December 2014 Texas Dental Journal by Texas Dental Association

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December 2014

Journal TEXAS DENTAL

INSIDE:

EPA PROPOSES NEW STANDARDS REQUIRING AMALGAM SEPARATORS THE LOCATION OF RECENT DENTAL SCHOOL GRADUATES IN UNDERREPRESENTED AREAS

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Texas Dental Journal l www.tda.org l December 2014

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TEXAS DENTAL JOURNAL Established February 1883

Vol 131, No 12

1046 ABOUT THE COVER

December 2014

1054

Author Dr Eric Solomon discusses the rationale for accepting dental students from underrepresented population groups to determine if they are more likely to practice in underrepresented population areas.

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OFFICIAL CALL FOR NOMINATIONS: SPEAKER OF THE HOUSE, SECRETARY-TREASURER, AND EDITOR

1043

TDA NOTICE OF GRANT AVAILABILITY 501(C)(3) NON-PROFIT DENTAL ORGANIZATIONS THE LOCATION OF RECENT DENTAL SCHOOL GRADUATES IN UNDERREPRESENTED AREAS

1046

Eric S. Solomon, MA, DDS The author investigated recent dental school graduates to determine whether their racial/ethnic background was related to racial/ethnic composition of the population where they practice.

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EPA PROPOSES NEW STANDARDS REQUIRING AMALGAM SEPARATORS Andrew Fohn and Joseph A. Bartoloni, DMD, MPH The authors explain that the Environmental Protection Agency is working on a new rule that would make amalgam separators mandatory in the near future.

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TEXAS DENTAL JOURNAL 2014 INDEX OF FEATURE ARTICLES

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THANK YOU, REVIEWERS

MONTHLYFEATURES 1036 Presidentâ&#x20AC;&#x2122;s Post 1038 Oral and Maxillofacial Pathology Case of the Month 1040 Critically Appraised Topic of the Month 1068 TEXAS Meeting Preview 1072 Value for Your Profession 1075 Memorial and Honorarium Donors

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1075 In Memoriam 1076 Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management 1078 Calendar of Events 1080 Advertising Briefs 1094 Index to Advertisers

Texas Dental Journal l www.tda.org l December 2014

Errata The Texas Dental Journal regretfully and inadvertently published the incorrect headshot for the coauthor of a manuscript that was published in the November 2014 issue. This is the correct headshot for Dr Daniel Perez, assistant professor, Department of Oral and Maxillofacial Surgery, UT Health Science Center at San Antonio.

Editorial Staff

Editorial Advisory Board

BOARD OF DIRECTORS

Daniel L. Jones, DDS, PhD, Editor Harvey P. Kessler, DDS, MS, Associate Editor Nicole Scott, Managing Editor Billy Callis, Publications Coordinator Barbara Donovan, Art Director Paul H. Schlesinger, Consultant

Ronald C. Auvenshine, DDS, PhD Barry K. Bartee, DDS, MD Patricia L. Blanton, DDS, PhD William C. Bone, DDS Phillip M. Campbell, DDS, MSD Michaell A. Huber, DDS Arthur H. Jeske, DMD, PhD Larry D. Jones, DDS Paul A. Kennedy Jr, DDS, MS Scott R. Makins, DDS Daniel Perez, DDS William F. Wathen, DMD Robert C. White, DDS Leighton A. Wier, DDS Douglas B. Willingham, DDS

The Texas Dental Journal is a peer-reviewed publication. Texas Dental Association 1946 S IH-35 Ste 400, Austin, TX 78704-3698 Phone: 512-443-3675 • FAX: 512-443-3031 Email: tda@tda.org • Website: www.tda.org Texas Dental Journal (ISSN 0040-4284) is published monthly (one issue will be a directory issue), by the Texas Dental Association, 1946 S IH-35, Austin, TX, 78704-3698, 512-443-3675. Periodicals Postage Paid at Austin, Texas and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S IH 35, Austin, TX 78704. Copyright 2014 Texas Dental Association. All rights reserved. Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, Out-ofstate ADA Affiliated $49.50. In-state Non-ADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA Affiliated, $17 Non-ADA Affiliated, September issue $17 ADA Affiliated, $65 NonADA Affiliated. For in-state orders, add 8.25% sales tax. Contributions: Manuscripts and news items of interest to the membership of the society are solicited. Electronic submissions are required. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. For more information, please refer to the Instructions for Contributors statement printed in the September Annual Membership Directory or on the TDA website: tda.org. All statements of opinion and of supposed facts are published on authority of the writer under whose name they appear and are not to be regarded as the views of the Texas Dental Association, unless such statements have been adopted by the Association. Articles are accepted with the understanding that they have not been published previously. Authors must disclose any financial or other interests they may have in products or services described in their articles. Advertisements: Publication of advertisements in this journal does Association of not constitute a guarantee or endorsement by the Association of Dental Editors and the quality of value of such product or of the claims made of it by Journalists. its manufacturer.

PRESIDENT David H. McCarley, DDS 972-562-0767, drdavid@mccarleydental.com PRESIDENT-ELECT Craig S. Armstrong, DDS 832-251-1234, drarmstrong01@gmail.com IMMEDIATE PAST PRESIDENT David A. Duncan, DDS 806-355-7401, davidduncandds@gmail.com VICE PRESIDENT, NORTHEAST Jerry J. Hopson, DDS 903-583-5715, dochop@verizon.net VICE PRESIDENT, SOUTHEAST William S. Nantz, DDS 409-866-7498, wn3798@sbcglobal.net VICE PRESIDENT, SOUTHWEST Joshua A. Austin, DDS 210-408-7999, jaustindds@me.com VICE PRESIDENT, NORTHWEST Steven J. Hill, DDS 806-783-8837, sjhilldds@aol.com SENIOR DIRECTOR, NORTHEAST William H. Gerlach, DDS 972-964-1855, drbill@gerlachdental.com SENIOR DIRECTOR, SOUTHEAST Karen A. Walters, DDS 713-790-1111, kwalters@sms-houston.com SENIOR DIRECTOR, SOUTHWEST John B. Mason, DDS 361-854-3159, jbmasondds@aol.com SENIOR DIRECTOR, NORTHWEST Charles W. Miller, DDS 817-572-4497, cwdam@sbcglobal.net DIRECTOR, NORTHEAST Dennis E. Stansbury, DDS 903-561-1122, drstansbury@gmail.com DIRECTOR, SOUTHEAST Duc “Duke” M. Ho, DDS 281-395-2112, ducmho@sbcglobal.net DIRECTOR, SOUTHWEST James R. Foster, DDS 956-969-2727, fosterdds@gmail.com DIRECTOR, NORTHWEST W. Kurt Loveless, DDS 806-797-0341, wklovedds@gmail.com SECRETARY-TREASURER* Ron Collins, DDS 281-983-5677, roncollinsdds@yahoo.com SPEAKER OF THE HOUSE* John W. Baucum III, DDS 361-855-3900, jbaucum3@gmail.com PARLIAMENTARIAN** Arthur C. Morchat, DDS 903-983-1919, amorchat@suddenlink.net EDITOR** Daniel L. Jones, DDS, PhD 214-828-8350, djones@bcd.tamhsc.edu *Non-voting member **Non-member attendee

Texas Dental Journal l www.tda.org l December 2014

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Texas Dental Journal l www.tda.org l December 2014

1035

President’s President’s Post Post

David McCarley, DDS, TDA President David McCarley, DDS, TDA President to come

…we have pullallquote many things to be thankful for and in this holiday season, we need to take the time to simply say, “Thank

his holiday season we have many things for which to be thankful — our families, our God, and our profession. I look around and see happy faces, even in long lines, and the spirt of giving

permeates the air. I reflect on what I am thankful for: the love and support of my spouse Lee Ann and my family, my understanding and exceptional staff, and the wonderfully caring competent TDA staff. I would not be able to do this without them. I am a part of the best profession in the world, in the best country in the world, at the best time there has ever been.

you.” It is also time

We are blessed in so many ways and need to be cognizant of all those

to get our crosses

and those we care about. Dr Pankey taught us about Aristotle’s Cross of

in balance and become mentors so we may pay it forward.

that make this possible. We need to make time for our family, our faith, Life: Work balances play while love balances worship. It is the delicate relationship of balancing our crosses that creates happiness and makes our lives meaningful. I am thankful to have had such great mentors that took the time and effort to guide me as I entered this wonderful profession. My dad, Dr L.B. McCarley, Dr Tom McDougal, the Pankey Institute, and the TDA have all been major influences in my life. I shudder to think where I would have been without their influence and support. Yes, we all have many things to be thankful for and in this holiday season, we need to take the time to simply say, “Thank you.” It is also time to get our crosses in balance and become mentors so we may pay it forward.

1036

Texas Dental Journal l www.tda.org l December 2014

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Texas Dental Journal l www.tda.org l December 2014

1037

Oral and Maxillofacial Pathology Case of the Month Radiolucent lesions with extensive periodontal bone destruction

Clinical History A 22-year-old female with a non-contributory past medical history presented for evaluation to her dentist with a chief complaint of bone pain and tooth mobility. Radiographic evaluation revealed extensive periodontal bone loss involving the supporting bone of the mandibular right second premolar and extending to the mesial root of the mandibular right first molar. Given the extensive destruction of the periodontal bone, the tooth appeared to be “floating in air.” Radiographic evaluation of the left side of the mandible revealed a well defined radiolucency that appeared non-corticated involving the area between the mandibular first and second molars. This lesion had a “punched out“ appearance (Figure 1). The teeth in the area responded normally to pulp vitality testing. Intra-oral evaluation revealed extensive mobility of the mandibular right second premolar. Given the significant mobility of the tooth and extensive destruction of the adjacent supporting bone, the decision was made to

Mitzi J. Palazzolo, DDS, MS, Maj, USAF, DC Staff, oral and maxillofacial pathologist, Wilford Hall Ambulatory Surgical Center/SAMMC, associate professor uniformed. University of the Health Sciences, JBSA-Lackland Air Force Base, Fort Sam Houston, Texas

Palazzolo

John Hellstein, DDS, MS professor, director surgical oral pathology, Department of Oral Pathology, Radiology and Medicine, College of Dentistry, University of Iowa, Iowa City, Iowa The views expressed are those of the authors and do not reflect the official views or policy of the Department of Defense or its components.

Hellstein

Figure 1. Panoramic radiograph exhibiting extensive periodontal bone loss around the mandibular second and first molar. A second radiolucent lesion was observed in the body of the mandible close to the roots of the mandibular left first and second molars.

1038

Texas Dental Journal l www.tda.org l December 2014

extract the tooth. The extraction was easily accomplished. At the same time, the extraction socket was thoroughly curetted and all of the soft tissue removed from the area was submitted for histopathologic evaluation. Subsequently, the radiolucency in the left mandible was also biopsied. Both lesions appeared microscopically similar.

Pathologic findings The bone lesions showed a diffuse infiltration of large, pale staining cells resembling histiocytes. These cells had a characteristic indented and vesicular nucleus classically described as â&#x20AC;&#x153;coffee beanâ&#x20AC;? shaped. Collections of plasma cells, lymphocytes, and eosinophils were observed in the background (Figure 2). Immunohistochemical stains using antibodies directed against CD1a and S100 protein were positive (Figures 3-4).

Figure 2. H&E stain revealed histiocytic cells with large vesicular and indented nuclei. A mixed inflammatory infiltrate consisting of plasma cells, lymphocytes, and eosinophils was observed.

What is the most likely diagnosis? See page 1076 for the diagnosis, follow-up care, and discussion.

Figure 3. Immunohistochemical stain for S100 protein was positive and highlights the large histiocytic cells.

Figure 4. Panoramic radiograph exhibiting extensive periodontal bone loss around the mandibular second and first molar. A second radiolucent lesion was observed in the body of the mandible close to the roots of the mandibular left first and second molars. Immunohistochemical evaluation for CD1a. The large histiocytic cells were positive. Texas Dental Journal l www.tda.org l December 2014

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to come

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Texas Dental Journal l www.tda.org l December 2014

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Texas Dental Journal l www.tda.org l December 2014

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OFFICIAL CALL FOR CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS: SPEAKER OF THE HOUSE, SECRETARY-TREASURER, AND EDITOR OFFICIAL CALL FOR SPEAKER OF THE HOUSE CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS

Section 140B of this chapter. To appoint tellers to assist him/ her in determining the result of any action taken by vote. f. To appoint members of reference committees in consultation with Candidacy announcements for the president, president-elect, the elective office of Texas Dental and the immediate past-president Association (TDA) Speaker of the by the Board of Directors’ first House may be submitted to TDA meeting of the calendar year. Secretary-Treasurer Dr Ron Collins g. To notify the divisional prior to the opening of the House of officers and the Committee on Delegates next May. Only an active, Credentials, Rules and Order, life, or retired member in good prior to the annual session, standing of this Association shall be the number of delegates and eligible. A curriculum vitae (CV) must alternates necessary to constitute accompany a letter of intent, and a quorum. the candidate will also have to sign h. To meet with the divisional a conflict of interest statement. If a officers prior to the meeting of CV is not submitted, the candidate the divisional caucuses at the must present his or her qualifications annual session to review the verbally before the House of Rules for Caucus Procedures, Delegates. Nominations are in order Nominations, And Elections. at the first meeting of the House of i. To appoint a parliamentarian pro Delegates and remain open until the tem, should it become necessary close of nominations at the end of for the parliamentarian to be the second meeting of the House absent during a session of the of Delegates; however, we request House of Delegates. that announcements of candidacy j. When the need shall arise, be made as early as possible so that appoint special committees to membership eligibility can be verified. perform duties not otherwise To become a nominee, a delegate assigned by these Bylaws, to must place the name of the candidate serve until adjournment sine die in nomination at the first meeting of of the session at which they were the House of Delegates. Please see appointed. the Manual on Caucus, Campaigns, k. In the event that the divisional Nominations and Elections at tda.org nominee for a particular office for full details. be declared ineligible, that the speaker of the House of Duties of the Speaker of the House Delegates shall direct the are enumerated in the Bylaws and divisional caucus to reconvene to include the following: select a new nominee. a. To serve as an ex-officio member l. The installation of officers shall be of the Board of Directors without held during the closing meeting vote. of the House of Delegates at b. To serve as an ex-officio member such time as determined by of the Executive Committee the speaker and conducted without vote. by the retiring president or c. To preside at all meetings of the past-president. The term of House of Delegates. new officers begins at the d. To determine the order of adjournment of the House of business for all meetings, subject Delegates. to the approval of the House of m. The secretary of this association accordance withl December 2014 shall serve as the secretary of the 1042Delegates, Texas DentalinJournal l www.tda.org e.

House of Delegates. In absence of the secretary, the speaker shall appoint a secretary pro tem of the House of Delegates. Candidacy announcements are to be mailed to TDA Secretary-Treasurer Dr Ron Collins, Texas Dental Association, 1946 S IH-35 Ste 400, Austin, Texas 78704, or emailed to TDA Executive Director Mike Geeslin: mike@tda.org. (Ref. TDA Bylaws, Chapter IV – Sections 100, 110A, 150C, 150D, Chapter V – Sections 10, 70Aa, and the TDA House Manual).

