March 2010 by Texas Dental Association

March 2010

Journal TEXAS DENTAL

Operative Dentistry Shear Bond Strengths Are Routine Sterilization Procedures Effective? TDA Financial Report, Proposed Budget and Budget Explanation / rg ns o . o a td ati nic al sit blic ectro ourn i V pu el l J a e a td for th Dent s

xa Texas Dental Journal l www.tda.org l March 2010 Te

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The Medicaid and Children’s Health Insurance Programs (CHIP) in Texas improve the health of children who might otherwise go without health care. CHIP and Medicaid help provide dental treatment to children in need. Partnered with caring dentists, these programs make a difference in children’s lives by restoring one smile at a time! In keeping with TDA's long-standing commitment to recruit more Medicaid/CHIP providers, we're offering various Medicaid/CHIP information opportunities at this year’s Texas Meeting.

CONTINUING EDUCATION PROGRAMS: Linda Altenhoff, DDS and Paul Kennedy, Jr., DDS Thursday, May 6 | 2:00 PM – 5:00 PM | Course Code #T01 | $15 FIRST DENTAL HOME TRAINING FOR DENTISTS - Presented by Linda Altenhoff, DDS First Dental Home training includes necessary information and reviews skills needed to provide dental checkups and dental anticipatory guidance for children 6 months through 35 months of age. This training is required in order for Texas Medicaid enrolled dentists to bill CDT D0145 and receive enhanced reimbursement. Educational funding provided by the Committee on Access to Dental Care, Medicaid, and CHIP. AGD SUBJECT CODE 430 HEAD START DENTAL HOME INITIATIVE – Presented By Paul Kennedy, Jr., DDS The Texas Dental Association is partnering with the American Academy of Pediatric Dentistry and the Office of Head Start to provide dental homes to all Head Start children in Texas. A dental home means that each child's oral health care is delivered in a comprehensive, continuously accessible, coordinated and family-centered way by a licensed dentist. This course explains how your office can participate in this ground breaking project. Educational funding provided by the Committee on Access to Dental Care, Medicaid, and CHIP. AGD SUBJECT CODE 430 Linda Altenhoff, DDS and William Steinhauer, DDS Friday, May 7 | 2:00 PM – 5:00 PM | Course Code #F01 | $15 TAKING THE MYSTERY OUT OF TEXAS MEDICAID Recent increases in Medicaid reimbursement rates in Texas have made the inclusion of Medicaid patients into a dental practice very feasible. You will learn how to incorporate Medicaid patients successfully into your practice and how to effectively bill Medicaid. This is a must for doctors and staff! Educational funding provided by the Committee on Access to Dental Care, Medicaid, and CHIP. AGD SUBJECT CODE 430.

You take care of the patients. We take care of the business.

• Full-time positions available in Texas and Louisiana locations • Part-time opportunities available in all locations • Generous Benefit plan • Knowledgeable, professional and experienced support staff • $2,500 bonus for referring a doctor • Unlimited Earning Potential $ (Fill in the blank and give us a call)

For more information: Office of Doctor Recruitment 405-707-6110 www.oceandental.net Chad Hoecker, DDS (General Dentist)

Equal Opportunity Employer

Texas Dental Journal l www.tda.org l March 2010 259 ARKANSAS • INDIANA • IOWA • KENTUCKY • LOUISIANA • OHIO • OKLAHOMA • TEXAS

Contents

TEXAS DENTAL JOURNAL n Established February 1883 n Vol. 127, Number 3, March 2010

NOTICE: 264 Official Call to the 2010 TDA House of Delegates 269 Upcoming ADA Appointive/Elective Positions 269 Official Call for Secretary/Treasurer Nominations FEATURE

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What is Different in Operative Dentistry?

Dr. Overton reviews contemporary concepts of cavity preparation for amalgam and composite restorations that are designed to retain maximum tooth structure.

J. D. Overton, D.D.S.

FEATURE

285

A Comparison of Shear Bond Strengths on Bleached and Unbleached Bovine Enamel

Andrew M. Dietrich, D.M.D., Jeryl English, D.D.S., M.S., Kathleen McGrory, D.D.S., M.S., Joe Ontiveros, D.D.S., M.S., John M. Powers, Ph.D, Harry I. Bussa Jr., D.D.S., M.S., Anna Salas-Lopez, D.D.S., M.S.

This study investigated whether tooth whitening with two different bleaching systems affects the shear bond strength achieved using an orthodontic self-etching primer.

FEATURE

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Dental Burs and Endodontic Files: Are Routine Sterilization Procedures Effective?

Drs. Morrison and Conrod evaluate the effectiveness of various sterilization procedures for dental burs and endodontic files and assess the sterile condition of new burs and files.

Archie Morrison, D.D.S., M.S., FRCD(C); Susan Conrod, D.D.S.

FEATURE

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Texas Dental Association 2009 Financial Report, 2011 Proposed Budget, and 2011 Budget Explanation

DEPARTMENTS

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The Presidentâ&#x20AC;&#x2122;s Message

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The View From Austin

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TEXAS Meeting Preview

BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION President Matthew B. Roberts, D.D.S. (936) 544-3790, crockettdental@gmail.com President-elect Ronald L. Rhea, D.D.S.

(713) 467-3458, rrhea@tda.org

Oral and Maxillofacial Pathology Case of the Month

Immediate Past President Hilton Israelson, D.D.S.

In Memoriam / TDA Smiles Foundation

(972) 669-9444, drisraelson@yahoo.com Vice President, Southeast Craig S. Armstrong, D.D.S.

Value for Your Profession

(832) 251-1234, carmst@aol.com

Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management

Vice President, Southwest Johnny G. Cailleteau, D.D.S.

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Calendar of Events

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Vice President, Northwest J. Brad Loeffelholz, D.D.S.

Whatâ&#x20AC;&#x2122;s on tda.org?

331 346

Advertising Briefs

(214) 363-2475, arletd@sbcglobal.net

Index to Advertisers

Senior Director, Southeast R. Lee Clitheroe, D.D.S.

(915) 581-3391, endoman@att.net

(817) 924-0506, jbldds@birch.net Vice President, Northeast Arlet R. Dunsworth, D.D.S.

(281) 265-9393, rlcdds@adamember.net Senior Director, Southwest John W. Baucum III, D.D.S.

EDITORIAL STAFF Stephen R. Matteson, D.D.S., Editor Nicole Scott, Managing Editor Barbara S. Donovan, Art Director Paul H. Schlesinger, Consultant

EDITORIAL ADVISORY BOARD Ronald C. Auvenshine, D.D.S., Ph.D. Barry K. Bartee, D.D.S., M.D. Patricia L. Blanton, D.D.S., Ph.D. William C. Bone, D.D.S. Phillip M. Campbell, D.D.S., M.S.D. Tommy W. Gage, D.D.S., Ph.D. Arthur H. Jeske, D.M.D., Ph.D. Larry D. Jones, D.D.S. Paul A. Kennedy, Jr., D.D.S., M.S. Scott R. Makins, D.D.S. Robert V. Walker, D.D.S. William F. Wathen, D.M.D. Robert C. White, D.D.S. Leighton A. Wier, D.D.S. Douglas B. Willingham, D.D.S. The Texas Dental Journal is a peer-reviewed publication. Texas Dental Association 1946 South IH-35, Suite 400 Austin, TX 78704-3698 Phone: (512) 443-3675 FAX: (512) 443-3031 E-Mail: 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, Texas, 78704-3698, (512) 4433675. Periodicals Postage Paid at Austin, Texas and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S. Interregional Highway, Austin, TX 78704. Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, Out-of-state ADA Affiliated $49.50. In-state Non-ADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA Affiliated, $17 Non-ADA Affiliated, September issue $17 ADA Affiliated, $65 Non-ADA Affiliated. For in-state orders, add 8.25% sales tax. Contributions: Manuscripts and news items of interest to the membership of the society are solicited. The Editor prefers electronic submissions although paper manuscripts are acceptable. 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: www.tda.org. Every effort will be made to return unused manuscripts if a request is made but no responsibility can be accepted for failure to do so. 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. Texas Dental Journal is a member of the American Association of Dental Editors.

aa de

(361) 855-3900, jbaucum3@msn.com Senior Director, Northwest Kathleen Nichols, D.D.S.

(806) 698-6684 toothmom@kathleennicholsdds.com Senior Director, Northeast Donna G. Miller, D.D.S.

(254) 772-3632 dmiller.2thdoc@grandecom.net Director, Southeast Karen E. Frazer, D.D.S.

(512) 442-2295, drkefrazer@att.net Director, Southwest Lisa B. Masters, D.D.S.

(210) 349-4424, mastersdds@mdgteam.com Director, Northwest Robert E. Wiggins, D.D.S.

(325) 677-1041, robwigg@suddenlink.net Director, Northeast Larry D. Herwig, D.D.S.

(214) 361-1845, ldherwig@sbcglobal.net Secretary-Treasurer J. Preston Coleman, D.D.S.

(210) 656-3301, drjpc@sbcglobal.net Speaker of the House Glen D. Hall, D.D.S.

(325) 698-7560, abdent78@sbcglobal.net Parliamentarian Michael L. Stuart, D.D.S.

(972) 226-6655, mstuartdds@sbcglobal.net Editor Stephen R. Matteson, D.D.S.

