August 2013
TEXAS DENTAL
Special Issue:
CANCER
Its Professional and Personal Impact
Inside: 4 Guest Essays • Oral Health 682 • Living in Limbo 692 Texas Dental Journal l www.tda.org l August 2013
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Plan to Attend
Education
Participate in challenging, cutting-edge CE courses that fit into your schedule and budget
Exhibition
Research and purchase dental products and services at a discount
Connections
Advance the dental industry through the House of Delegates and mingle with colleagues
The ADA Annual Session is your national dental meeting. Visit ADA.org/session for more information and register May 1!
TEXAS Dental Journal Established February 1883
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ABOUT THE COVER
Jeffery L. Corbet, DDS, of Bedford entered the cover photograph, titled “Jumbled Jellyfish,” in the Natural Wonders category of the TEXAS Meeting Photo Contest at the TDA annual session in May 2013. Dr Corbet used a Canon Powershot S5 to take the photo in October 2012 at the Jellies Experience Exhibit in the Monterey Bay Aquarium in Monterey, CA. He has practiced dentistry in Bedford for 28 years. Nature continues to provide scientists with more clues to the human body. Inspired by jellyfish’s long tentacles, scientists reported on a method using long strands of DNA tied to a microchip that floats in the bloodstream. It helps cancer patients by counting and sorting cancer cells, an indicator of how cancer treatments are working. Read more in an article published online in November 2012 in the Proceedings of the National Academy of Science: tinyurl.com/pnas-article.
SPECIAL ISSUE: CANCER — ITS PROFESSIONAL AND PERSONAL INFLUENCES 670 GUEST ESSAY: BE SMART AND BE AWARE! Michael L. Stuart, DDS
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GUEST ESSAY: FROM POSTER CHILD TO GOOD HEALTH Karen Cortell Reisman, MS
GUEST ESSAY: TIME IS A GIFT David Tillman, DDS
GUEST ESSAY: my experience with oral cancer Chad Capps, DDS
Oral health care in cancer patients: You can make a difference!
Jacqueline M. Plemons DDS, MS; K. Vendrell Rankin, DDS; and Elain Benton, RDH, CTTS
The authors highlight the dentist’s role in the management of patients treated with chemotherapy for various types of cancer as well as those who receive radiation therapy for cancer of the head and neck.
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LIVING IN LIMBO: ETHICS AND EXPERIENCE IN A CONVERSATION ABOUT PERSISTENT ORAL LESIONS
Catherine M. Flaitz, DDS, MS; and Nathan Carlin, PhD
In this award-winning article, a reprint from the May 2011 Texas Dental Journal, the authors present a case report on a patient suffering from oral lichen planus and oral cancer. They explain the patient’s “limbo experience” as he waits for a diagnosis and the importance of a dental professional’s empathy with a patient in such a situation.
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President’s Message The View From Austin Oral and Maxillofacial Pathology Case of the Month 2013 TDA Annual Session TEXAS Meeting Photo Contest Winner Critically Appraised Topic of the Month
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Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management In Memoriam / TDA Smiles Foundation and Memorial and Honorarium Donors Calendar of Events Value for Your Profession Advertising Briefs Index to Advertisers
TDA members, use your smartphone to scan this QR Code and access the online Texas Dental Journal.
Editorial Staff
Editorial Advisory Board
BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION
Stephen R. Matteson, DDS, Editor-in-Chief Daniel L. Jones, DDS, PhD, Associate Editor Harvey P. Kessler, DDS, MS, Associate Editor Nicole Scott, Managing Editor Lauren Oakley, Publications Coordinator Barbara Donovan, Art Director Paul H. Schlesinger, Consultant
Ronald C. Auvenshine, DDS, PhD Barry K. Bartee, DDS, MD Patricia L. Blanton, DDS, PhD William C. Bone, DDS Phillip M. Campbell, DDS, MSD Michaell A. Huber, DDS Arthur H. Jeske, DMD, PhD Larry D. Jones, DDS Paul A. Kennedy Jr, DDS, MS Scott R. Makins, DDS Daniel Perez, DDS William F. Wathen, DMD Robert C. White, DDS Leighton A. Wier, DDS Douglas B. Willingham, DDS
The Texas Dental Journal is a peer-reviewed publication. Texas Dental Association 1946 S IH-35 Ste 400, Austin, TX 78704-3698 Phone: 512-443-3675 • FAX: 512-443-3031 E-Mail: tda@tda.org • Website: tda.org Texas Dental Journal (ISSN 0040-4284) is published monthly, one issue will be a directory issue, by the Texas Dental Association, 1946 S IH-35, Austin, TX, 78704-3698, 512-443-3675. Periodicals Postage Paid at Austin, Texas and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S IH 35, Austin, TX 78704. Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, Out-ofstate ADA Affiliated $49.50. In-state Non-ADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA Affiliated, $17 Non-ADA Affiliated, September issue $17 ADA Affiliated, $65 NonADA Affiliated. For in-state orders, add 8.25% sales tax. Contributions: Manuscripts and news items of interest to the membership of the society are solicited. Electronic submissions are required. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. For more information, please refer to the Instructions for Contributors statement printed in the September Annual Membership Directory or on the TDA website: tda.org. All statements of opinion and of supposed facts are published on authority of the writer under whose name they appear and are not to be regarded as the views of the Texas Dental Association, unless such statements have been adopted by the Association. Articles are accepted with the understanding that they have not been published previously. Authors must disclose any financial or other interests they may have in products or services described in their articles. Advertisements: Publication of advertisements in this journal does not constitute a guarantee or endorsement by the Association of the quality of value of such product or of the claims made of it by Texas Dental Journal is a member of the its manufacturer. American Association of Dental Editors. Member Publication
PRESIDENT David A. Duncan, DDS 806-355-7401, davidduncandds@gmail.com PRESIDENT-ELECT David H. McCarley, DDS 972-562-0767, drdavid@mccarleydental.com IMMEDIATE PAST PRESIDENT Michael L. Stuart, DDS 972-226-6655, mstuartdds@sbcglobal.net VICE PRESIDENT, NORTHWEST David C. Woodburn, DDS 806-358-7471, olddave1@gmail.com VICE PRESIDENT, NORTHEAST Jean E. Bainbridge, DDS 214-388-4453, jbainbridgedds@sbcglobal.net VICE PRESIDENT, SOUTHEAST Gregory K. Oelfke, DDS 713-988-0492, greg@oelfke.com VICE PRESIDENT, SOUTHWEST Yvonne E. Maldonado, DDS 915-855-2337, yvonnedent2000@yahoo.com SENIOR DIRECTOR, NORTHWEST Steven J. Hill, DDS 806-783-8837, sjhilldds@aol.com SENIOR DIRECTOR, NORTHEAST Jerry J. Hopson, DDS 903-583-5715, dochop@verizon.net SENIOR DIRECTOR, SOUTHEAST William S. Nantz, DDS 409-866-7498, wn3798@sbcglobal.net SENIOR DIRECTOR, SOUTHWEST Joshua A. Austin, DDS 210-408-7999, jaustindds@me.com DIRECTOR, NORTHWEST Charles W. Miller, DDS 817-572-4497, cwdam@sbcglobal.net DIRECTOR, NORTHEAST William H. Gerlach, DDS 972-964-1855, drbill@gerlachdental.com DIRECTOR, SOUTHEAST Karen A. Walters, DDS 713-790-1111, kwalters@sms-houston.com DIRECTOR, SOUTHWEST John B. Mason, DDS 361-854-3159, jbmasondds@aol.com SECRETARY-TREASURER Ron Collins, DDS 281-983-5677, roncollinsdds@yahoo.com SPEAKER OF THE HOUSE John W. Baucum III, DDS 361-855-3900, jbaucum3@msn.com PARLIAMENTARIAN Michael Vaclav, DDS 806-355-7463, drvaclav@suddenlinkmail.com EDITOR Stephen R. Matteson, DDS 210-215-1515, texdented@gmail.com EXECUTIVE DIRECTOR Aaron Washburn 512-443-3675, aaron@tda.org LEGAL COUNSEL Mr. William H. Bingham 512-495-6000, bbingham@mcginnislaw.com
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President’s Message David Duncan, DDS, TDA President
Happy Summer! It’s that time of the year when we all hit the beach, golf course, or swimming pool. I hope this journal finds you well and that the sun is not beating down on your part of the state too much. And if it is I have but one word for you — sunscreen! Sun-lovers everywhere are rejoicing because the time has come to get outside and enjoy the great outdoors. Birds are singing, kids are laughing, and golfers are, well, let’s call it commenting. There is something about the sunshine that rejuvenates us and makes us want to get out of the house and act like a kid again.
Before this occurrence I was pretty complacent about skin cancer; now though, not so much. Anything measured in millimeters that can kill you gets my attention.
As a kid growing up in Amarillo, summer meant meeting your buddies at the golf course in the morning and baseball practice in the afternoon. We did this almost every day. And back then it was shorts, sometimes a shirt, and suntan lotion or oil, not sunscreen. Our goal was to see who could get the darkest! If I had only known … Jumping ahead 30 years, I vividly recall a phone call from my dermatologist in which he informed me that the biopsy from my neck was a malignant melanoma. At first I wasn’t aware of the magnitude this carried, nor was I aware that I probably acquired it when I was that young baseball player spending all day outside without any protection. As the story goes, I next visited the plastic surgeon, he removed it, and I was lucky. It was diagnosed early and the lesion was still shallow. Before this occurrence I was pretty complacent about skin cancer; now though, not so much. Anything measured in millimeters that can kill you gets my attention. This was my first dealing with cancer. Since that time I have had 3 more lesions successfully treated or removed, and I am coming up on the 5-year anniversary of having a kidney removed due to renal cell carcinoma. I tell you all this for 2 reasons. The first is to raise awareness so that maybe you will not have to go through what I did. Protect yourself and your kids from the sun! Wear sunscreen, and see a dermatologist! In my opinion you should see your dermatologist as often as you get your teeth cleaned. Secondly, I didn’t do this alone. Not only was my family there, my friends from TDA were there too. I received countless cards, calls, and visits from people all over the state who I knew only because of being in TDA. At the end of the day, I may or may not remember the resolutions we passed or the legislation we helped write, but I promise you I will remember the people with which I did it. Don’t let a life scare remind you to spend time with those you love. This issue of the Journal will include accounts similar to mine, members who are sharing their experiences with cancer and are in recovery. Please also see Dr Jacqueline Plemons’ article on the clinical complications dentists see in patients who have the disease. Cancer is nondiscriminatory and affects all of us in one way or another.
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Journal l www.tda.org l June 2011 2011 TexasTexas DentalDental Journal l www.tda.org l October
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The View From Austin Stephen R. Matteson, DDS, FiCD, editor-in-Chief
Lucky Me My family is riddled with cancer. Dad died of laryngeal carcinoma, Mom from large intestine carcinoma, my older sister Barbara of Hodgkin’s lymphoma, my younger sister Sue was a breast cancer survivor before dying of other causes, and my brother Dave is a prostate cancer survivor. My dermatogist has removed 2 superficial melanomas and 1 squamous cell carcinoma. So, i am quite a lucky guy to benefit from careful monitoring by my dermatologist, especially with my family history. This issue of the Journal is dedicated to TDA members or family members who graciously contributed their personal “stories” for the benefit of
readers. The consistent theme tells us about the importance of early detection and the need to quickly seek professional care if signs or symptoms of potential cancerous lesions occur. The editor is grateful to TDA immediate Past President Dr Michael Stuart who proposed the concept of this issue. You will find his article along with that of Ms Karen Cortell Reisman, Dr David Tillman, and Dr Chad Capps who provide their interesting experiences with cancer. Also included is an original article by Dr Jacqueline Plemons with an overview of the dentist’s role in the management of patients with cancer. And finally, a reprint of an article previously published in the
March 2011 issue of this Journal about the nervous time patients experience waiting for the results of tests for cancer diagnosis; the authors, Dr Catherine Flaitz and Dr Nathan Carlin received 2 awards for their publication, one from the international College of Dentists (iCD)–USA Section and one from the iCD–Texas Section (1). So, how lucky can a guy get to be healthy and serve as editor of this journal. i hope the information in this issue will be beneficial to the professional and personal experiences of our members. Reference
1.
Flaitz CM, Carlin N. Living in limbo: ethics and experience in a conversation about persistent oral lesions. Tex Dent J. 2011 May; 128(5): 427-37. PMiD: 21834365
TDA Editor Dr Steve Matteson (right) presents Dr Catherine Flaitz of Houston with the ICD–Texas Section 2012 Best Paper of the Year award at the annual meeting of American College of Dentists and the ICD in May 2012 in San Antonio. Her article was published in the May 2011 Texas Dental Journal and is reprinted in this issue, beginning on page 692. Photo printed with permission from the ICD–Texas Newsletter. The International College of Dentists – USA Section Journalism Awards awarded the Texas Dental Journal with a Golden Pen Division 1 award for the “Living in Limbo: Ethics and Experience in a Conversation About Persistent Oral Lesions” article by Drs Catherine Flaitz and Nathan Carlin in the May 2011 issue. The article is reprinted in this issue, beginning on page 692.
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Oral and Maxillofacial Pathology Case of the Month
Rameez Raja, BDS, Department of Diagnostic and Biomedical Sciences, The University of Texas School of Dentistry at Houston
Clinical History A 27-year-old Asian male presents with multiple red patches with white rimmed margins in his right buccal mucosa and lower lips. These red patches are similar in size and shape and are non-tender to palpation and non-indurated. Patient denies pain, sensitivity, or any other symptoms associated with these lesions. The lesions were noted as an incidental finding during a comprehensive oral examination; the patient was unaware of their presence. These lesions were initially diagnosed as aphthous ulcers by his dentist. However these lesions did not resolve when the patient returned for his follow-up appointment after 1 month. Patient’s medical history is significant for seasonal allergic rhinitis and bronchial asthma. He is using an albuterol inhaler and loratadine tablets as needed for his asthma and seasonal allergy, respectively. Patient is a non-smoker, has no known food or drug allergies but acknowledges consuming alcoholic beverages occasionally. Intraoral examination reveals multiple circular to oval erythematous patches surrounded by white borders on the right anterior buccal mucosa and lower labial mucosa. These red patches measure approximately 3 x 3 mm and upon close clinical examination, their surface epithelia appear intact without ulcerations or erosions. The entire dorsal surface of the tongue exhibits deep fissures and grooves consistent with fissured tongue. Isolated and well-demarcated erythematous patches of depapillation of irregular shape and size are noted on the dorsal and lateral surfaces of the anterior two-thirds of the tongue. These red patches with atrophied filiform papillae are partially surrounded by slightly raised scalloped white borders.
Raja
Vigneswaran
Nadarajah Vigneswaran, BDS, DMD, Dr Med. Dent., Department of Diagnostic and Biomedical Sciences, The University of Texas School of Dentistry at Houston
Figure 1. Ectopic erythema migrans of the right buccal mucosa presenting as multiple circular red patches with white periphery.
See page 704 for the answer and discussion.
Figure 2. Ectopic erythema migrans of the lower lip.
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Figure 3. Erythema migrans (migratory glossitis) with fissured tongue.
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Be Smart and Be Aware Michael L. Stuart, DDS
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such shock I had a hard time going back to finish the day. This was ME! I cannot have skin cancer, especially one as threatening as malignant melanoma! I am too busy for this! This happens to other people, not me! When the shock wore off, I began to make a few plans. Most of the decisions were simple. Let’s get the lesion off of me ASAP. As it turned out, it was determined that I had lymph node involvement as well. So, after having a total of 50 lymph nodes removed, I had one positive node. Still, not a big deal. I did interferon therapy and continued to work and serve as TDA president. Then, as a result of a PET (positron emission tomography) scan, my world was rocked again. A “suspicious” lymph node showed up next to my right clavicle. After having it excised, it turned out to be melanoma. Again! That resulted in me having to have very severe, debilitating chemotherapy. I lost 40 pounds in 8 weeks. I was not able to work in my office for 2 months. This was not a good time!
I
was always proud of my tan. I always tanned very easily. I never worried about skin cancer since I rarely, if ever,
burned. I never applied sunscreen since I wanted to look tanned and handsome. I loved the sun and wanted to be outside as much as possible. Before going to the beach, I would visit a tanning bed for a few hours, so I would be prepared for the sun. All wrong and all stupid!
It all started with a “bump” on my right forearm. No big deal; it did not look suspicious. I just looked at it and ignored it. Again, stupid. When I finally decided to go to the dermatologist to have it examined and biopsied, I had started to get a little concerned. I felt a little better, however, when the dermatologist said it did not look like a big deal. Again, wrong. I received the call at my office while treating patients. Melanoma. A referral to a surgeon for excision. I was in
After the chemotherapy, I thought I was totally clear. A good PET scan in January 2013. Another PET in May 2013, however, revealed a couple of areas of concern. I had another lesion next to my right clavicle, next to the positive lymph node. After excision, it also proved to be melanoma. The other suspicious area was in my left thigh. I felt I was taking 1 step forward and 2 steps back. So, as my oncologist says, the plot thickens! I want to tell you what I have learned. What would have I done differently? First, I would always wear sunscreen. Tans may look cool, but they can be deadly. Never get in a tanning bed. Next, see your dermatologist regularly. Have a full-body exam yearly. Also, if something looks suspicious, no matter what it is, have it checked. Melanoma can appear in unusual places and appear in different forms. Waiting and watching it will not make it go away. If it turns out to be nothing, then you have not lost anything. If it is something, catch it early. Statistics reveal those most vulnerable to melanoma are young females in their 20s who have religiously tanned since childhood. Trust me when I say, “It is not worth it!” If my experiences can save you or anyone you know from the devastating effects of skin cancer, then my trials can be for good. While I do not ultimately know what the long-term effects will be from my cancer, I appreciate the opportunity to warn others on how to best avoid it happening to you or your loved ones. Be smart and be aware! Texas Dental Journal l www.tda.org l August 2013
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From Poster Child to Good Health Karen Cortell Reisman, MS
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“You’re a poster child for mammograms,” the radiation oncologist said to me. “Why?” I asked, from my seat in his bad-aqua blue treatment room. “Because you found your breast cancer early. You’re going to be okay.” About a year ago I walked into that regular annual mammogram looking pretty good and feeling great. Nine months later – after a lumpectomy, 16 weeks of chemotherapy, 33 radiation treatments, and 101 doctor visits – I walked out of that bad-aqua blue treatment room bald, tired, and grateful. During this health journey there were days of euphoria, days of despair, and every kind of day in between filled with frustration, humor, fear, and gratitude. Here’s what I have come to know: •
•
•
•
“Normal” is great. It’s really not about how much money you make, or how many trips you take, or how large your practice is. It’s really about enjoying a normal day. Tragedy + time = humor. When I found out I was going to have chemo, I told my husband, Jimmy, “I always thought I might sleep with someone who’s bald, I just never thought it would be me.” Maintain best practices around exercise and diet. If you’re already in good shape, you’re ahead of the curve when you get a challenging diagnosis. Nurture your support system of family and friends. Create your safety net before you hit the wall. My family and friends made all the difference.