OFFICIAL CALL FOR SECRETARYTREASURER CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS Candidacy announcements for the elective office of Texas Dental Association (TDA) Secretary-Treasurer may be submitted to TDA SecretaryTreasurer Dr Ron Collins. Only an active, life, or retired member in good standing of this Association shall be eligible. A curriculum vitae (CV) must accompany a letter of intent, and the candidate will also have to sign a conflict of interest statement. If a CV is not submitted, the candidate must present his or her qualifications verbally before the House of Delegates. Nominations are in order at the first meeting of the House of Delegates and remain open until the close of nominations at the end of the second meeting of the House of Delegates; however, we request that announcements of candidacy be made as early as possible so that membership eligibility can be verified. To become a nominee, a delegate must place the name of the candidate in nomination at the first meeting of the House of Delegates. Please see

the Manual on Caucus, Campaigns, Nominations and Elections at tda.org for full details. Duties of the secretarytreasurer are enumerated in the Bylaws and include the following: a. Examine the income and expenses of this Association and report at each meeting of the Board of Directors. b. Serve as recording officer and custodian of the records of the House of Delegates and the Board of Directors. c. Ensure that the minutes of the House of Delegates and the Board of Directors be maintained. d. Serve as secretary to the Executive Committee, without the right to vote. e. Serve as secretary to the House of Delegates. f. Serve as chair of the Budget Committee. g. Serve as chair of the Assets Oversight Committee. h. Serve as the secretary of the American Dental Association Fifteenth Trustee District Delegation. i. Perform such other duties as shall be specified by the Board of Directors and these Bylaws. Candidacy announcements are to be mailed to TDA Secretary-Treasurer Dr Ron Collins, Texas Dental Association, 1946 S IH-35 Ste 400, Austin, Texas 78704, or emailed to TDA Executive Director Mike Geeslin: mike@tda.org. (Ref. TDA Bylaws, Chapter IV – Sections 70A-B, 110B; Chapter V – Sections 10, 70Aa, 80B; Chapter VI –Section 90G; Chapter VIII – Section 80).

OFFICIAL CALL FOR EDITOR CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS Candidacy announcements for the elective office of Texas Dental Association (TDA) Editor may be submitted to TDA Secretary-Treasurer Dr Ron Collins. Only an active, life, or retired member in good standing of this Association shall be eligible. A curriculum vitae (CV) must accompany a letter of intent, and the candidate will also have to sign a conflict of interest statement. If a CV is not

submitted, the candidate must present his or her qualifications verbally before the House of Delegates. Nominations are in order at the first meeting of the House of Delegates and remain open until the close of nominations at the end of the second meeting of the House of Delegates; however, we request that announcements of candidacy be made as early as possible so that membership eligibility can be verified. To become a nominee, a delegate must place the name of the candidate in nomination at the first meeting of the House of Delegates. Please see the Manual on Caucus, Campaigns, Nominations and Elections at tda.org for full details. Duties of the editor are enumerated in the Bylaws and include the following: a. To be editor-in-chief of all journals and publications of the Association and exercise full editorial control over such publications, subject only to policies established by the House of Delegates, Board of Directors, and these Bylaws and provided such content is not in conflict with or contrary to the TDA’s established policies, legislative agenda, or advocacy efforts. b. To control the selection of scientific material published in the Journal. The editor may appoint associate editors, with the concurrence of the Board of Directors, to gather and/or review material for publication. Such associate editors shall serve as long as the editor deems necessary; but never longer than the term of the editor. c. To attend all open meetings of the Board of Directors and the House of Delegates of this association, and the annual session of the American Dental Association. d. To hold no other elective office in this association or the American Dental Association while serving as editor, except the editor may be elected as delegate or alternate delegate to the ADA House of Delegates from his/her respective division. Candidacy announcements are to be mailed to TDA Secretary-Treasurer Dr Ron Collins, Texas Dental Association, 1946 S IH-35 Ste 400, Austin, Texas 78704, or emailed to TDA Executive Director Mike Geeslin: mike@tda.org.

TEXAS DENTAL ASSOCIATION NOTICE OF GRANT AVAILABILITY 501(C)(3) NONPROFIT DENTAL ORGANIZATIONS The Texas Dental Association (TDA) announces availability of financial assistance for qualifying 501(c)(3) non-profit organization affiliated with dentistry. The monies are derived from TDA Relief Fund interest income earned over the previous fiscal year. Grantees will be determined by the TDA Board of Directors. Eligibility: Grantees must be 501(c)(3) non-profit organizations affiliated with dentistry. Application: Letters of interest detailing the proposed project and associated budget should be mailed to: TDA Board of Directors Attn.: Mr Terry Cornwell 1946 S IH 35 Ste 400, Austin, TX 78704 Deadline: Letters of Interest must be postmarked no later than January 31, 2015. Approval: Letters of Interest will be reviewed and considered by the TDA Board of Directors at its February 2015 meeting. Notification: All recipients will be notified in writing by May 15, 2015. Previous Recipients: In 2014, grants were awarded to each of the following Texas organizations for direct patient care related expenses: $5,000 to Christian Community Action (Lewisville) for supplies and equipment; $2,500 to Dentists Who Care (McAllen) for its oral health education program; and $5,000 to San Jose Clinic (Houston) for prosthodontic services. For more information, please contact Mr Terry Cornwell, TDA, 512-443-3675 or terry@tda.org.

(Ref. TDA Bylaws, Chapter VI – SectionTexas Dental Journal l www.tda.org l December 2014 90I).

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The Location of Recent Dental School Graduates in Underrepresented Areas Eric S. Solomon, MA, DDS

About the Author Dr Eric S. Solomon is professor, Public Health Sciences, Texas A&M University Baylor College of Dentistry. Prior to joining the Baylor College of Dentistry in 1992, Dr Solomon served as the assistant executive director for application services and resource studies at the American Dental Education Association. He has published numerous articles and lectured widely on trends in dentistry, dental workforce, and dental education. Solomon may be reached by email at esolomon@bcd.tamhsc.edu. The author has no declared potential conflicts of financial interest, relationships, and/or affiliations relevant to the subject matter or materials discussed in the manuscript. This manuscript has been peer reviewed.

Abstract A rationale for accepting dental students from underrepresented population groups has been that they would be more likely to practice in underrepresented population areas. To examine this notion, recent dental school graduates were investigated to determine whether their racial/ethnic background was related to the racial/ethnic composition of the population where they practice. Our results show that recent graduates who were members of underrepresented population groups were more likely to practice in locations with a majority of the population from underrepresented population groups. Because recent graduates practice arrangements tend to be somewhat transient, it would be interesting to follow this cohort to see whether the characteristics of their practice locations change through time.

Key Words Underrepresented minority graduates, dental practice location, dental school admissions

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Introduction

Methods

ompelling arguments have been made for the need to increase the enrollment of underrepresented minority (URM) students in dental schools. In addition, studies have documented the lack of significant progress in dental schools increasing their underrepresented minority student bodies. A rationale for enrolling underrepresented minority students is that this would address manpower distribution inequities by producing clinicians more likely to serve underrepresented minority population groups. Unfortunately, there is very little evidence in the literature addressing the demographic characteristics of the patient populations of dentists or the demographic characteristics of the practice locations of recent dental school graduates. This study attempts to shed some light on the following questions:

All geographic zip codes in the state of Texas (N=1,822) were classified based upon their population composition. Zip codes with at least half their populations comprised of underrepresented population groups (Black, Hispanic, and Native American/Pacific Islander) were classified as “under represented (URM)”; all other zip codes were classified as “other.” Based upon this scheme, 537 zip codes (29.5%) were classified as “underrepresented.”

• What percentage of all recent dental school graduates locate in areas that are predominately comprised of an underrepresented minority population? • Are underrepresented minority graduates more likely to locate in underrepresented minority population areas?

Potential disparities in the distribution of dentists in underrepresented minority population areas was investigated. The number of dentists per 100,000 population was calculated for all zip codes. The dentist-to-population ratios of zip code with a majority population of URMs was compared to the zip codes with a minority of URMs. The dentist-to-population ratio in the URM group was 36.0 while the ratio in the non-URM group was 55.3. The Texas State Board of Dental Examiners database was used to select recent graduates from the Texas A&M University Baylor College of Dentistry (TAMUBCD). TAMUBCD graduates were selected if they had an active Texas Dental license, a Texas address, and had graduated between 2006 and 2011. Based upon these criteria, 371 graduates were selected for analysis. This represents 69.7% of all TAMBCD graduates during this time period; 65 of these graduates (17.5%) were classified as URM. The graduates’ addresses were a mix of home and work locations. Since we were only interested in their practice locations, an internet search was attempted for each of the graduates to determine the addresses associated with their practice sites. There were 343 successful internet search results (92.5%). The graduates were then classified by their racial/ethnic status in a similar manner to the coding of the zip code areas. Graduates classified as “underrepresented” (URM) were identified as Black, Hispanic, or Native American/Pacific Islander; all other graduates were classified as “other.” Therefore, both zip code areas and graduates were classified dichotomously as either URM or “other.” A chi square analysis was undertaken to determine whether URM graduates were more or less likely to locate in URM areas. A chi square analysis was also employed to see whether gender played a role in practice location. Finally, a student’s t-test was used to determine whether age played a role in practice location.

• Does gender or age have an impact on location in these areas?

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Results Table 1 shows the results of the analysis of practice location versus graduatesâ&#x20AC;&#x2122; racial/ethnic status.

TABLE 1. Demographic Characteristics of Population Areas Versus Minority Status of Graduates*

Population GRADUATE

OTHER

URM

TOTAL

Other

218 71.2%

88 28.8%

306 100.0%

URM

27 41.5%

38 58.5%

65 100.0%

TOTAL

245

126

371

*p â&#x2030;¤ .001 Overall, 34.0% of all recent graduates practice in an URM geographic area. This representation is slightly higher than the 29.5% of all zip codes that were classified as underrepresented. URM graduates were significantly more likely to locate in an underrepresented area than Other graduates. (58.5% versus 28.8%). Table 2 shows the results of the analysis of practice location versus gender.

TABLE 2. Demographic Characteristics of Population Areas Versus Gender of Graduates

Population GRADUATE

OTHER

URM

TOTAL

Female

116 68.6%

67 31.4%

183 100.0%

Male

129 63.4%

59 36.6%

188 100.0%

245

126

371

TOTAL p=.288 (ns)

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Almost half (49.3%) of the recent graduates were female. The gender distribution of graduates who practice in underrepresented geographic areas was very similar as well (36.6% of women 31.4% of men). These differences were not statistically significantly different. The age of the recent graduate was also analyzed by geographic area. There was virtually no difference in age between graduate location in URM areas (33.8 years old) and nonURM areas (34.0 years old) (p=.872).

Discussion This study was designed to investigate the practice locations of recent dental school graduates in terms of the racial/ethnic composition of their practice location areas. To simplify the analysis, areas that had a majority of their population comprised of underrepresented minority groups were designated URM areas. Recent graduates were also classified based upon their racial/ethnic status as URM or not. Overall, 29.5 percent of all the zip codes were classified as URM areas. If recent graduates were distributed equally into all areas, we would expect about 29.5 percent of all recent graduates to be located in URM areas. However, a slightly higher percentage of recent graduates, 34.0% of the graduates, were actually located in these URM areas. In addition, graduates who are members of an underrepresented minority group are more than twice as likely to practice in an URM area; 58.5%

of URM graduates versus 28.8% of non-URM graduates. The gender and age of the graduate appears to have very little impact of the location of a graduate in a URM area. While the focus of this study is on the practice location behavior of recent dental school graduates, there are questions that remain unanswered. These questions center on the fact that only recent graduates are investigated here; they are generally fairly young in addition to being very early in their dental careers. For example, it would be useful to know what motivated these graduates to select work in an URM area. One would suspect that the opportunities available in URM areas significantly influence the recent graduatesâ&#x20AC;&#x2122; practice location decisions. Therefore, it would be of interest to know whether these graduates remain in these locations or eventually establish a more permanent location in a non-URM area. An analysis of this cohort of graduates 5 years from now might provide some answers to these questions. If significant numbers of URM graduates remain in URM areas, the recruitment of URM students could be viewed as a viable strategy for achieving a more balanced geographical distribution of dentists.

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EPA Proposes New Standards Requiring Amalgam Separators Andrew Fohn Joseph A. Bartoloni, DMD, MPH

About the Authors Andrew Fohn, safety specialist, Department of Environmental Health and Safety, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Email: fohna@uthscsa.edu. Joseph A. Bartoloni, DMD, MPH, clinical associate professor, Department of Restorative Dentistry, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Email: bartoloni@uthscsa.edu. The authors have no declared potential conflicts of financial interest, relationships, and/or affiliations relevant to the subject matter or materials discussed in the manuscript. This manuscript was peer reviewed.

or more than 150 years, dentists have been using amalgam to successfully restore carious lesions or structural defects in teeth caused by tooth decay. It has been shown to be a safe and inexpensive solution for patients and in some ways it is still superior to composites. While dental amalgam has remained a popular and versatile restorative material, interest remains high in parts of the United States, as well as the world, in reducing the amount of mercury discharged from dental offices. For this reason, amalgam separators have been mandated in parts of Europe as well as in sensitive environmental regions within the U.S. as a method to lower mercury levels associated with amalgam entering the water system. While no national legislation mandating the use of amalgam separators has been passed to date, the Environmental Protection Agency (EPA) is working on a new rule that would make amalgam separators mandatory in the near future.

Abstract The Environmental Protection Agency has proposed new standards that would make amalgam separators mandatory for all dentists who place or remove amalgam. In an effort to reduce the amount of mercury released into the environment through effluent wastewater from dental practices, the proposed standards would require the use of existing technologies as well as the American Dental Associationâ&#x20AC;&#x2122;s Best Practices for Amalgam Waste. The proposed standard represents the first nationwide ruling requiring the use of amalgam separators and will affect all Texas dentists using amalgam.

Key Words Amalgam, mercury wastewater, amalgam separator, EPA

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Dental amalgam is a mixture of mercury and other metals that is combined into a paste for placement into a tooth, and then hardens to a durable solid (1). Introduced in the 1890s, amalgam has been declared by the American Dental Association (ADA) and Food and Drug Administration (FDA) to be a safe material for restorations. Although there has been some question as to the mercury content contained in amalgam and a reclassification to a Class II medical device, the FDA and ADA have maintained their positions regarding amalgamâ&#x20AC;&#x2122;s safety for use in patients (2). According to the EPA, there are approximately 160,000 dentists working in 120,000 dental clinics across the U.S. who place or remove amalgam. The ADA estimates that less than 1% of the total amount of mercury released into the environment comes from dental amalgam, but up to 50% of the mercury entering Publicly Owned Treatment Works (POTW) can be attributed to dental offices. Most of the mercury released due to human activity, which accounts for about half of all environmental mercury, can be traced to the combustion of fuels for energy production and waste management. With most dental facilities discharging wastewater directly into POTWs, an opportunity exists to reduce this source of mercury through the use of amalgam separators. Amalgam separators that conform to the International Organization for Standardization (ISO) criteria can filter out more than 95% of amalgam in wastewater (3).

Opened amalgam capsule displaying silver alloy powder and liquid mercury capsule. Photo credit: Andrew Fohn.

