August 2014
TEXAS DENTAL
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Texas Dental Journal l www.tda.org l August 2014
TEXAS DENTAL JOURNAL Established February 1883
n
Vol 131, No 8
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August 2014
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ABOUT THE COVER Pictured on the cover is an old railroad trestle with an iconic iron truss bridge over the Brazos River near Waco.
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REPLACEMENT OF MAXILLARY PERMANENT CENTRAL INCISORS LOST DUE TO TRAUMA IN THE MIXED-DENTITION Barry Rubel, DMD and Edward E. Hill, DDS, MS The authors present a case report involving a 9-year-old boy who had experienced traumatic loss of the maxillary central incisors.
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TRANSLATING RESEARCH INTO EVERYDAY CLINICAL PRACTICE: LESSONS LEARNED FROM A USA NATIONAL DENTAL PRACTICEBASED RESEARCH NETWORK Valeria V. Gordan, DDS, MS, MS-CI, Professor and The National Dental PBRN Collaborative Group This paper discusses practice-based research as a means to speed up the translation of research findings to clinical practice. It also reviews repair versus replacement of defective restorations as one example of the delay in the application of research findings to clinical practice. Thomas Oates, DMD, PhD, the director of the Southwest Region of the NIH-sponsored National Dental Practice-Based Research Network and co-director of the South Texas Oral Health Network, provides an introduction to the article.
MONTHLYFEATURES 568
President’s Message
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Value for Your Profession
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Critically Appraised Topic of the Month
610
Oral and Maxillofacial Pathology Case
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Oral and Maxillofacial Pathology Case of
of the Month Diagnosis and Management
the Month
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Calendar of Events
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Memorial and Honorarium Donors
616
Advertising Briefs
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In Memoriam
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Index to Advertisers
603
2014 TDA Annual Session TEXAS
Meeting Photo Contest
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Texas Dental Journal l www.tda.org l August 2014
TDA members, use your smartphone to scan this QR Code and access the online Texas Dental Journal.
Editorial Staff
Editorial Advisory Board
BOARD OF DIRECTORS
Daniel L. Jones, DDS, PhD, Editor Harvey P. Kessler, DDS, MS, Associate Editor Nicole Scott, Managing Editor Billy Callis, Publications Coordinator Barbara Donovan, Art Director Paul H. Schlesinger, Consultant
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 Daniel Perez, DDS William F. Wathen, DMD Robert C. White, DDS Leighton A. Wier, DDS Douglas B. Willingham, DDS
The Texas Dental Journal is a peer-reviewed publication. Texas Dental Association 1946 S IH-35 Ste 400, Austin, TX 78704-3698 Phone: 512-443-3675 • FAX: 512-443-3031 Email: tda@tda.org • Website: www.tda.org Texas Dental Journal (ISSN 0040-4284) is published monthly (one issue will be a directory issue), by the Texas Dental Association, 1946 S IH-35, Austin, TX, 78704-3698, 512-443-3675. Periodicals Postage Paid at Austin, Texas and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S IH 35, Austin, TX 78704. Copyright 2014 Texas Dental Association. All rights reserved. Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, Out-ofstate ADA Affiliated $49.50. In-state Non-ADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA Affiliated, $17 Non-ADA Affiliated, September issue $17 ADA Affiliated, $65 NonADA Affiliated. For in-state orders, add 8.25% sales tax. Contributions: Manuscripts and news items of interest to the membership of the society are solicited. Electronic submissions are required. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. For more information, please refer to the Instructions for Contributors statement printed in the September Annual Membership Directory or on the TDA website: tda.org. All statements of opinion and of supposed facts are published on authority of the writer under whose name they appear and are not to be regarded as the views of the Texas Dental Association, unless such statements have been adopted by the Association. Articles are accepted with the understanding that they have not been published previously. Authors must disclose any financial or other interests they may have in products or services described in their articles. Advertisements: Publication of advertisements in this journal does Association of not constitute a guarantee or endorsement by the Association of Dental Editors and the quality of value of such product or of the claims made of it by Journalists. its manufacturer.
PRESIDENT David H. McCarley, DDS 972-562-0767, drdavid@mccarleydental.com PRESIDENT-ELECT Craig S. Armstrong, DDS 832-251-1234, drarmstrong01@gmail.com IMMEDIATE PAST PRESIDENT David A. Duncan, DDS 806-355-7401, davidduncandds@gmail.com VICE PRESIDENT, NORTHEAST Jerry J. Hopson, DDS 903-583-5715, dochop@verizon.net VICE PRESIDENT, SOUTHEAST William S. Nantz, DDS 409-866-7498, wn3798@sbcglobal.net VICE PRESIDENT, SOUTHWEST Joshua A. Austin, DDS 210-408-7999, jaustindds@me.com VICE PRESIDENT, NORTHWEST Steven J. Hill, DDS 806-783-8837, sjhilldds@aol.com SENIOR DIRECTOR, NORTHEAST William H. Gerlach, DDS 972-964-1855, drbill@gerlachdental.com SENIOR DIRECTOR, SOUTHEAST Karen A. Walters, DDS 713-790-1111, kwalters@sms-houston.com SENIOR DIRECTOR, SOUTHWEST John B. Mason, DDS 361-854-3159, jbmasondds@aol.com SENIOR DIRECTOR, NORTHWEST Charles W. Miller, DDS 817-572-4497, cwdam@sbcglobal.net DIRECTOR, NORTHEAST Dennis E. Stansbury, DDS 903-561-1122, drstansbury@gmail.com DIRECTOR, SOUTHEAST Duc “Duke” M. Ho, 281-395-2112, ducmho@sbcglobal.net DIRECTOR, SOUTHWEST James R. Foster, DDS 956-969-2727, fosterdds@gmail.com DIRECTOR, NORTHWEST W. Kurt Loveless, DDS 806-797-0341, wklovedds@gmail.com SECRETARY-TREASURER* Ron Collins, DDS 281-983-5677, roncollinsdds@yahoo.com SPEAKER OF THE HOUSE* John W. Baucum III, DDS 361-855-3900, jbaucum3@gmail.com PARLIAMENTARIAN** Arthur C. Morchat, DDS 903-983-1919, amorchat@suddenlink.net EDITOR** Daniel L. Jones, DDS, PhD 214-828-8350, djones@bcd.tamhsc.edu *Non-voting member **Non-member attendee
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AACP Institute Gerald J. Murphy, BS, DDS | Director
Sleep Medicine and Dentistry Mini-Residency
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Class 2 | 2014–2015
Session 1 September 19–20, 2014 Session 2 November 7–8, 2014 Session 3 January 23–24, 2015
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President’s Message David McCarley, DDS, TDA President
FLUORIDE:
“
T
The Issue
of fluoride in the community water system. I guess I missed that benefit.
here seems to be a recent push by certain groups to remove fluoride from municipal water supplies and this issue seems to be on the rise. The TDA has sent 8 letters to 8 different communities considering the removal of fluoride from their water supplies within the last year. One of those letters, and the following battle that ensued, was in my community of McKinney. If you have not had the opportunity to experience this, then consider yourself fortunate. There were 40 or so vocal antifluoride protestors, most of whom were waving posters at the meeting. I was amazed by the level of demeaning statements toward dentistry and the dentists in the room. This seems to be consistent with many of the city council meetings addressing this issue. At the city council meeting in McKinney last year, we — dentists — were accused of profiting from the placing of fluoride in the community water system. I guess I missed that benefit. We told them that all studies point to a community savings in dental care of $38 for every $1 spent on fluoride. We were scoffed at and booed by the protestors. In the end the McKinney City Council saw fit to continue the city’s water fluoride program at the accepted level and the issue is at rest … until next time. The antifluoride groups are very well organized with national websites and Facebook pages. Most of their
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opposition is based on false science and statements taken out of context. Their position is that high levels of fluoride are toxic; therefore, any level of fluoride must be harmful and toxic also. As a microbiology graduate student in another life, we were expected to use data that was tested, confirmed, and definite. We could publish only in refereed journals; our results must be repeatable, verifiable, and reviewed by the experts in the field. Many times we had to repeat experiments looking at other variables to ensure that our data was accurate and unbiased. The antifluoride group’s false science is based on supposition and quotes with no verifiable evidence or studies. I am amazed sometimes at how easily some people accept opinions as fact and how easy it would be to lead them back into the dark ages. The American Dental Association (ADA) and the TDA Council on Dental Economics (CODE) have a wealth of information and reams of scientific studies that can aid your community when making the fluoride decision. You will find Jane S. McGinley, ADA manager of fluoridation and preventive health activities, and CODE Consultant (and former Chair) Dr Delton Yarbrough of Fort Stockton to be extremely knowledgeable and most helpful with fluoride issues. They have been through these battles many times and will help guide you and your district to meet the challenges that present themselves.
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Oral and Maxillofacial Pathology Case of the Month Clinical History A 26-year-old woman sought evaluation by her family dentist of a “thin film” of her mandibular vestibular mucosa, bilaterally (Figure 1). The mucosa in the region was completely asymptomatic but every few weeks she was able to “scrape off” parts of it, with no hemorrhage, pain or ulceration. She had been aware of the lesion for at least the past year and had sometimes noticed it on her lower lip mucosa as well. The patient revealed that her older sister had a “more mild case” which had been present for at least 5 months. Both women were sure that their oral mucosae were “perfectly normal” prior to the development of these plaques. Neither sister had a known systemic disease; neither was taking a medication, other than daily vitamins. They both had very good oral hygiene habits and had visited their dentist every 6-12 months all of their lives. No other family member had a similar problem. At examination she presented with bilateral grayishwhite alteration of the vestibular mucosa, with several small, soft, slightly elevated white papules (Figure 1). The papules could be partially scraped off and cytologic examination, ie, pap smear, of such scrapings showed the removable “membrane” to be comprised of mature keratin (Figure 2A). There were no ulcers or areas of erythema, induration or tenderness. In addition to the papules, a small portion of the left mandibular plaque could be partially removed with a tongue blade, leaving
A
Bouquot
Koeppen
Haddad
Jerry E. Bouquot, DDS, MSD, FICD, FACD, FRSM (UK), adjunct professor and past chair, Department of Diagnostic & Biomedical Sciences, University of Texas School of Dentistry at Houston, Houston, Texas Raymond G. Koeppen, DDS, MS, MBA, FACP, associate professor and chair, Department of Restorative Dentistry and Prosthodontics, University of Texas School of Dentistry at Houston, Houston, Texas Yasmine Haddad, DDS, PhD, clinical assistant professor, Departments of Diagnostic & Biomedical Sciences and General Practice & Public Health Dentistry, University of Texas School of Dentistry at Houston, Houston, Texas
B
Figure 1. Asymptomatic vestibular mucosal alteration. A) Thin, grayish white plaque of the mucosa can be partially scraped off; B) Close up of lesion, showing small, thick accumulations of partially sloughed keratin.
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A
B
C
D
Figure 2. Histopathology of Figure 1 lesion. A) Pap/PAS staining of cytology smear shows all keratinocytes to be mature (orange/red); B) & C) Thickened keratin layer is mostly comprised of large open epithelial cells (intracellular edema) with a thin parakeratin surface layer, focal loss of rete processes and a subepithelial infiltrate of chronic inflammatory cells; D) A cleft is present immediately beneath the keratin layer (on left).
normal appearing mucosa beneath. There were no other oral lesions identified.
subepithelial infiltrate of chronic inflammatory cells was seen but otherwise the submucosal stroma was normal.
The patient was very concerned about “a precancer” because she had “researched” white patches in the mouth and was aware of the nature of leukoplakia. She insisted on a microscopic evaluation and so an incisional biopsy was performed. On microscopic examination, the mature keratinocytes noted in the Pap smear were seen as a thickened layer of surface parakeratin, ie, hyperkeratosis or, more specifically, hyperparakeratosis (Figure 2B). Beneath this layer was a layer of mature keratinocytes with very large cell bodies and clear or almost clear cytosol, a feature often referred to as intracellular edema (Figures 2C and 2D). Beneath this, the epithelium was normal except for a region with a small cleft between the spindle cell layer and the keratin layer (Figure 2D). There were also areas showing flattening of the rete processes and thickening of the basement membrane. A mild
The biopsy diagnosis was “hyperkeratosis without dysplasia, with intracellular edema and with mild chronic mucositis.” With no dysplasia seen microscopically, and with the knowledge that inflammation and intracellular edema of the superficial epithelium can be a sign of chemical, physical, or thermal trauma, a more detailed evaluation of the patient’s habits was undertaken. She started using a new toothpaste with whitening and tartar-control compounds about a year and a half earlier, on the advice of her dentist. She did not smoke or drink alcohol excessively and seldom used mouthwashes. She did not chew gum or keep candy “or anything else” in the mandibular vestibules. This was true for her sister as well, who also had been using the same whitening toothpaste.
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Figure 3. Look-alike lesions: A) Smokeless tobacco keratosis of the vestibular and buccal mucosa; B) Patchy, thin, whitishgray macules are seen on alveolar mucosa anterior to the molar, where patient placed aspirin for a toothache; C) Cocaine burn of the left posterior vestibular and buccal mucosae is ulcerated (cocaine ulcer) and can be partially scrapped off, and is an area of repeated cocaine placement; D) “dentifrice reaction� from the 1970s was a thin whitish film of the vestibule which could be completely or partially scraped off, showing normal underlying mucosa.
A
B
D
C It was decided to empirically determine whether or not the toothpaste was an etiologic factor. Accordingly, she used only baking soda to brush her teeth over a period of 3 weeks; the mucosal film disappeared completely on both sides of her mandible within a week. At the conclusion of the 3 weeks she switched to her old non-whitening toothpaste; after 6 months there was no return of the mucosal macules. At that time, out of curiosity, she elected, without consulting her dentist, to switch back to the whitening toothpaste. A thin mucosal film developed within 5-6 weeks; the film disappeared within a week of returning to use of her original non-whitening toothpaste. What is the final diagnosis? See page 610 for the answer and discussion.
A
B
Figure 4. Idiopathic subcorneal acantholytic keratosis (SAK) of the left mandibular vestibule and alveolar mucosae in a 46 year old woman. A) Thin white film unevenly covers alveolar and vestibular mucosae; B) Finger pressure has pushed the white film into a central region near the first molar, with normal mucosa beneath.
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TDA 2015 IT’S ABOUT
YOUR PRACTICE Co n ne c t Lead e rs D r ive I n nova t i o n Shap e D e n t is t r y E nha nce Ca re e rs
texasmeeting.com
May 7-10 Texas Dental Journal l www.tda.org l August 2014
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REPRESENTING DENTISTS THROUGHOUT TEXAS BEFORE THE STATE BOARD OF DENTAL EXAMINERS
JKJ Pathology Oral Pathology Laboratory
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Protecting your patients, limiting your liability
EDWARD P. “JOE” WALLER, JR., D.D.S., J.D. ATTORNEY AT LAW BRIN & BRIN, P.C.
6223 IH 10 West SAN ANTONIO, TEXAS 78201 (210) 341-9711 FAX (210) 341-1854 jwaller@brinandbrin.com * Not certified by the Texas Board of Legal Specialization
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LAW OFFICES OF HANNA & ANDERTON EXPERIENCED LAWYERS REPRESENTING TEXAS DENTISTS MARK J. HANNA, JD Former General Counsel, Texas Dental Association
* Representation Before the Texas State Board of Dental
Examiners
* Medicaid Audits and Administrative Hearings * Employment Issues - Texas Workforce Commission
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FRANK B. WALKER, JD Former General Counsel, Texas State Board of Dental Examiners
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ROBERT M. ANDERTON, DDS, JD, LLM Past President, Texas Dental Association and American Dental Association
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Replacement of maxillary permanent central incisors lost due to trauma in the mixed-dentition Barry Rubel, DMD and Edward E. Hill, DDS, MS
About the Authors Barry Rubel, DMD, professor, Care Planning and Restorative Sciences, University of Mississippi School of Dentistry, 2500 North State St, Jackson, MS 39216; Phone: 601-984-6030; Fax: 601-984-6039; Email: brubel@umc.edu Edward E. Hill, DDS, MS, professor, Care Planning and Restorative Sciences University of Mississippi School of Dentistry, 2500 North State St, Jackson, MS 39216; Phone: 601-984-6030; Fax: 601-984-6039; Email: eehill@umc.edu The authors have no declared potential conflicts of financial interest, relationships, and/or affiliations relevant to the subject matter or materials discussed in the manuscript. This article has been peer reviewed.