As president of Speak For Yourself,® I give presentations and coach executives on how to speak for themselves to make more money. From my professional work and this personal experience, here are some communication tips to help you when interacting with your patients, colleagues, and friends who are dealing with medical situations. 1. Do stay in touch with someone who’s going through a health challenge. E-mail, text, phone message — all are great. 2. Do NOT ask the person who’s sick to return your call or electronic message. That’s a burden. 3. Do say or text, “You do not have to return this call/text/email.” 4. Do NOT ask, “What can I do to help you?” 5. Do something that you would like someone to do for you such as mail a get-well card (appreciated and unobtrusive), meet for a walk, wash her car, make a meal, drive him to a doctor appointment, bring lunch, take her to a manicure place, or make a donation in his honor. And, do tell her that she doesn’t have to write you a thank-you note. 6. Do not use Facebook or Twitter as a place to share your concern about him, unless he invites that opportunity. 7. Do NOT talk about your own experiences (or the medical outcome from your brother-inlaw’s mother’s aunt...) with this type of illness. You are there to hear your friend’s story, she is NOT there to hear yours. 8. Do listen, if he wants to talk. That’s right. Just listen. Biggest gift of all. These tips worked for me, and I hope you will use them as guidelines for you.
You can’t practice this great profession of dentistry if you are not healthy. My annual mammogram saved my life. Please do your annual mammogram/PSA (prostate specific antigen)/whatever test(s)! Who wants to be a poster child? Not me. But it sure beats the alternative. © Karen Cortell Reisman, M.S. Ms Reisman, author of 2 books and president of Speak For Yourself,® presents to dental associations, corporations, and executives on how to speak for themselves to make more money. Read her blog at karencortellreisman.com. She lives in Dallas with her husband, TDA member James H. Reisman, DDS, and is a member of the Dallas component of the Alliance of the TDA. Texas Dental Journal l www.tda.org l August 2013
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Time Time is a Gift is a Gift David Tillman, DDS
David Tillman, DDS
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alentine’s Day 2011, was But I hadn’t noticed the yellow not a good day. If you color overtaking me. “Yep,” as remember, February I stared at my eyes in a mirror, 2011 brought lots of snow “I’m yellow.” I guess you could days to North Texas. I used say I was stubborn but I couldn’t each snow day to fight what I ignore the jaundice. I responded thought was a pesky cold. On by going to the nearest doc-in-aValentine’s Day, our first patient box. I think the doctor had talked cancelled and I crashed for an to Amanda, “Sir, you’re yellow. hour under twoalentine’s blankets an was notYou need to go to the Dayin2011 a good shaking, andhospital.” now you’re yellow. I’m cancelling empty operatory toIfescape the February 2011 day. you remember, your day. Go to the hospital!” Amanda never North Texas lots of snow days. minced words. But I hadn’t noticed the yellow chills that were brought increasingly Once at Baylor, I realized why I hadn’t I used each snow day to fight what I thought color overtaking me.come “Yep,” as I stared at my overtaking me. Walking to the to the emergency room sooner. After the was a pesky cold. On Valentine’s Day, our eyes in a mirror, “I’m yellow.” I guess you could front office, Amanda confronted blood draw and stubborn chest x-ray, I I couldn’t ignore the first patient cancelled and I crashedobligatory for an say I was but met the doctor who also did not mince me, “Dr Tillman, you’re sick! hour under 2 blankets in an empty operatory jaundice. I responded by going to the nearest words. The entirety of his visit can be the doctor had talked to to escape the chills that were increasingly doc-in-a-box. I think You sleep all the time, you look as follows, “Good overtaking me.you’re Walking to the frontsummarized office, Amanda, “Sir,afternoon, you’re yellow. You need to go to exhausted, and now I’m Dr ____, you have lower right lobe Amanda confronted me, “Dr Tillman, you’re the hospital.” yellow. I’m cancelling your pneumonia, jaundice, and multiple myeloma sick! You sleep all the time, you’ve been (MM). (Long pause). Good luck to you.” I day. Go to the hospital!!” remember the sound of the curtain open Amanda never minced words.
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and close as the doctor disappeared. He satisfied his professional oath, delivered the diagnosis, but gave absolutely no human compassion, no hope for a future. I don’t remember crying, the tears would come later. I don’t remember very much of anything, only the diagnosis resonating in my head that night. I could only think of Tristan, my 11-year-old girl. “How am I going to tell her? How am I going to take care of her?” I thought. That evening I dreamt of walking her down an imaginary church aisle; she, dressed in a wedding gown. That dream recurred many times over the next weeks as I lay on a hospital bed. The dream became a goal. I don’t know when or if my daughter will marry, but from that time until now my singular focus is to see my girl become a woman and walk down an aisle. I encourage others to latch onto hope as they face similar challenges. My church also gave me hope. Those in our prayer ministry prayed for me every hour 24 hours a day those first months. Also, get-well cards from Sunday school kids lined my hospital room and my hospital pillow case was replaced by a home-made gift lovingly made by a church friend. Finally, I don’t think my wife Julie cooked the next few months as a continuous parade of food came to our home from church friends. All of these expressions of love fed that glimmer of hope to beat this thing inside me. I realized then that if my life were to end, I had not adequately provided for my family. Yes, I had a will and some insurance, had paid my bills, and nearly paid off the house. But my kids’ college and my retirement were a fantasy. Julie had no clue how to take over the practice, no clue what bills were due, or how to sign business checks. So I called my financial planner, Hufford Financial, to make
The tendency is to cocoon yourself at home during therapy, especially after hair loss. Instead, I resolved to live life fully, even as a baldy. sure I was prepared for all outcomes, and Julie spent many hours at the office familiarizing herself with my business, adding her name to office documents and accounts. During induction chemotherapy, my numbers didn’t improve very much. After much frustration, I sought a physician’s second opinion. This was a difficult decision because I liked and respected my oncologist. But I ultimately realized that I had the responsibility to myself and my family to make the best decisions I could about my care. Also, I networked with other MM patients through the North Texas MM Foundation, attending monthly meetings and conferences. This helped me understand my disease and see people who had beat MM. It helped my wife learn how she could support me in my care. And it helped me access a clinical study, which I am now a participant, and find an excellent physician, Dr Larry Anderson at UT Southwestern Medical Center. I worry that the money of cancer care, the marketing that I see on TV, will sway patients away from seeking a second opinion from a proven center of excellence in cancer treatment. During my care I made many calls to Mayo Clinic, MD Anderson, and Arkansas’ Myeloma Institute. Those inquiries helped me make informed decisions about my treatment and improved the outcome of my care. The tendency is to cocoon yourself at home during therapy, especially after hair loss. Instead, I resolved to live life fully, even as a baldy. A month after
my bone marrow transplant in March 2012, I was back at church singing in the choir and back at the office. Drs Tom Howorth, Richard Neal, and Jon Greene ably stepped in during my absence and I truly appreciate their assistance. In May 2012 I ran for my local school board of trustees and won. Later that month I took a longpromised fishing trip to the coast with my dad. What a great time we had! And what a shame that it took a bad diagnosis until a father and son could spend some quality time together. Also, I am planning a trip to Europe with my family, which we will take this Christmas. Finally, I continued work on a new dental office that will eventually provide a steady stream of income to my family regardless of me. I added operatories to the floor plan, again to improve income from a future associate, but also to ensure a seamless transition after my dental years are behind me. No, I don’t know how long I will live, but I will use my time. It is a gift. I don’t know why God allowed this to happen, but I know that He loves me and will use this to bring His life-saving love to others. I’ve faced cancer and I understand my foe. Cancer will be part of my life until I die. It has made me take better care of myself for my family. But cancer will not win, it will not take my love of life, family, and God. And so through this journey, my faith has strengthened, my resolve to care for and leave a legacy for my family and community is stronger, and my appreciation of each day has grown.
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My Experience with Oral Cancer Chad J Capps, DDS
Photo courtesy of the Oral Cancer Foundation; oralcancerfoundation.org
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n 2005 I was in the fall semester of my second year in dental school. One
morning on the way to a class in occlusion, I felt an ulceration on the lateral border of my tongue. Upon inspection I concluded that I must have bit my tongue in my sleep the night before. With a history of night terrors and a lot of movement
might heal faster with less discomfort if we ablated the area with a CO2 laser. This sounded much more comfortable than sutures in the side of my tongue so I consented. Unfortunately, the area failed to properly heal and as a result I finally had an incisional biopsy performed. The biopsy showed mild to moderate dysplasia. I was shocked. I never imagined that the lesion was precancerous. I did not fall into any of the stereotypical high-risk categories. In fact, I was a healthy 23-year-old with a negative history of tobacco and alcohol abuse.
in my sleep, this seemed to be the most logical explanation. Since I had not yet developed confidence in my newfound knowledge of oral lesions, I confirmed my diagnosis with the pathology department. They agreed that the lesion looked traumatic in nature. We decided to give it a few weeks to heal and then follow up if there were any problems. After several months passed and the lesion had not resolved, I returned to the pathology department. We concluded that the initial trauma must have been deep enough into the muscle to inhibit healing and as a result a traumatic granuloma developed. Although all of the clinical signs indicated that the lesion was traumatic in origin, we decided to biopsy the lesion just to be sure. So I went down to the Oral and Maxillofacial Surgery Department. They too thought that the ulcer appeared traumatic and thought that I
I had 7 incisional biopsies performed in the next 6 years. Every time, the results came back showing dysplasia throughout the specimen. Fortunately, it was only dysplasia; unfortunately, it meant that I fell into a gray area. As clinicians, we all know that early diagnosis with squamous cell carcinoma is critical. Stage One oral squamous cell carcinoma has a 5-year survival rate between 77-85%; any nodal involvement and those numbers drop below 45%. Finding the lesion early was a true blessing; however, it also meant that there was not an accepted treatment. Most surgeons do not feel comfortable taking a patient to the operating room for a lesion deemed pre-cancerous. I felt like there was a time bomb wrapped around my tongue. My instructions were to remove the bomb right before it went off, but I could not see the timer. How do you determine the exact point when dysplasia has turned into carcinoma but is only minimally invasive?
This paradox led us to the operating room in an attempt to excise all of the dysplastic tissue. We were very fortunate that we did because in the specimen we found minimally invasive squamous cell carcinoma. Since this initial surgery, I have had 2 others. The second surgery found carcinoma in situ. The third surgery discovered another area of minimally invasive squamous cell. I have not reached the conclusion of my story. The etiology of my lesion remains unknown and there is still dysplastic tissue on the lateral anterior third of my tongue. Hopefully I will have a resolution soon. Being on this side of treatment has been an educational experience, to say the least. It has taught me the importance of a thorough oral cancer exam and the effort required to truly care for your patients. As you treat your patients, remember to take the time to both educate and empathize. Although my experience has been challenging, it would have been even more daunting and frustrating if I did not have an understanding of oral biology. In fact, without my dental background there is a significant chance that my lesion would have metastasized long before it was found. Thank you for letting me share my experience. It is easier to overcome adversity if it assists someone else in his or her plight. I hope that this story will remind us of the important role we play in the diagnosis and treatment of oral cancer.
Thank you for letting me share my experience. It is easier to overcome adversity if it assists someone else in his or her plight.
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Texas Dental Association 143rd Annual Session TEXAS Meeting Photo Contest Texas 2013 Dental Association 143rd Annual Session 2013 TEXASWilliam Meeting Photo Contest Photographer: Tom Parker, DDS, of Dallas
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Title: “Enjoying the View” Photographer:Award: Logan Stanley, Best in DDS, Showof Marble Falls Title: “Uptown Invasion” Information on the 2014 TEXAS Meeting Photo will be available on/ texasmeeting.com in December 2013. Category: BlackContest & White / Abstract Artistic
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Information on the 2014 TEXAS Meeting Photo Contest will be available on texasmeeting.com in December 2013.
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Oral Health Care in
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Cancer Patients CanCer You Can Make a Difference! DifferenCe! Jacqueline M. Plemons, DDS, MS K. Vendrell Rankin, DDS Elain Benton, RDH, CTTS
INTRODUCTION
INTRODUCTION
ABSTRACT
Approximately 1.4 Approximately million people 1.4 in the million United people States inare the United States are Dentists diagnosed with cancer diagnosed each year, withexcluding cancer each “simple” year, excluding basal cell “simple” basal cell are in a unique position and squamous celland skinsquamous cancers occurring cell skin on cancers sun-exposed occurring areas on sun-exposed areas to care for cancer patients of the body. During ofthe thecourse body. of During theirthe treatment, course of roughly their treatment, oneroughly one- before, during and treatment. This pathird of cancer patients third will of cancer develop patients oral complications. will develop oral Dentists complications.after Dentists per outlines foundational are in a unique position are into a unique offer optimal position care to to offer these optimal patients care to these patients knowledge highlighting the ranging from providing ranging information from providing and implementing information and preventive implementing preventive dentist’s role in the manstrategies prior to treatment strategies prior to managing to treatment short-toand managing long-term short- and long-term agement of patients treatside-effects. This paper side-effects. will highlight This paper the dentist’s will highlight role inthe thedentist’s role in the with chemotherapy for management of patients management treatedof with patients chemotherapy treated with for chemotherapy various foredvarious various for types of cancer as types of cancer as well typesasofthose cancer who as receive well as those radiation whotherapy receivefor radiation therapy well as those who receive cancer of the headcancer and neck. of the head and neck. radiation therapy for canof the head and neck. Two tenets or basicTwo foundations tenets or are basic apparent foundations from are the apparent beginningfrom the cer beginning The value regarding the management regardingof the cancer management patients — of cancer prevention patients is — prevention is of the dentist in a multidisciplinary team the best medicine and the best a team medicine approach andbetween a team approach physiciansbetween and physicians and approach to cancer care is dentists will best serve dentists our will patients. best serve Optimal our oral patients. healthOptimal will allow oral health will allow along with specific a patient to approach a patient cancertotreatment approachwith cancer teeth treatment and oralwith tissues teeth and stressed oral tissues treatment modalities to that are as disease-free that are as possible as disease-free and more as possible able to withstand and more able to withstand improve the challenges of chemotherapy the challengesand of chemotherapy radiation. A dentist’s and radiation. ability A dentist’s abilitypatient comfort to evaluate a patient to evaluate prior to cancer a patient therapy prior to to address cancer therapy any to addressand any quality of life. acute needs as wellacute as potential needs aslong well as potential oral health longchallenges term oral health challenges -term is extremely important is extremely and should important be partand of an should overall becancer part of an overallTex cancer Dent J 2013;128(8): 683-690. management plan.management plan.
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CHEMOTHERAPY Chemotherapy for cancer may include the use of a single drug or, more often, a combination of drugs that have direct cyctotoxic effects on tumor cells (1). The epithelial lining of mucosal tissues is often affected resulting in mucositis and ulceration. Hemopoietic cells of the bone marrow are suppressed (myelosuppression) causing anemia, thrombocytopenia and neutropenia thus increasing the risk of infection and bleeding.
Dental treatment during chemotherapy is often complicated by repeated cycles of low blood cell counts followed by recovery with each round of cancer treatment.
Fortunately, most of the untoward effects of chemotherapy are reversible and subside quickly following treatment. Common oral side-effects include: • • • • • •
Mucositis Infection o Bacterial o Fungal (candidiasis) o Viral (commonly HSV-1) Bleeding (low platelet count) Taste disturbances (usually transient) Xerostomia/salivary hypofunction (usually transient) Neurotoxicity (mimics dental pain)
Before Chemotherapy
Before a patient begins chemotherapy, the dentist should perform a comprehensive oral evaluation including complete periodontal charting along with appropriate radiographs to identify any oral health needs. Oral hygiene or self-care instructions should be reviewed including the use of a soft-bristled toothbrush, mild fluoride-containing toothpaste, and gentle flossing. A prophylaxis or periodontal debridement (scaling and root planing) should be performed, and restorations should be placed or replaced in teeth identified as requiring immediate attention.
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About the Authors Dr Plemons, professor, Department of Periodontics, Texas A&M University Baylor College of Dentistry, Dallas, Texas.
Dr Rankin, professor and associate chair, Department of Public Health Sciences, Texas A&M University Baylor College of Dentistry, Dallas, Texas. Ms Benton, faculty, Department of Public Health Sciences, Texas A&M University Baylor College of Dentistry, Dallas, Texas.
Corresponding author’s address: Dr Jacqueline Plemons, 6031 Sherry Ln, Dallas, TX 75225; Phone: 214-369-8585; E-mail: drplemons@yahoo.com. This manuscript has been peer reviewed. The authors have no declared potential conflicts of financial interest, relationships, and/or affiliations, relevant to the subject matter or materials discussed in the manuscript.
Obvious sources of trauma should be eliminated including sharp edges of teeth or restorations. Patients should be advised not to wear removable appliances during treatment, and orthodontic brackets should be removed. Consider extraction of teeth that are potential sources of infection in the short-term, including those with severe periodontal disease, teeth with extensive decay with probable pulpal involvement or are symptomatic, and third molars at high risk of pericoronitis. Surgical therapy should be preceded by laboratory studies including neutrophil count and platelet count, especially for hematologic malignancies. Discussion regarding the potential oral side-effects of chemotherapy is appropriate at this point as a well informed patient is often an empowered patient.
