February 2011

Page 1

Februaryy 2011

Journal TEXAS DENTAL

Clinical Decision Making:

Fitting Evidence Into the Picture Dental School Knowledge

Clinical Experience Study Club Information

Marketing Information

Patients

Professional Guidelines

Local Opinion Leaders

Recent Lawsuits

Continuing Education

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Texas Dental Journal l www.tda.org l February 22011

Texas Dental Association 140th Annual Session 2010 TEXAS Meeting Photo Contest Award: Best of Show Photographer: Dr. Roy Tiemeyer Title: “Skimmers” For information on entering your photo in the 2011 TEXAS Meeting Photo Contest, please visit texasmeeting.com.

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Texas Dental Journal l www.tda.org l August 2010

Contents &RQWHQWV TEXAS DENTAL JOURNAL Q Established February 1883 Q Vol. 128, Number 2, February 2011 7(;$6 '(17$/ -2851$/ Q (VWDEOLVKHG )HEUXDU\ Q 9RO 1XPEHU )HEUXDU\

21 7+( &29(5 ON THE COVER (YLGHQFH %DVHG 'HQWLVWU\ Evidence-Based Dentistry

(YLGHQFH EDVHG GHQWLVWU\ FRPELQHV D GHQWLVWҋV WUHDWPHQW GHFLVLRQV ZLWK KLV RU KHU FOLQLFDO H[SHUWLVH DQG Evidence-based dentistry combines a dentist’s treatment decisions with his or her H[SHULHQFH DYDLODEOH UHVHDUFK DQG WKH SDWLHQWҋV QHHGV 7KH VNLOO LV D OLIHORQJ OHDUQLQJ SURFHVV HYHU clinical expertise and experience, available research, and the patient’s needs. The FKDQJLQJ DQG GHSHQGHQW RQ WKH GHQWLVWҋV VHDUFK IRU PRUH NQRZOHGJH DQG HYLGHQFH &RYHU FRQFHSW E\ skill is a lifelong learning process, ever-changing, and dependent on the dentist’s 'U -RKQ ' 5XJK D SURIHVVRU LQ WKH 'HSDUWPHQW RI 'HYHORSPHQWDO 'HQWLVWU\ DQG 'LUHFWRU RI WKH (YLGHQFH search for more knowledge and evidence. Cover concept by Dr. John D. Rugh, a %DVHG 3UDFWLFH 3URJUDP DW WKH 8QLYHUVLW\ RI 7H[DV +HDOWK 6FLHQFH &HQWHU DW 6DQ $QWRQLR 'HQWDO 6FKRRO

professor in the Department of Developmental Dentistry and Director of the Evidence Based Practice Program at the University of Texas Health Science Center at $57,&/(6 ³ (9,'(1&( %$6(' '(17,675< San Antonio Dental School in San Antonio, Texas. 3ULQFLSOHV RI (YLGHQFH %DVHG 'HQWDO 3UDFWLFH (%'3

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Hoda Abdellatif, B.D.S., Dr. PH.; Paul C. Dechow, Ph.D.; Daniel L. Jones, D.D.S., Ph.D. 6 7KRPDV 'HDKO ,, ' 0 ' 3K ' 7KH DXWKRU H[SODLQV KRZ WKH 1DWLRQDO /LEUDU\ RI 0HGLFLQHÒ‹V 3XE0HG GDWDEDVH FDQ SRZHUIXOO\ write up to come DVVLVW GHQWLVWV LQ HYLGHQFH EDVHG SUDFWLFH

Three PubMed Skills to Support Evidence-Based Dentistry

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Richard D. Bebermeyer, D.D.S., M.B.A.

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-RKQ ' 5XJK 3K ' :LOOLDP ' +HQGULFVRQ 0 $ 0 6 %LUJLW - *ODVV ' ' 6 0 6 Teaching Evidence-Based Practice at the University of Texas Health -RKQ 3 +DWFK 3K ' 6 7KRPDV 'HDKO ' 0 ' 3K ' *DU\ *XHVW ' ' 6 5LFKDUG 2QJNLNR Science Center at San Antonio Dental School .HYLQ *XUHFNLV ' 0 ' $UFKLH $ -RQHV ' ' 6 :LOOLDP ) 5RVH ' ' 6 John D. Rugh, PH.D.; William D. Hendricson, M.A., M.S.; Birgit J. Glass, D.D.S., M.S.; John P. 3HWHU *DNXQJD ' ' 6 0 6 3K ' 'HEUD 6WDUN ' 3 + %MRUQ 6WHIIHQVHQ ' ' 6 0 6 3K ' Hatch, PH.D.; Thomas S. Deahl, D.M.D., PH.D.; Gary Guest, D.D.S.; Richard Ongkiko; :LWK WKH DLG RI D \HDU JUDQW 87+6&6$ LV LPSOHPHQWLQJ DQG HYDOXDWLQJ D ´MXVW LQ WLPH OHDUQLQJµ Kevin Gureckis, D.M.D.; Archie A. Jones, D.D.S.; William F. Rose, D.D.S.; HYLGHQFH EDVHG SUDFWLFH PRGHO

Peter Gakunga, D.D.S., M.S., PH.D.; Debra Stark, D.P.H.; Bjorn Steffensen, D.D.S., M.S., PH.D.

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MONTHLY FEATURES

148 149 152 206 213 214 217

BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION

President’s Message 2IÀFLDO &DOO WR 'HOHJDWHV The View From Austin TDA 140th Annual Session 2010 TEXAS Meeting Photo Contest Oral and Maxillofacial Pathology Case of the Month TEXAS Meeting Preview Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management

218 220

Value for Your Profession In Memoriam / TDA Smiles Foundation Memorial & Honorarium Donors

221 224 240

Calendar of Events Advertising Briefs Index to Advertisers EDITORIAL STAFF

Texas Dental Journal (ISSN 0040-4284) is published monthly, one issue will be a directory issue, by the Stephen R. Matteson, D.D.S., Editor Texas Dental Association, 1946 S. IH-35, Austin, Texas, 78704-3698, (512) 443-3675. Periodicals Nicole Scott, Managing Editor Postage Paid at Austin, Texas and at additional mailBarbara S. Donovan, Art Director LQJ RIÀFHV 32670$67(5 6HQG DGGUHVV FKDQJHV Paul H. Schlesinger, Consultant to TEXAS DENTAL JOURNAL, 1946 S. Interregional Highway, Austin, TX 78704. EDITORIAL Annual subscriptions: Texas Dental Association PHPEHUV ,Q VWDWH $'$ $IÀOLDWHG WD[ ADVISORY BOARD 2XW RI VWDWH $'$ $IÀOLDWHG ,Q VWDWH 1RQ Ronald C. Auvenshine, D.D.S., Ph.D. $'$ $IÀOLDWHG WD[ 2XW RI VWDWH 1RQ $'$ $IÀOLDWHG 6LQJOH LVVXH SULFH $'$ $IÀOLBarry K. Bartee, D.D.S., M.D. DWHG 1RQ $'$ $IÀOLDWHG 6HSWHPEHU LVVXH Patricia L. Blanton, D.D.S., Ph.D. $'$ $IÀOLDWHG 1RQ $'$ $IÀOLDWHG )RU LQ VWDWH William C. Bone, D.D.S. orders, add 8.25% sales tax. Phillip M. Campbell, D.D.S., M.S.D. Contributions: Manuscripts and news items of interest to the membership of the society are solicited. The Tommy W. Gage, D.D.S., Ph.D. Editor prefers electronic submissions although paper Arthur H. Jeske, D.M.D., Ph.D. manuscripts are acceptable. Manuscripts should be Larry D. Jones, D.D.S. typewritten, double spaced, and the original copy Paul A. Kennedy, Jr., D.D.S., M.S. should be submitted. For more information, please refer to the Instructions for Contributors statement Scott R. Makins, D.D.S. printed in the September Annual Membership DirecRobert V. Walker, D.D.S. tory or on the TDA website: www.tda.org. All statements of opinion and of supposed facts are published William F. Wathen, D.M.D. on authority of the writer under whose name they Robert C. White, D.D.S. appear and are not to be regarded as the views of the Leighton A. Wier, D.D.S. Texas Dental Association, unless such statements Douglas B. Willingham, D.D.S. have been adopted by the Association. Articles are accepted with the understanding that they have not The Texas Dental Journal is a been published previously. Authors must disclose any ÀQDQFLDO RU RWKHU LQWHUHVWV WKH\ PD\ KDYH LQ SURGXFWV peer-reviewed publication. or services described in their articles. Advertisements: Publication of advertisements Texas Dental Association in this journal does not constitute a guarantee or 1946 South IH-35, Suite 400 endorsement by the Association of the quality of Austin, TX 78704-3698 value of such product or of the claims made of it by Phone: (512) 443-3675 its manufacturer. FAX: (512) 443-3031 E-Mail: tda@tda.org Texas Dental Journal is a member of the aa Website: www.tda.org American Association of Dental Editors.

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PRESIDENT Ronald L. Rhea, D.D.S. (713) 467-3458, rrhea@tda.org PRESIDENT-ELECT J. Preston Coleman, D.D.S. (210) 656-3301, drjpc@sbcglobal.net IMMEDIATE PAST PRESIDENT Matthew B. Roberts, D.D.S. (936) 544-3790, crockettdental@gmail.com VICE PRESIDENT, SOUTHEAST R. Lee Clitheroe, D.D.S. (281) 265-9393, rlcdds@windstream.net VICE PRESIDENT, SOUTHWEST John W. Baucum III, D.D.S. (361) 855-3900, jbaucum3@msn.com VICE PRESIDENT, NORTHWEST Kathleen M. Nichols, D.D.S. (806) 698-6684, toothmom@kathleennicholsdds.com VICE PRESIDENT, NORTHEAST Donna G. Miller, D.D.S. (254) 772-3632, dmiller.2thdoc@grandecom.net SENIOR DIRECTOR, SOUTHEAST Karen E. Frazer, D.D.S. (512) 442-2295, drkefrazer@att.net SENIOR DIRECTOR, SOUTHWEST Lisa B. Masters, D.D.S. (210) 349-4424, mastersdds@mdgteam.com SENIOR DIRECTOR, NORTHWEST Robert E. Wiggins, D.D.S. (325) 677-1041, robwigg@suddenlink.net SENIOR DIRECTOR, NORTHEAST Larry D. Herwig, D.D.S. (214) 361-1845, ldherwig@sbcglobal.net DIRECTOR, SOUTHEAST Rita M. Cammarata, D.D.S. (713) 666-7884, rmcdds@sbcglobal.net DIRECTOR, SOUTHWEST T. Beth Vance, D.D.S. (956) 968-9762, tbeth55@yahoo.com DIRECTOR, NORTHWEST Michael J. Goulding, D.D.S. (817) 737-3536, mjgdds@sbcglobal.net DIRECTOR, NORTHEAST Arthur C. Morchat, D.D.S. (903) 983-1919, amorchat@suddenlink.net SECRETARY-TREASURER Ron Collins, D.D.S. (281) 983-5677, roncollinsdds@hotmail.com SPEAKER OF THE HOUSE Glen D. Hall, D.D.S. (325) 698-7560, abdent78@sbcglobal.net PARLIAMENTARIAN Michael L. Stuart, D.D.S. (972) 226-6655, mstuartdds@sbcglobal.net EDITOR Stephen R. Matteson, D.D.S. (210) 277-8595, texdented@gmail.com EXECUTIVE DIRECTOR Ms. Mary Kay Linn (512) 443-3675, marykay@tda.org LEGAL COUNSEL Mr. William H. Bingham (512) 495-6000, bbingham@mcginnislaw.com

Texas Dental Journal l www.tda.org l February 2011

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entt plansâ€?â€? forr practice transitions g “treatme Creating 3 years‌ n 23 forr more than on Hindley III, A.S.A. L. Norto R Purchase/Sale off Practice ‡ Negotiations and Closing Documents ‡ Purchaserr Representation greements gers and Reformations ‡ Associate Buy-in and Partnership Ag Practice Merge d Origination off Loans Practice Valuations Leading to Mergerr and Acquisition ‡ Banking: Loan Packages and

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President’s Message Ronald L. Rhea, D.D.S., TDA President

Decision Points Decision Points, the autobiographical memoirs of President George W. Bush, was published by Crown Publishers in 2010. For those in leadership, regardless of your political persuasion, it is an enlightening read. President Bush states that his hope is “that this book will serve as a resource for anyone studying this period in American history,â€? and secondly “to give readers a perspective on decision making in a complex environment.â€? President Bush was forced to make decisions in the period following 9/11 that were far bigger than any decisions the rest of us will ever be required to make. He had to decide for instance, how to allow the intelligence community to seek out those terrorists already within our borders without the destruction of the civil liberties of the American people. He also had to make the decisions about entering into wars in Iraq and Afghanistan. While he got advice from all quarters, in the end, LW ZDV KH ZKR KDG WR Ă€QDOO\ GHFLGH (DFK RI WKHVH decisions has been re-examined many times.

While the decisions as president of the TDA are nothing in comparison to the decisions a president of our country must make, they are frequent and often affect many people. I am always pleased to have your input on these matters. As dentists, striving to serve our patients and to deliver to them the best of care that the art and science of dentistry has to offer, we all daily make decisions affecting the welfare of others. We are fortunate to have science backgrounds and to have the opportunity to “co-diagnoseâ€? with our patients. This special issue of the Texas Dental Journal is focused on Evidence Based Dentistry (EBD). In the decisions that we make in our practices, EBD is a valuable tool. While EBD will not account for the individual nuances that each of our patients EULQJV ZLWK WKHP LW ZLOO JLYH XV D VFLHQWLĂ€F IRXQdation upon which we, in conjunction with the SDWLHQW FDQ PDNH D Ă€QDO WUHDWPHQW GHFLVLRQ Articles in this issue will explain the principles of EBD, how it is being presented in Texas dental schools, and how we can incorporate EBD into RXU GDLO\ SUDFWLFHV IRU WKH EHQHĂ€W RI RXU SDWLHQWV Enjoy your Journal!

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2IĂ€FLDO &DOO WR WKH 7H[DV 'HQWDO $VVRFLDWLRQ +RXVH RI 'HOHJDWHV HOUSE OF DELEGATES: In accordance with Chapter IV, Section 70, paragraph A of the Texas Dental Association (TDA) %\ODZV WKLV LV WKH RIĂ€FLDO FDOO IRU WKH VW PHHWLQJ RI WKH 7H[DV 'HQWDO $VVRFLDWLRQ +RXVH RI 'HOHJDWHV 7KH RSHQLQJ VHVVLRQ of the House will convene at 8:00 a.m. on Thursday, May 5, 2011, in Ballroom B on the street level of the San Antonio Convention Center in San Antonio, Texas. The second meeting of the House will be at 8:30 a.m. on Saturday, May 7, 2011, in Ballroom B. The Sunday, May 8, 2011, meeting will be in the Marriott Rivercenter Hotel, starting at 8:30 a.m. REFERENCE COMMITTEE HEARINGS: Reference Committees will meet on Thursday, May 5, 2011, in the Convention &HQWHU SOHDVH VHH WKH RQ VLWH SURJUDP IRU VSHFLĂ€F URRP DVVLJQPHQWV 5HIHUHQFH &RPPLWWHH $ ZLOO VWDUW DW D P RU minutes after the adjournment of the House of Delegates, whichever is later. Reference Committee E will start at 12:00 noon. Reference Committee B will start at 1:00 p.m. Reference Committee C will start at 1:30 p.m. Reference Committee D will start at 2:00 p.m. The agendas for these meetings will be sent to the Delegates and Alternate Delegates prior to the meetings. REFERENCE COMMITTEE REPORTS: Reference Committee Reports will be e-mailed in PDF format to all participants and these reports may be downloaded from any location with Internet access. Printed reports will be available on Friday, May 6, DW D P RXWVLGH 5RRPV DQG WKH 7'$ &RQYHQWLRQ 2IĂ€FHV LQ ([KLELW +DOO & DQG PD\ EH GRZQORDGHG DW WKLV location. CANDIDATES FORUM: As a reminder, the TDA / ADA Candidates Forum will be held on Friday, May 6, 2011, from 2:00 p.m. WR S P LQ WKH &RQYHQWLRQ &HQWHU SOHDVH VHH WKH RQ VLWH SURJUDP IRU VSHFLĂ€F URRP DVVLJQPHQW DIVISIONAL CAUCUSES: Divisional Caucuses (Northwest, Northeast, Southwest, Southeast) will be held at 5:15 p.m. on )ULGD\ 0D\ SOHDVH VHH WKH RQ VLWH SURJUDP IRU VSHFLĂ€F URRP DVVLJQPHQWV DELEGATE BOOK: In accordance with TDA Bylaws, the Delegate Book will be sent 30 days prior to the Annual Session. The supplement to the Delegate Handbook, containing the agenda and subsequent reports, will be sent after the spring TDA Board of Directors meeting, April 1-2, 2011. Delegates and alternates will receive their House book in a searchable PDF format.

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The View From Austin Stephen R. Matteson, D.D.S., Editor

Evidence Based Dentistry “Doctor, look at this new restorative material my company is selling. It holds its color longer, seals the margins perfectly, is easy to handle. Research shows this is the best product on the market, and just for you, I can give you a great deal on the price.” Quite often, we hear these types of messages at our dental meetings and from salespersons about new products in dentistry. Being a skeptical bunch, we are leery of such tactics, but also want to adopt proven new technology in our practices; so who to believe? Experts at continuing education courses? Colleagues in our study clubs or dental societies? Mailings from commercial sources? Articles in journals? Online information sources? What was taught in dental school, our own experience in practice? The Texas Dental Journal requires authors to disclose DQ\ ÀQDQFLDO VXSSRUW IURP FRPSDQLHV WKDW DUH DVVRFLated with products in their manuscripts, as do most UHVSHFWHG VFLHQWLÀF MRXUQDOV 7KLV SURYLGHV WKH UHDGHU with information that they can use to assess the validity of statements in these articles. The TDA also requires similar disclosures from providers of courses at its annual meeting. I believe that cautious readers and course attendees take these disclosures seriously and use this information when deciding if new technologies or techniques should be adopted in their practices. It comes down to this: Should we make changes in our practices or not? Still, there remains the question of validity; and how do I, the practitioner, know that what I am reading or being told is the truth? Enter evidence-based dentistry, a.k.a. best practice. The American Dental Association GHÀQHV HYLGHQFH EDVHG GHQWLVWU\ DV

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“Evidence-based dentistry (EBD): An approach to oral health care that requires the judicious integration of V\VWHPDWLF DVVHVVPHQWV RI FOLQLFDOO\ UHOHYDQW VFLHQWLÀF evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences.” I think of it in two parts: :KDW GRHV WKH VFLHQWLÀF OLWHUDWXUH VD\ DERXW WKH validity of a particular material or technique? 2. Is the information important enough for me to make this change in my practice? This issue of the Texas Dental Journal is devoted to EBD and includes information on how to search for the evidence using PubMed, the Cochrane Collaboration, and the ADA website on this material. These sources SURYLGH DYHQXHV WR ÀQGLQJ HYLGHQFH RQ GHQWDO WRSLFV and providing the level of evidence. The ADA Council on Dental Accreditation (CODA) has recently updated its curriculum standard on this topic: “Standard 2-21: Graduates must be competent to access, critically appraise, apply, DQG FRPPXQLFDWH VFLHQWLÀF DQG OD\ OLWHUDture as it relates to providing evidencebased patient care. Intent: The education program should introduce students to the basic principles of clinical and translational research, including how such research is conducted, evaluated, applied, and explained to patients.”

In response to these standards, authors at Baylor College of Dentistry-Texas A&M Health Science Center, the University of Texas Dental Branch at Houston, and the University of Texas Health Science Center at San Antonio Dental School have kindly provided reports on their efforts to provide instruction on evidence based dentistry. The ADA has also sponsored a “Evidence-Based Dentistry Champions Conferenceâ€? in which dental practitioners from around the country attended training sessions with the intent that they would promote this subject in their dental communities. Dr. Josh Austin of San Antonio participated in this program and has kindly provided a report on his experience. In addition, the ADA has trained dentists to be reviewers of EBD articles submitted for publication in the Journal of the American Dental Association. Table 1 is a talley of ADA EBD champions and EBD reviewers in Texas (courtesy of Erica Vassilos, MPH, vassilose@ada.org, Manager, ADA Center for Evidence Based Dentistry, Division of Science.) It should also be noted that the scope of dental research is somewhat limited in that the number of meta-analysis and systematic reviews is low compared with that in medicine. The goal of EBD is to identify the best available HYLGHQFH RQ VSHFLĂ€F WRSLFV LQ RUGHU to provide practitioners with the latest available information. Clearly stating the level of evidence is a part of these efforts so dentists can weigh the value and importance of the information that is presented. For example, laboratory reports and individual case studies are of low value for clinical decision-making but can be important for the

Table 1. The EBD Champions from Texas, outlined by city, from DQG City

Number of EBD Champions

Colleyville, TX

1

Dallas, TX

2

Fort Worth, TX

1

Houston, TX

4

Pasadena, TX

1

San Antonio, TX

5

The ADA EBD Reviewers from Texas, outlined by city: City

Number of EBD Reviewers

Austin, TX

1

Converse, TX

1

Dallas, TX

1

Houston, TX

3

Plano, TX

1

San Antonio, TX

1

further development of research projects, while systematic reviews of the literature are of greater value to guide diagnosis and treatment planning. It is also important to understand that the research evidence at any point in time will only be what is available at that time, and that continuous monitoring of the literature will reveal new knowledge as it becomes available. )LQDOO\ RQH LPSRUWDQW SRLQW 3OHDVH QRWH WKDW WKH $'$ GHĂ€QLWLRQ RI (%' LQFOXGHV WKH VWDWHPHQW WKDW WKH Ă€QDO GHFLVLRQ RQ SDWLHQW FDUH LV GHSHQGHQW upon the “dentist’s clinical expertise and the patient’s treatment needs and preferences.â€? EBD provides input into such decisions and is not intended for use by third parties for reimbursement procedures, or is an attempt to direct dentists to make changes in practice procedures. The Editor is grateful to all contributors to this issue on EBD and hopes that the information contained will be of value to the readers. Reference: http://ebd.ada.org.

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Principles of Evidence-Based Dental Practice (EBDP) Hoda Abdellatif, B.D.S., M.P.H., Dr. PH., Paul C. Dechow, Ph.D., Daniel L. Jones, D.D.S., Ph.D.

Introduction To some the phrase “evidence-based dentistryâ€? appears odd insofar as the juxtapostioning of the words “evidence-basedâ€? and “dentistryâ€? implies that not all dental care is based upon evidence. Those bothered by the phrase include dental practitioners who believe that the training they’ve received in dental school was based upon current evidence and that that evidence ZLOO UHPDLQ VXIĂ€FLHQWO\ FXUUHQW WKURXJKRXW WKHLU SURfessional careers. Those bothered by the phrase also include dental patients who believe that their dental FDUH SURYLGHU E\ YLUWXH RI KLV FUHGHQWLDOV LQ WKH Ă€HOG of health care — well-recognized to be scholarly challenging — delivers the best possible care known to the Ă€HOG WRGD\

Abdellatif

Abstract In an effort to improve patient care, there has been a growing trend across the nation and the world to embed the principles of evidence-based dentistry into mainstream care delivery by private practicing dentists. Evidence-based dentistry is an essential tool that is used to improve the quality of care and to reduce the gap between what we know, what is possible, and what we do. An evidencebased health care practice is one that includes the decision PDNHUҋV DELOLW\ WR ÀQG DVVHVV and incorporate high-quality, valid information in diagnosis and treatment. The evidence is considered in conjunction with the clinician’s experience and judgment, and the patient’s preferences, values, and circumstances. This article introduces the basic skills of evidence-based dentistry. Their practice requires a discipline of lifelong learning in which recent and relevant VFLHQWLÀF HYLGHQFH DUH WUDQVlated into practical clinical applications.

Jones

Dr. Abdellatif is an assistant professor, Department of Public Health Sciences, Baylor College of Dentistry-Texas A&M Health Science Center (TAMHSC). Dr. Dechow is a professor and vice chair, Department of Biomedical Sciences, Baylor College of Dentistry-Texas A&M Health Science Center (TAMHSC). Dr. Jones is a professor and chair, Department of Public Health Sciences, Baylor College of DentistryTexas A&M Health Science Center (TAMHSC). Corresponding Author: Dr. Hoda Abdellatif, Department of Public Health Sciences, Baylor College of Dentistry, 3302 Gaston Avenue, Dallas, Texas 75246. Phone: (214) 828-8164; Fax: (214) 874-4555; E-mail:habdellatif@bcd.tamhsc.edu.

KEY WORDS: Evidencebased dentistry, evidencebased practice, hierarchy of evidence, steps in evidencebased dentistry. Tex Dent J 2011;128(2):155164.

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Principles of EBDP Unfortunately, dental care today is often not based upon the most current evidence, and the training requirements and infrastructure of modern dentistry has lacked mechanisms for assuring the incorporaWLRQ RI WKH ODWHVW VFLHQWLĂ€F Ă€QGLQJV )RU WKLV UHDVRQ WKH SKUDVH ´HYLdence-based dentistryâ€? is not simply a response to a lack of evidence in dental care, as the traditions and clinical experience of modern dentistry have led to a high level of care. Rather the phrase denotes a new methodology — based on a revolution in information infrastructure, clinical research design, and biostatistics — that enables all practiWLRQHUV IRU WKH Ă€UVW WLPH LQ KLVWRU\ WR KDYH UHDG\ DFFHVV WR ZHOO GRQH clinical studies and analyses, and to possess the intellectual tools to interpret this information for modern patient care. Evidence-Based Dental Practice (EBDP) is a thoughtful integration of the best available external evidence from systematic research, coupled with individual clinical expertise (1). As practitioners face healthcare questions and with the approach of EBDP, they are able to evaluate the relevance and quality of the evidence as it may apply to their speFLĂ€F SDWLHQW DQG FLUFXPVWDQFH (%'3 DOORZV WKH SUDFWLWLRQHU WR DVVHVV current and past research, clinical guidelines, and other information resources in order to identify relevant literature while differentiating EHWZHHQ KLJK TXDOLW\ DQG ORZ TXDOLW\ Ă€QGLQJV 7KRXJK WKLV SURFHVV was originally developed in cerWDLQ PHGLFDO Ă€HOGV LWV SULQciples apply to all health care arenas, including dentistry. The American Dental AssociaWLRQ GHĂ€QHV WKH WHUP ´HYLdence-based dentistryâ€? as “an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant VFLHQWLĂ€F HYLGHQFH UHODWLQJ WR the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences.â€? Simply stated, evidence-based dental practice is “the integration of the best research evidence with clinical expertise and patient valuesâ€? (Figure 1).

Figure 1

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EBDP Approach 7KH SUDFWLFH RI (YLGHQFH %DVHG 'HQWLVWU\ LQFOXGHV WKH IROORZLQJ ÀYH EDVLF VWHSV

Step 1:

Asking Converting the clinical question to an answerable question

Step 2:

Accessing Searching to identify pertinent clinical research studies, systematic reviews, guidelines, and other evidence-based resources to answer the question

Step 3:

Appraising Critically evaluating the evidence to assess its validity and relevance

Step 4:

Applying Making the decision based on sound evidence, professional expertise, and patient preferences

Step 5:

Assessing Evaluating the results and the process

%HIRUH SUHVHQWLQJ WKH ÀYH VWHS method for evidence-based practice, let’s ask: why is evidencebased practice important? Explosion of literature. Healthcare literature, with clinically DSSOLFDEOH ÀQGLQJV LV SXEOLVKHG at so great a rate that it is impossible for individual clinicians to keep up, especially across a EURDG ÀHOG RI KHDOWK FDUH According to Neiderman, dental clinicians would need to identify, obtain, read, and appraise more than one article per day, 365 days per year, for the rest of their professional lives in order to keep-to-date with just articles

addressing therapy. This is an impossible task (4). Unmet information needs. Practitioner information needs are not currently being met. For every three patients seen, two questions are generated. Due to lack of time and/or weak search skills, only 30 percent of physicians’ information needs were met during the patient visit, usually by another physician or other health professional (6). Implementation delay. ReVHDUFK ÀQGLQJV DUH RIWHQ GHOD\HG in being implemented into clinical practice. It has been reported

that the diffusion of new knowledge among health care workers is a slow process (7,8). According to Balas, it takes an average of 17 years for clinical research to be fully integrated into everyday practice (9). Despite the formidable advances in information technology, research design, and biostatistics that have enabled the revolution in evidence based practice, a sound method for EBDP is relatively simple and can be easily learned through practice and awareness, as can any other competency leading to effect modern clinical practice. What is this method? Texas Dental Journal l www.tda.org l February 2011

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Principles of EBDP

Step 1: Formulating the Question Where do the questions come from? Important clinical questions arise from daily encounters with patients in the practice setting. These questions often relate to therapy (e.g., which material is superior or what drug should be prescribed?), diagnosis (is this test accurate and reliable?), prognosis (what is this patient’s likely clinical course over time or what is the expected longevity of this restoration?), or causation (what is the etiology of this condition or is this treatment harmful?). 7R VHDUFK DQG Ă€QG WKH best available evidence, the clinician must ask a well-designed clinical question with all the components that will lead to the most relevant clinical research literature. A clear question will help one identify key words for use in a search of online databases. 7KH Ă€UVW VWHS LQ GRLQJ WKLV LV WR LGHQWLI\ the type of question: background or foreground. The type of question helps to determine the resources needed to answer the question. “Backgroundâ€? questions are usually asked because of a need for basic information or general knowledge about a disease or disease process. They are not asked because of a need to make a FOLQLFDO GHFLVLRQ DERXW D VSHFLĂ€F SDtient. “Foregroundâ€? questions are focused to REWDLQ VSHFLĂ€F NQRZOHGJH WR DVVLVW LQ clinical decisions or actions. A well-built focused clinical question includes the following four components (PICO) (10):

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‡ ‡ ‡ ‡

Patient’s disease or problem Intervention (exposure to treatment, risk factor, diagnostic test) Comparative intervention (if applicable — not always present) Outcome

The framework constructed through a “PICO� question provides the necessary components for asking an answerable online query. The following approach will help the framing of a good question: ‡

'HVFULEH WKH VXEMHFW RI WKH TXHVtion (P). It may be helpful to phrase the question in this form: “How would I describe a group of patients similar to this one?â€? ‡ 'HĂ€QH ZKLFK LQWHUYHQWLRQ , \RX DUH FRQVLGHULQJ IRU WKH VSHFLĂ€F SDtient or population; it could be an exposure to a disease, a diagnostic test, a prognostic factor, a treatment, or a risk factor. ‡ 'HĂ€QH FRPSDULVRQ & IRU WKH intervention. It may be appropriate to compare with no disease or treatment, but usually interventions for comparison will be a placebo, a different prognostic factor, different diagnostic method, or absence of a risk factor. In the case of treatment, the comparison is often to the “standard of care.â€? ‡ 'HĂ€QH WKH W\SH RI RXWFRPH 2 WR EH DVVHVVHG 2XWFRPHV PD\ FRQWDLQ VHYHUDO W\SHV $ TXHVWLRQ PD\ IRU H[DPSOH SHUWDLQ WR FKDQJHV LQ D VSHFLĂ€F V\PSWRP SURJQRVWLF LQGLFDWRU WKH RXWFRPH RI D GLDJQRVWLF WHVW RU D UHVSRQVH WR WKHUDS\ 2QH QHHGV WR VWDWH WKH RXWFRPH LQ D PHDVXUDEOH DQG FOLQLFDOO\ VLJQLĂ€FDQW ZD\ LQ RUGHU WR \LHOG PHDQLQJIXO UHVXOWV

Here is an example question that includes all four PICO components: “In patients with

undiagnosed oral lesions, can a toluidine blue mouth rinse, when compared to an oral biopsy, ef-

fectively detect oral cancer and/ or precancerous lesions?

