the need for the subsequent treatment—or that the abdominal surgeon should have first ordered a further CT study to assure that the driver was still in the appendix, before performing surgery, given the time that had passed. If, during litigation (had the case not settled pre-suit), the ED physician and/or the abdominal surgeon were co-defendants of the oral surgeon, they might be found partially liable and would be obligated to pay (or have paid on their behalf) their determined percentage portion of liability, but if the oral surgeon were the sole defendant, then many, if not most, jurisdictions would levy full liability against that oral surgeon under the theory that the initial wrongdoer is liable for the results of all actions which reasonably follow, even if some or all of those actions were negligent. [We point out here that States vary widely on this concept, so the general model presented here may vary significantly in particular situations.]

Finally, an OMS’s agreement or desire to settle may come at any step in the entire process, from the time an attorney’s letter is first received, to the moment before a jury enters the courtroom to render its verdict. It is a very personal decision, based upon very personal factors, and it is best made in conjunction with the attorneys representing them and the insurer indemnifying them.

As the nation’s leading dental malpractice insurance carrier, MedPro Group has unparalleled success in defending malpractice claims and providing patient safety & risk solutions. MedPro is the nation’s highest-rated malpractice carrier, rated A++ by A.M. Best. The Berkshire Hathaway business has been defending dentists’ assets and reputations since 1899 and will continue to for years to come.

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The opinions expressed through this post are the opinions of the individual authors and may not reflect the opinions of MedPro Group or any of its individual employees. This document should not be construed as medical or legal advice. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions. MedPro Group is the marketing name used to refer to the insurance operations of The Medical Protective Company, Princeton Insurance Company, PLICO, Inc. and MedPro RRG Risk Retention Group. All insurance products are underwritten and administered by these and other Berkshire Hathaway affiliates, including National Fire & Marine Insurance Company. Product availability is based upon business and/or regulatory approval and may differ among companies. © 2022 MedPro Group Inc. All rights reserved.

ORAL

and maxillofacial pathology diagnosis and management—from page 42

Diagnosis: Basal Cell Carcinoma

Discussion

Basal Cell Carcinoma (BCC) is the most common cancer in humans and according to the American Cancer Society, almost 2.5 million Americans will be diagnosed with BCC each year.1 While it rarely results in death or metastasis when found early, early detection is key to a favorable outcome. Most BCCs develop in the 4th decade of life or beyond, with a peak in individuals aged 80-89 years old.2,3 The main etiological factor for the development of BCCs is UV radiation. The UV damage is cumulative and accounts for the increasing incidence observed in the elderly. Approximately 80% of all BCCs are found on the head and neck, followed by the shoulders, back and chest.4,5 People who frequently experience sun exposure due to occupational or recreational activity are at an increased risk for the development of BCCs. Individuals with a light complexion, particularly those with blue eyes, red hair, or skin that is prone to freckling are at the greatest risk for developing BCCs.6 Additional risk factors for the development of BCC include exposure to indoor tanning, arsenic, irradiation, immunosuppression, and certain genetic disorders.7

Nevoid basal cell carcinoma syndrome (NBCCS), also known as Gorlin’s syndrome, is associated with multiple BCCs, odontogenic keratocysts in the jaws, palmar and plantar pitting, along with a variety of other developmental abnormalities and tumors.8 NBCCS is an autosomal dominant disorder resulting from inactivating mutations in the PTCH1 gene. Patients affected by NBCCS may develop BCCs at a much earlier age (mean age 25 years) and can develop a few BCCs to hundreds in both sun exposed and non-sun exposed areas.9

The most common clinical subtypes of BCCs include nodular, superficial and morpheaform. The nodular subtype, as illustrated in our case, is the most common clinical variant, accounting for 50-79% of all BCCs.7 As seen in our case, these present as papules or nodules with a pearly surface and arborizing telangiectasias.