The concern over mercury from amalgam entering the environment involves contamination of ecosystems and aquatic species by way of bioaccumulation. Mercury can enter the environment in various ways. Atmospheric mercury from power plants and factories re-enter the environment via dust and rain (4). It eventually accumulates in the water system, joining mercury already present originating from natural sources, dental facilities, and other industrial sources through effluent wastewater streams. Microorganisms naturally transform elemental mercury into methylmercury, a dangerous neurotoxin affecting the brain and nervous system. Methylmercury is a bioaccumulator and its concentration increases as it travels up the food chain (5). As an example, methylmercury absorbed by plankton is transferred into the

organisms that eat the plankton. Methylmercury concentrations are much higher in these organisms because plankton is their primary food source. As these organisms are eaten by higher-order predators such as fish-eating birds, large predatory fish, and aquatic mammals, the mercury concentration multiplies. Mercury poisoning in these tertiary animals results in reduced fertility, slower growth and development, and sometimes death. People who eat high amounts of shellfish and pelagic fish with elevated mercury levels are also susceptible to methylmercury accumulations, sometimes causing neurological damage. Developing fetuses and nursing infants are especially sensitive to methylmercury, which can cause cognitive impairments and difficulty in developing fine motor skills (6).

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or leased. There are also different types of amalgam separator units, such as sedimentation, filtration, and centrifugal action, with individual merits and drawbacks associated with each. Generally speaking, prices range from $100 to $3,000 for the initial installation and then $35$200 per month for maintenance, depending on the type of separator and size of the practice (8). There are also associated costs of maintenance and replacement parts to consider. The ADA provides a checklist that compares the different types and guides decision-making (9).

Chairside traps remove most solids from wastewater. Amalgam separator then removes over 95% of the remaining mercury content before wastewater discharge. Photo credit: Andrew Fohn

The State of Texas, through the Texas Commission on Environmental Quality (TCEQ), does not currently regulate the discharge of wastewater from dental offices unless that water is discharged directly into a body of water within the state. POTWs can choose to regulate wastewater entering their facilities based on a number of factors, one of which could be elevated mercury levels. A dental clinic that exceeds a local POTW’s limit on effluent mercury levels might be required to utilize the American Dental Association’s Best Practices for Amalgam Waste and use an amalgam separator to lower the mercury concentration (7). Currently, these regulations are implemented on a case-by-case basis and don’t affect Texas dentists as a whole.

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Chairside filters and traps are able to catch larger amalgam particles and other biosolids that may contain amalgam, but still allow suspended solids and some dissolved mercury through. Amalgam separators are usually installed in-line after the dental operatory and upstream of the vacuum pump, capturing the mercury and preventing it from entering the effluent water stream. The amalgam recovered by the separator can be sent to facilities to be recycled, rather than contaminating the environment. There are many options to consider when planning to install an amalgam separator, such as the number of amalgam restorations placed, number of operatories, and whether the facility is owned

Texas Dental Journal l www.tda.org l December 2014

Recently, European countries and some states have passed legislation requiring amalgam separators in dental clinics that place or remove amalgam restorations. As of this writing, at least Norway, Sweden, and Denmark all have banned amalgam as a restorative material and require amalgam separators in clinics that remove amalgam restorations (10). Additionally, 12 states and at least 19 cities have mandatory pretreatment programs that require the use of amalgam separators. At least 20 POTWs have implemented voluntary programs to reduce mercury discharge from dental offices, with mixed results. Programs containing a mandatory “second phase” create a higher success rate than programs that are purely voluntary. The ADA has also recently updated the ADA’s Best Practices for Amalgam Waste to include recommendations for dentists to install amalgam separators (11). The proposed standards will require all dentists affected to limit the amount of mercury released to

The proposed standards will require all dentists affected to limit the amount of mercury released to POTWs through the use of available technologies, such as amalgam separators, and the American Dental Associationâ&#x20AC;&#x2122;s Best Practices for Amalgam Waste. POTWs through the use of available technologies, such as amalgam separators, and Best Management Practices. Compliance would be met by installing, operating, and maintaining amalgam separators meeting the ISO 11143 Standard. Practices with existing amalgam separators that do not meet the ISO standard would be considered compliant for the life of the existing amalgam separator. No wastewater monitoring would be required, with annual certification of the pretreatment system and recordkeeping being sufficient. Compliance with this new EPA standard is expected to reduce the amount of metals discharged to POTWs by 8.8 tons per year, and would substantially reduce the amount of mercury entering POTWs and the aquatic environment (12). The EPA will be accepting public comments on this proposal until December 22, 2014. Complete information can be found in the Federal Register as well as on the agencyâ&#x20AC;&#x2122;s website (13,14). The EPA expects to finalize the rule in September 2015.

REFERENCES 1.

About Dental Amalgam Fillings. U.S. Food and Drug Association Website. http://www.fda.gov/MedicalDevices/ ProductsandMedicalProcedures/ DentalProducts/DentalAmalgam/ ucm171094.htm. Updated August 11, 2009. Accessed November 12, 2013. Statement on Dental Amalgam. American Dental Association website: www.ada.org/1741.aspx. Updated August 25, 2009. Accessed November 12, 2013. Batchu H, Rakowski D, Fan PL, Meyer DM. Evaluating amalgam separators using an international standard. Journal of the American Dental Association. 2006;137(7):999-1005 Exposure to Mercury: A Major Public Health Concern. World Health Organization website: www.who.int/ phe/news/Mercury-flyer.pdf 2007. Accessed November 19, 2014. Human Exposure: Mercury. Environmental Protection Agency website: www.epa.gov/hg/exposure. htm#1. Updated July 9, 2013. Accessed November 12, 2013. Mercury: Health Effects. Environmental Protection Agency website: www.epa.gov/hg/effects. htm Updated March 10, 2014. Accessed November 19, 2014. Best Management Practices for Amalgam Waste. American Dental Association website: www.ada.org/ sections/professionalResources/pdfs/ topics_amalgamwaste_brochure.pdf. October 2007. Accessed November 12, 2013. Mercury Source Control and Pollution Prevention Program Evaluation: Final Report. National Association of Clean Water Agencies. 2002:19 http:// www.nacwa.org/images/stories/ public/finalreport.pdf Amended July 2002. Accessed November 12, 2013.

10.

11.

12.

13.

14.

Professional Product Review: Amalgam Separators. American Dental Association. 2007:2-4 http://www.ada.org/sections/ professionalResources/pdfs/ amalgam_separators_ppr.pdf. Published Fall 2007. Accessed November 12, 2013. Bender M. Dental Mercury Use Banned in Norway, Sweden and Denmark Because Composites are Adequate Replacements. Reuters website: www.reuters.com/ article/2008/01/03/idUS108558+03Jan-2008+PRN20080103. Published January 3, 2008. Accessed November 12, 2013. Oral Health Topics: Amalgam Waste Best Management. American Dental Association website: www. ada.org/en/member-center/oralhealth-topics/amalgam-waste-bestmanagement Accessed November 20, 2014. Jones E. EPA Proposes Standards to Reduce Mercury Discharges from Dental Offices. Environmental Protection Agency website: yosemite. epa.gov/opa/admpress.nsf/ d0cf6618525a9efb8525735900 3fb69d/a0b992d4ba5c5c2e85257 d5e0065cc11!OpenDocument#ar ea. Released September 25, 2014. Accessed November 19, 2014. Federal Register Environmental Documents. Effluent Limitations Guidelines and Standards for the Dental Category. 2014;79(204):63258-63286. http:// www.gpo.gov/fdsys/pkg/FR-2014-1022/pdf/2014-24347.pdf. Published October 22, 2014. Accessed November 20, 2014. Dental Amalgam Effluent Guideline. Environmental Protection Agency website: water.epa.gov/scitech/ wastetech/guide/dental/index. cfm. Updated November 12, 2014. Accessed November 20, 2014.

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TEXAS DENTAL JOURNAL 2014 Index of Feature Articles (by Author) Adibi, Shawn S., DDS, FDOCS, MEd, FAAOM; Ogbureke, Ezinne I., DDS; Minavi, Brian B.; Ogbureke, Kalu U., BDS, MSc, DMSc, JD, FRCPath; Why Use Oral Splints for Temporomandibular Disorders (TMDS)?; June 2014; Vol. 131, Number 6:450. Adkins, Jay, DDS; Crow, Janet; The Dental Expert; October 2014; Vol. 131, Number 10:909. Aparna Naidu, DDS, MS; David Lifferth, BS; Robert S. Fuentes DDS, MD; Oral and Maxillofacial Pathology Case of the Month: Polymorphous Low-grade Adenocarcinoma; June 2014; Vol. 131, Number 6:426. Armstrong, Craig S., DDS; The Foundation of Dentistry: Ethics and Professionalism; October 2014; Vol. 131, Number 10:912. Bachoura, Alex DDS, MD; Vigneswaran, Nadarajah, DMD, Dr. Med. Dent.; Oral and Maxillofacial Pathology Case of the Month: Squamous Cell Carcinoma of the Tongue in a Patient with Fanconi Anemia; November 2014; Vol. 131, Number 11:966. Bates, Carole Lynne, DDS; Being a Rural Dentist; February 2014; Vol. 131, Number 2:136. Benito, Brian A.; Coppola, Kevin; Connor, Joseph, DDS; Critically Appraised Topic of the Month:

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Sealants Arrest Progression of Non-Cavitated Dentin Occlusal Caries in the Primary Dentition; November 2014; Vol. 131, Number 11:968. Bhattacharya, Aditi, BDS, MDS, PhD; Kessler, Harvey, DDS, MS; Oral and Maxillofacial Pathology Case of the Month: Verruciform Xanthoma; October 2014; Vol. 131, Number 10:962. Black, Richard C., DDS; 2015 Legislative Landscape; October 2014; Vol. 131, Number 10:882. Bouquot, Jerry E. , DDS, MSD, FICD, FACD, FRSM (UK); Koeppen, Raymond G., DDS, MS, MBA, FACP; Haddad, Yasmine, DDS, PhD; Oral and Maxillofacial Pathology Case of the Month: Toothpaste-Induced Mucosal Etching (TIME); August 2014; Vol. 131, Number 8:574. Bourland, T. Campbell, DDS, MS; The JFK Assassination from a Dental Perspective: An Interview with an Oral and Maxillofacial Surgeon—Jack Bolton, DDS, MSD; March 2014; Vol. 131, Number 3:210. Ciarrocca, Katharine, DMD, MSED; Lana L. Jackson, MD, PHARMD, FACS; and Scott S. de Rossi, DMD; Human Papillomavirus: The Fundamentals of HPV for Oral Health Care Providers; May 2014; Vol. 131, Number 5:366.

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Doerre, David L., DDS; Is the Fast Lane the Tortoise or the Hare?; February 2014; Vol. 131, Number 2:120. Duncan, David A., DDS; Outgoing President’s Address, May 1, 2014; June 2014; Vol. 131, Number 6:432. Duncan, David A., DDS; The Texas State Board of Dental Examiners: Safeguarding the Dental Health of Texans; October 2014; Vol. 131, Number 10:906. Edwards, Paul C., MSc, DDS; Oral Cancer Screening for Asymptomatic Adults: Do the United States Preventive Services Task Force Draft Guidelines Miss the Proverbial Forest for the Trees?; May 2014; Vol. 131, Number 5:360. El-Halaby, Ahmed, DDS, MSD; Araújo, Michel V. Furtado, DDS, MSc, MDS; Unusual Radiographic Finding During Routine Periodontal Maintenance: A Case Report; April 2014; Vol. 131, Number 4:297. Estes, Philip N. R., DDS; Prepared for the Challenge; February 2014; Vol. 131, Number 2:122. Farokhi, Moshtagh R. DDS, MPH; Glass, Birgit Junfin DDS, MS; Gureckis, Kevin M., DMD; A Student Operated, Faculty Mentored Dental Clinic Service Experience at the UTHSCA-San

Antonio for the Underserved Refugee Community: An Interprofessional Approach; January 2014; Vol. 131, Number 1:27. Fayazi, Sara, Battle-Siatita, Shelrethia, Texerira, Fabricio B., DDS; Critically Appraised Topic of the Month: Electrical Pulp Testing Has Not Been Shown to be Superior to Cold Test in Diagnosing Pulp Vitality; February 2014; Vol. 131, Number 2:118. Fohn, Andrew; Bartoloni, Joseph A., DMD, MPH; EPA Suggests Voluntary Amalgam Separators While Working Towards New Rule; December 2014; Vol. 131, Number 12:1054. Freeman, Kim, MA, DMD, MS; Dental Artifacts: Enlightened Diagnosis by Transillumination; February 2014; Vol. 131, Number 2:154. Freeman, Kim, MA, DMD, MS; Dental Artifacts: Why Would You Want to Weight?; May 2014; Vol. 131, Number 5:355. Freeman, Kim, MA, DMD, MS; Dental Artifacts: Looking for Your Sign; October 2014; Vol. 131, Number 10:876. Geneser, Matthew K., DDS; Hellstein, John W., DDS; Flaitz, Catherine M., DDS, MS; Oral and Maxillofacial Pathology Case of the Month: Herniated Dental Follicle; February 2014; Vol. 131, Number 2:164. Gerlach, William H., DDS; Helping All TDA Member Dentists Succeed; October 2014; Vol. 131, Number 10:914.

Gordan, Valeria V., DDS; Riley, Joseph L. III, DDS; Worley, Donald C., DDS; Gilbert, Gordon H., DDS; Restorative Material and Other Tooth-specific Variables Associated with the Decision to Repair or Replace Defective Restorations: Findings from The Dental PBRN; March 2014; Vol. 131, Number 3:219. Gordan, Valeria V., DDS, MS, MS-CI; Translating Research into Everyday Clinical Practice: Lessons Learned from a USA National Dental Practice-based Research Network; August 2014; Vol. 131, Number 8:590. Harvey, Phillip J., DDS; The Advantages of a Military Practice; February 2014; Vol. 131, Number 2:132. Hatch, John P., Deahl, Thomas S., Matteson, Stephen R.; Critically Appraised Topic of the Month: Remove Metallic Orthodonic Appliances Prior to MRI Imaging; January 2014; Vol. 131, Number 1:26. Heinrich-Null, Lisa, DDS; Worsham, Debrah, DDS; I Hate Politics, but I Love My Profession More!; October 2014; Vol. 131, Number 10:910. Israelson, Hilton, DDS; American Dental Association 15th District Trusteeâ&#x20AC;&#x2122;s Address, May 1, 2014; June 2014; Vol. 131, Number 6:436. Janik, Andrea, DDS; My Positive Experience; February 2014; Vol. 131, Number 2:142.

THANK YOU, REVIEWERS The editor of the Texas Dental Journal, on behalf of the Texas Dental Association, wishes to express his sincere appreciation to the manuscript reviewers for 2014. The quality of the Journal is largely dependent on the judgment and advice provided by these individuals. Our sincere thanks to the following individuals who volunteered their time and expertise in 2014: Dr Barry Bartee Dr Anneta Bitouni Dr Ali Bolouri Dr Peter Buschang Dr Jonathan Clemetson Dr Kevin Donly Dr Arlet R. Dunsworth Dr David Grogan Dr Archie Jones Dr Harvey Kessler Dr Elias Kontogiorgos Dr Marie Latortue Dr Howard S. McGuff Dr Shirley Miranda Dr Rahma Mungia Dr Amal Noureldin Dr Lynne Opperman Dr Kathleen Pace Dr Jacqueline M. Plemons Dr Andreea Voinea-Griffin Ms Donna Warren Dr William F. Wathen

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Jacob, Lisa S., DDS; Sharing a Roof; February 2014; Vol. 131, Number 2:128.

the Temporomandibular Joint; November 2014; Vol. 131, Number 11:980.

Depths: Results from The Dental PBRN; July 2014; Vol. 131, Number 7:520.