What is the Patient’s disease/ problem?

Patients with oral lesions

What is the Intervention?

Toluidine mouth rinse

What is the Comparison intervention?

Oral biopsy

What is the Outcome?

Detect oral cancer

Applying the PICO method is a systematic way to identify important concepts in a clinical scenario, and formulate a question for online searching. However, often one does not have an intervention for comparison. Also, different types of EBDP resources require different levels RI VSHFLÀFLW\ VR GHSHQGLQJ RQ the types of available resources, one might not search with all the 3,&2 FRPSRQHQWV DW ÀUVW

Remember, no matter what resources are available, one should always start by applying a PICO question to the clinical scenario so that the search has the potential to lead to relevant FOLQLFDO UHVHDUFK ÀQGLQJV $Q DLG to formulating PICO questions is available at http://medinformatics. uthscsa.edu/EviDents/.

Remember that minutes spent properly formulating the question will save hours of time in searching. Once you have formed your PICO question, understanding the type of question (therapy, diagnosis, prognosis, or causation) is also important in your search for evidence.

Step 2: Database/Resource Searching Having successfully formulated the clinical question related to the patient’s probOHP LQ WKH DERYH VWHS RQH QRZ QHHGV WR ÀQG WKH UHOHYDQW HYLGHQFH IRU DQVZHULQJ the question. There are several types of information resources that can be consulted, and these generally are categorized as (i) general information (background) UHVRXUFHV LL ÀOWHUHG UHVRXUFHV DQG LLL XQÀOWHUHG UHVRXUFHV 7KH WKUHH W\SHV DUH consulted in that order depending upon the particular situation.

General Information (Background) Resources The clinical question may fall outside one’s specialty area or involve a situation which is rare for a provider. A comprehensive overview of the area may be necessary. In such a case, background resources (e.g., textbooks and other reference material) FDQ EH D ÀUVW VWHS 7KH\ FDQ RIWHQ DVVLVW ZLWK GHYHORSLQJ WKH foreground question (PICO). Background resources provide detailed information, but seldom include the most current research on the topic. They often will include references to clinical research literature, from which one can judge the currency of the information.

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Principles of EBDP For example: a patient presents with a cracked tooth. If you need to refresh your knowledge of the clinical presentation, diagnosis and treatment of a cracked tooth, a background resource would be the best place to start.

Filtered Resources A second step in seeking an answer to a clinical question is WR FRQVXOW VR FDOOHG ´Ă€OWHUHGÂľ resources to see if the question has recently been investigated by a clinical expert or subject specialist, and if the evidence has been systematically compiled and synthesized into recommendations or guidelines. It often can be the case that the question has already been addressed in an evidencebased manner through clinical studies and associated systematic reviews. Because the literature has been searched and results HYDOXDWHG Ă€OWHUHG UHVRXUFHV FDQ be very useful to a clinician, saving time and providing the assurance of skilled review. The caveat, however, is that, relative to the vast variety of possible clinical TXHVWLRQV WKH Ă€OWHUHG OLWHUDWXUH may only include a small fraction. The conclusions produced by these resources still need to be evaluated by the clinician for DSSURSULDWHQHVV WR WKH VSHFLĂ€F patient, but are very helpful and HIĂ€FLHQW ZKHQ DQ DSSURSULDWH UHsource exists. There are many evidence-based review resources that synthesize and critically appraise current healthcare literature such as the ADA EBD Database (ebd. ada.org), the Cochrane Collaboration of Systematic Reviews, the National Guideline Clearinghouse,

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the Database of Abstracts of Reviews of Effectiveness (DARE), and the Journal of Evidence-Based Dental Practice (11-16). The TRIP (Turning Research into Practice) GDWDEDVH LV DQRWKHU ÀOWHUHG UHsource that allows health profesVLRQDOV WR HDVLO\ ÀQG WKH KLJKHVW quality material available online to support evidence-based practice (17). It simultaneously searches evidence-based sources of systematic reviews, practice guidelines, and critically-appraised topics and articles. These resources provide a variety of information backed up with links to the literature that was used to formulate the clinical recommendations. Synthesized EBDP resources are easy to use and help quickly connect practitioners with evidence-based answers to their clinical questions.

to the clinician to evaluate each study found to determine its validity, relevance, and applicability to the patient. Effectively searching and evaluating the studies IRXQG LQ XQÀOWHUHG UHVRXUFHV takes more time and skill, which LV ZK\ ÀOWHUHG UHVRXUFHV DUH WKH ÀUVW FKRLFH IRU DQVZHULQJ FOLQLcal questions. PubMed is considered the database of choice for the health sciences, as it provides nearly complete access to primary and secondary literaWXUH 8QOLNH ÀOWHUHG UHVRXUFHV literature searches performed in PubMed and other databases such as Ovid Medline and CIN+$/ SURYLGH D ÀUVWKDQG ORRN DW clinical research.

Making Search Decisions ‡

By using these EBDP resources, clinicians can make evidencebased decisions about patient FDUH LQ D IRFXVHG DQG WLPH HIĂ€cient manner.

8QĂ€OWHUHG 5HVRXUFHV Evidence is often not available via Ă€OWHUHG UHVRXUFHV ,I RQH GRHVQ¡W Ă€QG DQ DSSURSULDWH DQVZHU LQ Ă€OWHUHG UHVRXUFHV D VHDUFK RI XQĂ€OWHUHG UHVRXUFHV WKH SULPDU\ OLWerature) is needed to answer the FOLQLFDO TXHVWLRQ (YHQ LI WKH Ă€Otered resources address the quesWLRQ WKH Ă€QGLQJV PD\ EH GDWHG and new research may be available that addresses the question. ,Q VXFK D VLWXDWLRQ XQĂ€OWHUHG resources need to be consulted. These resources provide the most recent information, but it is up

‡

‡

:RXOG EDFNJURXQG LQIRUPDtion on your topic answer your question? For example, are you looking for presentation information, a list of differential diagnoses, or types of therapies? Try a recent background resource, such as a text book, a reference handbook, or a reliable professional internet resource. $UH \RX WU\LQJ WR GHFLGH RQ the best course of action (for diagnosis, treatment/prevention, prognosis, or etiology/ harm) and want to incorporate recent, valid evidence into your decision? Consult a ÀOWHUHG UHVRXUFH :HUH \RX XQDEOH WR ÀQG DQ answer to your question in a ÀOWHUHG UHVRXUFH RU GR \RX want to continue your inquiry by checking the primary clinical research literature? 7U\ DQ XQÀOWHUHG UHVRXUFH

Step 3: Critical Appraisal /RFDWLQJ DQG LQWHUSUHWLQJ WKH VFLHQWLÀF HYLGHQFH FDQ EH D FKDOlenging task. However, simply treating one’s patient in the same manner as 10 or 20 years ago may be inadequate or in the worst case, may be malpractice. After identifying an article or resource that seems appropriate to your question (step 2), you must critically appraise the information. If the study is from a primary source — one that provides original data on a topic with no commentary — you should do a “validity” (closeness-to-truth) check. There are three basic questions used to guide the critical analysis process (1): 1. Are the results of the study valid? 2. What are the results? 3. Are the results applicable to my patient?

Effectively searching and evaluating the studies found in unfiltered re-

6WXG\ YDOLGLW\ ³ WKH ÀUVW LVVXH IRFXVHV \RXU DQDO\VLV RQ WKH research design, methods, and manner in which the study was executed. A study without valid design, methods, or manner of execution yields little information, and the associated research article may be of little value. However, interpretation of clinical research is often highly technical so study groups or seeking expertise from clinical research experts may be needed in order to adequately evaluate a primary clinical research article. After concluding that a study described in an article is valid, then the second issue simply relates to understanding whether the results from the study are important, and whether they can be used in a way cliniFDOO\ IRU SRWHQWLDO EHQHÀW RU WR SUHYHQW KDUP

sources takes more time and skill, which is why filtered resources are the first choice for answering clinical questions. PubMed is considered the database of choice for the health sciences, as it provides nearly complete access to primary and secondary literature.

$IWHU DSSUDLVLQJ WKH YDOLGLW\ DQG WKH VSHFLÀFLW\ DQG LPSRUWDQFH RI WKH results, one needs to take into consideration the patient’s needs and preferences as well as evaluating the patient’s circumstances. Fortunately, a number of different appraisal tools are available on the internet for download and use. Several evidence-based groups provide critical appraisal checklists of these questions (18, 19). One of these groups is CASP, the Critical Appraisal Skills Programme, which has developed tools to help with the critical appraisal of research articles related to diagnosis, therapy, harm, and prognosis. The Evidence Pyramid provides an excellent short graphic review of which types of research articles, if done well, provide the greatest evidence. As you move up the pyramid the amount of available literature decreases, but increases in relevancy to the clinical setting (Figure 2). When evaluating the evidence, you need to keep in mind the “quality” of the individual studies and the “consistency” of evidence across all the studies being evaluated. The “quantity” of studies can be another

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Principles of EBDP factor to be consider but is of a lesser weight in the determining the evidence — in clinical research, the best research (well designed, controlled, and with adequate sample sizes or power) greatly exceeds in importance large numbers of lesser studies, RU WKH ÀUVW LQYHVWLJDWLRQV RI D question.

Figure 2

Once the review of the evidence is completed and the validity and relevance of the study determined, you need to communicate DQG GLVFXVV WKH ÀQGLQJV ZLWK your patient and decide how the HYLGHQFH VFLHQWLÀF LQIRUPDWLRQ apply to your question (step 4).

Step 4: Applying the Evidence To reach your conclusion regarding the applicability of the evidence, you may consult questions related to diagnosis, therapy, harm, and prognosis. Keep in mind that you must interpret the information based on the research methodology and evaluation criteria described, on your skill and experience, and on patient needs/preferences. Your professional expertise becomes SDUWLFXODUO\ LPSRUWDQW ZKHQ WKH VFLHQWLÀF HYLGHQFH LV ZHDN (few systematic reviews or rigorous primary clinical reVHDUFK VWXGLHV RQ D VSHFLÀF WRSLF ,I WKH SUDFWLWLRQHU ODFNV professional expertise and/or the evidence is weak, other professional expertise is sought, such as reliance upon peer specialists. The patient’s needs and preferences are WKH WKLUG DQG ÀQDO HVVHQWLDO FRPSRQHQWV RI (%'3 EHFDXVH EBDP is patient-centered care and includes respect for patient autonomy. The most a practitioner can do is to give advice on optimal care and then let patients make their own health care decisions.

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Step 5: Re-evaluating the Evidence In the process of executing EBDP, you have developed a clinical question (step 1), sought out answers to verify and support your clinical decision (steps 2 and 3), DQG XOWLPDWHO\ DSSOLHG WKH ÀQGLQJV WR \RXU SDWLHQW VWHS The last step in this process is to evaluate the effectiveness and HIÀFDF\ RI \RXU GHFLVLRQ LQ GLUHFW UHODWLRQ WR \RXU SDWLHQW You may ask questions such as: ‡ ‡ ‡

:DV WKH GLDJQRVLV DQG WUHDWPHQW VXFFHVVIXO" ,V WKHUH QHZ LQIRUPDWLRQ GDWD LQ WKH OLWHUDWXUH" +RZ FDQ , LPSURYH DQG RU XSGDWH P\ FOLQLFDO GHFLVLRQV"

Remember that all of these questions require thoughtful action and keeping up-to-date with the current literature.

Conclusion The above discussion may seem to many as very prescriptive — a sequence of steps to be followed that will lead to an answer. “Where is the art of health care?â€? one may ask. “By following this sequence, what’s to distinguish my delivery of dental care from another who follows the same steps?â€? The response to this critique involves recognizing that while the sequence is quite logical, it is subject to VSHFLĂ€F LQWHUSUHWDWLRQ DQG HYDOXDWLRQ DW HDFK VWHS For example, a slightly different PICO question may lead to a different published evidence, and ultimately to a different decision regarding a presenting patient. 7KH VSHFLĂ€F IRUPXODWHG TXHVWLRQ WKH VSHFLĂ€F GDWDEDVH UHVRXUFH VHDUFKHG WKH VSHFLĂ€F DSSUDLVDO WKH VSHFLĂ€F DSSOLFDWLRQ DQG UH HYDOXDWLRQ RI WKH HYLGHQFH ZLOO DOO OHDG WR D GHFLVLRQ WKDW LV VSHFLĂ€FDOO\ \RXUV EXW WKDW LQFOXGHV WKH Ă€QGLQJV RI WKH latest and most relevant clinical research. The other comment that should be made in conclusion is that the set of skills of EBDP (i.e., the generic steps to be pursued to arrive at the best evidence) are really quite straightforward, and will easily become second-nature to those who purVXH PDVWHU\ RI WKLV FRPSHWHQF\ (YHQ LQ WKH PRUH GLIĂ€FXOW DUHDV RI WKH LQWHUSUHtation of primary clinical research literature, continued study can in short order lead to greatly increased understanding of the nuances of clinical research and its interpretation. Unfortunately for many providers, it is not a set of skills that is discoverable by one’s self, and it is one in which the newer dental graduates will be increasingly conversant as the skill set is now being added to the curriculum of dental schools. Learning EBDP requires explicit communication, presentation, and practice. Although there are many dental care providers today who are without EBDP skills, leading to practice that is not evidence-based, regular courses are now being offered by the ADA, and various other dental and medical professional organizations that will provide introductions to this skill set, and eventually greater competency throughout the various health care professions.

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Principles of EBDP References 1. Sackett DL, Strauss S, Richardson WS. Evidence-based Medicine: how to practice and tech EBM. New York: Churchill Livingstone; 2000. 2. The Centre for Evidencebased Medicine. Finding the best evidence. Available at: http://www.cebm.net/index.aspx?o=1023. Accessed October2nd, 2010. 3. Neiderman R, Badovinac R. Traditional dental care and evidence-based dental care. J dent res1999; 78: 128891. 4. Neiderman R, Chen L, Muurzyn L. Benchmarking the dental randomized controlled literature on Medline. Evid Based Med 2002; 3:59. 5. Alper BS, Hand JA, ElliotSG, Kinkade S, Hauan, MJ, Onion DK, Sklar BM. How much effort is needed to keep with the literature relevant for pimary care? Journal of the Medical Library Association 2004; 92(4): 429-37. 6. Covell DG, Uman GC, Manning PR. Information needs LQ RIĂ€FH SUDFWLFH DUH WKH\ being met? Annals of Internal Medicine 1985; 103(4): 596-99. 7. Rogers EM. Diffusion of Innovations. Fourth Edition, The Free Press, New York, 1995.

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8. Cain M. and Mittman R. Diffusion of Innovation in health care. Available from: URL: http://www.chcf.org/ publications/2002/05/ diffusion-of-innovation-inhealth-care 9. Balas A E. Information systems can prevent errors and improve quality. J A M I A 2001; 8(4): 398-99. 10. Richards D. Asking the right question right EvidenceBased Dentistry 2000; 2: 20 - 21 11. The American Dental Association. Center for EvidenceBased Dentistry. Available from: URL: http://ebd.ada. org. Accessed September 15th , 2010 12. The Cochrane Collaboration. Oral Health Review Group. Available from: URL: http:// www.cochrane.org/reviews/ en/topics/84_reviews.html. Accessed October 10th, 2010. 13. National Institute for Health Research. Centre for Reviews and Dissemination. Available from: URL: http:// www.crd.york.ac.uk/crdweb/. Accessed October 10th, 2010. 14. The Journal of Evidencebased Dental Practice. Elsevier. Available at: http:// journals.elsevierhealth.com/ periodicals/ymed. Accessed October 10th, 2010.

15. The national guideline clearing house. Available from: URL: http://www.guideline. gov . Accessed October 20th, 2010. 16. The Database of Abstracts of Reviews of Effectiveness (DARE). Available from: URL: http://www.crd.york. ac.uk/crdweb/ . Accessed October 20th, 2010. 17. Turning Research into Practice (TRIP) database. Available at: http://www.tripdatabase.com/. Accessed November, 11th, 2010. 18. The Centre for EvidenceBased Medicine. Critical appraised sheets. Available from: URL: http:// www.cebm.net/index. aspx?o=1157 . Accessed September 2010 19. CASP, Critical Appraisal Skill Programme. Appraisal Tools. Available from: URL: http://www.phru.nhs.uk/ Pages/PHD/CASP.htm . Accessed September, 2010.

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Three PubMed Skills to Support Evidence-Based Dentistry

Abstract

S. Thomas Deahl II, D.M.D., Ph.D.

Library of Medicine’s

The National PubMed database

Introduction

can powerfully assist dentists in

PubMed at http://www.ncbi.nlm.nih.gov/pubmed can powerfully assist the clinician seeking the best evidence. Peerreviewed journals contain the highest-quality evidence for decision-making in clinical practice, and PubMed indexes most of these journals and their contents. PubMed, a database of the U.S. National Library of Medicine, contains millions of citations of journal articles and other publications, many with abstracts, and is updated four times per week. PubMed is the electronic equivalent of the (now-discontinued) print publication Index Medicus, which clinicians may remember using during their university education.

evidence-based practice. Three useful PubMed skills can improve WKH HIÀFLHQF\ RI WKH clinician’s search: (1) Use of MeSH terms; (2) Use of Limits; (3) Use of Clinical Queries.

Over 800 dental journals, including the Texas Dental Journal, are indexed in PubMed, along with many medical and pharmacy journals which may contain articles relevant to dentistry. Over 5,000 journals are currently indexed in this database. PubMed’s principal component is Medline, which covers references in the biomedical literature back to 1947.

KEY WORDS:

Although the dentist has many search options today, including databases such as Google and Bing, PubMed covers principally peer-reviewed clinical DQG VFLHQWLÀF SXEOLFDWLRQV 2WKHU VHDUFK HQJLQHV PD\ UHWXUQ PDQ\ RWKHU ÀQGLQJV IURP OHVV UHOLDEOH VRXUFHV DV ZHOO LQFUHDVLQJ WKH YROXPH RI PDWHULDO WKH FOLQLFLDQ PXVW VFDQ 3XE0HG WKHUHIRUH RIIHUV WKH SRWHQWLDO EHQHÀW RI reducing the amount of extraneous information the clinician must scan.

Dentistry

PubMed Medical Subject, Headings, Evidence-Based

Tex Dent J 2011; 128(2):167-173.

Deahl II Dr. Deahl II is n adjunct associate professor, Department of Developmental Dentistry, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, and The Institute for Natural Resources, Concord, California. Contact Information: Department of Developmental Dentistry, UTHSCSA Dental School, 7703 Floyd Curl Drive, San Antonio, TX 78258. Telephone: (210) 567-3500. E-mail deahl@uthscsa.edu 7KH DXWKRU KDV QR SRWHQWLDO FRQà LFWV RI ÀQDQFLDO LQWHUHVW UHODWLRQVKLSV DQG RU DIÀOLDWLRQV UHOHYDQW WR WKH VXEMHFW PDWWHU RU materials discussed in the manuscript.

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Three PubMed Skills A full tour and explanation of PubMed is beyond the scope of a single article. Readers desiring a full tour may take the free-ofcharge tutorial, a full version of which takes at least 2 hours, at http://www.nlm.nih.gov/bsd/ disted/pubmedtutorial/ PubMed contains hyperlinks from citations to full-text journal articles whenever they are available. For many citations in PubMed, only the abstract is available. If the clinician desires to read the full-text article which is unavailable online, he or she should contact a biomedical

library to obtain an interlibrary loan of the document. PubMed could be used, in academic settings, for an extensive review of the literature on a particular topic. The evidence-based clinician, however, usually does not want an extensive literature review but instead wants to TXLFNO\ ÀQG WKH EHVW RQH WZR RU three citations on a topic, read their abstracts, and in some cases peruse the full-text article. The three skills discussed in this article support this goal.

Figure 1. Source: National Library of Medicine at http://www.ncbi.nlm.nih.gov

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The PubMed user faces two FKDOOHQJHV 7KH ÀUVW FKDOOHQJH is that the database contains too many citations to inspect individually. PubMed adds 2,000 to 4,000 references each day, and over 712,000 citations were added in 2009. Therefore, HIÀFLHQW VHDUFK VWUDWHJLHV DUH needed to narrow the list of citations to only a few which may be perused individually. The second challenge is that the narrowing process, if conducted by the user injudiciously or too aggressively could screen out some of the most pertinent citations.

A well-designed PubMed search on a clinical problem should yield only a handful of citations, but should contain the very best, most pertinent citations. This article discusses three methods to help the busy clinician more HIIHFWLYHO\ ÀQG WKH EHVW HYLGHQFH to support clinical practice. Readers should consult their biomedical library’s reference librarian (this may be done by telephone or email) for additional help in searching PubMed.

Evidence-Based Skill #1: Use Mesh terms Although PubMed users may simply enter any terms into the search box at the top of the home page (see Figure 1), the use of MeSH terms may improve the effectiveness of the search. MeSH (an acronym for MEdical Subject Headings) is the controlled vocabulary used by National Library of Medicine indexers. Indexers assign relevant MeSH terms to each citation as it is entered into PubMed. Some of the assigned terms, though very relevant to the central topics of the citation, may not appear in the article’s title nor in the abstract. PubMed users who employ MeSH terms while searching may occasionally retrieve highly relevant citations that they would not retrieve without using MeSH. The basic strategy is to search the MeSH database for the best MeSH terms, and then use the MeSH terms to search PubMed. A video tour of the MeSH database begins at http://www. nlm.nih.gov/bsd/viewlet/mesh/ searching/mesh1.html

Figure 2. Source: National Library of Medicine at http://www.ncbi.nlm.nih.gov

Figure 3. Source: National Library of Medicine at http://www.ncbi.nlm.nih.gov

Step 1: In the PubMed home page,click on “MeSH Database” (Figure 1, see circled hyperlink). Step 2: In the resulting screen, enter a desired term into the search box. Note in Figure 2 that we have entered “parotid tumors.” Step 3: Click on the “Go” button to the right of the search box. Step 4: Peruse the available term(s) on the subsequent screen. Note in Figure 3 that the MeSH term is “Parotid Neoplasms.” Check the term(s) desired, then click on the drop-down menu “Send to search box with “AND”” as shown in Figure 3.

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Three PubMed Skills Step 5: On the resulting screen, click on “Search PubMed” to search the PubMed database using the selected MeSH term(s), as shown in Figure 4. Step 6: Note the search results, as shown in Figure 5. Note in Figure 5 that we have retrieved over 6,400 citations, too many to review. Retrieving a large number of articles raises the need for the next skill covered here, which is using PubMed Limits.

Evidence-Based Skill #2: Using PubMed Limits “Limits” allows PubMed users WR ÀOWHU FLWDWLRQV E\ VWUHQJWK RI evidence, such as “systematic review” or “randomized controlled trial”. The “Limits” function is found on the PubMed search page (see Figure 5, hyperlink circled). Click on the “Limits” hy-

Figure 4. Source: National Library of Medicine at http://www.ncbi.nlm.nih.gov

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perlink and peruse the resulting screen (see Figure 6). Citations may be limited by Type of Article, Species, Language, or other criteria. Limits most useful for ÀQGLQJ KLJKHVW TXDOLW\ HYLGHQFH on questions about therapy and prevention include “MetaAnalysis” and “Randomized Controlled Trial” in the “Type of Article section, and “Systematic Review” in the “Subsets” section of the Limits page. Selecting a Limit (as we have done, circled, in Figure 6) and then clicking on the “Search” button returns

Figure 5. Source: National Library of Medicine at http://www.ncbi.nlm.nih.gov

Figure 6. Source: National Library of Medicine at http://www.ncbi.nlm.nih.gov

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Three PubMed Skills

Figure 7. Source: National Library of Medicine at http://www.ncbi.nlm.nih.gov

)LJXUH Source: National Library of Medicine at http://www.ncbi.nlm.nih.gov

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results as shown in Figure 7, a much more reasonable number of results to review. For a tutorial on using Limits, see http://www.nlm.nih.gov/ bsd/disted/pubmedtutorial/ 020_210.html.

Evidence-Based Skill #3: Using Clinical Queries “Clinical Queries” is a PubMed tool that helps the user to quickO\ ÀQG VWURQJHU HYLGHQFH SHUWDLQing to the topic of interest. This tool is found at http://www.ncbi. nlm.nih.gov/pubmed/clinical as circled in Figure 8. Clicking on the “Clinical Queries” link returns the screen shown in Figure 9. On this screen, enter the term of interest (as we have done with “Parotid neoplasms”, choose the Category (Therapy, as shown circled; Diagnosis is also available from a drop-down menu) and choose the scope (Broad or Narrow, as shown circled). Then click on the “Search” button.

)LJXUH Source: National Library of Medicine at http://www.ncbi.nlm.nih.gov

This returns the screen shown in Figure 10. Note that the left-hand column shows a list of citations from Clinical Studies; the middle column shows a list RI FLWDWLRQV FODVVLÀHG DV 6\VWHPatic Reviews; and the right-hand column shows a category less often relevant to dental practice, Medical Genetics.

)LJXUH Source: National Library of Medicine at http://www.ncbi.nlm.nih.gov

This brief introduction to the powerful PubMed is intended to encourage the evidence-based clinician to search for the latest, best information for clinical practice. An hour or two exploring other aspects of 3XE0HG ZLOO UHZDUG WKH FOLQLFLDQ ZLWK DGGLWLRQDO LQVLJKWV RQ ÀQGLQJ the best evidence quickly.

A tutorial on using Clinical Queries is found at http://www.nlm. nih.gov/bsd/disted/pubmedtutorial/020_570.html.

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TEXAS MEETING E TH

MAY 5-8, 2011 San Antonio, Texas

Registration & Housing For The Texas Meeting Register & Select Courses Today Book Hotel Reservations Now For The Best Selection

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Back By Popular Demand At The Texas Meeting CPR Classes Exhibit Hall Happy Hours Healthy Smiles Golf Classic Nitrous Oxide Review & Exam TDA Assistants Registration Course Texas Meeting Blood Drive

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141st ANNUAL SESSION OF THE TEXAS DENTAL ASSOCIATION

2011 SPEAKERS Dr. Linda Altenhoff Dr. Robert Anderton Ms. Nancy Andrews Mr. Thomas Angeloni Ms. Karen Baker Ms. Lois Banta Mr. Kirk Behrendt Ms. Judy Bendit Dr. Scott Benjamin Ms. Jen Blake Dr. Lee Ann Brady Ms. Rosemary Bray Dr. Lynne Brock Dr. Steve Buckley Dr. Alan Budenz Mr. Timothy Caruso Mr. Paul Cash Ms. Debbie Castagna Mr. Bruce Christopher Dr. James Coll Dr. Sarah Conroy Mr. Aquileo Cortes Ms. Karen Davis Dr. Robert Dew Dr. Gary DeWood Dr. M. Franklin Dolwick Dr. Wendell Edgin Dr. Robert Edwab Dr. Clarence Feller Dr. Paul Feuerstein Dr. James Fondriest Ms. Cynthia Fong Ms. Ellen Gambardella Dr. Mitchell Gardiner Dr. Henry Gremillion Ms. Susan Gunn Dr. Kelly Halligan Dr. Timothy Hempton Dr. Maria Howell Dr. Randy Huffines Mr. Sam Hughes Dr. Richard Hunt Dr. Peter Jacobsen Dr. Arthur Jeske Ms. Rita Johnson Ms. Sheri Kay Dr. Martha Ann Keels Dr. Mark Kleive Dr. James Kohner Dr. Doug Lambert Dr. Brian LeSage

Dr. Roger Levin Dr. Donald Lewis Dr. David Little Dr. Eduardo Lorenzana Dr. Kaneta Lott Dr. Denis Lynch Ms. JoAn Majors Mr. Orlando Martinez Dr. Joseph Massad Mr. Chris Maurer Dr. Thomas McDonald Dr. Thomas McGarry Dr. John Carl McManama Dr. Dale Miles Dr. John Molinari Ms. Virginia Moore Dr. Jaimee Morgan Dr. Anita Murcko Dr. Mark Murphy Dr. Dan Nathanson Dr. Stephen Niemczyk Dr. Linda Niessen Dr. David Ostreicher Dr. Ray Padilla Mr. Chris Page Dr. Edwin Parks Mr. Tim Pendergrass Dr. Stan Presley Dr. Steve Ratcliff Ms. Karen Cortell Reisman Mr. Matt Roberts Dr. Jose Luis Ruiz Mr. Randy Saunders Dr. Stephen Schmitt Dr. Richard Schwartz Ms. Laurie Semple Dr. Jeffrey Sherman Ms. Pam Smith Ms. Tina Stein Dr. William Steinhauer Dr. John Svirsky Dr. Keith Thornton Dr. Karen Troendle Dr. Michael Unthank Dr. William van Dyk Dr. Clark Whitmire Ms. Gail Williamson Dr. Robert Winter Dr. James Wood Dr. Benjamin Young

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Component Peer Review Committee and Judicial Committee 2010-2011 Training Dates

Friday, May 6, 2011 The TEXAS Meeting San Antonio, Texas

Please contact Cassidy Neal at 512-443-3675 ext. 152 for meeting details including meeting times and meeting rooms.