Introduction As teeth erupt leading to the permanent dentition, a sequence of events occurs which result in a functional, esthetic, and stable occlusion (1). When the sequence is disrupted by trauma, corrective procedures may be needed in order to bring esthetic and functional components of the developing dentition back into harmony. Traumatic injuries to anterior teeth in children range from minor chipping to total tooth loss and occur more often in boys than in girls with the
Abstract Traumatic injuries to anterior teeth in children range from minor chipping to total tooth loss and occur more often in boys than in girls. The treatment of permanent tooth loss in younger patients is complicated by the difficulty of doing restorative procedures which may be influenced by pulpal size, clinical crown height, and a dental profile which is constantly changing. This case report presented a situation involving a 9-year-old boy who had experienced traumatic loss of the maxillary central incisors. Innovative materials coupled with sound principles of removable partial denture design were utilized to fabricate a cast metal removable denture prosthesis to satisfy the esthetic, functional and psychological dental needs of the patient and his parents.
Key Words Trauma, mixed dentition, esthetics
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maxillary central incisors being the most commonly affected teeth (2,3). Trauma resulting in tooth avulsion is often mishandled — ideal treatment would consist of preservation and replantation, so that the intervention is long term and remains until growth stops allowing for definitive replacement (4). The treatment of permanent tooth loss in younger patients is complicated by the difficulty of doing restorative procedures, which may be influenced by pulpal size, clinical crown height, and a dental profile, which is constantly changing. Placement of a fixed prosthesis or implant-supported crown for tooth replacement is seldom the best treatment choice because of incomplete craniofacial growth and the factors cited above (although implant-supported restorations have been used for select cases involving children with severe hypodontia) (5). If possible, tooth replacement using a removable prosthesis allows for some degree of adjustment and freedom of growth with minimal tooth preparation but still requires available undercuts for retentive clasps and possibly frequent remakes. Most interim removable partial prostheses have acrylic resin denture bases and artificial teeth. When a preadolescent patient is expected to wear an interim prosthesis for an indefinite period of time, the dental practitioner might want to consider using a cast metal denture base (5). A cast metal denture base will be more accurate and can be designed to be considerably less bulky and should be more durable. The purpose of this report is to share an opportunity where this treatment modality was utilized.
Case Report A 9-year-old boy was screened at the University of Mississippi School of Dentistry with of a history of trauma to his face about 9 months previously with loss of the maxillary central incisors. His medical history indicated no medical problems and intraoral findings were unremarkable except for the area of the avulsed teeth, although no scarring or defects were present. The main concern of the child and his parents was the replacement of the missing front teeth so that he would have better esthetics and be able to smile. Previous efforts to provide a satisfactory provisional prosthesis had failed. Appropriate diagnostic casts, an accurate interocclusal record, and surveyed casts were used to
determine design options for a removable prosthesis (Figure 1). Treatment goals were to develop a retentive prosthesis that would provide for a good esthetic outcome while being tolerated by the patient and also be adaptable so that it could be modified to allow for tooth eruption or until a more permanent course of treatment could be pursued. Since esthetics was a key concern and in order to allow freedom of his permanent teeth to erupt unhindered, a cast removable prosthesis was planned. A master cast was made from die stone after a polyether final impression was made and appropriate interocclusal records were recorded. A 19-gauge wrought wire was used for retention in the premolar area with a cast modified T clasp on the maxillary
Figure 1. Diagnostic casts of the patient.
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right and left first permanent molars allowing a passive fit (Figure 2). The major connector was a horseshoe design cast in Ticonium alloy (CMP Industries, Gardena, CA), which was kept away from any embrasures so that eruption of the permanent dentition could occur. Incorporated into this design was the ability to rebase the horseshoe palatal aspect as necessary during growth changes. Anterior teeth were fabricated by using the Gradia System from GC Lab Technologies Inc. (3737 W 127th St, Alsip, IL 60803) [a light-cured micro-ceramic composite system that has durability, natural opalescence and excellent lifelike esthetics (Figure 3)]. The patient and his parents were thrilled with the esthetic outcome and the patient tolerated wearing the appliance well (Figures 4,5). He was placed on recall to periodically monitor his dental health with future appointments aimed at direct composite bonding of his lateral incisors to enhance the cosmetic appearance of his smile.
Figure 2. Master case with cast metal base.
Discussion Finding an acceptable solution for the replacement of missing permanent teeth in a growing child can be perplexing. A prosthesis (fixed or removable) must accommodate for growth of the arch as well as eruption of permanent teeth. As indicated previously, implant-supported crowns and/or fixed partial dentureprostheses may be better utilized as definitive care after growth ceases. Even so, it is critical that the dentist appreciate the psychological impact of permanent anterior tooth loss on the child and parents with respect to
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Figure 3. Prosthetic teeth fabricated from micro-ceramic composite.
appearance and peer perception and that he/she make their best effort to satisfy the situational needs (7). This report presented a situation in which innovative materials coupled with sound principles of removable partial denture were utilized to provide an excellent solution to the esthetic, functional, and psychological dental needs of a child who had lost permanent anterior incisors. It is hoped that the information presented will be useful to other dental practitioners faced with similar problems. References 1.
2.
3.
4.
5.
6.
7.
McDonald Ralph E. Dentistry for the Child and Adolescent, 8th Edition. Elsevier, 2004. 22. Adekoya-Sofowora, CA. Traumatized anterior teeth in children: a review of the literature. Niger J Med. 2001;10(4):151-7. Ivancic JN, Bakarcic D, Fugosic V, Majstorovic M, Skrinjaric I. Dental trauma in children and young adults visiting a University Dental Clinic. Dent Traumatol. 2009;25(1):84-7. Brullmmann D, Schulze RK, d’Hoedt B. The treatment of anterior dental trauma. Dtsch Arztebl Int. 2010;108(3435):565-70. Kramer FJ, Baethge C. Tschernitschek H. Implants in children with ectodermal dysplasia: a case report and literature review. Clin Oral Implants Res. 2007;18(1):140-6. Phoenix Rodney D. Stewart’s Clinical Removable Partial Prosthodontics, 3rd Edition. Quintessence, 2002. 18.1.3. Polat ZS, Tacir IH. Restoring of traumatized anterior teeth: a case report. Dent Traumatol. 2008;24(3):e390-4.
Figure 4. Patient as he presented, with missing central incisors.
Figure 5. Patient with prosthesis in place.
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MEMORIAL and HONORARIUM Donors to the Texas Dental Association Smiles Foundation
IN MEMORY OF: Dr Billy Raye Clitheroe Dr Don Lutes Your memorial contribution supports: • •
educating the public and profession about oral health; and improving access to dental care for the people of Texas.
Please make your check payable to:
TDA Smiles Foundation, 1946 S IH 35, Austin, TX 78704
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In MEMORIAM Those in the dental community who have recently passed
ORAL and MAXILLOFACIAL PATHOLOGY LABORATORY Anne Cale Jones, DDS H. Stan McGuff, DDS
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Affiliation with a major health center with a large general and special surgical pathology faculty
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Telephone consultation available For additional information, please call (888) 728-4211 or (210) 567-4073.
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Oscar A. Thompson Irving, Texas July 21, 1933 – June 20, 2014 Good Fellow: 1988 • Life Member: 1988 • 50 Year: 2012 James W. Carpenter Lubbock, Texas October 21, 1927 – June 28, 2014 Good Fellow: 1977 • Life Member: 1992 • 50 Year: 2002 Jack F. Dean Dallas, Texas November 16, 1923 – July 8, 2014 Good Fellow: 1986 • Life Member: 1989 • 50 Year: 2000 Mary K. Outlaw Dallas, Texas October 16, 1924 – December 31, 2012 Good Fellow: 1976 • Life Member: 1989 • 50 Year: 2001 Henry E. Meador San Antonio, Texas February 19, 1915 – July 16, 2014 Good Fellow: 1984 • Life Member: 1982 • 50 Year: 1990
GUEST INTRODUCTION
The National Dental Practice-Based Research Network Thomas Oates, DDS Dr Thomas Oates is the interim associate dean for research and assistant dean for clinical research at the University of Texas Health Science Center at San Antonio (UTHSCSA) Dental School and professor and vice chair in the Department of Periodontics. Dr Oates is director for the Southwest Region of the NIH-sponsored National Dental Practice-Based Research Network (PBRN) and co-director of the South Texas Oral Health Network (STOHN) focusing on creating evidence that will guide oral health care in the future..
Editor’s note: Dr Oates introduces the second in a series of papers from the national PBRN group that will be published periodically in the Journal over the next year.”
T
he responsibility of producing evidenced-based answers to practical questions may seem daunting to one private practice alone. However, when you have hundreds of practices collaborating nationwide to answer questions relevant to their practice, the task becomes not only possible but beneficial to the practice of dentistry. As the late Dr Steve Matteson noted in his April 2013 Texas Dental Journal editorial, the “ weakness to the academic institution approach to research is not knowing whether the findings of those research efforts are applicable to patients seen in private practice.’’ The National Dental Practice-Based Research Network (National Dental PBRN) has dedicated itself to the endeavor of conducting research that yields “real world” results, directly applicable to clinical practice. In an effort to bridge the gap between science and practice, the National Institute of Dental and Craniofacial Research (NIDCR), as part of the National Institute of Health (NIH), established the National Dental PBRN in 2012. The network is comprised of 6 regions dedicated to working together to ask questions relevant to the practice of dentistry and develop studies to answer those questions. The Southwest Region, which includes Texas, Oklahoma, New Mexico, Arizona, and Kansas, is based at The University of Texas Health Science Center at San Antonio (UTHSCSA) Dental School, and has
almost 1,100 members of the 5,500 members nationwide. The national headquarters, where network activities are coordinated, is located at the University of Alabama at Birmingham. The national network is comprised of dental practitioners, dentists, and hygienists from across the nation, who are committed to advancing oral health knowledge by participating in dental research. They may participate directly through research in their practice with their patients, by responding to surveys, or by hearing about the research findings via the PBRN newsletters and meetings. In the network, dental clinicians work together with academicians to develop research that will answer these questions relevant to daily practice for the betterment of dentistry. This pursuit is reflected in the mission of the network to improve oral health by conducting dental practice-based research and by serving dental professionals through education and collegiality. This last year of the National Dental Practice-Based Research Network (PBRN) has been an exciting one of study development and implementation. Over the past year, the network has successfully completed its first online questionnaire study on Endodontic Isolation Techniques, has completed the pilot for the upcoming 4-year
Cracked Tooth Registry study, and has developed several more studies that will launch in 2015. The National Dental PBRN will be reporting preliminary study findings for the Endodontic Isolation Techniques and Cracked Tooth Registry pilot during a 2.5 CE hour presentation at this year’s ADA session in San Antonio on Thursday, October 9, 2014 (11:30 AM -2:00 PM, Course Code: 5385). The network will be prominent at the AADR symposium as well, on October 7 and 8 in the same venue as the ADA. Please join us at either or both of those sessions to hear the latest practice-based research results from the network and to learn more about our upcoming studies on topics such as Suspicious Occlusal Caries, Dentin Hypersensitivity and Risk of Oral Cancer. PBRNs are emerging as an essential resource in this new generation of evidence-based dentistry. The Texas Dental Journal looks forward to a series examining articles published by the National Dental PBRN, starting with “Translating research into everyday “ clinical practice: Lessons learned from a USA dental practice-based research network” by Valeria Gordon, the regional director of the South Atlantic region. These articles will showcase the breadth of the network’s interests as well as the potential for PBRNs to contribute studies of importance to the practice of dentistry. Texas Dental Journal l www.tda.org l August 2014
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Translating research into everyday clinical practice: Lessons learned from a USA national dental practicebased research network Valeria V. Gordan, DDS, MS, MS-CI, Professor and The National Dental PBRN Collaborative Group Reprinted from Dental Materials, 29/1, Valeria V. Gordan, Translating research into everyday clinical practice: Lessons learned from a USA dental practice-based research network, 3-9, Copyright 2013, with permission from Elsevier.
About the Author Dr Gordan is in the department of restorative dental sciences, University of Florida, Gainesville, Florida. Correspondence: Valeria V. Gordan PO Box 100415, Gainesville, FL 32610-0415; Phone 352 273 5836; Fax 352 273 7970; Email: ude.lfu.latned@nadrogv. For The DPBRN Collaborative Group
Abstract Clinical studies are of paramount importance for testing and translation of the research findings to the community. Despite the existence of clinical studies, a significant delay exists between the generation of new knowledge and its application into the medical/dental community and their patients. One example is the repair of defective dental restorations. About 75% of practitioners in general dental practices do not consider the repair of dental restorations as a viable alternative to the replacement of defective restorations. Engaging and partnering with health practitioners in the field on studies addressing everyday clinical research questions may offer a solution to speed up the translation of the research findings. Practice-based research (PBR) offers a unique opportunity for practitioners to be involved in the research process, formulating clinical research questions. Additionally, PBR generates evidence-based knowledge with a broader spectrum that can be more readily generalized to the public. With PBR, clinicians are involved in the entire research process from its inception to its dissemination. Early practitioner interaction in the research process may result in ideas being more readily incorporated into practice. This paper discusses PBR as a mean to speed up the translation of research findings to clinical practice. It also reviews repair versus replacement of defective restorations as one example of the delay in the application of research findings to clinical practice.
Key Words Practice-based, evidence-based, defective restorations, repair restorations, replace restorations
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If we want more evidence-based practice, we need more practice-based evidence. Lawrence W. Green, DrPH
Introduction
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he latest announcements from the USA government clearly state that American taxpayers are highly interested in immediate results for the research taking place these days (1,2). A significant delay exists between the generation of breakthroughs and their transfer through applications serving individual patients when science is not efficiently translated to daily clinical practice. Therefore, a substantial difference exists between the health care that patients may be eligible for and the health care that they actually receive (3-5). Enhancing the delivery of established therapies would save more lives than pursuing additional innovations in therapy (6,3). The time lag between discovery and its generalized adoption by the medical/dental profession has ranged from 17 to 24 years depending on the study and subject area (5). Part of the problem lies in the fact that most research is done in academic and industry environments and not directly by the end users. In the current research structure, many studies are so specific to certain
”
areas that the results are not easily transferred into general practice. Whereas studies in academia are often narrowly focused and may apply to a limited subset of patients or circumstances, practice-based research involves a broad spectrum of patients and practitioners. One way to speed up the translation of the research findings is to promote the engagement and partnership between research professionals and practitioners on problems identified by practitioners. In other words, the translation of the research findings into clinical practice can be improved if practitioners are recruited and engaged in the research process. Practice-based research networks (PBRN) offer a unique opportunity for practitioners to be involved in the research process, formulating clinical research questions that may improve the oral health of the population. PBRNs also offer researchers the chance to learn more about everyday issues involving oral health and interact with practitioners in the dental field. Additionally, practicebased research (PBR) offers 2 very important points for the advancement of health care: (1) it generates evidence-based knowledge with a
broader spectrum that can be more readily generalized to the public (ie, the evidence comes directly from the end-user “the everyday patient”); and (2) it speeds up the translation of research findings as passive absorption of knowledge usually either does not work or is very slow. With PBR, clinicians are involved in the entire research process from its inception, asking the clinical questions, being involved in the gathering of the research findings, as well as in its dissemination. Early practitioner interaction in the research process may result in ideas being more readily incorporated into practice. The obvious commitment from USA National Institute of Health to practice-based research and translational research shows where we are headed in response to the public’s concern (7-9). On April 12, 2012, USA NIH/NIDCR announced the establishment of a National Dental Practice-based Research Network awarding a $66.8 million, 7-year grant to consolidate its national dental practice-based research network initiative (10). The USA National Dental PBRN comprises 6 distinct regions throughout the United States and with administrative sites in Rochester, NY; Gainesville, FL; Birmingham, AL; Minneapolis, MN; San Antonio, TX; and Portland, OR.