Approximately 80% of all Basal Cell Carcinomas (BCC) are found on the head and neck, followed by the shoulders, back and chest. People who frequently experience sun exposure due to occupational or recreational activity are at an increased risk for the development of BCCs.

Sometimes referred to as a “rodent ulcer,” the central portion of the lesion may have an ulcerated or crusted surface that appears irregular in shape and depressed or umbilicated. The second most common clinical subtype of BCC is the superficial variant which accounts for up to 15% of cases.7 It presents as a well-circumscribed scaly macule, patch, papule or plaque that is pink to red in color with varying amounts of melanin pigmentation. In contrast to the other subtypes of BCC which most often occur on the head and neck, superficial BCCs tend to favor the trunk and extremities. The morpheaform clinical subtype is the least common, accounting for 5-10% of all BCCs.7 This variant is named for its clinical resemblance to morphea- a type of localized scleroderma which presents as a white to pink scar-like, or shiny indurated plaque or depression with ill-defined borders. This subtype exhibits more infiltrative growth and aggressive behavior than the other clinical subtypes of BCCs.

The clinical differential diagnosis for BCC includes other epithelial malignancies caused by UV exposure such as squamous cell carcinoma and melanoma, particularly amelanotic melanoma, where little to no melanin pigmentation is associated with the lesion. Keratoacanthoma, a rapidly growing and locally destructive skin tumor, can also clinically mimic BCC, as it presents as a nodular lesion with a central crust and commonly occurs on older fair-skinned individuals with a history of chronic sun exposure.10 Another entity that often presents as a nodular lesion with a central depression is molluscum contagiosum. Caused

by the molluscum contagiosum virus, this epithelial lesion most commonly arises in children and young adults and occurs as multiple lesions with a predilection for the skin of the head and neck.10 While the lesions caused by the molluscum contagiosum virus are usually small and spontaneously involute, immunocompromised individuals are prone to developing larger and more persistent lesions. Skin adnexal tumors can also present with features similar to BCC and are oftentimes found on the skin of the head and neck. Deep fungal infections, while not common in Texas, share clinical features with BCC. The variety of both benign and malignant entities that present with similar clinical features to BCC underscores the importance of close clinical examination and histologic evaluation for definitive diagnosis.

After the diagnosis of BCC is made, the treatment is determined largely by the clinical subtype and histologic features of the lesion as well as any concern for cosmetics or function based on the location of the BCC. Accurate assessment of the lesion’s clinical and histologic features for the risk of recurrence and clinical behavior is paramount for ensuring proper treatment. Low-risk BCCs are commonly treated with electrodesiccation and curettage or surgical excision. Other treatment options for low-risk lesions include topical 5-fluorouracil, cryosurgery, and photodynamic therapy. Higher-risk lesions are commonly treated with Mohs surgery, a specialized surgical procedure, where concurrent histologic evaluation of the excised tissue helps to ensure complete excision and therefore a lower recurrence rate.

If left untreated, BCC can become locally destructive and reach the size to where surgical resection is not possible and radiation may not be effective.

If surgery is contraindicated, radiation is the primary treatment option. If left untreated, BCC can become locally destructive and reach the size to where surgical resection is not possible and radiation may not be effective. Metastasis is rare, occurring in 0.003-0.1 percent of cases.6

With over 2 million Americans diagnosed with BCC each year and with

the preferred site being the skin of the head and neck region, no profession is more conveniently situated to diagnose basal cell carcinoma than dentists and every dentist would have multiple opportunities over a professional lifetime to diagnose BCCs, particularly in Texas. While BCCs technically have a clinical differential diagnosis, the provisional clinical diagnosis for any slowly progressing noduloulcerative

lesion of the facial skin, particularly in the fair skinned and elderly, should be BCC. Referral for appropriate workup, diagnosis and treatment provide a significant service to our patients. Both oral surgeons and dermatologists have the expertise to manage these skin cancers. Any patient in your practice with a history of skin cancer is at significant risk of developing additional lesions.