The Evidence-Based Dentistry Initiative at Baylor College of Dentistry Daniel L. Jones, D.D.S., Ph.D., Robert J. Hinton, Ph.D., Paul C. Dechow, Ph.D., Hoda Abdellatif, B.D.S., M.P.H., Dr. PH., Ann L. McCann, RDH, Ph.D., Emet D. Schneiderman, Ph.D., Rena D’Souza, D.D.S., Ph.D.

Introduction The NIH-NIDCR R25 Oral Health Research Education Grant initiative at the Texas A&M Health Science Center-Baylor College of Dentistry (BCD), designated “CUSPID”, is based on the theme that “Clinicians Using Science Produce Inspired Dentists”. CUSPID complements the recent advances

Jones

Hinton

Abdellatif

McCann

Schneiderman

D’Souza

Dr. Jones is a professor and chair, Department of Public Health Sciences, TAMHSC-Baylor College of Dentistry, Dallas, Texas. Dr. Hinton is a professor, Department of Biomedical Sciences, TAMHSC-Baylor College of Dentistry, Dallas, Texas. Dr. Dechow is a professor and vice chair, Department of Biomedical Sciences, TAMHSC-Baylor College of Dentistry, Dallas, Texas. Dr. Abdellatif is an assistant professor, Department of Public Health Sciences, TAMHSC-Baylor College of Dentistry, Dallas, Texas. Dr. McCann is an associate professor and Director of Assessment, TAMHSC-Baylor College of Dentistry, Dallas, Texas. Dr. Schneiderman is an associate professor, Department of Biomedical Sciences, TAMHSCBaylor College of Dentistry, Dallas, Texas. Dr. D’Souza is a professor and chair, Department of Biomedical Sciences, TAMHSC-Baylor College of Dentistry, Dallas, Texas. Send correspondence and reprint requests to: Dr. Daniel L. Jones, Department of Public Health Sciences, Baylor College of Dentistry, 3302 Gaston Avenue, Dallas, TX 75246; Phone: (214) 828-8350; Fax: (214) 874-4555; E-mail: djones@bcd.tamhsc.edu Supported by NIH-NIDCR grant DE018883 (to Dr. Robert J. Hinton and Dr. Daniel L. Jones).

Abstract This report describes the impact of an R25 Oral Health Research Education Grant awarded to the Texas A&M Health Science Center-Baylor College of Dentistry (BCD) to promote the application of basic and clinical research ÀQGLQJV WR FOLQLFDO WUDLQLQJ DQG encourage students to pursue careers in oral health research. At Baylor, the R25 grant supports a multi-pronged initiative that employs clinical research as a vehicle for acquainting both students and faculty with the tools of evidence-based dentistry (EBD). New coursework and experiences in all 4 years of the curriculum plus a variety of faculty development offerings are being used to achieve this goal. Progress RQ WKHVH IURQWV LV UHÁHFWHG LQ D nascent “EBD culture” characterized by increasing participation and buy-in by students and faculty. The production of a new generation of dental graduates equipped with the EBD skill set as well as a growing nucleus of faculty who can model the importance of evidence-based practice is of paramount importance for the future of dentistry.

KEY WORDS: evidence-based dentistry, curriculum, clinical research, faculty development Tex Dent J 2011; 128(2):177-180.

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EBD Initiative at Baylor at BCD in competencybased education and the development of a strong research infrastructure. These research advances LQFOXGH L D VLJQLÀFDQW increase in researchers supported by the NIDCR Research Infrastructure Enhancement Program (R24 and U24) awards to BCD; (ii) formal collaboration with the University of Texas-Southwestern Medical Center (UTSW) in Dallas; (iii) a comprehensive training program (T32 award) to develop dental student and faculty researchers for successful dental academic research careers. Collaboration with UTSW is a key part of the T32 grant, but also includes participation by BCD faculty and students in an NIH Roadmap K12 award for multidisciplinary training of Clinical Research Scholars, and a CTSA (Clinical and Translational Science Award — U54) to develop a strong infrastructure for clinical and translational sciences at UTSW and BCD.

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The basic goal of CUSPID is to incorporate critical thinking and formal instruction in evidence-based dentistry into a competencybased curriculum. The principal strategies are to (i) create a theme throughout the dental curriculum centered on the knowledge, SULQFLSOHV DQG VNLOOV RI VFLHQWLĂ€F LQTXLU\ QHFHVVDU\ IRU WKH GHQWLVW to critically evaluate new information and advances in treatment, and to participate in dental practice research networks; (ii) begin a Dental Scholars Program to provide selected dental students with additional training and experiences in clinical and translational research; and (iii) implement a faculty development program to IDFLOLWDWH DOO IDFXOW\ LQ WHDFKLQJ WKH VRXQG VFLHQWLĂ€F UDWLRQDOH IRU incorporation of new information and technologies into oral healthcare. We emphasize the evaluation and interpretation of clinical research as it relates to practice, and development of the skills needed to achieve its integration into clinical dentistry. For most GHQWDO VWXGHQWV WKLV VFLHQWLĂ€F EDVHG FRPSHWHQF\ KDV WKH FOHDUHVW applicability to future practice, where they will continue to exercise these skills as they seek out the newest advances.

Curricular Theme Development of courses/experiences in each year of the curriculum is central to the EBD initiative, and courses are introduced incrementally, 1 year at a time, laying the foundation in the D1 year and reinforcing this concept in subsequent years. We designed the EBD curriculum to become progressively more small group-driven, with clinical faculty taking an increasingly prominent role, and with EBD becoming integral to clinical instruction and practice. In Fall 2008, a D1 course titled Introduction to Evidence-Based Dentistry & Clinical Research made its debut. The year-long course, consisting of large group lectures/interactive sessions and small group discussions, has two primary aims: 1) to provide a foundation of knowledge necessary for the effective practice of EBD; 2) to begin to develop the practical skills needed for such practice. Foundational knowledge includes applied clinical epidemiology, biostatistics and some areas of modern dental and craniofacial research. The development of practical skills emphasizes how to evaluate clinical studies, how to formulate a focused clinical reVHDUFK TXHVWLRQ DQG KRZ WR VHDUFK WKH GHQWDO OLWHUDWXUH WR ÀQG DQG evaluate evidence to answer that question. The small group sessions consist of biweekly meetings of around 8-10 students with one or two faculty to discuss an assigned paper on a clinically-relevant topic, using a standardized article review format. In the D2 EBD course (Application of Evidence-Based Dentistry I), each student participates in small group sessions several times per semester to further practice analysis of clinical research articles. Each student

prepares a Critically Appraised Topic (CAT) report based on a clinical scenario written by BCD clinical faculty, and presents this report orally to the group and course faculty. An important feature of this course is the pairing of an EBD core faculty member with a clinical faculty member for each small group session. This approach has proven very successful in providing a clinical perspective on the evidence presented, especially in the CAT. We anticipate that extension of these experiences into the D3 and D4 years will feature an increasing integration of EBD into coursework and chairside interactions in clinical dentistry. The introduction of EBD into the D3 curriculum began in the fall of this year, and includes integration into the weekly case conferences students have with their group leaders and other students.

Faculty Development We have adopted a multipronged approach that offers faculty development experiences to accommodate different levels of interest and expertise. “Clinical Colloquium” In May 2009, a series of clinical updates on evidence-based topics of interest to clinical faculty was inaugurated. These seminars followed by Q&A sessions are intended to stimulate discussion among clinical faculty on subjects of wide clinical interest, with the hope of increasing familiarity with an evidence-based approach.

Expanded Scope of “Research Day” 7KH UHFRQÀJXUHG 5HVHDUFK DQG 6FKRODUVKLS 'D\ QRZ LQFOXGHV presentations by D2 students of the best of the Critically Appraised Topics (CATs), clinical case presentations by D3 and D4 students, and a keynote lecture on a clinical research topic. Summer EBD Fundamentals Course for Clinical Faculty For those clinical faculty with a previous research background or a desire to learn more about EBD, we have provided opportunities for more formal and intensive training. In recognition of the need for EBD ‘champions’ (clinical faculty who will carry the EBD effort into the D3-D4 years), core EBD faculty have created a course that meets twice weekly for 8-9 weeks. The course covers the basic tools of EBD (PICO, PubMed searching, fundamentals of statistics, research design, levels of evidence, Critically Appraised Topics). Funding for Off-campus EBD Workshops and Conferences The R25 grant provides funds to support attendance by faculty (and students) at EBD/ critical thinking-themed conferences and workshops.

The Dental Scholars Track The Dental Scholars track was created for a few select dental students who express interest and aptitude for a career in patient-oriented research and/or dental academics. Three entering D1 students from the FODVV RI ZHUH FKRVHQ DV WKH ÀUVW 'HQWDO 6FKRODUV $OO WKUHH SDUticipated in faculty-mentored research projects in Summer 2009. The students attended college seminars featuring speakers on developmental biology of the craniofacial region and craniofacial surgery, preceded by a journal-club discussion of one of the speaker’s articles. Activities in ensuing years will include elective courses in teaching and dental academia, attendance at clinical research workshops, participation in Texas Dental Journal l www.tda.org l February 2011

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EBD Initiative at Baylor an academic fellows program and teaching practicum and rotations in clinical research. Each dental scholar receives a 25 percent reduction in tuition for years D2-D4 and will be afforded special recognition as a graduate with honors in scholarship at the graduation ceremony.

Outcomes Student reviews of the D1 EBD course indicate an appreciation for the applicability of the skill set being taught as well as the small group sessions that encourage them to work in teams to review articles. The D2 EBD course, which is entirely small group-based, is regarded even more highly. Faculty development efforts have energized subsets of the clinical faculty. We are encouraged by the willingness of a core group, mostly comprised of restorative (D3) and general dentistry (D4) faculty, to acquire EBD tools via the summer course for clinical faculty. The attendance and informal feedback from faculty regarding our Clinical Colloquium speakers indicates the program is having the intended effect: knowledge transfer that also heightens appreciation for the importance of evidence in clinical decisionmaking. The aims of this grant, if achieved, will result in a graduating dentist who is better equipped to DQDO\]H DQG ÀOWHU WKH PDVVLYH DPRXQW RI LQIRUmation to which he/she will be subjected and to decide whether and/or how to incorporate this information into the treatment of patients. In addition, the training of dental school faculty in the principles and practices of EBD will enrich them professionally while enabling them to serve as role models for students. Finally, providing a clinical/translational research-based track may induce a small subset of DDS students to choose careers in academic dentistry and/or clinical research.

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Teaching Evidence-Based Abstract Practice at The University of This brief report outlines the curriculum for eviTexas Dental Branch at Houston current dence-based practice at The Richard D. Bebermeyer, D.D.S., M.B.A.

Introduction In 2002, the American Dental Association (ADA) deYHORSHG WKH IROORZLQJ GHĂ€QLWLRQ IRU WKH WHUP ´HYLGHQFH based dentistry,â€? or EBD: “an approach to oral health care that requires the judicious integration of sysWHPDWLF DVVHVVPHQWV RI FOLQLFDOO\ UHOHYDQW VFLHQWLĂ€F evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences (1).â€? More recently, in August of 2010, the ADA’s Commission on Dental Accreditation adopted new Accreditation Standards for Dental Education Programs (2). This change evolved over the past 3 years, with input from all constituents. Among the new standards is an emphasis on evidence-based practice. 0RUH VSHFLĂ€FDOO\ WKHUH LV D VWDWHPHQW WKDW ´JUDGXDWHV must be competent in the use of critical thinking and

University of Texas Dental Branch at Houston (UTDB). This curriculum is now based on the American Dental Association’s Commission on Dental Accreditation 2010 Accreditation Standards for Dental Education Programs. Evidence-based practice is introduced to students in the ÀUVW \HDU FXUULFXOXP 6WXGHQWV learn to be clinically effective through use of the components of evidence-based practice, information search and retrieval, critical thinking (appraisal), and through information resource evaluation and then application to the patient or population. Planned innovations in curriculum include further implementation of evidence-based decision-making in clinical courses, including development of the clinical prescription as a means of demonstrating competence in asking and answering clinical questions, and of the portfolio as a means of demonstrating overall competence.

KEY WORDS: evidenceBebermeyer Dr. Bebermeyer is professor and chairman, Department of Restorative Dentistry and Biomaterials; The University of Texas Dental Branch at Houston; Houston, Texas, 77030. Phone: (713) 500-4286; Fax: (713) 500-4108; E-mail: Richard.D.Bebermeyer@uth.tmc.edu Please address all reprint requests to: Richard D. Bebermeyer, D.D.S.

based practice (EBP); education, dental Tex Dent J 2011; 128(2):183185.

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Teaching EB Practice at UTDB problem-solving, including their use in the comprehensive care of patients, VFLHQWLÀF LQTXLU\ DQG UHVHDUFK PHWKRGRORJ\µ $OVR that “graduates much be competent to assess, critiFDOO\ DSSUDLVH DSSO\ DQG FRPPXQLFDWH VFLHQWLÀF DQG OD\ OLWHUDWXUH DV LW UHODWHV WR providing evidence-based SDWLHQW FDUHµ

Discussion $W WKH 8QLYHUVLW\ RI 7H[DV 'HQWDO %UDQFK DW +RXVWRQ 87'% ZH KDYH WUDGLWLRQDOO\ WDXJKW WKH relationship of science, and relevant research, to dental pracWLFH +RZHYHU PRUH UHFHQWO\ there has been increased emSKDVLV RQ ´FOLQLFDO HIIHFWLYHQHVVµ on the use of best evidence for GHFLVLRQ PDNLQJ LQ SUDFWLFH )RU H[DPSOH ZKDW EHJDQ LQ WKH 1990’s as the entering student’s LQWURGXFWLRQ WR WHFKQRORJ\ DW 87'% ³ IRU H[DPSOH FDOLEUDWing all students on e-mail or WKH XVH RI WKH OLEUDU\ UHVRXUFHV ³ KDV HYROYHG LQWR D FRXUVH HQWLWOHG ,QWURGXFWLRQ WR 'HQWDO ,QIRUPDWLFV 7KH FRXUVH GLUHFWRU GHÀQHV GHQWDO LQIRUPDWLFV DV ´WKH VFLHQWLÀF ÀHOG WKDW VWXGLHV and pursues the effective uses of dental data, information, and NQRZOHGJH IRU VFLHQWLÀF LQTXLU\ problem solving, and decision

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PDNLQJ PRWLYDWHG E\ HIIRUWV WR LPSURYH KXPDQ RUDO KHDOWKµ 7KLV FRXUVH WDXJKW GXULQJ WKH ÀUVW ZHHNV RI WKH GHQWDO VWXGHQWV· ÀUVW \HDU QRZ LV WDXJKW LQ a combination of formats including lecture, on-line learning modules and interactive casebased learning in the SimulaWLRQ &HQWHU 7RSLFV LQFOXGH GHÀQLQJ GHQWDO LQIRUPDWLFV DQG HYLGHQFH EDVHG SUDFWLFH GHFLVLRQ PDNLQJ LQ GHQWLVWU\ information search and retrieval; FULWLFDO WKLQNLQJ DQG LQIRUPDWLRQ UHVRXUFH HYDOXDWLRQ FULWLFDO DSSUDLVDO ( KHDOWK DQG FRQVXPHU LQIRUPDWLFV DQG WHFKQRORJ\ LQ GHQWDO SUDFWLFH 7KH IDFXOW\ PHPEHUV WHDFKLQJ this course include general dentists, a biomedical informatician, WKH $VVLVWDQW /LEUDU\ 'LUHFWRU D OLEUDULDQ D ELRPHGLFDO VFLHQWLVW SOXV VWDII IURP (GXFDWLRQ DQG 7HFKQRORJ\ 6HUYLFHV In preparation for using this NQRZOHGJH DQG VNLOO LQ VXEVHTXHQW FRXUVHV DQG FOLQLFV VWXdents are given simulated clinical FDVHV IRU ZKLFK WKH\ PXVW IRUP D VHDUFKDEOH FOLQLFDO TXHVWLRQ GHPRQVWUDWH DQ HIÀFLHQW FRPSXWHU VHDUFK RI GDWDEDVHV H J 3XE Med and Cochrane Oral Health 5HYLHZV WR ÀQG WKH EHVW HYLGHQFH GHÀQH WKH OHYHOV RU TXDOLW\ RI HYLGHQFH DQG GHVFULEH KRZ the evidence can be applied to FOLQLFDO SUDFWLFH RU KHDOWK SROLF\ In addition, the cases involve D TXHVWLRQ UHODWLQJ WR HWKLFV LQ GHQWDO SUDFWLFH

87'% FRQWLQXHV WR VHHN PHDQV to integrate these aspects of HYLGHQFH EDVHG GHQWLVWU\ (%' VXEVHTXHQW FRXUVHV DQG FOLQLFV :KHQ 87'% IDFXOW\ PHPEHUV ZHUH VXUYH\HG LQ UHJDUGLQJ XVH RI HYLGHQFH EDVHG GHQWLVWU\ in their courses, it became apparent that the levels of appliFDWLRQ YDU\ ZLGHO\ +RZHYHU GLUHFWRUV RI FRXUVHV VXFK DV 3HULRGRQWDO 7KHUDS\ /RFDO $QHVWKHsia and Biomaterials report that WKH\ URXWLQHO\ LQFOXGH (%' DV LW UHODWHV WR GHQWDO SUDFWLFH (%' is also used in some post-docWRUDO SURJUDPV PRVW FRPPRQO\ LQ WKH ´MRXUQDO FOXEVµ RU OLWHUDWXUH UHYLHZ FRXUVHV LQ ZKLFK UHVLGHQWV FULWLFDOO\ DSSUDLVH WKH VFLHQFH UHSRUWHG LQ WKH OLWHUDWXUH $ PRGHO IRU WKLV ZDV UHSRUWHG E\ *UDQW LQ LQ DQ DUWLFOH HQWLWOHG ´$Q (YLGHQFH %DVHG -RXUQDO &OXE IRU 'HQWDO 5HVLGHQWV LQ D *35 3URJUDPµ ,Q IDFW IRU critical appraisal of research and VFLHQWLÀF DUWLFOHV VRPH XVH WKH appraisal instruments or forms SURYLGHG E\ RUJDQL]DWLRQV VXFK DV WKH &ULWLFDO $SSUDLVDOV 6NLOOV 3URJUDPPH &$63 $QRWKHU PHDQV RI DSSO\LQJ (%' WR OHDUQLQJ LV ´OHDUQLQJ E\ SRUWIROLRµ $W 87'% WKH 6FKRRO RI 'HQWDO +\JLHQH KDV XVHG WKLV IRU \HDUV DQG WKH GHQWDO VWXGHQWV ZLOO OLNHO\ XVH WKH SRUWIROLR LQ WKH QHDU IXWXUH 7KH QHZ &2'$ VWDQGDUGV ZLOO UHTXLUH VFKRROV to assess overall competence of HDFK JUDGXDWH QRW MXVW FRPSHWHQFH LQ LQGLYLGXDO SURFHGXUHV 7KH SRUWIROLR FDQ DVVLVW LQ teaching and measuring overall FRPSHWHQFH (DFK VWXGHQW E\

composing a portfolio of cases, photographs, and materials progresses through the stages of gathering and processing new information, critiFDO UHà HFWLRQ LQWHUSUHWDWLRQ DQG DSSOLFDWLRQ 7KLV W\SH RI OHDUQLQJ LV relevant to each student’s work and life, and is most likely to retain the student’s interest in education. The student must decide on how to practice effectively and on how to proceed with life-long learning. With portfolio learning, the student must set learning goals, identify learning resources (books, online learning, web databases, continuing HGXFDWLRQ FRXUVHV HWF PRQLWRU DQG UHà HFW RQ KRZ ZHOO WKH OHDUQing is proceeding, list and document achievements, and use what s/ he has learned to plan into the future. It is notable that the portfolio can be used in documenting overall competence, and may well replace human subjects in clinical dental licensure examinations, as has been recently implemented in California.

Conclusion This brief report outlines the current curriculum for evidence-based dentistry at The University of Texas Dental Branch at Houston. This curriculum is based on the American Dental Association’s Commission on Dental Accreditation 2010 Accreditation Standards for Dental Education Programs. Evidence-based practice is introduced to stuGHQWV LQ WKH ÀUVW \HDU FXUULFXOXP DQG LV XVHG LQFUHDVLQJO\ WKURXJK the 4 years. Students learn to be clinically effective through use of the components of evidence-based practice, information search and retrieval, critical thinking (appraisal), and through information resource evaluation and then application to the patient or population. Planned innovations in curriculum include further implementation of evidencebased decision-making in clinical courses, and use of the portfolio as a means of demonstrating overall competence. The clinical prescription may be implemented as a means of clinical decision support, and of demonstrating competence in forming and answering clinical questions, relying on each student’s use of best evidence rather than simply expert opinion. References 1. American Dental Association, policy statement on evidence-based dentistry. Available at: http://www.ada.org/1754.aspx. Accessed Nov. 18, 2010. 2. American Dental Association, Commission on Dental Accreditation; Accreditation Standards for Dental Education Programs. Available at: http://www.ada.org/sections/educationAndCareers/ pdfs/predoc.pdf. Accessed Nov. 18, 2010. 3. Grant, WD. An Evidence-Based Journal Club for Dental Residents in a GPR Program. J Dent Ed 2005; 69(6);681-6. 4. Critical Appraisal Skills Programme; Tools for appraising research. Available at: http://www.sph.nhs.uk/what-we-do/public-healthworkforce/resources/critical-appraisals-skills-programme. Accessed Nov. 18, 2010.

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Teaching Evidence-Based Practice at the University of Texas Health Science Center at San Antonio Dental School John D. Rugh, Ph.D.; William D. Hendricson, M.A., M.S.; Birgit J. Glass, D.D.S., M.S.; John P. Hatch, Ph.D.; S. Thomas Deahl II, D.M.D., Ph.D.; Gary Guest, D.D.S.; Richard Ongkiko; Kevin Gureckis, D.M.D.; Archie A. Jones, D.D.S.; William F. Rose, D.D.S.; Peter Gakunga, D.D.S., M.S., Ph.D.; Debra Stark, D.P.H.; Bjorn Steffensen, D.D.S., M.S., Ph.D.

Introduction One of the most serious challenges facing all health professionals is dealing with the explosion of new biomedical information and products. The exponential increase in new knowledge and the useful half-life of knowledge (7-10 years) DUH PDNLQJ LW H[WUHPHO\ GLIÀFXOW IRU FOLQLFLDQV WR NHHS XS to-date. The number of articles published annually in peerreviewed dental journals has grown from 6,212 in the year 1970 to 13,600 in 2009. Adding to the problem is the inDr. Rugh, professor, Department of Developmental Dentistry and Director of the Evidence Based Practice Program, UTHSCSA, San Antonio, Texas. Mr. Hendricson, assistant dean for educational and Rugh Hendricson Glass Deahl II Guest faculty development, UTHSCSA, San Antonio, Texas. Dr. Glass, professor, Department of Comprehensive Dentistry and Associate Dean for Academic Affairs, UTHSCSA, San Antonio, Texas. Dr. Hatch, professor, Department of Developmental Dentistry and Department of Psychiatry Behavioral Medicine Division STRONG STAR Multidisciplinary PTSD Research Consortium, UTHSCSA, San Antonio, Texas. Ongkiko Gureckis Jones Rose Dr. Deahl , adjunct associate professor, Department of Developmental Dentistry, UTHSCSA, San Antonio, Texas, and The Institute for Natural Resources, Concord, California. Dr. Guest, professor, Department of Comprehensive Dentistry and Assistant Dean for Predoctoral Clinics, UTHSCSA, San Antonio, Texas. Mr. Ongkiko, database administrator, UTHSCSA, San Antonio, Texas, and Instructor at the University of the Incarnate Word ADCaP, San Antonio, Texas. Dr. Gureckis, associate professor, Department of Comprehensive Dentistry, UTHSCSA, San Antonio, Texas. Gakunga Stark Steffensen Dr. Jones, associate professor, Department of Periodontics, UTHSCSA, San Antonio, Texas. Dr. Rose, assistant professor, Department of Comprehensive Dentistry, UTHSCSA, San Antonio, Texas. Dr. Gakunga, assistant professor, Department of Developmental Dentistry, UTHSCSA, San Antonio, Texas. Dr. Stark, evaluation specialist in the Academic Center for Excellence in Teaching, UTHSCSA, San Antonio, Texas. Dr. Steffensen, professor, Department of Periodontics, professor, Department of Biochemistry and Associate Dean for Research, UTHSCA, San Antonio, Texas.

Abstract The overarching goal of the Evidence-Based Practice Program at San Antonio is to provide our graduates with life-long learning skills that will enable them to keep up-todate and equip them with the best possible patient care skills during their 30-40 years of practice. Students are taught to (1) ask focused clinical questions, (2) search the biomedical research literature (PubMed) for the most recent and highest level of evidence, (3) critically evaluate the evidence and (4) make clinical judgments about the applicability of the evidence for their patients. Students must demonstrate competency with these “just-in-time” learning skills through writing concise one-page Critically Appraised Topics (CATs) on focused clinical questions. The school has established an online searchable library of these Critically Appraised Topics. This library provides students and faculty with rapid, upto-date evidence-based answers to clinical questions. The long-range plan is to make this online library available to practitioners and the public. Tex Dent J 2011; 128(2):187-190.

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Teaching EB Practice at SA crease in marketing journals and Internet based sources of information ‌ and misinformation. One recent strategy, used in medicine, of dealing with the Ă RRG RI QHZ LQIRUPDWLRQ DQG keeping up-to-date involves a “just-in-time learningâ€? approach (1,2). This approach entails learning skills that will allow WKH FOLQLFLDQ WR TXLFNO\ Ă€QG QHZ knowledge related to a patient’s VSHFLĂ€F SUREOHP ZKHQ QHHGHG at the point of care (Figure 1). This “just-in-time learningâ€? approach is in contrast to passively reading three to four journals each month, attending weekend CE courses, and memorizing large quantities of information

that may or may not be useful. The strategy assumes the clinician has a solid basic science and clinical foundational knowledge base with which to interpret and put into perspective the new knowledge.

highest level of evidence, 3. Critically evaluate the evidence and 4. Make clinical judgments about the applicability of the evidence for their patients.

With the aid of a 4-year NIH Education Research grant, the University of Texas Health Science Center at San Antonio Dental School is implementing and evaluating a “just-in-time learning� evidence-based practice (EBP) model. Students are taught four evidence-based practice skills enabling them to:

These skills are taught in the context of having students prepare Critically Appraised Topics (CATs) that are one-page summaries of the four-step process mentioned above (Figure 2). The overarching goal is to provide students with life-long learning skills that will enable them to keep up-to-date during their expected 30-40 years of practice.

1. Ask focused questions (in a PICO format), 2. Use a systematic PubMed VHDUFK VWUDWHJ\ WR ÀQG WKH

The four evidence-based practice skills are introduced in the freshman year in parallel with foundational basic science and

Figure 1

The San Antonio EBP/CATs program emphasizes a “just-in-time learning� model as a strategy to help graducates keep up-to-date after graduation. 188

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preclinical courses. An 18-hour sophomore course in the fall sePHVWHU IRFXVHV VSHFLÀFDOO\ RQ WKH four EBP skills. Each student must then demonstrate the EBP/ CAT skills in the spring of the sophomore year by writing a CAT on a focused clinical question under the guidance of a faculty mentor. The student and faculty mentor edit and ultimately publish the completed CAT on the UTHSCSA’s online searchable CAT Library. A PubMed learning lab rotation in the junior year requires the student to demonstrate correct PubMed search strategies for six focused clinical questions. The skills are reinforced in the context of formal clinically relevant case presentations required of each student in the spring of the junior year.

The same EBP/CAT skills are taught in seven of the school’s residency programs during a 26hour research methods course. The residents then apply the EBP/CAT skills, in the Interdisciplinary Biomedical Core Course. This course provides a foundation in the principles of basic sciences for the clinical disciplines. To satisfy the criteria for completion of the course, each resident is required to write a CAT. The CAT is focused on the broad area of dental basic science, pertaining to a clinical question, or disease mechanism. The CAT is reviewed by a member of the Biomedical Core Course faculty and published in the UTHSCSA’s CATs Library.