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One classic example: Repair versus replacement? Replacement of defective restorations is one of the most frequent problems encountered by general practitioners today and accounts for over 50% of the work performed in general dental practice (11-13).
What have we learned from dentists participating in practicebased research regarding repair versus replacement treatment? As reported in previous publications, close to 75 percent of clinicians participating in Dental PBRN also chose replacement more often than repair for the treatment of defective restorations.
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The rerestoration cycle has been described for over 35 years (14-16) and since then innumerous in vitro (17,18) and clinical studies (19-21) have shown that removal of the existing restoration will significantly remove sound tooth structure resulting in subsequently larger dental restorations. The removal of existing restorations may also cause additional stress on the tooth with possible pulp and dentin reactions to thermal, chemical, bacterial, or mechanical stimuli (22,23), depending on the size and depth of the existing restored site. The first restoration placed in an unrestored tooth can affect the overall longevity of the tooth as proposed by the life-cycle of a tooth (24). In this model the first restoration placed on a tooth is when the patient is around age 6, and subsequent restoration replacements every 8 to 12 years lead to progressively larger restorations and, ultimately, to tooth loss when patient reaches age 56. Another important inference from this model would be to delay or avoid the surgical intervention into the restored tooth as much as possible, since this process will affect the remaining tooth structure and, consequently, reduce the survivability of the tooth.
Repair of defective restorations offers a less invasive and more conservative approach to restoration replacement and has the potential to delay the rerestoration cycle. Additionally, longitudinal cohort studies have demonstrated that the success rate of treatment for failed restorations not necessarily surpass the clinical performance of other alternative treatments such as repairing, sealing, or monitoring teeth at risk (25-32). Another milestone study by MertzFairhurst and colleagues (33) concluded in a long-term clinical study (over 10 years) that sealed restorations exhibited superior clinical performance and longevity compared with unsealed restorations. The study also concluded that sealed composite restorations placed over cavitated carious lesions arrested the clinical progress of the lesions (33). Even though the results of these studies (25-33) have been published for several years, and schools have included the repair of dental restorations in their curriculum (34-37), clinicians still do not routinely consider the repair or sealing of restorations as a viable treatment option for the treatment of defective restorations (38-43). Several reasons may account for this including, clinicians’ tradition, lack of reimbursement for these procedures, professional community standards, and absence of baseline knowledge regarding the existing restoration.
What have we learned from dentists participating in practice-based research regarding repair versus replacement treatment? As reported in previous publications, close to 75 percent of clinicians participating in Dental PBRN also chose replacement more often than repair for the treatment of defective restorations (19,39,43-45). Also consistent with previous findings, most of the dentists (75%) participating in a practice-based study involving close to 10,000 restorations chose replacement over repair of defective restorations when they had not placed the original restoration (p<0.001) (14,43,46-48). Another study, based on insurance claims, also suggests that patients who change dentists are far more likely to have restorations replaced and not necessarily repaired (49). Restorations may become defective due to a number of reasons related to either clinician factors, patient factors, and/or material properties (50). It is not always possible to single out factors and often a combination may be the cause of the defect or restoration failure. The reasons for restoration failure are not routinely recorded by practicing dentists and often only the end result is registered. Practicing dentists reported the diagnosis of secondary caries as the main reason for restoration treatment, followed by restoration fracture, marginal degradation, and margin discoloration (43). These findings are consistent with others reported in the literature (51-54). Although the study by Bogacki and colleagues reported that changing
dentist was the main reason for restoration replacement (49). Even though secondary caries was identified as the primary cause for restoration treatment, it also leads to the highest number of repair treatments (30%). The clinical diagnosis of secondary caries is illdefined and marginal staining is often mistakenly diagnosed by clinicians as caries lesions (11,12,51-58). Without objective criteria, it becomes challenging to correctly differentiate between secondary caries and staining or degradation of the restoration margin (59). When assessing a restoration with a defect or discoloration at the margins, if the dentist is unable to clearly reject a secondary caries diagnosis, he or she will most likely choose replacement as opposed to other options of nonsurgical treatment, including systematic monitoring of the restored tooth. This continues to occur despite the fact that previous studies have shown no relationship between the development of secondary caries and the size of the leakage or gap, except in cases in which the crevice exceeds 250 μm or 400 μm (60-63). The criteria for the treatment of defective restorations should not be based solely on visual, tactile or radiographic examination, but primarily on the caries risk of the patients and caries activity of the site. Future research that focuses on biomarkers may identify and count the bacteria present at the crevice (ie, acid-producing versus alkali producing bacteria) have the potential to aid in the diagnosis of caries in the faulty margins of existing restorations (64).
Even though studies report a decline in the use of dental amalgam, because of its inferior esthetic appearance, alleged adverse health effects, and environmental concerns, many of existing restorations are still amalgam (45, 65-69). The PBR study showed that most of the restorations that were treated in the study were amalgam (56%), which were replaced primarily (56% of cases) with direct tooth-colored restorative materials. The restorative material was five times more likely to be changed when the original restoration was amalgam. The probability of changing from amalgam to another restorative material varied according to several characteristics of the original restoration. The change was most likely to take place when (1) the treatment was a replacement; (2) the tooth was not a molar; (3) the tooth was in the maxillary arch; and (4) the original restoration involved a single surface (45). The choice of repair over replacement of defective restorations differs among dentists according to certain dentist’s characteristics. Dentists who placed the original restoration, dentists who graduated from dental school within the last 15 years, and dentists who work in large group practices (3 or more practitioners) repaired defective restorations more often than they replaced the restorations (43). Some patients’ characteristics were also associated with a greater likelihood of repair versus replacement, such as older patient age, original restorative material different than amalgam, restorations in molar teeth, and fewer surfaces in the original restoration (43).
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How can we speed up the translation of research findings? Clinicians are bombarded by vast amounts of information from manufacturers, in dental journals, and in continuing education courses. What evidence do clinicians use to make drastic improvements in preventive and restorative care? How can clinicians accept and translate the evidence into practice? Traditionally, journal articles, workshops, academic classes, and conferences have been the usual mode of educating practitioners. Patient education and financial incentives have also been used, with all methods showing small to modest effects (6,70). Research has shown that new methods and materials will have better acceptance if transmitted by leaders in the field. This is not necessarily an individual with the highest degree or visibility, but is someone trusted as an opinion leader or mentor (6,71). A goal of PBRNs is to share results and possible solutions to certain problems by promoting the networking and collegiality among practitioners and participants about their daily work and practicing environment (72). PBRN practitioners are offered several venues to interact with each other through annual and training meetings, study clubs, participating in webinars, as well as other means of interaction through virtual communication such as chat rooms, Facebook, Twitter, and LinkedIn. Besides the above mentioned means, dissemination of information also happens through monthly electronic publications and quarterly newsletter which highlights various activities and study results. Participating in PBRN activities may create openness to change and the practitioner-investigators act as agents for change (73). Additionally, presentations on study results given by fellow practitioner-investigators, rather than academicians, seem to have a greater influence on practitioners as opposed to clinical faculty presentations (6).
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Clinicians are bombarded by vast amounts of information from manufacturers, in dental journals, and in continuing education courses. What evidence do clinicians use to make drastic improvements in preventive and restorative care? How can clinicians accept and translate the evidence into practice?
We also learned that bringing the evidence into the dental office through PBR may efficiently change dentists’ attitudes and daily practice. In one PBR study, 998 clinicians participated in a baseline questionnaire with clinical case scenarios about the diagnosis and treatment of dental caries. From the 998 clinicians, 133 were asked to participate in a nationwide meeting. Those participating in the meeting were mailed their results from the baseline questionnaire 45 days prior to the meeting, were asked to complete a new questionnaire at the meeting’s registration desk; and another questionnaire upon leaving the meeting. During the meeting, clinicians had the opportunity to participate in panel discussions with question-and-answer sessions, as well as in informal gatherings and formal breakout sessions in which clinicians discussed pre-assigned topics at assigned tables. At the end of the meeting, one third of clinicians actually changed, in the second questionnaire, how they responded to the clinical case scenario questions. The improvement was towards using more prevention and delaying the treatment process in certain instances, according to the latest evidence-based research results. Clinicians were receptive to changing how they treat patients as a result of being engaged in the scientific process with their fellow clinicians (73). Informal reports provided by clinicians also confirmed that collegial interaction has an important role in changing clinicians’ approaches in clinical practice. The initial responses from clinicians prior to the meeting
reported that less than one-third of respondents had any intention of changing diagnosis or treatment approaches to caries management. However, at the end of the meeting, these clinicians reported their intention to change their approach towards diagnosis and treatment of dental caries, thus taking the next step toward implementing change and translating the latest scientific evidence into regular clinical practice. This “change in intention” is consistent with the health change theory, which suggests that this step is a prelude to the subsequent “next step” of actually implementing change (74,75). Acquiring new information is necessary, but not enough for a change in behavior (76). This is why passive dissemination of knowledge, guidelines, and attendance at meetings are not necessarily effective for the translation of research into practice (77). In addition to participating in annual meetings, one powerful tool for translation of the study findings is to create opportunities for practitioners to reflect on their own decisionmaking process and quality of care. At the end of each PBRN study, clinicians are provided a summary of their results in a simple and visual format (eg, tables and/or colorful bar graphs) and the results of others in their region and network-wide. This approach discusses how PBRNs can have a direct impact on the translation of research into routine clinical care. Clinicians are given the chance to reflect upon their daily clinical practice and their choices
in the delivery of dental care while comparing them to those from their fellow clinicians in a non-threatening manner. Therefore, they feel free to change as they learn from each other’s results and taking their experience into account. One of the reasons clinicians have reported joining the network is to have the opportunity to answer questions related to routine dental care. A significant amount of information offered to dentists seems to be manufacturer-driven, so there is a concern for bias. The desire to be a part of a community that has the possibility to generate research questions and to answer them with new knowledge is the main reason that clinicians join the network (78,79). Other reasons for joining a PBRN are: (1) to provide a focus for clinical excellence by devoting increased short-term attention to one particular area of clinical practice at a time; (2) to improve the logistics of daily clinical operations as they need to plan ahead of time when studies are taking place; (3) to serve as a team-building experience for practice staff, engaging the entire staff in the excitement of discovery and quality improvement; (4) to distinguish the practice from other practices, acting as a practice promoter or practice builder; and (5) to enhance communication with patients by showing that the practitionerinvestigator cares about the scientific basis of clinical practice. In PBRN research, practitioners are given the personal experience of exploring a question from its concept to the final stage of data analysis. Texas Dental Journal l www.tda.org l August 2014
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PBRNs have the ability to use a variety of research methodologies including randomized clinical trials, observational and retrospective studies. Each of these different study designs have their own potential of resulting in greater impact on daily practice by being more easily adapted to the research environment. Not all methods of transmitting results have equal success in incorporating these results. Naik and Petersen highlights the importance of developing connections between researchers and practitioners in dissemination of information and Innvaer and colleagues conclude that increasing personal contacts and relationships between researchers and care leaders is an important facilitator of using evidence in making policy decisions (4,80).
Concluding remarks Even though several long-term prospective studies have supported the repair versus replacement of restorations, these studies did not randomly assign the treatment (8183). The results of the studies serve now as basis to obtain institutional review board approval for conducting randomized, controlled clinical trials which provide the highest level of evidence. Additionally, in order for these studies to be generalizable to most patients, they would be conducted in a general practice setting. The research conclusion of these studies will enable dentists and their patients to make educated decisions based on evidence.
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Traditional federally-funded or corporate-funded research in academic institution has significant value that can complement the studies that are conducted in PBRNs. Academic research addresses different questions that can provide more rapid answers to clinician’s questions and lead to follow-up by PBRNs. In a controlled setting, researchers can undergo calibration exercises and the risk factors of study populations can also be more carefully controlled. Results from pilot and preliminary studies can then lead to relevant questions for PBRNs to pursue. The results from PBR can be more generalizable to the public at large, therefore it facilitates the application of the findings for policy changes and the establishment of standard of care. PBRNs can be an effective venue for translation of research findings as participants serve as change agents. Acknowledgements This investigation was supported by NIH grants DE-16746, DE-16747, and DE-22516. Opinions and assertions contained herein are those of the authors and are not to be construed as necessarily representing the views of the respective organizations or the National Institutes of Health.