(210) 277-8595, smatteson@satx.rr.com Executive Director Mary Kay Linn

(512) 443-3675, marykay@tda.org Legal Counsel William H. Bingham

(512) 495-6000 bbingham@mcginnislaw.com

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President’s Message Matthew B. Roberts, D.D.S., TDA President

By the time this president’s message reaches your hands, the primary elections for state and local offices will be complete. Without a doubt this election cycle has had everything a political junkie loves. Multiple, contested elections at the local level and, at the top of the ticket, a bloody primary for the Governors’ office will clarify the ballot for November. There will then be a lull while each party regroups and gears up for the general election this November. If I am correct, there will be a massive effort by the winners to replenish the cash that was expended fighting through the primary elections.

Some state dental associations have initiated legislative activity to block this practice. The TDA is certainly aware of this move by third-party payors and will be making recommendations to the TDA House of Delegates this May.

So what does this mean for your Texas Dental Association? The legislative department will certainly assess any friendly incumbents who have lost primary battles and evaluate support for those who may take their place. The Council on Legislative and Regulatory Affairs is currently working on the legislative agenda for the 2011 session. The councils’ recommendations will go to the TDA Board of Directors and ultimately be approved or changed by the TDA House of Delegates. I encourage each of you to stay engaged and support those candidates that support the TDA’s agenda.

While this may be old news by the time you read this month’s issue, it bears repeating — membership in the Texas Dental Association was up last year. I am very appreciative of the commitment by our members during these difficult economic times. Moving forward, retention of our current members and the continuing effort to recruit new members remains a priority of this Association.

There is a move by insurance companies across the country, including Texas, to expand control of fees charged by dentists. The dental benefits industry is attempting, and being successful in many cases, in setting caps on the amount a contracting dentist can charge for services not covered by their dental plan.

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If you like to read material online, check out the new online Texas Dental Journal. The EZ Flip setup allows the reader to view the Journal as if you were holding the printed version. This is another example of the continued upgrade that Dr. Steve Matteson is instituting during his first year as editor of the Journal.

This month’s Journal features articles on operative dentistry, sterilization of burs, and bond strength of bleached and unbleached enamel. Techniques, materials, and treatment options in operative dentistry have certainly changed during my practice career. What hasn’t changed is the ultimate goal of restoring a patient’s mouth to optimum oral health. I trust that the articles you find within these pages will strengthen your knowledge and improve your practice.

SAVOR THE

Register now for the Academy of General Dentistry (AGD) 2010 Annual Meeting & Exhibits, July 8 to 11, and the AGD House of Delegates, July 6 to 8, and prepare to savor the flavors of New Orleans! Visit www.agd.org/neworleans and click on â&#x20AC;&#x153;Register Nowâ&#x20AC;? to sign up today. The registration brochure is available for download exclusively on the AGD 2010 Annual Meeting & Exhibits Web site. This registration program is simply too hot to mail!

For your convenience, registration is available at www.agd.org/neworleans.

Participants can register online on our Web site or by downloading the registration brochure and faxing the registration form with their credit card information to 312.440.0513 or by mail to Academy of General Dentistry, Annual Meeting, 38943 Eagle Way, Chicago, Illinois 60678-1389. On-site registration will be available as well. See you in New Orleans!

AGD 2010 Annual Meeting & Exhibits July 6 to 8, 2010: AGD House of Delegates July 8 to 11, 2010: AGD Annual Meeting & Exhibits Visit the AGD Web site for more information at www.agd.org/neworleans.

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Official Call to the 2010 Texas Dental Association House of Delegates HOUSE OF DElEGATES: In accordance with Chapter IV, Section 70, paragraph A of the Texas Dental Association (TDA) Bylaws, this is the official call for the 140th meeting of the Texas Dental Association House of Delegates. The opening session of the House will convene at 8:00 a.m. on Thursday, May 6, 2010, in Ballroom B on the street level of the San Antonio Convention Center in San Antonio, Texas. The second meeting of the House will be at 8:30 a.m. on Saturday, May 8, 2010, in Ballroom B. The Sunday, May 9, 2010, meeting will be in the Marriott Rivercenter Hotel, starting at 8:30 a.m. REFERENCE COMMITTEE HEARINGS: Reference Committees will meet on Thursday, May 6, 2010, in the Convention Center (please see the on-site program for specific room assignments). Reference Committee A will start at 11:00 a.m. or 15 minutes after the adjournment of the House of Delegates, whichever is later. Reference Committee E will start at 12:00 noon. Reference Committee B will start at 1:00 p.m. Reference Committee C will start at 1:30 p.m. Reference Committee D will start at 2:00 p.m. The agendas for these meetings will be sent to the Delegates and Alternate Delegates prior to the meetings. REFERENCE COMMITTEE REPORTS: Reference Committee Reports will be available on Friday, May 7, 2010, at 9:00 a.m. outside Room H062, the TDA Convention Office in Exhibit Hall C, and may be downloaded at TDAâ&#x20AC;&#x2122;s Internet CafĂŠ near the entrance to the exhibits. CANDIDATES FORUM: As a reminder, the TDA / ADA Candidates Forum will be held on Friday, May 7, 2010, from 3:00 p.m. to 4:00 p.m. in the Convention Center (please see the on-site program for specific room assignment). DIVISIONAl CAUCUSES: Divisional Caucuses (Northwest, Northeast, Southwest, Southeast) will be held at 5:15 p.m. on Friday, May 7, 2010 (please see the on-site program for specific room assignments). DElEGATE BOOK: In accordance with TDA Bylaws, the Delegate Book will be sent 30 days prior to the Annual Session. The supplement to the Delegate Handbook, containing the agenda and subsequent reports, will be sent after the spring TDA Board of Directors meeting, March 26-27, 2010. Delegates and alternates will receive their House book in a searchable PDF format.

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Free CE credits are just a click away.

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To view the courses online, visit www.txhealthsteps.com.

Current Topics – 26 Courses Under These Categories

• Adolescent Health

• Oral Health

• Overview of Best Practices and Children’s Services

• Genetic Screening

• Laboratory Services

• Developmental/Mental Health Screening and Assessment

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• Pharmacy

• Acute and Chronic Medical Conditions • Case Management New Topics – 7 Courses • Pediatric Referral Guidelines

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

Stephen R. Matteson, D.D.S., Editor

Tobacco Use Cessation Efforts in Dental Offices Tobacco Use Cessation Efforts in Dental Offices I grew up in a home with smokers. Both of my were smokers; my mom used Iparents grew up in heavy a home with smokers. Both of Chesterfields and my dad would “walk my a mile for my parents were heavy smokers; mom a Camel” (a phrase from olddad Camel ad). My used Chesterfields andanmy would visits to one grandparents’ place were marred “walk a mile for a Camel” (a phrase from by the sight of my grandfather who has lost a an old Camel ad).from Mysmoking visits toinduced one grandportion of his nose cancer parents’ were marred by the sight and whenplace his bandage slipped from place, his of mycavity grandfather who had lostaakid portion nasal was displayed; a sight would remember. family physician told mycancer, dad to of his noseThe from smoking induced quit at age 35 to no effect. from Laryngeal andsmoking when his bandage slipped place, carcinoma was diagnosed in my dad’s 62nd ayear his nasal cavity was displayed; a sight and he diedremember. 4 years later.The He was a salesman kid would family physician and had the gift of gab. It was distressing to wittold my dad to quit smoking at age 35 to ness his pain, suffering, and especially his loss no effect.after Laryngeal carcinoma diagof speech a laryngectomy was was required. nosed in my dad’s 62nd year, and he died Needless to say, these experiences had a major 4 yearsme, later. was acessation salesman impact andHe smoking hasand beenhad a longgift timeofinterest mine. the gab. Itofwas distressing to witness

his pain, suffering, and especially his loss Annually, 443,000 Americans (over 18 percent of of speech after a laryngectomy was reall deaths) die because of smoking. Secondhand quired. Needless to say, these experiences smoke kills about 50,000 of them. The Centers had a major impact and smoking cesfor Disease Control andme Prevention estimated sation has been a longlost interest of mine. that adult male smokers an average of 13.2 years of life and female smokers lost 14.5 years Smokers in my environment get tired of of life because of smoking (1995-1999). Nearly my I like to show them radio- to one lectures. of every five deaths in the US is related graphs jaw cancer (I have a collection smoking.of Cigarette smoking kills more Amerifrom my dental schooladdiction, teaching days) and cans than AIDS, alcohol automobile many friends evade my threats to show accidents, suicides, homicides, and use of illegal drugs combined. them such pictures in textbooks. You may

be wondering why I am telling you about Smokers in my environment get tired of my all of this. A search of the literature about rantings. I like to show them radiographs of jaw smoking cessation efforts cancer (I have a collection fromsuggests my dentalthat school recommendations by dentists and the teaching days), and many friends evade my dental to team theirsuch patients can result threats showtothem pictures in textbooks. You be percent wonderingreduction why I am telling you in a may 10-15 in smoking about all of this. of the literature about measured afterA search 12 months. The relationsmoking cessation efforts suggests that recomship of spit tobacco with oral cancer offers mendations by dentists and dental and teamdena special opportunity for the dentists to their patients can result in a 10-15 percent tal hygienists to inform patients about the reduction in smoking measured after 12 months. risk of oral cancer from tobacco use.cancer Quit The relationship of spit tobacco with oral rates aare alsoopportunity improved for bydentists the recomoffers special and denmendations ofinform physicians nurses. tal hygienists to patientsand about the risk of oral cancer from tobacco use. Quit rates are also An interesting controlled trial on smoking improved by the recommendations of physicians cessation and nurses. was reported in 1989 in the

Journal of the American Dental AssociaA psychologist friend of mine tells me that the tion. Following is the abstract describing fear cancer many years down the road is not thatofarticle.