San Antonio’s EBP initiative includes a formal faculty development program on evidence-based practice, which emphasizes the four EBP skills and the preparation of CATs. To date, 32 hours of faculty EBP workshops have been provided. Sixty-two (62) faculty members have completed training in EBP/CATs writing and are serving as student CAT mentors. The goal is to integrate these EBP skills into all levels of the curriculum and into direct patient care activities with the faculty. One General Practice Group is testing the use of the formal CAT protocol to investigate and report clinical problems and questions during the weekly group meetings. The implementation has been challenged by recent state

Figure 2

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Teaching EB Practice at SA budget cuts and associated restructuring of departments within our school to help achieve Ă€QDQFLDO JRDOV +RZHYHU ZH believe that these disruptions are temporary and expect full implementation by summer of 2012. Another important goal of the project was to create a searchable online CATs library, which has now been established and includes 200 CATs developed by our students, residents and faculty. This online library provides students and faculty with rapid, up-to-date, evidence-based answers to clinical questions. The library includes a mechanism for faculty and practitioners to FRPPHQW RQ VSHFLĂ€F &$7V 7KH library is searchable by keywords and currently is accessible by our dental students and faculty on the schools “intranetâ€?. Ultimately the online library will be available to practicing dentists and educators worldwide, as well as to the public. We anticipate the library will reach 500 CATs by the fall of 2011. An important aspect of this searchable evidence-based knowledge center is that the individual CATs will be updated every 2 years. CATs will be reassigned to students to be rewritten, with faculty oversight, in light of recent publications and/or practice guidelines. The updated CAT will go through the same review and approval process as the original CATs to ensure that it is based on the best available and most recent evidence. Our CATs library will be modeled after the searchable online CAT libraries that have

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been established in several medical schools. Future plans are to encourage practicing dentists, students, and faculty from other schools to contribute and/or comment on the CATs. These CATs will undergo the same review process for quality. We also envision providing continuing education credit for dentists using the CATs library. In addition we are planning to offer continuing education programs dealing with EBP “just-in-time-learningâ€? skills. We hypothesize that this comprehensive, school-wide collaboration among student and faulty in the preparation and review of CATs will strengthen skills associated with critical appraisal of the literature and foster more rapid integration of UHVHDUFK Ă€QGLQJV LQ ERWK WKH dental school curriculum and dental private practice. The goal is to have these “problem-basedâ€? or “just-in-time learningâ€? skills Ă€UPO\ HVWDEOLVKHG XSRQ JUDGXation to enable young clinicians to keep up-to-date and deal with the plethora of new knowledge, products and procedures they will face during their practice experiences. Our 4-year NIH grant includes funding for a comprehensive outcomes assessment of the program that will allow us to assess its effectiveness. Initial outcomes have been very encouraging, and we look forward to assessing the impact on our students practice behaviors 5-10 years after graduation (3-6).

This program is supported by an Education Research Grant from the NIDCR, NIH/1R25DE018663 to Dr. John D. Rugh (PROJECT DIRECTOR/PRINCIPAL INVESTIGATOR), Endowed Clinical Professorship funds to Dr. Kevin Gureckis DQG E\ WKH 'HQWDO 'HDQV 2IĂ€FH DW UTHSCSA. References 1.

2.

3.

4.

5.

6.

Ebell MH, Shaughnessy A. Information mastery: Integrating continuing medical education with the information needs of clinicians. Journal of Continuing Education in the Health Professions, 23:S5362, 2003. Harden RM. A new vision for distance learning and continuing medical education. Journal of Continuing Education in the Health Professions, 25(1):43-51, 2005. Wallmann E, McLin S, Rugh JD, Hendricson WD, Hatch JP. EBP Course Increases Knowledge, AtWLWXGHV DQG &RQĂ€GHQFH LQ 'HQWDO Students. Journal of Dental Research, Issue 89 (Special Iss B):IADR/AADR 88th General Session, Barcelona, Spain, 2010. (www.dentalresearch.org). Hendricson WD, Rugh JD, Hatch JP, Stark DL, Deahl T, Wallmann ER. Validation of an Instrument to Assess Evidence-Based Practice Knowledge, Attitudes, Access and &RQĂ€GHQFH LQ WKH 'HQWDO (QYLURQment. Journal of Dental Education, 75(2): 131-144, 2011. Rugh JD, Hendricson WD, Hatch JP, Glass BJ. Keeping Up-to-Date: The San Antonio CATs Initiative. Journal of the American College of Dentists, Vol. 77:2, 2010. Rugh JD, Hatch JP, Hendricson WD. Assessing Outcomes of Research Methods Courses, Journal of Dental Research, Issue 89 (Special Iss A):673, AADR 39th Annual Meeting, Washington, D.C., 2010. (wwwdentalresearch.org).

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The Challenges of Transferring Evidence-Based Dentistryy Into Practice

Abstract

Richard T. Kao, D.D.S., Ph.D. Reprinted byy permission off the California Dental Association. Copyright 2006.

Introduction The dental profession is committed to providing g the best possible dental care for patients. This is proving g to be more complex x due to a virtual “information explosionâ€? on new therapies, techniques, and materials; increased consumer understanding g off treatment possibilities and therapeutic outcomes; and changing g socio-demographic patterns. Though the profession advocates the importance off evidence-based dental disease prevention and treatment, practitioners have been slow to implement this concept. In 2003, the California a Dental Association (CDA) formulated an evidencebased dentistry y action plan that included the formation off a task force to monitor evidence-based dentistry y efforts and implement programs to educate CDA members on this methodology. The challenges off transferring g evidencebased dentistry y into clinical practice were key y issues addressed by y the task IRUFH DQG PXFK RI WKHLU GHOLEHUDWLRQV DQG SHUVSHFWLYHV DUH UHĂ HFWHG LQ WKLV paper. Possible solutions for eliminating g barriers against evidence-based care will also be explored.

The goal of evidence-based dentistry is to help practitioners provide their patients with optimal care. This is achieved by integrating sound research evidence with personal clinical expertise and patient values to determine the best course of treatment. Though clinicians embrace this concept, its implementation in clinical practice has been slow. In this paper, barriers against the implementation of evidence-based care are examined and possible solutions are offered. Tex Dent J 2011; 128(2):193-199.

Kao 'U .DR LV DQ DVVRFLDWH DGMXQFW SURIHVVRU 'HSDUWPHQW RI 3HULRGRQWRORJ\ 8QLYHUVLW\ RI WKH 3DFLĂ€F $UWKXU $ 'XJRQL 6FKRRO of Dentistry. He also is past chair, Task Force on Evidence-based Dentistry, California Dental Association, and has a private practice in Cupertino, California. Send correspondence and reprint requests to: Dr. Richard T. Kao, 10440 S. De Anza Blvd., Suite D-1, Cupertino, CA, 95014.

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Challenges of Transferring EBD What Is Evidence- Barriers Against Evidence-based Care Though the concept appears fundamentally simple and reasonable, based Dentistry clinicians have been slow to implement evidence-based dentistry. For practitioners, evidence-based dentistry as a concept is not and How Do Den- clinical unlike the logical and common-sense patient-oriented approach that was advocated in the 1980’s and 1990’s as comprehensive care. The tal Practitioners VLJQLĂ€FDQW GLIIHUHQFH LV WKH HPSKDVLV RQ FOLQLFDO GHFLVLRQ PDNLQJ EDVHG on the body of evidence present in the literature. This difference has Interpret It? deterred the implementation of evidence-based care. It has been sugThe CDA Task Force on Evidence-Based Dentistry recomPHQGHG D GHĂ€QLWLRQ RI HYLGHQFH based dentistry drawn from the “Oral Health in Americaâ€? report by the U.S. Surgeon General, which is philosophically consistent with the American Dental $VVRFLDWLRQ¡V GHĂ€QLWLRQ Evidence-based dental practice is the integration of an individual practitioner’s experience and expertise, with a critical appraisal of relevant available external clinical evidence from systematic research, and with consideration for the patient’s needs DQG SUHIHUHQFHV 7KLV GHĂ€QLWLRQ stresses the importance of three elements: a dentist’s expertise and clinical judgment, relevant clinical evidence that is present in the literature, and the informed patient’s preference. In a dental practice that incorporates an evidence-based approach, the practitioner’s experience is primary since it is his responsibility to consider all three components ZKHQ GHĂ€QLQJ WKH EHVW FRXUVH of treatment. Ideally, evidencebased treatment is characterized by the intersection of these three elements.

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JHVWHG WKDW SHUKDSV DV OLWWOH DV SHUFHQW RI GHQWDO FDUH LV MXVWLĂ€HG E\ peer-reviewed, published, and appropriately analyzed dental research (3,4). This paper will examine barriers that clinicians encounter in their attempts to incorporate evidence-based dentistry into clinical practice.

7KH ,QIRUPDWLRQ 2YHUĂ RZ Barrier

be clinically relevant or available to practitioners.

One of the main concerns clinicians have is the challenge of keeping up with a constantly expanding knowledge base. No one knows exactly how many dental research articles are published in a single year. In 1998, it was estimated that approximately 10,000 dental research articles were published in English (5). Considering the fact there is an equal amount of research published in foreign languages, this number may safely be doubled.

A recent survey was performed of systematic reviews from 1966 to December 31, 2002, on MEDLINE and the Cochrane Library’s Database of Abstracts of Reviews of Effectiveness (7). A total of 592 DUWLFOHV ZHUH LGHQWLÀHG DQG WKRVH ODFNLQJ D ZHOO GHÀQHG VHDUFK process, clearly delineated inclusion and exclusion criteria, and a re-examination of the raw or synthesized data from all included studies were eliminated. Furthermore, reviews not published in English were excluded. Using these criteria, 131 systemDWLF UHYLHZV ZHUH LGHQWLÀHG RQO\ 96 of which had direct clinical relevance. These 96 reviews covered a wide range of dental topics; however, 17 percent of them concluded that the eviGHQFH ZDV LQVXIÀFLHQW WR DQVZHU the key question. An additional 50 percent hedged in answering the key question, noting that the supporting evidence was weak or limited in quantity. It was concluded that despite the growing number of systematic reviews, more than one-half of these are unable to answer the key clinical question due to weak studies.

It is inconceivable for private practitioners to even consider analyzing this overwhelming volume of research. Therefore, most rely on systematic reviews. Unfortunately, the number of systematic reviews that address clinical topics in dentistry is small, but growing (6). The Cochrane Library lists only three reviews that met the minimum criteria for systematic reviews published in 1993. However, in 1999 there was an exponential increase to 484 reviews. Systematic reviews not only identify all relevant information contained LQ WKH OLWHUDWXUH EXW DOVR GHĂ€QH the key question, inclusion and exclusion criteria, and literature search parameters, and evaluate the quality of the study and information obtained. When systematic reviews are structured appropriately, multiple studies may be combined to potentially provide clinical insight. Further scrutiny of these reviews indicates that these reviews may not

An additional problem with systematic reviews is their inability to inform practitioners about new dental materials and techniques, such as the ever-evolving implant design materials, tooth-colored restorative materials, and adhesives. Both the names and formulations of these products are changing VR UDSLGO\ WKDW LW LV GLIĂ€FXOW WR

sort them out. Further complicating this situation are savvy sales representatives who often provide slick marketing pieces with questionable claims. Some practice consultants even view these sales representatives as the key providers of information about advances in dental services, products, and technology (8). In the absence of reliable systematic reviews and VFLHQWLÀFDOO\ VRXQG GDWD FOLQLcians are forced to depend on either clinical trial and error or commercial market information. Further confounding clinicians is the fact that the few relevant systematic reviews published in journals often are interspersed with weaker studies and case reports/series. Consequently, in addition to being inundated with non-refereed journals and marketing information, clinicians perceive there is a dental LQIRUPDWLRQ RYHUà RZ DQG WKH\ are unable to distinguish the presence and importance of valid published systematic reviews. Additionally, there are few good systematic reviews that deÀQLWLYHO\ JXLGH SUDFWLWLRQHUV RQ clinically relevant procedures. 3HUKDSV WKH GLIÀFXOW\ RI LPSOHmenting evidence-based care is that the amount of relevant clinical evidence is so poor or the questions are so unrelated to clinical issues that it appears that evidence-based dentistry is not used. The challenge for evidence-based dentistry advocates is to ensure the increase in the number of systematic reviews WKDW DGGUHVV ZHOO GHÀQHG DQG clinically relevant key questions. Texas Dental Journal l www.tda.org l February 2011

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Challenges of Transferring EBD Guideline or Treatment Algorithm Barrier Despite their limited number, clinicians question whether these systematic reviews can lead to conclusions that will result in clinical practice guidelines (7). Practitioners are then concerned DERXW ZKHWKHU WKH\ PXVW ÀUPO\ adhere to such guidelines. Although dentists’ adherence to clinical practice guidelines has not been studied extensively, IDFWRUV LQà XHQFLQJ SK\VLFLDQ DGherence have been examined (9). These studies have shown that there are several impediments, such as unawareness of the existence of guidelines, personal disagreement with the guideOLQHV ODFN RI FRQÀGHQFH LQ H[pected results, practice inertia, and other external barriers. In the independent and often isolated dental practice environment, these same barriers may SURYH WR EH MXVW DV GLIÀFXOW LI QRW HYHQ PRUH VLJQLÀFDQW

Patient-Related Barrier Patient preferences can be a barrier to adherence to evidence-based care. Patient decisions about care are based on two major factors: personal GHVLUH DQG LQVXUDQFH EHQHÀWV With increased dental advertising and ready access to information on the Internet, today’s patients are well-informed consumers. Commercial marketing of esthetic and implant dentistry procedures and results have resulted in more demand

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for these services. Though there are longevity and survival studies for esthetic materials, the nature of these materials is changing so rapidly it is not clear whether this information is still germane to the various generations of composites, adhesives, veneer materials, and implants entering the marketplace. When such an information void exists, it is easy to be LQà XHQFHG E\ PDUNHWLQJ MDUJRQ and non-refereed publications. In the face of growing patient demand, non-existent evidence, DQG VLJQLÀFDQW HFRQRPLF JDLQV associated with these services, LW LV GLIÀFXOW IRU FOLQLFLDQV WR provide evidence-based care. ,QVXUDQFH EHQHÀWV ZDUUDQW DWtention since approximately 69 percent of patients have dental insurance (10). Practitioners are understandably concerned that the insurance industry may misuse information to GHÀQH HYLGHQFH EDVHG GHQWLVWU\ and dictate the types of procedures and treatment that will be covered. This fear stems from dental carriers’ history of regulating covered services and terms of re-treatment. Instead of informing the public that these regulations are based on purchase-service utilization analyses, third parties frequently suggest in their denials that provided services are not FOLQLFDOO\ VRXQG RU VFLHQWLÀFDOO\ based. Additionally, outcomes assessment in terms of patient satisfaction has largely been ignored by the insurance industry. Though patient satisfaction

can be quite high for esthetic procedures such as esthetic crown lengthening, bleaching, veneers, and dental implants, these procedures are generally QRW FRYHUHG EHQHĂ€WV ,QVXUDQFH carriers have given the public WKH LPSUHVVLRQ WKH\ GHĂ€QH WKH parameter of care through their regulations and coverage, even though their decisions may often be contrary to evidence obtained from well-designed, peer-reviewed studies and patient preferences.

Internal and External Barriers Faced by Clinicians &'$¡V GHĂ€QLWLRQ RI HYLGHQFH based dentistry emphasizes the importance of a dentist’s expertise and clinical judgment. Though these are largely based on past clinical experiences, RWKHU IDFWRUV FDQ LQĂ XHQFH WKH clinician’s decision. Awareness and familiarity with the evidence remain one critical problem. It is clear that most clinicians either do not have access to or are not capable of evaluating the primary literature. Though there are numerous articles that inform clinicians on the art of evaluating the literature, most clinicians are still heavily dependent on systematic reviews (7,11-18). As previously mentioned, there are presently a limited number of reviews, with the majority KHGJLQJ RQ GHĂ€QLWLYH FOLQLFDO recommendations due to weak or limited supporting evidence (7). Faced with these system-

When such an information void exists, it is easy to be influenced by marketing jargon and non-refereed publications. In the face of growing patient demand, non-existent evidence, and significant economic gains associated with these services, it is difficult for clinicians to provide evidence-based care.

DWLF UHYLHZV FOLQLFLDQV¡ Ă€UVW intuition is to decide if the key question is clinically relevant. Even with relevant reviews, clinicians may not agree with a VSHFLĂ€F JXLGHOLQH GXH WR SHUsonal experiences or expected outcomes. There are also internal barriers which may prevent adoption of evidence-based dentistry. Clinicians may fall prey to practice inertia and not be motivated to change. Altering therapeutic regimens in a small practice may require behavioral adaptations among the staff. At times, clinicians still practice in the same fashion as they were taught in their earlier training. Though this is inappropriate given the rate of change in clinical dentistry and availability of continuing education courses, this nevertheless does occur. Additionally, many of the procedures and GHFLVLRQV DUH Ă€QDQFLDOO\ EDVHG Though a more conservative

DQG OHVV SURÀWDEOH SURFHGXUH may be evidence-based, clinicians still need to deal with the temptation of providing a more SURÀWDEOH SURFHGXUH 7KLV LV driven by both business pressure associated with running a practice and the need to make a living. External factors not under the clinician’s control also impact evidence-based dentistry. For example, necessary access to certain equipment or changes in facility design may be costprohibitive, making adherence to certain aspects of evidenceEDVHG GHQWLVWU\ GLIÀFXOW 2WKHU EDUULHUV LQFOXGH LQVXIÀFLHQW staff support, poor reimbursement, escalating practice operational costs, and increased liability.

Embracing Evidence-based Care Evidence-based dentistry have been the buzzwords for the type of quality dental care promoted by academicians and dental policymakers for the past decade. Yet, this practice philosophy has not been readily embraced by clinicians. This paper has revealed barriers against universal acceptance of evidence-based care, but what are some possible solutions? Evidence-based care has much potential in improving patient care. more about patient expectations and outcome satisfaction for dental care. Until each of the four stakeholders learn to appreciate the weakness, strengths, potentials, and barriers toward implementation for all concern, the growth and

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Challenges of Transferring EBD implementation of evidencebased care will be slow. Academicians and evidencebased dentistry advocates must begin to appreciate that evidence-based dental care entails more than randomized controlled trials, refereed journals, meta-analysis, and systematic reviews. These have little meaning for the clinician trying to provide dental care. The profession must be able to frame answerable questions based on clinical problems. To do so retrospectively through systematic reviews has been a failure to date (7). The National Institute of Dental and Craniofacial Research recently committed $75 million over the next 7 years to establish three practice-based research networks (19). The proposed objective of the practice-based research networks is to accelerate clinical trials and studies of important issues in oral health care. Though it is of concern that these centers have been awarded funds without any evidence of their ability to develop these networks or GHĂ€QH JHQHUDO TXHVWLRQV WR EH addressed, the practice-based research networks may be a golden opportunity to develop the informational-evidence element of evidence-based dentistry. Instead of conducting systematic reviews or performing meta-analysis on disjointed studies presently in the literature, the practice-based research networks may provide

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a prospective mechanism for addressing issues of clinical approaches and effectiveness in a real-world environment. The challenge to academicians and evidence-based dentistry advocates will be to design answerable questions based on clinical problems that can be tested in this network. The experts in clinical dentistry have always been the practitioners. Academicians and evidencebased dentistry advocates should partner with astute clinicians so basic problems can EH LGHQWLÀHG ,W LV LPSRUWDQW these problem areas be identiÀHG E\ IURQWOLQH GHQWLVWV DQG not by bureaucrats, ivory tower academicians, or statisticians. If the questions are appropriately framed, practice-based research networks can generate important and timely information to guide the delivery of dental health care and improve patient outcomes. More importantly, this information is more likely to be accepted, adopted, and translated into daily practice by clinicians. Another step for removing patient-associated barriers to evidence-based dentistry would be for the dental insurance industry to educate its subscribers on the nature of its business. While it is acknowledged dental LQVXUDQFH EHQHÀWV SURPRWH oral health, it is important for insurance carriers to educate subscribers on the limitations RI EHQHÀWHG FDUH 7KHVH OLPLWDtions are based on a business model utilizing employer-paid

insurance premiums to provide D GHÀQHG OHYHO RI FDUH IRU HPployees. When treatment falls RXWVLGH RI WKLV GHÀQHG OHYHO (i.e., cosmetic dentistry, implants, etc.), patient preferences should be respected. In lieu of denials and commentaries, carriers should acknowledge the patient’s preference and the treatment as an accepted option despite the fact that it is not covered by insurance. Given the sheer volume of VFLHQWLÀF LQIRUPDWLRQ DYDLODEOH it will be a challenge for our dental educators, journal editors, and public policymakers to provide an effective information transfer. Though an increasing number of schools and residency programs are instituting curricula for teaching the principles and practice of evidence-based care, success has been limited (20). It is questionable as to how much of the evidence-based decisionmaking process is utilized after training. If evidence-based dentistry is to succeed, it is critical that these problems associated with the dissemination of the evidence-based systematic reviews be evaluated. Additionally, evidence-based dentistry teaching strategies need to be developed. This task falls to dental educators, dental associations, and journal editors.

Conclusion Despite the barriers that have prevented evidence-based dentistry from being readily embraced by dental clinicians, there should be no mystery or fear surrounding this concept. This logical, common-sense, patient-oriented approach is not different from the comprehensive care that was the popular in the 1980’s and 1990’s. The difference is that we are in an enviable position where WKHUH LV ÀQDOO\ D FULWLFDO PDVV of information that can help us in our patient care decisions. In evidence-based dentistry, there is a “conscientious, explicit and judicious use of current best evidence” to be used in clinical decision-making (21). This information is an adjunct, not a substitute for clinical judgment and patient preferences. When used in concert, it has the potential to provide optimal treatment. References 1. U.S. Department of Health and Human Services. National call to action to promote oral health in America: a report of the surgeon general. Available at http:// www.surgeongeneral.gov/ topics/oralhealth/nationalcalltoaction.htm (Accessed April 13, 2006.) 2. American Dental Association, ADA positions and statements: ADA policy on evidence-based dentistry. Available at www.ada.org/ prof/resources/ positions/ statements/evidencebased. asp. (Accessed April 13, 2006.)

3. Antczak-Bouckoms A, Symposium: The Cochrane collaboration: Creating a registry of clinical trails (abstract). J Dent Res 74(Spec. Issue A):69, 1995. 4. Kugel G, Squier C, Fact vs. ÀFWLRQ ³ WKH WUDQVIHU RI VFLHQWLÀF NQRZOHGJH LQWR the dental curriculum (abstract). J Dent Res 77(Spec. Issue):106, 1998. 5. Niederman R, Badovinac R, Tradition-based dental care and evidence-based dental care. J Dent Res 78:128891, 1999. 6. The Cochrane Library, Database of abstracts of reviews of effectiveness. Available at www.nicsl.com.au/ cochrane/guide_data.asp. (Accessed April 13, 2006.) 7. Bader J, Ismail A, Survey of systematic reviews in dentistry. J Am Dent Assoc 135:464-73, 2004. 8. Levin RP, The hidden resource to your practice. Implant Dent 14:210, 2005. 9. Cabana MD, Rand CS, et al, Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 282:1458-65, 1999. 10. Evidence-based care and risk assessment. Insurance Solutions newsletter. Issue:4-15, May-June 2002. 11. Richards D, Lawrence A, Evidence-based dentistry. Br Dent J 179:270-3, 1995. 12. Sutherland SE, Evidencebased dentistry: Part I. Getting Started. J Can Dent Assoc 67:204-6, 2001.

13. Sutherland SE, Evidencebased dentistry: Part IV. Research design and levels of evidence. J Can Dent Assoc 67:375-8, 2001. 14. Sutherland SE, Evidencebased dentistry: Part V. Critical appraisal of the dental literature. J Can Dent Assoc 67:442-5, 2001. 15. Newman MG, Improved clinical decision-making using the evidence-based approach. Ann Periodontol 1:i-ix, 1996 16. Hamilton J, Assessing ‘Real Science’: Poor studies, industry ties taking toll. J Calif Dent Assoc 32:29-39, 2004. 17. Richardson WS, Wilson MC, et al, The well-built clinical question: A key to evidencebased decisions. ACP J Club 123:A12-3, 1995. 18. Guyatt GH, Haynes RB, et al, Users’ guides to the medical literature XXV : Evidence-based medicine. Principles for applying the user’s guides to patient care. JAMA 284:1290-6, 2000. 19. Pilstrom BL, Tabak L, The National Institute of Dental and Craniofacial Research: Research for the practicing dentist. J Am Dent Assoc 136:728-37, 2005. 20. Hatala R, Guyatt G, Evaluating the teaching of evidence-based medicine. JAMA 288:1110-2, 2002. 21. Sackett DL, Rosenberg WMC, et al, Evidence-based medicine: What it is and what it isn’t. BMJ 312:71-2, 1996.

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The American Dental Association’s Center For Evidence-Based Dentistry: A Critical Resource For 21st Centuryy Dental Practice Julie Frantsve-Hawley, R.D.H., Ph.D. Arthur Jeske, D.M.D., Ph.D.

Introduction $V KHDOWK FDUH SURIHVVLRQDOV WUDLQHG LQ D VFLHQWLĂ€cally-structured educational model, dentists have a special responsibility y to their patients to provide care that is evidence-based, and to be able to effectively communicate the evidence for dental treatments to their patients, so that patients can make informed decisions about their care. This principle is effectively y enunciated by y the American Dental AssociaWLRQ¡V $'$ GHĂ€QLWLRQ RI WKH WHUP ´HYLGHQFH EDVHG dentistryâ€? (EBD) as follows: Evidence-based d dentistry (EBD)) is s an n approach h to o orall health h care e thatt requires the e judicious s integration n off systematicc assessments RI FOLQLFDOO\ UHOHYDQW VFLHQWLĂ€F HYLGHQFH UHODWLQJ WR WKH patient’s s orall and d medicall condition n and d history, with the e dentist’s s clinicall expertise e and d the e patient’s s treatmentt needs s and d preferences.

Frantsve-Hawley

Jeske

Dr. Frantsve-Hawley is the director of the ADA A Center for Evidence-Based Dentistry. Dr. Jeske is a professor, Department of Restorative Dentistry and Biomaterials, University of Texas Dental Branch at Houston.

Abstract Through its website (http:// www.ada.org/prof/resources/ebd/index.asp), the American Dental Association’s Center for EvidenceBased Dentistry offers dental health professionals access to systematic reviews of oral health-related UHVHDUFK ÀQGLQJV DV ZHOO DV Clinical Recommendations, which summarize large bodLHV RI VFLHQWLÀF HYLGHQFH LQ the form of practice recommendations, e.g., the use of professionally-applied WRSLFDO à XRULGH DQG SLW DQG ÀVVXUH VHDODQWV $QRWKHU feature of the site of great practical importance to the practicing dentist is the Critical Summary, which is a concise review of an individual systematic review’s methodology and ÀQGLQJV DV ZHOO DV WKH importance and context of the outcomes, and the strengths and weaknesses of the systematic review and its implications for dental practice. Tex Dent J 2011; 128(2):201205.

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ADA EBD: Crititical Resource Recognizing the importance of and need for accessible, highquality information on evidencebased dentistry, and the fact that dental research doesn’t do any good if it doesn’t reach the clinician, the ADA created the Center for Evidence-Based Dentistry (EBD) to connect the ODWHVW UHVHDUFK ÀQGLQJV ZLWK WKH daily practice of dentistry. The EBD website (http://ebd.ada.org) provides on-demand access to systematic reviews, summaries and clinical recommendations

Figure 1

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that translate the latest scholDUO\ ÀQGLQJV LQWR D XVHU IULHQGO\ format. ADA members and stakeholders determined that they needed one centralized online resource to DFFHVV WKH PRVW FXUUHQW VFLHQWLÀF information. The resource that emerged should provide concise, clinically relevant information for the dental profession. The website, illustrated in Figure 1, was supported by a grant from the National Library of Medicine

and the National Institute for Dental and Craniofacial Research (grant number G08 LM008956). The EBD website was launched in March, 2009, is open-access, and provides current, clinically UHOHYDQW DQG FRQFLVH VFLHQWLĂ€F information in a user-friendly format (Figures 1, 2). All dental professionals worldwide can now access the EBD website for information for dental and health care professionals and, as a next phase, the ADA

will develop content for the general public. Key features of the EBD website include: ‡ A database of systematic reviews. The database has over 1,300 systematic reviews and is updated monthly. ‡ Critical Summaries of systematic reviews. One-page synopses of the key elements of a systematic review with clinical implications written by practicing dentists trained in critical assessment of published studies. Sample summary can be seen at http://ebd.ada.org/SystematicReviewSummaryPage. aspx?srId=51de1696-175d44ff-87af-565d7fe0fba4 ‡ Clinical Recommendations. These provide useful tools that can be applied in making evidence-based clinical treatment decisions.

‡

‡

Links to many other useful resources. This is a central resource for EBD information, and has links to many outside resources including; tutorials, glossaries, and databases Clinical Questions. If you have a clinical question that isn’t covered here, you can submit it through the website for consideration of future systematic reviews or studies.

‡

‡ ‡ ‡ ‡ ‡ ‡

A panel of world renowned EBD Experts provides oversight for the EBD website, including training and overseeing the dentists that write the Critical Summaries. Panel members include: ‡ Dr. James Bader, University of North Carolina ‡ 'U -DQHW &ODUNVRQ 8QLYHUVLty of Dundee; Cochrane Oral Health Group

‡ ‡ ‡ ‡

'U 3DXO 6 )DUVDL %RVWRQ University School of Dental Medicine 'U &DUORV )ORUHV 0LU 8QLYHUsity of Alberta 'U -RKQ *XQVROOH\ 9LUJLQLD Commonwealth University 'U 3KLOLSSH +XMRHO 8QLYHUsity of Washington 'U 0LNH -RKQ 8QLYHUVLW\ RI Minnesota 'U $VEMRUQ -RNVWDG 8QLYHUsity of Toronto 'U 'HERUD 0DWWKHZV 'DOhousie University 'U -RVHSK 0DWWKHZV 8QLversity of New Mexico 'U 6HUJLR 8ULEH 8QLYHUVLGDG Austral de Chile 'U .DWH 9LJ 7KH 2KLR 6WDWH University 'U 5REHUW :H\DQW 8QLYHUVLW\ of Pittsburgh

Figure 2 Texas Dental Journal l www.tda.org l February 2011

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ADA EBD: Crititical Resource A wealth of scienWLÀF LQIRUPDWLRQ LV available at the EBD website, including “Frequently Asked Questions”, systematic reviews and Critical Summaries of those systematic reviews, ADA Clinical Recommendations for EBD, all with easy-to-use topic selection features (Figures 3–5). Finally, the EBD website offers the dentist the capability to suggest clinical ideas based on questions that arise in dental practice that require science-based answers (Figure 6).