References 1. Committee for economic development (May 23rd 2012);The future of taxpayer-funded research: Who will control access to the results? http://www.ced. org/images/content/issues/ innovation-technology/DCCReport_ Final_2_9-12.pdf. 2. Federal Research Public Access Act (May 5th 2012); http://www. taxpayeraccess.org/issues/frpaa/ index.shtml. 3. Solberg LI, Elward KS, Phillips WR, Gill JM, Swanson G, Main DS, Yawn BP, Mold JW, Phillips RL, Jr, the NAPCRG Committee on Advancing the Science of Family Medicine How can primary care cross the quality chasm? Annals Fam Med. 2009;7(2):164–169. (PMC free article) (PubMed) 4. Naik AD, Petersen LA. The neglected purpose of comparativeeffectiveness research. N Engl J Med. 2009;360(19):1929–1931. (PMC free article) (PubMed) 5. Contopoulos-Ioannidis DG, Alexiou GA, Gouvias TC, Ioannidis JP. Life cycle of translational research for medical interventions. Science. 2008;321:1298–1299. (PubMed) 6. Ting HH, Shojania KG, Montori VM, Bradley EH. Quality improvement: Science and action. Circulation. 2009;119:1962–1974. (PubMed) 7. Zerhouni E. Medicine. The NIH roadmap. Science. 2003;302:63–72. (PubMed) 8. NIH Roadmap for Clinical Research: Clinical research networks and NECTAR (May 11th 2012); http://nihroadmap.nih.gov/ clinicalresearch/overview-networks. asp. 9. Woolf SH. The meaning of translational research and why it matters. JAMA. 2008;299(2):211– 213. (PubMed)
10. (May 25th 2012); Award announcement http://www. nidcr.nih.gov/Research/ ResearchResults/NewsReleases/ CurrentNewsReleases/NDPBRN.htm. 11. Pink FE, Minden NJ, Simmonds S. Decisions of practitioners regarding placement of amalgam and composite restorations in general practice settings. Oper Dent. 1994;19:127–132. (PubMed) 12. Mjör IA, Moorhead JE, Dahl JE. Reasons for replacement of restorations in permanent teeth in general dental practice. Int Dent J. 2000;50:360–366. (PubMed) 13. Simecek JW, Diefenderfer KE, Cohen ME. An evaluation of replacement rates for posterior resin-based composite and amalgam restorations in U.S. Navy and Marine Corps recruits. J Am Dent Assoc. 2009 Feb;140(2):200–9. quiz 249. (PubMed) 14. Elderton RJ. Assessment of the quality of restorations. A literature review. J Oral Rehabil. 1977 Jul;4(3):217–26. (PubMed) 15. Elderton RJ, Osman YI. Preventive versus restorative management of dental caries. J Dent Assoc S Afr. 1991 Apr;46(4):217–21. (PubMed) 16. Tyas MJ. Placement and replacement of restorations by selected practitioners. Aust Dent J. 2005 Jun;50(2):81–9. (PubMed) 17. Gordan VV. In vitro evaluation of margins of replaced resin based composite restorations. J Esthet Dent. 2000;12:217–223. (PubMed) 18. Gordan VV, Mondragon E, Shen C. Evaluation of the cavity design, cavity depth, and shade matching in the replacement of resin based composite restorations. Quintessence Inter. 2002;32:273– 278. (PubMed) 19. Brantley CF, Bader JD, Shugars DA, Nesbit SP. Does the cycle of rerestoration lead to larger
restorations? J Am Dent Assoc. 1995 Oct;126(10):1407–13. (PubMed) 20. Gordan VV. Clinical evaluation of replacement of Class V resin based composite restorations. J Dent. 2001;29:485–488. (PubMed) 21. Mjör IA, Gordan VV. Failure, repair, refurbishing and longevity of restorations. Oper Dent. 2002;27(5):528–534. (PubMed) 22. Hirata K, Nakashima M, Sekine I, Mukouyama Y, Kimura K. Dentinal fluid movement associated with loading of restorations. J Dent Res. 1991;70:975–978. (PubMed) 23. Bissada NF. Symptomatology and clinical features of hypersensitive teeth. Arch Oral Biol. 1994;39(Suppl):31S–32S. (PubMed) 24. Simonsen R. New materials on the horizon. JADA. 1991;122(7):24–31. (PubMed) 25. Gordan VV, Shen C, Riley J, 3rd, Mjör IA. Two-year clinical evaluation of repair versus replacement of composite restorations. J Esthet Restor Dent. 2006;18:144–154. (PubMed) 26. Gordan VV, Riley J, 3rd, Blaser PK, Mjör IA. Two-year clinical evaluation of alternative treatments to replacement of defective amalgam restorations. Oper Dent. 2006;31(4):418–425. (PubMed) 27. Gordan VV, Garvan CW, Blaser PK, Mondragon E, Mjör IA. A long-term evaluation of alternative treatments to replacement of resin-based composite restorations: Results of a seven-year study. J Amer Dent Assoc. 2009;140:1476–1484. (PubMed) 28. Gordan VV, Riley JL, III, Blaser PK, Mondragon E, Garvan CW, Mjör IA. Alternative treatments to replacement of defective amalgam restorations: Results of a 7-year clinical study. JADA. 2011;142(7):842–849. (PubMed) 29. Moncada G, Martín J, Fernández E, Vildósola P, Caamaño C,
Caro MJ, Mjör IA, Gordan VV. Alternative treatments for resin based composite and amalgam restorations that have marginal defects: 12-month clinical trial. Gen Dent. 2006;54:314–318. (PubMed) 30. Moncada G, Fernández E, Martín J, Arancibia C, Mjör IA, Gordan VV. Increasing the longevity of amalgam and resin-based composite restorations by minimal intervention: Results of a 2-year clinical trial. Oper Dent. 2008;33:243–249. 31. Moncada G, Martin J, Fernández E, Hempel MC, Mjör IA, Gordan VV. Sealing, repair and refurbishment of Class I and Class II defective restorations: A three-year clinical trial. J Amer Dent Assoc. 2009;140:425–432. (PubMed) 32. Martin J, Fernández E, Estay J, Gordan VV, Mjör IA, Moncada G. Using sealants to treat the margins of defective restorations: Results of a five-year clinical study. Oper Dent. in press. 33. Mertz-Fairhurst EJ, Curtis JW, Jr, Ergle JW, Rueggeberg FA, Adair SM. Ultraconservative and cariostatic sealed restorations: Results at year 10. J Am Dent Assoc. 1998 Jan;129(1):55–66. (PubMed) 34. Gordan VV, Mjör IA, Blum I, Wilson NHF. Teaching students the repair of resin based composite restorations: A survey of North American dental schools. J Amer Dent Assoc. 2003;134:317–323. (PubMed) 35. Blum IR, Lynch CD, Schreiver A, Heidemann D, Wilson NHF. Repair versus replacement of defective composite restorations in German dental schools. Eur J Prosth Rest Dent. 2011;19:56–61. (PubMed) 36. Blum IR, Lynch CD, Wilson NHF. Teaching of direct composite restoration repair in undergraduate dental schools in the United Kingdom and Ireland. Eur J Dent Educ. 2012;16(1):53–58. (PubMed) Texas Dental Journal l www.tda.org l August 2014
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37. Blum IR, Lynch CD, Wilson NHF. Teaching of the repair of defective composite restorations in Scandinavian dental schools. J Oral Rehab. 2012;39(3):210–216. (PubMed) 38. Gordan VV, Mjör IA. Letter to the Editor of the Journal of the American Dental Association. JADA. 2003;134(9):1170–1172. 39. Gordan VV. Letter to the Editor of the Journal of the American Dental Association. JADA. 2009;140(9):1078–1079. 40. Gordan VV, Garvan CW, Richman J, Fellows JL, Rindal DB, Qvist V, Heft MW, Williams OD, Gilbert GH, for The DPBRN Collaborative Group How dentists diagnose and treat defective restorations: Evidence from the Dental PBRN. Oper Dent. 2009;34:664–673. (PMC free article) (PubMed) 41. Gordan VV. Letter to the Editor of the Journal of the American Dental Association. JADA. 2010;141(3):248– 252. 42. Gordan VV. Letter to the Editor of the Journal of the American Dental Association for paper: Alternative treatments to replacement of defective amalgam restorations: Results of a 7-year clinical study. JADA. 2011;142:1336–1337. 43. Gordan VV, Riley JL, III, Geraldeli S, Rindal DB, Qvist V, Fellows JL, Kellum HP, Gilbert GH, The DPBRN Collaborative Group Repair or replacement of defective restorations by dentists in the Dental PBRN. JADA. 2012;143(6):593–601. (PMC free article) (PubMed) 44. Setcos JC, Khosravi R, Wilson NH, Shen C, Yang M, Mjör IA. Repair or replacement of amalgam restorations: Decisions at a USA and a UK dental school. Oper Dent. 2004 Jul-Aug;29(4):392–397. (PubMed)
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45. Gordan VV, Riley JL, III, Worley DC, Gilbert GH, for The DPBRN Collaborative Group Restorative material and other tooth-specific variables associated with the decision to repair or replace defective restorations: Findings from the Dental PBRN. J Dent. 2012;40:397–405. (PMC free article) (PubMed) 46. Elderton RJ, Nuttall NM. Variation among dentists in planning treatment. Br Dent J. 1983;154:201– 206. (PubMed) 47. Davies JA. The relationship between change in dentist and treatment received in the general dental service. Br Dent J. 1984;157:322– 324. (PubMed) 48. Bader JD, Shugars DA. Understanding dentists’ restorative treatment decisions. J Public Health Dent. 1992;52:102–110. (PubMed) 49. Bogacki RE, Hunt RJ, del Agila M, Smith WR. Survival analysis of posterior restorations using an insurance claims database. Oper Dent. 2002;27:488–492. (PubMed) 50. Hickel R, Manhart J. Longevity of restorations in posterior teeth and reasons for failure. J Adhes Dent. 2001;3(1):45–64. (PubMed) 51. Rytomaa I, Jarvinen V, Jarvinen J. Variation in caries recording and restorative treatment plan among university teachers. Community Dent Oral Epidemiol. 1979;7:335– 339. (PubMed) 52. Merrett MCW, Elderton RJ. An in vitro study of restorative dental treatment decisions and dental caries. Br Dent J. 1984;157:128–133. (PubMed) 53. Bader JD, Shugars DA, McClure FE. Comparison of restorative treatment recommendations based on patients and patients simulations. Oper Dent. 1994;19:20–25. (PubMed)
54. Bader JD, Shugars DA. Agreement among dentists’ recommendations for restorative treatment. J Dent Res. 1993;72:891–896. (PubMed) 55. Kay E, Watts A, Paterson R, Blinkhorn A. Preliminary investigation into the validity of dentists’ decisions to restore occlusal surfaces of permanent teeth. Community Dent Oral Epidemiol. 1988;16:91–94. (PubMed) 56. Noar SJ, Smith BGN. Diagnosis of caries and treatment decisions in approximal surfaces of posterior teeth in vitro. J Oral Rehabil. 1990;17:209–218. (PubMed) 57. Deligeorgi V, Wilson NH, Fouzas D, Kouklaki E, Burke FJ, Mjör IA. Reasons for placement and replacement of restorations in student clinics in Manchester and Athens. Eur J Dent Educ. 2000;4:153–159. (PubMed) 58. Qvist V, Laurberg L, Poulsen A, Teglers PT. Class II restorations in primary teeth: 7-year study on three resin-modified glass ionomer cements and a compomer. Euro J Oral Sci. 2004;112:188–196. (PubMed) 59. Mjör IA, Toffenetti F. Secondary caries: A literature review with case reports. Quintessence Int. 2000;31:165–179. (PubMed) 60. Soderholm KJ, Antonson DE, Fishlschweiger W. Correlation between marginal discrepancies at the amalgam tooth interface and recurrent caries. In: Anusavice KJ, editor. Quality evaluation of dental restorations. Quintessence; Chicago: 1989. pp. 85–108. 61. Kidd EA, O’Hara JW. Caries status of occlusal amalgam restorations with marginal defects. J Dent Res. 1990;69:1275–1277. (PubMed)
62. Kidd EAM, Joyston-Bechal S, Beighton D. Marginal ditching and staining as a predictor of secondary caries around amalgam restorations: A clinical and microbiological study. J Dent Res. 1995;74:1206–1211. (PubMed) 63. Ozer L. Based on a thesis submitted to the graduate faculty. University of Copenhagen, in partial fulfillment of the requirements for the M.S. degree; Copenhagen, Denmark: 1997. The relationship between gap size, microbial accumulation and structural features of natural caries in extracted teeth with Class II amalgam restorations. 64. Gordan VV, Garvan CW, Ottenga ME, Schulte R, Harris PA, McEdward DL, Magnusson I. Could alkali production be considered an approach for caries control? Caries Res. 2010;44:547– 554. (PMC free article) (PubMed) 65. Mutter J. Is dental amalgam safe for humans? The opinion of the scientific committee of the European Commission. J Occup Med Toxicol. 2011;6:2. (PMC free article) (PubMed) 66. Neghab M, Choobineh A, Hassan Zadeh J, Ghaderi E. Symptoms of intoxication in dentists associated with exposure to low levels of mercury. Ind Health. 2011;49:249– 254. (PubMed) 67. Lynch CD, Guillem SE, Nagrani B, Gilmour AS, Ericson D. Attitudes of some European dental undergraduate students to the placement of direct restorative materials in posterior teeth. J Oral Rehabil. 2010;37:916–926. (PubMed) 68. Edlich RF, Cross CL, Wack CA, Long WB, 3rd, Newkirk AT. The food and drug administration agrees to classify mercury fillings. J Environ Pathol Toxicol Oncol. 2008;27:303– 305. (PubMed)
69. Forss H, Widström E. Reasons for restorative therapy and the longevity of restorations in adults. Acta Odontol Scand. 2004 Apr;62(2):82– 86. (PubMed) 70. Lee TH. Eulogy for a quality measure. N Engl J Med. 2007;357:1175–1177. (PubMed) 71. Gilbert GH, Richman JS, Gordan VV, Rindal DB, Fellows JL, Benjamin PL, Wallace-Dawson M, Williams OD. DPBRN Collaborative Group. Lessons learned during the conduct of clinical studies in the Dental PBRN. J Dent Educ. 2011 Apr;75(4):453–465. (PMC free article) (PubMed) 72. Gilbert GH, Williams OD, Rindal DB, Pihlstrom DJ, Benjamin PL, Wallace MC, DPBRN Collaborative Group The creation and development of the dental practice-based research network. J Am Dent Assoc. 2008 Jan;39(1):74–81. (PubMed) 73. Gilbert GH, Richman JS, Qvist V, Pihlstrom DJ, Foy PJ, Gordan VV, the DPBRN Collaborative Group Change in stated clinical practice associated with participation in The Dental Practice-Based Research Network. Gen Dent. 2010;58(6):520–528. (PMC free article) (PubMed) 74. Painter JE, Borba CPC, Hynes M, Mays D, Glanz K. The use of theory in health behavior research from 2000 to 2005: A systematic review. Annals Behav Med. 2008;35(3):358– 362. (PubMed) 75. Prochaska JO. Decision making in the transtheoretical model of behavior change. Med Decis Making. 2008;28(6):845–849. (PubMed) 76. Rohrbach LA, Grana R, Sussman S, Valente TW. Type II translation: Transporting prevention interventions from research to real-world settings. Eval Health Prof. 2006;29(3):302–333. (PubMed)
77. Farmer AP, Legare F, Turcot L, Grimshaw J, Harvey E, McGowan JL, Wolf F. Printed educational materials: Effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2008 Jul;16(3):CD004398. (PubMed) 78. (May 7, 2012);Testimonials. 2012 Available at: http:// www.dpbrn.org/users/ Testimonials/testimonialsection_ networkwidemeeting.asp. 79. (May 22, 2012);Testimonials videos. 2012 Available at: http://www. youtube.com/user/DentalPBRN. 80. Innvaer S, Vist G, Trommald M, Oxman A. Health policy-makers’ perceptions of their use of evidence: A systematic review. J Health Serv Res Policy. 2002;7(4):239–244. (PubMed) 81. Sharif MO, Fedorowicz Z, Tickle M, Brunton PA. Repair or replacement of restorations: Do we accept built in obsolescence or do we improve the evidence? Br Dent J. 2010 Aug 28;209(4):171–174. (PubMed) 82. Sharif MO, Catleugh M, Merry A, Tickle M, Dunne SM, Brunton P, Aggarwal VR. Replacement versus repair of defective restorations in adults: Resin composite. Cochrane Database Syst Rev. 2010 Feb 17;(2):CD005971. (PubMed) 83. Sharif MO, Merry A, Catleugh M, Tickle M, Brunton P, Dunne SM, Aggarwal VR. Replacement versus repair of defective restorations in adults: Amalgam. Cochrane Database Syst Rev. 2010 Feb 17;(2):CD005970. (PubMed)
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TEXAS DENTAL ASSOCIATION 144TH ANNUAL SESSION
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Disinfection and Sterilization in Dentistry By Amy Knepshield Condrin, OSHA Review, Inc.
D
isinfection and sterilization are essential for preventing transmission of infectious pathogens to patients and your staff. How do you know if you and your staff are effectively performing these tasks? The Texas Administrative Code (TAC) defines disinfection and sterilization requirements for Texas dentists. Additionally, the Centers for Disease Control and Prevention (CDC) recommends varying levels of disinfection and sterilization (determined by the type of procedure and equipment used). Using these requirements and recommendations as a guide, this article will help you and your staff determine how to properly disinfect and sterilize, and what to look for in the products you use to do the job.
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Before we get started, you’ll need to be familiar with a few terms.
Sterilization is a process that kills all forms of microbial life.
Cleaning is an essential first step before sterilization and disinfection. Cleaning is defined as the removal of visible soil, blood, proteins, microorganisms, and other debris from surfaces, crevices, serrations, joints, and lumens, or instruments, devices, and equipment. This step prepares items for safe handling and/ or further decontamination. Debris removal is usually accomplished through use of detergent and water, or enzyme cleaner and water, by a manual or mechanical process.
Note: Many liquid disinfectants and sterilants are used alone or in combinations in the healthcare setting. (These include alcohols, chlorine compounds, formaldehyde, glutaraldehyde, ortho-phthalaldeyde, hydrogen peroxide, iodophors, peracetic acid, phenolics, and quaternary ammonium compounds.) Commercial formulations of these chemical mixtures are considered unique products, and are not interchangeable. Misuse can create excessive costs and/or safety hazards. Users should read labels carefully to ensure the correct product is selected for an intended use, and that it is applied properly.
Disinfection is a process that eliminates many or all pathogenic organisms, except bacterial spores. It’s usually accomplished with liquid chemicals. A disinfectant is defined as a physical or chemical agent that removes, inactivates, or destroys pathogens on a surface or item to the point where the surface or item is no longer capable of transmitting infectious particles, thereby rendering the surface or item safe for handling, use, or disposal. A note about disinfectants: You might assume disinfectants can be used as cleaners, or vice versa. However, unless a disinfectant is also labeled as a cleaner, it cannot be used to clean. Consider using a US Environmental Protection Agency (EPA)-registered product labeled for both cleaning and disinfecting—but be certain both steps are performed separately.
ENVIRONMENTAL SURFACES (AND EQUIPMENT) Environmental Surface Disinfection refers to the disinfection of clinical and environmental surfaces. Texas State Board of Dental Examiners (TSBDE) requires all contaminated surfaces and equipment be disinfected between each patient.