OFFICES OF MARK J. HANNA

J. Hanna JD Former General Counsel, Texas Dental Association

REFERENCES

1. The American Cancer Society. Key Statistics for Basal and Squamous Cell Skin Cancers. 2022. https://www.cancer.org/cancer/basal-andsquamous-cell-skin-cancer/about/key-statistics. html

2. Muzic JG, Schmitt AR, Wright AC, et al. Incidence and Trends of Basal Cell Carcinoma and Cutaneous Squamous Cell Carcinoma: A Population-Based Study in Olmsted County, Minnesota, 2000 to 2010. Mayo Clin Proc. 2017;92(6):890-898.

3. Crowson AN. Basal cell carcinoma: biology, morphology and clinical implications. Mod Pathol. 2006;19 Suppl 2:S127-147.

4. Scotto J, Kopf AW, Urbach F. Non-melanoma skin cancer among Caucasians in four areas of the United States. Cancer. 1974;34(4):1333-1338.

5. Maafs E, De la Barreda F, Delgado R, Mohar A, Alfeiran A. Basal cell carcinoma of trunk and extremities. Int J Dermatol. 1997;36(8):622-628.

6. Goldberg LH. Basal cell carcinoma. Lancet. 1996;347(9002):663-667.

7. Marzuka AG, Book SE. Basal cell carcinoma: pathogenesis, epidemiology, clinical features, diagnosis, histopathology, and management. Yale J Biol Med. 2015;88(2):167-179.

8. Gorlin RJ, Goltz RW. Multiple Nevoid BasalCell Epithelioma, Jaw Cysts and Bifid Rib. 1960;262(18):908-912.

9. Lo Muzio L. Nevoid basal cell carcinoma syndrome (Gorlin syndrome). Orphanet J Rare Dis. 2008;3:32.

10. Brad W. Neville CMA, Douglas D. Damm, Angela C. Chi. Oral and Maxillofacial Pathology. 4th ed. 3251 Riverport Lane, St. Louis, MO 63043: Elsevier; 2016.

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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-WEST (ID #539): 100% FFS practice in the Texas hill country with strong hygiene recall (approx. 30% of total production) and an increasing revenue trend over the past 3 years. Freestanding building, 3 fully equipped operatories, newly installed computers in each room, digital sensors, hand-held x-ray units, practice management software (Dentrix Ascend), and paperless charts. The real estate is also for sale. AUSTIN-NORTH (ID #572): 100% FFS, state-of-the-art office in north Austin featuring a modern buildout with 7 equipped operatories, a CBCT, a digital scanner, and a CEREC milling unit in over 2,600+ sq ft. The office is ideally located in a high visibility retail shopping center with easy access to the surrounding community. AUSTIN-NORTH (ID #575): GD practice in the Killeen/Harker Heights/Copperas Cove area. 4 operatories with recently purchased chairs, digital X-rays, intraoral cameras, and paperless charts.

1,800+ active patients, 40+ new patients per month, revenue of mid-6 figures with 30-35% of total production derived from hygiene

procedures, and excellent profitability. EAST

TEXAS (ID #573): 100% FFS, GD practice and real estate in a bustling east Texas city. Freestanding building, 1,675 sq ft, 4 fully equipped operatories with computers throughout, a digital scanner, intra-oral cameras, and all the other items necessary to treat a large active patient base (over 5,000 visits in the last 24 months and a steady flow of 25+ new patients per month). This is an extremely successful practice with tremendous profitability.

HOUSTON-NORTHEAST (ID #488): FFS/PPO practice and real estate, growing suburb 45 minutes NE of Houston. 1,800 total patients, steady flow of new patients, solid hygiene recall, and consistent revenue of high six figures per year. The office contains 6 fully equipped operatories, plumbed nitrous, digital X-rays, CBCT, and computers throughout.