Figure 3

The dental profession can take great pride in the leadership role in evidence-based dentistry that the ADA has taken with the establishment of the Center for Evidence-Based Dentistry and the EBD website. Application of WKH VFLHQWLÀF LQIRUPDtion provided in this endeavor will continue to strengthen our profession, maintain our high professional standards, and enrich and improve the care of all of our patients.

Figure 4

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Figure 5

Figure 6 Texas Dental Journal l www.tda.org l February 2011

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206 Texas Dental Journal l www.tda.org l Paul February 2011 Apilado, DDS (General Dentist); Chad Hoecker, DDS (General Dentist & Owner)

ADA Evidence-Based Dentistry Champions Conference Joshua Austin, D.D.S.

Introduction As a young private practitioner, I can still remember my course on dental evidence during dental school. During the spring semester of our Ă€UVW \HDU DW WKH 8QLYHUVLW\ RI 7H[DV +HDOWK 6FLence Center at San Antonio Dental School (UTHSCSA), Dr. John Rugh ran “Clinical Judgement and Evaluation.â€? We were all just trying to survive the onslaught of microbiology, physiology, and pharmacology. We knew little of dentistry RWKHU WKDQ WKH IDPLOLDU VFHQW RI KHDWHG Ă RZLQJ inlay wax. We had no idea that dental evidence would shape the way we practice dentistry for the entirety of our careers. Throughout dental school, we were always told, “Here at UTHSCSA, we teach our students to practice evidence-based dentistry.â€? It was told to us countless times by professors and deans. It was always said with conviction and meaning. Because of this obvious emphasis from our educators, we as students never really admitted that we weren’t absolutely sure what evidence based dentistry meant. We just knew it had to be good. During dental school, there are few issues practicing evidence based dentistry. Lectures are almost always cited with the most recent and classic literature. Clinical procedures are performed with professors well-versed and even published in the

Dr. Austin is in private practice in San Antonio, Texas; and chair of the TDA Committee on the New Dentist.

Austin

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ADA EBD Conference literature. The disconnect with evidence based dentistry comes when the dental student graduates and enters practice. It is at this time many practitioners lose their link to the evidence. Thankfully, the American Dental Association (ADA) is helping to rejuvenate its members’ interest in evidence based dentistry.

Participants attend the ADA’s EvidenceBased Dentistry Champions Conference in May 2009 in Chicago, IL. Photo courtesy ADA News. ©2010 American Dental Association.

Time becomes the biggest enemy in the average private practice. Today’s practicing dentists are completely overwhelmed with payroll, staff issues, patient management, and patient care. By the end of a busy day of practice, the last thing a dentist wants to do is sit and read a peerreviewed journal. Dentists today need WKLQJV IDVW DQG FHQWUDOL]HG :H QHHG D KXE ZKHUH ZH FDQ ÀQG JRRG LQIRUPDWLRQ RQ WKH WRSLF ZH DUH VHDUFKLQJ IRU TXLFNO\ DQG HIÀFLHQWO\ 7KH $'$ ÀJXUHG WKLV RXW and created its Center for Evidence-Based Dentistry website. The Center for Evidence-Based Dentistry website is extremely well laid out. Information is easily accessible, searchable, and broken down into categories. It is HYHU\WKLQJ D GHQWLVW FRXOG ZDQW IRU ÀQGLQJ ZKDW WKH HYLGHQFH DFWXDOO\ VD\V DERXW the procedures we perform on a daily basis. Within 5 minutes, a dentist can gain great overviews on the current literature pertaining to the desired topic. The only problem was that I wanted more. I wanted to know more about evidence itself. What is a systematic review? What is a meta-analysis? Where do these studies come from? What makes for a good study? How can I utilize this more in my practice? I had questions, so I turned to the ADA for answers. The ADA informed me of a new program they were launching called “The Evidence-Based Dentistry Champions Conference.” Coming from San Antonio, we know a few things about champions (sorry, Mavs and Rockets fans). The idea of the conference intrigued me. I applied with the ADA and received word a few weeks later that I had been accepted into its new program and would attend the May 2009 Evidence-Based Dentistry Champions Conference. The conference took place Thursday through Saturday at the ADA headquarters in Chicago. Thursday’s opening session gave attendees an update on levels of dental evidence and resources to locate it. Part of the session was devoted to rehashing some of the topics we all explored in our dental evidence class from dental school. The presenters broke down the differences, strengths, and weaknesses of the study types. A clear linear ascension from weak evidence to strong

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evidence was drawn and made very clear. In addition, we received a lesson on the use of the Pub-Med website to locate data and studies. After Thursday, we each had a refreshed background in levels of evidence which included skills for deciphering strong evidence from weak evidence. With the use of Pub-Med, we each then had a tool to use for the location of new evidence. Friday brought an emphasis on why evidence and literature is important to dentistry. The ADA brought several speakers in from educators to private practitioners, all to help drive home the idea that evidence is critical to the practice of dentistry. With the background we re-learned on Thursday, we were shown the ADA’s Center for Evidence Based Dentistry website and how to use it. The ADA had practitioners who had reviewed literature and written some of their clinical recommendations speak on the process and use of these clinical recommendations. 3DUW RI )ULGD\ ZDV GHYRWHG WR WDEOH GLVFXVVLRQV LGHQWLI\LQJ REVWDFOHV WR ÀQGLQJ and using evidence in practice on a daily basis. These obstacles were surprisingly universal to almost all dentists in the room. Each table seemed to echo the same obstacles and frustrations to utilizing evidence based dentistry in practice. Afterwards, we examined strategies to overcome these obstacles. Many of these strategies involved using resources and tools already in place that are free to ADA members.

Dr. Leslie Winston of Proctor and Gamble speaks at the ADA’s Evidence-Based Dentistry Champions Conference in May 2009 in Chicago, IL. Photo courtesy ADA News. Š2010 American Dental Association.

As the conference moved to Saturday, the topics changed focus from using evidence-based dentistry in practice to spreading information to our colleagues. The IRFXV ZDV QRW RQ VKDULQJ SDUWLFXODU OLWHUDWXUH RU HYLGHQFH ZH PD\ ÀQG EXW VKDUing the methods and strategies we had previously learned with other dentists. This may be done at a study club, table clinic or, as I did, at a component society general membership meeting. The conference gave me all the tools I needed to pass this information on to others. There are worse things to do in the world than spend 4 days in Chicago in May. A visit to Wrigley Field to see the Cubs play would normally be the highlight of such D WULS $QG WKRXJK LW PD\ VRXQG XQEHOLHYDEOH , GHÀQLWHO\ IHHO WKDW WKH $'$ (YLdence-Based Dentistry Champions Conference stole the show from Wrigley Field. , KDG GHÀQLWH JRDOV DQG REMHFWLYHV LQ DWWHQGLQJ WKLV FRQIHUHQFH , ZDV DEOH WR JDLQ the information and skills I desired after spending 3 days at the ADA. It would be untruthful for me to claim that my entire practice has changed since attending this conference. Practicing evidence-based dentistry is a much more subtle shift. Being a more recent graduate, much of my training is still accepted and supported by literature. There are, however, regular instances in which I must look into the literature to answer a clinical dilemma faced in my practice. With the tools I learned at the ADA Evidence-Based Dentistry Champions Conference, I IHHO WKDW , FDQ ÀQG SURFHVV DQG DSSO\ WKH PRVW FXUUHQW DQG DFFHSWHG HYLGHQFH WR maximize the level of patient care I provide. Texas Dental Journal l www.tda.org l February 2011

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7H[DV 'HQWDO $VVRFLDWLRQ WK $QQXDO 6HVVLRQ 7(;$6 0HHWLQJ 3KRWR &RQWHVW &DWHJRU\ %ODFN :KLWH $EVWUDFW $UWLVWLF $ZDUG VW 3ODFH Photographer: Leanna R. Sims-Gowan of Mabank, Texas Title: “Old Lock” For information on entering your photo in the 2011 TEXAS Meeting Photo Contest, please visit texasmeeting.com.

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How Effective is That Treatment? The Number Needed to Treat

Abstract

S. Thomas Deahl II, D.M.D., Ph.D.

Introduction As you consider adopting a new treatment (or a new preventive agent) in clinical practice, you should ask a series of questions. Among the most important questions you can ask are as follows: ,V WKH HYLGHQFH IRU WKLV QHZ WUHDWPHQW WUXH LQ RWKHU words, is the evidence valid)? ,V WKLV QHZ WUHDWPHQW IHDVLEOH IRU P\ SUDFWLFH DV ZHOO DV EHQHÀFLDO DQG DIIRUGDEOH IRU P\ SDWLHQWV" ,V WKLV QHZ WUHDWPHQW VXIÀFLHQWO\ HIIHFWLYH WKDW LW LV worth my efforts to adopt (in other words, how effective is this treatment)? Applying these critical questions is especially important today as marketing of dental equipment, instruments, and materials increasingly complete, for the dentist’s attention, with the results of long-term clinical studies. At least these three questions should be answered before adopting a new treatment or preventive agent. This article aims to help you adGUHVV WKH WKLUG TXHVWLRQ 6SHFLÀFDOO\ ZH ZRXOG OLNH WR NQRZ +RZ FDQ we best describe the relative effectiveness of a new treatment (compared to some other treatment we are already using)? This article

The Number Needed to Treat (NNT) is a tool useful for comparing the relative effectiveness of two or more therapeutic or preventive interventions. The NNT may be presented by authors of a clinical research article, or, if not provided, may be calculated by the reader if the authors have reported outcomes as positive or negative per research subject. The NNT is simply calculated as the inverse of the absolute risk reduction. The NNT is most meaningful when reSRUWHG ZLWKLQ D FRQÀGHQFH interval and when describing clinical trials of higher validity such as randomized controlled trials and meta-analyses of such trials. Several example NNTs from the dental and medical literature are reported.

KEY WORDS: EviDeahl II Dr. Deahl is an adjunct associate professor, Department of Developmental Dentistry, University of Texas Health Science Center at San Antonio Dental School, San Antonio, Texas, and The Institute for Natural Resources, Concord, California. Send correspondence to S. Thomas Deahl II, DMD, PhD, Department of Developmental Dentistry, UTHSCSA, 7703 Floyd Curl Drive, San Antonio, Texas 78258. Phone: (210) 567-3500; E-mail deahl@uthscsa.edu.

dence-based dentistry, number needed to treat, effectiveness, clinical trials Tex Dent J 2011; 128(2):211-219.

This article has been peer reviewed.

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How Effective is That Treatment? describes a handy clinical tool called the Number Needed to Treat, abbreviated “NNT,” that helps us compare effectiveness in a useful way. 7KH 117 ZDV ÀUVW UHSRUWHG LQ WKH %ULWLVK OLWHUDWXUH of evidence-based medicine in 1988 and has been advocated and reported in both the British and American literature since then (1–5).

How to Calculate the NNT Let’s assume we have two treatments to compare. We read a journal article in which the new treatment (Agent Blue), has been compared in clinical research to an older and widely used (Control) treatment with regard to the cure of a particular disease. The journal article we read informs us that the researchers have taken 100 patients who have the disease we want to treat, and randomized them to two groups of 50 each (Group 1 and Group 2). The two groups are represented in the “Before Treatment” column of Figure 1, with each patient represented by an “x.”

One hundred percent of patients in both groups have the disease. Now let’s administer the old Control treatment to all Group 1 patients, and the new Agent Blue to all Group 2 patients, as shown in the “Treatment” column of Figure 1. At the end of the study, an examiner checks all of our patients to see which ones still have the disease and which ones do not. Those who still have the disease are indicated with an “x,” and those who have been cured are indicated with an “o,” as shown in the “After Treatment” column of Figure 1. Those in Figure 1 who represent cures above and beyond the Control rate of treatment are represented by o. The NNT is inversely proportional to these Agent Blue-dependent cures, indicated by “o”s, among the entire group. The smaller the NNT, the fewer “x’s” we will need to treat with Agent Blue to get one “o.” In this example, Agent Blue outperforms Control. We note that the Control resulted in 11 out of 50 “cures.” So the Control group is left with a disease rate of 39 / 50 = 0.78 (that is, 78 percent still have the disease). We note that Agent Blue resulted in

Figure 1. Before Treatment Group 1

Group 2

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

Treatment

Control

Agent Blue

After Treatment o o x x x

o x x x x

o x x x x

o x x x x

o x x x x

o x x x x

o x x x x

o x x x x

o x x x x

o x x x x

oooooooooo oooooooooo oooooooooo oooxxxxxxx xxxxxxxxxx

11 “cures” in 50 patients 39/50 = 0.78 still diseased 33 “cures” in 50 patients 17/50 = 0.34 still diseased

x = patient with the disease o = patient without the disease o = patient without the disease, helped by Agent Blue, who would not have been helped by Control treatment

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33 out of 50 “cures�, so these patients are left with a disease rate of 17 / 50 = 0.34 (34 percent still have disease). How can we describe these results? We could calculate the Relative Risk Reduction (RRR), which is the (Control disease rate minus the Experimental disease

rate) divided by the Control disease rate (0.78 – 0.34) / 0.78 = 0.56. This RRR means that Agent %OXH SURYLGHG D SHUFHQW UHODWLYH EHQHÀW WKDW is a 56 percent reduction in the risk for continued disease, compared to the Control treatment. This is summarized in Table 1.

Table 1. Relative Risk Reduction for Agent Blue vs. Control Treatment

Agent Blue vs.

Control Disease

Experimental

Relative Risk

Rate (CDR)

Disease Rate (EDR)

Reduction (RRR)

39 / 50 = 0.78

17 / 50 = 0.34

(0.78-0.34) = 0.56

Control

0.78

What the NNT Means The problem with the RRR is that even trivial results in a large study could give a similar risk reduction. Imagine that we have Agent Green, a new preventive agent, to be administered to 5,000 healthy people for the next 5 years, and with this we hope to reduce the risk for a particular disease. We’ll compare its effectiveness to a Placebo, given to another 5,000 healthy people, during the same 5 years. At the end of the 5-year period we ÀQG GLVHDVH LQ RI WKH 3ODFHER JURXS DQG RI WKH Agent Green group. Again, we calculate a RRR of 0.56. See the calculation of this in Table 2. This is bothersome, as we sense that although, yes, the Agent Green agent does reduce the likelihood of disease better than Placebo; we’d be much less impressed with it than with Agent Blue in the earlier example.

The Number Needed to Treat (NNT) overcomes this problem by taking into account the absolute proportions of the sample cured by each treatment (or control, or placebo). /HW¡V FDOFXODWH WKH 117 IRU RXU Ă€UVW H[DPSOH Agent Blue. We subtract the Experimental disease rate (0.34) from the Control disease rate (0.78) and then take the inverse of the difference: (1 / 0.78-0.34) = 2.3. For discussion purposes we can round 2.3 up to 3. This means that we would need to treat about 3 patients with Agent Blue in order to obtain 1 cure more than could be obtained with the Control treatment. Applying the same calculations to the preventive Agent Green results reveals an NNT of 227. So, although Agent Blue and Agent Green have identical RRRs, they have drastically different NNTs. These cal-

Table 2. Relative Risk Reduction for Agent Green vs. Placebo Control Disease

Experimental

Relative Risk

Rate (CDR)

Disease Rate (EDR)

Reduction (RRR)

Agent Green vs.

39 / 5000 =

17 / 5000 =

(0.0078-0.0034) = 0.56

Placebo

0.0078

0.0034

0.0078

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How Effective is That Treatment? Table 3. Relative Risk Reduction Compared to NNTs

Agent Blue vs. Control

Agent Green vs. Placebo

Control Disease Rate (CDR)

Experimental Disease Rate (EDR)

Relative Risk Reduction (RRR) = CDR - EDR CDR

39 / 50 = 0.78

17 / 50 = 0.34

(0.78-0.34) 0.78 = 0.56

0.78-0.34 = 0.44

= 2.3

39 / 5000 = 0.0078

17 / 5000 = 0.0034

(0.0078-0.0034) 0.0078 =0.56

0.0078-0.0034

= 227

culations and results are shown in Table 3. NNTs of treatments in dentistry are shown in Table 4. Note that they range from 2 (for single dose acetaminophen for preventing postoperative dental pain at 4 – 6 hours after the procedure) to 25 (for prophylactic amoxicillin for preventing single-implant failure within 3 months or more of dental implant placement). Note that the fourth column of Table 4 lists not just the NNT, but also LWV SHUFHQW FRQÀGHQFH LQWHUYDO (CI). This is given to remind us that the NNT calculated from any given article is an estimate of the true NNT, and that the true NNT is 95 percent likely to lie within WKH UDQJH GHVFULEHG E\ FRQÀdence interval (6).

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The last row of Table 4 states NNH rather than NNT. NNH is the “Number Needed to Harm,” and is calculated using the risk of a particular adverse outcome, VXFK DV D VSHFLÀF VLGH HIIHFW RI treatment. NNH is calculated in a way analogous to the NNT, but uses the rates of “adverse event(s)” rather than “cure” or “case of disease prevented.” Of course, we would like the NNH to be a large number and the NNT to be a small number, which would mean that we would have to treat few patients in order to get a cure, but we would have to treat many patients in order to get an adverse event. NNH can only be calculated if the authors have measured the proportion of patients in each group (treatment and control) who have experienced an adverse event. NNH have rarely been reported

Absolute Risk Reduction (ARR) = CDR - EDR

Number Needed to Treat (NNT) = 1 / ARR

= 0.0044

in the dental research literature. The NNH of 2, for retro-second molar periodontal defects following third molar removal, reported in the last row of Table 4 is one of the few examples. An example of NNH from the medical literature relevant to dentistry is as follows: the NNT for treating DVWKPD ZLWK ÁXWLFDVRQH DW ug/day is 2.9 (95 percent CI 2.4 to 3.4) (7). At this dose the NNH for oral candidiasis is 90 (27 to 750), meaning that we’d only expect about one case of oral candidiasis for every 90 patients WUHDWHG ZLWK XJ GD\ ÁXWLFDVRQH ,I WKH GRVH RI ÁXWLFDVRQH is increased to 1000 ug/day, the NNH for oral candidiasis is only 23 (14 to 75). If we have a clinical research paper giving us both NNT and NNH, we could use both to calcu-

Table 4. Some NNTs from Recent Research in Dentistry Treatment YV FRPSDULVRQ [study type]

(QGSRLQW

Number of VXEMHFWV studied

NNT &,

Reference

Acetominophen Single dose [SR of RCTs]

Acute postoperative dental pain 4 to 6 hours after procedure

2690

2.7 (2.5 to 3.0)

(9)

Prophylactic amoxicillin [SR of RCTs]

Prevention of single-implant failure within 3 months or more of dental implant placement

316

25 (13 to 100)

(10)

7RSLFDO Ă XRULGH varnish applied HYHU\ ZHHNV [RCT]

3UHYHQWLRQ RI ZKLWH VSRW OHVLRQV in adolescent patients XQGHUJRLQJ À[HG DSSOLDQFH orthodontic treatment

(CI not SURYLGHG

Guided tissue regeneration, with or without graft materials (vs. open Ă DS GHEULGHPHQW [SR of RCTs]

Gaining at least one extra site with 2mm or more attachment, in periodontal infrabony pockets.

737

8 (5 to 33)

(12)

Systemic antibiotic prophylaxis in third molar surgery [SR of RCTs]

Prevention of alveolar osteitis

2932

13 (9 to 26)

(13)

Systemic antibiotic prophylaxis in third molar surgery [SR of RCTs] (15 to 73)

Prevention of surgical wound infection

2398

25

(13)

Third molar surgery [RCT]

Acquiring periodontal defect on distal of second molar postoperatively, within 6 months of third molar extraction

40

NNH 2

(14)

Explanation: NNT: Number Needed to Treat NNH: Number Needed to Harm SR of RCTs: Systematic review of several randomized controlled trials. RCT: a single randomized controlled trial &, &RQĂ€GHQFH LQWHUYDO &, LV WKH UDQJH RI YDOXHV LQ WKLV FDVH 117 YDOXHV ZLWKLQ ZKLFK ZH H[SHFW WKH WUXH DQVZHU WR reside most of the time. In other words, the true NNT is likely to be somewhere within this range. Texas Dental Journal l www.tda.org l February 2011

215

How Effective is That Treatment? late a ratio called the Likelihood of Help vs. Harm, abbreviated LHH. The LHH is simply the ratio of the NNH to the NNT, and is the likelihood that the patient will be

helped rather than harmed. In WKH ÁXWLFDVRQH H[DPSOH MXVW SUHsented, the LHH for 100 ug/day is 90 / 2.9 = 30, meaning that for every 30 patients helped with their

asthma; approximately one patient would develop oral candidiasis. NNTs of treatments in medicine are shown in Table 5.

Table 5. Some NNTs from Medicine 7UHDWPHQW (vs. comparison) [study type]

Endpoint

117 SHUFHQW CI, when provided)

5HIHUHQFH

Calcium and vitamin D supplementation for 3 years (placebo)

Prevention of one hip fracture

20 (13-57)

(15)

Triple therapy for 6-10 weeks (vs. histamine antagonist) [RCT]

Cure of peptic ulcer

1.1 (1.6-2.1)

(16)

Finasteride for \HDUV (vs. placebo) [RCT]

Prevent benign prostatic K\SHUSODVLD VXIÀFLHQWO\ WR avoid an operation

39 WR

(17)

Duloxetine 80-120 mg/day for 8 to 9 weeks (vs. placebo) [9 pooled clinical trials]

50 percent improvement in symptoms of major depression

7 (5 to 18)

(18)

,QÁXHQ]D YDFFLQH YV SODFHER [RCT]

3UHYHQWLRQ RI ODERUDWRU\ FRQÀUPHG VHDVRQDO LQÁXHQ]D $ and B in adults over age 60 in the winter of 1991-1992

&, QRW provided)

NNH 10 for local reaction Herpes zoster vaccine (vs. placebo) [RCT]

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Texas Dental Journal l www.tda.org l February 2011

Prevention of shingles for three years after vaccination in subjects age 60 or over

175 (CI not provided)

Prevention of shingles for three years after vaccination in subjects age 70 or over

231 (CI not provided)

Prevention of post-herpetic neuralgia for three years after vaccination in subjects 60 or over

1087 (CI not provided)

(20)

Note that the NNT can be calculated when the UHVHDUFKHUV KDYH FODVVLĂ€HG HDFK SDWLHQW DV H[SHriencing either a “positive outcomeâ€? or a “negative outcome.â€? For example let’s suppose a study has reported that in a clinical trial of an analgesic, 32 of 100 patients given placebo experienced at least 50 percent reduction in pain, whereas 70 of 100 patients given the analgesic “Agent Grayâ€? experienced at least 50 percent reduction in pain. Note that in WKLV H[DPSOH KRZ WKH LQYHVWLJDWRUV KDYH GHĂ€QHG D “positive outcomeâ€? as the patient experiencing at least 50 percent reduction in pain, and they have measured each patient against this outcome. Even if the authors did not report an NNT for Agent Gray, a reader could do so by calculating the control disease rate (100 minus 32 patients taking Placebo are still in pain = 68 percent) and the experimental disease rate (100 minus 70 patients taking Agent Gray are still in pain = 30 percent). These control and experimental disease rates could then be used to calculate RRR, ARR, and NNT as shown in Table 6. It is interesting to note that in such articles, not only have the authors provided us with the information with which to calculate the helpful NNT, but they have in so doing also given us their answer to WKH TXHVWLRQ ´:KDW ZRXOG EH D FOLQLFDOO\ VLJQLĂ€FDQW result from this treatment?â€? In this example, a clinLFDOO\ VLJQLĂ€FDQW UHVXOW LQ D VLQJOH SDWLHQW ZRXOG EH “pain reduction of at least 50 percent.â€? We readers are welcome to agree or disagree with the authors’ choice, but at least they have taken a stand on the LPSRUWDQW PDWWHU RI FOLQLFDO VLJQLĂ€FDQFH

Why We Can’t Calculate an NNT for All New Treatments To enable us to calculate an NNT, the article’s auWKRUV PXVW KDYH GHĂ€QHG LQ DGYDQFH RI WKH VWXG\ what constitutes a successful outcome for each patient. At the end of the study they then measure the proportion of patients who attained this successful outcome, and compare them to the proportion who did not attain a successful outcome. For example, in the Agent Blue vs. Control example given earlier, 66 percent of patients taking Agent Blue were cured, whereas only 22 percent of Control patients were cured. As another example, in which “cureâ€? and “no cureâ€? do not strictly apply, DXWKRUV PD\ KDYH GHĂ€QHG ´VXFFHVVÂľ DV UHDFKing a particular threshold, such as “In this study of Analgesic Brown, we considered a patient as a treatment success if he or she reported pain reduction of at least 60 percent at the end of the study. Any patient who reported less than 60 percent SDLQ UHGXFWLRQ ZRXOG EH FODVVLĂ€HG DV D WUHDWPHQW failure.â€? Note how both of these examples provide us an understanding of exactly what proportion of patients reached success, even if the “successâ€? is DUELWUDULO\ GHĂ€QHG DV LQ WKH $QDOJHVLF %URZQ VWXG\ 8QIRUWXQDWHO\ PDQ\ UHVHDUFKHUV GR QRW GHĂ€QH WKH threshold for “successâ€? on a per-patient basis, but instead simply measure each patient on a continuous variable (such as % pain reduction per patient) and then report the mean (average) outcome for each group. For example, an article might report results like these: “Patients treated with Agent Purple reported mean pain reduction of 72 percent, where-

Table 6. Example of an NNT Calculation from Provided Data Control Disease Rate (CDR)

Agent Gray vs. Control

70 / 100 = 0.70

Experimental Disease Rate (EDR)

Relative Risk Reduction (RRR) = CDR - EDR CDR

Absolute Risk Reduction (ARR) = CDR - EDR

Number Needed to Treat (NNT) = 1 / ARR

32 / 100 = 0.32

(0.70 – 0.32) 0.70 = 0.46

0.70 - 0.32 = 0.38

= 2.6

Texas Dental Journal l www.tda.org l February 2011

217

How Effective is That Treatment? as patients treated with placebo reported mean pain reduction of 37 percent.� NNTs cannot be calculated when patient outcomes, measured on a continuous scale, have been averaged for a group of patients. The authors in such a case apparently intend to let the readers decide for themselves how much of a change in the outcome LV FOLQLFDOO\ VLJQLÀFDQW DQG WKH reader does not have the information needed to calculate the NNT. In summary, the NNT is a useful concept with which to compare the effectiveness of various treatments or preventive agents. The NNT is useful when considered in the context of whether evidence is valid (true) and whether it is applicable to a particular patient. Note that the NNT is appropriate for treatments of disease (medical, surgical, behavioral, and so forth) and for preventive methods, but not for diagnostic tests. Although the arithmetic for calculating NNT is simple, online calculators are available for your convenience. An example NNT calculator is available at www. ebem.org/nntcalculator.html. Note that the NNT is only as good as the research on which it is based. NNTs are generally calculated from the results of welldesigned randomized controlled trials (RCTs) and combined reviews (meta-analyses) of such trials. NNTs of less-stringent study designs (cohort studies or case series) would not be worth calculating as they could convey D IDOVH VHQVH RI FRQÀGHQFH LQ WKH

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data. Therefore users should Ă€UVW SD\ DWWHQWLRQ WR WKH YDOLGLW\ of the research article (were the subjects randomized to treatment or control? Were the treating clinicians, the examining clinicians, and the patients all blinded to the treatments provided? Were there at least 30 patients per group? Was there at least an 80 percent completion rate in each group?) If the answers to any of these questions is “no,â€? then an NNT would be of little value.

Questions and Answers about NNT Q. Does NNT predict how my particular patient will respond to a treatment? A. No. Your patient will either respond or not. NNT does not tell you how likely YOUR patient is to respond. An NNT of 5 (95 percent CI 2 – 7) allows us to estimate that in a group of 5 patients treated with the same treatment, one of them will respond, but we cannot predict which patient will respond. Q. Could a large NNT be used by a third-party payer to compare the effectiveness of various treatments, and to exclude certain treatments with large NNTs as not worth paying for? A. This concern was raised in the medical literature soon DIWHU WKH 117 ZDV ÀUVW GHYHO-

oped (8). If I were in charge of an insurance company, that’s exactly what I’d do, assuming I were not collecting so much money that I could afford to pay for everything and anything. Furthermore, if I were a premium payer, I would want my premium dollars to go only to pay, for other policyholders, for treatments with a low NNT so that there would be some dollars left for me when I needed care. Therefore, if I were a clinician, I would be looking for treatments with low NNTs! Q. Can NNT be used to evaluate diagnostic technologies, such as FOTI or 3DCT? A. No. Tools other than NNT are used to evaluate diagnostic technologies. NNT is applicable only to interventions of therapy and prevention. Q. Is NNT the only indicator that I should rely on for comparison of treatments? A. No. NNT is helpful, but only as a statement of the results of research. You must also evaluate its validity (don’t bother applying NNT to non-randomized trials; NNT means little if study size was less than 30 patients per group, etc) and you must evaluate its applicability (even if a treatment has a low NNT, it does not mean much to my practice if the treatment is too expensive, or risky, or something my patients are unlikely to comply with or agree to).

Q. I don’t recall seeing NNTs reported in the last few articles I’ve read. Are they commonly reported in journals? A. Until recently, relatively few dental clinical research articles have provided NNTs. They have been very popular in the medical literature and are catching on in dentistry. <RX FDQ ÀQG DUWLFOH DEVWUDFWV reporting numbers needed to treat from relatively valid articles in dentistry by typing the following into the search box at PubMed www. ncbi.nlm.nih.gov/pubmed: (“number needed to treat” AND dentistry) AND (MetaAnalysis[ptyp] OR Randomized Controlled Trial[ptyp]) References 1.

2.

3.

4.

5.