Clean. Then Disinfect. Surfaces MUST be cleaned of debris prior to disinfection. Surfaces cannot be adequately covered with disinfecting solution if dirt and debris remain on the surfaces. After cleaning surfaces with a cleaning solution,
coat with a chemical disinfectant for the recommended contact time, and then wipe dry if necessary. Dental staff must follow product label and safety data sheet (SDS) instructions for safety, efficacy, and proper disinfection. Housekeeping surfaces such as walls and floors should be cleaned using a detergent or a product that combines a cleaner and disinfectant on a regular basis, when spills occur, and when surfaces are visibly soiled. Housekeeping surfaces only need to be disinfected if they were potentially contaminated with blood or other infectious material. Clinical contact surfaces such as countertops, dental units, should be disinfected with an EPA-registered surface disinfectant (low-level or intermediate-level), or barrierprotected and cleaned at the end of the day.
Your Surface Disinfectants (Pesticides) Should Be: Registered with EPA and Texas Department of Agriculture. In dentistry, antimicrobials (such as surface disinfectants, sanitizers, and dental unit waterline cleaners) designed to destroy or inactivate disease-producing bacteria and other microorganisms are considered pesticides. (The term “pesticide” encompasses any chemical intended to destroy pests, control their activity, or prevent them from causing damage.) In Texas, all pesticides must be registered and approved for use Texas Dental Journal l www.tda.org l August 2014
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by the EPA and Texas Department of Agriculture. All surface disinfectants regulated by the EPA must be labeled with an EPA registration number. Labels on EPA-approved surface disinfectants also specify: technical and safety information, indications for use (contact time, application methods), and approved efficacy claims. Only claims listed on the registered label can be made regarding a disinfectant’s efficacy. Hospital-Level. Your surface disinfectant must have hospital-efficacy claims, which are defined by the EPA as broad-spectrum disinfectants with demonstrated efficacy against Salmonella choleraesuis, Staphylococcus aureus, and Pseudomonas aeruginosa. Labeled as Effective Against HIV/HBV or TB. In dental settings, a surface disinfectant should also list label claims against human immunodeficiency virus (HIV) and hepatitis B virus (HBV), or Mycobacterium bovis (TB). Stronger disinfectants are not necessarily better, and can actually harm equipment, the environment, and your staff. It’s important to select a disinfectant that provides the least hazardous side effects, yet is still efficacious for bloodborne pathogens of concern in a dental office.
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INSTRUMENTS
1.
Clean Reusable instruments must be cleaned before sterilization. Debris can prevent heat or chemical vapor from contacting instrument surface area, and hinder sterilization. Reusable instruments should be cleaned with hands-free, automated cleaning equipment such as an ultrasonic unit. If manual scrubbing is necessary, a longhandled brush should be used to keep hands away from the contaminated sharp instruments. If instruments cannot be cleaned immediately, pre-soaking them can improve the cleaning process.
2.
Package After cleaning, all instruments should be packaged or wrapped before sterilization if they are not to be used immediately after being sterilized. The packages/ wraps should remain sealed until the day they will be used and must be stored in a way so as to prevent contamination.
Note that care should be taken when transporting contaminated dental instruments to the central processing area. Instruments should be containerized, and staff should never reach hands into containers holding contaminated instruments or handle the instruments with their hands.
Disposable Instruments If disposable needles must be recapped, either the one-handed scoop technique or an actual recapping device must be used. Safe needle-handling practices during dental treatment are required by Occupational Safety & Health Administration (OSHA) and recommended by CDC. Disposable sharps must be disposed of in a sharps container. (OSHA’s Bloodborne Pathogens [BBP] Standard mandates additional needle safety provisions.) Disposable items labeled for single use only—such as high-speed suction tips and saliva ejectors—must not be used on more than one patient.
Reusable Instruments Instruments that contact intact skin should be cleaned and disinfected. Otherwise, reusable instruments should undergo 3 steps prior to reuse: cleaning, packaging, and sterilization.
Packaging materials include: wrapped perforated instrument cassettes, plastic or paper pouches, and woven or nonwoven sterilization wraps. Materials should be compatible with the type of sterilization process being used. To maintain the integrity of the package, follow only manufacturer’s instructions for sealing the package. Do not use staples, pins, or paper clips to seal packages.
3.
•
•
•
Sterilize The CDC classifies reusable dental instruments as critical, semicritical, or noncritical.
3.
Critical instruments penetrate soft tissue or bone (ie scalpels, scalers, and burs). Semi-critical instruments contact oral tissue without penetration (ie dental mouth mirrors and dental impression trays). Non-critical instruments contact intact skin.
4.
Critical and semi-critical instruments require sterilization after use. Sterilants used to process these types of instruments must be approved by the US Food and Drug Administration (FDA). Non-critical instruments are not required to be sterilized, and may be wiped down with a surface disinfectant that’s been registered with the EPA.
5.
Dry-heat sterilization requires a higher temperature, 300˚F and up, and a longer cycle time than steam sterilization since dry air contains less heat than steam. Ethylene oxide gas (ETO) can be used for sterilizing heatsensitive or moisture-sensitive instruments. Because they have long cycle times, are costly, and pose potential hazards, ETO sterilizers are not frequently used in dental offices. Chemical Sterilants (often referred to as cold sterile solutions) should be used on heat-sensitive items only. Such items should be soaked in the chemical sterilant for the required duration—often 8 to 10 hours—and then rinsed with sterile water. Contact the instrument manufacturer to make sure your “heat-sensitive” item is in fact heat-sensitive.
2.
Steam sterilization use pressure to produce steam that is hotter than the 212˚F at which water normally vaporizes, increasing the autoclave water’s boiling point up to 260˚F. The sterilization cycle generally runs 15 to 20 minutes. Chemical vapor sterilization occurs when a liquid chemical, usually formaldehyde, is heated to produce a vapor that kills all microorganisms on the dental instruments.
All sterilization must be performed using sterilization equipment cleared by the FDA. Additionally, all staff members who operate the sterilizer must receive training on proper sterilizer operation procedures and instrument processing techniques in the office. Your staff should keep the following points in mind when operating a sterilizer: •
•
•
The TSBDE refers to 5 acceptable sterilization methods in the dental setting: 1.
Sterilization Equipment
Packages should be positioned to maximize the exposure of the paper portion of the package, because neither steam nor chemical vapor can penetrate plastic. The sterilizer must not be overloaded, and there should be as much space as possible between pouches. Operating parameters recommended by the equipment manufacturer should always be
All sterilization must be performed using sterilization equipment cleared by the FDA.
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•
followed (sterilization times, temperatures, and others provided). Before a sterilizer is unloaded, the wrapped packages must be visibly dry. If they’re wet, they may draw bacteria into the packaging material, which could contaminate the instruments. Wet packages may indicate a problem with the sterilizer. Common factors of improper sterilization include chamber overload, low temperature/ pressure, inadequate time, failure to preheat sterilizer, cycle interruption, and expired chemical (chemiclaves).
Store Sterilized instruments should be stored in a clean, dry environment to maintain the integrity of the package. It’s a good practice to rotate the packages so that those sterilized first are used first. However, instruments remain sterile until the package is opened or compromised. If packaging is compromised, instruments should be recleaned, repackaged, and resterilized. While not required, it’s recommended that all packages be marked with the date of sterilization and the sterilizer that processed the package to facilitate easy identification and recall of
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affected packages, should there be a sterilization failure. Sterilizer Monitoring The TAC states that “sterilization equipment and its adequacy shall be tested and verified in accord with American Dental Association (ADA) recommendations.” The ADA recommends that dental offices monitor sterilizers at least weekly with biological indicators. Biological monitoring is the standard for assuring proper sterilization of dental instruments. Biological test strips with non-pathogenic bacterial spores are placed in the sterilizer and processed with a normal load. If a sterilizer is operating properly, the spores should not survive the sterilization process. To verify effective sterilization, the test strips are cultured to determine if the spores exhibit any growth. Here are 2 tips on where to place spore test strips: •
•
Place a test strip in the sterilizer according to the sterilizer manufacturer’s instructions. If there are no instructions, a strip should be placed within a wrapped set of instruments in the most difficult area to be sterilized, normally the lower front area of the sterilizer. It’s a good practice to place the spore test strip in a different location of the sterilizer each week to help identify any “cold spots” within the sterilizer.
Chemical indicators can help assess physical conditions and identify procedural errors. These are recommended to be included in each load. External indicators that change color when a specific parameter is reached should be applied on the outside of the sterilization packages. Internal chemical indicators should be placed inside each package next to the instruments to ensure that the sterilizing agent reached the inside of the package. Physical Parameters including cycle time, temperature, and pressure— which are evaluated by checking the gauges and displays on the sterilizer— should be checked. Correct readings don’t verify sterilization, but incorrect readings can help identify a problem with the sterilization cycle. You should also periodically check door gaskets, vents, and internal/ external surfaces. Refer to the sterilizer manufacturer’s instructions for maintaining and cleaning the sterilizer. TDA Perks Program partner OSHA Review, Inc. produces an effective and economical cleaner/disinfectant, SUV; and an accurate and economical weekly spore-testing service, Spore Check System. For information regarding SUV or Spore Check System, call: 800-555-6248. Mention TDA Perks to receive special Perks pricing and benefits. For more information regarding these and other TDA Perks Program, please visit tdaperks.com or call 512-443-3675.
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Oral and Maxillofacial Pathology Diagnosis and Management
Toothpaste-Induced Mucosal Etching (TIME) Oral and Maxillofacial Pathology Case of the Month (from page 574)
Discussion Based on the clinical behavior and microscopic features of this lesion, it seems logical to consider the thin whitish plaque to be a mild chemical alteration or “burn,” similar to the chemical burn of smokeless tobacco keratosis, also referred to as snuff pouch or snuff pouch keratosis (Figure 3A) (1-3). Both lesions have excess surface keratin with a very unique layer of pale, bloated keratinocytes beneath this keratin, ie, intracellular edema (Figure 2). The edema of the tobacco-related lesion is thought to result from the high pH and/or the chemicals of the tobacco and has been referred to as “etching,” and so the present authors suggest the diagnostic name Toothpaste-Induced Mucosal Etching (TIME) for the microscopically and clinically similar toothpaste-related lesions. The 2 entities are different in 2 significant ways, however: 1) the sloughing aspect of TIME is not seen in smokeless tobacco keratosis; 2) TIME is not a precancerous lesion. Several other oral “burns” show intracellular edema or etching, but without the hyperkeratosis, eg, peroxide burn from the strong oxidizing activity of that product; aspirin burn (Figure 3B) from the low pH of acetylsalicylic acid; and cocaine burn (Figure 3C) (3,4). These and other “burns” are listed in Table 1 along with
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several developmental anomalies with a similar clinical and/or microscopic appearance (3-11). It should be mentioned here that these lesions are burns, not allergic reactions, which tend to produce erythema, blisters and ulceration of oral tissues (3). This is not the first time popular toothpastes have caused white or gray surface changes of the oral mucosa. During the 1990s a potentially premalignant leukoplakialike white plaque was reported as an apparent response to the herbal compound sanguinaria, contained in toothpastes (3,12). This did not look at all like TIME, being thick and white and nonsloughing, but during the 1960s and 1970s a very TIME-like mandibular vestibular whitish-gray “film” was frequently encountered by dentists (6-11). It frequently could be scraped off easily to leave a normal mucosa beneath. This was so strongly associated with the use of a specific toothpaste that it eventually came to be called a dentifrice reaction (Figure 3D). Although there was little published about this phenomenon at the time, it was suggested that changes in the type or quantity of either sodium laureate or triclosan were responsible (6,7). Why refer to this as “etching” when the lesion can be partially removed by scraping? Because the sloughing aspect is not seen in most cases,
in our experience, and because sloughing of the keratin layer is the least understood characteristic. Such sloughing is seen in only 2 oral lesions: 1) it is occasionally seen in white sponge nevus; 2) it is a defining characteristic of the recently reported, rare entity called subcorneal acantholytic keratosis or SAK (Figure 4) (3,5,13,14). The authors suggest that the sloughing in TIME is unique and SAK-like, ie, it is not an allergic reaction and it is not a “desquamation” as described in oral blistering disorders, such as pemphigus and pemphigoid. The microscopic defect in desquamating disorders is much deeper in the epithelium, not within or just under the keratin and, moreover, none show clinically normal mucosa beneath the slough (3). TIME is not well reported in the peer-reviewed literature and, in fact, has for all practical purposes remained unnamed until now, except for the previously mentioned totally non-descriptive “dentifrice reaction.” Strange as it seems for what is, we believe a rather common phenomenon, the present report appears to be the first to describe the microscopic appearance of these lesions in humans. How common is it? A prevalence study has not been done, but each of the present authors have seen numerous examples in our own patients and
Table 1: Disorders with thin, asymptomatic, poorly demarcated, whitish-gray oral mucosal macules, and characterized by the microscopic presence of superficial etching (intracellular edema) of the epithelium (3-11). Diagnosis
Comment
Smokeless tobacco keratosis (1,3)
Also called snuff pouch; found only in area of habitual tobacco placement (chewing tobacco or snuff); asymptomatic; no background erythema except with tobacco with very high pH; first noticed usually within a couple of years after habit onset, disappears within a few weeks of habit cessation. Hereditary disorder with congenital or childhood-onset; whitish-gray to white macules of buccal and other oral mucosae; occasionally the lesion can be partially scraped off. Hereditary disorder identical to white sponge nevus except that there is eye involvement (may eventuate in blindness) and the epithelium shows premature keratin production (dyskeratosis). Familial disorder with congenital or childhood-onset; whitish-gray to white macules of buccal and other oral mucosae; disappears with stretching of the mucosa; has racial predilection for African Americans.
White sponge nevus (3,5)
Witkop disease (3,5)
Leukoedema (3)
Chronic cheek bite (3)
F rictional keratosis of buccal mucosa in response to chronic biting of the cheeks; linear whitish-gray line along occlusal plane; may also be seen on lateral tongue and, rarely, lower lip mucosa; histopathology often shows neutrophils in the keratin layer.
Toothpaste-induced mucosal etching (TIME)
Asymptomatic whitish-gray “film” of mucosa of mandibular vestibule and oral floor (where residual toothpaste pools); may be partially scraped off; from whitening toothpastes; first appears several weeks or months after beginning of product use, disappears with discontinuation of product use.
Dentifrice reaction (6-11)
istorical name for TIME lesions (from 1960s and 1970s); mandibular H vestibular “film” could be partially scraped off; lesion disappeared a few days or weeks after discontinued use of toothpaste.
Aspirin burn (3)
F rom placement of aspirin or aspirin powder directly on mucosa, usually for self-treatment of toothache; severe cases are painful, but not mild cases; can be partially scraped off; heals within days of discontinued use of topical aspirin.
Cocaine burn (4)
From placement of cocaine or crack powder directly on mucosa; severe cases are slightly painful, but not mild cases; can be partially scraped off; heals within days of discontinued use of topical drug.
Peroxide burn (3)
From excessive use of 3% hydrogen peroxide as a mouthrinse.
Listerine burn (3)
Buccal and mandibular vestibular whitish-gray macules; burning sensation; is response to excessive use of a high alcohol mouthwash, such as Listerine.
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Oral and Maxillofacial Pathology,Continued
one (JB) has been repeatedly told by cosmetic and family dentists that they see TIME lesions daily, often multiple times a day. The internet has numerous anecdotal comments from users of whitening toothpastes who mention, without a diagnostic name, white, sloughing mucosal films, although there are many others describing more severe problems, such as mucosal burning, tenderness, ulceration and loss of taste (15-17). The TIME lesion itself appears to be innocuous, and so the lack of a good evidence-based literature has not been a serious problem. TIME is, as far as we can tell, simply an oral pathology oddity, one that can be easily recognized and easily diagnosed. No biopsy is required and the lesion will presumably remain, without problems, as long as the whitening or tartar-control toothpaste is used. It should disappear with discontinued use as it did in our patient. This is another similarity that TIME has to smokeless tobacco keratosis, which typically disappears within a few months of stopping the tobacco chewing habit, even when the habit has been present for decades (1,3). TIME, however, has no potential for the development of a malignancy as far as is known. We are suggesting that no treatment is needed for TIME unless the patient is psychologically concerned by the sloughing, in which case a simple change of dentifrice will effect cure.