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a very effective motivator for smokers to quit their“Fifty habit while short-term effects such private practitioners and as bad breath, skin discoloration, facial wrinkles, their office staff members were and financial implications tend totobe more randomly assigned one of effective four motivators. The combination of nicotine replacegroups: participants received a ment products with smoking cessation counselprotocol for smoking management ing is reported to enhance patient compliance. andonline a lecture on for thepatient consequences Several services counseling and management ofbelow. smoking, or inmust are available and are listed Patients be advised to select the appropriate nicotine addition, had nicotine gum freely replacement product based on their level of available to patients, had stickers smoking and toto follow directions for their attached theirthe charts, or had use carefully. these products available gum andI found reminders. The percentin local pharmacies and grocery stores but was age of patients in each group who surprised to see them be fairly expensive.

had quit smoking a year later was

An interesting on smoking 7.7, 16.3,controlled 8.6, andtrial 16.9, respec-cessation was reported in 1989 in the Journal tively, indicating a significant mainof the American Association. BelowThe is the effect forDental the gum conditions. abstract describing that article.

availability of nicotine gum also

“Fifty private practitioners office significantly increasedand thetheir amount staff members were randomly assigned of time that patients reported theyto one of four groups: participants received a received smoking cessation counprotocol for smoking management and a selingonfrom the dentists and office lecture the consequences and managestaff.” (Cohen or SJ, BK,nicoment of smoking, in Stookey addition, had Katz, Drook CA,toChristen tine gumBP, freely available patients, AG. had Helping smokers quitcharts, smoking: stickers attached to their or hada gum and reminders. Thetrial percentage of parandomized clinical with private tients in each Jgroup who had quit smoking practices. Am Dent Assoc. 1989 a Jan; year later was 41-5.) 7.7, 16.3, 8.6, and 16.9, 118(1): respectively, indicating a significant main for the (use of) gum So,effect let me encourage theconditions. readers toThe availability of nicotine gum also signifi-in the energize tobacco cessation efforts cantlyoffice, increased the amount time that dental to organize theof dental team received smokingof to patients engagereported patientsthey with a discussion cessation counseling from the dentists and risks of tobacco use, and provide access office staff.” (Cohen SJ, Stookey BK, Katz, to BP, tobacco support programs. Drookcessation CA, Christen AG. Helping smokPatients’ be focused ontrial ers quit attention smoking: acan randomized clinical these the Jperformance of the with risks privateduring practices. Am Dent Assoc. 1989 Jan; 118(1): clinical 41-5.) examination by cancer screening

dentists and dental hygienists and followLet me encourage the readers to energize up discussions by written tobacco cessationaccompanied efforts in the dental office, to materials beteam helpful. organize themay dental to engage patients with a discussion of risks of tobacco use, and provide

My dadtomissed happy years to access tobacco many cessation support programs. enjoy hisourchildren and didn’t to hygiene meet I believe dental assisting and get dental any of his have greatthegrandchildren. Maybe we colleagues opportunity to motivate can helpto some our tobacco-using patients patients quit smoking because they spend considerable time oura patients. to avoid such a alone loss. with What great gift that Discussions would be. during the cancer screening clinical

examination by dentists and dental hygienists

accompanied by written materials may also be Resources: helpful. One other suggestion to remind dental The following online sites are excellent team members counselingand should be resources for that information materials to continued is to place a “smoking alert sticker” on assist dental professionals in their efforts smokers’ charts. Repeated efforts in this regard to cessation. areencourage often neededtobacco and can use be effective because

patient readiness quit is an Education essential factor The Dental to Oncology Pro1. and that moment is difficult to predict. gram is based at the Baylor School of Dentistry andhappy can be accessed My dad missed many years to enjoy at: www.doep.org his children and did not get to meet any of his great-grandchildren. Maybe weBoard can help 2. The Washington State ofsome our tobacco patients to avoid such a loss. Health using sponsors a program called WhatQuitline a great gift that wouldadvice be. and support to provide to smokers seeking assistance to stop Resources products and be Visit using tda.orgtobacco for a list of resources for can patients found at: smoking. quitline.org wishing to quit The following online sites are also excellent resources for information 3. The American Dental Association and provides materials tomaterials assist dental professionals in about tobacco use theirand efforts encourage cessation. itstohealth risks.tobacco Theseuse may be 1. obtained The Dentalat: Oncology Education Program ada.org. is basedMainstream at the Baylor College of Dentistry 4. Project provides inforand canfor be dealing accessedwith at: doep.org. mation addictions 2. The Washington State Board of Health including tobacco use and is sponsponsors a program called “Quitline to prosored by National Cancer Institute. vide advice and support to smokers seeking This program canusing be found www. assistance to stop tobaccoat:products projectmainstream.net. and can be found at: quitline.org 3.

The American Dental Association provides

materials about tobacco use and its health Bibliography: risks. These may be S. obtained at: ada.org. 1. Garg RK, Tandon Smoking habits 4. of “Project Mainstream” adolescents and provides the roleinformaof dention for dealing with addictions including tists. J Contemp Dent Pract. 2006 tobacco use and is sponsored by National May 1; 7(2):120-9. Cancer Institute. This program can be 2. Garvey Dental office interventions found at:AJ. projectmainstream.net. are essential for smoking cessaBibliography tion. J Mass Dent Soc. 1997 Spring; 1. Garg RK, Tandon S. Smoking habits of ado46(1):16-19. lescents and the role of dentists. J Contemp 3. Gorin SS, Heck JE. Meta-analysis of Dent Pract. 2006 May 1; 7(2):120-9. efficacy of tobacco counselingare by 2. the Garvey AJ. Dental office interventions health care providers. Cancer Epiessential for smoking cessation. J Mass demiol Biomarkers Prev. 2004 Dec; Dent Soc. 1997 Spring; 46(1):16-19. 3. 13(12):2012-22. Gorin SS, Heck JE. Meta-analysis of the efficacy of tobacco counseling by health care S. Effectiveness 4. Warrnakulasuriya providers. Epidemiol Biomarkers of tobaccoCancer counseling in the denPrev. 2004 Dec; 13(12):2012-22. tal office. J Dent Educ. 2002 Sep; 4. Warrnakulasuriya S. Effectiveness of 66(9):1097-87. tobacco counseling in the dental office. J Dent Educ. 2002 Sep; 66(9):1097-87.

Notice: Upcoming ADA Appointive / Elective Positions 1. ADA Council Appointments: Our trustee, Dr. S. Jerry Long, forwards the names of interested and able persons to the ADA for consideration for these appointments. Dr. Long’s next opportunity for recommending an individual will be to the Council on ADA Sessions and Council on Access, Prevention and Interprofessional Relations. 2. ADA Delegate and Alternate Delegate positions: Become available annually; work through your local Society to be nominated at the division caucus in May in San Antonio. 3. ADA Trustee-elect: This is the year for individuals interested in serving as the next ADA Trustee to make that intent known by submitting in writing a statement of your intent along with your credentials to the TDA Secretary/Treasurer to be received by July 30, 2010. The individual to be put forth by the 15th District Delegation is selected at the second delegation caucus in August 2010. Trustee election will take place at the ADA Annual Meeting in Las Vegas in October 2011. 4. ADA 2nd Vice President: This position is available on an annual basis. Make your interest in this position known to the Planning and Review Committee as early as possible prior to July 1, 2010, if you want to present a brochure. Contact Dr. Long immediately or contact the Planning and Review Committee of the 15th District Delegation through Donna Cortez, (800) 832-1145.

Official Call for Secretary/Treasurer Nominations TDA secretary-treasurer Dr. J. Preston Coleman will not seek re-election at the May 2010 TDA House of Delegates. Therefore, the position is open for nominations. 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 nominee will also have to sign a conflict of interest statement. We request that nominations are made as early as possible so that membership eligibility can be verified and the House of Delegates can be prepared for an informal vote.

Official Call for Secretary/Treasurer Nominations

Duties TDA secretary-treasurer Dr. J. Preston Coleman not seek re-election at theBylaws May 2010and TDA include House of Delegates. Therefore, the of the Secretary-Treasurer arewill enumerated in the the following: position is open for nominations.

• an Serve of member the Budget Committee; Only active,as life,chair or retired in good standing of this Association shall be eligible. A curriculum vitae (CV) must accompany a • Serve as chair of Assets Management Committee; letter of intent and the nominee will also have to sign a conflict of interest statement. We request that nominations are made as early as • Examine income and expenses of TDA at each Board for meeting; possible so that membership eligibility can be verified and the and Housereport of Delegates can be prepared an informal vote. • Ensure that House are of enumerated Delegates and TDA minutes Duties of the Secretary-Treasurer in the Bylaws andBoard include the following:are maintained; • Serve as a non-voting member of TDA Executive Committee; and • Serve as chair of the Budget Committee; • Perform other duties as specified by the Board of Directors. • Serve as chair of Assets Management Committee; • Examine income and expenses of TDA and report at each Board meeting; areoftoDelegates be mailed to Board Dr. J. Preston Coleman, TDA Secretary-Treasurer, Texas • Nominations Ensure that House and TDA minutes are maintained; Association, 1946ofSouth IH-35, Suite 400, • Dental Serve as a non-voting member TDA Executive Committee; and Austin, Texas 78704; or e-mailed to TDA Director Mary Kay Linn, marykay@tda.org. • Executive Perform other duties as Ms. specified by the Board of Directors.