Jones, Daniel L., DDS, PhD; Editor Message; May 2014; Vol. 131, Number 5:357.

Nguyen, Teresa; Almujel, Saad; Bryk, Clarence C., DDS, MS; Critically Appraised Topic of the Month: In Patients with Moderate Malocclusion, Orthodontic Treatment Provides No Significant Improvement to Periodontal Health; August 2014; Vol. 131, Number 8:570.

Roberts, Matthew B., DDS; The Affordable Care Act: A Texas View; October 2014; Vol. 131, Number 10:894.

Kacher, John E., DDS; Oral and Maxillofacial Pathology Case of the Month: Ectopic Geographic Tongue (Erythema migrans); April 2014; Vol. 131, Number 4:292. Liang, Hui, DDS, MS, PhD; Cheng, Yi-Shing Lisa, DDS, MS, PhD; Kessler, Harvey P., DDS, MS; Crossland, Jay A., DDS; Oral and Maxillofacial Pathology Case of the Month: Stafne Defect (Lingual Mandibular Bone Depression); March 2014; Vol. 131, Number 3:254. Maldonado, Yvonne E., DDS; Pediatric Public Health; February 2014; Vol. 131, Number 2:140. McCandless, Georganne P., DDS; A Practice with One Big Voice; February 2014; Vol. 131, Number 2:131. McCarley, David H., DDS; Incoming President’s Address, May 4, 2014; June 2014; Vol. 131, Number 6:442. McGuff, H. Stan, DDS; Jones, Anne Cale, DDS; Ellis, Edward III, DDS, MS; Nicolas, Marlo M., MD; Oral and Maxillofacial Pathology Case of the Month: Inflammatory Myofibroblastic Tumor; July 2014; Vol. 131, Number 7:502. Nagella, Neeraj, DMD, MD; Alsabban, Lena, BDS; Perez, Daniel, DDS; Chondromyxoid Fibroma of

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Oneacre, Lee, DDS; Condrey, James, DDS; Establishing Your Roots in Grassroots; October 2014; Vol. 131, Number 10:916. Palazzolo, Mitzi J., DDS, MS, Maj, USAF, DC; Hellstein, John, DDS, MS; Oral and Maxillofacial Pathology Case of the Month: Langerhans Cell Histiocytosis; December 2014; Vol. 131, Number 12:1038. Peppard, Mark, DDS; Electronic Health Records — Where Is Dentistry?; October 2014; Vol. 131, Number 10:898. Qari, Hiba BDS, MS; Ghali, G. E. , DDS, MD, FACS; Williams, Todd A. DDS; Wright, John M. DDS, MS; Oral and Maxillofacial Pathology Case of the Month: Central Giant Cell Granuloma; January 2014; Vol. 131, Number 1:16. Rankin, K. Vendrell, DDS; Comment and Editorial; May 2014; Vol. 131, Number 5:359. Rindal, D.B., Gordan, V.V., Fellows, J.L., N.L. Spurlock, Bauer, M.R., Litaker, M.S., Gilbert, G.H.; Differences Between Reported and Actual Restored Caries Lesion

Texas Dental Journal l www.tda.org l December 2014

Roberts, Shannon, DDS; Gallardo, Francisco, DDS; Brown, Ronald, DDS; Critically Appraised Topic of the Month: Dentists’ Awareness of Posture in Reducing Pain in Musculoskeletal Disorder; April 2014; Vol. 131, Number 4:296. Robledo, Juliana, DDS; Maller, Steven, DDS, MS; Boyle, Joseph S., DDS; Higgins, Russell A., MD; Oral and Maxillofacial Pathology Case of the Month: Myeloid Sarcoma With Monocytic Differentiation; May 2014; Vol. 131, Number 5:350. Rowan, Stephanie D., RN, MSN; DiBurro, Mark, RDH, MPH; Westbrook, Steven, DMD; Redding, Spencer W., DDS, MEd; Miller, Frank R., MD, FACS; Prevalence of HPV Associated Oropharyngeal Cancer among South Texans; May 2014; Vol. 131, Number 5:376. Rubel, Barry, DMD; Hill, Edward E., DDS, MS; Replacement of Maxillary Permanent Central Incisors Lost Due to Trauma in the Mixed-Dentition; August 2014; Vol. 131, Number 8:582. Shinta, Mustafa, DDS; Philip, Judy, DDS; LittleStar, Mark; Critically Appraised Topic of the Month: CAD/CAM Zirconia Posterior Crowns Have Higher Failure Rate Compared to Full Gold Crowns; July 2014; Vol. 131, Number 7:508.

Shwarts, Ellis; Laughinghouse, Megan; Taverna, Melanie V., MS, RDH; Critically Appraised Topic of the Month: STOPBang Questionnaire is Useful for Obstructive Sleep Apnea Screening; June 2014; Vol. 131, Number 6:420. Sibley, David, DDS; View from the Capitol; October 2014; Vol. 131, Number 10:888. Singh, Puneeta H.; Jones, John D., DDS; Case Report: Immediate Dentures in an HIV Positive Patient; July 2014; Vol. 131, Number 7:512. Solomon, Eric S.; The Location of Recent Dental School Graduates in Underrepresented Areas; December 2014; Vol. 131, Number 12:1046. Sport, Ian; Garza, Natalie; Rose, William, DDS; Critically Appraised Topic of the Month: 1.5-2 mm of Coronal Dentin Needed for Crown Buildup; May 2014; Vol. 131, Number 5:344. Veilleux, Leigh; Patel, Supriya; Hargreaves, Kenneth, DDS, PhD; Critically Appraised Topic of the Month: Traumatized Anterior Toth with Pulpal Calcification Can Be Treated with an Esthetic Restoration and Radiographic Follow-Up; October 2014; Vol. 131, Number 10:860. Wade, Herbert L. Jr, DDS; Making a Difference in the Lives of Medicaid Children; October 2014; Vol. 131, Number 10:902.

Waldman, H. Barry, DDS, MPH, PhD; Wong, Allen, DDS, EdD; Texas Dental Establishments in 2011; January 2014; Vol. 131, Number 1:35. Waldman, H. Barry, DDS, MPH, PHD; Wong, Allen, DDS, EDD; Dental Establishments in Texas: Metropolitan and Micropolitan Statistical Areas; October 2014; Vol. 131, Number 10:868.

Meet the TDA Legislative Team; October 2014; Vol. 131, Number 10:892. Official Call for Nominations: Speaker of the House, SecretaryTreasure, and Editor; November 2014; Vol. 131, Number 11:970. TDA Governance: Candidates Forum; April 2014; Vol. 131, Number 4:286.

Walton, William M., DDS; My Life as a Correctional Dentist; February 2014; Vol. 131, Number 2:124.

TDA Legislative Resource Guide; October 2014; Vol. 131, Number 10:918.

Woodmansey, Karl F., DDS; The Unrecognized Intuitive Superpowers of Dentists; November 2014; Vol. 131, Number 11:990.

TDA Notice of Grant Availability 501(c)(3) Non-Profit Dental Organizations; November 2014; Vol. 131, Number 11:971.

Wright, Stephen R., DDS; Transitioning for the Future; February 2014; Vol. 131, Number 2:144. Zimmermann, Richard, DDS; Seitz, Stefanie, DDS; Nyugen, Donald; Digital Dentistry and implant dentistry: A Case Report; April 2014; Vol. 131, Number 4:303.

OTHER Call for Nominations; January 2014; Vol. 131, Number 1:20. The Council on Legislative and Regulatory Affairs; October 2014; Vol. 131, Number 10:890.

The TDAâ&#x20AC;&#x2122;s 144th Annual Session, The Texas Meeting; January 2014; Vol. 131, Number 1:43. Texas Dental Association Directory of Members; September 2014; Vol. 131, Number 9. Texas Dental Association Gold Medal Winner: Dr. Richard C. Black; November 2014; Vol. 131, Number 11:974. Texas Dental Association 2013 Financial Report, 2015 Proposed Budget, and 2015 Budget Explanation; March 2014; Vol. 131, Number 3:234.

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ORAL and MAXILLOFACIAL PATHOLOGY LABORATORY Anne Cale Jones, DDS H. Stan McGuff, DDS l

Affiliation with a major health center with a large general and special surgical pathology faculty

Free local courier or overnight mail service

24 hour turn-around time following receipt of specimens in the majority of cases

Free biopsy bottles, cytological smear kits, consultation request forms, and biohazard bags

Telephone consultation available For additional information, please call (888) 728-4211 or (210) 567-4073.

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FREE Practice Valuation

Know the value of your most valuable asset. Contact us today.

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Texas Dental Journal l www.tda.org l December 2014

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PREVIEW

Q&A with Dr

George Merijohn

Dr George Merijohn is a well-known periodontist from San Francisco. Recently, he was interviewed by the TDA Council on Annual Session about the program he will present at the TEXAS Meeting in May 2015. What follows is a summary of that interview.

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Q A

Dr Merijohn, much of your passion in dentistry appears related to prevention and correction of gingival recession. Why is recession considered to be such a problem?

Gingival recession is highly prevalent worldwide. Depending on the population surveyed, the percentage of people affected ranges from 30% to 100%, with its prevalence and severity increasing with age. In the United States alone, the prevalence of ≥1 mm recession in persons 30 years and older has been reported to be 58%, and averaged 22% teeth per person. What’s more, it has been reported in the literature that gingival recession afflicts approximately 85% of dentists and dental students. Dentists who treat the esthetic zone are especially frustrated with gingival recession returning after orthodontic tooth movement and/or after porcelain margins are perfectly placed. Clinicians invest substantial time and effort in the esthetic zone both in our continuing education and practice. Check out the abundance of interesting esthetic zone CE offerings at the 2015 TDA program. The seminar and workshop I will be presenting for the TDA are especially designed to enhance esthetic zone clinical outcomes. Dental hygienists and clinical staff always want to know, “How does one avoid getting gingival recession in the first place, and then after it’s treated, how do we keep it from coming back?” The Management and Prevention of Gingival Recession Interactive Seminar addresses these issues and provides evidencebased, practical, and systematic approaches that attendees will be able to use in their practices the next day. We are all familiar with patient-driven concerns about gingival recession such as when it interferes with comfort, function, and esthetics. Anecdotal evidence suggests that the main reason for gingival recession treatment is the patient raising the issue. Unfortunately, most often it is only the high smile line patients who are concerned and their focus rarely goes beyond the facial aspect of the anterior teeth. An unfavorable consequence of gingival recession is the exposure of root surfaces to a potentially cariogenic supragingival microbiota. In the United States, the prevalence of root caries experience has been reported to be 55.9% among those aged 75+ years. Of great concern is that the group aged 65 and older, which was 12% of the population in 2000, is expected to exceed 20% by 2030 and root caries is expected to increase along with it. Nobody likes to have or treat root caries. Yet root caries and gingival recession are on a collision course. Our profession needs to connect the dots and do so quickly. Prevention of gingival recession is an essential element in the primary prevention of root caries. This alone is reason to incorporate practical protocols for management and prevention of gingival recession into daily clinical practice.

“

How does one avoid getting gingival recession in the first place, and then after it’s treated, how do we keep it from coming back?

”

Dr George Merijohn’s Class Schedule at the Texas Meeting:

George Merijohn, DDS Dr Merijohn operated his San Francisco periodontal practice for 28 years and is associate professor for Post Graduate Periodontics UC San Francisco and University of Washington.

FRIDAY, MAY 8 Management and Prevention of Gingival Recession: The Interactive Seminar 8:00 AM – 11:00 AM Autogenous Gingival Grafting: The KIWImethod™ Minimally Invasive Non-palatal Approach 1:00 PM – 4:00 PM SATURDAY, MAY 9 Autogenous Gingival Grafting: The KIWImethod™ Minimally Invasive Non-palatal Approach 8:30 AM – 11:30 AM

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Q&A with Dr George Merijohn

What are some of the modifiable conditions that increase the risk of gingival recession?

The published scientific evidence demonstrates that there are 14 core modifiable conditions associated with increased risk including damaging oral hygiene methods, damaging oral habits, oral appliances, certain common dental procedures, and orthodontic tooth movement.

Case A. Before

Case A. After

Case B. Before

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The key thing is that especially for the susceptible patient, decreasing exposure to modifiable conditions will decrease future risk for gingival recession and increase the likelihood of its long-term prevention. Attendees of the seminar will learn how to quickly spot who is susceptible to gingival recession and who is not so susceptible.

Texas Dental Journal l www.tda.org l December 2014

Case B. After

Q A

What is the difference in a traditional gingival graft compared to your minimally invasive technique?

Conventional palatal tissue harvesting is often associated with notable disadvantages. Patients fear having tissue peeled off the roof of their mouths; there often is protracted pain at the palatal harvest site; people experience difficulty chewing and talking — with and without wound protection materials; and excessive postoperative bleeding and complications are not unusual. The minimally invasive techniques I teach in KIWImethod® Workshops substantially reduce these disadvantages and as a result, the patient experience is more positive and appreciative. Additionally, the nonpalatal gingival harvesting method taught in the workshop often provides superior color and texture match because it is gingiva/gingival connective tissue rather than palatal mucosa/submucosal mixed tissue.

Q A

What are some of the advantages of using autologous tissue compared to cadaveric dermal tissue?

There are 3 main advantages: 1. Compared to any other tissue source and/ or regenerative materials, over the years our best systematic reviews have repeatedly demonstrated that autogenous tissue is the gold standard for root coverage, reducing recession, gaining clinical attachment, and increasing keratinized tissue. 2. With autogenous tissue, there is zero risk of disease transmission and there are no cadaver skin “yuck factor” objections from patients. 3. With autogenous tissue, the dentist does not have to buy expensive donor tissue or biomaterials.

Q A

What can the general dentists in your course take home for use when they get back to the office on Monday?

I strongly recommend that every dentist taking the KIWImethod® Minimally Invasive Gingival Grafting hands-on workshop also take the interactive seminar, Management and Prevention of Gingival Recession. The seminar Management and Prevention of Gingival Recession is an interactive, fun format for dentists, dental hygienists, all staff members, and dental specialists alike.

SEMINAR •

Learn the 3 major factors associated with increased susceptibility to gingival recession.

•

Take away practical concepts regarding the recognition and management of risk exposures that can be implemented in the busy clinical setting.

•

Understand what are essential data to collect and record for monitoring patients.

•

Practice with chairside clinical decision support tools designed to help the clinician focus on triage, evaluation, planning, and patient communication regarding the prevention and management of gingival recession.

•

Discover clinical decision-making criteria for when and how to monitor gingival recession, when a patient is a candidate for surgical evaluation or referral to a periodontist, and if surgery is the treatment of choice, what should be considered key surgical outcome objectives.

WORKSHOP • • • • • • • • •

When to consider surgery Surgical outcome objectives Surgical procedure selection Donor tissue options Minimally invasive surgical procedures for root coverage and non-root coverage outcomes Minimally invasive autogenous donor tissue harvesting; Postoperative instructions Practical tips on post-operative phase patient management When to treat, when to refer

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Provided by TDA Perks Program

value for your

profession

Finding a Location for Your Practice: Essential Considerations By Patrick Valentz; Principal, Xite Healthcare Real Estate

pening day of a new practice marks the culmination of years of training and preparation. But before a practice can open, a decision on where to build it must be made. The importance of having a strategic location cannot be overstated—never has location been more critical to a practice’s success and longevity. And finding one requires much preparation as well. Carefully consider the following as you search for the best location for your practice.