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References 1. Pindborg JJ, Reibel J, RoedPeterson B, Mehta FS. Tobaccoinduced changes in oral leukoplakia epithelium. Cancer 1980; 45; 2330-2336. 2. Bouquot JE. Leukoplakia and erythroplakia: a review and update. Pract Perio Aesth Dent 1994; 6:1-10. 3. Neville B, Damm D, Allen C, Bouquot J. Oral and Maxillofacial Pathology, 3rd edition. Philadelphia: W. B. Saunders, 2008. 4. Bouquot JE, Johnson CD, Afshari A. The abused mouth, part I: cocaine-associated oral damage (review and case reports). J Greater Houston Dent Soc, 2009; 81:16-21. 5. Hennekam R, Allanson J, Krantz I. Gorlin’s syndromes of the head and neck, Oxford Publ., Oxford, England, 2010. 6. Skaare A, Eide G, Herlofson B, Barkvoll P. The effect of toothpaste containing triclosan on oral mucosal desquamation. A model study. J Clin Periodontol 1996; 23:1100-1103. 7. Rubright WC, Walker JA, Karlsson UL, Diehl DL. Oral slough caused by dentifrice detergents and aggravated by drugs with antisialic activity. J Am Dent Assoc 1978; 97:215-220. 8. Kowitz G, Jacobson J, Meng Z, Lucatorto F. The effects of tartarcontrol toothpaste on the oral soft tissues. Oral Surg Oral Med Oral Pathol 1990; 70:529-536. 9. Herlofson BB, Barkvoll P. Oral mucosal desquamation caused by two toothpaste detergents in an experimental model. Eur J Oral Sci 1996; 104:21-26. 10. Kuttan NA, Narayana N, Moghadam BK. Desquamative stomatitis associated with routine use of oral health care products. Gen Dent 2001; 49:596-602.
11. Joiner A. Whitening toothpastes: a review of the literature. J Dent 2010; 38 (Suppl 2):e17-24. Epub 2010 May 24. 12. Eversole LR, Eversole GM, Kopcik J. Sanguinaria-associated oral leukoplakia: comparison with other benign and dysplastic leukoplakic lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 89:455-464. 13. Bouquot J, Collins B. Subcorneal acantholysis – first reported cases. Proceedings, annual meeting, American Academy of Oral & Maxillofacial Pathology, Montreal, Quebec, Canada, May, 2009. 14. Bouquot J. Subcorneal acantholysis and other unreported oral lesions – a clinicopathologic review. Proceedings, annual meeting, Canadian Academy of Oral & Maxillofacial Pathology & Oral Medicine, Minneapolis, Minnesota, June, 2012. 15. Gagari E, Kabani S. Adverse effects of mouthwash use. A review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995; 80:432-439. 16. Consumer Affairs. Consumer Complaints & Reviews. http:// www.consumeraffairs.com/ cosmetics/ crest.html. Accessed 9/23/12. 17. Amazon.com. Customer Reviews. Crest 3D White Vivid Fluoride Anticavity Radiant Mint Toothpaste, 4-Ounce Carton (Pack of 6). http://www.amazon.com/ Crest-Fluoride-Anticavity-RadiantToothpaste/product-reviews/ B00336EUSG?pageNumber=2. Accessed 9/23/12.
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CALENDAR OF EVENTS SEPTEMBER2014 8-13 The American Association of Oral and Maxillofacial Surgeons presents its 96th annual meeting at the Hawaii Convention Center in Honolulu, HI. For more information, please contact Dr Robert C. Rinaldi, AAOMS, 9700 W Bryn Mawr, Rosemont, IL 60018; Phone: 847-678-6200; Fax: 847-6786286; Email: inquiries@aaoms.org; Website: aaoms.org.
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12-13 The Texas Academy of General Dentistry will hold the Lone Star Dental Conference in Austin. To register, or for more information, please visit tdagd.org. 18-19 The El Paso Dental Conference will be held at the El Paso Convention Center. To register, or for more information, please visit elpasodentalconference. org.
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The TDA Smiles Foundation will hold a 20-chair, 1-day Texas Mission of Mercy in Fort Stockton. For more information, please contact Foundation Manager Judith Gonzalez at TDASF, 1946 S IH 35 Ste 300, Austin, TX 78704; Phone: 512448-2441; Email: judith@tda.org; Website: tdasmiles.org.
19-22 The American Academy of Periodontology presents its annual meeting in San Francisco, CA. For more information, please contact Mr John Forbes, AAP, 737 N Michigan Ave Ste 800, Chicago, IL. Phone: 312-7875518: Fax: 312-787-3670; Email: aap-info@perio.org; Website: perio. org.
OCTOBER2014 9-14 The American Dental Association presents its annual meeting at the Henry B. Gonzalez Convention Center in San Antonio, TX. For more information, please visit ada.org.
DECEMBER2014 5-6 The Southwestern Society of Pediatric Dentistry hold their 2014 2-day CE meeting at the Westin Galleria in Dallas. For more information, please visit aapd.org. 8-9 The ADA’s Institute for Diversity in Leadership will meet at the ADA headquarters in Chicago. For more information, please visit ada.org. 12-13 The ADA’s Council on Ethics, Bylaws, and Judicial Affairs (CEBJA) will meet For more information, please contact Mr Earl Sewell at ADA, 211 East Chicago Ave, Chicago, IL 60611; Phone 312-440-2499; Website: ada. org.
THE TEXAS DENTAL JOURNAL’S CALENDAR will include only meetings, symposia, etc., of statewide, national,
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The ADA will host a Mission of Mercy dental clinic in San Antonio, in conjunction with the annual meeting, to treat local residents without access to care. For more information, please visit ada.org.
and international interest to Texas dentists. Because of space limitations, individual continuing education courses will not be listed. Readers are directed to the monthly advertisements of courses that appear elsewhere in the Journal.
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ADVERTISING BRIEFS PRACTICE OPPORTUNITIES ABILENE: 2- to 4-operatory stand-alone dental office with all equipment included; digital x-ray and pano. Call 325-762-0444. ADS WATSON, BROWN & ASSOCIATES: Excellent practice acquisition and merger opportunities available. DALLAS AREA: 5 general dentistry practices available (East Dallas, Richardson, Southeast of Dallas, and north of McKinney). FORT WORTH AREA: 2 general dentistry practices (West Fort Worth and Arlington). NORTH TEXAS: 2 pediatric practices. HOUSTON AREA: 1 orthodontic practice. EAST TEXAS AREA: 1 general dentistry practice. WEST TEXAS AREA: 1 general dentistry practice. AUSTIN AREA: 1 general dentistry practice available northwest of Austin. BRYAN/COLLEGE STATION AREA: 1 general dentistry practice available. SAN ANTONIO AREA: 1 general dentistry practice available. OKLAHOMA AREA: 1 general dentistry practice available. For more information and current listings, please visit our website at adstexas.com or call ADS Watson, Brown & Associates at 469-222-3200.
ADVERTISING BRIEF INFORMATION SUBMISSION AND CANCELLATION DEADLINE: 20th, 2 months prior to publication (eg, November 20th for January issue) MONTHLY RATES: First 30 words = $40; each additional word = 10¢ Ads must be submitted via e-mail, fax, or web through tda.org and are not accepted by phone. Journal editors reserve the right to edit copy of classified advertisements. Any dentist advertising in the Texas Dental Journal must be a member of the American Dental Association. Advertisements must be not quote revenues or gross or net incomes; only generic language referencing income will be accepted.
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ALLEN: We are a privately-owned Allen practice looking for a FT Associate to work 4 days a week. Someone with 5 years experience in general dentistry. We focus on family, cosmetic and implant dentistry. The goal is quality, not quantity. Newer building with state of the art equipment, technology, and 4 operatories finished out. Great earning potential with our PPO patient base. If you are interested in becoming a long-term part of a wonderful community with great families, this is the office for you. Please email your cover letter and resume to info@allentexasfamilydental.com. AMARILLO: General dentist for a locally owned practice looking to provide care for our patients as well as build their own patient base. Ownership opportunity available. Please contact Dr Britt Bostick, DDS, bbost35821@aol.com or call 806438-5745. AMARILLO: Pediatric dentist for a locally owned practice looking to provide care for our patients as well as build their own patient base. Ownership opportunity available. Please contact Dr Britt Bostick, DDS, bbost35821@aol.com or call 806438-5745. ARLINGTON / FORT WORTH: Associate position available. Full time dentist and specialist needed to join our successful dental group in Arlington & Fort Worth. Interested candidates should email CV to txdentaljobs@gmail.com.
ASSOCIATE FOR TYLER GENERAL DENTISTRY PRACTICE: Well-established general dentist in Tyler with over 34 years experience seeks a caring and motivated associate for his busy practice. This practice provides exceptional dental care for the entire family. Our office is located in beautiful East Texas and provides all phases of quality dentistry in a friendly and compassionate atmosphere. The practice offers a tremendous opportunity to grow. The practice offers excellent production and earning potential with a possible future equity position available. Our knowledgeable staff will support and enhance your growth and earning
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ADVERTISING BRIEFS AUSTIN PEDIATRIC PRACTICE SEEKING FULL TIME ASSOCIATE: Great benefits! Progressive, fast-paced practice. Capable, caring staff. We are looking for a bright career-oriented pediatric dentist to join an organization committed to providing high quality dental care to children and adolescents. Our dental team strives to offer exceptional care with integrity. For consideration send your confidential resume to dentalresume27@yahoo.com. AUSTIN PRIVATE PRACTICE SEEKS ASSOCIATES (GPs, Prosthodontists): due to growth and increased capacity. Excellent compensation / benefits. Email resume to operations@ omnidentalgroup.com or call 512-773-9239. AUSTIN, SAN ANTONIO & DALLAS AREA PRACTICE OPPORTUNITIES MCLERRAN & ASSOCIATES: CORPUS CHRISTI AREA (ID # T238): This established, fee for service general family practice is located in a single story professional complex with excellent visibility off of a major thoroughfare. The practice has five fully equipped and computerized operatories with digital x-ray. The practice boasts consistent gross collections in the mid six figures annually, strong cash flow, a committed and well-trained staff, strong hygiene recall and a solid fee for service patient base. This is a turnkey practice with strong growth potential. CORPUS CHRISTI AREA (ID #T231): This is an opportunity to purchase an established, general dentistry practice located on the South Coast of Texas in an area that is experiencing rapid growth as a result of oil drilling in the nearby Eagle Ford Shale. The practice has a large, fee for service/PPO patient base, strong new patient flow, consistent
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annual revenue in the mid six figures, and solid cash flow. The office occupies a free standing building with 2 fully equipped operatories (digital X-ray units and computers) and ample room to add 2-3 additional operatories. The real estate is owned by the seller and being offered for sale at fair market value. Given its close proximity to the Gulf of Mexico, this turnkey practice is an ideal opportunity for an avid fisherman/outdoorsman or beach lover. SOUTH OF SAN ANTONIO (ID #T235): This established general dentistry practice is located on a main thoroughfare in a quaint, rural town located approximately 90 miles southeast of San Antonio. This practice is in a high growth, low competition area in the Eagle Ford Formation. The practice has realized consistent annual revenue of six figures the past two years while maintaining low overhead, strong profitability of 50%, and solid new patient flow (currently averaging 27 new patients per month). The office space of the practice encompasses 1,200 square feet and has 3 fully equipped operatories with digital X-ray units and computers (one additional plumbed operatory for expansion). The building is also being offered for sale. SAN ANTONIO (ID #247): This established Orthodontic specialty practice is located in highly desirable and quickly growing area of San Antonio. The office is located in a beautiful, single story, free standing condominium and the decor is representative of the middle to upper class demographics of the area. It has four treatment chairs, is computerized throughout and has digital radiography technology. This practice would be an excellent starter opportunity or satellite location and presents a new owner with tremendous upside potential and turn key facility. The doctor is
ADVERTISING BRIEFS selling to transition into retirement. SAN ANTONIO (ID #T244): This established, general family practice is located in a newly built-out facility located in a vibrant, high traffic retail location in a desirable area of San Antonio. The practice caters to a middle to upper middle income, fee for service/PPO patient base and boasts a strong new monthly patient count as a result of strong patient referrals, online marketing, and a highly visible location. This truly is a one of a kind location in a great area of San Antonio. HILL COUNTRY NORTH OF SAN ANTONIO (ID #T243): Doctor is retiring and selling this established quality general family practice and the building/ real estate that is located in desirable hill country community within close proximity to San Antonio. The practice has seen consistent collections of approximately mid six figures per year over the past three years with strong cash flow. The practice caters to a fee for service/PPO, middle class patient base and boasts strong new monthly patient flow with limited external marketing. The real estate will be sold at Fair Market Value as determined by an independent appraiser. WEST OF SAN ANTONIO (ID #T242): This established, fee for service general family practice was started from scratch in 1970 and has been in its current location for 28 years. The practice boasts a large active patient base, strong hygiene recall program, and excellent net cash flow after expenses. There is tremendous upside potential due to limited external marketing, no involvement in discounted insurance plans, a good amount of specialty work being referred out, and huge growth related to the Eagle Ford shale oil boom. This practice presents an excellent opportunity for someone who wants
to get away from the San Antonio city life, while still having access to its amenities. SAN ANTONIO (ID #T240): This established, fee for service general family practice is located in a professional building in a highly visible location on San Antonioâ&#x20AC;&#x2122;s north side. The practice boasts a 100% fee for service patient base with consistent gross collections in the mid six figures annually. The practice has four fully equipped operatories, with a fifth plumbed, and is computerized, has digital x-rays and a CEREC. This is an excellent opportunity with strong growth potential. SAN ANTONIO (ID #T239): A thriving multi-office pediatrics practice in the Seguin/San Marcos area is seeking a full time associate to work between both locations. Both facilities are state-of-the-art, featuring 12
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ADVERTISING BRIEFS treatment areas and the latest amenities, including a movie theater, arcade, ceiling mounted televisions, and toddler play areas. Both offices are designed for high volume patient flow, as they see an average of over 100 patients each day. The patient base reflects the local blue-collar and educational communities. There is a mix of insurance, self-pay and state funded patients. The offices provide a full range of pediatric dental services and have very active sedation general anesthesia schedules. The associate doctor must be a graduate of a US dental school and hold a US pediatric dental training certificate. Spanish speaking is highly desired but not required. To learn more about this associate opportunity, please contact us at 512-900-7989 or texas@ dental-sales.com. Please also send a current CV. KILLEEN/HARKER HEIGHTS AREA (ID #T245): This general family practice is located about an hour north of Austin in a large free standing building with excellent visibility. It has eight plumbed and equipped operatories, with an opportunity to add a total of four additional treatment rooms. This practice has a fee for service/PPO patient base and has consistent annual revenue of seven figures with strong net income. It boasts an incredibly strong hygiene recall program, large monthly new patient count, a well-trained and committed staff, and turn-key facility. The real estate is owned by the seller and is being offered for sale at fair market value. This is an excellent opportunity with tremendous upside potential. AUSTIN (ID #T246): This fee for service/PPO general family practice was started from scratch 17 years ago in a desirable single story retail center in NW Austin. The practice has a solid patient base that reflects
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the middle to upper middle income demographics of the area. It has three fully equipped treatment rooms with the potential to add a fourth by plumbing/equipping the consultation room. The office boasts modern decor and is well-equipped with digital x-ray units and is computerized throughout. This is a great opportunity to get into an established practice with solid potential for less than a comparable start up. The selling doctor is transitioning due to a disability that arose in 2012. AUSTIN (ID #T241): This is an opportunity to purchase a growing practice in the rapidly developing area of East Austin. The office is situated directly on a busy street and has excellent signage and visibility. The facility has a quality build-out and 4 fully equipped operatories with computers and digital radiography. The practice has healthy new patient flow, low overhead, and tremendous upside potential. This is a great starter practice or satellite location. HILL COUNTRY WEST OF AUSTIN (ID #T236): This predominately fee-forservice general family practice is located in a desirable community in the heart of the Texas Hill Country. It boasts a great reputation and has been in its current location since 1980. The office has three fully equipped operatories, with the ability to add an additional operatory. There is a strong opportunity for growth, as the owner is not actively marketing the practice, does not participate in any PPOs and is referring out a fair amount of specialty procedures. The practice has a strong foundation of active patients with a good amount of upside potential. This is an excellent opportunity for someone who enjoys the beautiful Hill County and wants to get away from the big city. AUSTIN (ID # T222): This is a unique
ADVERTISING BRIEFS opportunity to purchase a practice located in a busy retail center in Austin. The practice is ideal for a doctor or company looking for a large facility to establish a multiple doctor and hygienist office for less than the cost of building out a shell space and equipping a startup. The practice has a total of 18 plumbed operatories with 6 operatories currently equipped. The practice revenue was on pace to be around the mid six figures in 2013 with only one doctor producing. Serious inquiries only as this is a unique opportunity not suited for most solo practitioners looking to acquire a practice. CENTRAL AUSTIN (ID #T225): Located in a very desirable area of north central Austin, this established fee for service general family practice offers a lot for an incoming dentist. The practice is located in a 1,500 square foot, four operatory facility within a small two story professional condominium building. The practice boasts a committed and well-trained staff, strong hygiene program, solid active patient base and gross annual revenues averaging in the mid six figures over the last three years. While the practice is a strong opportunity “as-is,” an incoming owner doctor would have ample opportunity to grow the practice given that the current owner is not accepting any PPOs, relies only on word of mouth referral to generate new patient flow and is referring a significant amount of specialty work out of the office. Contact McLerran & Associates: David McLerran or Brannon Moncrief in Austin 512-9007989, San Antonio 210-737-0100. Practice sales, appraisals, buyer representation, and lease negotiations. To request more information on our listings, register at www.dental-sales.com.