Laupacis A, Sackett DL, Roberts RS. An assessment of clinically useful measures of the consequences of treatment. New England Journal of Medicine 318(26):1728-1733, 1988. Moore A. What is an NNT? Monograph in the What Is? Series. April 2009. http://www. medicine.ox.ac.uk/bandolier/ painres/download/whatis/ NNT.pdf as accessed March 2, 2010. Watt E, Burrell A. Implementing NNTs. Monograph in the What Is? Series. April 2009. http://www.medicine.ox.ac. uk/bandolier/painres/download/whatis/Imp-NNTs.pdf as accessed March 2, 2010. Simon S. Number needed to treat. Monograph in the “Ask Dr. Mean” series. Children’s Mercy Hospitals & Clinics, July 2008. http://www.childrens-mercy.org/stats/ask/nnt. asp as accessed March 2, 2010 Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine, 3rd edition. New York: Elsevier 2005.

6.

7.

8.

9.

10.

11.

12.

13.

14.

Anonymous. Swot’s Corner: 117V DQG &RQÀGHQFH ,QWHUvals. Bandolier http://www. medicine.ox.ac.uk/bandolier/ band18/b18-9.html as accessed March 2, 2010. Powell H, Gibson PG. Inhaled corticosteroid doses in asthma: an evidence-based approach. Medical Journal of Australia 178:223-225, 2003. Black HR, Crocitto MT. Number needed to treat: Solid science or a path to pernicious rationing? American Journal of Hypertension 11(8):128S134S, 1998. Derry C, Derry S, Moore RA, McQuay HJ. Single dose oral ibuprofen for acute postoperative pain in adults. Cochrane Database of Systematic Reviews (3):CD001548, 2009 Esposito M, Grusovin MG, Talati M, Coutthard P, Oliver R, Worthington HV. Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications. Cochrane Database of Systematic Reviews (3):CD004152, 2008 Stecksen-Blicks C, Renfors G, Oscarson ND, Bergstrand F, Twetman S. Caries-preventive HIIHFWLYHQHVV RI D ÁXRULGH YDUnish: a randomized controlled WULDO LQ DGROHVFHQWV ZLWK À[HG orthodontic appliances. Caries Research 41(6):455-9, 2007. Needleman IG, Worthington HV, Giedrys-Leeper E, Tucker RJ. Guided tissue regeneration for periodontal infra-bony defects. Cochrane Database of Systematic Reviews (2) CD01724, 2006. Ren YF, Malmstrom HS. Effectiveness of antibiotic prophylaxis in third molar surgery: a meta-analysis of randomized controlled clinical trials. Journal of Oral and Maxillofacial Surgery 65(10):1909-21, 2007 Karapataki S, Hugoson A, Kugelberg CF. Healing following GTR treatment of bone de-

15.

16.

17.

18.

19.

20.

fects distal to mandibular 2nd molars after surgical removal of impacted 3rd molars. Journal of Clinical Periodontology 27(5)325-32, 2000. Chapuy MC, Arlot ME, Debouef F. Vitamin D3 and calcium to prevent hip fractures in elderly women. New England Journal of Medicine 327:1637-42, 1992. Moore RA. Helicobacter pylori and peptic ulcer. A systematic review of effectiveness and overview of the economic EHQHÀWV RI LPSOHPHQWLQJ WKDW which is known to be effective. 1994 December. Bandolier http://www.medicine.ox.ac. uk/bandolier/bandopubs/ hpyl/hpall.html as accessed March 2, 2010. Anonymous. More on BPH. Bandolier 46, December 1997. http://www.medicine.ox.ac. uk/bandolier/band46/b46-4. html accessed March 2, 2010. Cookson J, Gilaberte I, Desaiah D, Kajdasz DK. TreatPHQW EHQHÀWV RI GXOR[HWLQH LQ major depressive disorder as assessed by number needed to treat. International Clinical Psychopharmacology 2006 September;21(5):267-72. Anonymous. Prevention DQG WUHDWPHQW RI LQÁXHQ]D $ and B. Therapeutics Letter, November/December 2000, Therapeutics Initiative, University of British Columbia. Shootsky SA. Live attenuated varicella-zoster vaccine: Is it worth it? UCLA Department of Medicine Clinical Commentary, February 20, 2007. http://www.med.ucla.edu/ modules/wfsection/article. php?articleid=294 As accessed April 26, 2010.

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219

In Memoriam Those in the dental community who have recently passed Gilcrease, Walter Lewis San Marcos, Texas November 20, 1931 РNovember 17, 2010 /WWL .MTTW_ !! Π4QNM !!

Hardeman, Strotha E. .WZ\ ?WZ\P <M`I[ 7K\WJMZ ! ! ¡ December 11, 2010 /WWL .MTTW_ !! ÂŒ 4QNM !!

Grove, Arthur Henry Sherwood, Arkansas November 25, 1926 РDecember 5, 2010 /WWL .MTTW_ ! ! Π4QNM !! .QN\a AMIZ

Ivy, Ralph Carroll El Paso, Texas June 30, 1920 РNovember 18, 2010 /WWL .MTTW_ ! Π4QNM ! .QN\a AMIZ

Wells, Joe Edward ?QKPQ\I .ITT[ <M`I[ 5IZKP ! ¡ December 11, 2010 /WWL .MTTW_ ! ÂŒ 4QNM ! ! .QN\a AMIZ

Memorial and Honorarium Donors to the Texas Dental Association Smiles Foundation In Honor of: Dr. Norman Speck Dr. Stephen Buehler Dr. Diana Smith Dr. Frank Greider ,Z )VLa ,WMZÆMZ Dr. Annette Gemp Dr. Behzad Nazari Dr. Matthew Gemp Dr. Ronada Davis Dr. Chris Gowan Dr. Russell Hilliard Dr. Mark Speck Dr. Helen Jafari Dr. Bradley Wilson Dr. Terry Ott Dr. Mark Hiller Dr. Stephen Lukin Dr. John Weatherford Dr. John Glauser Dr. Arezo Zarghouni Dr. Brian Martinez Dr. Fadi Salha Dr. David Emmers Dr. Raja Nasir Dr. John Stockman Dr. Jeffrey Hoover Dr. Chester Barker Dr. Stephen Cheff Dr. Rhil Buckley Dr. Donald Lee Dr. Byron J. Hall Dr. Ron Hill Dr. James Seale *a ;IU]MT 0 )LIU[ 11 , , ;

In Honor of:

In Memory of: Jean Coffey George Elder Alice Volney Marjorie Lawless Calvin Clayton Roger Smith Margaret Lilly R. Dean Cleveland Ted Keck Annie Kirk Murphy Maxine Moody Edward Foster *a ,Z *M^MZTa BQV[MZ

In Memory of: Dr. Lewis Gilcrease *a ,Z 5Z[ :][[MTT 8I]TI 7_MV[

Dr. Jorge Quirch Dr. Jerry Long Dr. Rhonda Davis

The Honorable Jim White *a ,Z 5Z[ ,WV 4]\M[

*a 5MLQKIT +MV\MZ -VLWLWV\QK[ ,Z[ /IZITI 3IXILQI /WZLWV ?MTKP

Brad Hatten *a ,Z 5Z[ :][[MTT 8I]TI 7_MV[

AW]Z UMUWZQIT KWV\ZQJ]\QWV []XXWZ\[" ΠML]KI\QVO \PM X]JTQK IVL XZWNM[[QWV IJW]\ WZIT PMIT\P# IVL ΠQUXZW^QVO IKKM[[ \W LMV\IT KIZM NWZ \PM XMWXTM WN <M`I[ 8TMI[M UISM aW]Z KPMKS XIaIJTM \W" TDA Smiles Foundation, 1946 S IH 35, Austin, TX 78704

220

Texas Dental Journal l www.tda.org l February 2011

Oral and Maxillofacial Pathology Case of the Month Clinical History This case involves a 95-year-old male patient with a history of papillary and/or verrucous gingival lesions which had been removed several times. 7KH SDWLHQW KDV D PHGLFDO KLVWRU\ VLJQLÀFDQW IRU prostate cancer and breast cancer, and he is currently on tamoxifen.

John E. Kacher, D.D.S., director, JKJ Pathology —Oral Medicine/Oral Pathology, The Woodlands, Texas

Kacher

Three biopsies had been performed in the past, all from either the right or left facial mandibular JLQJLYD 7KH ÀUVW ZDV GLDJQRVHG DV ´DW\SLFDO SDSillary hyperplasia with lichenoid change” 3 years ago (Figure 1). The next biopsy was performed 3 months ago and was signed out as “verrucous hyperplasia with epithelial dysplasia, moderate” (Figure 2) The last biopsy was diagnosed 1 month ago as “epithelial dysplasia, severe” (Figure 3).

What is your diagnosis? See page 225 for the answer and discussion.

Figure 1. Appearance of original lesion as an exophytic growth of the right mandibular facial gingiva with a papillary/verrucous surface.

Figure 2. Second lesion presenting as a leukoplakic verrucous lesion on the anterior marginal mandibular gingiva. Figure 3. Histology of third lesion, exhibiting a somewhat papillary surface with dysplastic changes that focally extend into the upper third of the epithelium. Texas Dental Journal l www.tda.org l February 2011

221

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7Ke &KaUaFteUistiFs RI Thriving Dentists

Kirk Behrendt, ACT Speaker & Coach

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3RZeU 6teSs 7R 0ake Your Practice Thrive In Any Economy Friday, May 6, 2011 8:30 AM – 11:30 AM 6teSs 7R ,QsSiUe <RXU Team To Sell More Dentistry Friday, May 6, 2011 1:30 PM – 4:30 PM The 12 Most Effective Dental Marketing Tactics Available Today Saturday, May 7, 2011 8:30 AM – 11:30 AM

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Traveling all over the world and observing thousands of dental practices operate; we have noticed some very clear trends that are becoming more obvious with every month that passes. Basically, there are two distinct groups in dentistry. There are those who are thriving in practice, and there are those who are starving in practice. Years ago, you could be clueless as to how to run a business and still make money in dentistry if you had a dental license. That is simply not the case any PRUH 7KH SOD\LQJ ÀHOG LV QRZ OHYHO 'HQWLVWV DUH QRZ IXOO\ H[SRVHG WR WKH H[DFW same challenges that every entrepreneur has to deal with in growing a business. Dentists who recognize this trend have embraced it to thrive in dentistry. Others who have resisted this trend tend to struggle for the oxygen to keep their practice breathing. The time has come for dentists to whole-heartedly choose one of these two paths. This month we examine the nine common characteristics of the thriving dentist: 1.

They Have Purpose, Conviction, and Clarity of Vision. The thriving dentist can tell you without hesitation where they are planning to go and what they SODQ WR GR RQFH WKH\ JHW WKHUH <RX < DOPRVW QHYHU VHH WKHP ZDIĂ H ZKHQ LW comes to sharing what they believe about dentistry. Procuring this purpose, FRQYLFWLRQ DQG YLVLRQ KDV GHYHORSHG WKHP LQWR GHQWLVWU\Ň‹V ELJJHVW GHĂ€FLHQF\ÂŤ great leaders.

2.

They Are Hungry in Learning. The thriving dentist has an intense appetite for learning. Continuing Education has never been an expense. It is actually exciting. They don’t hesitate to take their entire team to a course that seemingly has value. They know that they don’t know everything. Pete Dawson

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VDLG WR PH WKH Ă€UVW WLPH ZH PHW ´%H YHU\ FDUHIXO RI WKH GHQWLVW ZKR KDV LW DOO Ă€JXUHG RXW (YHQ at my age and experience I have never thought WKDW , KDG LW DOO Ă€JXUHG RXW , OHDUQ VRPHWKLQJ new all the time from my students. It is very exciting.â€? 3.

They Learn Best By Doing. While being hungry in learning, they understand that the best way to truly learn is to DO. They know that the best way to learn how to swim is to jump right in. Adult learning is most effective experientially. Ken Blanchard said that the “biggest gap in the world is between knowledge and application.â€? Starving dentists see this gap in application with pessimistic achievability, while the thriving dentist sees it with optimistic achievability and a QHFHVVDU\ SDVVDJHZD\ WR IXOĂ€OOLQJ WKHLU SXUpose. They know that there are “no shortcutsâ€? to becoming the best, and that it may include some great failures along the way.

4.

They Have Great Support and “Touchableâ€? Mentors or Coaches. They have spent a lifetime surrounding themselves with the right people. They found mentors, coaches, or LQVWUXFWRUV WKDW WKH\ ZHUH DEOH WR FUHDWH VLJQLĂ€cant relationships with and share in a process of intimate learned experience. These mentors or coaches are “touchableâ€? which means that they have an intimate working relationship that includes critical feedback (not just someone they met a few years ago that gets together with them for dinner once and a while). They also (consciously or unconsciously) have practiced what Michael Collins revealed in his book “Good to *UHDW :K\ 6RPH &RPSDQLHV 0DNH WKH /HDSÂŤ and Others Don’tâ€? in which he said, “Contrary to popular belief, people are NOT our greatest asVHWÂŤRQO\ WKH 5,*+7 3(23/( DUH RXU JUHDWHVW asset.â€? Who they have become in dentistry has been an evolutionary process that has attracted, kept and appropriately nurtured great talent that KDV IXHOHG VLJQLĂ€FDQW JURZWKÂŤSHUVRQDOO\ DQG professionally.

5.

Their Practice is Structured for Success. They have very clear goals and monitor them constantly. The entire operation is very well VWUXFWXUHG ZLWK V\VWHPV WKDW UHĂ HFW WKH SXUSRVH that is being served. Ambiguity is an enemy to their practice. Very rarely do you ask a team member in a thriving practice a question about

Thriving dentists IBWF UBLFO UIF TUFQT to make sure that the JNBHF BOE CSBOE UIFZ QSPKFDU BSF SFĂŠFDUFE XJUI HSFBU BDDVSBDZ JO XIBU UIFJS QBUJFOUT BDUVBMMZ FYQFSJFODF

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Thriving Dentists exceed the standards of that picture will greatly determine how successful you are in living out your vision. You would hope that people don’t judge a book by its FRYHUÂŤEXW WKH\ GRÂŤDQG \RX GR WR 7KH RWKHU WKLQJ WR recognize with “looking the partâ€? is that our standards grow higher every month with every new shopping mall, high end coffee shop and brilliant restaurant that opens around us. Consumers’ expectations are growLQJ DW H[SRQHQWLDO UDWHV ,W LV LPSRUWDQW WKDW \RX UHĂ HFW the image of being “with or ahead of the curve.â€?

how they do things and you are met with the reply “I’m not sure.â€? Predictability in daily business operations and predictability in the delivery of technical dentistry becomes the critical component to how high their IXOĂ€OOPHQW OHYHO DFWXDOO\ LV 6.

7.

8.

224

They Understand That “Dentistry is 51 Percent %XsiQess aQG 3eUFeQt 7eFKQiFalÂľ This is great quote given to me by my friend Dr. Gary DeWood of the Pankey Institute that is so incredibly true. Knowing how to do the dentistry is not nearly enough to run a successful practice. The thriving dentist knows that cash is to their business what oxygen is to their life. And that living in a surplus of cash is a byproduct RI EHLQJ DQ H[WUDRUGLQDU\ EXVLQHVVÂŤ QRW WKH SULPDU\ goal. The thriving dentist has developed a hungry awareness of how successful businesses (or practices) work and would almost certainly be successful in any other profession for this reason. They Are Excellent Communicators. Thriving GHQWLVWV KDYH HPEUDFHG D OLIHORQJ MRXUQH\ IRU VLJQLĂ€cant relationships. They have done this not only in practice, but also in life. They understand that truly effective communication has a lot to do with non-verbal messaging, intense listening, and sometimes talking. Some of the highest producing dentists that we coach actually do very little talking (in comparison to their patients) in their new patient experience. They have an incredible ability to get patients talking in a way that they feel excited about themselves. Patients most often end up being the driving force in treatment plans rather than the dentist and teams. The thriving dentist KDV D FRQĂ€GHQW SRVWXUH UHĂ HFWHG ZLWK JUHDW VLQFHULW\ that procures higher levels of trust and likeability. They Look The Part. Thriving dentists have taken the steps to make sure that the image and brand they SURMHFW LV UHĂ HFWHG ZLWK JUHDW DFFXUDF\ LQ ZKDW WKHLU patients actually experience. They walk the talk. They are everything other patients say they are. They dress like patients would expect them to dress. The esthetLFV RI WKHLU IDFLOLW\ UHĂ HFW ZKDW SDWLHQWV ZRXOG H[SHFW to see. Their practice is usually in a great location. You see, people create an image of who you might be when they hear about you. How well you meet or

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9.

They Do a TON of Marketing. 7KULYLQJ GHQWLVWV Ă€UVW of all understand that marketing is not just and external effort, but rather EVERYTHING THEY DO. Their internal operations and how they train patients to refer are very well choreographed. They are willing to take great risks when it comes to projecting their brand. Their website is top notch. Their image pieces (logo, stationary, etc) are very sharp. Their staff clearly UHĂ HFWV WKHLU EUDQG 7KHLU DGV VXSSRUW HYHU\WKLQJ WKH patient truly experiences in their practice. The lab they use is the best. They are involved with organized dentistry and most often respected by their peers. Marketing for them is doing everything they possibly can to increase the “top of mindâ€? awareness for anyone who is considering their kind of services.

Where you are in dentistry is a choice. It may be conscious or unconscious, but nevertheless, it is still a choice. If you are thriving in dentistry, and you read these nine characteristics, it probably supported the beliefs you already have and act on. You have chosen to thrive. On the other hand, if you are starving and you read this article, you may have discounted a few of these characteristics as “things I should have doneâ€? or “things I can’t doâ€?. ,Q WKDW FDVH , VWURQJO\ VXJJHVW WKDW \RX Ă€QG VRPH FRPIRUW in the current state of your practice, because the future will only be a slight variation of what you have now. Choosing to thrive is something very few people do. We were given this great gift of choice. My hope is that you use it wisely and let it work its magic in your life.

Oral and Maxillofacial Pathology Diagnosis and Management

Proliferative Verrucous Leukoplakia Oral and Maxillofacial Pathology Case of the Month (from page 221)

Discussion Proliferative Verrucous Leukoplakia (PVL) is a rare multifocal leukoplakia GHÀQHG E\ ERWK FOLQLFDO DQG KLVWRpathologic parameters. This disease typically begins with white plaques which slowly spread and tend to recur after biopsy. Both the clinical and histologic appearance occupy D VSHFWUXP RI FKDQJHV IURP ÁDW hyperkeratoses to verrucous lesions that may demonstrate varying levels of dysplasia (1).

als using drugs that inhibit viral RNA synthesis have been attempted (4). The differential diagnosis for PVL based on clinical information includes: verrucous hyperplasia with dysplasia, verrucous carcinoma, or atypical papilloma. It is important to note that clinical history plays a large part in diagnosis of PVL. This case was diagnosed based on the history of spreading verrucous leukoplakic lesions that recur, and histopatholoJ\ WKDW ÀWV LQWR WKH VSHFWUXP RI 39/

PVL has a strong female predilection and is not associated with any traditional risk factors for oral cancer. The progression is relentless with eventual transformation into invasive squamous cell carcinoma. One study demonstrated that with a mean time of 7.7 years, 70.3 percent of patients developed oral cancer at a PVL site (2).

This particular patient is being referred to a major cancer center for potential enrollment in a drug trial.

Other studies have demonstrated an association between PVL and infection with human papillomavirus, most notably type 16 (3). Due to WKH GLIÀFXOW\ RI WUHDWLQJ WKH GLVHDVH from a surgical approach, some tri-

2.

3.

4.

Palefsky J, Silverman S, et al. Association between proliferative verrucous leukoplakia and infection with human papillomavirus type 16: J. of Oral Pathology & Medicine (1995) 24:5 193-197. Azfar, RS James, WD. Proliferative Verrucous Leukoplakia: Treatment & Medication. eMedicine Specialties -> Dermatology 12/16/2009.

Special thanks to Dr. Gayle Bradshaw for sharing this case. Website: www.bradshawperiodontics.com

References 1.

Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology, 2nd edition. Philadelphia: WB Saunders Company 2002; 607-608. Silerman S, Gorsky M. Proliferative verrucous leukoplakia: A follow-up study of 54 cases: Oral Surg Oral Med Oral Pathol Oral Radiol Endod (1997) 84:2 154157.

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Provided by TDA Perks Program

value for your

profession

Does Payroll Outsourcing Make Sense for Your Practice? Brian Bauml, President, Netchex Central Texas, LLC +DYLQJ \RXU RZQ GHQWDO SUDFWLFH FDQ EH D ÀQDQFLDOO\ DQG SHUVRQally rewarding experience. As with every entrepreneurial endeavor, the positive aspects of running your own business are tempered by the realities of hiring and developing staff, keeping up with the latest dental technologies and techniques, submitting required reporting to the government—on time and accurately, managing your receivables, and dealing with the inevitable insurance reimbursement headaches. Although some of these issues are unique to a dental or medical practice, you wouldn’t be the only small business owner who wishes he had more time to focus on growing and managing his business and could spend less time on activities WKDW GLGQҋW FRQWULEXWH WR ERWWRP OLQH SURÀWV For many entrepreneurs, this is possible through outsourcing tasks that take up their time but don’t help their business JURZ RU EHFRPH PRUH SURÀWDEOH ,I \RXҋUH

226

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tired of all the headaches associated with paying your employees, it might be time to outsource your time tracking, payroll, and HR activities to a reliable, competent and time tested business partner.

Processing payroll is a high-risk, low-reward business activity. If you process payroll manually, you’ve got to keep track of payroll regulations and changes in withholding tables—a time-consuming task. Calculating the actual payroll amounts and deductions are equally tedious; and it’s very easy to make a mistake. Then, there’s the arduous chore of writing checks and making all the SURSHU TXDUWHUO\ DQG HQG RI \HDU ÀOLQJV IRU IHGHUDO DQG state payroll taxes. It’s not uncommon for small businesses to spend 2 to 3 hours processing each payroll, if they do it by hand or use payroll software.

Mistakes are costly. Employee morale dips when you give an employee a check or a W2 with errors. If payroll records are accidently accessed by the wrong staff person, pay-rate GLIIHUHQWLDOV RU RWKHU FRQÀGHQWLDO LQIRUPDWLRQ FDQ EH breached. Employees may forgive, but they might not IRUJHW ,I \RX ÀOH ODWH RU ZLWK DQ LQFRUUHFW DPRXQW \RXҋOO have to pay a payroll penalty. Every year, four out of ten VPDOO EXVLQHVVHV SD\ DQ DYHUDJH SD\UROO ÀQH RI for payroll errors. When you add it all up, that’s billions RI GROODUV LQ SD\UROO ÀQHV :KHQ \RX FRQVLGHU WKHVH payroll penalties and the value of your time, processing payroll internally can be a very costly proposition.

Already Outsource?

services, you can enter and view payroll information from anywhere at any time, as long as you have Internet access. 3UHGHÀQHG DQG HPSOR\HU FUHDWHG UHSRUWV OHW \RX WUDFN and monitor your payroll, hours worked, and HR data. Employers have online access to payroll reports from D VHFXUH ZHE VLWH 3D\UROO LQIRUPDWLRQ FDQ EH PRGLÀHG in real time, and calculations viewed instantly, guaranteeing an accurate payroll every time. Employees can view and print their payroll records and W2s, alleviating administrative burden that frequently arises when employees need proof of payment history for loan applications and other purposes. Payroll can be processed whenever it’s convenient. Paychecks can be printed, signed, stuffed and delivered or routed to your employee’s bank accounts electronically via direct deposit. Once you enter your payroll data or import hours from an automated time clock, web-based payroll services can automatically calculate, GHGXFW SD\ DQG ÀOH DOO IHGHUDO 6WDWH DQG ORFDO WD[HV W-2s are automatically prepared at the end of the year DQG ÀOHG ZLWK WKH 6RFLDO 6HFXULW\ DGPLQLVWUDWLRQ

Save Time and Money Beyond increased control, online payroll services save small-business owners time and money. It only takes a few minutes to process payroll online, so your time could be freed up for more important things; like caring for your patients, expanding your practice, accelerating receivables, recruiting the right new employee, or spending more time with your family.

Even if you’re already outsourcing payroll, there may be room for improvement. Payroll services change over time, and there are new capabilities that are worth checking out. If you’ve already outsourced to a service bureau, CPA or bookkeeper, it’s worth considering whether your provider is giving you everything you want at the best price point. Payroll service offerings today, including automated time and attendance tracking options and human-resource record keeping, are better than ever.

How do the new payroll services save money? If a payroll service is processing thousands of payrolls for its clients, economies of scale allow it to work more HIIHFWLYHO\ DQG HIÀFLHQWO\ DQG WKRVH VDYLQJV FDQ EH passed on to its clients. In addition, because new online payroll services don’t have the same cost structure as traditional ones, their prices can be as much as 15 - 25 percent lower. Moreover, many payroll services guarantee that you won’t incur a payroll tax penalty, which can represent considerable savings.

The Benefits of WebBased Payroll Services

Other Considerations

Enhanced Control and Accessibility The internet has greatly improved the process of outVRXUFLQJ SD\UROO 7KH NH\ EHQHĂ€W RI DQ RQOLQH SD\UROO service is enhanced control. With web-based payroll

Once you’ve decided that outsourcing your payroll makes sense, it’s a good idea to gather information and ask questions that will help you select the best business partner. Consider the following: 1. What type of company you prefer: a large multinational, publically traded company or a privatelyheld regional processor? Large companies offer Texas Dental Journal l www.tda.org l February 2011

227

safety in numbers; but a small business might not get the attention it deserves. Large companies have deep pockets, but are shareholder-focused. Accordingly, they operate quarter-to-quarter, which can cause annual price increases DQG DIIHFW LQWHUQDO VWDIÀQJ DQG service levels. If you choose a regional processor, make sure payroll outsourcing is its core business; not a side one. Because losing even a small client has a large impact on a smaller company, customer service—by necessity—is a VWURQJ EHQHÀW LW FDQ RIIHU LWV customers. Smaller companies tend to be more nimble, and can adapt more quickly to changes in technology, client requirements and expectations. Look for a smaller provider who has a track record of at least 5 to 7 years. Make sure it assumes liability in writLQJ IRU PLVWDNHV LI LW PLVÀOHV your taxes. Speaking of taxes, another desirable feature that offers employer peace of mind is a service provider’s ability to direct you to the IRS e-File website that documents what SD\UROO WD[HV KDYH EHHQ ÀOHG on your behalf, and when they were submitted. 2. Request a copy of the provider’s SAS70 document. This provides a written third-party review over the company’s policies and procedures, (including business continuity and security,) which publicly-traded companies must provide to third-party auditors in order to be in compliance with Sarbanes-Oxley reporting requirements. Even better would be an SAS70II document, which not only describes policies and procedures, but also tests them in a production environment.

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3. Ask a prospective company how its employees are trained. Are they herded into a classroom with eight other unrelated companies with varying payroll expertise, or are they personally trained on appropriate applications? 4. Ask your prospective service provider about its customer service model and culture. Many large payroll outsourcing companies use voice-response technology to route your call to the correct support group. Once you’re in the appropriate department, your account is supported in a call-center environment. Smaller providers typically offer a dedicated customer service contact backed up by a team, and have its calls answered by a live person who will route you to the correct service group. This can provide clients faster, more accurate, consistent and personalized support when it’s needed most. If you require more functionality than automated time and attendance tracking, does your potential service provider have what you need, and does it include it as part of its product offering? Is it supported by the same point of contact you’d have for your payroll service? If so, how integrated are the applications? Do you need to log in using multiple user IDs and passwords? 5. Almost all payroll service providers offer a web interface, out of necessity. Unfortunately, many clients don’t realize until it’s too late that their web access is actually tied to a mainframe computer. Here’s DQ HDV\ ZD\ IRU \RX WR ÀQG RXW if yours is: Check whether or not the application is accessible from any Internet Explorer browser, or if a workstation

PXVW GRZQORDG D GLJLWDO FHUWLĂ€cate to access the application over the Internet. Or, if you’re accessing a preview of your processed payroll, check if the preview occurs instantaneously, or if it takes 30-60 minutes, because the data needs to be “crunchedâ€? by a mainframe. 6. Lastly, if things go wrong who can you turn to? Ask your sales contact how long he’s worked for his current employer. It’s not unusual for sales persons to come and go frequently, minimizing your chance of having a friendly ally available, if needed. How far up the “chainâ€? can you go if you have a problem that can’t (or won’t) get resolved? It’s very important to have executive sponsorship to insure that you’ll have a favorable outsourcing experience. With many large companies, the buck usually stops with a regional vicepresident of customer service; while with a smaller company, a client can speak directly with the CEO if necessary. In summary, outsourcing payroll is truly a viable alternative in today’s workplace. It simply doesn’t make sense to waste time, money and resources on a tedious task that is ancillary to your core business. If you determine that outsourcing is right for you, conducting due GLOLJHQFH LV NH\ WR Ă€QGLQJ WKH ULJKW payroll service. NetChex, a TDA Perks partner, offers payroll, human resources, reporting and labor management services, and was recently named in Inc. magazine’s list of the 5,000 fastest-growing companies in the country. For more information regarding NetChex, please call: (877) 729-2661. For more information regarding TDA Perks Program, visit www.tdaperks.com, or call (512) 443-3675.