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Timeline

By the time you see crew at a construction site in a desirable commercial location, a lease on that space has probably already been negotiated. This is why a proactive and aggressive approach is so important to securing the location you want. Ideally, a dentist planning to open a practice should begin the process of locating a property a year or more in advance. A 12-month timeframe allows for the completion of necessary planning and

Texas Dental Journal l www.tda.org l December 2014

paperwork, as well as construction and customization of the new facility.

Practice Goals

This is most important. What are your long-term goals and objectives for your practice? When you sign a 10year lease on a dental office property, you make what amounts to a 20-year commitment. This is one of the many reasons that it is so critical to ask questions like, “Where do I see my practice in 5 years? Ten? Do I plan to

add an associate eventually? Will this space be sufficient as my practice expands?” You may need 3 operatories now, but limiting yourself to a property that only accommodates 3 may prove an unwise decision in 5 years. Avoid choosing a location that will inhibit your practice’s growth. Also, determine what demographic segments you want to serve. Knowing answers like these is critical to determining the size of your space and your intended client base.

monument or pylon sign, if available. Natural and man-made barriers make it difficult for people to see your practice. Also, inconvenient U-turns and traffic-laden intersections typically are deterrents to potential patients, who may seek more accessible offices. Given the choice between a practice near a peaceful access road and an office located across a major freeway, research and common sense indicate that most people would opt for the path of least resistance.

Residents and Nearby Businesses

Price vs. Value

It’s important to take a data-driven approach to selecting an area for your new practice or relocation of a practice.

Demographics

Review the area’s demographics. Do they support your practice goals? For example: What’s the average household income? The median age, and medical-insured versus Medicaid population? Can the population density support your goals for practice growth? Is the area near up-and-coming neighborhoods experiencing population growth? Are new schools and shopping centers under construction? Is a hospital nearby? These will affect the population—and your client base now and in the future.

Competition

Also, have a commercial real-estate firm conduct a thorough competition analysis of the selected area to ensure it’s not oversaturated with competitors. While the presence of other dentists in the area should not necessarily deter you, it’s worthy of substantial consideration. Your practice type—and whether or not it serves a niche market—will help determine if a nearby competitor might adversely affect your business.

Shared Property

If you choose to open your practice in a mixed-used or retail development, keep in mind that the other businesses that inhabit the building may negatively or positively affect your ability to attract and maintain patients. Many dentists are selecting locations in multi-unit properties that have other tenants that complement their services. These locations might be close to a competitor, but highly visible or on a major thoroughfare to growing areas. You may benefit from speaking to your real estate consultant regarding the demographics of the area, and together determining if potential patients would be attracted to—or deterred by—nearby businesses.

Visibility, Accessibility

Make sure the space you will occupy has visibility to drive-by traffic and good sign opportunities on the building—and any

Too many dentists limit their focus to the price per square foot when leasing a new property, viewing it as a consideration that supersedes all others—including the value of the location. A decision to settle for a less desirable property could lead to the downfall of a practice. Be sure your final choice is not a compromise based solely on the initial financial investment, but one that takes into account the future of your practice. When dentists settle for less expensive real estate, they often find themselves spending the real-estate savings on more marketing to make up for lack of visibility, appeal, or loss of business due to a new competitor that leases in a superior location.

Final Tips

After you’ve chosen a location, it’s important to negotiate the following up front: rental rate, tenant improvement allowance, operating expenses, time to complete interior construction, landlord and tenant responsibilities, and signage. Even some of the most skilled and knowledgeable practitioners ultimately fail due to poor planning. Invest a substantial amount of time researching and speaking with dentalspecific real estate professionals, contractors, designers, and equipment specialists. These organizations specialize in developing dental practices from the ground up, and serve as advisors throughout the process of building your practice. A dental real estate professional with a comprehensive knowledge of the Texas dentistry market will help you implement a data-driven plan with a 360˚ perspective of your practice’s needs that’s conducive to your success. TDA Perks Partner Xite Healthcare Real Estate finds the best location for a practice to increase a dentist’s probability of success. Xite can negotiate your lease, help with the purchase of a practice or building to suit. The company uses the most comprehensive real-estate database to provide a clear picture of competition in an area, and identifies a target patient base using key demographic criteria. TDA members receive a free initial demographic analysis. Reach Xite at the following numbers: Dallas: 214-306-4555; Austin: 512-270-2864; San Antonio: 210-625-5577; Houston: 832-220-5565. For more information about this and other TDA Perks Programs, visit tdaperks.com or call 512-443-3675. Texas Dental Journal l www.tda.org l December 2014

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MEMORIAL and HONORARIUM Donors to the Texas Dental Association Smiles Foundation

IN MEMORY OF: Reverend Deacon Joe Kaizen Robertson Orchard Dental Associates

Mr Henry C Moody Robertson Orchard Dental Associates

Mr Clyde “Cash” Perrere Dr Elizabeth Hunsaker and Dr and Mrs Stephen Hunsaker

Mr Joseph Siegfried Dr Elizabeth Hunsaker and Dr and Mrs Stephen Hunsaker

Ms Penelope Solomos Drs Elizabeth Hunsaker and Kathy O’Keefe

Ms Dora Linda Taylor Robertson Orchard Dental Associates

Your memorial contribution supports: • educating the public and profession about oral health; and • improving access to dental care for the people of Texas. Please make your check payable to: TDA Smiles Foundation, 1946 S IH 35, Austin, TX 78704

In MEMORIAM Those in the dental community who have recently passed

John S. Eads III El Paso, Texas February 16, 1933 – November 21, 2014 Good Fellow: 1995 Life Member: 2000 Haskell Gruber San Antonio, Texas December 6, 1922 – November 8, 2014 Good Fellow: 2010 Life Member: 1988 Henry F. Harman Victoria, Texas August 11, 1922 – October 31, 2014 Good Fellow: 1978 Life Member: 1987 • 50 Year: 1998 Kermit E. Keeley Norman, Oklahoma December 6, 1929 – September 13, 2014 Good Fellow: 2004 Life Member: 1994 • 50 Year: 2013 Tommy Thomas Longview Houston, Texas August 31, 1924 – October 22, 2014 Good Fellow: 1973 Life Member: 1989 • 50 Year: 1998 Timothy Agnew Mayer McAllen, Texas June 17, 1945 – November 11, 2014 Good Fellow: 1997 Life Member: 2011 James S. Millsap El Lago, Texas June 1, 1927 – October 30, 2014 Good Fellow: 1978 Life Member: 1992 • 50 Year: 2003 Robert Beverly Moore Houston, Texas February 23, 1927 – October 30, 2014 Good Fellow: 1979 Life Member: 1992 • 50 Year: 2003 Clifford Ochsenbein Bedford, Texas May 30, 1921 – November 3, 2014 Life Member: 1986 • 50 Year: 1998

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Oral and Maxillofacial Pathology Diagnosis and Management

Langerhans cell histiocytosis Oral and Maxillofacial Pathology Case of the Month (from page 1038)

Discussion Langerhans cell histiocytosis, formerly known as histiocytosis X, is a disease characterized by the neoplastic proliferation of Langerhans cells (1). In 1868, Paul Langerhans discovered the epidermal dendritic cells that now bear his name. The ultrastructural hallmark of the Langerhans cell, the Birbeck granule, was described a century later. Therefore, before the advent of the electron microscope and the recognition of the Langerhans cell histiocyte, this condition was known as histiocytosis X (2,3). The term “Langerhans cell histiocytosis” was introduced by the Writing Group of the Histiocyte Society (4). Historically, 3 clinical subtypes of Langerhans cell histiocystosis were recognized: eosinophilic granuloma, Hand-Schuller-Christian disease, and Letterer-Siwe disease. However, the clinical spectrum of Langerhans cell histiocytosis is broad and therefore, this arbitrary clinical classification has since been revised to correlate better with treatment and outcomes. The histiocytes in Langerhans cell histiocytosis exhibit phenotypic characteristics of bone marrow dendritic cells (2). These cells are derived from CD34+ hematopoietic myeloid stems cell and are classified as antigen presenting cells (5,6). Recent studies evaluating the clonality of the lesional cells support the fact that Langerhans cell histiocytosis

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is a neoplastic proliferation (7). The first case of Langerhans cell histiocytosis, although not recognized as a histiocytic disease at the time, was first described in 1865 in a 4-year-old boy with punched out radiolucencies of the calvarium, Langerhans cell histiocytosis affects patients over a wide age range (2,3). However, more than 50% of the cases are diagnosed in patients less than 10 years of age (8). There is a definite male predilection, and patients are more likely to be of North European origin (9). Sixty to 70% of Langerhans cell histiocytosis can be seen as solitary or multifocal bone defects (9,10). Oral changes may be the initial presentation in all forms of Langerhans cell histiocytosis. Moreover, mandibular or maxillary lesions are a common manifestation of the condition. The radiographic presentation of Langerhans cell histiocytosis may be quite variable and non-specific requiring biopsy to establish the diagnosis (10). In some instances, Langerhans cell histiocytosis may result in severe destruction of supporting bone and it may mimic periodontal disease making it a diagnostic challenge for the clinician. In the maxillofacial region, the disease may present in a variety of ways including mobile teeth, bone pain, swelling and even pathological fracture. Teeth without bony support have been referred to as “teeth floating in air” and the non-corticated lesions have

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been described as “punched-out radiolucencies” (11). Approximately 10-20% of all the cases of Langerhans cell histiocytosis affect the jaws. The mandible is 3 times more frequently affected than the maxilla. Other sites involved may include the skull, ribs, and vertebrae. The classic feature is solitary or multiple bone lesions. Affected infants and children less than 10 years of age commonly have skull and femoral lesions. In contrast, patients 20 years or older have lesions affecting the ribs, shoulder girdle and mandible. The posterior regions of the jaws are more frequently involved than the anterior regions. Maxillary or mandibular lesions are effectively treated with curettage. Inaccessible bone lesions are generally treated with low doses of radiation (9,12). The prognosis for bone lesions in the absence of significant visceral involvement is generally good. Survival in these cases is quite favorable with only a 7% mortality rate. However, progression or dissemination of the disease may occur, particularly for patients who have 3 or more bones affected. Chronic disseminated histiocytosis is used to classify disease involving bone, skin, and viscera. Acute disseminated histiocytosis includes prominent cutaneous, visceral, and bone marrow involvement affecting mainly infants, clinically presenting like leukemia with a reserved prognosis.

Follow-up

The patient received a full-body scan which revealed a single nodule in the lung. This nodule proved to be lung involvement with Langerhans cell histiocytosis. No other lytic lesions were found involving bone. The patient was treated with aggressive curettage and extraction of the involved areas of the mandible. In addition, the patient received chemotherapy. The patient was doing well at a 7-year follow-up. A recent cone beam CT scan did not show any sign of recurrences or new lesions. REFERENCES 1.

Uckan S, Gurol M, Durmus E. Recurrent multifocal Langerhans cell eosinophilic granuloma of the jaws: report of a case. J Oral Maxillofac Surg 1996;54(7):906-9. 9. Key SJ, O’Brien CJ, Silvester KC, Crean SJ. Eosinophilic granuloma: resolution of maxillofacial bony lesions following minimal intervention. Report of three cases and a review of the literature. J Craniomaxillofac Surg 2004;32(3):170-5. 10. Holzhauer AM, Abdelsayed RA, Sutley SH. Eosinophilic granuloma: a case report with pathologic fracture. Oral Surg 8.

Oral Med Oral Pathol Oral Radiol Endod 1999;87(6):756-9. 11. Broadbent V, Gadner H, Komp DM, Ladisch S. Histiocytosis syndromes in children: II. Approach to the clinical and laboratory evaluation of children with Langerhans cell histiocytosis. Clinical Writing Group of the Histiocyte Society. Med Pediatr Oncol 1989;17(6):492-5. 12. Ladisch S, Gadner H. Treatment of Langerhans cell histiocytosis-evolution and current approaches. Br J Cancer Suppl 1994;23:S41-6.

Nicholson HS, Egeler RM, Nesbit ME. The epidemiology of Langerhans cell histiocytosis. Hematol Oncol Clin North Am 1998;12(2):379-84. Coppes-Zantinga A, Egeler RM. The Langerhans cell histiocytosis X files revealed. Br J Haematol 2002;116(1):3-9. Leonidas JC, Guelfguat M, Valderrama E. Langerhans’ cell histiocytosis. Lancet 2003;361(9365):1293-5. Chu T, D’Angio GJ, Favara BE, et al. Histiocytosis syndromes in children. Lancet 1987;2(8549):412. Favara BE, Feller AC, Pauli M, et al. Contemporary classification of histiocytic disorders. The WHO Committee On Histiocytic/ Reticulum Cell Proliferations. Reclassification Working Group of the Histiocyte Society. Med Pediatr Oncol 1997;29(3):157-66. Favara BE. Langerhans’ cell histiocytosis pathobiology and pathogenesis. Semin Oncol. 1991;18(1):3-7. Willman CL, Busque L, Griffith BB, et al. Langerhans’-cell histiocytosis (histiocytosis X)--a clonal proliferative disease. N Engl J Med 1994;331(3):154-60.

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CALENDAR OF EVENTS FEBRUARY2015 February 28-March 1 The American Academy of Restorative Dentistry will host its Annual Scientific Session in Chicago. For more information, please contact Ms Cindy Metcalf, American Academy of Restorative Dentistry, PO Box 1764, Broken Arrow, OK 74013-1764. Phone: 918-455-2380; E-mail: cindym@valornet.com; Website: restorativeacademy.com.

APRIL2015 10-11 The TDA Smiles Foundation will hold a 40-chair, 2-day Texas Mission of Mercy in Dallas. For more information, please contact Missions Coordinator Sara Harney at TDASF, 1946 S IH 35 Ste 300, Austin, TX 78704; Phone: 512-448-2441; Email: sara@tda.org; Website: tdasmiles.org. 17-18 The Arkansas Dental Association will host its Annual Scientific Session at the Statehouse Convention Center in Little Rock, AR. For more information please contact Ms. Angela Rogers, ASDA, 7480 Highway 107, Sherwood, AR 72120; Phone: (501) 834-7650; E-mail: info@arkansasdentistry.org; Web: arkansasdentistry.org.

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25-27 The Oklahoma Dental Association will host its Annual Meeting at the Tulsa Convention Center in Tulsa, OK. For more information please contact Ms. Lynn Means, ODA, 317 NE 13th St, Oklahoma City, OK 73104; Phone: (405) 848-8873; E-mail: lmeans@okda.org; Web:okda.org.

MAY2015 7-10

The Texas Dental Association will host its annual Texas Meeting at the Henry B. Gonzalez Convention Center in San Antonio, Texas. For more information, please contact Sandy Blum, annual session director, TDA, 1946 S IH 35 Ste 400, Austin, TX 78704; Phone: 512-4433675; FAX: 512-443-3031; E-mail: paula@ tda.org; Web: texasmeeting.com.