During Chemotherapy Timing of Dental Treatment: Dental treatment during chemotherapy is often complicated by repeated cycles of low blood cell counts followed by recovery with each round of cancer treatment. In general, care should be delayed during chemotherapy unless an emergent need is identified. Timing of care is critical to prevent potential serious complications such as infection and bleeding. Risk of infection is highest when neutrophil counts have reached their nadir (lowest), usually occurring 10-14 days following treatment. Platelet counts generally follow the same pattern, so the risk of bleeding problems will be highest during the same time period. Consultation with the patient’s physician is required at this point as care must be taken to ensure that absolute neutrophil counts and platelet counts have recovered to an acceptable level prior to any dental treatment (ANC >1,000/mm3 and platelet count >75,000/mm3 ). In general, the safest time to treat a
patient during chemotherapy is within 1 week of their next anticipated round of chemotherapy. The need for antibiotic prophylaxis should also be discussed with the physician. Mucositis: Mucositis is a common side-effect of chemotherapy affecting 40% of patients during their first cycle of cancer treatment. It occurs as a result of direct toxicity of chemotherapeutic agents to the mucosa of the oral cavity as well as the remainder of the gastrointestinal tract. Oral tissues experience mucosal thinning and submucosal ulceration causing severe discomfort and significantly affecting a patient’s quality of life (2). The condition begins approximately 7-10 days after initiation of chemotherapy and lasts for approximately 1-2 weeks. Its clinical course generally parallels blood cells counts with the most severe lesions occurring at or near the lowest neutrophil counts followed by recovery. The risk of secondary infection is increased in patients with mucositis due to lack of epithelial integrity. A variety of agents are recommended for the management of patients with mucositis as a result of chemotherapy. Oral rinsing during treatment in general serves several purposes including lubrication and hydration as well as removal of gross debris and bacterial plaque. Rinses such as a mixture of baking soda, salt and water, saline rinses, and calcium phosphate rinses provide palliative relief. Alcohol-free solutions of chlorhexidine may be prescribed but should not be used as a substitute for good oral hygiene in the absence of mucosal lesions. Bland saline rinses continue to be the standard of care for patients experiencing mucositis during chemotherapy. Mucosal surface protectants help coat irritated and ulcerated surfaces and reduce pain, and the use of ice chips provide relief. Topical anesthetics provide
temporary relief, but care must to be taken to avoid tissue trauma and choking. “Magic mouthrinses” containing a combination of products such as magnesium hydroxide, lidocaine, diphenhydramine, and water are often prescribed for palliative care and made available to patients through compounding pharmacies. Treatment of mucosal pain at its more severe stage may require systemic analgesics including opioids (3). Palifermin (a modification of keratinocyte growth factor) is approved by the U.S. Food and Drug Administration (FDA) to prevent mucositis in people with hematologic (blood cell) cancers treated with highdose chemotherapy or receiving stem cell transplant (4-6). It reduces both a patient’s chance of experiencing mucositis and reduces its severity. Given intravenously before and after treatment, patients should be encouraged to discuss its potential use with their physician. Infections: Bacterial infections during chemotherapy may first present as a fever of unknown origin. Care must be taken to identify potential oral sources of infection (odontogenic, periodontal, etc.) as well as infection due to mucositis. Treatment generally involves the use of broad-spectrum antibiotics preceded by cultures as necessary. Fungal infections during chemotherapy are common and can cause pain, a generalized burning sensation, angular cheilitis, difficulty in swallowing and taste disturbances. Topical antifungals such as nystatin (only formulations without sugar) or clotrimazole should be considered along with systemic medications including fluconazole or itraconazole (7,8). Reactivation of latent viruses, most commonly HSV-1, occurs frequently during chemotherapy resulting in multiple ulcerations of Texas Dental Journal l www.tda.org l August 2013
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the oral and perioral tissues and significant discomfort (9). Systemic antivirals such as acyclovir, valacylovir and famciclovir are effective treatment modalities. Others: Xerostomia/salivary hypofunction and taste disturbances occur as a side-effect of the many drugs used in management of cancer patients during chemotherapy and usually subside relatively quickly following treatment. In addition, some patients experience deep jaw pain as a result of the neurotoxicity of chemotherapy agents that can mimic dental pain. Exclusion of possible odontogenic source, patient reassurance, palliative care, and time will eventually lead to resolution.
After Chemotherapy Most patients will be able to return to a more routine dental care plan or regimen following completion of chemotherapy. The need for optimal oral health should be stressed in the event that future cancer therapy is indicated.
RADIATION THERAPY FOR HEAD & NECK CANCERS Squamous cell carcinoma of the head and neck is the fifth most common cancer worldwide with 400,000 new cases diagnosed each year in the United States. It accounts for approximately 11,000 deaths annually in the U.S. and 200,000 deaths worldwide. Most patients are diagnosed in an advanced stage often requiring a combination of treatment modalities including surgery, radiation therapy, and less frequently, chemotherapy. Radiation therapy is designed to directly kill tumor cells, but damage to normal surrounding tissues is common. A tissue sparing technique
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for radiotherapy, intensity modulated radiation therapy (IMRT), has become the standard of care by providing a mechanism to adjust the amount of radiation to the various head and neck tissues dependent on tumor location and need for treatment. The greatest benefit of using IMRT has been the ability to spare the salivary glands in many cases as well as other vital structures. Patients with head and neck cancer commonly require a 5-week course of treatment for tumor control and are seen once a day, Monday through Friday, ultimately resulting in a cumulative dose of 5000-7000 cGy. All patients undergoing radiation treatment for head and neck cancer will likely develop oral side-effects ranging from acute conditions to longterm challenges including: • • • • • •
Mucositis Xerostomia/salivary hypofunction Loss or distorted taste (dysgeusia or hypogesia) Caries Trismus Osteoradionecrosis
Before Radiation Therapy
Before a patient begins radiation therapy, the dentist should perform a comprehensive oral evaluation including complete periodontal charting along with appropriate radiographs to identify any immediate oral health needs as well as potential issues of concern likely to occur in the future. Sources of trauma should be eliminated and patients should be discouraged from wearing removable dental prostheses during treatment. Ideally, orthodontic brackets should be removed to prevent soft-tissue trauma. Oral hygiene instructions should be given followed by a prophylaxis or periodontal debridement, and fluoride delivery trays should be fabricated. The critical need for meticulous oral hygiene over the patient’s entire lifetime must be
stressed in an attempt to prevent significant side-effects in the future. An attempt should be made to determine which teeth are to be included in the field of radiation. Restorations should be placed as necessary, and endodontic therapy should be completed on teeth with decay and pulpal involvement that is confined to the tooth or on teeth with varying degrees of endodontic involvement that are not in the field of radiation. Extraction should be considered for partially erupted third molars at risk of pericoronitis, non-restorable teeth due to extensive decay or fracture, teeth with periapical pathosis within the field of radiation including unresolved periapical lesions, teeth with moderate or advanced periodontitis especially those with excessive mobility or signs of active disease, as well as teeth that are within the field of radiation of patients in whom long-term oral hygiene compliance is question¬able. Tori removal should be considered if mandibular teeth are to be extracted. At least 14 days should be allowed for healing following extraction or surgery prior to initiation of radiation therapy. If extractions or dental surgery are not possible prior to initiation of radiation therapy, they should be postponed for approximately 4-6 weeks following completion of treatment but should not be delayed for long due to increased risk of osteoradionecrosis. Amifostine is a systemic cytoprotectant that helps prevent damage to the salivary glands as a result of radiation therapy. It is usually administered intravenously 15-30 minutes prior to each radiation treatment, but is associated with sideeffects such as low blood pressure and nausea. Patients should be informed of its potential benefits and encouraged to discuss its potential use with their radiation oncologist.
A novel approach to preserve salivary gland function includes surgical transfer of the submandibular gland to the submental space away from the field of radiation prior to treatment (10).
During and After Radiation Therapy
Mucositis: Mucositis as a result of radiation therapy is very common and may necessitate delay in treatment as well as compromised treatment outcome. Radiation induced mucositis usually starts during the second week of treatment when the mucosal surfaces become thin and atrophic, and ulcerative lesions begin to develop (11). Patients often complain of pain, a burning sensation and difficulty in eating and/or swallowing. Infection from oral bacteria and yeast is a risk due to the lack of intact epithelial surfaces. Customized tongue-displacing dental stents may be fabricated prior to radiation therapy and are used to physically move uninvolved mucosal structures away from areas planned to receive high doses of radiation. These devices enhance mucosal sparing, provide reproducible immobilization, and are generally well tolerated by patients. Management of patients with radiation-induced mucositis is essentially identical to patients with mucositis during chemotherapy mentioned previously including the use of bland mouthrinses, mucosal coating agents, topical anesthetics, and analgesics. Mucositis usually subsides slowly over a few weeks following completion of radiation therapy. Xerostomia/Salivary Hypofunction: Xerostomia is the term used to describe the subjective sensation of oral dryness (what a patient Texas Dental Journal l www.tda.org l August 2013
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feels), while salivary gland hypofunction reflects an objective, measurable decrease in salivary flow (hyposalivation). Common complications in patients experiencing radiation-induced salivary hypofunction include:
Complete recovery of normal taste sensation following radiation therapy may take several months. Permanent loss may occur when radiation dosages approach 6000 cGy, which is within the anticipated range with fractionated therapy for squamous cell carcinomas of the head and neck.
• Difficulty chewing, swallowing, and speaking • Altered taste sensation • Mucosal trauma • Surface infections, including candidiasis • Halitosis • Caries • Attrition, abrasion, and erosion • Loose or uncomfortable removable prostheses Several over-the-counter products are designed to provide palliative care for patients with dry mouth and are available in a variety of forms, including toothpastes, oral rinses, lozenges, sprays, gels, chewing gums, and candies/mints (12). They often contain a combination of ingredients including pH modifiers, preservatives, thickeners, humectants, sweeteners (preferably xylitol), and flavorings. Due to their short duration of action and relative expense, many patients prefer to drink water periodically throughout the day. Dry lips are best managed with the use of lanolinbased lip balms. In patients with some degree of residual salivary flow, prescription salivary stimulants should be considered including pilocarpine (Salagen®) and cevimeline (Evoxac®) (13,14). Potential side-effects include sweating, gastrointestinal upset, tachycardia, increased pulmonary secretions, increased smooth muscle tone and blurred vision. Acupuncture has been explored as an alternative treatment method to improve salivary flow and reduce xerostomia following radiation therapy.
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Fungal infections are common during radiation therapy and can become recurrent following radiation therapy due to salivary hypofunction. Candidiasis can cause pain, a generalized burning sensation, angular cheilitis, difficulty in swallowing, and taste disturbances although it is asymptomatic in some patients. Topical antifungals such as nystatin (formulations without sugar) or clotrimazole are often prescribed as well as systemic medications including fluconazole or itraconazole. Care must be taken to treat removable appliances that may act as a source of reinfection. Caries: Loss of salivary flow results in a reduction in pH buffering capacity and antimicrobial activity, decreased remineralization capacity, altered dental pellicle formation, and a lack of oral clearance. The highly acidic environment as a result of acidogenic bacteria and acids in the diet creates a significant risk for rampant caries primarily affecting root surfaces and tooth structure around existing restorations (15). Patients should be educated in the selection of non-
cariogenic foods and drinks and the deleterious influence of frequent intake on remineralization capability as well as the importance of regular professional dental care as an integral part of a caries prevention plan. Although over-the-counter fluoridecontaining toothpastes effectively reduce caries, patients with salivary hypofunction as a result of radiation therapy often require products with a higher concentration of fluoride. Prescription-strength toothpastes and gels containing 1.1% sodium fluoride (5000 ppm) are indicated for daily use in high-risk patients. Fluoride gels are either painted on the teeth with a toothbrush or applied in fabricated fluoride delivery trays. In-office fluoride therapy for high-risk patients is most commonly accomplished by the application of fluoride varnish every 6 months. Alternatives to topical fluoride therapy include products containing casein phosphopeptide-amorphous calcium phosphate (eg, Recaldent™ or MI Paste™) and toothpastes containing tri-calcium phosphate or calcium sodium phosphosilicate; although, their effectiveness in patients with salivary hypofunction is
not known. In addition, there is some evidence that the regular use of xylitol containing chewing gum could play a role in caries prevention by increasing salivary flow as a result of chewing, reversing decreases in plaque pH and enhancing remineralization. Loss or Distorted Taste: Complete recovery of normal taste sensation following radiation therapy may take several months. Permanent loss may occur when radiation dosages approach 6000 cGy, which is within the anticipated range with fractionated therapy for squamous cell carcinomas of the head and neck (16). Trismus: Trismus occurs as a result of fibrosis of the muscles of mastication following radiation therapy (17). Muscle fibers shorten and tighten (contract) making it difficult for patients to open their mouths. It generally begins 3-12 months after radiation therapy and is unpredictable in its frequency and severity although it is associated with higher doses of radiation. As a result, a baseline measurement of a patient’s ability to open should be obtained prior to radiation therapy (usually between 35-55 mms). Treatment usually begins with oral physical therapy including daily exercises, application of heat, and the use of non-steroidal anti-inflammatory agents. Commercially available appliances such as the Therabite™ can help provide increased opening but require regular daily use. Osteoradionecrosis: Osteoradionecrosis (ORN) occurs as a late stage complication from radiation therapy that ultimately results in the inability of bone to heal following trauma such as dental extractions (although it can occur spontaneously) (18). It occurs much more frequently in the mandible, which shows progressive hypovascularity and fibrosis.
Irradiated areas are hypocellular and lacking in cells required for healing including fibroblasts, osteoblasts, and undifferentialed osteocompetent cells. ORN occurs most frequently in patients who have received radiation doses of 6000 cGy or greater. Clinical signs and symptoms include pain, swelling, trismus, bone exposure, pathologic fracture, malocclusion, and oral cutaneous fistula formation. The best treatment for ORN is prevention by performing a thorough pretreatment dental evaluation to identify and treat teeth in need of extraction or any other dental surgery and by providing patient education regarding the need for meticulous oral hygiene and frequent follow-up to help ensure future oral health. Should extraction or surgery be necessary following radiation therapy, hyperbaric oxygen treatment is recommended although its efficacy has been questioned. The most common regimen to prevent ORN prior to extractions includes 20 compression/decompression cycles (dives) prior to extraction followed by 10 cycles after extraction. Patients who present with or develop osteoradionecrosis are generally managed with a combination of topical and systemic antibiotics, hyperbaric oxygen treatment, sequestrectomy with primary closure, resection of necrotic bone, and bone graft reconstruction as necessary dependent on severity.
CONCLUSION Management of the cancer patient can be a challenging yet rewarding prospect for dentists. A multidisciplinary team approach is essential for oral management of the cancer patient before, during, and after cancer treatment. Management of oral complications of cancer
therapy includes patient education, pretreatment assessment and intervention, preventive treatment strategies, and timely management of complications as they occur. Dentists are in a unique position to play an integral role in patient care at a time when patients may need them most. References 1. Sonis ST: Mucositis as a biological process: a new hypothesis for the development of chemotherapyinduced stomatotoxicity. Oral Oncol 34 (1): 39-43, 1998. 2. Sonis ST, Elting LS, Keefe D, et al.: Perspectives on cancer therapy-induced mucosal injury: pathogenesis, measurement, epidemiology, and consequences for patients. Cancer 100 (9 Suppl): 1995-2025, 2004. 3. Clarkson JE, Worthington HV, Furness S, et al.: Interventions for treating oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev (8): CD001973, 2010. 4. Vadhan-Raj S, Trent J, Patel S, et al.: Single-dose palifermin prevents severe oral mucositis during multicycle chemotherapy in patients with cancer: a randomized trial. Ann Intern Med 153 (6): 358-67, 2010. 5. Worthington HV, Clarkson JE, Bryan G, et al.: Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev 12: CD000978, 2010. 6. Spielberger R, Stiff P, Bensinger W, et al.: Palifermin for oral mucositis after intensive therapy for hematologic cancers. N Engl J Med 351 (25): 2590-8, 2004. 7. Lalla RV, Latortue MC, Hong CH, et al.: A systematic review of oral fungal infections in patients receiving cancer therapy. Support Care Cancer 18 (8): 985-92, 2010.
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8. Clarkson JE, Worthington HV, Eden OB. Interventions for preventing oral candidiasis for patients with cancer receiving treatment. Cochrane Database Syst Rev.24;(1):CD003807, 2007. 9. Elad S, Zadik Y, Hewson I, et al.: A systematic review of viral infections associated with oral involvement in cancer patients: a spotlight on Herpesviridea. Support Care Cancer 18 (8): 9931006, 2010. 10. Jha N, Seikaly H, Harris J, et al.: Phase III randomized study: oral pilocarpine versus submandibular salivary gland transfer protocol for the management of radiationinduced xerostomia. Head Neck 31 (2): 234-43, 2009. 11. Vera-Llonch M, Oster G, Hagiwara M, et al.: Oral mucositis in patients undergoing radiation treatment for head and neck carcinoma. Cancer 106 (2): 32936, 2006.
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12. Jensen SB, Pedersen AM, Vissink A, et al.: A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: prevalence, severity and impact on quality of life. Support Care Cancer 18(8):103960, 2010. 13. Rieke JW, Hafermann MD, Johnson JT, et al.: Oral pilocarpine for radiation-induced xerostomia: integrated efficacy and safety results from two prospective randomized clinical trials. Int J Radiat Oncol Biol Phys 31 (3): 661-9, 1995. 14. Chambers MS, Jones CU, Biel MA, et al.: Open-label, long-term safety study of cevimeline in the treatment of postirradiation xerostomia. Int J Radiat Oncol Biol Phys 69 (5): 1369-76, 2007. 15. Hong CH, Nape単as JJ, Hodgson BD, et al.: A systematic review of dental disease in patients undergoing cancer therapy.
Support Care Cancer 18 (8): 100721, 2010. 16. Hovan AJ, Williams PM, Stevenson-Moore P, et al.: A systematic review of dysgeusia induced by cancer therapies. Support Care Cancer 18(8):10817, 2010. 17. Louise Kent M, Brennan MT, Noll JL, et al.: Radiation-induced trismus in head and neck cancer patients. Support Care Cancer 16 (3): 305-9, 2008. 18. Peterson DE, Doerr W, Hovan A, et al.: Osteoradionecrosis in cancer patients: the evidence base for treatment-dependent frequency, current management strategies, and future studies. Support Care Cancer 18 (8): 108998, 2010.
Peer Review: Process Snapshot Peer review is organized dentistry’s dispute resolution process that generally handles complaints from patients against dentists regarding the quality or appropriateness of clinical dental treatment received.
Need a peer review sign for your office? You may print a copy of the peer review sign from the Resources section of the members homepage on the TDA Website (tda.org).
For more information about peer review please contact the Council on Peer Review via Donna Cortez at 512-443-3675 ext. 152.