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Calendar of Events 230

0aUFK 2–5 The Alliance of the American Dental Association will hold a conference in Richmond, VA. For more information, please contact Ms. Patricia Rubik-Rothstein, AADA, 211 E. Chicago Ave., Ste. 730, Chicago, IL 60611-2678. Phone: (312) 440-2865; FAX: (312) 440-2587; E-mail: manager@allianceada.org; Web: ada.org. 2–9 The American Academy of Dental Practice Administration will hold its annual meeting at the JW Marriott Resort in San Antonio, TX. For more information, please contact Ms. Kathy S. Uebel, AADPA, 1063 Whippoorwill Ln., Palatine, IL 60067. Phone: (847) 934-4404; FAX: (847) 934-4410; E-mail: executivedirector@aadpa.org; Web: aadpa.org. 2–5 The Academy of Laser Dentistry will hold its 18th annual conference and exhibition at the Loews Coronado Bay Resort in San Diego, CA. For more information, please contact Ms. Gail Siminovsky, ALD, 3300 University Dr., Ste. 704, Coral Springs, FL 33075. Phone: (954) 346-3776; FAX: (954) 757-2598; E-mail: laserexec@laserdentistry.org; Web: lasterdentistry.org. 3–5 The Academy of Osseointegration will hold its annual meeting, From Fundamentals to New Technologies for the next 25 Years, at the Washington DC Convention Center in Washington, DC. For more information, please contact Ms. Gina Seegers, 85 W. Algonquin Rd., Ste. 550, Arlington Heights, IL 60005-4422. Phone: (847) 439-1919; FAX: (847) 439-1569; E-mail: ginaseegers@osseo.org; Web: osseo.org. 11 – 16 The Omicron Kappa Upsilon will meet in San Diego, CA. For more information, please contact Dr. Jon B. Suzuki, OKU, Temple University Dentistry, 3223 North Broad St., Philadelphia, PA 19140. Phone: (215) 707-7667; FAX: (215) 707-7669; E-mail: suzuki@dental.temple.edu; Web: oku.org. 11 – 16 The American Dental Education Association will hold its annual session and exhibition at the Manchester Grand Hyatt in San Diego, CA. For more information, please contact Ms. Michelle Allgauer, ADEA, 1400 K Street, NW, Ste. 1100, Washington, DC 20005. Phone: (202) 289-7201; FAX: (202) 289-7204; E-mail: allgauerm@adea.org; Web: adea.org. $SUil 11 – 13 The American Association of Public Health Dentistry will hold its National Oral Health Conference at the Hilton Pittsburgh in Pittsburgh, PA. For more information, please contact Ms. Pamela J. Tolson, CAE, 3085 Stevenson Dr., 6SULQJÀHOG ,/ 3KRQH )$; ( PDLO QDWRII#DDSKG RUJ :HE DDSKG RUJ 13 – 16 The American Association of Endodontists will hold its annual session at the San Antonio Convention Center in San Antonio, TX. For more information, please contact Mr. James M. Drinan, AAE, 211 E. Chicago Ave., Ste. 1100, Chicago, IL 60611-2616. Phone: (312) 266-7255; FAX: (312) 266-9867; E-mail: jdrinan@aae.org; Web: aae.org. 15 &16 The TDA Smiles Foundation (TDASF) will hold a Texas Mission of Mercy event in Dallas, TX. For more information, please contact TDASF, 1946 S. IH 35, Ste. 300, Austin, TX 78704; Phone: (512) 448-2441; Web: tdasf.org. 28 – 30 The American Dental Society of Anesthesiology will hold its annual meeting at the Westin Keirland Resort & Spa in Scottsdale, AZ. For more information, please contact Ms. Barbra Josephson, ADSA, 211 E. Chicago Ave., Ste. 780, Chicago, IL 60611. Phone: (312) 664-8270; FAX: (312) 642-9713; E-mail: barbra.josephson@mac.com; Web: adsahome.org. 0a\ 5–8 The Texas Dental Association will hold its 141st annual session, The TEXAS Meeting, at the Henry B. Gonzalez Convention Center in San Antonio, Texas. For more information, please contact TDA, 1946 S. IH 35, Ste. 400, Austin, TX 78704. Phone: (512) 443-3675; FAX: (512) 443-3031; Web: texasmeeting.com. 6 The TDA Smiles Foundation (TDASF) will hold its Healthy Smiles Golf Classic in San Antonio, TX. For more information, please contact TDASF, 1946 S. IH 35, Ste. 300, Austin, TX 78704; Phone: (512) 443-2441; Web: tdasf.org.

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17 – 21 7KH $PHULFDQ $FDGHP\ RI &RVPHWLF 'HQWLVWU\ ZLOO KROG LWV DQQXDO VFLHQWLĂ€F VHVVLRQ DW WKH +\QHV &RQYHQWLRQ &HQWHU in Boston, MA. For more information, please contact Ms. Kelly Radcliff, AACD, 5401 World Dairy Dr., Madison, WI 53718. Phone: (800)543-9220; FAX: (608)222-9540; E-mail: kelly@aacd.com; Web: aacd.com. 26 – 29 The American Academy of Pediatric Dentistry will hold its 64th annual session at the Marriott Marquis New York in New York, NY. For more information, please contact Dr. John S. Rutkauskas, CAE, AAPD, 211 E. Chicago Ave., Ste. 1700, Chicago, IL 60611-2663. Phone: (312) 337-2169; FAX: (312) 337-6329; E-mail: jrutkauskas@aapd.org; Web: aapd.org. -XQH 11 The TDA Smiles Foundation (TDASF) will hold a Smiles on Wheels mission in Mineral Wells, TX. For more information, please contact TDASF, 1946 S. IH 35, Ste. 300, Austin, TX 78704; Phone: (512) 448-2441; Web: tdasf.org. 15 – 18 The ADA will hold its 25th New Dentist Conference in Chicago, IL. For more information, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org. 17 – 18 7KH 6RXWKZHVWHUQ 6RFLHW\ RI 2UDO 0HGLFLQH ZLOO KROG LWV QG DQQXDO PHHWLQJ ´'LDEHWHV ,QĂ DPPDWRU\ 3HULRGRQWDO Disease and the Relationship to Systemic Health,â€? at the Marriott Plaza San Antonio Hotel in San Antonio, TX. For more information, please contact Dr. Ron Trowbridge, 2943 Thousand Oaks, Ste. 4, San Antonio, TX 78247. Phone (210) 653-7174; FAX (210) 653-8204. 23 – 25 The ADA Council on Access, Prevention and Interprofessional Relations (CAPIR) will meet in Chicago, IL. For more information, please contact Ms. Carrie Campbell, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 4402500; FAX: (312) 440-7494; E-mail: campbellc@ada.org; Web: ada.org. -XO\ 15-17 ADPAC, the American Dental Political Action Committee, will meet. For more information, please contact Ms. Cynthia Taylor, ADA, 1111 14th St., N.W., Ste. 1200, Washington, D.C. Phone: (202) 789-5172; FAX: (202) 898-2437; E-mail: taylorc@ada.org. 28 – 31 The Academy of General Dentistry will have its annual meeting and exhibition at the Ernest Morial Convention Center in New Orleans, LA. For more information, please contact Ms. Rebecca Murray, AGD, 211 E. Chicago Ave., Ste. 900, Chicago, IL 60611. Phone: (312) 440-3368; FAX: (312) 440-0559; E-mail: agd@agd.org; Web: agd.org. 28 – 30 The International Association of Comprehensive Aesthetics will meet at the Manchester Grand Hyatt in San Diego, CA. For more information, please contact Ms. Mary Williams, IACA, 1401 Hillshire Dr., Ste. 200, Las Vegas, NV 89134. Phone: (888) NOW-IACA; FAX: (702) 341-8510; E-mail: info@theiaca.com; Web: theiaca.com. $XJXVW 5&6 The TDA Smiles Foundation (TDASF) will hold a Texas Mission of Mercy event in Texarkana, TX. For more information, please contact TDASF, 1946 S. IH 35, Ste. 300, Austin, TX 78704; Phone: (512) 448-2441; Web: tdasf.org. 18 & 19 National Conference on Dentist Health and Wellness will be in Chicago, IL. For more information, please contact Ms. Mary Gilliam, ADA, 211 E. Chicago Ave., Chicago, IL 60611-2678. Phone: (312) 440-2500. FAX: (312) 4407494; E-mail: online@ada.org; Web: ada.org.

The Texas Dental Journal’s Calendar will include only meetings, symposia, etc., of statewide, national, and international interest to Texas dentists. Because of space limitations, individual continuing education courses will not be listed. Readers are directed to the monthly advertisements of courses that appear elsewhere in the Journal.

Calendar of Events

9 – 11 The ADA will hold its Washington Leadership Conference in Washington, D.C. For more information, please contact Mr. Brian Sodergren, ADA, 1111 14th St., NW, Ste. 1100, Washington, DC 20005. Phone: (202) 789-5168; FAX: (202) 789-2258; E-mail: sodergrenb@ada.org; Web: ada.org.

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L ] (K IMPORTANT: Ad briefs must be in the TDA ofĂ€FH E\ WKH WK RI WZR months prior to the issue for processing. For example, for an ad brief to be included in the January issue, it must be received no later than November 20th. Remittance must DFFRPSDQ\ FODVVLĂ€HG ads. Ads cannot be accepted by phone or fax. * Advertising brief rates are as follows: 30 words or less — per insertion‌$40. Additional words 10¢ each. The JOURNAL reserves the right to edit copy RI FODVVLĂ€HG DGYHUWLVHments. Any dentist advertising in the Texas Dental Journal must be a member of the American Dental Association. All checks submitted by non-ADA members will be returned less a $20 handling fee. * Advertisements must not quote revenues, gross or net incomes. Only generic language referencing income will be accepted. Ads must be typed.

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MCLERRAN AND ASSOCIATES:

project in medical center. Good equipment, nice decor, and loyal patient base. ID #105.

AUSTIN: Associate to purchase. High grossing, family practice located in retail center with seven operatories was recently remodeled. Near major freeway. High growth area. Practice boast solid, well-established patient base. ID #108.

SAN ANTONIO: Four operatory general family practice located in professional RIĂ€FH EXLOGLQJ RII RI EXV\ WKRURXJKIDUH LQ DIĂ XHQW QRUWK FHQWUDO VLGH RI WRZQ 9HU\ nice equipment and decor. Excellent opportunity. ID #003.

$867,1 1RUWK KLJK JURVVLQJ ÀYH RSHUDtory practice in free-standing building. Plenty of room to expand. Fee-for-service patient base, good equipment. Owner wishes to sell and continue part-time as an associate. ID #115.

SAN ANTONIO: Well-established, endodontic specialty practice with solid referral base. Located in growing, upper middle income area. Contact for more information. ID #074.

PRACTICE OPPORTUNITIES

CORPUS CHRISTI: Doctor retiring, six op RIÀFH ZLWK H[FHOOHQW YLVLELOLW\ DQG DFFHVV Good numbers, excellent patient base, good upside potential. Excellent practice for starting doctor. Priced to sell. ID #023. CORPUS CHRISTI: Three operatory, feefor-service/crown and bridge oriented family practice in great location. High grossing practice on 3-day week! Doctor ready to retire. Make an offer. ID #098. RIO GRANDE VALLEY: Excellent four operatory, 20-year-old general practice. 0RGHUQ QHZ ÀQLVK RXW LQ UHWDLO ORFDWLRQ with digital radiography. Fee-for-service patient base and very good new patient count. Great numbers. Super upside potential. ID #093. SAN ANTONIO — Prosthodontic practice with almost new equipment and build out. Doctor wants to sell and continue to ZRUN DV DVVRFLDWH %HDXWLIXO RIÀFH 3HUIHFW IRU VWDQG DORQH RU VDWHOOLWH RIÀFH ,' SAN ANTONIO, NORTH CENTRAL — Twoop practice just off major freeway; perfect VWDUWHU RIÀFH 7HUULÀF SULFLQJ ,' 6$1 $1721,2 6ROLG ÀYH RS JHQHUDO IDPily practice located in high visibility retail

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SAN ANTONIO: Oral surgery specialty practice. Very good referral base. Almost new build out, great location, and excellent equipment. Good gross and net. Transition available. ID #113. SAN ANTONIO, NORTH CENTRAL: Six operatory general practice located in high growth area. All operatories have large windows with great views. Very nice equipment, solid patient base, great hygiene program. Priced to sell. ID #112. SAN ANTONIO, NORTH CENTRAL: 7KUHH RSHUDWRU\ RIÀFH LQ UHWDLO RIÀFH FHQter with great visibility and access. New equipment and nice build out. Good solid numbers, very low overhead. ID #111. SAN ANTONIO: Six operatory practice with three chair ortho bay located in 3,400 VT IW EXLOGLQJ 0RGHUQ RIÀFH ZLWK QHZHU equipment. Free-standing building on busy thoroughfare. Practice has grossed in VHYHQ ÀJXUHV IRU ODVW \HDUV *UHDW ORFDtion with super upside potential. ID #055. SAN ANTONIO, NORTH CENTRAL: Five operatory, state-of-the-art facility with new equipment. Located in a medical proIHVVLRQDO EXLOGLQJ LQ KLJK JURZWK DIà XHQW DUHD *URVVLQJ VHYHQ ÀJXUHV ZLWK KLJK QHW income. ID #106.

SAN ANTONIO NORTH WEST: Excellent, four-chair general family practice in high WUDIÀF UHWDLO FHQWHU DFURVV IURP EXV\ PDOO location. Solid gross income on 30 hours/ week. Ideal opportunity for doctor wanting a quick start in low overhead operation. ID #086. SAN ANTONIO, SOUTHEAST: Three operaWRU\ \HDU ROG SUDFWLFH LQ KLJK WUDIÀF retail center, good equipment, solid patient base, low overhead. Perfect location for a VDWHOOLWH RIÀFH RU KLJK JURVV 0HGLFDLG RIÀFH ID #121. NEW; SAN ANTONIO, SOUTHEAST: Three RSHUDWRU\ VDWHOOLWH RIÀFH ORFDWHG LQ KLJKO\ visible retail center. Excellent location. Practice has tremendous upside potential. ID #121. 1(: 6(*8,1 7KUHH RSHUDWRU\ \HDU old practice with condo is priced very aggressively as doctor must sell. Call now to learn more about this great deal. ID #118. SOUTH TEXAS BORDER: General practitioner with 100 percent ortho practice. Very high numbers, incredible net. ID #021. WACO AREA: Modern and high-tech, three op general family practice grossing in midVL[ ÀJXUHV ZLWK KLJK QHW LQFRPH /DUJH OR\DO SDWLHQW EDVH 2IÀFH LV ZHOO HTXLSSHG IRU GRFWRU VHHNLQJ D PRGHUQ RIÀFH ,' #107. Contact McLerran Practice Transitions, Inc.: statewide, Paul McLerran, DDS, (210) 737-0100 or (888) 656-0290; in Austin, David McLerran, (512) 750-6778; in Houston, Tom Guglielmo and Patrick Johnston, (281) 362-1707. Practice sales, appraisals, buyer representation, and lease negotiations. See www.dental-sales.com for pictures and more complete information.

GARY CLINTON / PMA NORTHWEST OF DALLAS CARROLLTON AREA PRACTICE FOR SALE: Well-established practice/exceptional recall; full general service practice with lots of crown and bridge. Retiring dentist. Will continue to work as needed 1 day per week. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.â€? I personally handle every appraisal/ WUDQVLWLRQ VDOH 1R FRQĂ LFW RI LQWHUHVW dual representation. Authorized closing DJHQW HVFURZ DJHQW IRU QXPHURXV Ă€QDQFLDO LQVWLWXWLRQV &HUWLĂ€HG DSSUDLVDOV based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). 9HU\ FRQĂ€GHQWLDO '): WATS: (800) 583-7765. WE NEED SELLERS! GARY CLINTON / PMA: Serving the dental profession since 1973: I have buyers! Sell your practice and travel while you have your health. In many cases, you can stay on to work 1-2 days per week if you wish. I need practices to sell/transition as follows: Any practice in or near Austin, San Antonio, DFW and Houston areas, and other Texas locations. We have buyers for orthodontic, oral surgery, periodontic, pedodontic, and general dentistry practices. Values for practices have never been higher. Tax advantages high for present time. One hundred percent funding available, even those YDOXHG DW PRUH WKDQ VHYHQ Ă€JXUHV &DOO PH FRQĂ€GHQWLDOO\ ZLWK DQy questions. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.â€? I personally handle every appraisal/ WUDQVLWLRQ VDOH 1R FRQĂ LFW RI LQWHUHVW dual representation. Authorized closing agent/escrow agent for numerous

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Ă€QDQFLDO LQVWLWXWLRQV &HUWLĂ€HG DSSUDLVDOV based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very FRQĂ€GHQWLDO '): :$76 (800) 583-7765. ORTHODONTIC PRACTICES FOR SALE / TRANSITION — GARY CLINTON / PMA TEXAS: O-1 Houston/Webster / Friendswood / South of Houston area — Few orthodontists in this area; tremendous opportunity area. Doctor retiring; ZLOO WUDQVLWLRQ H[FHOOHQW RSHUDWLQJ SURĂ€W O-2 West Central Texas mid-sized to larger community — Ideal transition; professional referral based; traditional fee-for-service, referral, highly productive. Gorgeous building with room for two in this planned 50/50 partnership; within 5 years complete buy-out with owner working 1-2 days as needed. O-3 South Texas — Retiring orthodontist; 100 percent buy-out / transition; seller will stay 1-2 GD\V SHU ZHHN DV QHHGHG 6HYHQ Ă€JXUH SUDFWLFH FROOHFWLRQV SHUFHQW SURĂ€WV lovely building. He is ready to spend time with his grandchildren. Easy drive to San Antonio. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.â€? I personally handle every DSSUDLVDO WUDQVLWLRQ VDOH 1R FRQĂ LFW RI interest/dual representation. Authorized closing agent/escrow agent for numerous Ă€QDQFLDO LQVWLWXWLRQV &HUWLĂ€HG DSSUDLVDOV based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very FRQĂ€GHQWLDO '): :$76 (800) 583-7765. GARY CLINTON / PMA ARLINGTON PRACTICE FOR SALE: The place to be for young families. Texas Rangers baseball. Cowboys football, and Six Flags for entertainment. Well-established practice. Excellent recare program. Near seven Ă€JXUH JURVV *DUGHQ VW\OH RIĂ€FHV DQG operatories. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute

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of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.â€? I personally handle every DSSUDLVDO WUDQVLWLRQ VDOH 1R FRQĂ LFW RI interest/dual representation. Authorized closing agent/escrow agent for numerous Ă€QDQFLDO LQVWLWXWLRQV &HUWLĂ€HG DSSUDLVDOV based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very FRQĂ€GHQWLDO '): :$76 (800) 583-7765. GARY CLINTON / PMA FORT WORTH AREA GENERAL PRACTICES FOR SALE: Fl — Excellent patient base; well-established recall. Bread and butter practice. Very fast growing area near Texas Motor Speedway. Average gross ZLWK H[FHOOHQW QHW ) Âł \HDU ROG practice in southwest Fort Worth. Associate buy-out or outright sale. Solid recall program. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.â€? I personally handle every DSSUDLVDO WUDQVLWLRQ VDOH 1R FRQĂ LFW RI interest/dual representation. Authorized closing agent/escrow agent for numerous Ă€QDQFLDO LQVWLWXWLRQV &HUWLĂ€HG DSSUDLVDOV based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very FRQĂ€GHQWLDO '): :$76 (800) 583-7765. ORAL SURGERY PRACTICE FOR SALE HOUSTON AREA — GARY CLINTON / PMA: State-of-the-art practice. Fast growing location. Economy is strong in Texas. Many referring doctors for cosmetic and implant surgery. Outright sale. 6HYHQ Ă€JXUH JURVV 6HOOHU DQG IDPLO\ DUH relocating out of state; will transition on a limited basis. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.â€? I personally handle every DSSUDLVDO WUDQVLWLRQ VDOH 1R FRQĂ LFW RI interest/dual representation. Authorized

closing agent/escrow agent for numerous Ă€QDQFLDO LQVWLWXWLRQV &HUWLĂ€HG DSSUDLVDOV based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). 9HU\ FRQĂ€GHQWLDO '): WATS: (800) 583-7765. GARY CLINTON / PMA PLANO / FRISCO AREA: Future rapid growth area where people will want to live. Practice in the middle of the high growth area. ProMHFWHG VHYHQ Ă€JXUH JURVV 1HZO\ HTXLSSHG JRUJHRXV RIĂ€FH :H KDYH WKH EHVW VRXUFHV for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.â€? I personally handle every DSSUDLVDO WUDQVLWLRQ VDOH 1R FRQĂ LFW RI interest/dual representation. Authorized closing agent/escrow agent for numerous Ă€QDQFLDO LQVWLWXWLRQV &HUWLĂ€HG DSSUDLVDOV based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). 9HU\ FRQĂ€GHQWLDO '): WATS: (800) 583-7765. GARLAND / RICHARDSON AREA FULLY EQUIPPED OFFICE SPACE ONLY — GARY CLINTON / PMA TEXAS: No paWLHQWV GHQWLVW UHORFDWHG RIĂ€FH (TXLSSHG digital six-operatory space in strip shopping center. Call Gary Clinton, dental practice appraiser/broker, for more information, (214) 503-9696. GARY CLINTON/PMA WEST OF FORT WORTH PRACTICE FOR SALE: A little more than an hour west of Fort Worth, WKLV LV DQ H[FHOOHQW KLJK VL[ Ă€JXUH JURVVLQJ SUDFWLFH ZLWK KLJK RSHUDWLQJ SURĂ€WV Excellent recall; six operatories. Fee-forservice; No DMO or low fee PPO. We have the best source for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years you’ve seen the name ... a name you can trustâ€?. I personally handle every appraisal, associate transition/sale. No real estate commisVLRQ (YHU\ FDOO LV YHU\ FRQĂ€GHQWLDO &DOO (214) 503-9696; WATS: (800) 583-7765.

GOLDEN TRIANGLE GENERAL DENTAL PRACTICE — SALE: Outstanding practice for sale developed by published mentor. Supported by outstanding staff and latest in dental equipment. Strong UHYHQXHV DQG SURÀW PDUJLQ ([FHOOHQW QHZ SDWLHQW à RZ *LYHQ KLJK OHYHO RI ))6 UHYenues, doctor to transition to comfort level of purchaser. Come build your retirement in low competition community. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. SOUTH HOUSTON GENERAL DENTAL PRACTICE — SALE: 0RVW DWWUDFWLYH RIÀFH located on busy thoroughfare in rapidly growing south Houston suburb. Six WUHDWPHQW URRPV ÀYH IXOO\ HTXLSSHG 7ZR additional plumbed operatories such that practice has capacity to grow well in exFHVV RI VHYHQ ÀJXUHV &RQWDFW 7KH +LQGOH\ Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com. NORTH TEXAS GENERAL DENTAL PRACTICE — SALE: Small, well-established practice in mid-sized community in north Texas. Three fully-equipped operatories. Experienced staff with excellent skills. Doctor will assist with transition. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com. CORPUS CHRISTI GENERAL DENTAL — SALE: Moderate revenues with a very KHDOWK\ SURÀW PDUJLQ ([SHULHQFHG DQG OR\DO VWDII 7RWDOO\ GLJLWDO DQG KLJKO\ HIÀcient facility layout. If you need to practice to refund your retirement, but don’t ZDQW WR ÀJKW WKH FRPSHWLWLYHQHVV RI WKH city, come see this practice. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. DFW METROPLEX ORAL SURGERY PRACTICE — SALE: Well-established practice enjoying 2009 revenues exceedLQJ VHYHQ ÀJXUHV IURP WZR ORFDWLRQV Extensive referral base, experienced staff, DQG KLJKO\ TXDOLÀHG PHQWRU WR DVVLVW LQ transition. Don’t miss this opportunity. Contact The Hindley Group at (800) 8561955. Visit us at www.thehindleygroup. com. Texas Dental Journal l www.tda.org l February 2011

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NORTHWEST HOUSTON GENERAL DENTAL PRACTICE — SALE: New practice in growing area located near well-traveled Highway 290 and Jones Road. Two fully equipped treatment rooms with three others plumbed for expansion. Digital X-rays. Moderate revenues on 3.5 days per week. If you want to be in the rapidly growing NW quadrant, this practice is for you. Contact The Hindley Group at (800) 8561955. Visit us at www.thehindleygroup. com. SOUTH OF HOUSTON GENERAL DENTAL PRACTICE — SALE: Established practice in mid-size town generating revenues apSURDFKLQJ VHYHQ ÀJXUHV WKH ODVW \HDUV Associate in place providing orthodontic treatment. Building is also for sale. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. WEST HOUSTON GENERAL DENTAL PRACTICE — SALE: Wonderful opportunity in rapidly growing community west of Houston. Excellent revenues, steady new patient à RZ )RXU RSHUDWRULHV &DSDEOH VWDII &RQtact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. LAS VEGAS ORAL SURGERY PRACTICE — SALE: Excellent practice with revenues RI VHYHQ ÀJXUHV ZLWK QHW SURÀW PDUJLQ over 48 percent. Strong professional referUDO EDVH DQG QHZ SDWLHQW à RZ /DWHVW LQ 3D digital projection including CT scanner. Highly skilled, experienced staff. Doctor will assist in transition. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. DALLAS / FORT WORTH: Area clinics VHHNLQJ DVVRFLDWHV (DUQ VLJQLÀFDQWO\ DERYH industry average income with paid health and malpractice insurance while working in a great environment. Fax (312) 944-9499 or e-mail cjpatterson@kosservices.com. WACO PEDIATRIC DENTAL PRACTICE — SALE: Well-established practice with PRGHUDWH UHYHQXHV DQG KLJK SURÀW PDUJLQ on 4 days per week. Limited competition and a large facility. Ample room to grow in this community that is home to Bay-

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lor University. All ortho cases are being completed, unless purchaser would like to expand new cases. No Medicaid being seen, but good opportunity with facility capacity. Experienced staff and steady QHZ SDWLHQW à RZ :RQGHUIXO PHQWRU Building also available. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. SOUTH OF HOUSTON GENERAL DENTAL PRACTICE — SALE: Outstanding practice with very high growth potential H[SHULHQFLQJ D VWURQJ QHZ SDWLHQW à RZ 0RGHUDWH UHYHQXHV DQG D KHDOWK\ SURÀW margin on 4 days per week. Extremely ZHOO TXDOLÀHG PHQWRU WR DVVLVW LQ WUDQVLtion. Building also for sale. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com. BRYAN/COLLEGE STATION GENERAL DENTAL PRACTICE — SALE: Well-established practice in mid-size town. Four opHUDWRULHV +HDOWK\ UHYHQXHV H[FHOOHQW SURÀW PDUJLQ DQG VWURQJ QHZ SDWLHQW à RZ 'RFWRU must transition due to health reason. Contact The Hindley Group, LLC, at (800) 8561955. Visit us at www.thehindleygroup.com. EAST TEXAS GENERAL DENTAL PRACTICE — SALE: Well-established practice in small town in hills in East Texas. Moderate revenues on 4 days per week; three operatories; excellent staff. Room to expand in adjacent space. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com. FORT WORTH ORTHODONTIC PRACTICE — SALE: Excellent opportunity for VDWHOOLWH RIÀFH JHQHUDO GHQWLVW ZDQWLQJ to add orthodontics to services offered; female dentist desiring part-time position while children in school; or older dentist wanting to utilize orthodontics as less physically taxing exit strategy. Doctor will mentor or assist with transition. Contact The Hindley Group, LLC, at (800) 8561955. Visit us at www.thehindleygroup. com. WEST TEXAS GENERAL DENTAL PRACTICE — SALE: 6SDFLRXV RIÀFH ZLWK ÀYH

fully-equipped operatories; two additional spaces plumbed for future use. Strong UHYHQXHV DQG SURĂ€W PDUJLQ ([FHOOHQW QHZ SDWLHQW Ă RZ (LJKW K\JLHQH GD\V SHU ZHHN Contact The Hindley Group. LLC, at (800) 856-1955. Visit us at www.thehindleygroup. com. ARLINGTON ORAL SURGERY PRACTICE — SALE: Highly successful practice with strong revenue history of more than VHYHQ Ă€JXUHV 6HOOLQJ GRFWRU FXW SURGXFtion in half due to back injury but will assist purchaser in rebuilding practice. Extensive referral pattern. Building also for sale. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www. thehindleygroup.com. SOUTHEAST OF HOUSTON GENERAL DENTAL PRACTICE —SALE: Wonderful location on well-traveled street. Excellent UHYHQXHV DQG SURĂ€W PDUJLQ )RXU IXOO\ equipped operatories. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. DALLAS/FORT WORTH GENERAL DENTAL PRACTICE — SALE: Fully digitized DQG SDSHUOHVV RIĂ€FH RQ ZHOO WUDYHOHG VWUHHW Four operatories with space for one additional. Strong revenues, excellent staff, and wonderful mentor to assist in transition. Contact The Hindley Group at (800) 8561955. Visit us at www.thehindleygroup. com. ASSOCIATESHIPS: EAST TEXAS GENERAL DENTAL PRACTICE — Small but busy practice generating mid-range revenues on 4 days per week. Located in quaint small town with excellent access to IRUHVWV DQG ODNHV IRU KXQWLQJ Ă€VKLQJ DQG boating. Excellent opportunity for dentists looking ahead to separation from the military. Pre-determined buy-in terms. SOUTH CENTRAL TEXAS PERIODONTAL —Wonderful practice completing periodontal treatment seeks long-term associate who desires to be a partner within 1-2 years. Great location with strong new SDWLHQW Ă RZ 3UH GHWHUPLQHG SXUFKDVH and partnership terms. Wonderful mentor looking for an “equally-yokedâ€? individual.