HOUSTON-SOUTHWEST (ID #565): Large, comprehensive GD practice in southwest Houston. Spacious 3,200+ sq ft, 8 fully equipped ops (with 10 total operatories), digital radiography, computers in operatories, a digital scanner and CBCT. Revenue of over 7 figures with over 40% profitability. This is a great opportunity for a highly trained clinician or group that is looking for a large office that they can continue to grow into.

HOUSTON-SOUTHEAST (ID #566): GD office located in a growing suburb SE of Houston.

PPO/Medicaid patient base, strong and consistent cash flow, a steady flow of new patients, and solid hygiene recall. The 1,950 sq ft, high visibility, retail space features 6 total operatories (5 equipped), a digital pano, paperless charts, an E4D digital scanner/milling unit, and computers throughout. With almost all expanded procedures being referred out, little to no marketing/advertising, and a stellar location, this practice is primed for future growth.

HOUSTON-NORTH (ID #568): Turnkey GD practice in a rapidly growing suburb of Houston. FFS/PPO office, modern build out, 3 equipped operatories, computers in ops, digital radiography, intra oral cameras, paperless charts, and a digital pano. This is an ideal opportunity for a buyer who is interested in a start-up and is ready to take an office that is primed for growth to the next level!

HOUSTON-NORTH (ID #571): Established GD practice in a highly desirable suburb in north Houston. 2,600+ sq ft office, 6 fully equipped operatories with digital radiography, digital Pano, Cerec digital scanner, and a Cerec milling unit. The practice serves a large FFS/PPO patient base, revenue of over mid-6 figures, and has a strong hygiene recall program. The doctor refers out all implant placement, oral surgery, and orthodontics.

HOUSTON-WEST/ ENERGY CORRIDOR (ID #574): GD Practice located in west Houston near the Energy

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Corridor. High-visibility retail office with 1,575 sq ft, 5 equipped operatories, digital radiography, computers in ops, and paperless charts. Large patient base made up of majority PPO/FFS patients with a small percentage of revenue derived from Medicaid patients. Strong new patient flow (approximately 40 new patients per month) and tremendous upside potential. MIDLAND/ODESSA (ID: #567): 100% FFS GD practice in Midland/ Odessa. The 1,440 sq ft condo is well equipped with 3 fully furnished operatories, digital radiography, intra-oral cameras, and a digital pano and CBCT. Dedicated, multi-generational patient base, a fantastic reputation, word of mouth referrals, consistent hygiene recall, low overhead, and strong cash flow. NORTHEAST

TEXAS (ID #554): 100% FFS GD practice in a desirable town in northeast Texas with 7 figures in revenue and strong net income. The turn-key practice features 4 fully equipped operatories with digital radiography, intra oral cameras, paperless charts, CBCT, and a digital scanner. TO REQUEST MORE INFORMATION ON MCLERRAN & ASSOCIATESí LISTINGS: Please register at www.dentaltransitions. com or contact us at 512-900-7989 or info@ dentaltransitions.com.

BEAUMONT: GENERAL (REFERENCE

“BEAUMONT”). Small town practice near a main thoroughfare. 80 miles east of Houston. Collections in 7 figures. Country living, close enough to Houston for small commute. Practice in a stand-alone 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, dentist office, sterilization area, lab area. Majority of patients are 30 to 65 years old. Practice has operated at this location for over 38 years. Practice sees patients about 16 days a month. Collection ratio of 100%. The practice is a fee-for-service practice. Building is owned by dentist and is available for sale. Contact Christopher Dunn at 800-930-8017 or Christopher@DDRDental.com.