Living in
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Limbo
Ethics and Experience in a Conversation About Persistent Oral Lesions Catherine M. Flaitz, DDS, MS Nathan Carlin, PhD
This award-winning article was originally printed in the May 2011 Texas Dental Journal. The International College of Dentists (ICD) — USA Section presented TDA with a Golden Pen journalism award in 2012 for this article, and the ICD — Texas Section presented Drs Flaitz and Carlin with its 2011-12 Literary Award.
Introduction In “Living in Limbo: Life in the Midst of Uncertainty,” Donald Capps and Nathan Carlin write about “limbo situations” in everyday life. An example of a limbo situation includes the experience of finding oneself out of work or being laid off and not knowing when or if one will find a new job — they call this work-related limbo (1). Another example of a limbo situation involves waiting to get married. Some couples, for example, do not have parental approval to proceed with their wedding plans, and, because they do not want to alienate themselves from their families and because they also do not want to give up on their relationship, they find themselves in relational limbo. Going through a divorce is another example of relational limbo (2). These authors also include a chapter on illnessrelated limbo, such as waiting while health care professionals try to determine one’s diagnosis and prognosis (3). Their book is filled with real life stories of people living in limbo, and they write about how these persons have made the best of these states, situations that seem to be more or less universal to all stages and walks of life (4).
Abstract This case report presents a conversation that the authors had with a patient who is suffering from oral lichen planus and oral cancer. The reason that the authors approached the patient for an interview was to find out why he decided to enroll in an experimental study related to his oral cancer. The patient reported that it was “the waiting” that led him to enroll in this study — that is, the pressure of waiting for oral cancer to reemerge was simply unbearable, and enrolling in this experimental study enabled him to take a more proactive approach to his illness. The authors view this “waiting” as a “limbo experience” and reflect on the implications of this limbo experience for dental ethics and research ethics.
Key words: Oral cancer, oral lichen planus, dental ethics, research ethics, limbo experiences, autonomy, patient preferences Tex Dent J 2013;128(8): 693-701.
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In their book, Capps and Carlin wrote about limbo situations from a theological perspective for a religious audience (5). In this article, we draw on their ideas, but we do not write from a theological perspective, and we write for a clinical audience. And while these authors did apply the idea of limbo to illness, they did not think about illness-related limbo in terms of bioethics. Here we apply the idea of limbo to dental ethics, a subfield of bioethics, and we do so by interpreting a conversation that we had with a patient who has oral cancer. We begin by reviewing the clinical details of this patient because these details will help orient readers to the case. We then view the case in terms of Capps and Carlin’s notion of limbo so as to bring certain ethical issues to light that otherwise usually go unnoticed because there is not a vocabulary in dental ethics, or in bioethics, to talk about such situations. We argue that the notion of limbo can help health care professionals understand autonomy and patient preferences more fully. The tone of this essay, we also want to point out, is conversational, because this, we felt, would reflect the tone of our conversation with the patient.
BACKGROUND INFORMATION When one of the authors (C.F.) mentioned to the patient that she would be interested in telling his story, he immediately agreed. We later followed up with the patient, and explained that we would like to interview him and to write about his experience in a journal article. The patient remained enthusiastic and gave verbal consent for this case report. In order to maintain the privacy of the patient, he will be referred to as Mr O.C. His story is a long and complicated one because it is dealing with 2 different oral diseases, which may or may
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not be related. This patient is in his 60s, and he reported that, throughout his life, he would only go to the dentist primarily when he had a problem. He also noted that he smoked 2 packs of cigarettes a day, and that he began smoking around the age of 14 and continued for 30 years. He also reported that he drank beer periodically. Encouraged by his family because he was having breathing problems at work, he discontinued cigarette smoking on his own in the mid-1980s. In 2000, he developed periodontal disease with severe gingival recession that resulted in a referral to the periodontist. At that time, the periodontist recommended a gingival graft for the management of the receding gums. Mr O.C. was also informed that there were unusual white patches in the roof of his mouth, close to the donor graft site. Following patient consent, a biopsy was performed at the time of the periodontal surgery. At the return visit, Mr O.C. was informed that he had lichen planus and that it was a chronic condition caused by stress and aggravated by certain foods and beverages. He understood that there was no treatment to cure this mouth disease. After the follow up visit, he did not return to the periodontist
because the grafting procedure did not seem to be successful. To control the symptoms of lichen planus, he learned to avoid certain foods by trial and error. He never mentioned the oral condition to other health care providers, and none of them questioned him about having an oral problem. Up to this point he did not recall any health care provider, including the dentist, performing an oral cancer examination.
CLINICAL DISEASE PROGRESSION The symptoms in the mouth worsened in 2007, when he noticed a red patch covering the side of the tongue, along with the typical white patches in his mouth caused by lichen planus. For more than 6 months, he avoided spicy foods, but eating became more problematic as the pain became constant. At the encouragement of his wife, the patient recalls that he went to see an otolaryngologist, who diagnosed the lesions as leukoplakia and recommended that all of the white and red patches on the tongue be removed by laser treatment. After observing the laser treatment results and the lack of healing on one side
About the Authors Dr Flaitz, distinguished teaching professor, Department of Diagnostic and Biomedical Sciences, and adjunct faculty, Department of Pediatric Dentistry, The University of Texas School of Dentistry at Houston; adjunct faculty, McGovern Center for Humanities and Ethics, the University of Texas School of Dentistry at Houston, Houston, Texas. Dr Carlin, assistant professor and director, Medical Humanities and Ethics Certificate Program, McGovern Center for Humanities and Ethics, The University of Texas Health Science Center at Houston, Houston, Texas. Corresponding author’s address: Catherine M. Flaitz, DDS, MS, University of Texas School of Dentistry, Department of Diagnostic and Biomedical Sciences, Room SOD-5357, 7500 Cambridge St, Houston, TX 77054; Phone: 713-486-4146; Email: catherine.m.flaitz@uth.tmc.edu. This manuscript has been peer reviewed. The authors declare potential conflicts of financial interest, relationships, and/or affiliations relevant to the subject matter or materials discussed in the manuscript. Dr Nathan Carlin receives royalties for copies of “Living in Limbo: Life in the Midst of Uncertainty.” Dr Catherine Flaitz receives grant funding and speaking sponsorship from Trimira for the Identafi® 3000.
of the tongue, a decision was made to refer Mr O.C. to a head and neck oncologic surgeon. A wide excision of the lesion on the tongue was performed by the surgeon, who submitted the tissue for microscopic examination. At the follow up appointment, Mr O.C. and his wife were informed that a diagnosis of oral squamous cell carcinoma with clear margins had been made. Approximately 2 years later, the lesion on the tongue recurred and a second surgery was performed, along with removal of the nodes in the neck. After the second surgery, Mr O.C. was given the diagnosis of oral squamous cell carcinoma with the good news that the lymph nodes in the neck were free of tumor. He was also informed that the cancer may recur and, if it did, chemoradiotherapy would be the next treatment approach. After the family researched its options, a decision was made to seek experimental chemoprevention at an academic cancer center. Once arriving at the academic cancer center, a multidisciplinary approach to care was advised that included a head and neck oncologic surgeon, who supervised the entry into an experimental chemoprevention study, and referral to an oral and maxillofacial pathologist for evaluation and management of the lichen planus. The tender oral lesions were widespread and ranged from thick verrucoidappearing plaques on the tongue to white lacy striations and plaques with and without focal areas of ulceration and erythema on the buccal and labial mucosa and attached gingiva (Figures 1-2). Targeted laser ablation, repeat biopsies, multiple laboratory tests, periodic examinations that include screening with autofluorescence light devices, and appropriate topical and systemic medications have become the standard protocol for managing these 2 oral diseases. The patient
Figure 1. White plaque on the anterior tongue with fresh surgical biopsy site. Note the small size of the tongue and the large depression on the left lateral border where the oral cancer was excised twice.
Figure 2. White striations and plaques with superficial areas of ulcerations and erythema of the buccal mucosa.
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is aware that lichen planus rarely undergoes spontaneous remission and has a reported annual malignant transformation rate of about 0.5 percent (7). Further, he knows the average 5-year survival rate for his type of oral cancer is about 80 percent (8). For these reasons, long-term annual follow up of these oral diseases will be a necessary part of his routine to beat the odds.
WHAT IS A LIMBO SITUATION? We now want to move to a discussion of limbo situations. Capps and Carlin define limbo situations as intermediate and indeterminate states and/or places of neglect, confinement, or oblivion (5). They also offer a framework for identifying and understanding such situations, which they derived from their conversations with people living in limbo as well as from psychological literature (5, 6). They suggest that there are different types of limbo situations, such as limbo situations in early life, relational limbo, work-related limbo, illness-related limbo, and limbo situations involving dislocation and doubt. They suggest that there are different durations of limbo situations — that is, limbo situations can be acute or chronic, and, moreover, some acute limbo situations last longer than others. They suggest that there can be different kinds of distress in limbo situations, such as anxiety and worry or dread and despair, and that there can be different intensities or degrees of any given type of distress in an acute limbo situation. The longer one finds oneself in an acute limbo situation, the more likely it is that one will experience various kinds and higher degrees of distress. It is one thing, for example, to be out of work for a month, but it is quite another to be out of work for 2 years and, because of finances, foreclosing on one’s home. This framework, we found, proved to be useful in interpreting our conversation with Mr O.C., as one can observe Mr O.C.’s kinds and intensities of distress changed when the type of his limbo situation changed.
Capps and Carlin define limbo situations as intermediate and indeterminate states and/or places of neglect, confinement, or oblivion
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ORAL LICHEN PLANUS AS A LIMBO SITUATION: LIVING WITH IRRITATION A significant confounder to this patient’s oral malignancy is the original diagnosis of lichen planus that was made about 7 years prior to the occurrence of oral cancer. Although the patient was aware that he had lichen planus, a diagnosis which was biopsy-confirmed, he did not understand the cause or potential complications of this chronic disease. In part, this may have been due to the fact that he sought treatment for periodontal disease and gingival recession. It was only during the periodontal surgery, which included a palatal grafting procedure, that a biopsy of the adjacent mucosa was excised for evaluation of a white patch. The patient noted that he did not follow up for routine periodontal maintenance because he did not feel that the surgery had been successful. It is normal for patients who have oral lichen planus to fluctuate between periods of disease exacerbation and remission for years. This, in itself, is a kind of limbo situation. Although many patients with lichen planus control the symptoms by meticulous oral hygiene, monitoring their diets, and the periodic use of topical steroids, there are the inevitable flare-ups that can create a prolonged state of uncertainty along with a loss of control and a compromise in the quality of life. To complicate matters, the drugs most commonly used to control the signs and the symptoms of lichen planus are dermatologic agents that are adapted for oral
The patient did comment on how lichen planus affected his daily life. He noted that he lived with a chronic state of oral discomfort, and that he coped with his discomfort by avoiding certain foods. In this sense, he lived in a chronic state of confinement.
use. Pharmacists are often unaware of this off-label use of the drug, and so, when they question this application inside the mouth, patients are often confused and unnerved. It is further disconcerting to patients when the drug label clearly states in bold letters, “For external use only — call Poison Control, if ingested.” Not unexpectedly, some individuals fear the potential complication of long-term topical steroid use as much as the disease itself, thus creating another layer of unease, as patients wonder, “Am I doing more harm than good by using these agents?” (9, 10). The patient did comment on how lichen planus affected his daily life. He noted that he lived with a chronic state of oral discomfort, and that he coped with his discomfort by avoiding certain foods. In this sense, he lived in a chronic state of confinement. He reported that he did not seek additional care for the lichen planus because he was informed that there was no cure — only that it was aggravated by stress and certain foods. Furthermore, he never mentioned the oral problem to other health care providers because he tended to seek care intermittently and for specific reasons—he did not want to bother anyone with an unrelated concern. In terms of Capps
and Carlin’s framework, although he was experiencing an acute limbo situation that lasted for many years, he did not experience significant levels of anxiety because he knew that his condition was not curable and because lichen planus was not life threatening (5). Oral lichen planus, understood here as a case of illness-related limbo, was characterized more by irritation and frustration than by any other emotions. When reflecting on his diagnosis of lichen planus, the patient stated that he wished that he would have known more about the disease and that rare cases may undergo malignant transformation. On this detail, we pointed out to the patient that the association of the oral malignancy with this persistent inflammatory disease was controversial, and we also emphasized that it was uncertain if managing the lichen planus would have had any impact on disease progression (7). Both of these facts are all part of the limbo of living with this common oral disorder. In any case, what is striking about this observation from the patient is that, in retrospect, he would have preferred to have had lived with the uncertainty of the possibility that rare cases of lichen planus undergo malignant transformation then than to living with the
uncertainty that he lives with now. Why? Because the uncertainty that he lives with now has a tinge of regret: “If I would have acted sooner, could my oral cancer have been prevented?” An important problem with lichen planus is that it can mask more serious oral diseases because it is red, white, or ulcerated—similar to oral cancer. Although semiannual or annual periodic evaluations are emphasized for early detection of suspicious lesions, a health care provider cannot prevent a malignancy from developing. The health care provider faces some uncertainty because of the lack of disease predictability and the overlapping clinical features with more serious diseases, and so health care professionals often live in their own kind of limbo, creating, as it were, a kind of double patient-dentist limbo. The uncertainty of health care professionals, we suggest, should be openly discussed so that realistic expectations and management approaches are decided jointly. With this particular patient, the persistent oral lesions and constant tenderness allowed him to rationalize that the painful tongue lesions were a part of the lichen planus, which significantly delayed the seeking of care and the diagnosis of the oral cancer. Texas Dental Journal l www.tda.org l August 2013
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ORAL CANCER AS A LIMBO SITUATION: THE DECISION TO PARTICIPATE IN AN EXPERIMENTAL STUDY We now want to move to a discussion of oral cancer as a limbo situation, the situation in which the patient is currently experiencing. In our conversation with the patient, our initial interest was to find out why he had volunteered to take part in an experimental study at the academic cancer center. We also wanted to view his decision in context. We wanted, in other words, something more than a one sentence answer such as, “Because I want to live,” or “Because I want to help other people.” We, therefore, asked the patient a series of questions so as to encourage him to tell his story. Much of the conversation focused on the clinical disease progression. At various points during the conversation, we asked the patient how he felt during different stages of the progression of his illness. The most striking part of the interview was when we asked the patient to comment on the worst part of his disease. He did not identify pain as the worst part, and he did not identify the financial hardships, though considerable, as the worst part. The worst part, he said, was “the waiting.” This comment from the patient is what led us to use the category of limbo to understand this patient’s experience.
Enrolling in an experimental study, the patient told us, gave him a way of being proactive. He was on the offense now — he was no longer just waiting for the cancer to return.
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When the patient was diagnosed with oral squamous cell carcinoma, he remembers feeling frightened, especially because he was told that there was nothing that could cure his condition. He remembers that he was given several options. One was to do nothing, but this would lead to death. Another was to have surgery. He was reluctant to have surgery, however, because he remembers that his neighbor developed cancer of the neck and that he had multiple surgeries and yet he ended up dying anyway. He did not want to end up like his neighbor. A third option was to have some combination of chemotherapy and radiation, but he was advised that this should only be “a last resort.” At first, he elected to do nothing, because he did not want to end up like his neighbor. His wife, however, persuaded him to have surgery. This decision — Which option do I take? — is a kind of limbo situation, and his wife helped him through this one as he elected to have surgery. After he had the surgery, he thought — or hoped — that it was all over, and he felt a sense of relief. But when the cancer came back, he felt a renewed sense of dread, for he recalled the fate of his neighbor. The first surgery, then, provided a sense of closure for him — he was moving from being ill to being well — but, after the cancer returned, it became obvious that he would have to return to limbo after each surgery to
see if the cancer would return. It is this waiting for the cancer to return — a cancer that would slowly take away his tongue, that would slowly take away his speaking abilities, and that would slowly take away his life — that proved too much for him to bear. In contrast to the waiting involved with lichen planus, the waiting involved with oral squamous cell carcinoma produced high levels of dread and anxiety in the patient because his life, not simply his quality of life, was at stake. Surgery, then, became no longer an adequate option for him, because “the waiting” literally became a place of oblivion. He needed another way, something other than doing nothing or having surgery, and preferably something other than “the last resort.” This other way was enrolling in an experimental study. Enrolling in an experimental study, the patient told us, gave him a way of being proactive. He was on the offense now — he was no longer just waiting for the cancer to return. When he enrolled in the study, he was troubled by the fact that he could receive a placebo instead of the experimental drug, because this would directly challenge his sense of agency. His reason for enrolling in the study, after all, was to be proactive, but, if he received a placebo, he would be confined back in the limbo of waiting for the cancer to return. We do not know if he is receiving the drug — it is a randomized, double-blind, controlled study — but the patient believes he is receiving the experimental drug because he thinks that he has developed some of the side effects associated with the experimental drug. When he developed these side effects, both he and his wife jumped for joy, because now, he believes, he is no longer just waiting for the cancer to return, but, rather, he is waiting for a cure — waiting for life, not waiting for death. These side effects, whether real or perceived, became an occasion for hope.