Nominations are to be mailed to Dr. J. Preston Coleman, TDA Secretary-Treasurer, Texas Dental Association, 1946 South IH-35, Suite (According Article V, Section of theDirector Constitution Texas Dental Association and the 400, Austin, Texasto78704; or e-mailed to TDA10 Executive Ms. Mary of Kaythe Linn, marykay@tda.org.

TDA Bylaws, Chapter IV — Section 30, Chapter V — Section 40, Chapter VI — Sections 10,

(According to Article V, Section 10 of the Constitution of the Texas Dental Association and the TDA Bylaws, Chapter IV — Section 30, 20, 30, 70, and 90). Chapter V — Section 40, Chapter VI — Sections 10, 20, 30, 70, and 90).

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What is DIFFERENT in Operative Dentistry? J. D. Overton, D.D.S.

Management of Soft Dentin: The first time I heard a dentist seriously discuss routinely choosing to leave soft decayed dentin in teeth was 1987. i was a second-year AEGD resident with a DDs diploma that was 9 years old so i had placed several thousand direct restorations by that time. i concluded in a heartbeat that this dentist was a buffoon and proceeded on my merry way confident in my clinical experience and training. Everyone knows that a good dentist gets all of the demineralized dentin out of the tooth. if getting that last bit of damaged dentin exposed the pulp chamber, then that was what the tooth needed. i was wrong! now it is sometimes my job to help my experienced instructors that have stood in those comfortable shoes, confident that the aggressive management of soft dentin is the only correct thing to do, change the way they do business. if a tooth has no history of unstimulated pain and a vital normal pulp then we consider a pulp exposure to be an iatrogenic event. that is correct. we now teach that leaving soft dentin near the pulp, is a superior treatment to total soft dentin removal resulting in a pulp exposure (1). while

Abstract There have been both large and small changes in operative dentistry in the last 30 years. Extension for prevention is no longer the mantra. The design features of amalgam preparations have moved into the smallest preparations possible to gain full access to the carious dentin. The default Class 2 amalgam or resin composite is a slot preparation with no preparation of the occlusal fissures. Class 1 fissure caries once implied the entire fissure system was to be cut out. Now only the known carious portions of the fissure are cut away, the tooth is restored, and the remaining fissures in that tooth are sealed. Resin composite preparations have no depth requirements and saucer shaped boxes are more favorable for lowering shrinkage strains on the bonded walls. Re-mineralization of proximal lesions that can be seen on a radiograph is now a proven successful service for many lesions that are at or just into the dentin by radiographic interpretation. The largest paradigm shift has been in the decision that in vital teeth with normal pulps soft dentin can be left over a vital asymptomatic pulp with every expectation that the direct restoration will be successful long term.

KEY WORDS: Overton

Dr. J.D. Overton is Head, Division of Operative Dentistry, Department of Restorative Dentistry, University of Texas Health Science Center, San Antonio, Texas (UTHSCSA).

Preparation design, amalgam, resin composite, fissures, caries, re-mineralization Tex Dent J;127(3):271-278.

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What is DIFFERENT in Operative Dentistry? it has been advocated by some researchers, at the University of Texas Health Science Center at San Antonio (UTHSCSA) we do not do a “re-entry” procedure at a later date to remove the last of the soft dentin (2, 3). Our protocol is Dycal over the soft dentin nearest the pulp, Vitrebond over the Dycal, and a bonded amalgam or bonded resin composite restoration. This protocol has been in practice at UTHSCSA since 1991. The unknown factors with this approach focus on how many millimeters of clean margin you need for predictable success. The bond and seal to tooth is significantly better with clean dentin than caries affected dentin so we teach that all margins should be free of demineralized dentin (4, 5). In larger teeth the cavity preparation will have more millimeters of clean margin and in smaller teeth there will be less. The clear goal is to not get a pulp exposure. All the research tells us that the box floor is a very, very difficult place to get a good seal (6, 7). Our best recommendation is to stop removing soft dentin when we estimate the preparation is 0.5 to 1.0 mm from the pulp space without consideration for how soft that dentin really is. If that implies that the surface dentin near the pulp is “mush,” that is still preferred over a clinical pulp exposure. An obvious risk for the patient is that they change dentists and the soft dentin is diagnosed as “recurrent caries” rather than “residual caries”. Our chart notes need to be detailed when soft dentin is left in a preparation and the transferring patient should take a copy of the treatment record to the gaining dentist.

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Why try to get any of the soft dentin out of the tooth? There may well be a time when for select teeth we will not try to remove any soft dentin. This plan was tested by Murtz-Fairhurst with occlusal caries lesions that were sufficiently large to be diagnosed on a bite wing radiograph (8). In the study test group, 156 resin composite restorations were placed without any removal of soft dentin and no dentin bonding agent. A failure rate of 14 percent at 10 years was the equal of the control which was a GV Black preparation of all fissures removing all caries and restoring with amalgam (16 percent failures). Based in part on the results of this study we do not teach either of the first two techniques but do teach the third preparation design used in the study. The third design was the preventive amalgam restoration (PAR) in which only the known carious fissures were prepared. As the last step, the PAR had the amalgam margins and uninvolved fissures sealed with pit and fissure sealant. The PAR had a 2 percent failure rate at the 10-year recall visit in their study. We expect that a preventive resin restoration (PRR) may have similar success to the PAR but that has not been tested in a long term clinical trial.

Fissure management: We find that children are in a different treatment category than adults when the question is fissure management. A systematic review by Gooch found good advantage to sealant placement on molar teeth in children with

non-cavitated surfaces, incipient lesions, or even cavitated carious lesions (9). The ADA expert panel did not identify an advantage to preparation of the fissure with a bur or pumice or toothbrush since all appeared to be similarly effective. We follow their summary evaluation which is to use a toothbrush to prepare the surface prior to sealant placement in children. Adults without clear evidence of fissure caviation have stood the test of time without occlusal breakdown of the occlusal fissures and grooves. This leads us to recommend a significantly higher threshold before we do any treatment on the occlusal surfaces. Adults with low caries risk receive no treatment of fissures not known to be carious at the dentin-enamel junction. Adults with high caries risk receive no treatment for occlusal surfaces that are well coalesced. The high caries risk adult receives sealants in teeth with deep fissures. For select at-risk adult teeth with significant staining in the fissures, we have 1/16 round burs available to remove stain from fissures prior to sealant placement.

Class 1 Restorations not near the pulp: Only the parts of the fissures known to have demineralization to the dentin are cut with a bur. Based on laboratory studies, it is still our recommendation that enamel not supported by dentin be removed from the occlusal surface (10). Grisanti showed that bonded composite provided significantly less sup-

Figure 1. Distal slot preparation and independent occlusal preparation. This preparation would be correct for a resin composite or for a bonded amalgam restoration

port for dentin deprived enamel than natural dentin. Restoration of the prepared portions of the tooth can be with either amalgam or resin composite. The restoration is completed with a sealant on the restoration margins and in the un-involved fissures (PAR or PRR).

Class 2 restorations not near the pulp: The proximal restoration is an independent event from the occlusal restoration. The slot preparation with no involvement of the occlusal anatomy except for gaining access to the proximal lesion is our default Class 2 preparation (Figure 1). Slot amalgam preparations can either have full length retention grooves or be bonded in place (11, 12). If grooves are selected, they need to oppose each other. The retention grooves extend through the occlusal enamel which resembles the retention grooves one would cut for a gold onlay preparation (13) (Figures 2 and 3). We do not recommend retention grooves for resin composite preparations. The most favor-

Figure 2. View of lingual full length retention groove with opposing facial groove.

Figure 3. Distal slot amalgam showing lingual retention groove that extends to the occlusal surface Texas Dental Journal l www.tda.org l March 2010

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What is DIFFERENT in Operative Dentistry? able outline form for a slot resin composite preparation would be saucer shaped which reduces the strains on the adhesive bond when the resin composite shrinks (14, 15) (Figure 4). The traditional amalgam box form with parallel facing walls can work but increases the strains on the bond as the resin composite shrinks. Some regional testing agencies have been reluctant to accept the amorphous or saucer shaped composite slot preparation because they cannot score a preparation that has an outline form strictly dictated by the carious advance even if that is clearly best for the patient. For both amalgam and resin composite, the expectation that both facial and lingual proximal contacts are always broken with the proximal preparation is out of date (Figure 5). Now only the carious advance determines the outline of the preparation. Many preparations do extend past the proximal contact but the demineralized tissue dictates that design. A composite separating ring can be used to create space for matrix placement in preparations that are still in contact with the adjacent tooth. The ring works equally well to help develop a quality proximal contact for resin composite restorations (Figures 6â&#x20AC;&#x201C;9).

Figure 4. Saucer shaped resin composite slot preparation.