JUNE2015 12-13 The TDA Smiles Foundation will hold a 20-chair, 2-day Texas Mission of Mercy in Lufkin. For more information, please contact Missions Coordinator Sara Harney at TDASF, 1946 S IH 35 Ste 300, Austin, TX 78704; Phone: 512-448-2441; Email: sara@tda.org. THE TEXAS DENTAL JOURNALâ&#x20AC;&#x2122;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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ADVERTISING BRIEFS PRACTICE OPPORTUNITIES ABILENE: 2- to 4-operatory stand-alone dental office with all equipment included; digital x-ray and pano. Call 325-762-0444. ADS WATSON, BROWN & ASSOCIATES: Excellent practice acquisition and merger opportunities available. DALLAS AREA: 5 general dentistry practices available (East Dallas, Richardson, Southeast of Dallas, and north of McKinney). FORT WORTH AREA: 2 general dentistry practices (West Fort Worth and Arlington). NORTH TEXAS: 2 pediatric practices. HOUSTON AREA: 1 orthodontic practice. EAST TEXAS AREA: 1 general dentistry practice. WEST TEXAS AREA: 1 general dentistry practice. AUSTIN AREA: 1 general dentistry practice available northwest of Austin. BRYAN/COLLEGE STATION AREA: 1 general dentistry practice available. SAN ANTONIO AREA: 1 general dentistry practice available. OKLAHOMA AREA: 1 general dentistry practice available. For more information and current listings, please visit our website at www.adstexas.com or call ADS Watson, Brown & Associates at 469-222-3200. AMARILLO: For lease. Stand-alone dental office building with 2 operatories; equipment negotiable. Perfect for startup, downsizing, or satellite office. Great location. Email inquiries to barbbnh@gmail.com.

ADVERTISING BRIEF INFORMATION SUBMISSION AND CANCELLATION DEADLINE: 20th, 2 months prior to publication (eg, November 20th for January issue) MONTHLY RATES: First 30 words = $60; each additional word = 10Â˘ Ads must be submitted via e-mail, fax, or web through tda.org and are not accepted by phone. Journal editors reserve the right to edit copy of classified advertisements. Any dentist advertising in the Texas Dental Journal must be a member of the American Dental Association. Advertisements must be not quote revenues or gross or net incomes; only generic language referencing income will be accepted.

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AMAZING PRACTICE OPPORTUNITY IN NORTH DALLAS: Sherri L. Henderson & Associates, LLC has acquired a periodontal practice & building for sale in Canyon Creek Professional Plaza. This is a great location for a general dentist practice group or various specialty professionals. It is perfect for a practice merger or someone needing to relocate to a larger space. The periodontist is willing to stay on as an associate specialist or move on. The space available is approx. 4,500 sq ft. The space includes 8 unique, large, private treatment rooms; X-ray units in all rooms; private doctor office; administrative private office; 2 large consultation rooms; very large front desk area; beautiful, open reception area with great natural skylights; and ample parking. This is a very busy, high-traffic building complex totalling 9,000 sq ft. The other half of the building is owned by another dental group, and the common area space includes a dental lab that could be beneficial for both sides. For more information, contact Sherri at (972) 562-1072 or email sherri@slhdentalsales.com. Listing #3002. Photos available. ARLINGTON / FORT WORTH: Associate position available. Full time dentist and specialist needed to join our successful dental group in Arlington and Fort Worth. Interested candidates should email CV to txdentaljobs@gmail.com. ASSOCIATE FOR TYLER GENERAL DENTISTRY PRACTICE: Well-established general dentist in Tyler with over 34 years experience seeks a caring and motivated associate for his busy practice. This practice provides exceptional dental care for the entire family. Our office is located in beautiful East Texas and provides all phases of quality dentistry in a friendly and compassionate atmosphere. The practice offers a tremendous opportunity to grow. The practice offers excellent production and earning potential with a possible future equity position available. Our knowledgeable staff will support and enhance your growth and earning potential while helping create a smooth transition. Interested candidates should call 903-509-0505 and/or send an email to steve.lebo@ sbcglobal.net.

AUSTIN: Progressive, patient-centric office is seeking an experienced dentist; must be friendly, caring, and professional. Opportunity is available (if desired) for practice ownership. Serious inquiries email: fahoosha@gmail.com, mike@miloinc.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. For consideration send your confidential resume to dentalresume27@yahoo.com. AUSTIN PRIVATE PRACTICE SEEKS ASSOCIATES (GPs, prosthodontists) due to growth and increased capacity.

Excellent compensation / benefits. Email resume to operations@omnidentalgroup.com or call 512-773-9239. AUSTIN: A well-established pediatric practice is seeking an energetic dedicated full-time pediatric dentist. We have an extensive client base with continued growth. Our office is a leader in all aspects of pediatric dentistry including sedation and anesthesia dentistry. We have 3 offices with state-of-the art technology and a highly trained support staff. We are looking for the right fit for our practice. Ideally, someone who is looking for a longterm opportunity. New grads are welcome to apply. Please email resume to tal@austinchildrensdentistry.com. AUSTIN: Endodontist (Full-time or part-time) wanted. New office, large ops, great staff and support, large patient pool (6 practices in our group), 35-40% of collections

DDR Dental Trust

Serving Texas Dentists for more than 40 Years

• Practice Appraisals • Practice Sales • Associate Agreements

800-930-8017

James L. Dunn, Trustee Texas Dental Journal l www.tda.org l December 2014

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ADVERTISING BRIEFS (base first 3 months). Contact: DeAnn Young, dyoung@ riverrockdentalfamily.com, www.512rock.com. AUSTIN: My Kidâ&#x20AC;&#x2122;s Dentist has an excellent opportunity for a pediatric dentist to work 10 days a month in our Austin offices. Contact Ed at 949-842-7936 or email CV to looname@pacden.com for more information. AUSTIN, SAN ANTONIO & DALLAS AREA PRACTICE OPPORTUNITIES MCLERRAN & ASSOCIATES: CORPUS CHRISTI AREA (ID #T231): This is an opportunity to purchase an established, general dentistry practice located on the South Coast of Texas in an area that is experiencing rapid growth as a result of oil drilling in the nearby Eagle Ford Shale. The practice has a large, fee-forservice/PPO patient base, strong new patient flow, consistent annual revenue in the mid 6 figures, and solid cash flow. The office occupies a free-standing building with 2 fully-equipped operatories (digital X-ray units and computers) and ample room to add 2-3 additional operatories. The real estate is owned by the seller and being offered for sale at fair market value. Given its close proximity to the Gulf of Mexico, this turnkey practice is an ideal opportunity for an avid fisherman/outdoorsman or beach lover. SOUTH OF SAN ANTONIO (ID #T235): This established general dentistry practice is located on a main thoroughfare in a quaint, rural town located approximately 90 miles southeast of San Antonio. This practice is in a high growth, low competition area in the Eagle Ford Formation. The practice has realized consistent annual revenue of 6 figures the past 2 years while maintaining low overhead, strong profitability of 50%, and solid new patient flow (currently averaging 27 new patients per month). The office space of the practice encompasses 1,200 square feet and has 3 fully-equipped operatories with digital X-ray units and computers (1 additional plumbed operatory for expansion). The building is also being offered for sale. SAN ANTONIO (ID #T255) This established, general dentistry practice has a fantastic location on a busy street in a rapidly growing area of North San Antonio. The practice boasts a large, predominantly fee-for-service patient base, consistent annual revenue of mid-high six figures, and exceptional net cash flow. The

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office space has an attractive build-out, 4 fully-equipped operatories with computers, and digital radiography. The practice has strong upside potential through increasing internal/external marketing and retaining services that are currently being referred to specialists. This opportunity will not last long! SAN ANTONIO (ID #T253) This established pedo practice is located in a desirable area of San Antonio and features 4 fully-equipped operatories. The practice boasts annual revenue of just under seven figures, low overhead, exceptional net income of mid six figures per year, a large, diverse patient base (fee-forservice, PPO & Medicaid), and strong hygiene production. The seller is available for a transition. SAN ANTONIO (ID #T251): This established family practice is located in a free-standing building on a busy street in a desirable neighborhood of San Antonio. The office space boasts an attractive/modern build out with 5 fully-equipped operatories with digital X-ray units (ScanX) and computers. The practice has a predominately fee-for-service patient base. The seller is available to continue working in the practice on a part-time basis following the sale to facilitate a smooth transition of ownership. SAN ANTONIO (ID #T250) This established general family practice was started from scratch at its current location over 40 years ago and is located in a free-standing building with excellent visibility on a major thoroughfare on the NE side of San Antonio. The office has 4 fully-equipped operatories with a fifth plumbed. The practice sees a middle income, fee-forservice/PPO patient base with the majority of new patients coming from either word-of-mouth referrals or involvement in PPOs. The practice is relatively turn-key and presents a new owner with tremendous amount of upside potential given the prime location, lack of external marketing currently being done to promote the practice, limited doctor work hours, and specialty work being referred out of the practice. Both the practice and real estate are available for purchase. EAST OF SAN ANTONIO (ID #248): This practice is located in a small professional building in a beautiful hill country town about 100 miles west of San Antonio. The practice currently operates as a part-time, low volume, low overhead operation and would be ideal for a dentist looking to practice part-time, acquire a satellite location, or acquire a practice in a low

ADVERTISING BRIEFS competition area. There is significant upside potential due to limited external marketing and limited involvement in discounted insurance plans. This is a great opportunity to get into an established practice for less than a comparable start up in a beautiful hill country community. The selling doctor is relocating for a new job out of private practice. SAN ANTONIO (ID #T244): This established, general family practice is located in a newly built-out facility located in a vibrant, high traffic retail location in a desirable area of San Antonio. The practice caters to a middle to upper middle income, fee-for-service/PPO patient base and boasts a strong new monthly patient count as a result of strong patient referrals, online marketing, and a highly visible location. This truly is a one of a kind location in a great area of San Antonio. HILL COUNTRY NORTH OF SAN ANTONIO (ID #T243): Doctor is retiring and selling this established quality general family practice and the building/real estate that is located in desirable hill country community within close proximity to San Antonio. The practice has seen consistent collections of approximately mid six figures per year over the past three years with strong cash flow. The practice caters to a fee-for-service/ PPO, middle class patient base and boasts strong new monthly patient flow with limited external marketing. The real estate will be sold at Fair Market Value as determined by an independent appraiser. WEST OF SAN ANTONIO (ID #T242): This established, fee-for-service general family practice was started from scratch in 1970 and has been in its current location for 28 years. The practice boasts a large active patient base, strong hygiene recall program, and excellent net cash flow after expenses. There is tremendous upside potential due to limited external marketing, no involvement in discounted insurance plans, a good amount of specialty work being referred out, and huge growth related to the Eagle Ford shale oil boom. This practice presents an excellent opportunity for someone who wants to get away from the San Antonio city life, while still having access to its amenities. SAN ANTONIO (ID #T239): A thriving multi-office pediatrics practice in the Seguin/San Marcos area is seeking a full time associate to work between both locations. Both facilities are state-ofthe-art, featuring 12 treatment areas and the latest amenities, including a movie theater, arcade, ceiling

Top Associateships WE HAVE ASSOCIATESHIPS FOR EVERYONE > High revenue, high income practices > Solo private practices > Small/Medium Texas and regional groups > Public Health > Medicaid and kids practices > Correctional care positions with good salary + benefits > Native American Health Center positions For the past 12 years, AJ Riggins has been placing dentists in permanent jobs with dental practices and organizations in all parts of Texas. Based in Dallas, we have our finger on the pulse of the Texas market.

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mounted televisions, and toddler play areas. Both offices are designed for high volume patient flow, as they see an average of over 100 patients each day. The patient base reflects the local blue-collar and educational communities. There is a mix of insurance, self-pay and state funded patients. The offices provide a full range of pediatric dental services and have very active sedation general anesthesia schedules. The associate doctor must be a graduate of a US dental school and hold a US pediatric dental training certificate. Spanish speaking is highly desired but not required. To learn more about this associate opportunity, please contact us at 512-900-7989 or texas@dental-sales. com. Please also send a current CV. AUSTIN (ID #T257) This beautiful general dentistry practice is located in a highly visible retail location in central Austin. The office boasts a high end, modern build-out, state-of-the-art technology (including digital radiography, computers throughout the office, and 3D Cone Beam), and 5 fully-equipped operatories. The practice has a large Fee-for-service/PPO Texas Dental Journal l www.tda.org l December 2014

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ADVERTISING BRIEFS patient base, annual revenue of high six figures, strong net cash flow, and healthy new patient flow. AUSTIN (ID #T254) If you are thinking about starting a practice or opening a satellite office in the Austin area, this opportunity is a MUST SEE. This dental office is located in a highly desirable area in Northwest Austin with great demographics and features a high end build-out, 3 fully-equipped operatories (with 2 additional plumbed operatories), digital Pano, computers, etc. Call us today for more details! NORTHWEST AUSTIN (ID #249): This state of the art perio practice features a beautiful, turn-key facility with modern decor, high end finish out, and 4 fullyequipped operatories (with computers and digital X-ray units). The practice serves a PPO/Fee-for-service patient base, is currently seeing an average of 40 new patients per month, and is on pace to realize annual revenue of high six figures in 2014. The doctor is planning to retire but is available for a transition. You can purchase this turn-key practice for less than it would cost to start a practice from scratch! AUSTIN (ID #T246): This fee-for-service/PPO general family practice was started from scratch 17 years ago in a desirable single story retail center in NW Austin. The practice has a solid patient base that reflects the middle to upper middle income demographics of the area. It has three fully-equipped treatment rooms with the potential to add a fourth by plumbing/equipping the consultation room. The office boasts modern decor and is well-equipped with digital x-ray units and is computerized throughout. This is a great opportunity to get into an established practice with solid potential for less than a comparable start up. The selling doctor is transitioning due to a disability that arose in 2012. AUSTIN (ID #T241): This is an opportunity to purchase a growing practice in the rapidly developing area of East Austin. The office is situated directly on a busy street and has excellent signage and visibility. The facility has a quality build-out and 4 fully-equipped operatories with computers and digital radiography. The practice has healthy new patient flow, low overhead, and tremendous upside potential. This is a great starter practice or satellite location. HILL COUNTRY WEST OF AUSTIN (ID #T236): This predominately fee-forservice general family practice is located in a desirable

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community in the heart of the Texas Hill Country. It boasts a great reputation and has been in its current location since 1980. The office has three fully-equipped operatories, with the ability to add an additional operatory. There is a strong opportunity for growth, as the owner is not actively marketing the practice, does not participate in any PPOs and is referring out a fair amount of specialty procedures. The practice has a strong foundation of active patients with a good amount of upside potential. This is an excellent opportunity for someone who enjoys the beautiful Hill County and wants to get away from the big city. AUSTIN (ID # T222): This is a unique opportunity to purchase a practice located in a busy retail center in Austin. The practice is ideal for a doctor or company looking for a large facility to establish a multiple doctor and hygienist office for less than the cost of building out a shell space and equipping a startup. The practice has a total of 18 plumbed operatories with 6 operatories currently equipped. The practice revenue was on pace to be around the mid six figures in 2013 with only one doctor producing. Serious inquiries only as this is a unique opportunity not suited for most solo practitioners looking to acquire a practice. Contact McLerran & Associates: David McLerran or Brannon Moncrief in Austin 512-900-7989, or San Antonio 210-737-0100. Practice sales, appraisals, buyer representation, and lease negotiations. To request more information on our listings, register at www.dental-sales.com. BRYAN/COLLEGE STATION: Relationship based practice in Bryan/College Station area seeks part-time associate. Experience in occlusion and prosthodontics is desired. Email resume to dentalpath2013@gmail.com. COLORADO DENTAL PRACTICE FOR SALE. Located in southwest Colorado near the San Juan mountains. Ski, fly fish, hike, and hunt. Itâ&#x20AC;&#x2122;s all in your backyard. Established fee-for-service restorative practice with state-of-theart equipment and furnishings is waiting for you in this mountain town community. Collecting mid-6 figures with the potential to do way more. Owner is relocating to pursue a new phase in his dental career. Get of the Texas