IMPLICATIONS FOR DENTAL ETHICS In the closing questions of our interview, we asked the patient if he had any advice for other patients. He said, “Don’t put it off.” By this he meant that, when a person begins to notice something wrong in his or her mouth, they should go to a health care professional right away. He said that he was afraid that there might be something wrong, and that this fear prevented him from seeking help. He knew that something was seriously wrong for about 6 months or more before he sought help. This advice from the patient has implications for educational initiatives about both lichen planus and oral cancer. Honest and open discussions about the risk factors, clinical features,
management options, prognosis, and the advantages and disadvantages of oral cancer screening devices and adjunctive tests are important so that patients are armed with adequate information to make an informed decision about their health. The patient’s advice is well grounded in dental ethics (11). We also asked the patient if he had any advice for health care professionals. He said, “I would have liked to have known that my first condition could have led to something cancerous.” That is, he would have liked full-disclosure, and, as he put it, no “sugar-coating.” The principle of veracity in the American Dental Association Code of Ethics supports the patient’s advice here — he wants to know the truth of his situation so that he can make decisions based on the best available evidence (12). This advice from the patient is also well grounded in dental ethics (13). The patient’s advice also suggests the importance of ethics education for health care professionals, and that students need to know not only basic knowledge of their profession’s codes of ethics, but also, how to apply this knowledge in daily clinical practice. The advice from the patient is straightforward and, as noted, well supported in dental ethics. Viewing this case report in light of limbo underscores other issues in dental ethics, as well — specifically, ethical issues related to autonomy and patient preferences. A few words about key sources in bioethics are needed to put our reflections in context. A key document in the founding and establishing the field of bioethics is the Belmont Report, which stresses the importance of autonomy, which literally means “self-rule,” and respect for persons, as well as other principles (14). Thomas Beauchamp and James Childress later came to refer to autonomy/respect for persons as “respect for autonomy” (15). The basic approach of Beauchamp and Childress in bioethics came to be called the “principlist approach,” which involves weighing and balancing, as well as specifying, the principles of respect for autonomy, beneficence, nonmaleficence, and justice in a given bioethical dilemma (16). Some bioethicists have criticized the principlist approach for being simplistic and mechanistic, leading to a kind of listing of principles related to an ethical dilemma rather than a sophisticated application of the principles (17). This oversimplification of the principlist approach is, perhaps, related to a pedagogical strategy for teaching medical ethics in medical schools, which is sometimes called the “four boxes” (18). The 4 boxes that students use to analyze an ethical dilemma include medical indications, patient preferences, quality of life, and contextual issues. While Beauchamp and Childress never intended their approach to be reduced to a listing of facts and observations, others have argued that the Texas Dental Journal l www.tda.org l August 2013
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way to rectify such oversimplification is by turning to story and narrative (15, 19). We support this turn to story and narrative, as intimated by our telling of the patient’s story here, as a way of strengthening the principlist approach. Why? This turn invites the application of various tools from the humanities to understand human experience, such as Capps and Carlin’s framework for understanding limbo situations, in bioethics (5). What issues in bioethics does the category of limbo bring to light in this case report? We argue that the framework of limbo provides a deeper understanding of his autonomy as expressed in his preference to participate in an experimental study. In terms of bioethics, what is relevant here is not only that he wants to participate in this study, but also, why he wants to do so, and the category of limbo provides an explanation of why he wants to participate in this experimental study. Mr O.C. wants to be proactive rather than reactive and, therefore, to do something other than simply wait because the quality of the waiting in the limbo of oral cancer, in contrast to the limbo of lichen planus, was characterized not by irritation and confinement, but, rather, by anxiety and dread as oblivion lay in the horizon. Viewing Mr O.C.’s decision to participate in an experimental study in light of his comments about “the waiting,” one might wonder about the relationship between his need to find a way out his illness-related limbo related to oral cancer and his understanding of the nature of the experimental drug. Some bioethicists might be pessimistic about the likelihood that the experimental drug, if the patient is actually receiving it and not a placebo, would add any quantity or quality to his life, and that such studies, some worry, exploit false hope for the sake of science and research (20). These
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PRACTICEPOINTS The lessons learned so far from the experiences of this patient are straightforward and outlined below. 1. It is not uncommon for patients to delay seeking care when they feel that they are experiencing a serious disease. Empathy for the fears of the patient, as well as an honest discussion about the oral problem, are critical for motivating the patient to receive appropriate care. 2. Detailed disclosure about a disease is important so that the patient can understand the full impact of the condition. At times, referral to a more experienced specialist may be necessary to provide the patient with the most current and accurate information. 3. Sometimes patients are not aware that their dentist is evaluating them for oral abnormalities, such as cancer, during a routine examination. For this reason, it is important to inform the patient what the oral examination entails and why it is being performed. 4. Communication styles of patients vary, and reserved conversation should not be interpreted as lack of interest. Furthermore, respect for an authority figure, such as the dentist, may significantly inhibit the asking of life-saving questions, unless the patient is encouraged to do so. The patient in this case report did not want to bother health care professionals with his questions about lichen planus. 5. Oral potentially malignant disorders, such as lichen planus, are challenging because of the persistence of the disease, variable malignant transformation rate, unpredictable behavior, and debate over the best treatment approaches. These uncertainties induce not only illness-related limbo for the patient, but also stressful ambiguity for health care providers. 6. Not all limbo situations are the same. For this patient, lichen planus produced one kind of limbo experience — one that was relatively free of dread and anxiety — but oral cancer produced a different kind of limbo experience — one that was characterized by dread and anxiety. The difference between the 2 situations is on account of the fact that the latter is life-threatening and, therefore, produced higher levels of distress. 7. Enrolling in experimental research protocols may be one way that patients attempt to propel themselves out of illness-related limbo.
are valid concerns. Perhaps one way to begin to think about them, based on our conversation with this patient, is to weigh the likelihood of harm that will come to the patient on account of the experimental drug against the distress of this patient’s experience of living in limbo. For this patient, the side effects are minor and they are an occasion for celebration, symbolizing to him that he — not cancer — is on the offense. Viewing the issue in this way means that the risk-benefit analysis is not only a biomedical matter, but also, a personal and individual matter, and that this analysis is more a matter of art than science, more a matter of reflection than calculation.
CONCLUDING COMMENTS When one is living in limbo, one needs to find a way to pass the time. Mr O.C. continues to work and much, if not all, of his time is spent battling his illness. He has found that he is much closer to his family than before, and that, together, they are fighting oral cancer in ways that, without the study, they could not. Perhaps, in time, he will feel differently. But, for now, this experimental research study offers a ray of hope into the darkness of the limbo of oral cancer. Acknowledgements The authors wish to express gratitude to Thomas Cole, director of the McGovern Center for Humanities and Ethics, Jeffrey Spike, director of the Campus-Wide Ethics Program at UTHealth, and to the faculty of the Campus-Wide Ethics Program. The authors would also like to thank Laurence McCullough for suggesting the application of the idea of limbo to bioethics.
References 1. Capps, D, Carlin, N. Work-related limbo. In Living in limbo: life in the midst of uncertainty. Eugene, OR: Cascade Books. 2010, 45-63. 2. Capps, D, Carlin, N. Relational limbo. In Living in limbo: life in the midst of uncertainty. Eugene, OR: Cascade Books. 2010, 27-43. 3. Capps, D, Carlin, N. Illness-related limbo. In Living in limbo: life in the midst of uncertainty. Eugene, OR: Cascade Books. 2010, 65-90. 4. Carlin, N, Capps, N. Matters of life and death—and limbo: and other mundane issues in bioethics. Houston Medical Journal 2011, In Press. 5. Capps, D, Carlin, N. Introduction. In Living in limbo: life in the midst of uncertainty. Eugene, OR: Cascade Books, 2010, 1-10. 6. Scott, W. Depression, confusion and multivalence. Int J Psychoanal 1960;41:497-503. 7. Van der Waal I. Potentially malignant disorders of the oral and oropharyngeal mucosa; present concepts of management. Oral Oncol 2010;46:423-25. 8. Altekruse SF, Kosary CL, Krapcho M, Neyman N, Aminou R, Waldron W, et al (eds). SEER Cancer Statistics Review, 19752007, National Cancer Institute. Bethesda, MD, http://seer.cancer. gov/csr/1975 2007/, based on November 2009 SEER data submission, posted to the SEER web site, 2010. 9. Al-Hashimi I, Schifter M, Lockhart PB, Brennan M, Bruce AJ, Epstein JB, et al. Oral lichen planus and oral lichenoid lesions: diagnostic and therapeutic considerations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103(suppl 1):S25.e1-S25.e12. 10. Gonzalez-Moles MA, Scully C. Vesiculo-erosive oral mucosal disease management with topical
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corticosteroids: (2) Protocols, monitoring of effects and adverse reactions, and the future. J Dent Res 2005;84:302-8. Odom, J, Bowers, D. Informed consent and refusal. In Weinstein, B (ed.), Dental ethics. Philadelphia: Lea & Febiger, 1993, 65-80. American Dental Association. Principles of ethics and code of professional conduct, January 2011: www.ada.org/sections/ about/pdfs/ada_code.pdf. Kahn, J, Hasegawa, T. The dentistpatient relationship. In Weinstein, B (ed.), Dental ethics. Philadelphia: Lea & Febiger, 1993, 53-64. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont report, April 18, 1979: http://ohsr.od.nih.gov/ guidelines/belmont.html. Beauchamp, T, Childress, J. The principles of biomedical ethics (5th ed.). New York: Oxford University Press, 2001: ix. Beauchamp, T. Principlism and its alleged competitors. Kennedy Inst Ethics J 1995;5(3):181-98. Clouser, K., Gert, B. A critique of principlism. J Med Philos 1990;15:219-36. Jonsen, A., Siegler, M, Winslade, W. Clinical ethics: a practical approach to ethics decisions in clinical medicine (4th ed). New York: McGraw Hill, 1998: http:// depts.washington.edu/bioethx/ tools/4boxes.html. Charon, R. Narrative medicine: form, function, and ethics. Ann Intern Med 2001;134:83-7. Appelbaum, P, et al. False hopes and best data: consent to research and the therapeutic misconception. In Emanuel, E et al. (eds.), Ethical and regulatory aspects of clinical research: readings and commentaries. Baltimore: The Johns Hopkins University Press, 2003: 216-221.
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Oral and Maxillofacial Pathology Diagnosis and Management
Erythema Migrans (Ectopic migratory glossitis/ Ectopic geographic tongue) Oral and Maxillofacial Pathology Case of the Month (from page 666)
Discussion Erythema migrans, also known as benign migratory glossitis or geographic tongue, is a common inflammatory condition of the oral mucosa, primarily the tongue, of unknown etiology (3). The incidence of this condition varies 1-3% in the U.S. population and up to >10% in other populations. It is usually asymptomatic and is frequently diagnosed as an incidental finding during routine intraoral examination. Erythema migrans may become clinically evident in early childhood and rarely causes any symptoms. These lesions exhibit a wide variety of clinical presentations that include annular, circinate, or serpiginous red patches with raised white borders. These clinical presentations produce a “map-like” appearance of the tongue, thus the descriptive term of “geographic tongue.” The clinical appearance and location of these lesions also change with time and are therefore called “migratory glossitis.” Although rare, some patients may report soreness or burning sensation for acidic or spicy food and beverages. Patients with erythema migrans of the tongue often have a fissured tongue and in rare instances may have similar lesions in other intraoral mucosal sites (ie, buccal and labial mucosa, soft palate) (1). These lesions are
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diagnosed as erythema migrans or ectopic migratory glossitis as in the current case. A higher prevalence of ectopic migratory glossitis has been observed in patients with atopy who present with allergic rhinitis and/or asthma (2). Interestingly, our patient who is healthy otherwise had both of these medical conditions. Migratory glossitis (erythema migrans of the tongue) has a classic presentation and can be diagnosed by clinical examination alone, without additional diagnostic tests or biopsy. However, erythema migrans involving the lateral and ventral surfaces of the tongue may mimic erythroplakia, erosive lichen planus or erythematous candidiasis. Differential diagnoses for ectopic migratory glossitis may include recurrent aphthous stomatitis, herpetic gingivostomatitis and contact hypersensitivity mucositis. In fact, the buccal mucosal lesions of our patient were initially diagnosed as minor aphthous ulcers by his dentist. The history of onset and the clinical presentation of these lesions are very crucial for the differential diagnosis. Unlike ectopic erythema migrans, which is a chronic condition, aphthous and herpetic ulcers are acute, painful, and will heal within 1-2 weeks without any treatment in healthy immunocompetent patients. Moreover, close inspection of the
patient’s lesions reveals that these red patches have no surface ulcerations or erosions. Recurrent intraoral herpetic ulcers occur exclusively in attached mucosa and are preceded by vesicles. Clinical history, symptoms and appearance of the red patches in the right buccal mucosa and lower lip are diagnostic for ectopic migratory glossitis. Although biopsy is not indicated for the diagnosis of either migratory glossitis or ectopic geographic tongue, lesions with atypical clinical presentations or locations may need to be biopsied to distinguish them from erythroplakia, erosive lichen planus or contact hypersensitivity mucositis. Microscopic features of erythema migrans include parakeratosis with neutrophilic infiltration (Munro abscess), acanthosis and elongation of rete ridges, which closely resembles the histology of psoriasis and hence has the microscopic description of “psoriasiform mucositis.” Although migratory glossitis is not an intraoral form of psoriasis, a higher prevalence of migratory glossitis has been reported in patients with psoriasis than the general populations (4). Moreover, patients with psoriasis and migratory glossitis share similar HLAantigen types, namely HLA-Cw6 and HLA-DR5. However, the association
between psoriasis and migratory glossitis still remains unknown. Microscopic features of hyperplastic candidiasis and Reiter’s syndrome also closely resemble that of erythema migrans. Patients with asymptomatic erythema migrans need no treatment or clinical monitoring. Patients with erythema migrans who complain of soreness or sensitivity for spicy or acidic food or beverages are treated with topical corticosteroids. It should also be noted that lesions of migratory glossitis (geographic tongue) can coexist with burning tongue syndrome (Glossodynia) in some patients, and these patients may mistakenly associate their symptoms of glossodynia to geographic tongue. Glossodynia commonly presents in postmenopausal women as burning or altered sensation of the tongue
without any abnormal clinical or laboratory findings. Symptoms of glossodynia are not related to the presence or absence of erythema migrans. Unlike symptomatic migratory glossitis patients, patients with burning tongue syndrome complain of constant tongue burning that is not exacerbated by spicy or acidic food. References 1. Jainkittivong, A. and R.P. Langlais, 2005. Geographic tongue: Clinical characteristics of 188 cases. J Contemp Dent Pract, 6(1): 123-135. Available from http://www.ncbi.nlm.nih.gov/ pubmed/15719084. 2. Marks, R. and M.J. Simons, 1979. Geographic tongue--a
manifestation of atopy. Br J Dermatol, 101(2): 159-162. Available from http://www.ncbi. nlm.nih.gov/pubmed/486322. 3. Neville, B., D. Damm, C. Allen and J. Bouquot, 2009. Dermatologic diseases. In: Oral & maxillofacial pathology, B. NevilleD. DammC. Allen and J. Bouquot, (Eds.). SAUNDERS/ELSEVIER, St. Lousi, Missouri: pp: 779-781. 4. Zargari, O., 2006. The prevalence and significance of fissured tongue and geographical tongue in psoriatic patients. Clin Exp Dermatol, 31(2): 192-195. Available from http://www.ncbi. nlm.nih.gov/pubmed/16487088. DOI 10.1111/j.13652230.2005.02028.x.
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Memorial and Honorarium Donors to the Texas Dental Association Smiles Foundation
In Memory of: Mrs Chris Collins Dr Hubert Askew
Jay Irvin Gaynor South Plains Dental Society
Donald Bunch
In Memoriam Those in the dental community who have recently passed
Alexander, Leo G Duncanville, Texas March 28, 1931 – June 1, 2013 Good Fellow, 1984 Life, 1997 Fifty Year, 2008
Dr Robert C Cody
Don F Woodruff Nueces Valley District Dental Society Your memorial contribution supports: • •
educating the public and profession about oral health; and improving access to dental care for the people of Texas.
Please make your check payable to:
Chumlea, Billy J Bedford, Texas November 9, 1920 – June 15, 2013 Good Fellow, 1970 Life, 1985 Fifty Year, 1994
TDA Smiles Foundation, 1946 S IH 35, Austin, TX 78704
Thomas John Kennedy of Texas, DDS, PLLC Progressive, team-oriented practice seeking full-time associate dentists in DFW, Austin, San Antonio and Houston. Provide dental care in surroundings geared toward patient satisfaction. Starting salary of at least $150,000 (five days per week with minimum 5 years experience) with innovative, production-based bonus structure. Full benefits package includes 401(k), licensure payment, paid vacations/ holidays, health, life and malpractice insurance. Earn what you deserve now, not later. Please contact me in complete confidence for more details:
Rudd, Kenneth D San Antonio, Texas February 10, 1916 – June 14, 2013 Life, 1982 Fifty Year, 1993 Wheatley, Elmer D Iowa Park, Texas January 25, 1937 – May 18, 2013 Good Fellow, 1987 Life, 2003 Fifty Year, 2012
Dr Tom Kennedy Office: 800-658-2177 Facsimile for CVs: 800-393-5188 drtom@oksupportgroup.com
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CALENDAR OF EVENTS
SEPTEMBER2013
OCTOBER2013
26-28
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The TDA Smiles Foundation will hold a 40-chair Texas Mission of Mercy in Abilene. For more information, please contact Foundation Manager Judith Gonzalez at TDASF, 1946 S IH35 Ste 300, Austin, TX 78704; Phone: 512-448-2441; E-mail: judith@tda.org; Web: tdasmiles.org.
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The American Association of Oral and Maxillofacial Surgeons will host its 95th annual meeting in Orlando, FL. For more information, please contact Dr Robert C. Rinaldi, AAOMS, 9700 W. Bryn Mawr, Rosemont, IL 60018. Phone: 847-678-6200; FAX: 847-6786286; Website: aaoms.org.
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The Texas Academy of General Dentistry will host its annual Lone Star Dental Conference in Austin, Texas. For more information, please contact Laura Ceglio, Communications Coordinator, TAGD, 409 W Main St, Round Rock, TX 78664. Phone: 512-244-0577; FAX: 512-244-0476; E-mail: laura@tagd. org; Website: tagd.org.
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31-5
31-2
The American Student Dental Association will host its 37th Annual ASDA Conference in Naples, FL. For more information, please contact Dr Dan Ward, ASDA, 635 Madison Ave, New York, NY 10022. Phone: 800454-2732; E-mail: dward@columbus. rr.com; Website: asdatoday.com. The American Dental Association will host its 154th Annual Session in New Orleans, LA. For more information, please contact ADA conference and meeting services, ADA, 211 East Chicago Ave Ste 730, Chicago, IL 60611-2678. Phone: 312-4402500; FAX: 312-440-2707 ; E-mail: annualsession@ada.org; Website: ada.org. The Alliance of the American Dental Association will host its annual conference in New Orleans, LA. For more information, please contact Ms Patricia Rubik-Rothstein, AADA, 211 East Chicago Ave Ste 730, Chicago, IL 60611-2678. Phone: 312-4402865; FAX: 312-440-2587; E-mail: manager@allianceada.org; Website: allianceada.org.
JANUARY2014 26-28
The American Dental Association will host its annual president’s-elect conference in Chicago, IL. For more information, please contact the ADA, 211 East Chicago Ave Ste 730, Chicago, IL 60611-2678. Phone: 312-440-2500; FAX: 312-440-2707; Website: ada.org.
FEBRUARY2014 30-1
The Dallas County Dental Society will host its annual Southwest Dental Conference in Dallas, TX. For more information, please contact Jane Evans, Southwest Dental Conference Director, DCDS, 13633 Omega Rd, Dallas, TX 75244. Phone: 972386-5741; FAX: 972-233-8636; E-mail: jane@dcds.org; Website: swdentalconf.org.