Figure 5. 27-year-old conservative amalgam restorations that did not open the facial contact.

Bevels for resin composite preparations: The available clinical trials on beveling suggest that bevels do

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Figure 6. Saucer shaped resin composite preparation with facial bevel.

Figure 7. Segmental matrix band and ring. The ring can be placed on the matrix or the wedge side depending on what offers the best matrix contours.

not improve clinical performance when placed on the functional surfaces of resin composite preparations. Lang presented results of a clinical trial that involved 16 teeth with a bevel on the occlusal of either a facial or lingual wall and no bevel on the opposing occlusal wall. The no bevel side had less chipping (16). Dos Santos found no difference in performance in Class 1 or Class 2 beveled preparations in primary molars at 24 months (17). Isenberg and Leinfelder looked at beveled and nonbeveled margins after 2 years of clinical service (18). The beveled surfaces had 10 percent more wear and bevels did not improve any of the clinical features evaluated in the study. A clinical trial of bevels for Class 3 restorations showed no difference in performance (19). Lacking clinical evidence supporting beveling surfaces that may be in areas of clinical load we teach students not to bevel occlusal surfaces of posterior teeth or lingual surfaces of maxillary anterior teeth. There are two bench top studies that show a superior gingival seal if the facial and lingual box walls are beveled (20, 21). We lack clinical studies to confirm that these bevels actually improve long-term performance so we

Figure 8. Resin composite restoration done by a junior dental student during an examination from Figure 6 & 7.

Figure 9. Separating ring will push the teeth apart to create space for the thickness of the matrix band. Texas Dental Journal l www.tda.org l March 2010

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What is DIFFERENT in Operative Dentistry? recommend that in areas that offer simple access that a 0.5 to 1 mm wide, 45 degree bevel of the enamel on facial or lingual box walls is appropriate. In areas of limited access we do not recommend a vertical wall bevel because it increases the complexities of placing the restoration and could well place the adjacent tooth at risk of damage during bevel placement. All margins on cementum or dentin should be 90 degrees with no gingivally angled bevels (22). At times in the course of routine removal of soft dentin on the box floor the gingival margin will have unsupported enamel remaining. Holan in an extracted tooth study showed that leaving the unsupported enamel resulted in a better gingival seal at the box floor than was possible if the enamel was removed (23). Leaving the enamel on that gingival margin makes the restoration less complex for the dentist and isolation easier to obtain in certain circumstances. We teach gentle instrumentation of the enamel with an enamel hatchet to remove friable enamel as a test for enamel that can safely be left behind on the box floor. In the esthetic zone, bevels can help with the color blend for resin composite which is a valid reason to place an enamel bevel. The esthetic bevel should be short and near 45 degrees if a hybrid resin composite is the chosen restorative material. Esthetic bevels can be longer and more tapered if a microfill resin composite is used.

Caries Dye: Caries dyes can identify areas of

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interest to the dentist but do not tell them what to do (24). There are false positives and false negatives with caries dye. That said, we are convinced that experienced dentists will identify soft dentin in unexpected places with the routine use of dye. We do not use dye in the esthetic zone because dye will at times stain deep dentin and to date we have not identified a safe solvent that will remove the dye. A blue-green dye (not red) is recommended so there is no confusion with dye vs. pink of the pulp.

Re-mineralization: Radiographic interpretation is currently taught with the following abbreviations with “E” for enamel lesions and “D” for lesions in the dentin. E1 = surface etch visible on the radiograph E2 = etch pattern is the full depth of the enamel D1 = first evidence of dentin de-mineralization at the DEJ (research shows that only 40 percent of these will be cavitated) D2 = Up to ½ the dentin thickness is demineralized on the radiograph D3 = Greater than ½ the dentin thickness is demineralized on the radiograph We teach a high threshold before placing the first restoration in a tooth because that day starts the re-restoration cycle. Until the enamel is cavitated, research has shown that the enamel surface can be remineralized. The enam-

el is only cavitated 40 percent of the time when the radiograph is at the D1 stage so the majority of lesions that are just visible in dentin could still be arrested or reversed without a restoration (25). If the patient is willing to change the environment with diet changes and fluoride use then radiographically evident lesions up to and including D1 should be re-mineralized rather than treated with restorations (26, 27, 28, 29).

Direct Restorative Materials: Compomers without dentin bonding, early production no wash dentin bonding systems and gallium alloy restorations are on the short list of recent dental materials that made it to the USA market only to fail rather quickly (30, 31). Just about every dental restorative material you can buy will easily last more than a year if you use it correctly. A systematic review concluded that laboratory testing is not predictive of long-term bonding success so we encourage everyone to depend on clinical studies for materials guidance (32). We are fortunate to have a number of clinical trials but at times the trial results are overshadowed by big, glossy cartoon drawings in an advertisement. A good example is the claim that a flexible liner or flexible restorative material will help hold your restoration in place when the tooth flexes. The perfect test for this comes with Class V noncarious cervical lesions because the preparations are not retentive. Clinical trials consistently show the stiff composite with no

liner to be equal to or better than any of the flexible combinations (33, 34.) We no longer teach the use of copal varnish, zinc oxide eugenol liners, or zinc phosphate bases under amalgam restorations. Amalgam bonding is routinely used for deep or large amalgam restorations placed at UTHSCSA. A 6-year clinical study of cusp replacing amalgam restorations that were adhesively bonded with Amalgambond Plus with HPA had zero debonds of the amalgam in the 6 years of the study (35).

Summary: We have examined some large and small changes in preparation design. At least three clinical trials concluded that it is not a good idea to bevel the occlusal preparation margins of resin composite preparations. When correctly done, proximal slot preparations will be as successful as the preparations most of us were taught which cut out healthy occlusal grooves. Clinical research has shown value to a combination of small amalgam preparations when combined with fissure sealants (certainly PAR and probably PRR). While it sounds like heresy, soft dentin near the pulp can be left in deep preparations with good results for the patients. Incipient lesions up to and including radiographic evidence of early dentin involvement can be treated without cavity preparation using a re-mineralization protocol. At this time it is impossible to practice operative dentistry based 100 percent on scientific

evidence because the science in dentistry is incomplete. The research literature is inconclusive on almost every aspect of cavity design. Operative dentistry has accepted preparation designs without well controlled long term clinical trials for proof of concept. We teach and practice with “best evidence” knowing full well that research someday could show us a better design. About the only definite truth an expert in operative dentistry can offer is that smaller preparations that preserve enamel and dentin are superior to large, aggressive preparations. References 1. Ricketts DNJ, Kidd EAM, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD003808. DOI: 10.1002/14651858.CD003808. pub2. 2. Leksell E, Ridell K, Cvek M, Mejare I. Pulp exposure after stepwise versus direct complete excavation of deep carious lesions in young posterior permanent teeth. Endodontic Dental Traumatology 1996; 12:192-6. 3. Magnusson BO, Sundell SO. Stepwise excavation of deep carious lesions in primary molars. Journal of the Association of Dentistry for Children 1977; 8(2):36-40. 4. Yoshiytama M, Tay F, Tori Y et. al. Resin adhesion to carious dentin, Am J Dent. 2003 Feb; 16(1):47-52 5. Say EC, Nakajima M, Senawongse P, Soyman M, Ozer F, Tagami J. Bonding to sound vs. caries –affected dentin using photo- and dual-cure adhesives. Oper Dent. 2005 Jan-Feb; 30(1):90-8. 6. Purk JH, Dusevich V, Glaros A, Eick JD. Adhesive analysis of voids in Class II composite resin restorations at the axial and gingival cavity walls restored under in vivo versus in vitro conditions. Dent Mater. 2007 Jul; 23(7):8717. 7. Araujo Fde O, Vieira LC, Monteiro

Junior S. Influence of resin composite shade and location of the gingival margin on the microleakage of posterior restorations. Oper Dent. 2006 Sep-Oct; 31(5):556-61. 8. Mertz-Fairhurst EJ, Curtis JW Jr, Ergle JW, Rueggeberg FA, Adair SM Ultraconservative and cariostatic sealed restorations: results at year 10. J Am Dent Assoc. 1998 Jan; 129(1):55-66. 9. Gooch BF, Griffin SO, Gray SK et. al. Preventing Dental Caries Through School-Based Sealant Programs: Updated Recommendations and Reviews of Evidence. J Am Dent Assoc 2009;140;135665. 10. Grisanti LP2nd, Troendle KB, Summitt JB. Support of occlusal enamel provided by bonded restorations. Oper Dent 2004 JanFeb;29(1):49-53. 11. Summitt JB, Osborne JW, Burgess JO. Effect of grooves on resistance/retention form of Class 2 approximal slot amalgam restorations. . Oper Dent. 1993 Sep-Oct; 18(5):209-13. 12. Della Bona A, Summitt JB The effect of amalgam bonding on resistance form of Class II amalgam restorations. Quintessence Int. 1998 Feb; 29(2):95-101. 13. Summitt JB, Della Bona A, Burgess JO. The strength of Class II composite resin restorations as affected by preparation design. Quintessence Int. 1994 Apr; 25(4):251-7. 14. Hörsted-Bindslev P, Heyde-Petersen B, Simonsen P, Baelum V. Tunnel or saucer-shaped restorations: a survival analysis. Tunnel or saucer-shaped restorations: a survival analysis. Clin Oral Investig. 2005 Dec; 9(4):233-8. 15. Nordbø H, Leirskar J, von der Fehr FR. Saucer-shaped cavity preparations for posterior approximal resin composite restorations: observations up to 10 years. Quintessence Int. 1998 Jan; 29(1):511. 16. Lang LA, Burgess JO, Lang BR, and Wang R.F. Wear of Composite Resin Restorations in Beveled and Nonbeveled Preparations. J. Dent. Res 1995; 74:164 (Abstract #1226). 17. dos Santos MP, Passos M, Luiz RR, Maia LC. A randomized trial of resin-based restorations in