ADVERTISING BRIEFS heat and the rat race and enjoy real living again. Practice is attractively priced to sell. Email inquiries to t1h2oyd3@ yahoo.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 email cjpatterson@kosservices.com. DALLAS AREA: New and beautiful general dentistry practice on I-30 near Rockwall. Over 5 years of clinical experience required. Perfect for dentists who refer endo! Pay based on collections. PPO and Medicaid accepted. M-F 2:00 PM - 8:00 PM and Saturdays available. Visit mockingbirddentalgroup.com. DALLAS TOLLWAY &LBJ: Dentists needed part-time and full-time for new, extended-hours, high production, treatment-oriented practice opening just prior to Memorial Day. Must be comfortable with most molar endo and wisdom tooth extraction cases. Implants experience a huge plus. Plenty of C&B. Dentures also an opportunity. 1099 contract position with generous commission. For immediate consideration, please email your CV and availability to cv@erdentist.com. DDR DENTAL —ODESSA: General practice: Cosmetic practice with high six figure gross and high net income. Excellent recall program and stable patient base. More than 2,000 sq. ft. using four operatories (2 dental and 2 hygiene), well maintained with latest equipment, digital x-ray and paperless charts. Contact Chrissy Dunn at 800930-8017 or visit www.DDRDental.com (seller is DDR Dental Trust Member). DDR DENTAL — NEAR AUSTIN: Denture practice: Denture practice 20 miles from Austin with seven figure gross and very, very high net income. Excellent referral program and employed denturist. Well-equipped office using 5 operatories (1 surgical suite). Well-oiled machine that still has growth potential. Contact Chrissy Dunn at 800-930-

8017 or visit www.DDRDental.com (seller is DDR Dental Trust Member). DDR Dental — AUSTIN (South Lamar): General practice: Well established on South Lamar Blvd in Austin. Very high traffic and booming area. Practice in historic house that is highly visible. Four operatories in use, plumbed for 1 more. Low six figure gross but a great patient base and growth opportunity. Building also available for sale. Contact Chrissy Dunn at 800-930-8017 or visit www. DDRDental.com. DDR DENTAL — NORTH HOUSTON: General practice: Seven figure gross with expected very high six figure net income. Six fully-equipped operatories. Office inside professional building. Hispanic area and Medicaid accepted. Contact Chrissy Dunn at 800-930-8017 or visit www.DDRDental.com (seller is DDR Dental Trust Member). DENTISTS: A practice of 1 year looking for a BC/BE pediatric dentist to come on board as employee with possible buy-in. This is an all pediatric dentists’ office. You would be working next to a BC pediatric dentist. Good terms with great pay and work hours. Must be able to get Board Certified within 1 year. OR cases done at El Paso’s Children’s Hospital. Excellent opportunity. Contact 719671-5617 or tparco@dentalquestions.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 and experienced dentists welcome. We offer benefits, a helpful working environment and an opportunity to grow. We accept most insurance and Medicaid. Please submit your resume via email to jennifer@smileworkshop.com or call our office at 214-757-4500. EAST DALLAS COUNTY GENERAL PRACTICE FOR SALE: 32+ year old established practice located in professional office building with good visibility. 100% FFS practice has four fully functioning operatories. Dentist retiring. Great opportunity! Call 214-533-3071.

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ADVERTISING BRIEFS EAST TEXAS: Well-established dental practice seeks caring, proficient, and motivated dentist for associate employment. Our office is located in a mid-sized town with abundant outdoor activities including hunting and fishing and a “small town” atmosphere. We offer all phases of dentistry. Interested candidates should email correspondence and resume to mloon242@aol.com. EDINBURG — FALCON DENTISTRY PA dba Falcon Dental Center seeks dentist in Edinburg. Doctor of Dental Surgery degree required. Texas dental license required. Qualified applications may submit resume directly to Atlantis Gloria Moya, office manager, via fax at 956-287-4926 or via email at falcondentistry@gmail.com. EL PASO: Full-time position for a general dentist. Do not waste your best years at dead-end jobs. Great earning potential and future partnership option. Affordable El Paso Dental is looking for a Texas-licensed dentist to work fulltime in our office in El Paso. Applicant must be licensed in the state of Texas and have 1 year of experience. If interested please submit a resume with an accurate contact number and email address to the following: drdarj@gmail.com. EL PASO: We are hiring a skilled and compassionate dentist to join our stable and successful practice. We are seeking a highly professional dentist with a knack for general dentistry. Prospective candidates must be dynamic, fun loving, and looking for a long-term commitment. Our practice is highly productive affording our providers an opportunity to attain competitive compensation. If interested, please forward your CV to annette@vistahillsfamilydental.com. EL PASO COUNTY: General practice — #TX-1179. 4 operatories. Beautiful, recently built. Well equipped. Owner must sell (family relocation). 2014 collections projected at mid-low 6 figures. Price: $245,000. For details contact Amanda Christy (NPT, LLC) 877-365-6786 x230, a.christy@NPTdental.com or www.NPTdental.com.

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ENDODONTIST —FULL TIME, KILLEEN: Carus Dental, established in 1983 in Austin, has always been committed to the traditional doctor-patient relationship and to the highest quality in dental care and service. We currently have approximately 48 doctors on staff across our 21 practices in Austin, Houston and Central Texas. We offer dental services in general dentistry, oral surgery, orthodontics, pediatric dentistry, endodontics, periododontics and prosthodontics in some or all of our practices. Carus Dental has been accredited by the Accreditation Association of Ambulatory Health Care since 2000. We offer a competitive salary and excellent benefit package including a 401k, health insurance and a professional work environment. To learn more about American Dental Partners and Carus Dental please visit us at www.amdpi.com and www.carusdental. com. If interested, please send CV and cover letter to kateanderson@amdpi.com. EXCELLENT FULL-TIME POSITION: Sherri L. Henderson & Associates, LLC is looking for a qualified general dentist to transition into an active family and cosmetic practice in the Alamo Heights area of San Antonio. The owner established the practice in 1980. The practice produces seven figures annually and is dedicated to performing high quality dental care to families of the surrounding communities. The practice is currently 2,115 sq ft with four treatment rooms and is capable of expanding into an additional 1,300 sq ft in an adjoining space. The position is for a full-time, experienced dentist who will have the opportunity to become a partner in the near future. He/she will be working with a very dedicated and knowledgeable team. Compensation, insurance and benefit plans are negotiable. For more information, please contact our office at 972-562-1072, email sherri@slhdentalsales.com, or visit our website at www. slhdentalsales.com. Photos and a practice overview are available. Refer to listing #3015. 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

ADVERTISING BRIEFS surgical procedures. No Medicaid, no DHMO practice in 6 ops, 2 surgical suites, all operatories computerized with digital X-ray and intra-oral cameras; digital panoramic X-ray; paperless charts for easy documentation. Visit www. todaysdentistrytexas.com. The Galveston area is just south of Clear Lake 25 minutes which has planned communities with superior schools, multiple educational, recreational and cultural venues as well as access to all of the Houston cultural and sport venues, shopping and restaurants. We are minutes away from all types of water sports including several large marinas. http://goo.gl/maps/lWkF. Possibility of buy-in and partnership possible after an interim term. Interview today! Email CV to kkcarroll10yahoo.com or call 832-385-8875. GARLAND: Equipped dental office for lease. Downtown Garland. Dental office, 4 ops, chairs, pano, digital scanner, X-ray unit, etc. Available for immediate release. Please call 214-415-9096. GARY CLINTON HOUSTON PRACTICE FOR SALE: Far West Houston Great Opportunity. Well established practice in a high growth area. Trust your life’s work to the most experienced appraiser/broker. For over 40 years, you have seen the name, Gary Clinton, working as a management consultant, appraiser, consultant and sales broker of general dental and specialty practices in Texas. I have buyers for all metro areas of Texas. Knowledgeable buyers are willing to pay the fair market value in growth areas commanding higher values. My certified appraisals use comparables from Texas practices in the same or similar parts of Texas. Senior Appraiser Member of The Institute of Business Appraisers, Inc. Call Gary Clinton confidentially at 1-800-583-7765. GARY CLINTON ORTHO PRACTICES FOR SALE AUSTIN/ SAN ANTONIO AREA AND WEST CENTRAL TX: The Texas economy especially in these areas is breaking records! Control your destiny. Time to own your practice. 100% funding available at great rates. Trust your life’s work to the most experienced appraiser/broker. For over 40 years, you have seen the name, Gary Clinton, working as a management consultant, appraiser, consultant, and sales

broker of general dental and specialty practices in Texas. I have buyers for all metro areas of Texas. Knowledgeable buyers are willing to pay the fair market value in growth areas commanding higher values. My certified appraisals use comparables from Texas practices in the same or similar parts of Texas. Senior Appraiser Member of The Institute of Business Appraisers, Inc. Call Gary Clinton confidentially at 1-800-583-7765. GARY CLINTON FORT WORTH AREA PRACTICES FOR SALE: FW-1 Southeast Fort Worth. Retiring dentist. Low overhead; owns 1,200 sq ft building. Trust your life’s work to the most experienced appraiser/broker. For over 40 years, you have seen the name, Gary Clinton, working as a management consultant, appraiser, consultant and sales broker of general dental and specialty practices in Texas. I have buyers for all metro areas of Texas. Knowledgeable buyers are willing to pay the fair market value in growth areas commanding higher values. My certified appraisals use comparables from Texas practices in the same or similar parts of Texas. Senior Appraiser Member of The Institute of Business Appraisers, Inc. Call Gary Clinton confidentially at 1-800-583-7765. GARY CLINTON MCKINNEY AREA PRACTICE FOR SALE: State of the art practice in high visibility shopping center. 4 operatories digitally equipped. Trust your life’s work to the most experienced appraiser/broker. For over 40 years, you have seen the name, Gary Clinton, working as a management consultant, appraiser, consultant and sales broker of general dental and specialty practices in Texas. I have buyers for all metro areas of Texas. Knowledgeable buyers are willing to pay the fair market value in growth areas commanding higher values. My certified appraisals use comparables from Texas practices in the same or similar parts of Texas. Senior Appraiser Member of The Institute of Business Appraisers, Inc. Call Gary Clinton confidentially at 1-800-583-7765. GARY CLINTON PRACTICE FOR SALE SOUTH OF FORT WORTH ALVARADO/CLEBURNE AREA: Well-established family practice. Collections near $700,000 so far in 2014 not including the small amount of orthodontics done by Texas Dental Journal l www.tda.org l December 2014

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ADVERTISING BRIEFS doctor. Excellent staff. Six equipped operatories plus 1 ortho bay. Mostly fee-for-service with no DMO/HMO plans. Trust your lifeâ&#x20AC;&#x2122;s work to the most experienced appraiser/broker. For over 40 years, you have seen the name, Gary Clinton, working as a management consultant, appraiser, consultant and sales broker of general dental and specialty practices in Texas. I have buyers for all metro areas of Texas. Knowledgeable buyers are willing to pay the fair market value in growth areas commanding higher values. My certified appraisals use comparables from Texas practices in the same or similar parts of Texas. Senior Appraiser Member of The Institute of Business Appraisers, Inc. Call Gary Clinton confidentially at 1-800-583-7765. GARY CLINTON PRACTICE OF SALE IN AMARILLO: Dentist wishes to relocate. Low overhead in an underserved area. Nice office with great recall. Call Gary Clinton, Appraiser/Broker. Member of The Institute of Business Appraisers, Inc. 1-800-583-7765. GENERAL PRACTICE. SUGARLAND, TEXAS. Sixoperatory practice for sale. Four operatories equipped; turnkey operations; 2013 collections were mid-6 figures. Working only 3 days per week; all equipment and building less than 2 years old. Very clean, very modern office; all digital. Great opportunity for any specialist as well as general dentist. Asking $325K. For more info, please email sugarrichdental@gmail.com. GREAT DENTIST TO WORK WITH KIDS: Good opportunity for someone who likes children. Busy practice. Great personality. Competent dentist not afraid to work. Great pay. Sedation will be taught. Send resume ASAP to Carol Erickson, info@txkidsdental.com, 9411 Alameda Avenue Ste P, El Paso, TX 79907. Call 602-309-2180 GREAT OPPORTUNITY FOR SPECIALIST: An endodontic practice in southwest Houston is seeking to share space with a part or full time periodontist, oral surgeon or orthodontist in a state of the art dental office. 4 operatories fully-equipped with digital x-rays and microscope. For more information, please contact 713- 932-1913.

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GUN BARREL CITY: East Texas 2-operatory, standalone dental office. 1200 sq ft remodeled home. All removable prosthetic practice. All fee-for-service. Mid-6 figure income. 12 hours per week schedule. Growth potential for general dentistry and implants. Doctor wants to retire and travel. Contact 903-432-9414 in the evenings. HOBBS, NEW MEXICO: Exceptional opportunity for a general dentist seeking a quality, fee-for-service practice to purchase. This premier, established practice has a fine reputation in providing comprehensive quality care to the surrounding communities. This practice has a dynamic, experienced team and a strong emphasis on CE and professional growth. Please send your CV with a cover letter and written goals in confidence to: pam@ lifetransitions.com. HOUSTON AREA PRACTICE: Jeff Jones, DDS, HS Professional Practice Transitions. Excellent opportunity to capitalize on a fully digital high tech practice. Highly visible location with a great lease. Beautiful finish out includes 5 chairs with room for expansion. Impressive new patient flow with strong hygiene revenue and gross receipts in high-6 figures. Owner willing to stay on as associate needed. To learn more, contact: Jeff Jones, DDS, with HS Professional Practice Transitions 830-832-5522, or dr.jeff.jones@henryschein.com. HOUSTON AREA PRACTICE OPPORTUNITIES! MCLERRAN & ASSOCIATES-HOUSTON: UPDATED!! UPPER WEST GALVESTON BAY. Profitable general practice located in a highly visible office building in the heart of a vibrant oil and gas commercial center and community. 3 fullyequipped operatories, strong hygiene revenues, and over 1,100 active patients. Very high cash flow for new owner. (#H194) NEW!! MEMORIAL CITY HOUSTON Established, general, fee-for-service practice located in the Town & Country/Memorial City area. The practice features a strong hygiene re-care system and over 600 active patients. With 3 treatment room and very favorable rent terms, this is a spectacular opportunity in the highly desirable energy corridor! (#H264) NEW!! NORTHEAST of HOUSTON Well established general dentistry practice