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The TDA Smiles Foundation will hold a 60-chair Texas Mission of Mercy in Houston. For more information, please contact Foundation Manager Judith Gonzalez at TDASF, 1946 S IH35 Ste 300, Austin, TX 78704; Phone: 512-448-2441; E-mail: judith@tda.org; Web: tdasmiles.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.
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Provided by TDA Perks Program
value for your
profession
Building a Strong Online Presence — Any Why It’s So Important Rachel Taylor, Demandforce, Inc.
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W
ith so many people turning to the Internet to help them make informed decisions, it’s crucial for dental practices to create and maintain an online presence in order to be successful.
Many people turn to the Internet to check a dentists’ credentials, compare practices, and read comments and reviews from other patients before they make the decision to try a new dentist. The last thing you want is a weak online presence that impedes your practice growth. Follow the simple tips in this article, and you and your staff will find establishing your online reputation is easy.
Maintain a User-Friendly Website If you don’t have one, creating a practice website is a critical first step to building your online presence. A site with a clean design, succinct information, and that’s easy to navigate is a user-friendly one. Keep in mind that your office is one of many on the Internet, and potential patients want to find information quickly. It should be as easy as possible for visitors to learn about your practice and what makes it unique. Your practice’s key statistics, contact information, location, and marketing pieces should be placed at the forefront of the site. A feature that’s proven very successful for dental practices is an appointment scheduler. Making it easy for users to request appointments 24/7 is a good way to grow your client base and can help convert an individual from an Internet surfer into a patient.
Collect Reviews “Virtual” word-of-mouth is spreading on websites, search engines, and review sites. Having a variety of reviews posted can increase your visibility on the web, and lend credibility to your practice, as potential patients are more likely to be persuaded by comments made by your patients than solely by the information provided by your practice. Collecting online reviews is the best way for your practice to set itself apart from competitors and bring in new patients.
Ask for Reviews How do you start collecting them? Have a place to display reviews on your website. A quick reminder posted in the office or a personalized email announcing that you’ve launched a review feature and encouraging patients to share their thoughts is generally an effective way to let your patients know about the opportunity. Chances are you already have plenty of loyal patients who have great things to say about your practice, so all you have to do is give them a place to easily share their feedback.
Deal with Negative Reviews Quickly No matter how fantastic your practice is, there are bound to be a few patients who are unsatisfied with a visit they had. Fortunately, you can often turn a negative into a positive. By responding to a negative review, you can show your proactive customer service and commitment to quality patient care. You can even contact the unsatisfied patient directly to see if there’s a way to improve the situation. A complaint is often based on a miscommunication and might be resolvable through a phone call. Very frequently, a reviewer will remove a negative post to reflect that an effort to rectify the situation was made. If not, keep in mind that both positive and negative reviews in your social media profiles or on your site could work in your favor: the presence of negative reviews lets people know they’re not fabricated, which brings more legitimacy to your reviews. However, there are instances when a negative review could be damaging or simply untrue. If that’s the case, it’s absolutely appropriate to delete it. If it’s posted somewhere other than your own site, send an email to the site’s moderator to ask him to remove it. You’ll need to provide a clear-cut reason for requesting removal. Following are a few guidelines to determine whether a review should be removed: Remove a review if it: • Threatens you or your staff. • Uses profanity. • Contains private information about members of your staff. • Is non-factual or not from a current patient.
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If a review for your practice falls in one of the aforementioned categories, you can be confident in your request for removal. It’s important your reviews are truthful and accurately reflect a patient experience; however, your practice shouldn’t suffer because of an inaccurate review.
Claim Your Business Profiles Whether you know it or not, it’s likely your practice has existing profiles on sites like Yelp, CitySearch, and Google+. These sites are a great way for potential patients to find your practice, but they can also be riddled with inaccuracies if they have not been claimed and edited by you. Claiming your business profile is easy to do. Usually sites have an area that asks users to claim their profile. All you have to do is click and authenticate that you’re the owner of your practice, and you’ll be able to edit and monitor the page. This lets you keep a closer eye on what’s being said about your practice, and can help you quickly respond to or request removal of negative reviews. Taking ownership of these pages also lets you ensure that they link to your website, which—if you follow our earlier suggestion—will let web users request an appointment and ultimately help grow your practice.
Keep Your Information Consistent It may seem obvious, but it’s important to make sure all of your practice information (location, hours of operation, staff directory, and contact information) posted on the web is accurate, up-to-date, and spelled correctly. You can’t afford to make it any more difficult for your patients to find your practice among the massive amounts of information available online. Search engines are more likely to pick up information that’s consistent across multiple sites, so your information matching up can also greatly increase your website’s ranking on Google. The higher your ranking on Google, the more visible your practice’s website is to potential patients.
Create a Facebook Page If your practice is not on Facebook, change that today. Facebook is quickly becoming the platform for wordof-mouth referrals and commerce—more than 1 billion people use the social networking site. You can’t afford to
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not have your practice represented and miss opportunities to be seen by and interact with potential clients. Having a Facebook profile doesn’t cost you anything, but it could help bring in major revenue to your practice. Creating a profile for your practice is simple to do—it takes as little as 5 minutes to accomplish. Much as it is with your website, it’s essential that your practice Facebook page has accurate information, and that it links directly to your website. Facebook does have restrictions and rules for businesses that differ from personal pages, so it’s important to keep those guidelines in mind when creating and managing your practice’s social media presence. With Facebook’s new policies, users only see 15% of what a business posts on Facebook after liking it. To have your posts more visible, you can pay to have “sponsored posts” that go out to a larger amount of people in your fan base, as well as those in their network. While it’s not necessary to pay for each post, it may be a good practice to promote posts when you have a big promotion, announcement, or event going on to ensure your post gets the maximum amount of views.
Interact With Fans Being on Facebook can provide wide exposure and greater visibility online, but it only works if you’re regularly interacting with your fans with posts. A good rule to
You can’t afford to not have your practice represented and miss opportunities to be seen by and interact with potential clients. Having a Facebook profile doesn’t cost you anything, but it could help bring in major revenue to your practice.
Use “Real” Photos Giving a face to your office name is an important way to make patients feel familiar with you and your team before stepping in your office, so having a profile picture is imperative. Posting pictures is easy, and you should share what’s going on in your office every day. Take pictures of your team in the office, around your waiting room, or even of long-time patients to breathe life and personality into your Facebook page.
Getting Help follow is the 80/20 rule: 80% of your posts should be informative—related to dentistry and your business and 20% should be personal or fun. Show you’re a dental leader, but not a boring one. Interesting posts can help you reach potential patients and stand out in a sea of mediocre content. A few ideas that have been very successful in generating interaction with Facebook fans are creating contests and giveaways, and posting pictures.
Ask Trivia Questions Everyone loves a little friendly competition, so why not try applying that idea to your Facebook with Trivia nights? Pick a night each week to ask your audience a question. It can relate to your practice (“What year did our office open?”) Or it can relate to dentistry (“What does DDS stand for?” or “What life-threatening disease can be prevented by regular flossing?”) The goal is to get your followers to interact with your practice, and keep your office in their minds. You can even heat up the competition with an incentive. Something such as “Like this post by the end of the day to have a chance to win a $5 gift certificate!” often works well. You can increase the amount of money, give discounts on dental services, or ask people to comment.
As the importance of having an online reputation and gaining visibility with potential patients increases, so does the number of tools that can help your practice build one. Several vendors can compile reviews from your patients and feed them to your website and other online destinations, as well as help you create a strong social media presence. For example, Demandforce, an electronic patient communications system, certifies that all reviews it collects are submitted by its clients’ actual patients. It then syndicates the certified reviews to Google’s local business listings. With the help of an up-to-date website, strong online reviews, and a healthy social media presence, you’ll increase your visibility and attractiveness to potential patients and begin to reap the benefits right away. TDA Perks Partner Demandforce integrates seamlessly with existing practice management software to automate online communications and marketing. Learn more at Demandforce.com/tda or call 800-210-0355. Mention TDA Perks to receive special TDA-member pricing. For more information regarding TDA Perks Program, please visit tdaperks.com or call 512-443-3675.
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ADVERTISING BRIEFS Practice OpportunitieS ABBEVILLE DENTISTRY: We are seeking an honest, hard-working, patient-focused dentist who wants to contribute to a culture of caring, nurturing, and skilled professionals. If you have the desire to be a part of a team where you can focus on patients and not worry about the headaches that come with the business side of dentistry, please call us. If you are seeking an environment that provides stability, growth, and continuing education, we’d like to share with you how you can fit into that plan. Twenty years ago, I started my practice simply dedicated to serving my patients and community. Now, I’m privileged to guide over 10 practices and 80 wonderful staff. I’ve turned the administrative, operations and marketing efforts over to people who enjoy doing those sorts of things so our doctors and staff can focus on their patients. Iíve also been able to provide young doctors with an environment where they can grow and practice what they love doing without the worry of costly overhead or administrative headaches. At the same time, offering the potential for significant income and a great life balance. You’ll enjoy a great environment with no egos and no political barriers. We’re growing and need a few quality individuals to join us in creating something truly special. We’re forming a new, interactive, fun environment that kids and their parents will find
ADVERTISING BRIEF INFORMATION SUBMISSION AND CANCELLATION DEADLINE: 20th, 2 months prior to publication (eg, November 20th for January issue) MONTHLY RATES: First 30 words = $40; each additional word = 10¢ Ads must be submitted via e-mail, fax, or web and are not accepted by phone. Journal editors reserve the right to edit copy of classified advertisements. Any dentist advertising in the Texas Dental Journal must be a member of the American Dental Association. Advertisements must be not quote revenues or gross or net incomes; only generic language referencing income will be accepted.
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refreshing and exciting. If you’d like to talk about this opportunity, please give me a call. I’d be happy to share the vision, the success and the expectations we have while answering your questions candidly and openly. I hope you’ll consider this position and give me a call. Britt Bostick, DDS. 806.438.5745 or email bbost38521@ aol.com. ADS WATSON, BROWN & ASSOCIATES: Excellent practice acquisition and merger opportunities available. DALLAS AREA: 6 general dentistry practices available (Dallas, North Dallas, Highland Park, and Plano); 5 specialty practices available (2 ortho, 1 perio, 1 pedo). FORT WORTH AREA: 2 general dentistry practices (north Fort Worth and west of Fort Worth). CORPUS CHRISTI AREA: 1 general dentistry practice. CENTRAL TEXAS: 2 general dentistry practices (north of Austin and Bryan/ College Station). NORTH TEXAS: 1 orthodontic practice. HOUSTON AREA: 3 general dentistry practices. EAST TEXAS AREA: 2 general dentistry practices and 1 pedo practice. WEST TEXAS: 3 general dentistry practices (El Paso and West Texas). NEW MEXICO: 2 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. AMARILLO: General dentist for a locally owned practice looking to provide care for our patients as well as build their own patient base. Ownership opportunity available. Please contact Dr Britt Bostick, DDS, bbost35821@aol.com or call 806-438-5745. AMARILLO: Pediatric dentist for a locally owned practice looking to provide care for our patients as well as build their own patient base. Ownership opportunity available. Please contact Dr Britt Bostick, DDS, bbost35821@aol.com or call 806-438-5745.
AMAZING PRACTICE SELL: (Sherri L. Henderson & Associates, LLC) Northeastern Oklahoma Green Country. This great general practice draws from 5 large surrounding counties and is 35 minutes from Tulsa. Busy traffic location; 1,550 sq ft, 2 ops, 1 hygiene op, and 1 additional shared hygiene op. The doctor is retiring after 45 years in practice. Great production potential and chance to own or lease half of the beautiful free-standing building (3,100 sq ft). Pictures available — #3001. Call Sherri at 972-562-1072. Visit www.slhdentalsales.com. Anxious to sell in the CORPUS CHRISTI AREA: Sherri L. Henderson & Associates. The DDS is relocating to another city. The general practice was established in 1982 in a professional office complex with 1,400 sq ft and 3 existing treatment rooms. This location would make a great place for a start-up or satellite practice and it has plenty of space next door for expansion. The location is on one of the busiest streets with access to Padre Island Drive. This is a cash basis practice with a dedicated loyal staff and great revenue potential. The current owner has extensive experience with TMJ and sleep apnea and would be willing to return to the practice periodically if the new owner was interested. Pictures available — #3070. Contact 972-562-1072 or email sherri@slhdentalsales.com. Visit www. slhdentalsales.com. ARLINGTON / FORT WORTH: Associate position available. Full time dentist and specialist needed to join our successful dental group in Arlington & Fort Worth. Interested candidates should email CV to info@ ismiledental.net. ASSOCIATE FOR TYLER GENERAL DENTISTRY PRACTICE: Well-established general dentist in Tyler with over 30 years experience 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 patients. Our office is located in beautiful East Texas and provides all phases of quality dentistry in a friendly and compassionate atmosphere. The practice offers a tremendous opportunity to grow a solid foundation with the doctor. The practice offers excellent production and earning potential with a possible future equity position available. Our knowledgeable staff will support and enhance your growth and earning 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 dental office in small, quaint town. Potential for practice purchase. 361-645-8148. ASSOCIATES and PARTNERS AVAILABLE: Sherri L. Henderson & Associates. Is it time for you to add another provider? Is it time for you to go golfing or fishing more? Let us help you find the perfect associate and potential buyer. We have candidates ready in all parts of Texas looking for your specific practice profile. There are many graduates as well as very experienced dentists looking for the opportunity to transition into your already established practice. These dentists have great people skills, case presentation experience and can be a very valuable and reliable addition to your bottom line. If you are confused about the right timing or simply would like to talk about the opportunities, call us today for a complimentary consultation in person or by telephone. We are experienced in practice sales, associate and partner placement and can assist you in making that transition dream become a reality. Call 972-562-1072 or e-mail sherri@slhdentalsales.com. Visit www.slhdentalsales.com. ATTRACTIVE EAST TEXAS DENTAL PRACTICE: SLH Dental Sales is looking for a qualified buyer that would like the opportunity to immediately transition into a general dentist office. This well-established practice Texas Dental Journal l www.tda.org l August 2013
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ADVERTISING BRIEFS has been in its current location since 1993 and is in a beautiful home surrounded by many professional buildings and a stable community. The current dentist is transitioning, and both the practice and building are for sale. This predominantly fee-for-service practice contains 2 dentist operatories and 2 hygienist operatories, along with a welcoming reception area, business and private offices, lab, etc., with room for expansion. For more information, please contact our office at 972-562-1072, e-mail sherri@slhdentalsales. com, or visit our website at www.slhdentalsales.com Video available. Listing #3005.
private offices, and 6 highly experienced employees. The owner occupies a portion of the building complex and is looking to transfer ownership of both patient base and the building space immediately. For more information, please contact our office at 972-562-1072, e-mail sherri@slhdentalsales.com, or visit our website at www.slhdentalsales.com. Pictures available. Listing #3050.
AUSTIN: Progressive, patient centric office is seeking an experienced dentist; must be friendly, caring and professional. Opportunity is available (if desire) for practice ownership. Serious inquiries email: fahoosha@ gmail.com, mike@miloinc.com.
BEAUMONT AREA: FOR SALE: Well-established 3 operatory, 17-year-old general practice. Great location with good visibility and high traffic flow. Modern equipment and computer system with Eagle Soft dental software. Staff is excellent and long standing. Practice is fully functional in all aspects and ready for buyer to step in seamlessly. Building is a free-standing country style office in beautiful condition and seller will sell or lease. Please inquire via email at drbob.willis@henryschein.com.
AUSTIN PEDIATRIC PRACTICE SEEKING FULL-TIME ASSOCIATE: Great benefits! Progressive, fast-paced practice. Capable caring staff. We are looking for a bright career-oriented pediatric dentist to join an organization committed to providing high quality dental care to children and adolescents. Our dental team strives to offer exceptional care with integrity. Send your confidential resume to dentalresume27@yahoo. com for consideration.
BEAUTIFUL EAST TEXAS: Long-standing general practice in a stable community of over 14,000 with a great referral base. Three ops, full-time hygienist, and great staff. Doctor desires a quick sale and will aid in a smooth transition. Opportunity for ownership and start building equity for a minimal investment, with scheduled patients on day one. Contact Dr Guy Walker, Paragon Dental Transitions, 573-225-2877, www. paragon.us.com.
Awesome practice in LONGVIEW, TEXAS — For Sale: SLH Dental Sales is looking for a qualified buyer that would like the opportunity to immediately transition into a general dental office in this growing town of east Texas. The owner is willing to stay for a negotiated amount of time if necessary to insure a smooth transition. The location of the practice is near the hospital in a beautiful scenic area surrounded by many professional buildings. The staff is excited and ready for a future owner that will allow the current owner to pursue other opportunities. The office space is 1,500 sq ft with 4 treatment rooms equipped, 2
BROWNSVILLE SEEKING ASSOCIATE: Established general dental office in Brownsville (30 minutes away from South Padre Island) is seeking a caring, energetic associate. We are a busy office providing dental care for mostly children. Our knowledgeable staff will support and enhance growth and earning potential allowing the associate to focus on patient dental care. Interested candidates should call 956-546-8397.
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CENTRAL TEXAS AREA: Immediate associate dentist position available. An established general dentistry practice in San Marcos is seeking candidates for an
ADVERTISING BRIEFS associate dentist position. Candidates should be interested in creating an exceptional experience for their patients and working in a dynamic office environment. Gorgeous office that is equipped with the latest technology such as all digital X-rays, CT scan and pano, in room screens for patient education, and intraoral cameras. The experienced and professional staff allows a doctor to focus on the needs of their patients. Our staff will support and enhance your growth and earning potential while helping create a smooth transition. The U.S. Census Bureau released a report this year naming San Marcos’ population is expected to grow by 70% during the next 2 decades. All candidates must have a current Texas dental license, professional demeanor and be open to personal development and coaching. Please submit your resume and answer to the following question to be considered for this position to dental_resumesm@yahoo.com. Why did you decide to pursue a career in dentistry and what do you like the least and the best about it? Consulting & Staging For Your Transition! SLH DENTAL SALES (Sherri L. Henderson & Associates). ARE YOU PREPARED FOR THE FUTURE? Let us help you make a transition plan. We can analyze the market, review your current patient base, secure the staff, spruce up the office space, and much more. We specialize in practice transition consulting and can assist you in a plan to help you create all the right conditions to begin that step from retiring to starting up a new practice. Our team has decades of hands on experience in the dental market place as practice owners, employees and management advisors. We are here to help you prepare for an associate, partner, start-up or practice sale. We have a huge database of qualified applicants waiting and the time could not be better to begin the process. Our contact with you is strictly confidential and we are happy to schedule a complimentary consultation to discuss your options. Call 972-562-1072 or e-mail sherri@slhdentalsales.com; www.slhdentalsales.com.