HOUSTON

(SHARPSTOWN AREA): GENERAL (REFERENCE

“SHARPSTOWN GENERAL”). Motivated seller. Well established general dentist with high6 figure gross production. Comprehensive general dentistry in the southwest Houston area focused on children (Medicaid). Very, very high profitability. 1,300 sq ft, 4 operatories in single building. 95% collection ratio. Over 1,200 active patients. 20% Medicaid, 45% PPO, and 35% fee-for-service. 30% of patients younger than 30. Office open 6 days a week and accepts Medicaid. Contact Christopher Dunn at 800-930-8017 or Christopher@DDRDental.

com. HOUSTON (BAYTOWN AREA): GENERAL (REFERENCE “BAYTOWN GENERAL”). Motivated seller. Well established general practice with mid-6 figure gross production. Comprehensive general dentistry in Baytown on the east side of Houston. Great opportunity for growth! 1,400 sq ft, 4 operatories in single story building. 100% collection ratio. 100% fee for service. Practice focuses on restorative, cosmetic and implant dental procedures. Office open 3 - 1/2 days a week. Practice area is owned by dentist and is available for sale. Contact Christopher Dunn at 800-930-8017 or Christopher@ DDRDental.com.

DALLAS: Hageman Family Dentistry. 9,900 sq ft building, on 2/3 acre. Prime location with easy access on and off Highway 67. 9 fully equipped operatories, digital X-rays, new computers in operatories, office and doctor’s offices. Cephalometric, laser, and Panorex machines. Beautiful waiting room seats 20 patients comfortably; practice thriving for 50 years, 40 years in present location. Annual income for past 5 years: 7 figures. Dr David Hageman is ready to retire! Upstairs rental spaces income for over 5 years: 5 figures per year. For info call 214-215-2525, Sandy Ward, Adm.

HOUSTON, COLLEGE STATION, AND LUFKIN (DDR DENTAL Listings). (See also AUSTIN for other DDR Dental listings and visit www. DDRDental.com for full details. LUFKIN: GENERAL practice on a high visibility outer loop highway near mall, hospital and mature neighborhoods. Located within a beautiful single-story, free-standing building, built in 1996 and is also available for purchase. Natural light from large windows within 2,300 sq ft with 4 operatories (2 hygiene and 2 dental). Includes a reception area, dentist office, a sterilization

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

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area, lab area, and break room. All operatories fully equipped. Does not have a pano but does have digital X-ray. Production is 50% FFS and 50% PPO (no Medicaid), with collection ratio above 95%. Providing general dental and cosmetic procedures, producing mid six figure gross collections. Contact Christopher Dunn at 800-930-8017 or Christopher@DDRDental. com and reference “Lufkin General or TX#540”.

HOUSTON: GENERAL (SHARPSTOWN). Well established general dentist with high-6 figure gross production. Comprehensive general dentistry in the southwest Houston area focused on children (Medicaid). Very, very high profitability. 1,300 sq ft, 4 operatories in single building. 95% collection ratio. Over 1,200 active patients. 20% Medicaid, 45% PPO, and 35% fee-for-service. 30% of patients younger than 30. Office open 6 days a week and accepts Medicaid. Contact Chrissy Dunn at 800-930-8017 or chrissy@ddrdental. com and reference “Sharpstown General or TX#548”. HOUSTON: GENERAL (PEARLAND AREA). General located in southeast Houston near Beltway 8. It is in a freestanding building. Dentist has ownership in the building and would like to sell the ownership in the building with the practice. One office currently in use by seller. 60 percent of patients age 31 to 80 and 20% 80 and above. Four operatories in use, plumbed for 5 operatories. Digital pano

and digital X-ray. Contact Christopher Dunn at 800-930-8017 or christopher@ddrdental. com and reference “Pearland General or TX#538”. HOUSTON: PEDIATRIC (NORTH HOUSTON). This practice is located in a highly sought-after upscale neighborhood. It is on a major thoroughfare with high visibility in a strip shopping center. The practice has three operatories for hygiene and two for dentistry. Nitrous is plumbed for all operatories. The practice has digital X-rays and is fully computerized. The practice was completely renovated in 2018. The practice is only open 3 -1/2 days per week. Contact Christopher Dunn at 800-930-8017 or christopher@ddrdental. com and reference “North Houston or TX#562”. WEST HOUSTON: MOTIVATED SELLER. Medicaid practice with production in mid-6 figures. Three operatories in 1,200 sq ft in a strip shopping center. Equipment is within 10 years of age. Has a pano and digital X-ray. Great location. If interested contact chrissy@ddrdental.com. Reference “West Houston General or TX#559”.