AUSTIN: A busy pediatric dentistry office in Austin, TX is looking to add a General Dentist. Please submit a resume via email to tal@ austinchildrensdentistry.com. AUSTIN: A well-established pediatric practice is seeking an energetic dedicated full-time pediatric dentist. We have an extensive client base with continued growth. Our office is a leader in all aspects of pediatric dentistry including sedation and anesthesia dentistry. We have 3 offices with state-of-the art technology and a highly trained support staff. We are looking for the right fit for our practice. Ideally, someone who is looking for a long-term opportunity. New grads are welcome to apply. Please email resume to tal@ austinchildrensdentistry.com. AUSTIN: Multi-specialty practice in north central Austin is looking for an endodontist twice a month. This could increase to more days soon. The office is a provider for PPO/Cash patients only, no HMO or DMO. The reimbursement is the higher of the two: four figures per day or 40% production. Please forward your resume to info@austin-dentistry. com. AUSTIN: My Kid’s Dentist has an excellent opportunity for a pediatric dentist to work 10 days a month in our Austin offices. Contact Ed at 949842-7936 or email CV to looname@pacden.com for more information. AWESOME PRACTICE IN EAST TEXAS FOR SALE: SLH is looking for a qualified associate or new graduate, with an option to buy, that would Texas Dental Journal l www.tda.org l August 2014
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ADVERTISING BRIEFS like the opportunity to immediately transition into a general dentistry practice in this growing town of East Texas. The owner is willing to stay for a negotiated amount of time if necessary to ensure a smooth transition. The location of the practice is near the hospital in a beautiful scenic area surrounded by many professional buildings. The staff is excited and ready for a new member and future owner that will allow their current dentist to pursue other opportunities. The office space is 1,500 square feet with 4 treatment rooms equipped, 2 private offices, and 6 highly experienced employees. The new practitioner will lease space from the group dental practice. The group practice occupies a portion of the building complex and is looking to transfer ownership of the patient base and/or equipment within six months. Listing #3050 CB. Pictures can be made available. For more information contact our office at 972-562-1072 or email sherri@slhdentalsales. com or visit our website at www.slhdentalsales. com. COLORADO DENTAL PRACTICE FOR SALE. Located in southwest Colorado near the San Juan mountains. Ski, fly fish, hike, and hunt. It’s all in your backyard. Established fee-forservice restorative practice with state-of-the-art equipment and furnishings is waiting for you in this mountain town community. Collecting mid-6 figures with the potential to do way more. Owner is relocating to pursue a new phase in his dental career. Get of the Texas heat and the rat race and enjoy real living again. Practice is attractively priced to sell. Email inquiries to t1h2oyd3@yahoo. com.
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DALLAS / FORT WORTH: Area clinics seeking associates. Earn significantly above industry average income with paid health and malpractice insurance while working in a great environment. Fax 312-944-9499 or email cjpatterson@ kosservices.com. DALLAS AREA: New and beautiful general dentistry practice on I-30 near Rockwall. Over 5 years of clinical experience required. Perfect for dentists who refer endo! Pay based on collections. PPO and Medicaid accepted. M-F 2:00 PM. - 8:00 PM and Saturdays available. Visit mockingbirddentalgroup. com. DALLAS TOLLWAY & LBJ: Dentists needed parttime and full-time for new, extended-hours, high production, treatment-oriented practice opening just prior to Memorial Day. Must be comfortable with most molar endo and wisdom tooth extraction cases. Implants experience a huge plus. Plenty of C&B. Dentures also an opportunity. 1099 contract position with generous commission. For immediate consideration, please email your CV and availability to cv@erdentist.com. DDR DENTAL™ - AUSTIN: General practice. Well established Austin practice in terrific North Austin location. Well designed and decorated office. Fronts high-traffic Hwy 182. Four operatories in use and plumbed for 4 more. Mid six figure gross and high net income. Free standing building also available for sale. Contact Chrissy Dunn at 800930-8017 or view the practice at www.DDRDental. com (DDR Dental Trust™ Member)
ADVERTISING BRIEFS DDR DENTAL™ - WEST HOUSTON (WESTHEIMER): General practice. Mid six figure gross with very high net income (low overhead). Four operatories on very small inexpensive footprint. Well established patient base. Contact Chrissy Dunn at 800-930-8017 or view the practice at www.DDRDental.com (DDR Dental Trust™ Member) DDR DENTAL™ – NORTH HOUSTON: General practice. Seven figure gross with expected high six figure net income. Six fully equipped operatories. Office inside professional building. Well established patient base. Contact Chrissy Dunn at 800-9308017 or view the practice at www.DDRDental.com To obtain timely information about the practices that we have for sale and recently sold, please visit our website at www.DDRDental.com. DENTISTS: A practice of 1 year looking for a BC/BE pediatric dentist to come on board as employee with possible buy-in. This is an all pediatric dentists’ office. You would be working next to a BC pediatric dentist. Good terms with great pay and work hours. Must be able to get Board Certified within 1 year. OR cases done at El Paso’s Children’s Hospital. Excellent opportunity. Contact 719-6715617 or tparco@dentalquestions.com. DENTON COUNTY: Lease space for pediatric dentist for lease or sale. Plumbed and cabinets for gas and suction for 5 chairs in open area and one private operatory. Large waiting room, finance office, consult room, 2 private offices, kitchen/
lounge. 2,560 sq ft. In building with 2 general dentists. 972-317-6211 DFW AREA: Seeking general dentists and specialists. Our offices are located in the Dallas / Fort Worth area. We are looking for caring, energetic associates. New graduate and experienced dentists welcome. We offer benefits, a helpful working environment and an opportunity to grow. We accept most insurance and Medicaid. Please submit your resume via email to jennifer@ smileworkshop.com or call our office at 214-7574500. EAST TEXAS: Well-established dental practice seeks caring, proficient, and motivated dentist for associate employment. Our office is located in a mid-sized town with abundant outdoor activities including hunting and fishing and a “small town” atmosphere. We offer all phases of dentistry. Interested candidates should email correspondence and resume to mloon242@aol. com. EDINBURG — FALCON DENTISTRY PA DBA FALCON DENTAL CENTER seeks dentist in Edinburg. Doctor of Dental Surgery degree required. Texas dental license required. Qualified applications may submit resume directly to Atlantis Gloria Moya, office manager, via fax at 956-2874926 or via email at falcondentistry@gmail.com. EL PASO: Full-time position for a general dentist. Do not waste your best years at dead end jobs. Great earning potential and future partnership
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ADVERTISING BRIEFS option. Affordable El Paso Dental is looking for a Texas-licensed dentist to work full- time in our office in El Paso. Applicant must be licensed in the state of Texas and have 1 year of experience. If interested please submit a resume with an accurate contact number and email address to the following: drdarj@gmail.com. EL PASO: We are hiring a skilled and compassionate dentist to join our stable and successful practice. We are seeking a highly professional dentist with a knack for general dentistry. Prospective candidates must be dynamic, fun loving, and looking for a long term commitment. Our practice is highly productive affording our providers an opportunity to attain competitive compensation. If interested, please forward your CV to annette@vistahillsfamilydental. com. EL PASO: Well-established general practice of over 30 years seeking full-time general dentist associate. Associate would be sole dentist at one of 2 office locations with full staff including hygienist. Income opportunity well above average. Professional opportunity even greater. Send resume to drartbejarano@gmail.com. ENDODONTIST â&#x20AC;&#x201D; FULL TIME, KILLEEN: Carus Dental, established in 1983 in Austin, has always been committed to the traditional doctor-patient relationship and to the highest quality in dental care and service. We currently have approximately 48 doctors on staff across our 21 practices in Austin, Houston and Central Texas. We offer dental services in general dentistry, oral surgery,
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orthodontics, pediatric dentistry, endodontics, periododontics and prosthodontics in some or all of our practices. Carus Dental has been accredited by the Accreditation Association of Ambulatory Health Care since 2000. We offer a competitive salary and excellent benefit package including a 401k, health insurance and a professional work environment. To learn more about American Dental Partners and Carus Dental please visit us at www.amdpi.com and www.carusdental.com. If interested, please send CV and cover letter to kateanderson@amdpi.com. GALVESTON: Well-established, successful practice of 35 years needs FT associate dentist for FFS/PPO practice. Experienced staff, new equipment, Galveston. Senior owner loves to teach sedation, implants, and other surgical procedures. No Medicaid, no DHMO practice in 6 ops, 2 surgical suites, all operatories computerized with digital X-ray and intra-oral cameras; digital panoramic X-ray; paperless charts for easy documentation. Visit www.todaysdentistrytexas. com. The Galveston area is just south of Clear Lake 25 minutes which has planned communities with superior schools, multiple educational, recreational and cultural venues as well as access to all of the Houston cultural and sport venues, shopping and restaurants. We are minutes away from all types of water sports including several large marinas. http://goo.gl/maps/lWkF. Possibility of buy-in and partnership possible after an interim term. Interview today! Email CV to kkcarroll10yahoo.com or call 832-385-8875.
ADVERTISING BRIEFS GENERAL PRACTICE. Sugarland, Texas. 6-operatory practice for sale. Four operatories equipped; turnkey operations; 2013 collections were mid6 figures. Working only 3 days per week; all equipment and building less than 2 years old. Very clean, very modern office; all digital. Great opportunity for any specialist as well as general dentist. Asking $325K. For more info, please email sugarrichdental@gmail.com. GREAT DENTIST TO WORK WITH KIDS: Good opportunity for someone who likes children. Busy practice. Great personality. Competent dentist not afraid to work. Great pay. Sedation will be taught. Send resume ASAP to Carol Erickson, info@ txkidsdental.com, 9411 Alameda Avenue Ste P, El Paso, TX 79907. 602-309-2180 GREAT OPPORTUNITY FOR SPECIALIST: An endodontic practice in southwest Houston is seeking to share space with a part or full time periodontist, oral surgeon or orthodontist in a state-of-the-art dental office. 4 operatories fully equipped with digital x-rays and microscope. For more information, please contact (713) 932-1913. HOUSTON/CLEAR LAKE â&#x20AC;&#x201D; DENTAL OFFICE: In high visibility smaller professional building at highest traffic corner location in adjacent family oriented, high income master planned community. Adjacent CVS, nearby schools, retail and office centers, NASA and other long term tenants (UTMB orthopedic and urgent childcare center, podiatrist and chiropractor) drive patient traffic. Nice finishes and all plumbing and electrical in place for 6 or more operatories, offices and consult
rooms. Lease incentives, negotiable terms. Dwight Donaldson, Monument Real Estate, 281-240-0077, ddonaldson@terramarktx.com. HOUSTON-AREA PRACTICE OPPORTUNITIES! MCLERRAN & ASSOCIATES-PRACTICE SALES OF TEXAS: NEW! NORTH OF HOUSTON: Established general cosmetic practice located in one of the fastest growing communities in the Houston area. The turnkey, 5-operatory facility has a comfortable, cozy ambiance, equipment that is in very good condition, and room for expansion and solid growth potential (#H234). NEW! SOUTHWEST OF HOUSTON: Established general practice with a highly visible location, 4 operatories, strong employment base, and a healthy new patient flow with majority PPO/FFS. The owner is looking for an experienced practitioner that will exhibit an ownership attitude in order to maximize income for both parties. Partial buy-in opportunity will be available in the future for the right doctor (#H93). NEW! NORTH OF HOUSTON: This general family practice was started in 2008 when the seller purchased the existing build-out and equipment of an established dentist who relocated his practice. Upgrades include digital radiography (intraoral and panoramic) and flat screen TVs in the operatories. With an active base of over 800 patients, new patient flow of 25 patients per month, a visible retail strip center location, and opportunity for expanded office hours, growth potential is solid. Value acquisition with strong upside potential (#H236). SOUTHWEST HOUSTON: PPO/FFS practice, visible retail location on main thoroughfare in growing southwest family oriented area. With low overhead, a recently remodeled Texas Dental Journal l www.tda.org l August 2014
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ADVERTISING BRIEFS interior, 3 operatories, and 1,100 sq ft, the practice represents a value purchase with significant upside potential. Recent website and social media platform development will also allow the buyer to effectively reach out to the community to further enhance patient flow. Very limited schedule for the owner and significant outbound referrals for endo, perio, oral surgery, and orthodontics (#H243). NORTHWEST HOUSTON: This general and orthodontic dentistry practice is located on a well-traveled road in the northwest Houston/ Hockley area. The area is expected to grow tremendously over the next few years with the expansion of major roads in the area. The practice sees approximately 30 new patients per month and hygiene produces 27% of production. With a strong hygiene department, high new patient flow and low overhead, the practice is set for continued profitability and growth (#H231). PRICE REDUCED! UPPER WEST GALVESTON BAY: Profitable General practice located in a highly visible office building in the heart of a vibrant oil and gas commercial center and community. Three fully-equipped operatories, strong hygiene revenues, and over 1,100 active patients (#H194). NEW! NORTHEAST OF HOUSTON: Established, extremely profitable general practice in single tenant, 3,400 sq ft professional building; 5 plumbed and equipped operatories, steady level of annual collections over past 4 years (#H232). NORTHWEST HOUSTON: This general dentistry practice has established for 11 years in the Northwest Houston area. The practice is located in a Kroger and CVS Pharmacy shopping center with great visibility and high foot traffic. The practice is conveniently located close to 3 major highways in the Houston area
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(#H226). GALVESTON: Established fee-for-service practice, collections have been increasing in recent years and are consistently over 6 figures. With a solid economic base, the practice enjoys a strong recall system, an experienced and stable staff, and has seen over 2,500 patients in the last 24 months. The facility is free standing and has 8 equipped operatories with room for expansion (#H161). NORTHWEST HOUSTON ASSOCIATE POSITION WITH FUTURE BUY-IN: Established general dentistry practice is located near a high traffic intersection in the booming northwest Houston/Copperfield area. Revenues in low-7 figures a strong hygiene department, and a very healthy new patient flow, the practice is set for continued profitability and growth. (#H225) SOUTHEAST HOUSTON: Well established general practice, located in highly visible shopping center, 5 operatories, stable patient base, room for expansion, comfortable dĂ&#x2C6;cor (#H197). SOUTHWEST OF HOUSTON: Established general practice, 4 operatories, stable blue collar patient base, petrochemical economic base, 2,000 sq foot building available. Doctor working only part-time (#H174). To see our most up-to-date listings, please go to dental-sales.com. Contact McLerran & Associates in Houston: Tom Guglielmo, Patrick Johnston, Mac Winston, 866-756-7412 or 281-3621707, houstoneasttx@dental-sales.com. Practice sales, appraisals, buyer representation, and partnership counseling. HOUSTON AREA PRACTICE OPPORTUNITIES! MCLERRAN & ASSOCIATES-HOUSTON: NEW!! NORTHWEST HOUSTON Established orthodontic practice located in a fast growing area of Houston