DALLAS / FORT WORTH: Area clinics seeking associates. Earn significantly above industry average income with paid health and malpractice insurance while working in a great environment. Fax 312-944-9499 or e-mail cjpatterson@kosservices.com. DALLAS AND ROCKWALL: Orthodontic or other specialty office for lease to share with owner. Furnished and equipped. Dallas office is 4,000 sq ft in Lake Highlands area with 2,500 sq ft leasable residence above. Rockwall office is 1,800 sq ft in antique building and furnishings. E-mail rcppc@sbcglobal.net. DALLAS AREA: New and beautiful general dentistry practice on I-30 near Rockwall. Over 5 years of clinical experience required. Perfect for dentists who refer endo! Pay based on collections. PPO and Medicaid accepted. M-F 2:00 PM - 8:00 PM and Saturdays available. Visit www.mockingbirddentalgroup.com. DALLAS: Solo general practice in North Dallas serving local Asian community. Well-maintained facility on busy street with 3 ops and fourth plumbed. Doctor retiring and desires a quick transition. Long time loyal staff. Mainly FFS with exceptional collection rate and low overhead. Contact Dr Guy Walker, Paragon Dental Transitions, 573-225-2877 www.paragon.us.com. DENTALONE PARTNERS is opening new offices in Austin and the surrounding areas. Each practice is unique in that it has an individual name like Preston Hollow Dental Care or Waterside Dental Care. Our patient base consists of approximately 70% PPO and 30% fee-forservice. All our offices have top of the line Pelton and Crane equipment, digital X-rays, and intra-oral cameras. We offer competitive compensation packages with benefits. To learn more about working with one of DentalOne Partner practices, please contact Andrew Risolvato at 972-755-0838 or andrew.risolvato@ dentalonepartners.com.
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ADVERTISING BRIEFS DENTALONE PARTNERS is opening new offices in Dallas and the surrounding areas. Each practice is unique in that it has an individual name like Preston Hollow Dental Care or Waterside Dental Care. Our patient base consists of approximately 70% PPO and 30% fee-forservice. All our offices have top of the line Pelton and Crane equipment, digital X-rays and intra-oral cameras. We offer competitive compensation packages with benefits. To learn more about working with one of DentalOne Partner practices, please contact Andrew Risolvato at 972-755-0838 or andrew.risolvato@ dentalonepartners.com. DENTALONE PARTNERS is opening new offices in San Antonio and the surrounding areas. Each practice is unique in that it has an individual name like Preston Hollow Dental Care or Waterside Dental Care. Our patient base consists of approximately 70% PPO and 30% fee-for-service. All our offices have top of the line Pelton and Crane equipment, digital X-rays, and intraoral cameras. We offer competitive compensation packages with benefits. To learn more about working with one of DentalOne Partner practices, please contact Andrew Risolvato at 972-755-0838 or andrew. risolvato@dentalonepartners.com. DENTALONE PARTNERS is opening new offices in the upscale suburbs of Houston. Each practice is unique in that it has an individual name like Gulf Breeze Dental Care or Waterside Dental Care. All of our offices have top-of-the-line Pelton and Crane equipment, digital X-rays, and intra-oral cameras. Our patient base consists of approximately 70% PPO and 30% fee-for-service. We offer competitive compensation packages with benefits. To learn more about working with DentalOne Partner practices, please contact Andrew Risolvato at 972-7550838 or andrew.risolvato@dentalonepartners.com. DFW AREA: Seeking general dentists and specialists. Our offices are located in the Dallas / Fort Worth area. We are looking for caring, energetic associates. New graduate
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and experienced dentists welcome. We offer benefits, a helpful working environment, and an opportunity to grow. We accept most insurance and Medicaid. Please submit your resume via e-mail to jennifer@ smileworkshop.com or call our office at 214-757-4500. DFW, AUSTIN, SAN ANTONIO, AND HOUSTON: ASSOCIATE DENTIST OPPORTUNITY: Pacific Dental Services and its supported owner dentists have exciting associateship opportunities throughout the state of Texas (DFW, Austin, San Antonio, and Houston). Practices are uniquely named (ie, The Woodlands Smiles Dentistry and Orthodontics) and owned by general dentists make all clinical decisions in a traditional, practice setting while PDS provides the business support services. Associates see 12 to 13 patients a day in a PPO/FFS setting (no Medicaid). Practices are state-of-the-art, fully digital, and equipped with Cerec CAD/CAM 4.0 with Omnicam, lasers, and intra-oral cameras. Exciting comp package with full benefits, CE, malpractice insurance, and partnership/ ownership opportunities. To learn more, please visit www.jobs.pacificdentalservices.com. EL PASO Dentistry 4 Kids is searching for an associate dentist to join our team in El Paso, TX! EPD4K provides care primarily for children 6 months to 21-years-old. Prefer a general dentist with 2 to 3 years minimum experience and eligible to practice dentistry in Texas. Associate will examine, diagnose and provide treatment counseling to patients. In addition, you’ll be trained on treatment via conscious sedation. Guaranteed minimum of 6 figures, medical, vision, 401K opportunities, malpractice insurance and in-house CE opportunities. Please send resume to brentcroberts@ gmail.com. EL PASO/HORIZON: Orthodontist needed ASAP on the East side of El Paso and Horizon area. This is a part time position 2 days per week. Excellent salary. Great environment. Send resume to info@txkidsdental.com.
ADVERTISING BRIEFS EL PASO: Full-time position for a general dentist. Do not waste your best years at dead-end jobs. Great earning potential and future partnership option. Affordable El Paso Dental is looking for a Texas-licensed dentist to work full-time in our office in El Paso, TX. Applicant must be licensed in the state of Texas and have 1 year of experience. If interested please submit a resume to the following email address: drdarj@gmail.com. Please provide an accurate contact number and email address. EL PASO: General dentist / implantologist would like an associate to work with until he or she feels comfortable in taking over the practice. Plan to retire at the end of 2013. Cam-Log implants, bone grafts — will teach my associate these procedures. Also, I do all other general dentistry procedures. Office has 3 operatories and 1,400 sq ft. Located in an attractive retail strip in east El Paso. Courteous, talented staff willing to stay with new doctor. Call Tony Marquez, DDS, PhD, at 915-594-4048 or e-mail me at marquezdental@gmail.com. EL PASO: Selling a state-of-the-art general practice with orthodontic patients. Building is 6,000 sq ft for sale or lease. Whole building available. Partnership also available as well as many other options. Building is beautiful and only 1 year old with 11 ops fully equipped with digital X-rays, Softdent, Adec, Marcus equipment. Located on east side of El Paso. For more information please contact Dr Oscar Vargas at 915-276-2242. EL PASO: We are hiring a skilled and compassionate dentist to join our stable and successful practice. We are seeking a highly professional dentist with a knack for general dentistry. Prospective candidates must be dynamic, fun loving, and looking for a long-term commitment. Our practice is highly productive affording our providers an opportunity to attain competitive compensation. If interested, please forward your CV to annette@vistahillsfamilydental.com.
GALVESTON: Well-established, successful practice of 35 years needs full-time associate dentist for FFS/PPO practice. Experienced staff, new equipment, Galveston. Senior owner loves to teach sedation, implants, and other surgical procedures. No Medicaid, No DHMO practice in 6 ops, 2 surgical suites, all operatories computerized with digital X-ray and intra-oral cameras; digital panoramic X-ray; paperless charts for easy documentation. Visit www.todaysdentistrytexas.com. The Galveston area is just 25 minutes south of Clear Lake, which has planned communities with superior schools, multiple educational, recreational and cultural venues as well as access to all of the Houston cultural and sport venues, shopping and restaurants. We are minutes away from all types of water sports including several large marinas. http://goo.gl/maps/ lWkF. Possibility of buy-in and partnership possible after an interim term. Interview today! E-mail CV to kkcarroll10yahoo.com or call 832-385-8875. GARY CLINTON DENTON PEDO/ORTHO PRACTICE FOR SALE: 4-chair bay and 2 operatories equipped; another bay unequipped for 4 more chairs; fast growing area; excellent opportunity. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the institute of business appraisers, inc., now the National Association of Certified Valuators and Analysts (“NACVA”). I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name...a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which Congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available. DFW 214-503-9696. WATS 800-583-7765. Texas Dental Journal l www.tda.org l August 2013
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ADVERTISING BRIEFS GARY CLINTON EAST DALLAS PRACTICE FOR SALE: Doctor retiring for health reasons; well-established 30+ year old practice. High demand lower income area. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the institute of business appraisers, inc., now the National Association of Certified Valuators and Analysts (“NACVA”). I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name...a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which Congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available. DFW 214-503-9696. WATS 800-583-7765. GARY CLINTON HOUSTON PRACTICES FOR SALE: H-1 Far North of Woodlands Area. Premier practice; Near 7 figure gross with 5 operatories; exceptional recall; over 30 years; well-established. Digital equipment. Hygiene profits will cover debt service. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the institute of business appraisers, inc., now the National Association of Certified Valuators and Analysts (“NACVA”). I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name...a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which Congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty
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appraisals and practice sales. 100% funding available. DFW 214-503-9696. WATS 800-583-7765 GARY CLINTON NORTH OF DALLAS/DENTON AREA General practices for sale: D-1 Denton Practice: 5 operatories; nice equipment. 30-plus-year dentist retiring. Flexible transition; No low fee plans. D-2 Plano Area Practice: General dental practice; some implants; fee-for-service/PPO practice; Great visibility. Gross is in the mid 6-figure range. D-3 Frisco/McKinney area practice: Premier Practice. Well established restorative/preventative practice; Gross near one million; 6 fully equipped operatories; beautiful office with windows overlooking landscaped area. Will sell or lease building. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the institute of business appraisers, inc., now the National Association of Certified Valuators and Analysts (“NACVA”). I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name...a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which Congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available. DFW 214-503-9696. WATS 800-583-7765. GARY CLINTON PRACTICES FOR SALE: SOUTHWEST FORT WORTH AREA: Above-average gross; 4 operatories; excellent lease. Few dentists in area. Primarily fee-for-service. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the institute of business appraisers, inc., now the National Association of Certified Valuators and Analysts
ADVERTISING BRIEFS (“NACVA”). I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name...a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which Congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available. DFW 214-503-9696. WATS 800-583-7765. GARY CLINTON PRACTICES SOUTH OF DALLAS: Waco area: near 7-figure gross 30+-year-old general practice for sale. Exceptional practice. Excellent recall; cosmetic; implants and restorative; transition and/ or complete sale; PRN transition. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the institute of business appraisers, inc., now the National Association of Certified Valuators and Analysts (“NACVA”). I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name...a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which Congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available. DFW 214-503-9696. WATS 800-583-7765. GARY CLINTON TEXAS TWO ORAL SURGERY PRACTICES: SA-1 San Antonio outlying area. W-1 West Texas central area. Oral surgeons retiring; Flexible transition. Sellers phase out. Each practice
near or above 7-figure gross annually; each has high net over 50%. Both are in mid-sized communities. All confidential. Gary Clinton, Oral Surgery Appraiser. 1-800-583-7765. GARY CLINTON WEST TEXAS “BIG COUNTRY” PRACTICE FOR SALE: W-1 7-figure gross; 60% net. Only dentist in small progressive community. Progressive family dentist retiring to travel. Upgraded equipment. Nice office. Doctor will sell or lease building. W-2 Abilene Practice; retiring dentist; very nice garden style office; very good recall; will consider merger. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the institute of business appraisers, inc., now the National Association of Certified Valuators and Analysts (“NACVA”). I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name...a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which Congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available. DFW 214-503-9696. WATS 800-583-7765. GARY CLINTON, BROKER/SENIOR APPRAISER/ CONSULTANT with almost 40 years in dentistry: We need sellers...general and specialty practices! We have pre-qualified buyers. When we sell your practice, if you own your office, there is no real estate commission. Gary Clinton, PMA. I need practices in or near Austin, San Antonio, DFW, and Houston area and other metro Texas locations which are in high demand. Call me confidentially. 1-880-583-7765 or 214-503-9696 Dallas area.
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ADVERTISING BRIEFS GENERAL: Golden Triangle (Port Arthur): 6-figure gross and very high net income practice in small gulf coast town. Dentist earns 6 figures per year for work 4 days a week. 2,200 sq ft with 6 fully equipped operatories, 4 dentist and 2 hygiene. Extensively remodeled in 2001. Real estate for sale. Single tenant, stand-alone building, 30 plus space parking bordered by 2-lane street and residential area. High patient growth. Patients from major employers such as Shell, DuPont, Texaco, Chevron and Shell. Call DDR at 800-930-8017 or www.ddrdental. com. GENERAL: Houston (Bellaire/Post Oak): Terrific growth practice with great facilities nested in neighborhoods and schools. Fronts high traffic Chimney Rock. Interior and equipment rebuilt in 2009. Total of 8 operatories plumbed with 4 operatories in use. Free-standing building with 7,000 total sq ft, also for sale. Call 800930-8017 or visit www.ddrdental.com. GENERAL: Houston (I-45 North): 6-figure gross with high net income. Six-figure income for dentist. Growth opportunity within patient base. Well cared for facilities with 7 operatories. Call 800-930-8017 or visit www. ddrdental.com. Geriatric Dental is looking for dentists to work 1 to 3 days a week at nursing homes in the following areas: North Texas: Fort Worth/mid-cities; Central Texas: Waco/Temple; South Texas: Weslaco/McAllen/ Brownsville (bilingual (Spanish) is desired). The days of work are flexible between Monday and Saturday and are typically 8:00 AM to 5:00 PM. The ideal candidate should be a licensed dentist with a background in geriatric dentistry and over 3 years of service. Dental services offered: cleanings, X-rays, fillings, extractions, dentures, and oral surgery. Description of services: comprehensive exams, explanation of treatment options, training of nursing home staff on proper daily oral hygiene. If you are interested in this position,
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please email jodywilliamson@gmail.com with your most current resume. You can contact him after submitting your resume at 512-695-3138. This is a contract job. Principals only. Recruiters, please don’t contact this job poster. Please do not contact job poster about other services, products, or commercial interests. GOLIAD: Associate/buy-in partnership opportunity available in high producing and high collection practice. 100% fee-for-service practice. If you have excellent communication skills, a light touch and above average skills, we should meet. Our practice uses Cerec technology, places and restores implants, is 100% digital and has a high emphasis on cosmetic dentistry. Great emphasis on patient comfort with oral sedation used extensively. Our town has an excellent school district and our patients have a great appreciation for quality dentistry. Visit our website at www.goliaddentalcare. com. Call Dr Dan Garza at 361-645-2381 or email dmolar@sbcglobal.net. GP / ORTHODONTIC OPPORTUNITY IS KNOCKING! Are you a GP with orthodontic interests? Would you like to learn more about orthodontics with the possibility of limiting to orthodontics some day? Do you like the idea of small town living, no traffic jams, a paradise for outdoor activities and yet only a short ride to large town amenities? Here is your chance. In the small town of Tishomingo, OK, we have an opportunity for the right person to become an associate (with buyout future) to join a busy 9-chair GP-orthodontic clinic with currently over 600 orthodontic cases in progress. The goal is for the right person to start practicing restorative dentistry 90% and orthodontics 10% the first year, with each succeeding year moving forward toward a full orthodontic practice. Even if you have an orthodontic interest but are low on confidence, not a problem. Dr Austin has been teaching orthodontics to GPs for 20 years. If interested, please contact Dr Austin at 580371-2396 or ronaustin79@gmail.com.