ADVERTISING BRIEFS located in Northeast Houston. This practice is in a highly visible, free-standing building with ample real estate available for expansion and a great staff! Motivated seller has worked 3 days a week at this office for the past two years but the patient flow would support a full-time dentist. The practice features 3 treatment rooms with new equipment and a comfortable, modern décor. Owner will sell the building if the buyer is interested. Associate buy-in opportunity is also a possibility. (#H260) NEW!! NORTHWEST HOUSTON Established Prosthodontic practice located in high growth area of Northwest Houston. The stand-alone building provides a visible location along a major thoroughfare and includes 3,200 sq ft of office space, 5 fully-equipped operatories, and an on-site lab. Procedures performed by the seller and offered through the practice include hygiene services, crown and bridge, dentures and partials, All-on-4 Implant Appliance, fixed and removable implant treatment, and full mount reconstruction. Annual revenues are consistently high6 figures with very strong after debt service cash flow. Seller is phasing into retirement and is open to work as an associate during an extended transition after closing. The real estate is also available to purchase. (#H251) SPRING/THE WOODLANDS Very motivated seller! This space features high visibility and is located in Spring, close to The Woodlands and only 10 minutes from the new ExxonMobil Campus in a recently remodeled 1,200 sq ft dental space. There is a very high quality website in place, rent is very reasonable for the area, has 3 equipped operatories and provides room for expansion. (#H261) INSIDE LOOP 610 HOUSTON Established restorative practice that provides general and cosmetic procedures, and focuses on comprehensive treatment and complete oral rehabilitation. Strong revenues for 2013 with doctor working a reduced schedule (approximately 24 hours per week). Many procedures are referred out, including endo, perio, oral surgery, orthodontics and implant placement. The 1,900 square foot facility has digital x-rays, 3 equipped operatories, a comfortable ambience, room for expansion, and a very reasonable monthly rent. Seller desires to transition out of ownership which will afford more career flexibility. Seller is willing to assist with a reasonable transition time frame. The office is turnkey and due to

the geographic location, represents a great opportunity for a new owner. (#H262) WEST HOUSTON general, family and cosmetic practice located on a major thoroughfare, in established community. 4 operatories equipped with a fifth ready for expansion. 2013 revenues were high on only 3 doctor days per week. Healthy new patient flow and lots of upside potential. (#H241) NORTH of HOUSTON Established, very productive, 100% fee-for-service practice focusing on cosmetic and advanced procedures. Practice is located in an upscale shopping/living community near the intersection of two major thoroughfares. The practice build out is elegant with quality finishes and materials, but promotes a very warm and comfortable environment for patients. The practice is equipped with high-tech equipment, such as digital x-rays, a CTScan Radiograph unit, and several pieces of implant surgery equipment. There are 4 fully-equipped operatories, all with ADEC chairs, in the approximately 2,500 square foot facility. Revenues have historically been in low seven figures. Seller will consider an outright sale, but the practice will best be transitioned with a phased structure. The Seller’s ability to mentor a new owner will help to ensure an effective transfer of patients. (#H256) EAST TEXAS: Established, extremely profitable general practice in single tenant, 3400 sq ft professional building. 5 plumbed and equipped operatories, steady level of annual collections over past 4 years. (#H232) NORTH OF HOUSTON Established General Cosmetic practice located in one of the fastest growing communities in the Houston area. The turnkey, 5 operatory facility has a comfortable, cozy ambience, equipment that is in very good condition, and room for expansion. Collections for the last 4 years have averaged in the high 6 figures and there is solid growth potential. (#H234) To see our most up to date listings, please go to www.dental-sales.com. Contact McLerran & Associates in Houston: Tom Guglielmo, Patrick Johnston, Mac Winston 866-756-7412 or 281362-1707, houstoneasttx@dental-sales.com. Practice sales, appraisals, buyer representation, and partnership consulting. HOUSTON/CLEAR LAKE — DENTAL OFFICE: In high visibility smaller professional building at highest traffic Texas Dental Journal l www.tda.org l December 2014

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ADVERTISING BRIEFS corner location in adjacent family oriented, high income master planned community. Adjacent CVS, nearby schools, retail and office centers, NASA and other long term tenants (UTMB orthopedic and urgent childcare center, podiatrist and chiropractor) drive patient traffic. Nice finishes and all plumbing and electrical in place for 6 or more operatories, offices and consult rooms. Lease incentives, negotiable terms. Dwight Donaldson, Monument Real Estate, 281-240-0077, ddonaldson@ terramarktx.com. HUMBLE, TEXAS: Carus Dental, established in 1983 in Austin, TX, has always been committed to the traditional doctor-patient relationship and to the highest quality in dental care and service. We currently have 55 doctors on staff across our 21 practices in Austin, Houston and central Texas. We offer dental services in general dentistry, oral surgery, orthodontics, pediatric dentistry, endodontics, and periodontics in some or all of our practices. We are seeking part-time Endodontist for our Humble, TX, practice, three days every other week. To learn more about American Dental Partners and Carus Dental please visit us at www.amdpi.com and www.carusdental.com. If interested, please send CV and cover letter to kateanderson@amdpi.com. LUBBOCK: Fee-for-service practice looking for an associate dentist to provide patient care as well as build their own patient base; 4 days per week and possible future ownership opportunity. Experience in extractions, root canal therapy, and implants preferred. Please send CV to toothmom@kathleennicholsdds.com. NORTH TEXAS: Pediatric dentist needed for busy north Texas practice. Enjoy life in Sherman, Texas, a familyoriented city conveniently located just 1 hour north of Dallas, but without the hustle and bustle of the big city! Excellent practice opportunity for motivated and nurturing pediatric dentist seeking full-time associate with potential for partnership. Practice has a great reputation and is committed to providing quality comprehensive care for our patients and families in a fun and relaxed atmosphere.

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State-of-the-art facility with highly trained and dedicated staff. Competitive compensation and benefits. Fee-forservice, 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. OPPORTUNITY TO TRANSITION INTO A BUSY ORAL SURGERY PRACTICE within a multi-disciplined practice. Present oral surgeon is retiring. Practice is private fee-forservice. New i-CAT (3D) in office. For information contact Paul Kennedy, DDS at pkennedy@gte.net or 361-960-6484. ORAL SURGEON NEEDED. Oral surgeon will be busy for a full day or two with implant and bone grafts. Competitive pay. Flexible in scheduling. Please call 361-387-3442. ORAL SURGERY PRACTICES FOR SALE: OS-1 Central Area Texas. Doctor retiring. Flexible Transition with Seller phase out. High net over 50% in Mid-sized community. OS-2 Texas Hill Country/Central Area Well established bread and butter practice. Work 4 days a week; no hospital cases but available to add by purchaser. Very little on call time. Great schools in the mid-sized community in beautiful area with lakes and trees. All are confidential. Gary Clinton, Oral Surgery Broker/Appraiser. Call 800-583-7765. ORTHODONTIST PT POSITION: Part time position for an orthodontist. Please submit your resume to jobs@capitalchildrensdentistry.com. PERIO PRACTICE FOR SALE: North Texas area periodontal practice for sale. All fee-for-service. Modern office focusing on comprehensive care. Seller relocating out of state but will provide transition. Very good collections and profit. Seller has developed active study group in the area. The staff are in place and the referral sources have historically been strong. Five operatories in a free-standing building in desirable community outside of the Metroplex. Excellent

ADVERTISING BRIEFS mix of surgery and implant. Paperless and digital. CBCT and Perio Lase. Satellite office can be purchased separately or with main office. For additional information, please contact Dan Lewis at dan@lewishealth.com or 972-4371180 on behalf of the Seller.

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.

PRACTICE FOR SALE SOUTHWEST OF FORT WORTH in fast growing area. Average gross; 6 operatories; Excellent lease. Seller is relocating. Need to move quickly on this one. DFW 214-503-9696. WATS 800-583-7765.

SAN ANTONIO: A general practice (FFS/PPO) having gross receipts in mid 6 figures while practicing only 3.5 days per week with no marketing. This is an exceptional opportunity to profit from day one in a newly remodeled office equipped with 3 chairs for a fraction of the cost of a new start up. Tremendous potential to grow practice rapidly as current dentist refers out majority of endo, ortho, perio, pedo, and oral surgery cases. To learn more about this practice contact: Dr. Jeff Jones, 830-832-5522. Visit dr.jeff.jones@henryschein.com.

PRACTICE OPPORTUNITY: We are a Texas-based family group dental practice serving patients of all ages. With a busy workload and high traffic, our needs extend to general dentists, orthodontists, pediatric dentists, and endodontists. Qualified, compassionate and motivated doctors interested in opportunities to provide high quality care in communities in Texas may contact us. Our offices provide: State-of-theart, high-tech facility; in-house digital X-rays; paperless charting; 3-D models; digital tracing and imaging. Work alongside in-house board certified PEDIATRIC DENTISTS, ORAL SURGEONS, ENDODONTISTS AND GENERAL DENTISTS, allowing one to provide the absolute best care possible to even the most challenging cases. To join our team, please forward your CV to tx.dentistrygroup@gmail.com. PROSPER-CELINA AREA: Fourteen year family practice available in Prosper-Celina area. Dentist retiring from private practice. docjwf@hotmail.com. RIO GRANDE VALLEY: A well-established, privately owned Harlingen practice seeks experienced dentist associate to work 3-4 days a week. Our new location offers 4 state-of-the-art equipped operatories with 3 available to expand. We focus on delivering quality dentistry in a friendly, relaxing environment. Excellent production and earning potential with the opportunity to grow with the practice. Please email cover letter and resume to office@ valleyfamilydentistry.org

SAN MARCOS: Immediate associate dentist position available in an established general dentistry practice in San Marcos, Texas. Candidate should be interested in creating an exceptional experience for their patients and working in a dynamic office environment. Office is equipped with all digital xrays, CT scan and pano, in room screens for patient education, and intraoral technology. Duties and Responsibilities Include: Maintain our culture and brand in all aspects of the business. Efficiently manage productivity and profitability. Properly diagnose, treatment plan and discuss alternative solutions for all patients. Provide comprehensive dental care for all patients while creating a welcoming and comfortable environment. Qualifications: Current Texas Dental License. Leadership skills. Professional demeanor. Excellent communication skills. Open to personal development and coaching. Compensation: Based on experience and production. Please submit your resume and answer to the following question to be considered for this position at dental_resumesm@yahoo.com. Why did you decide to pursue a career in dentistry and what do you like the least and best about practicing dentistry? We will contact you to schedule an interview after resume review and if all requirements are met.

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ADVERTISING BRIEFS SMALL TOWN COLORADO PRACTICE: Seven figures in collection in 2013. Excellent staff willing to stay, including in-house lab technician. Doctor willing to stay to introduce to patients or work. Hunting and fishing a short walk away. Great potential for growth. Over 3,500 active patients. 6 equipped operatories. Ideal for raising families. Contact: Kyle Francis, 719-459-1021, Kfrancis@ professionaltransition.com SUGAR LAND, CYPRESS, PEARLAND AND THE WOODLANDS: Full- and part-time positions available. Well established and rapidly growing practices that offer great financial opportunity. High income potential and future equity position. Email CV to Dr Mike Kesner, drkesner@ madeyasmile.com. TEXAS PRACTICE TRANSITIONS, INC. Rich Nicely has been serving Texas dentists since 1990. Visit www.txpt.com or call at (214) 460-4468; Rich@tx-pt.com. NORTH OF HOUSTON: Medium-sized full-fee patient base; Digital x-rays; Free-standing building; long-term staff; 4 days of hygiene per week. EAST TEXAS: Medium-sized PPO patient base. Free-standing. VICTORIA: Medium-sized practice; PPO patient base; free-standing building, longterm staff; doctor refers out lots of dentistry. EL PASO: East side; Large practice; full-fee patient base. EL PASO: West side; medium-sized practice; mostly PPO patient base. BEAUMONT: Medium sized PPO practice; very nice freestanding building, 5 ops. SAN ANTONIO: Very large, hightech, implant focused, full-fee restorative practice with 7 equipped treatment rooms in a highly visible free-standing building with digital x-rays, a cone beam x-ray and a digital impression scanner. Long term staff and 10 days of hygiene per week. The doctor desires to sell half the practice now and the other half in 5 years prior to retirement. DALLAS SUBURB: Medium sized PPO practice, 5 treatment rooms, digital x-rays. Highly visible retail location. WACO: Great associate opportunity. Waco practice looking for motivated associate with a desire to join a PPO/feefor-service practice. Great pay, great work environment with two other dentists and top notch staff. Please contact

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Dr Johnson at 435-237-2339 or email at johnson.2978@ gmail.com.

OFFICE SPACE DALLAS AND ROCKWALL: Orthodontic or other specialty office for lease to share with owner. Furnished and equipped. Dallas office is 4,000 sq ft in Lake Highlands area with 2,500 sq ft leasable residence above. Rockwall office is 1,800 sq ft in antique building and furnishings. Email rcppc@sbcglobal.net. FORT WORTH: Great dentist/orthodontic office space available for rent in TCU area of Fort Worth. 915 sq. ft. Available March 2015. Contact us at (817) 479-9501 for pricing and additional details. GROVES/GOLDEN TRIANGLE AREA: Dental office building for sale or lease. Approximately 1500 sq. ft. with brick exterior. Plumbed for four operatories. Three operatories are fully-equipped with chairs, cabinetry, and x-ray machines. Excellent condition and move-in ready. Call 409728-3565 or email mvsv123@aol.com. NORTH TEXAS DENTAL PRACTICE OPPORTUNITIES: Lewis Health Profession Services has multiple career opportunities available in the greater Dallas/Fort Worth area. Practices for sale, associate opportunities, finished out dental offices, and specialty practice opportunities. Lewis Health Profession Services has 30 years experience in dental practice transitions, with over 1,000 successful transitions completed. Dentistry is our only business. We confidentially deal with all clients. Lewis Health Profession offers seller representation, buyer representation, opportunity assessments, associate placement and strategic planning services. Please check out our web site at www.lewishealth.com for current opportunities. For additional information, contact Dan Lewis at Lewis Health Profession Services 972-437-1180 or dan@lewishealth. com.

ADVERTISING BRIEFS SEGUIN: Orthodontic office space for lease in. Office was phased down when orthodontist retired. Office is equipped and functional. Great for a start up or a satellite location. Email inquiries to lmassadds@gmail.com.

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 HAVE MIRROR AND EXPLORER, WILL TRAVEL: Sick leave, maternity leave, deployment, vacation or death, I will cover your office. Call Robert Zoch, DDS, MAGD at 512-263-0510 or drzoch@yahoo.com. OFFICE COVERAGE for vacations, maternity leave, illness. Protect your practice and income. Forest Irons and Associates. “Dentists Helping Dentists Since 1983.” Call 800-433-2603 (EST). Visit www.forestirons.com. PRACTICE COVERAGE by a Texas colleague during personal, maternity, expansion, transition or disability leave. Emergencies, short notice OK. That’s why we’re here. All inquiries treated with absolute confidentiality. Keep your cash flowing when you’re away. DOCTORS PER DIEM team members are fully licensed with liability insurance and DEA authority. DOCTORS PER DIEM INC. needs many more providers to cover all of Texas. Join us, won’t you? Take 1-minute to register. There’s no charge and no obligation ever. Work only when and where you want. Negotiated daily minimum guarantee, plus percent of production. Bread and butter procedures. New dentists welcome. DOCTORS PER DIEM INC. Register: http:// www.doctorsperdiem.com/register. Email: docs@ doctorsperdiem.com or call 800-600-0963. Trusted integrity, since 1996. We know how.

MISCELLANEOUS HANDS ON EXTRACTION CLASSES: Learn advanced extraction techniques, elevating flaps, suturing, third molar removal, sinus perforation closure, using instruments properly and how to handle large abscesses and bleeding. Classes combine lecture and participation on live patients. Website: www.weteachextractions.com Phone: 843-488-4357 Email: drtommymurph@yahoo.com. LOOKING TO HIRE A TRAINED DENTAL ASSISTANT? We have dental assistants graduating every 3 months in Dallas and Houston. To hire or to host a 32-hour externship, please call the National School of Dental Assisting at 800-383-3408; Web: schoolofdentalassistingnorthdallas.com.

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