ADVERTISING BRIEFS in a visible retail strip center. The facility is state of the art with high quality finishes, digital radiography (pan/ceph), and equipment that is in excellent condition. With a solid base of private pay patients, and a young family demographic, the practice has strong upside potential. 2013 revenues were great for the 7 chair facility, with room for expansion. (#H247) NEW!! SUBURB OF HOUSTON: Established 17 years ago this PPO/feefor-service general, family practice is located in a free standing building with 8 operatories, excellent visibility, easy patient access, was constructed with quality materials and finishes, and has an elegant, comfortable dĂŠcor. The practice is equipped with a digital panoramic unit, digital x-ray sensors, intraoral cameras and computers throughout. With approximately 2,700 active patients and over 60 new patients per month, revenues have been consistently at or above low 7 figures for the last few years. With the growth in the energy sector of the United States economy, the area will enjoy a very stable work force and local economy for many years to come. (#H238) UPDATED!! EAST TEXAS: Established, extremely profitable general practice in single tenant, 3400sqft professional building. 5 plumbed and equipped operatories, steady level of annual collections over past 4 years. (#H232) HOUSTON: Over 80% fee-for-service orthodontic practice in a highly visible, retail location along a main thoroughfare. With almost 3,000 square feet, 5 equipped treatment rooms, digital radiography, computers throughout, and a very elegant buildout, this office is turn-key. 2013 revenues and production increased over 26% from 2012. Great location with lots of future growth in the area. (#H245) NORTH OF HOUSTON Established General
Cosmetic practice located in one of the fastest growing communities in the Houston area. The turnkey, 5 operatory facility has a comfortable, cozy ambience, equipment that is in very good condition, and room for expansion. Collections for the last 4 years have averaged in the mid-high six figures and there is solid growth potential. (#H234) SOUTHWEST HOUSTON PPO/FFS practice, visible retail location on main thoroughfare in growing Southwest family oriented area. With low overhead, a recently remodeled interior, 3 operatories, and 1,100 square feet, the practice represents a value purchase with significant upside potential. Recent website and social media platform development will also allow the buyer to effectively reach out to the community to further enhance patient flow. (#H243) SOUTH OF HOUSTON: Established general practice with a highly visible location, four operatories, strong employment base, and a healthy new patient flow with majority PPO/FFS. The owner is looking for an experienced practitioner that will exhibit an ownership attitude in order to maximize income for both parties. (#H193) To see our most up to date listings, please go to www.dental-sales. com. Contact McLerran & Associates in Houston: Tom Guglielmo, Patrick Johnston, Mac Winston 866- 756-7412 or 281-362-1707, houstoneasttx@ dental-sales.com. Practice sales, appraisals, buyer representation, and partnership consulting. HUMBLE, TEXAS: Carus Dental, established in 1983 in Austin, TX, has always been committed to the traditional doctor-patient relationship and to the highest quality in dental care and service. We currently have 55 doctors on staff across our Texas Dental Journal l www.tda.org l August 2014
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ADVERTISING BRIEFS 21 practices in Austin, Houston and central Texas. We offer dental services in general dentistry, oral surgery, orthodontics, pediatric dentistry, endodontics, and periodontics in some or all of our practices. We are seeking Part-Time Endodontist for our Humble, TX, practice, three days every other week. To learn more about American Dental Partners and Carus Dental please visit us at www.amdpi.com and www.carusdental.com. If interested, please send CV and cover letter to kateanderson@amdpi.com. LAREDO: We are looking for a pediatric dentist for a rapidly growing practice. Strong referral sources. Hospital cases performed twice a week at local hospital. State-of-the-art practice with digital X-rays and charts. If part-time, then dentist can fly in to see patients and still maintain living at their current city. Partnership in future is an option if candidate interested. Please email t2tpdlaredo@ gmail.com. LONGVIEW PEDIATRIC PRACTICE SEEKING FULL-TIME ASSOCIATE: Sherri L. Henderson & Associates, LLC is looking for a qualified associate to transition into an active pediatric dental practice. The associate will be working with a knowledgeable staff and a great new patient flow. This practice is dedicated to performing high quality dental care for the children and adolescents of the surrounding communities. The dentist/owner established the practice 14 years ago, and offers a future opportunity to buy-in. This beautiful pediatric practice is 5,000 sq ft, with 4 doctor chairs and 4 hygiene chairs, plus a quiet room and a new patient room. A
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full-time schedule of 4.5 days per week is offered, with salary based on 40% of production. Health insurance and benefit plans are negotiable. Listing #3435. Photos available. For more information, please contact our office at 972-562-1072, email sherri@slhdentalsales.com, or visit our website at slhdentalsales.com. MIDLAND: One of the fastest growing cities in Texas needs a dynamic, caring, patient-focused dentist to join our growing practice. Associate and buy-in opportunities are available. Please contact Dr Britt Bostick, DDS, at bbost35821@aol.com or call 806-438-5745. NORTH TEXAS: Pediatric dentist needed for busy north Texas practice. Enjoy life in Sherman, Texas, a family-oriented city conveniently located just 1 hour north of Dallas, but without the hustle and bustle of the big city! Excellent practice opportunity for motivated and nurturing pediatric dentist seeking full-time associate with potential for partnership. Practice has a great reputation and is committed to providing quality comprehensive care for our patients and families in a fun and relaxed atmosphere. State-of-theart facility with highly trained and dedicated staff. Competitive compensation and benefits. Feefor-service, limited Medicaid. Must possess high personal standards, strong work ethic, excellent technical and communication skills, and be willing to treat the full range of pediatric dental patients. Opportunities for in office conscious sedation, IV sedation and hospital dentistry. Please email resume/CV to bth1@cableone.net.
ADVERTISING BRIEFS OPPORTUNITY TO TRANSITION INTO A BUSY ORAL SURGERY PRACTICE within a multidisciplined practice. Present oral surgeon is retiring. Practice is private fee-for-service. New i-CAT (3D) in office. For information contact Paul Kennedy, DDS at pkennedy@gte.net or 361-9606484. ORAL SURGEON NEEDED. Oral surgeon will be busy for a full day or two with implant and bone grafts. Competitive pay. Flexible in scheduling. Please call 361-387-3442. ORTHODONTIST PT POSITION: Part time position for an orthodontist. Please submit your resume to jobs@capitalchildrensdentistry.com. PEDIATRIC PRACTICE FOR SALE: Very large private pediatric practice in large metropolitan area in Texas, mix of PPO and Medicaid in a beautiful, free-standing 5,000 sq ft building with 10 chairs. Highly profitable private practice established 30 years. Texas Practice Transitions, Inc. Rich Nicely has been serving Texas dentists since 1990. Visit www.tx-pt.com or call at 214-460-4468; Rich@ tx-pt.com. PRACTICE FOR SALE SOUTHWEST OF FORT WORTH in fast growing area. Average gross; 6 operatories; Excellent lease. Seller is relocating. Need to move quickly on this one. DFW 214-5039696. WATS 800-583-7765. PRACTICE OPPORTUNITY: We are a Texas-based family group dental practice serving patients of all
ages. With a busy workload and high traffic, our needs extend to General Dentists, Orthodontists, Pediatric Dentists, and Endodontists. Qualified, compassionate and motivated doctors interested in opportunities to provide high quality care in communities in Texas may contact us. Our offices provide: State of the art, high-tech facility; in-house digital X-rays; paperless charting; 3-D models; digital tracing and imaging. Work alongside in-house board certified Pediatric Dentists, Oral Surgeons, Endodontists and General Dentists, allowing one to provide the absolute best care possible to even the most challenging cases. To join our team, please forward your CV to tx.dentistrygroup@gmail.com. SAN ANTONIO NORTH WEST: Associate needed. Established general dental practice seeking quality oriented associate. New graduate and experienced dentists welcome. GPR, AEGD preferred. Please contact Dr Henry Chu at 210-684-8033 or versed0101@yahoo.com. SAN ANTONIO: A general practice (FFS/PPO) having gross receipts in mid 6 figures while practicing only 3.5 days per week with no marketing. This is an exceptional opportunity to profit from day one in a newly remodeled office equipped with 3 chairs for a fraction of the cost of a new start up. Tremendous potential to grow practice rapidly as current dentist refers out majority of endo, ortho, perio, pedo, and oral surgery cases. To learn more about this practice contact: Dr. Jeff Jones, 830-832-5522 / dr.jeff. jones@henryschein.com.
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ADVERTISING BRIEFS SLH DENTAL SALES (Sherri L. Henderson & Associates): Consulting and staging for your transition! Let us help you make a transition plan. We can analyze the market, review your current patient base, secure the staff, spruce up the office space, and much more. We specialize in practice transition consulting and can assist you in a plan to help you create all the right conditions to begin that step from retiring to starting up a new practice. Our team has decades of handson experience in the dental market place as practice owners, employees, and management advisors. ASSOCIATES, PARTNERS AND BUYERS AVAILABLE. Are you seeking an associate, partner, or buyer? SLH has qualified candidates ready in all parts of Texas looking for your specific practice profile. There are many graduates as well as very experienced dentists looking for the opportunity to transition into your already established practice. These dentists have great people skills, case presentation experience and can be a very valuable and reliable addition to your bottom line. Contact us. If you are unsure about the right timing or simply would like to talk about the opportunities, call us today for a complimentary consultation in person or by telephone. All contact with you is strictly confidential. Call on our experience to assist you in making that transition dream become a reality. Call 972-5621072 or email sherri@slhdentalsales.com, website slhdentalsales.com. SMALL TOWN COLORADO PRACTICE: Seven figures in collection in 2013. Excellent staff willing to stay, including in-house lab technician. Doctor
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willing to stay to introduce to patients or work. Hunting and fishing a short walk away. Great potential for growth. Over 3,500 active patients. 6 equipped operatories. Ideal for raising families. Contact: Kyle Francis, 719-459-1021, Kfrancis@ professionaltransition.com SUGAR LAND, CYPRESS, PEARLAND AND THE WOODLANDS: Full- and part-time positions available. Well established and rapidly growing practices that offer great financial opportunity. High income potential and future equity position. Email CV to Dr Mike Kesner, drkesner@ madeyasmile.com. TEXAS PRACTICE TRANSITIONS, INC. Rich Nicely has been serving Texas dentists since 1990. Visit www.tx-pt.com or call at 214-460-4468; Rich@ tx-pt.com. PEDIATRIC: Very large private pediatric practice in large metropolitan area in Texas, mix of PPO and Medicaid in a beautiful, free standing 5,000 sq ft building with 10 chairs. Highly profitable private practice established 30 years. HUNTSVILLE: Medium sized full fee patient base; digital x-rays; free standing building; long term staff; 4 days of hygiene per week. ARLINGTON: Highly visible large sized practice and building on major road; 6 equipped treatment rooms; digital x-rays; 100% paperless; mix of PPO and DHMO patients. EAST TEXAS: Small full fee patient base. Great building with water views from each of the 4 treatment rooms. VICTORIA: Medium sized practice; PPO patient base; free standing building, long term staff; doctor refers out lots of dentistry. MIDLAND: Large sized practice; full fee
ADVERTISING BRIEFS patient base; digital x-rays; modern free standing building; long term staff. EL PASO: East side; large practice; full fee patient base. EL PASO: West side; medium sized practice; mostly PPO patient base. OKLAHOMA: 1 hour outside OKC; Large full fee office, 5 treatment rooms, fantastic building; urgent sale situation. WACO: Great associate opportunity. Waco practice looking for motivated associate with a desire to join a PPO/fee-for-service practice. Great pay, great work environment with two other dentists and top notch staff. Please contact Dr Johnson at 435-237-2339 or email at johnson.2978@gmail. com.
our only business. We confidentially deal with all clients. Lewis Health Profession offers seller representation, buyer representation, opportunity assessments, associate placement and strategic planning services. Please check out our web site at www.lewishealth.com for current opportunities. For additional information, contact Dan Lewis at Lewis Health Profession Services 972-437-1180 or dan@lewishealth.com. SEGUIN: Orthodontic office space for lease in. Office was phased down when orthodontist retired. Office is equipped and functional. Great for a start up or a satellite location. Email inquiries to lmassadds@gmail.com.
OFFICE SPACE
FOR SALE
DALLAS AND ROCKWALL: Orthodontic or other specialty office for lease to share with owner. Furnished and equipped. Dallas office is 4,000 sq ft in Lake Highlands area with 2,500 sq ft leasable residence above. Rockwall office is 1,800 sq ft in antique building and furnishings. Email rcppc@ sbcglobal.net.
EQUIPMENT FOR SALE: New handheld portable X-ray unit. New intraoral wall X-ray unit, new mobile X-ray on wheels. New chairs/units operatory packages, new implant motors. Everything is brand new, with warranty. Contact nycfreed@aol.com.
NORTH TEXAS DENTAL PRACTICE OPPORTUNITIES: Lewis Health Profession Services has multiple career opportunities available in the greater Dallas/Fort Worth area. Practices for sale, associate opportunities, finished out dental offices, and specialty practice opportunities. Lewis Health Profession Services has 30 years experience in dental practice transitions, with over 1,000 successful transitions completed. Dentistry is
IMTEC IMPLANT SYSTEM. $600, 24 implants, torque wrenches, surgical items and adapters, sterilization kit, instruction disk. Never used. Integral implants. $200, 11 coated implants and surgical drills, placement and retrieval instruments. $500 (regularly $1,500), 4 Misch basic setup physics forceps. Contact Dr. James Grogan, 469585-9622, docharleyday@sbcglobal.net.
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ADVERTISING BRIEFS INTERIM SERVICES HAVE MIRROR AND EXPLORER, WILL TRAVEL: Sick leave, maternity leave, deployment, vacation or death, I will cover your office. Call Robert Zoch, DDS, MAGD at 512-263-0510 or drzoch@yahoo. com.
MISCELLANEOUS EXTRACTION/ORTHODONTIC CE, SEPTEMBER 26-27, MINNEAPOLIS: 18 Total CE Hours. Dr DePaul will teach PowerProx Six Month Braces; Dr Fletcher and Murph will teach Extractions using Pig Jaws. Dr McCall will teach Immediate Dentures Tuition: $2294 for both ($1299 extraction only) ($1195 ortho only) sixmonthbraces@hotmail.com drtommymurph@yahoo.com IV SEDATION TRAINING FOR DENTISTS. This “mini-residency” includes 60 hours of didactic and the administration of IV sedation to at least 20 dental patients while supervised. Program meets requirements to obtain TSBDE Permt Level III for Moderate Sedation. Houston, TX Sept. 2014 888581-4448 www.SedationConsulting.com LOOKING TO HIRE A TRAINED DENTAL ASSISTANT? We have dental assistants graduating every 3 months in Dallas and Houston. To hire or to host a 32-hour externship, please call the National School of Dental Assisting at 800-383-3408; Web: schoolofdentalassisting-northdallas.com.
PLACE A CLASSIFIED AD IN THE
TEXAS DENTAL JOURNAL It’s a member benefit! Reach more than 9,000 of your dental colleagues. COST
PRINT: $40 fo rthe first 30 words. 10 cents per word after that. ONLINE: $10 a month (no word limit). $60 one-time additional fee to post online immediately.
CONTACT
For more information, please visit tda.org or contact Billy Callis at 512-443-3675 ext 150 or by email: bcallis@tda.org.
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If you or a dental colleague are experiencing impairment
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