Excellent staff. SAN ANTONIO PERIODONTAL AND ENDODONTIST ASSOCIATESHIPS — Periodontal associateship with pre-determined buy-in for very active, PXOWL RIĂ€FH SHULRGRQWDO SUDFWLFH (QGRGRQtist associate also needed in this practice. Outstanding mentor and cohesive staff. If you are “equally yokedâ€? and the right person, this is an outstanding opportunity. WEST TEXAS GENERAL DENTAL PRACTICE — Associateship with pre-determined buy-in and partnership terms. Nine operatories. Strong mentor and experienced VWDII ([FHOOHQW UHYHQXHV DQG SURĂ€W PDUJLQ Large Medicaid component. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com. HOUSTON AREA PRACTICE FOR SALE: 3URĂ€WDEOH SUDFWLFH IRU VDOH :HOO established. Call Jim Robertson at (713) 688-1749. ADS WATSON, BROWN & ASSOCIATES: Excellent practice acquisition and merger opportunities available. DALLAS AREA — Six general dentistry practices available (Dallas, North Dallas, Highland Park, and 3ODQR Ă€YH VSHFLDOW\ SUDFWLFHV DYDLODEOH (two ortho, one perio, two pedo). FORT WORTH AREA — Two general dentistry practices (north Fort Worth and west of Fort Worth). CORPUS CHRISTI AREA — One general dentistry practice. CENTRAL TEXAS — Two general dentistry practices (north of Austin and Bryan/College Station). NORTH TEXAS —One orthodontic practice. HOUSTON AREA — Three general dentistry practices. EAST TEXAS AREA —Two general dentistry practices and one pedo practice. WEST TEXAS — Three general dentistry practices (El Paso and West Texas). NEW MEXICO —Two general dentistry practices (Sante Fe, Albuquerque). For more information and current listings, please visit our website at www.adstexas.com or call ADS Watson, Brown & Associates at (469) 222-3200. DALLAS / FORT WORTH: Dental One is RSHQLQJ QHZ RIĂ€FHV LQ WKH XSVFDOH VXEurbs of Dallas and Fort Worth. Dental 2QH LV XQLTXH LQ WKDW HDFK RIĂ€FH RI RXU RIĂ€FHV KDV LWV RZQ LQGLYLGXDO QDPH VXFK Texas Dental Journal l www.tda.org l February 2011

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as Riverchase Dental Care and Preston +ROORZ 'HQWDO &DUH $OO RXU RIĂ€FHV KDYH top-of-the-line Pelton and Crane equipment, digital X-rays, and intra-oral cameras. We are 70 percent PPO, 30 percent full fee. We take no managed care or Medicaid. We offer competitive salaries and EHQHĂ€WV 7R OHDUQ PRUH DERXW ZRUNLQJ IRU Dental One, please contact Rich Nicely at (972) 755-0836. HOUSTON DENTAL ONE is opening new RIĂ€FHV LQ WKH XSVFDOH VXEXUEV RI +RXVWRQ 'HQWDO 2QH LV XQLTXH LQ WKDW HDFK RIĂ€FH RI RXU RIĂ€FHV KDV LWV RZQ LQGLYLGXDO QDPH $OO RXU RIĂ€FHV KDYH WRS RI WKH OLQH Pelton and Crane equipment, digital Xrays, and intra-oral cameras. We are 100 percent FFS with some PPO plans. We ofIHU FRPSHWLWLYH VDODULHV EHQHĂ€WV DQG HTuity buy-in opportunities. To learn more about working for Dental One, please call Andy Davis at (713) 343-0888. FULLY EQUIPPED MODERN DENTAL OFFICE SPACE AVAILABLE FOR LEASE. Have four ops. Current doctor is only using 2 days a week. Great opportunity to start up new practice (i.e., endo, perio, oral surgery). Available days are Monday, Tuesday, Thursday per week. If you are wanting an associate, please inquire. Call (214) 315-4584 or e-mail ycsongdds@yahoo.com. TEXAS PANHANDLE: Well-established 100 percent fee-for-service dental practice for immediate transition or complete sale at below market price by retiring dentist. Relaxed work schedule with community centrally located within 1 hour of three PDMRU FLWLHV 7KH RIĂ€FH EXLOGLQJ FDQ EH leased or purchased separately and is spaciously designed with four operatories, GRFWRUV¡ SULYDWH RIĂ€FH DQG VHSDUDWH RIĂ€FH rental space. This is an excellent and profitable opportunity for a new dentist, a dentist desiring to own a practice, or a satellite practice expansion. Contact C. Vandiver at (713) 205-2005 or clv@tauruscapitalcorp. com.

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SUGAR CREEK / SUGAR LAND: General dentist looking for periodontist, endo, ortho specialist to lease or sell. Suite is 1,500 sq. ft. with four fully-equipped WUHDWPHQW URRPV ODE EXVLQHVV RIĂ€FH telephone system, computers, reception and playroom; 5 days per week. If seriously interested, please call (281) 3426565. AUSTIN: Unique opportunity. AssociateVKLS DQG IURQW RIĂ€FH SRVLWLRQ DYDLODEOH IRU husband/wife team. Southwest Austin, Monday through Thursday. Option to purchase practice in the future. Send resume and questions to newsmile@onr. com. GALVESTON ISLAND: Unique opportunity to live and practice on the Texas Gulf coast. Well-established fee-for-service, 100 percent quality-oriented practice looking for a quality oriented associate. Ideal for a new graduate or for an experienced dentist wanting to relocate and become part of an established practice with a reputation for providing comprehensive, quality dental care with a personable approach. Practice references available from local specialists. Contact Dr. Richard Krumholz, (409) 762-4522. GENERAL DENTIST NEEDED to provide comprehensive dental services for community health center dental practice. Services include examination, diagnosis, and treatment of registered patients of the center. Scope of services include diagnostic, preventive, restorative, oral surgery, and endodontics. The center is a QRQ SURĂ€W )4+& ORFDWHG LQ %U\DQ &ROOHJH Station. E-mail cover letter and resume to Dr. Alonge at oalonge@bvcaa.org. HOUSTON: General dentist with pediatric experience needed. Full-time position available. Excellent compensation. Please send CV to cvanalfen@yahoo.com.

ASSOCIATE FOR TYLER GENERAL DENTISTRY PRACTICE: Well-established JHQHUDO GHQWLVW LQ 7\OHU ZLWK \HDUV H[perience seeks a caring and motivated associate for his busy practice. This practice provides exceptional dental care for the entire family. The professional staff allows a doctor to focus on the needs of their SDWLHQWV 2XU RIÀFH LV ORFDWHG LQ EHDXWLful East Texas and provides all phases of quality dentistry in a friendly and compassionate atmosphere. The practice offers a tremendous opportunity to grow a solid foundation with the doctor. The practice offers excellent production and earning potential with a possible future equity position available. Our knowledgable staff will support and enhance your growth and earning potential while helping create a smooth transition. Interested candidates should call (903) 509-0505 and/or send an e-mail to steve.lebo@ sbcglobal.net. ASSOCIATE NEEDED FOR NURSING HOME DENTAL PRACTICE. This is a non-traditional practice dedicated to delivering care onsite to residents of long term care facilities. This practice is centered in Austin but visits homes in the central Texas area. Portable and mobile equipment and facilities are used, as well DV VRPH À[HG RIÀFH YLVLWV 3DWLHQW SRSXODtion presents unique technical medical, and behavioral challenges, seasoned dentist preferred. Buy-in potential high for the right individual. Please toward CV to e-mail renee@austindentalcares.com; FAX (512) 238-9250; or call (512) 238-9250 for additional information. PEDIATRIC DENTIST: Pediatric Dental Wellness is growing and needs a dynamic dentist to work full time in our pediatric practice. The perfect complement to our dedicated staff would be someone who is compassionate, goal oriented, and has a genuine love for working with children. If you are a motivated self-starter that is willing to give us a long-term commitPHQW SOHDVH DSSO\ 6DODU\ SOXV EHQHÀWV /RRNLQJ WR ÀOO SRVLWLRQ LPPHGLDWHO\ 6HQG resumes and cover letters to candice,n. moore@gmail.com.

GREAT OPPORTUNITY FOR A PEDIATRIC DENTIST OR GP to join our expanding practice. We are opening a new practice in the country (Paris, Texas), just 1 hour past the Dallas suburbs and our original location. The need for a pediatric dentist out there is tremendous, and we DUH WKH RQO\ SHGLDWULF RIÀFH IRU PLOHV LQ any direction. We are looking for someone that is personable, caring, energetic, and loves a fast-paced working environment in a busy pediatric practice. We are willing to WUDLQ WKH ULJKW LQGLYLGXDO LI ZRUNLQJ ‡ ZLWK children is your ambition. This position is part-time initially, and after a short training period will lead to full-time. If you join our team, you will be mentored by a %RDUG FHUWLÀHG SHGLDWULF GHQWLVW DQG ZLOO develop experience in all facets of pediatric dentistry including behavior management using oral conscious sedation as well as IV sedation. For more information, please visit our websites at www.wyliechildrensdentistry.com and www.parischildrensdentistry.com. Please e-mail CV to allenpl2345@yahoo.com. SOUTHWEST FT. WORTH — GENERAL DENTAL PRACTICE WITH BUILDING FOR SALE OR LEASE: This very successful, well-established practice has an excellent patient base with referrals from near and far. The seller is retiring immediately or will negotiate a comfortable transition. With a low overhead and excellent SURÀW PDUJLQ WKLV SUDFWLFH PDNHV D JUHDW investment for just the right person. Five treatment rooms, 3,200 sq. ft. plus 800 sq. ft. for additional expansion or rental space. The practice is located in a high visibility and stable economic community. With this practice comes an experienced staff, computers in all treatment rooms, nice equipment, imaging software, and much more. Get out of that associate position and be an owner! Appraisal performed by a CPA/CFP/CVA. Call (972) 562-1072 or (214) 697-6152 or e-mail sherri@slhdentalsales.com.

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GREAT PRACTICE IN BEAUTIFUL EAST TEXAS. This fee-for-service practice was established by a prominent communityinvolved dentist with an excellent reputaWLRQ IRU TXDOLW\ FDUH 7KH RIĂ€FH KDV sq. ft. with four available treatment rooms DQG D ODUJH SULYDWH RIĂ€FH 'RQ¡W PLVV WKH opportunity to become part of this stable economic town with an experienced staff and a growing patient base. Interested? Call (972) 562-1072 or e-mail sherri@ slhdentalsales.com. ASSOCIATE SUGAR LAND AND CYPRESS: Large well-established practice with very strong revenues is seeking an associate. Must have at least 2 years experience and be motivated to learn and succeed. FFS and PPO practice that ranks as one of the top practices in the nation. Great mentoring opportunity. Possible equity position in the future. Base salary guarantee with high income potential. Two days initially going to 4 days in the near future. E-mail CV to Dr. Mike Kesner, drkesner@madeyasmile.com. SEEKING ASSOCIATE DENTISTS. Dental Republic is a well-established general dental practice with various successful locations throughout the Dallas Metroplex. A brand new state-of-the-art facility in a bustling location will be opening soon. Join our outstanding and professional team in creating beautiful healthy smiles for all. Let us give you the opportunity to enhance your professional career with exFHOOHQW KRXUV FRPSHWLWLYH VDODU\ EHQHĂ€WV and by forming long-lasting friendships with our patients and staff members. Please contact Phong at (214) 960-3535 or e-mail CV to phong@dentalrepublic. com. CARE FOR KIDS, A PEDIATRIC FOCUSED PRACTICE, is opening new practices in the San Antonio and Houston area. We are looking for energetic full-time general dentists and pediatric dentists to join our team. We offer a comprehensive FRPSHQVDWLRQ DQG EHQHĂ€WV SDFNDJH LQcluding medical, life, long- and short-term

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GLVDELOLW\ LQVXUDQFH à H[LEOH VSHQGLQJ DQG 401(K) with employer contribution. New graduates and dentists with experience are welcome. Be a part of our outstanding team, providing care for Texas’ kids. Please contact Anna Robinson at (913) 322-1447; e-mail: arobinson@amdpi.com; FAX: (913) 322-1459. DDR PRACTICE SALES — DUNN/ISENHART: SERVING TEXAS DENTISTS FOR OVER 40 YEARS. National direct (and fax): (800) 930-8017. CORPUS CHRISTI: Laid back lifestyle with WKH EHQHÀWV RI WKH *XOI &RDVW /XFUDWLYH revenues on 4 days per week. Denture focus could be expanded to a broader scope of restorative general treatment. In-house lab with experienced technician. Great location, great staff, and a great lifestyle. 0RWLYDWHG VHOOHU +LJK VL[ ÀJXUH JURVV SURYLGHV RZQHU VL[ ÀJXUH LQFRPH 'HQWLVWV will work as associate if desired. Call DDR Practice Sales at (800) 930-8017. BRYAN/COLLEGE STATION AREA: Wellestablished practice serving rural community of 5,000 just 20 minutes from College 6WDWLRQ 3URYLGLQJ VHYHQ ÀJXUH JURVV collections with substantial 40 percent net. High quality implant practice. Four IXOO\ HTXLSSHG RSHUDWRULHV SULYDWH RIÀFH two full-time hygienists and a great staff. Ownership of free-standing 1,900 sq. ft. building is optional. Over 4,000 patient base with average age of 45. Call DDR Practice Sales at (800) 930-8017. GALVESTON: Must sell for relocation. Thriving practice in Galveston providing the best of both worlds ... the great outdoors and a laid back lifestyle, yet quick access to metropolitan Houston. This 15-year practice has three fully equipped RSHUDWRULHV SULYDWH RIÀFH IXOO WLPH K\gienist, and a great staff. Half interest in free-standing building included in price. *HQHUDWLQJ PLG VL[ ÀJXUH JURVV FROOHFtions on only 3 days per week. Owner currently splits time with out-of-town practice. Call DDR. Practice Sales at (800) 930-8017.

AUSTIN: Five operatory, two hygienists, one associate dentist, gross of seven ÀJXUHV LQ 0DWXUH SUDFWLFH GRFWRU wants to sell practice but is also willing to work contact for buying dentist; great location in beautiful Austin. Practice in the heart of most desired city in Texas. Substantial net income with four fully equipped operatories and two full-time hygienists. Current associate will remain at buyer’s discretion. Call DDR Practice Sales at (800) 930-8017. DALLAS: 3UDFWLFH LQ KLJK WUDIÀF SURIHVsional building, run very lean. Mid sixÀJXUH QHW 1HHG WR DGG SDWLHQW FKDUWV WR your practice? Call DDR Practice Sales at (800) 930-8017. CORPUS CHRISTI: General dentistry practice — location, location, location; 25-year-old practice grossed more than VHYHQ ÀJXUHV ODVW \HDU ZLWK D VLQJOH GHQWLVW DQG RQH K\JLHQLVW 8SGDWHG RIÀFH YHU\ SURÀWDEOH SUDFWLFH H[FHOOHQW VWDII &DOO DDR Practice Sales at (800) 930-8017. HOUSTON: Motivated buyer seeking Galleria area practice. Willing to acquire RIÀFH VWDII RU FKDUWV RQO\ /RRNLQJ WR expand his practice. Call DDR Practice Sales at (800) 930-8017. SAN ANTONIO: Beautiful fast-growing DUHD H[FHSWLRQDO SUDFWLFH ZLWK ÀYH RSeratories. Ten-year-old practice, doctor PRWLYDWHG WR VHOO (DUQV D VHYHQ ÀJXUH gross on 4-day week. Excellent opportunity for younger dentist to make his or her mark. Call DDR Practice Sales at (800) 930-8017. SAN ANGELO, ABILENE: Associates — outstanding earnings. Historically proven at over twice the national average for general dentists; future potential even greater. Thriving, established practice in great location. Bright and spacious facilLW\ ([SHULHQFHG HIÀFLHQW OR\DO VWDII %HVW of all worlds; big city, earnings, smalltown easy lifestyle, outstanding outdoor recreation. Contact Dr. John Goodman at john@goodman.net or (325) 277-7774.

ASSOCIATE DENTIST NEEDED IN EULESS: Well-established general practice seeking full-time associate/future partner. Cosmetic and full family practice. Please send resume to wendy.tcd@sbcglobal.net. TWO-YEAR DENTAL ASSOCIATESHIP — EL PASO: We are a quality children’s GHQWDO RIÀFH HPSOR\LQJ JHQHUDO GHQWLVWV and dental anesthesiologists. Pay per year for 2-year agreement equals generous VL[ ÀJXUH LQFRPH 6DODULHV RQ SHUFHQWDJH based commissions. Will train in oral sedation. Ownership opportunities available. Send resume to info@txkidsdental.com. Call (915) 858-6868. ESTABLISHED, SUCCESSFUL GENERAL PRACTICE AVAILABLE FOR OWNERSHIP ZLWK QR SHUVRQDO ÀQDQFLDO LQYHVWment. Niche market limited to removable prosthetics and related services. Guaranteed minimum salary plus unlimited SRWHQWLDO IURP QHW SURÀWV )XOO EHQHÀWV package. Onsite lab. Monday through FriGD\ D P WR S P 3URIHVVLRQDO JUDWLÀcation, personal rewards. E-mail michele. cooke@affordablecare.com. GREAT OPPORTUNITY FOR ORTHODONTISTS AND GENERAL DENTISTS to join our busy practices providing orthodontic care in the Rio Grande Valley area. We are looking for orthodontists to oversee all aspects of patient care and general dentists to work in coordination with our orthdontists to be able to provide the highest quality care for our patients. Be a part of our exceptional team helping the children of Texas get great smiles. Please contact Dr. Hal D. Lerman at (214) RU H PDLO WR Qà T E#VZEHOO net. KATY: Dr. Bui X. Dinh, D.D.S., M.S. is looking for a dentist right now with minimum 2 years experience. Please contact RIÀFH PDQDJHU 0LFKHOOH or fax resume to (281) 579-6045.

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FOR SALE — GREAT 41-YEAR SUCCESSFUL PRACTICE IN SOUTH CENTRAL TEXAS. Owner retiring but will stay through transition period. Five operatories in beautiful building, Pan-O, digital X-ray. Experienced long-term dependable staff. Room for multiple dentists. Please mail letter of interest to Box 1, TDA, 1946 S. IH 35, Ste. 400, Austin, TX 78704. SEEKING ASSOCIATE: Established JHQHUDO GHQWDO RIÀFH LQ %URZQVYLOOH minutes away from South Padre Island) is seeking a caring, energetic associate. We DUH D EXV\ RIÀFH SURYLGLQJ GHQWDO FDUH IRU mostly children. Our knowledgeable staff will support and enhance growth and earning potential allowing the associate to focus on patient dental care. Interested FDQGLGDWHV VKRXOG FDOO NEW, TYLER: Excellent opportunity, location, and lifestyle. Join an established doctor and share a 2-year-old, free-standing, award-winning building on busy south Tyler Street. Five of 10 ops and SULYDWH RIÀFH DYDLODEOH 6KDUH UHFHSWLRQ lab, and sterilization. Equity position in property available or lease. E-mail dburrow@suddenlinkmail.com. TEMPLE DENTAL CENTER IN TEMPLE, TEXAS, IS FOR SALE: Doctor changing professions. Firesale! Four operatories, tons of equipment and instruments, three ZDOO ; UD\V ÀOP MXVW QHHGV VHQVRUV WR FRQYHUW 3DQRUH[ DOVR HDVLO\ FRQYHUWHG 9HORSH[ SURFHVVRU &DOO DQG leave message. E-mail doctorbrown80@ hotmail.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 FRQWDFW 'U +HQU\ &KX DW or versed0101@yahoo.com.

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EXPERIENCED DENTIST IS NEEDED FOR A PRIVATE GROUP PRACTICE LOCATED IN SPRING. General dentistry practice with a comfortable and friendly atmosphere without administrative responsibilities. Fulltime position with competitive compensaWLRQ EHQHÀWV DQG à H[LEOH VFKHGXOH *UHDW opportunity for a quality oriented person. 3OHDVH FDOO 'U $NHUPDQ RU e-mail yourhappydentist@aol.com. TEXAS — PEDIATRIC DENTAL ASSOCIATE NEEDED. Fast-growing pediatric dental practice is looking for a pediatric GHQWLVW WR MRLQ RXU WHDP :H DUH ORFDWHG QRUWK RI 6DQ $QWRQLR MXVW PLQXWHV from New Braunfels and 45 minutes from Austin. We offer a generous compensation package including paid time off and holidays. Experience is a plus, but new graduates are welcome. Please respond via e-mail to Sherri at velezluke@yahoo. FRP RU E\ ID[ OFFICE SPACE SPACE AVAILABLE FOR SPECIALIST. New professional building located southwest of Fort Worth in Granbury between HOHPHQWDU\ DQG MXQLRU KLJK VFKRROV RII of a state highway with high visibility and WUDIÀF &DOO SPECIALTY DENTIST NEEDED NEXT TO DENTIST IN HIGH GROWTH, HIGH TRAFFIC AREA IN ROUND ROCK, north of Austin in one of the fastest-growing FRXQWLHV $YDLODEOH DW VT IW )RU PRUH LQIRUPDWLRQ H PDLO MRKQ# KHUURQSDUWQHUV FRP RU FDOO SHERMAN — 1,750 SQ. FT. DENTAL OFFICE. Building has established genHUDO GHQWLVW DQG SHULR LPSODQW GHQWLVW 3OXPEHG DQG UHDG\ WR JR +LJK WUDIÀF DQG visibility with lots of parking. Sherman is beautiful and growing town 50 miles north of Dallas and near Lake Texoma, the second largest lake in Texas. It has great schools, a vibrant arts community, and is home to many, many Fortune 500 companies such as Texas Instruments DQG 7\VRQ )RRGV &DOO

ALLEN: Prior dental, high end practice that relocated. Five plumbed and ready RSV UHFHSWLRQ RIÀFH FRQIHUHQFH WZR bath, some built-in cabinets, no equipPHQW +LJK WUDIÀF YLVLELOLW\ ZLWK ORWV RI SDUNLQJ $Ià XHQW UHVLGHQWLDO DFURVV WKH street from large grocer. Offering 5-7 years lease plus extensions. Levin Realty, (323) 954-1934, levinrealty@sbcglobal. net. ROUND ROCK — DENTAL SPACE AVAILABLE FOR LEASE: 323 Lake Creek, 2,032 sq. ft. Lease rate is $18 PSF 36) 111 ([LVWLQJ DLU OLQHV DQG plumbing. Call Darren Quick, (512) 2553000. ROUND ROCK — ORTHODONTIST SPACE FOR LEASE: On IH-35, between FM 620 and Hwy. 79. Call Darren Quick, (512) 255-3000. INGLESIDE DENTAL BUILDING FOR SALE! 1,700 sq. ft., two chairs plumbed. Rental side, near Corpus Christ!. Busy main street location. Vacant, no equipment. Landscaping, parking, owner/denWLVW ÀQDQFLQJ SKRWRJUDSKV E-mail mbtex@aol.com or call (702) 4802236. ARLINGTON DENTAL OFFICE FOR LEASE: Current doctor is only using 1 day a week. Has four up-to-date operatories with HD TVs in each op, assistant computer, doctor computer, Casey educational system, digital X-rays, digital panoramic machine, electric handpiece, sterilization room, laboratory, and Cerec CAD/CAM technology. Perfect for new practice start up. Visit our website to view RXU RIÀFH &RQWDFW LQIR# docdds.com, www.docdds.com. WHITNEY: Free-standing vacant building for sale. Perfect location, 6 miles from the lake for any specialty start-up. Location near hospital complex, 2,600 sq. ft., no HTXLSPHQW IRXU EDWKURRPV SULYDWH RIÀFH built 1978. Pictures are available. For more information call (972) 562-1072 or e-mail sherri@slhdentalsales.com

COMPLETE DENTAL OFFICE CONTAINING 3,362 SQ. FT. OF AREA located in busy shopping center anchored by 27,000 sq. ft. Dollar Tree store available December 15, 2010. Location is at a busy intersection that includes Walgreen’s, HEB Grocery, McDonald’s, Whataburger, Big Lots, and Hallmark Cards. Some dental chairs and equipment may be purchased from existing dentist and shopping center RZQHU ZLOO ÀQDQFH DGGLWLRQDO EXLOGRXW LI required. Current dentist has occupied this location for over 10 years and recently built his own building. Rent — $14 per sq. ft. plus NNN charges of $3.60 per sq. ft. Contact Cynthia Ellison at Grubb & Ellis Co. in San Antonio, (210) 804-4847. FOR SALE LARGE INVENTORY OF QUALITY REFURBISHED AIR DRIVEN DENTAL HANDPIECES. All have been repaired DQG WHVWHG E\ D TXDOLÀHG WHFKQLFLDQ $OO have new ceramic bearing turbines and DOO DUH ÀEHURSWLF )RU VDOH ³ 6WDU SWL, $269; Kavo 640B, $279; Kavo 642B, $299; Kavo 647B, $299; Midwest Tradition push button or lever, $239; new Kavo PXOWL à H[ FRXSOHU ÀYH KROH QHZ Kavo coupler six-hole, $149; new Star FRXSOHU ÀYH KROH 6ORZ VSHHG DQG implant handpieces available, too. Quality discounts are possible. I have been a TDA member for 25 years. If what you are looking for is not on this list, we stock a wide variety at wonderful prices, just inquire. Call (877) 863-4848 or visit our website, www.truespindental.com. FOR SALE: Two mauve Dental-EZ dental chairs. Recovered 2007. Both are in good working order. Will sell single or as a pair. If sold single, $600 each. Pick-up only. If interested, please e-mail for pictures, voigtel9092@sbcglobal.net. INTERIM SERVICES TEMPORARY PROFESSIONAL COVERAGE (Locum Tenens): Let one of our distinguished docs keep your overhead FRYHUHG \RXU UHYHQXH à RZ RSHQ ZLGH

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your staff busy, your patients treated DQG ERRNHG IRU UHFDOO DOO IRU D à DW GDLO\ rate not a percent of production. Nation’s largest, most distinguished team. Shortnotice coverage, personal, maternity, and disability leaves our specialty. Free, no REOLJDWLRQ TXRWHV $EVROXWH FRQÀGHQWLDOLW\ Trusted integrity since 1996. Some of our team seek regular part-time, permanent, or buy-in opportunities. Always seeking new dentists to join the team. Bread and butter procedures. No cost, strings, or obligations — ever! Work only when you wish. Name your fee. Join online at www. doctorsperdiem.com. Phone: (800) 6000963; e-mail: docs@doctorsperdiem.com. INTERIM SERVICES OFFICE COVERAGE for vacations, maternity leave, illness. Protect your practice and income. Forest Irons and

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Associates, (800) 433-2603 (EST). Web: www.forestirons.com. “Dentists Helping Dentists Since 1983.â€? MISCELLANEOUS 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: www.schoolofdentalassisting-northdallas. com. DENTAL OFFICE needed to lease 12 hours per week for Dental Assisting 6FKRRO &ODVV KRXUV DUH GXULQJ RIĂ€FH downtime one weekend day and one ZHHNGD\ HYHQLQJ /HDVH SD\PHQW WR RIĂ€FH is $500 to $1,500 per month, depending on enrollment. Seeking locations in Dal-

las, San Antonio, and Houston. Please call the National School of Dental Assisting at (800) 509-2864. THE NATIONAL SCHOOL OF DENTAL ASSISTING — NORTH DALLAS offers the Texas RDA course and exam. Call (800) 383-3408 for available dates. DOCTORSCHOICEGOLDEXCHANGE. COM: Try our high prices for dental scrap. Check sent 24 hours after you approve our quote. See why we have so many repeat customers. Visit www. DoctorsChoiceGoldExchange.com. THE DENTAL HANDPIECE REPAIR GUY, LLC. I’m pleased to inform you that we are now operating a full-service handpiece repair shop in Friendswood, Texas, where my father Dr. Ronald Groba has

been practicing for over 35 years. I have been doing his handpieces for over 20 years and decided to provide this service to other dentists. First and foremost, we provide expert service for your precision LQVWUXPHQWV DQG DUH TXDOLÀHG WR VHUYLFH nearly every make and model of highspeed, low-speed, and electric handpieces on the market. We use quality parts, take less time, and our costs are lower. We provide free pickup and delivery, warranties, and next-day service on most high-speed units and a 1-week turnaround for slow speeds, ultrasonic sealers, and electrics. The Dental Handpiece Repair Guy wants to be your handpiece servicing facility of choice. We would appreciate a chance to earn your business! Call (800) 569-5245 or visit our website, www.thedentalhandpiecerepairguy.com.

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Advertisers Ads Watson, Brown & Accociates ....................... Ace on Hold (TDA Perks) ...................................... AFTCO ....................................................................176

Your Patients Trust You. Who can YOU Trust?

A.J. Riggins Co ......................................................245 Anesthesia Education and Safety Foundation ..........................................................165 Crown Dental Studio ............................................. DDR Dental Trust ................................................... Dental Practice Specialists................................... Dental Systems......................................................

The Professional Recovery Network (PRN) addresses sses personal needs invo involving counseling servicess for dentists, hygienists, dental students and hygiene iene students with alcohol or chemic chemical dependency, de ncy, or any other mental or emotional diffi fficulties.. We provide impaired dental profes profe siona nals with the support and means to confiden confide tial rec ecovery. If you or another other dental professional are con co cerned aboutt a possible impairment, call the t Professsional Recovery Netw Networkk and start the recovery process recover ess today. If you call to get help for or someone som in need, your name and location loc willll not be divulged. vulged. The Professional Recovery Re Network wor staff will ask for your name and an phone numbers mbe so we may obtain more information and le let you know that something is being don done.

Doctors Per Diem ..................................................244 EVAC V ....................................................................... Fortress Insurance ................................................146 Gary Clinton, PMA .................................................175 Hanna, Mark — Attn. at Law .................................176 Henderson, Sherri L. & Associates......................151 Hindley Group........................................................146 Inspection Connection.......................................... JKJ Pathology........................................................ Kennedy, Thomas John, D.D.S., P.L.L.C..............245 LVI Global/Dr. Reece..............................................154 L Ocean Dental.......................................................... Paragon, Inc. .......................................................... Patterson Dental ..........................Inside Front Cover Portable Anesthesia Services .............................. Professional Recovery Network...........................246 Robertson, James M .............................................

Statewide ide Toll-fr Toll-free Helpline 800-727 27-5152 Emergency ergency 24-hour Cel Cell: 512 2-496-7247

Shepherd, Boyd Wilson ........................................ Southern Dental Associates.................................147 SPDDS .................................................................... TDA A Express .......................................................... TDA A Financial Services Insurance Program.......................................... %DFN &RYHU TDA A Perks Program ..................... Inside Back Cover

Professional Recovery Network 12007 Research Researc Blvd. Suite 201 Austin, TX 78759 www.rxpert.org

Texas Health Steps ................................................143 T Texas Medical Insurance Company .....................166 T TEXAS Meeting ......................................................174 UTDB Houston ....................................................... UTHSCSA ............................................................... UTHSCSA A Oral & Maxillofacial Lab ...................... Waller, Joe..............................................................175

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