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class 1 and class 2 beveled preparation in primary molars:24-month results. J Am Dent Assoc. 2009 Feb; 140(2):156-66. 18. Isenberg BP, Leinfelder KF. Efficacy of beveling posterior composite resin preparations. J Esthet Dent. 1990 May-Jun; 2(3):70-3. 19. Ovist V, Strom C. 11-year assessment of Class-III resin restorations completed with two restorative procedures. Acta Odontol Scand. 1993 Aug; 51(4):253-62. 20. Hilton TJ, Ferracane JL. Cavity preparation factors and microleakage of Class II composite restorations filled at intraoral temperatures. Am J Dent. 1999 Jun; 12 (3):123-30. 21. Opdam NJ, Roeters JJ, Kuijs R,Burgersdijk RC. Necessity of bevels for box only Class II composite restorations. J Prosthet Dent. 1998 Sep; 80(3):274-9. 22. Microleakage of tooth-colored restorations with a beveled gingival margin. Owens BM, Halter TK, Brown DM. Quintessence Int. 1998 June; 29(6):356-61. 23. Holan G, Eidleman E, Wright GZ. The effect of internal bevel on marginal leakage at the approximal surface of Class 2 composite restorations. Oper Dent 1997 SepOct; 22(5):217-21. 24. Starr CB, Langenderfer WR. Use of a caries-disclosing agent to improve dental residentsâ&#x20AC;&#x2122; ability to detect caries. Oper Dent. 1993 May-Jun; 18(3):110-4. 25. Pitts N, Rimmer An in vivo Comparison of Radiographic and Directly Assessed Clinical Caries Status of Posterior Approximal Surfaces in Primary and Permanent Teeth. Caries Res 1992; 26:146-52. 26. Hellwig E, Altenburger M, Attin T, Lussi A, Buchalla W. Remineralization of initial carious lesions in deciduous enamel after application of dentifrices of different fluoride concentrations. Clin Oral Investig. 2009 June 2. [Epub ahead of print] 27. Morgan MV, Adams GG, Bailey DL, Tsao CE, Fischman SL, Reynolds EC. The anticariogenic effect of sugar-free gum containing CPP-ACP nanocomplexes on approximal caries determined using digital bitewing radiography.Caries Res. 2008;42(3):171-84. 28. Kleber CJ, Milleman JL, Davidson KR, Putt MS, Triol CW, Winston AE. Treatment of orthodontic white spot lesions with a re-mineralizing dentifrice applied by tooth brushing or mouth trays. J Clin Dent. 1999;10(1Spec No):44-9. 29. Whitaker EJ. Primary, secondary and tertiary treatment of dental caries: A 20-year case report. J Am Dent Assoc 2006;137:348-52. 30. Huth KC, Manhart J, Sellbertinger A, et al. Clinical Performance of a Compomer in Posterior Permanent Teeth. Am J Dent 2004; 17:51-55. 31. Navarro MF, Franco EB, Bastos PA et al. Clinical evaluation of gallium alloy as a posterior restorative material. Quintessence Int. 1996 May; 27(5):315-20. 32. Heintze SD, Systematic reviews:1. The correlation between laboratory tests on margin quality and bond strength. II. The correlation between margin quality and clinical outcome. J Adhes Dent. 2007 Dec; 9(6): 546. 33. Reis A, Loguercio AD. A 24-month Follow-up of Flowable Resin Composite as an Intermediate Layer in Noncarious Cervical Lesions. Oper Dent 2006; 31(5):52329. 34. Peumans M, De Munck J, Van Landuyt KL, et al. Restoring cervical lesions with flexible composites. Dent Materials2007 Jun; 23(6): 749-54. 35. Summitt JB, Burgess JO, Berry TG, et al. Six-year clinical evaluation of bonded and pin-retained complex amalgam restorations. Oper Dent. 2004 May-Jun: 29(3):261-8.

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A Comparison of Shear Bond Strengths on Bleached and Unbleached Bovine Enamel Andrew M. Dietrich, D.M.D., Jeryl English, D.D.S., M.S., Kathleen McGrory, D.D.S., M.S., Joe Ontiveros, D.D.S., M.S., John M. Powers, Ph.D, Harry I. Bussa Jr., D.D.S., M.S., Anna Salas-Lopez, D.D.S., M.S.

INTRODUCTION Beginning in the early 1980’s, bonding of orthodontic brackets had become the routine for attaching fixed appliances to teeth, replacing the need to fit and cement bands on each tooth (1). this eliminated a frustrating and time consuming process that often required the extraction of teeth because 4-6 mm of space was taken up by band material. Many different products and bonding techniques have come to the market, but the gold standard still seems to be the acid etch technique introduced by Buonocore in 1955 (2). this technique uses a 15 second application of 37 percent phosphoric acid to the enamel surface. After etching, the tooth is rinsed and dried. Primer is then applied and light cured before a bracket is bonded with resin cement. Over the years this technique has been modified The University of Texas Dental Branch at Houston, Departments of Orthodontics and Restorative Dentistry and Biomaterials All correspondence and requests for reprints should be sent to: Andrew Dietrich, 1 Hermann Museum Circle Apt 3085, Houston, TX 77004

Abstract Introduction: This study investigated whether tooth whitening with two different bleaching systems affects the shear bond strength achieved using an orthodontic self-etching primer. Methods: The sample of 210 bovine incisors was divided into three groups. One group served as the control, while the other two groups received either an over-the-counter “white strip” bleaching regimen (Opalescence TresWhite) or a “power bleaching” in-office regimen (Opalescence Boost). Each bleaching group was divided into three groups to be tested at three time intervals post-bleaching: immediately, 24 hours, and 7 days. Results: When compared to the control, the shear bond strength attained on Opalescence TresWhite treated specimens was not significantly lower at any time interval post-bleaching. Immediately after bleaching and 24 hours after bleaching, the Opalescence Boost treated groups showed significantly lower shear bond strengths than both the control groups and the Opalescence TresWhite groups. Conclusions: Bleaching with 38 percent hydrogen peroxide immediately and 24 hours before bonding reduced the shear bond strengths. After seven days the bond strengths were normal. Bleaching with 10 percent hydrogen peroxide in the form of white strip material did not reduce shear bond strengths.

KEY WORDS:

Tooth bleaching, hydrogen peroxide (H2O2), dental bonding, orthodontic adhesives

Tex Dent J;127(3):285–291.

Materials were supplied by: 3M Unitek and Ultradent

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A Comparison of Shear Bond Strengths on

These bonding agents, termed self etching primers, were designed initially for dentin bonding but there are now several commercial products intended for bonding to enamel. The field of esthetic dentistry has also seen an exponential rise in popularity. Patients now demand esthetic “tooth colored” restorations and whiter teeth. 286

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to increase efficiency by reducing the steps required. First the primer and adhesive were combined in fifth generation bonding agents, eliminating one of the three steps (3). Now all three steps have been combined into one step, using sixth and seventh generation bonding agents (3). These bonding agents, termed self etching primers, were designed initially for dentin bonding but there are now several commercial products intended for bonding to enamel. The field of esthetic dentistry has also seen an exponential rise in popularity. Patients now demand esthetic “tooth colored” restorations and whiter teeth. While tooth bleaching has been used in dentistry for more than a century, bleaching in the office was, until recently, only used to whiten nonvital stained teeth (4). The technique was modified for use on vital teeth with intrinsic stains, such as tetracycline (5), and is now used to whiten all teeth. In 1989, the first at-home “nightguard” bleaching system was introduced by Haywood and Heymann (6). Since then, bleaching has become more accessible to both dentists and patients, with bleaching materials becoming available in over-thecounter kits and special toothpastes. These bleaching procedures are so common that we now see them used not only at the dental office, but also in whiting centers at the local malls. Information about tooth bleaching can be found in articles and advertisements on the internet, popular magazines, and television programming. Bleaching is now available in three main forms. The in-office version or power bleaching is done with high concentrations of hydrogen peroxide (25-40 percent), a heat source or chemical activator, and a rubber dam to protect the gingival tissues (4). The second form includes the professionally dispensed and supervised products for home use. This regimen involves the use of a soft plastic night guard and varying concentrations of hydrogen peroxide (6-15 percent) or carbamide peroxide (5-36 percent) (4). The third technique includes over-the-counter products such as toothpastes, paint on applications and “white strips.” White strips are applied to the teeth in the form of an adhesive membrane with hydrogen peroxide (6-10 percent) lining the inner side (4). With the advent of new materials in the field of bonding and bleaching, it is important to ascertain what effect these new orthodontic bonding materials will have on these bleached enamel surfaces. The pupose of this study was to compare the shear bond strengths attained with a popular sixth generation orthodontic self etching primer (3M Uniek,

Transbond Self-etching Primer) on bovine enamel treated with two commonly used bleaching techniques: over-the-counter white strip material (Opalescence TresWhite Supreme) and in-office power bleaching (Opalescence Boost).