ADVERTISING BRIEFS HARLINGEN/Texas Valley. One full-time or 2 parttime positive, skillful general dentists needed. Wellestablished practice, owned by Dr Joe B. Whitley, serves children ages 12 to 17 delivering preventive, restorative, and some prosthetic services. Excellent fee schedule, no Medicaid or DMO’s. Virtually no down time and doctor compensated based on production, not collection. Please send all queries/CV’s to whitleydental@aol.com or call Pam at 361-991-7207. HOUSTON AND SAN ANTONIO: 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 compensation and benefits package including medical, life, long- and short-term disability insurance, flexible spending, and 401(K) with employer contribution. New graduates and dentists with experience are welcome. Be a part of our outstanding team, providing care for kids of Texas. Please contact Anna Robinson at 913-3221447; e-mail arobinson@amdpi.com; FAX: 913-3221459. HOUSTON AREA PRACTICE OPPORTUNITIES! MCLERRAN & ASSOCIATES: NEW! HOUSTON: East Houston: Established general practice, PPO/FFS, 3 operatories, more than 800 active patients and stable hygiene production. Trade area has strong middle income demographics and is experiencing population growth. Great merger possibility. #H188 NEW! BEAUMONT: Established general, family practice. Seller retiring for health reasons, very motivated. Located on busy thoroughfare with good visibility, free standing building, 3 operatories, comfortable decor. Historical revenues near mid 6 figures. 1,100 active patients, strong hygiene department, experienced staff and solid patient demographic. Real estate is also available for purchase. #H186 NEW! HOUSTON: Established general, family and cosmetic practice, strong hygiene production and
implant/full mouth reconstruction focus. Freestanding building with high visibility/access, 7 operatories, 1 available for expansion. Active patient count more than 2,200, FFS/out of Network PPO revenues mid-7 figures in 2012. Seller available for a strong transition. Real estate available for purchase. #H178 NEW! HOUSTON: NORTH HOUSTON: General, family dental practice offers all aspects of dentistry, including conscious sedation and orthodontics. Local population increasing with limited competition in the area. The 4,000 sq ft facility has 5 treatment rooms and 4 orthodontic bays. 2012 revenues were more than mid-6 figures. Strong new patient flow, visible location, poised for growth. 12,000 sq ft professional building also for sale by building owners. (#H177) HOUSTON: Established general, family practice, private pay and PPO insurance patients. 2013 revenues are on track to increase by over 10% compared to 2012 revenues. Highly visible retail center, 6 ops, 2 more that are plumbed, digital X-rays, remodeled about 3 years ago. Visible freeway sign included. (#H181) HOUSTON: General, cosmetic practice located in a visible retail center with 1,900 sq ft, 4 fully equipped operatories, digital X-rays, an upscale decor, with adjacent lease space available for possible expansion. 2012 collections were near mid 6-figures with seller working 3 days per week. (#H180) SOUTHWEST OF HOUSTON: Established general practice, 4 operatories, stable blue collar patient base, petrochemical economic base, 2,000 sq ft building available. Doctor working only part-time. (#H174) SOUTHWEST HOUSTON: General practice in a visible retail location, 6 equipped operatories, digital X-rays, digital pan, computerized throughout. Recently remodeled with a comfortable decor. 2012 revenues near 7 figures. (#H173) WEST OF HOUSTON: Beautiful general practice located in a high growth area west of Houston. Opened in 2006, the 2,500 sq ft facility has 5 operatories (3 equipped), a quality build out, and an elegant decor. With digital X-rays and computers throughout, over 1,100 active patients, and 30 to 40 new patients per month, this office is turnkey and poised for growth. Revenues
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ADVERTISING BRIEFS have been increasing in recent months with 2013 starting out strong. (#H171) WEST OF HOUSTON: Rural dental clinic, good visibility in a retail strip center, stable patient base, priced to sell. (#H168) To see our most up-to-date listings, please go to dental-sales.com. Contact McLerran & Associates in Houston: Tom Gugleimo and Patrick Johnston, 800-474-3049 or 281-362-1707, houstoneasttx@ dental-sales.com. Practice sales, appraisals, buyer representation and partnership consulting. HOUSTON AREA: Great opportunity for a pediatric dentist. A part-time position available now in the Houston area. Flexible scheduling and a great work environment. Already established a flow of patients. Requirements: Texas state license. For more information, please e-mail mydentalsmile@gmail.com. HOUSTON, DALLAS, SAN ANTONIO: HealthDrive is seeking part-time dentists. We are a mobile practice providing the highest standard of dental care to the elderly residents of extended care facilities. Please contact Tanya Jones at 857-255-0293 or tjones@ healthdrive.com. KILLEEN: Dental office building for sale in a very busy professional plaza, near Killeen Civic Center, 2,047 sq ft. Office condo, 5 ops, 1 steri center, 1 X-ray room for pano, 2 offices, 1 reception room, 1 patient waiting room, 1 break room, 2 storages, 1 unisex restroom, 5 telephones with voicemail, 9 speakers with amp. Entire office is networked with CAT-5. For details please call Laurie at 254-519-2875, e-mail cfdental1@gmail.com. LAWTON, OK: Busy, productive practice for sale. Price reduced for quick sale. State-of-the-art office; 4 operatories; digital X-rays. Only 45 minutes from Wichita Falls, TX. Call Max Wilson at 405-359-8784. MCALLEN AREA. Growing and expanding pediatric dental practice has immediate position for a full-time pediatric dentist. We are looking for an enthusiastic,
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skilled clinician with a strong work ethic. Our core value is to treat our patients as if they were our own family. Our office has state-of-the-art equipment including digital radiographs and computerized records. We offer conscious sedation in office and general anesthesia at local hospital. We have a well-trained staff. Our practice is located in one of the fastest communities in America. Rio Grande Valley offers a multitude of activities, a vibrant nightlife and is a short 1 hour drive to South Padre Island. Compensation based on collection. Desirable to be fluent in Spanish. We provide work Visa/Green Card sponsorship. Interested candidates please contact Dr Daniel Mego at 956-854-4146, dfmego@gmail.com. MCKINNEY: Two-chair dental practice for sale. Primarily a Medicaid practice for more than 10 years. Located in a nice office building close to 380 and 75. This place is ready to walk in a treat patients. Great for a new grad in a growing community. For more information, contact Tom at 214-538-6560 or e-mail collincountydentalpractice@ aol.com. Medical Center Area Practice for sale. Partnership dissolving. Priced below market. Call Jim Robertson 713-688-1749. MIDLAND: One of the fastest growing cities in Texas needs a dynamic, caring, patient-focused dentist to join our growing practice. Associate and/ buy-in opportunities are available. Please contact Dr Britt Bostick, DDS, at bbost35821@aol.com or call 806-438-5745. NORTH TEXAS: Pediatric dentist needed for busy north Texas practice. Enjoy life in Sherman, Texas, a familyoriented city with the convenience just 1 hour north of Dallas, but without the hustle and bustle of the big city! Excellent practice opportunity for motivated and nurturing pediatric dentist seeking full-time associate with potential for partnership. Practice has a great reputation and is committed to providing quality
ADVERTISING BRIEFS comprehensive care for our patients and families in a fun and relaxed atmosphere. State of the art facility with highly trained and dedicated staff. Competitive compensation and benefits. Fee-for-service, limited Medicaid. Must possess high personal standards, strong work ethic, excellent technical and communication skills, and be willing to treat the full range of pediatric dental patients. Opportunities for in office conscious sedation, IV sedation and hospital dentistry. Please email resume/CV to bth1@cableone.net. ORTHODONTIC PRACTICES FOR SALE: Five-chair orthodontic practice in McKinney. Eight-chair orthodontic office in Arlington. Texas Practice Transitions, Inc. Rich Nicely has been serving Texas dentists since 1990. Visit www.tx-pt.com or call at 214460-4468; rich@tx-pt.com. PARIS / WYLIE: Great opportunity for a pediatric dentist to join our expanding practice. We are actively looking for the right associate who is interested in a once in a lifetime opportunity. We are opening a third location to our practice just 1 hour outside of Dallas. The need for a pediatric dentist in the area is tremendous and we are the only pediatric office within 50 miles any direction. We are looking for someone who is personable, caring, energetic, loves a fast-paced working environment in a busy pediatric practice. We are willing to train the right individual if working with children is your ambition. If you join our team, you will be personally mentored by Dr Allen Pearson, a board certified pediatric dentist, and you will be given the opportunity to develop experience in all facets of pediatric dentistry, including: behavior management, using oral conscious sedation, IV sedation as well as practice and business management. Current associate is producing gross personal income of 6 figures plus on a 4 day work week, working only 11 months a year. For more information, please visit our web sites: www.wyliechildrensdentistry.com and www. parischildrensdentistry.com. Please e-mail your CV to allenp12345@gmail.com.
PEDIATRIC PRACTICE FOR SALE: Very large private pediatric practice in large metropolitan area in Texas, mix of PPO and Medicaid in a beautiful, free-standing 5,000 sq ft building with 10 chairs. Highly profitable private practice established 30 years. Texas Practice Transitions, Inc. Rich Nicely has been serving Texas dentists since 1990. Visit www.tx-pt.com or call at 214460-4468; rich@tx-pt.com. SAN ANGELO: For sale: excellent 5 operatory, 35-yearold general practice. Recently remodeled location in a busy complex. Solid fee-for-service patient base. All modern equipment. Solid hygiene program. Mid- to high-6 figure collections consistently, 98% collections rate. Recent practice appraisal. Other unique perks to this practice. Doctor moving out of state, willing to negotiate on price, and transition details as well as sell/lease of building. Please inquire by e-mail at texasdentistry@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 contact Dr Henry Chu at 210-684-8033 or versed0101@yahoo. com. SUGAR LAND, CYPRESS, PEARLAND AND THE WOODLANDS: Full- and part-time positions available. Well-established and rapidly growing practices that offer great financial opportunity. High income potential and future equity position. E-mail CV to Dr Mike Kesner, drkesner@madeyasmile.com. TEXAS PRACTICE TRANSITIONS: Rich Nicely has been serving Texas dentists since 1990. Visit www. tx-pt.com or call at 214-460-4468; rich@tx-pt.com. ORTHODONTIC PRACTICES: Five chair orthodontic practice in McKinney. Eight-chair orthodontic office in Arlington. PEDIATRIC: Very large private pediatric practice in large metropolitan area in Texas, mix of Texas Dental Journal l www.tda.org l August 2013
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ADVERTISING BRIEFS PPO and Medicaid in a beautiful, free-standing 5,000 sq ft building with 10 chairs. Highly profitable private practice established 30 years. MCKINNEY: mid-sized collections in 5 treatment rooms in a beautifully finished facility, paperless, 100% digital practice with a digital pano. NORTH TEXAS: Large prosthodontic practice 30 minutes from Dallas, premier free-standing building with 7 ops, 100% digital, 100% full fee. RURAL 30 MINUTES FROM DALLAS. Smaller practice in a nice free-standing building, digital X-rays, 100% full fee. DALLAS SUBURB: Large practice, 6 ops, 100% digital, 1,900 full fee patients, 8 days of hygiene. WEST TEXAS, small practice in Panhandle area. ONE HOUR NORTH OF HOUSTON: Medium-sized full-fee practice, freestanding building, digital X-rays. EAST TEXAS: Very low overhead, medium sized full fee practice in freestanding building. THE HINDLEY GROUP, LLC: Dental Practice Sales — NEW LISTING — WEST CENTRAL TEXAS PRACTICE FOR SALE: 25-year-old well-established family dental practice for sale. Open 4.5 days per week. 2,400 sq ft building with 4 fully-equipped operatories. Three direct digital X-Ray units in operatories plus numerous other upgrades to equipment and building, which is also for sale. Steady new patient growth and outstanding staff. NORTHWEST HOUSTON GENERAL DENTAL PRACTICE: Well-established, very traditional practice with moderate fee-for-service revenues and healthy profit margin. Open 4 days a week. 1,200 sq ft facility with 3 fully equipped operatories. Doctor retiring. NEW LISTING: NORTH OF HOUSTON GENERAL DENTAL PRACTICE: Very well-established practice in the same location for 31 years. Strong cash revenues with some PPO insurance. Practice open 4 days per week. 2,200 sq ft with 5 operatories. Loyal, experienced staff. Doctor is retiring. NEW LISTING — TEXAS PANHANDLE GENERAL DENTAL PRACTICE: Twenty-five year established practice with strong high percentage restorative revenues and healthy profit margin. Open 3 full and 2 half days a week. Four fully equipped operatories on
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busy I40 corridor with nice curb appeal! Building is also for sale. Significant Medicaid component. Motivated seller. ALBUQUERQUE, NEW MEXICO GENERAL DENTAL PRACTICE: Same location for 8 years. Three fully equipped operatories. Steady growth with 20-40 new patients per month. Significant Medicaid with growing PPO revenues. Call 800-856-1955 or email jenny@ thehindleygroup.com THE HINDLEY GROUP, LLC. Associateship Listings — SOUTH OF DALLAS ASSOCIATESHIP: Large thriving family general dental practice located in moderate size suburb south of Dallas. Associate wanted to join a 2 doctor practice and eventually buy-out interest of senior doctor. Beautiful new facility; fully digitized with 7 fully equipped operatories and an additional 3 hygiene rooms and 2 portable hygiene carts. Very strong revenues and healthy profit margin. Outstanding staff and excellent mentors! Pre-determined buy-in terms. Call 800-856-1955 or email jenny@thehindleygroup.com. WACO: Great associate opportunity. Waco practice looking for motivated associate with a desire to join a PPO/fee-for-service practice. Great pay, great work environment with 2 other dentists and top notch staff. Please contact Dr Johnson at 435-237-2339 or email at johnson.2978@gmail.com. West Houston Practice for sale. Doctor retiring. All fee-for-service. Call Jim Robertson 713688-1749.
Office Space ARLINGTON: Prime office suite for lease. Approx 2,594 sq ft. High visibility building with orthodontist and dentist on I-20 service road. Terrific opportunity. Call 817-269-3124. AUSTIN: Excellent office location just north of the Mueller development. This space not only close
ADVERTISING BRIEFS to Mueller households but also University Hills, Windsor Park, French Place, and other East Austin neighborhoods. Built in the late 60s/early 70s, this building is iconic for the period. Specifically built for dental/ orthodontist offices, it would be perfect for a dentist to move into with most of the infrastructure already in place. Simply install operatories and other equipment and you are ready to go. It can also be totally remodeled for your specific needs and taste. This property has 2 buildings. Building 2 stands alone and is 1,100 sq ft. Building 1 is currently set up as a duplex with separate electric meters. Each side is 1,150 sq ft. All space is currently available. Contact Greg Brooks 512-799-8973, tgregorybrooks@gmail.com.
CARROLLTON: Great opportunity for orthodontist or pedodontist. Fully equipped orthodontic office with 5 ops in main treatment area, separate private office, consult room, pano/ceph room, and lab. All dental chairs, units, equipment and furnishings included. Located in professional building with 4 general dentists and a board certified periodontist, all with established practices and would be good referral sources. An excellent opportunity for a new orthodontist, pedodontist or one seeking a satellite office. Ready to start patients tomorrow! Space is for rent and/or purchase. Premier location just 1 block south George Bush turnpike and 1 block north of Newman Smith High School. Please call 214-850-8087.
DDR Dental Trust
Serving Texas Dentists for more than 40 Years
• Practice Appraisals • Practice Sales • Associate Agreements
800-930-8017
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ADVERTISING BRIEFS EAST TEXAS DENTAL PRACTICE: Malakoff, Texas, dental practice for sale. Malakoff is near Athens, Texas. Dentist retiring due to health. General practice established in this location in 1974. Location will make a great place for a start-up or satellite practice due to numerous surrounding small towns. The practice, equipment and real estate are available for purchase. Lot on main highway is also available for future office site. There is a great potential for growth. Current practice is only 3 days a week. For more information contact either of the following: Stanley Fulgham, 817-657-7239, 9:00 AM to 8:00 PM Monday through Saturday or email to stanleyf@sbcglobal.net. Donna Fulgham, 214-642-2038 9:00 AM to 8:00 PM or email to rodneyshouse@comcast.net. EL PASO: New dental offices for lease at Renova Plaza. Seeking complimentary specialties to 3 general practitioners and 1 periodontist. Suites can be finished to suit. Highest quality architecture and construction in upscale neighborhood; strong demographics. Agent: Etzold & Co 915-845-6006. FORT WORTH / TCU DENTAL OFFICE FOR LEASE: Building has 4 dental offices and 1 unit available. Comes with 2 examining rooms with chairs, third room does not have a chair. Has a private office with a 1/2 bathroom, reception plus waiting area, lab room, approximately 1,200 sq ft. Great location near TCU. Very seldom does this building have a vacancy. Our current dentist is retiring. 2417 Park Hill Drive. Contact Sharon May at sharon@maysrealty.com or call at 817721-3759. FORT WORTH: Fully equipped dental suites for lease in growing North Fort Worth. Ideal for dental specialist-oral surgeon, endodontist or periodontist. Please contact Jennifer at 817-366-2268.
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FULLY EQUIPPED MODERN DENTAL OFFICE space available. For lease. Has 4 ops. Great opportunity to start your own dental office. Call 713-291-9492 or e-mail ameecoinc@gmail.com. GRANBURY: Great location, high visibility and traffic. Approx 6,000 sq ft building, approx 3,000 sq ft of dental; 6 ops. For lease or possible sale. Call 817-2639014 or e-mail jeremy@mirandadentistry.com. HARRIS COUNTY: Practice for sale - 100% financing available. Three ops (2 fully-equipped), operates only 2 days/week, established 1999. Call ProMed 888-2776633 or e-mail info@promed-financial.com. HOUSTON / LEAGUE CITY: Medical/office space available for lease in a stellar location, right outside the largest school in Texas with 4,200 students on campus. In a fast growing area with a lot of young families, located close to the waterfront, boardwalk, Gulf Coast beaches, Houston downtown, NASA and Hobby Airport. Home to one of the state’s top rated Independent school districts, stunning yet affordable waterfront neighborhood developments, NASA, BOEING, UTMB. Contact Vijay Bhagia 832-618-0652 or eduvillageland@ gmail.com. MIDLAND: Retiring owner selling legacy, 30-year plus, small, general practice. Obtain a patient base or add to your existing practice without taking on much debt. Call 432-556-2867. NORTH TEXAS DENTAL PRACTICE OPPORTUNITIES: Lewis Health Profession Services has multiple career opportunities available in the greater Dallas/Fort Worth area. Practices for sale, associate opportunities, finished out dental offices, and specialty practice opportunities. Lewis Health Profession Services has 30 years experience in dental practice transitions, with over 1,000 successful transitions completed.
ADVERTISING BRIEFS Dentistry is our only business. We confidentially deal with all clients. Lewis Health Profession offers seller representation, buyer representation, opportunity assessments, associate placement and strategic planning services. Please check out our web site at www.lewishealth.com for current opportunities. Contact Dan Lewis at Lewis Health Profession Services 972-437-1180 or dan@lewishealth.com for additional information. ROUND ROCK: Orthodontist needed next to dentist in high growth high traffic area in Round Rock, north of Austin in one of the fastest-growing counties. For more information, e-mail john@herronpartners.com or call 512-457-8206.
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: schoolofdentalassisting-northdallas.com. THE NATIONAL SCHOOL OF DENTAL ASSISTING... NORTH DALLAS offers the Texas RDA course and exam. Call 800-383-3408 for available dates.
SAN ANTONIO FOUR-OPERATORY PRACTICE FOR SALE: We have outgrown the space, looking to relocate. Space is perfect for a specialist. Transition available. The space is located right off the Dominion Country Club golf course in San Antonio. Very modern, tranquil, pleasant location, granite countertops, plumbed for nitrous, second floor with balcony. Please contact Dr Stratton at 210-687-1150 or e-mail tiffini@dominiondentalspa. com.
For Sale EQUIPMENT FOR SALE: New handheld portable X-ray unit. New intraoral wall X-ray unit, new mobile X-ray on wheels. New chairs/units operatory packages, new implant motors. Everything is brand new, with warranty. Contact nycfreed@aol.com.
Interim Services OFFICE COVERAGE for vacations, maternity leave, illness. Protect your practice and income. Forest Irons and Associates, 800-433-2603 (EST). Web: www. forestirons.com. “Dentists Helping Dentists Since 1983.�
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Your Patients Trust You. Who can YOU Trust? The Professional Recovery Network (PRN) addresses personal needs involving counseling services for dentists, hygienists, dental students and hygiene students with alcohol or chemical dependency, or any other mental or emotional difficulties. We provide impaired dental professionals with the support and means to confidential recovery. If you or another dental professional are concerned about a possible impairment, call the Professional Recovery Network and start the recovery process today. If you call to get help for someone in need, your name and location will not be divulged. The Professional Recovery Network staff will ask for your name and phone numbers so we may obtain more information and let you know that something is being done.
Statewide Toll-free Helpline 800-727-5152 Emergency 24-hour Cell: 512-496-7247
Professional Recovery Network 12007 Research Blvd. Suite 201 Austin, TX 78759 www.rxpert.org
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