LUBBOCK #TX182: 5-op general practice, digital, updated, and high-tech in a desirable location using Dentrix and referring out specialty services. Practice has a strong hygiene program. For details contact Geremy Haseloff: 806-777-4732, Geremy.Haseloff@henryschein. com. SAN ANGELO #TX3082: General practice

with 5 ops and low overhead. Highly profitable practice on a 4-day schedule per week, plus 100% FFS. Seller refers out all specialties. Room to grow keeping procedures in house. Real estate is available for purchase or lease. For details contact Geremy Haseloff, geremy. haseloff@henryschein.com, 806-777-4732. HOUSTON #TX3114: Beautiful prosthodontic practice in Uptown/West Oaks area. 3 ops +1 plumbed, digital. Dentrix, digital pan and x-ray, i/o camera. Consistent 7-figure annual revenues for past 5 years. Great opportunity. Contact Josh Griebahn, josh.griebahn@henryschein. com, 713-882-8485. CINCO RANCH/KATY AREA #TX3183: Check out this hidden startup gem opportunity! This beautiful finished out, 6-op practice is in a major hot spot. This practice is fully digital and paperless, CBCT/with Ceph, all ADEC units with integrated electric handpieces, and i/o cameras. Practice has low6 figures in current annual revenue and just needs a full-time provider. Great opportunity in a market where to build out a new office will take 8-12 months. For more contact Josh Griebahn, josh.griebahn@henryschein.com, 713-882-8485. AMARILLO AREA #TX3221: Very profitable 7-figure collection practice with over 41 years of Goodwill! In addition, the real estate is beautiful, recently new, and available for purchase also. Over 90% FFS. This practice has it all! High profit margins, high

number of patients, great location, visibility, and the best equipment and technology. Twelve fully equipped operatories! Technology features 2 CEREC scanners, 2 CEREC mills, 3D Printer, Sirona CBCT(3D), Laser, Sensors, Intraoral cameras, surgical handpieces. It even has more room for expansion and growth! Contact Geremy Haseloff: 806-777-4732, geremy.haseloff@henryschein.com. KATY AREA #TX3226: This 13-treatment room GP is located in a strip center on a major street. This amazing find with a 2,400+ active patient base also has 50+ new patients per month. This beautiful practice has everything you need and want and is fully digital with state-of-theart equipment and great cash flow. Patient base is 45% PPO, 13% FFS, and 42% Medicaid. Come and get an early look at this practice! Contact Josh Griebahn: 713-882-8485, josh. griebahn@henryschein.com. DALLAS #TX3258: General dentistry practice with 3 ops and older equipment in nice shape. Great location on a busy main road. Very low overhead, reasonable rent, affluent community, this practice is ready to take to the next level, adding technology of your choosing! Our seller is ready to retire leaving a legacy of 50+ years of caring for patients in the area. Contact Geremy Haseloff: 806-777-4732, geremy.haseloff@henryschein. com. SAN ANTONIO #TX3284: Located in a rapidly growing community, this 4-op pediatric