Methods Two hundred ten bovine incisors were stored in a disinfecting solution of 0.25 percent sodium azide solution in saline for 1 month. The roots of the incisors were shortened with a slow speed diamond saw (Isomet, Buehler, Lake Forest, IL, USA) to be embedded in resin cylinders. The facial surfaces were left exposed to be ground and used as bonding surfaces. The surfaces were ground and polished using the Ecomet 6 Variable Speed Grinder-Polisher (Buehler, Lake Forest, IL, USA) with 600 grit silicon carbide paper to ensure an adequate and reproducible bonding surface. The specimens were randomly divided into three groups: two groups of 90 and one group of 30. One group of 30 teeth was stored in distilled water in an incubator at 37 degrees Celsius and used as the control. The other two groups of 90 both received a bleaching regimen. One group was bleached using Opalescence TresWhite Supreme. This material comes in the form of an adhesive membrane (white strip material) with 10 percent hydrogen peroxide. The strips were applied according to manufacturerâ&#x20AC;&#x2122;s instructions to the ground surfaces: they were applied for a period of 1 hour a day for 10 days. At the end of the hour, the teeth were scrubbed with a toothbrush and distilled water and then stored in distilled water in an incubator at 37 degrees Celsius to simulate an oral environment. The other group was bleached using Opalescence Boost, a powerful in-office bleaching agent. Opalescence Boost is a chemically activated bleaching agent with a hydrogen peroxide concentration of 38 percent. The bleach was administered in three 15 minute applications over the course of 1 hour. Every 5 minutes the bleach was agitated with a microbrush. At the end of the application, the teeth were scrubbed clean using a toothbrush and distilled water. At the end of the bleaching regimen, both groups of 90 bleached teeth were further divided into three groups each to be tested at three time intervals: immediately, 24 hours and 7 days (one group for each time interval). The control group of 30 was also divided into three groups of 10 and tested at each of the three time intervals.

With the advent of new materials in the field of bonding and bleaching, it is important to ascertain what effect these new orthodontic bonding materials will have on these bleached enamel surfaces.

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A Comparison of Shear Bond Strengths on The teeth were all bonded using 3M Unitek Self-etching Primer, a commonly used sixth-generation bonding agent that is distributed in a unit-dose package. The contents of two blister wells were mixed in a third well before application. The specimens were blown dry, then the thoroughly mixed bonding agent was applied with a scrubbing motion for 5 seconds on the ground surface. An oil and moisture free air source was used to deliver a gentle air burst for 1 to 2 seconds to dry the primer into a thin film. The mounted tooth was then placed into an Ultradent shear bond test jig to facilitate bonding of a resin cylinder to the facial surface. The resin used for all groups was 3M Unitek Transbond XT. Photopolymerization was accomplished with curing light (Ortholux LED-3M Unitek) held directly over the opening in the jig to the resin. Each cylinder was light cured for 10 seconds according to manufacturer’s instructions for bonding ceramic

Concentration of Bleach

brackets. The specimens in the group to be tested immediately were bonded as soon as the bleach was removed and immediately sheared utilizing a universal testing machine (Instron Corp., Canton, MA, USA) at a crosshead rate of 0.5 mm/minute. The groups that were to be tested at 24 hours and 7 days were stored in a simulated oral environment (distilled water, 37 degrees Celcius) until they were ready to be tested. At that time they were bonded and immediately tested in the same manner described. Mean values and standard deviations of bond strengths were calculated. The data was analyzed statistically with analysis of variance (ANOVA) and Fisher’s PLSD multiple comparisons test (StatView 5, SAS Institute, Cary, NC) performed at the 0.05 level of significance.

Immediate

Results The descriptive statistics for the shear bond strengths are presented in Figure 1. Fisher’s PLSD intervals for comparisons of means between bleach concentrations and among times were 1.1 and 1.4 MPa, respectively. Figure 2 depicts the mean shear strength values. Shear bond strengths were at their lowest when tested immediately after bleaching treatment in the case of both bleaching regimens, although it was not statistically significant in the case of Opalescence TresWhite treatment. When compared to the control, the shear bond strength attained on Opalescence TresWhite treated specimens was not significantly lower at any time interval post bleaching. Also, the Opalescence TresWhite group did not show a significant difference between the means of its shear bond strengths at any of the three time intervals.

24 hours

7 days

Control

17.6 (2.9)ac

17.6 (2.6)ad

17.6 (3.2)ae

10 percent

16.5 (4.4)bc

16.7 (3.1)bd

16.7 (3.4)be

38 percent

9.9 (3.0)

13.6 (3.2)

17.1 (3.6)e

* Means with standard deviations in parentheses. Fisher’s PLSD intervals for comparisons of means between bleach concentrations and among times were 1.1 and 1.4 MPa, respectively. Means with the same superscripted letters are not different statistically (p>0.05). Figure 1. Shear bond strength (MPa) of enamel exposed to bleach before bonding.

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Bleached and Unbleached Bovine Enamel The specimens treated with Opalescence Boost showed definite effects. Immediately after bleaching and 24 hours after bleaching, the Opalescence Boost groups showed significantly lower shear bond strengths than both the control groups and the TresWhite groups. However, after 7 days the Opalescence Boost treated specimens had shear bond strength values that were not significantly different from the controls.

Discussion While the majority of studies that utilized a 25-35 percent hydrogen peroxide on enamel surfaces have shown a significant decrease in shear bond strength when composite application was performed immediately after the completion of bleaching (7-19), most of these studies were done in the restorative dentistry field, using different materials than we have tested. Studies investigating the appropriate time point for bonding of composites have reported that bond strength values returned to normal after anywhere from 24 hours (7, 17) to 2 weeks (15). In addition there were only a few studies utilizing a selfetching primer as the bonding agent (17, 20-22). It is apparent that there is a need for further investigation into the effects of bleaching on shear bond strength and how long it takes for these values to return to normal levels.

It is apparent that there is a need for further investigation into the effects of bleaching on shear bond strength and how long it takes for these values to return to normal levels.

The results of this study suggest that the white strip bleaching material Opalescence TresWhite Supreme has no effect on the shear bond strengths achieved with the orthodontic bonding agent and adhesive when used according to the manufacturerâ&#x20AC;&#x2122;s recommendations. On the other hand, our results show that the Opalescence Boost in-of-

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A Comparison of Shear Bond Strengths on fice bleaching material can have disastrous effects on shear bond strengths. These decreased shear bond strengths are most severe immediately but are still present 24 hours after bleaching. However, after 7 days the shear bond strengths have returned to normal. Several factors are thought to be responsible for the reduction in composite bond strength to bleached enamel. Bleaching with hydrogen peroxide or hydrogen peroxide-releasing agents may result in a significant decrease of enamel calcium and phosphate content and in morphological alterations in the most superficial enamel crystallites (23,24). Moreover, acid etching of bleached enamel surface produced loss of prismatic form resulting in an enamel surface which appeared to be over-etched (25). Additionally, it was suggested that the enamel and dentin organic matrix was altered by the oxidizing effect of hydrogen peroxide (26,27). These aspects may lead to an enamel surface that does not allow for formation of a strong and stable bond between the composite applied and the superficial etched enamel layer. Furthermore, reduction in bond strength in hydrogen-peroxide-treated enamel could be caused by residual oxygen present in enamel and dentin pores after completion of the bleaching treatment. Liberation of the oxygen could either interfere with resin infiltration into enamel and dentin or inhibit polymerization of resins that cure via a free-radical mechanism (28â&#x20AC;&#x201C;30). The latter aspect might result in oxygen-inhibited polymerization of the composite components directly in contact with the dental hard tissues leading to a soft interface not able to withstand debonding forces sufficiently. It appears that the Opalescence TresWhite does not have a high enough concentration of hydrogen peroxide (10 percent) to affect the shear bond strength values. It is suggested that due to its low concentration of hydrogen peroxide, it could not produce enough free radical oxidizing agents to alter the surface of the enamel or leave behind any residual oxygen in enamel pores to inhibit the polymerization of composite. Knowing that bleaching can have an effect on bonding, the orthodontist should always ask if the patient has been bleaching before bonding fixed appliances or fixed retainers. It is wise to wait 7 days before bonding brackets in a patient who has undergone an in-office bleaching procedure. In the case of a patient who has been using white strips, it does not appear to be of concern to our bonding procedures.

Conclusion Bleaching with 38 percent hydrogen peroxide immediately and 24 hours before bonding reduced the shear bond strengths achieved with an orthodontic self-etching primer and adhesive to enamel. After 7 days the bond strength values returned to normal. Bleaching with 10 percent hydrogen peroxide in the form of white strip material did not reduce shear bond strengths achieved with an orthodontic self-etching primer and adhesive to enamel.