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office is fully digital with real estate for sale! 52 new patients per month will help drive doctor production and support a new owner. Don’t miss this opportunity! Contact Josh Griebahn: 713-882-8485, josh.griebahn@henryschein. com. HOUSTON #TX3297: Montrose area practice has 4 ops and is FFS with amazing location. Practice has Dentrix, Dexis, CBCT unit with i/o cameras and a fantastic team. RE is also for sale with tenant income. Net earnings are mid-6 figures before debt service on 3 days per week. Don’t miss out on this amazing opportunity! Contact Josh Griebahn: 713-882-8485, josh.griebahn@henryschein. com. HUMBLE #TX3305: Located just outside of Atascocita and Humble, this 7-op practice is everything you need to have a successful practice. Office is fully digital, updated and located in a busy strip center. This practice won’t be on the market long! Contact Josh Griebahn: 713-882-8485, josh.griebahn@ henryschein.com. AUSTIN/ROUND ROCK

#TX3311: Don’t miss this opportunity! Located in Round Rock, this 8-op, 3,400 sq ft, single provider, general practice comes with beautiful real estate and good revenue. The office comes equipped with Dentrix, digital imaging, scanning system, and digital pan. Practice is FFS with annual revenues near 7 figures in collections. Doctor is referring out all implant placement and most oral surgery. This practice

has the potential to be a multi-million dollar producing practice! Selling doctor is willing to transition for 6-12 months if needed. Contact Josh Griebahn: 713-882-8485, josh.griebahn@ henryschein.com.

SAN ANGELO: To those desiring the perfect balance between work and play: Are you interested in taking over a successful readymade practice with a great salary low-to-mid 6 figures? Located in west central Texas, San Angelo is a city of 100,000+ but offers a small town feel and excellent quality of life. The city was named the Visual Arts Capital of Texas in 2021 and is alive with a vibrant mixture of arts and culture for children and adults. It is consistently ranked as one of the best small cities for business and employment. San Angelo is home to award winning Angelo State University, three lakes, the beautiful Concho Riverwalk, an incredible nationally ranked Art Museum, and one of the best preserved forts in the nation, Fort Concho—all with numerous kid-involved programs. As a Texas friendly city, live music is offered almost daily at one of many venues and one-of-a-kind restaurants in town. The community is diverse, with an active young professional group, outstanding medical facilities, ranked sports teams, great hunting and fishing, and a low cost of living. Easy traffic takes you anywhere in the city within

10 minutes. It is a great place to raise a family and a great place to live, work, and play. The 2,400 sq ft newly remodeled dental office, built to accommodate 2 dentists, is a free-standing building with natural light in each operatory. An extremely healthy hygiene program is in place with 2 hygienists. There are 6 operatory rooms—4 equipped. The majority of practice is FFS cash, with over 3,000 active patients. The practice has an excellent reputation in the local community. A bonus package is included for preferred equipment needs. Contact Geremy Haseloff @ 806-777-4732 or geremy.haseloff@ henryschein.com.

SOUTHEAST HOUSTON: Above mid-6 figures of adjusted net production and almost full collection (97%). Fee-for-service and PPO practice, highest-net income. The total collection over total production is about 90%. 4 days/week, free weekends. No Medicaid, no HMO/DMO, no in-network and no hassle. This practice has been in this area for over 40 years; the current practice location was built in 2006 in a new building with all new equipment. 4000 sq ft, 5 fully equipped operatories, and 5 additional operatories plumbed. CBCT with pano and digital X-ray with a Phosphor-Plate scanner require little to no maintenance. We have a few digital sensors too. Microscopes and Fotona Lasers are available. Doctors over

70 years of age are ready to retire. Instead of using a broker, we are willing to provide a discount equal to the broker fee. Interested parties can contact us by calling or texting our personal cell number 346-754-9643. Email: smile.office@proton.me. Principals only. Sales agents and buyers bonded to the broker, please don’t contact this sales poster. Do NOT contact us with unsolicited services or offers.

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.

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HAVE MIRROR AND EXPLORER, WILL TRAVEL: Sick leave, maternity leave, vacation, or death, I will cover your general or pediatric practice. Call Robert Zoch, DDS, MAGD, at 512517-2826 or drzoch@yahoo.com.

THAT COMES WITH 5-STAR RE VIE WS.