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References 1. Proffit WR, Fields HW Contemporary Orthodontics. St.Louis, MO:Mosby 2000; 397-399. 2. Buonocore M.G A simple method of increasing the adhesion of acrylic filling materials to enamel surfaces. J Dent Res, 1955; 34(6):849-53. 3. Craig RG, Powers JM. Restorative Dental Materials. 11 ed. 2002, Mosby. 271-72. 4. Kihn PW. Vital tooth whitening. Dent Clin North Am, 2007; 51(2):319-31, viii. 5. Cohen S, Parkins FM. Bleaching tetracyclinestained vital teeth. Oral Surg Oral Med Oral Pathol, 1970; 29(3):465-71. 6. Heywood V, Heymann HO. Night guard vital bleaching. Quintessence Int, 1989; 20:173-76. 7. Dishman MV, Covey DA, Baughan LW. The effects of peroxide bleaching on composite to enamel bond strength. Dent Mater, 1994; 10(1):33-36. 8. McGuckin RS, Thurmond BA, Osovitz S. Enamel shear bond strengths after vital bleaching. Am J Dent, 1992; 5(4):216-22. 9. Stokes AN, Hood JA, Dhariwal D, Patel K. Effect of peroxide bleaches on resinenamel bonds. Quintessence Int, 1992; 23(11):76971. 10. Titley KC, Torneck CD, Ruse ND, Krmec D. Adhesion of a resin composite to bleached and unbleached human enamel. J Endod, 1993; 19(3):112-15. 11. Titley KC, Torneck CD, Smith DC, Adibfar A. Adhesion of composite resin to bleached and unbleached bovine enamel. J Dent Res, 1988; 67(12):1523-28. 12. Titley KC, Torneck CD, Smith DC, Chernecky R, Adibfar A. Scanning electron microscopy observations on the penetration

Bleached and Unbleached Bovine Enamel and structure of resin tags in bleached and unbleached bovine enamel. J Endod, 1991; 17(2):7275. 13. Torneck CD, Titley KC, Smith DC, Adibfar A. The influence of time of hydrogen peroxide exposure on the adhesion of composite resin to bleached bovine enamel. J Endod, 1990; 16(3):123-28. 14. Torneck CD, Titley KC, Smith DC, Adibfar A. Effect of water leaching the adhesion of composite resin to bleached and unbleached bovine enamel. J Endod, 1991; 17(4):156-60. 15. Van der Vyver PJ, Lewis SB, Marais JT. The effect of bleaching agent on composite/enamel bonding. J Dent Assoc S Afr, 1997; 52(10):601-603. 16. Barbosa CM, Sasaki RT, Florio FM, Basting RT. Influence of time on bond strength after bleaching with 35 percent hydrogen peroxide. J Contemp Dent Pract, 2008; 9(2):81-88. 17. Miyazaki M, Sato H, Sato T, Moore BK, Platt JA. Effect of a whitening agent application on enamel bond strength of selfetching primer systems. Am J Dent, 2004; 17(3):151-55. 18. Montalvan E, Vaidyanathan TK, Shey Z, Janal MN, Caceda JH. The shear bond strength of acetone and ethanol-based bonding agents to bleached teeth. Pediatr Dent, 2006; 28(6):531-36. 19. Turkkahraman H, Adanir N, Gungor AY. Bleaching and desensitizer application effects on shear bond strengths of orthodontic brackets. Angle Orthod, 2007; 77(3):489-93. 20. Uysal T, Sisman A. Can Previously Bleached Teeth Be Bonded Safely Using Self-etching Primer Systems? Angle Orthod, 2008; 78(4):711-15. 21. Adebayo OA, Burrow MF, Tyas MJ. Effects of conditioners on microshear bond strength to enamel after carbamide peroxide bleaching and/or casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) treatment. J Dent, 2007; 35(11):862-70. 22. Moule CA, Angelis F, Kim GH, Le

S, et al. Resin bonding using an all-etch or self-etch adhesive to enamel after carbamide peroxide and/or CPP-ACP treatment. Aust Dent J, 2007; 52(2):133-37. 23. Perdigao J, Francci C, Swift EJ, Ambrose WW, Lopes M. Ultramorphological study of the interaction of dental adhesives with carbamide peroxide-bleached enamel. Am J Dent, 1998; 11(6):291-301. 24. Ruse ND, Smith DC, Torneck CD, Titley KC. Preliminary surface analysis of etched, bleached, and normal bovine enamel. J Dent Res, 1990; 69(9):1610-13. 25. Josey AL, Myers IA, Romaniuk K, Symons AL. The effect of a vital bleaching technique on enamel surface morphology and the bonding of composite resin to enamel. J Oral Rehabil, 1996; 23(4):244-50. 26. Hegedus C, Bistey T, Flora-Nagy E, Keszthelyi G, Jenei A. An

atomic force microscopy study on the effect of bleaching agents on enamel surface. J Dent, 1999; 27(7):509-15. 27. Kodaka T, Toko T, Debari K, Hisamitsu H, Ohmori A, Kawata S. Application of the environmental SEM in human dentin bleached with hydrogen peroxide in vitro. J Electron Microsc (Tokyo), 1992; 41(5):381-86. 28. McGuckin RS, Thurmond BA, Osovitz S. Enamel shear bond strengths after vital bleaching. Am J Dent, 1992; 5(4):216-22. 29. Torneck CD, Titley KC, Smith DC, Adibfar A. Adhesion of light-cured composite resin to bleached and unbleached bovine dentin. Endod Dent Traumatol, 1990; 6(3):97-103. 30. Rueggeberg FA, Margeson DH. The effect of oxygen inhibition on an unfilled/filled composite system. J Dent Res, 1990; 69(10):1652-58.

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Dental Burs and Abstract Endodontic Files: Are Routine Sterilization Procedures Effective? Archie Morrison, D.D.S., M.S., FRCD(C); Susan Conrod, D.D.S. Originally published in the Journal of the Canadian Dental Association (JCDA), February 2009, Vol. 75, No. 1. Reprinted with permission.

Diseases may be transmitted by indirect contact when dental instruments contaminated by one patient are reused for another patient without adequate disinfection or sterilization between uses (1). the process of sterilization is designed to render instruments free of all microbial life, including bacterial spores, which can be very difficult to kill (1, 2). Any procedure that eliminates bacterial spores will also kill viruses such as HiV, hepatitis c, and hepatitis B (1). there are no degrees of sterility; rather, an instrument is sterile or it is not (2). resterilization of dental instruments for reuse on another patient happens regularly in all dental clinics (3). resterilization is simply the repeated application of a steriliza-

Conrod

Morrison

Dr. Conrod is a resident in the department of oral and maxil-lofacial surgery, Dalhousie University, Halifax, Nova Scotia. Dr. Morrison is an associate professor of oral and maxillofacial surgery, Dalhousie University, Halifax, Nova Scotia. Correspondence to: Dr. Susan Conrod, Oral and Maxillofacial Surgery, QEII HSC VG Site, 1278 Tower Road, Halifax, NS B3H 2Y9.The authors have no declared financial interests in any company manufacturing the types of products mentioned in this article.This article has been peer reviewed.

Purpose: The complex miniature architecture of dental burs and endodontic files makes precleaning and sterilization difficult. Devising a sterilization protocol for endodontic files and dental burs requires care, and some have suggested that these instruments be considered single-use devices. One purpose of this study was to determine the effective-ness of various sterilization techniques currently used in dentistry for the resterilization of dental burs and endodontic files. The second aim was to determine whether new dental burs and endodontic files, as supplied in packages from the manufacturer, are sterile. Materials and Methods: The sterility of new (unused) and used dental burs and endodontic files before and after various sterilization procedures was analyzed. New burs and files were tested immediately after removal from manufacturersâ&#x20AC;&#x2122; packaging, with or without prior sterilization. Burs and files that had been used in various dental offices were precleaned, packaged, resterilized and then tested for various pathogens. Each item was individually removed from the sterilization packaging, transferred by sterile technique into Todd-Hewitt broth, incubated at 37Â°C for 72 hours and observed for bacterial growth. Results: Sterilization procedures were 100 percent effective for unused burs and unused files but were less than 100 percent effective for all other test groups. Contamination rates following sterilization ranged from 15 percent for one group of used burs (p = 0.01) to 58 percent for one group of used files (p < 0.001). Conclusions: Dental burs and endodontic files, as packaged by the manufacturer, are not sterile and should therefore be sterilized before first use. The resterilization procedures tested here were not adequate, and more rigorous sterilization procedures are needed. If such procedures cannot be devised, these instruments should perhaps be considered single-use devices. For citation purposes, the electronic version is the definitive version of this article: www. cda-adc.ca/jcda/vol-75/issue-1/39.html. Tex Dent J;127(3):295â&#x20AC;&#x201C;300.

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Dental Burs and Endodontic Files: Are Routine tion procedure to an instrument or device to remove contamination, allowing for its use in treating multiple patients (4). Dental burs and endodontic files are commonly treated in this way. These devices can become contaminated with blood, saliva, necrotic tissue, and pathogens; therefore, if such devices are to be reused, it is important to ensure sterility and minimize any associated risk of cross-contamination of patients with dangerous pathogens (3). Precleaning and sterilization of some devices can be difficult because of their small size and complex architecture (3). Endodontic files are slender, tapered instruments, about 25 mm long, with intricate topography and spiral cutting edges used for cleaning and shaping root canals during endodontic treatment (5). Because of their size and shape, it is difficult to remove all biologic material during resterilization procedures (3, 5). Dental burs come in a variety of shapes and sizes, all with very complex

and detailed surface features. Used instruments must be thoroughly precleaned before sterilization, to remove debris, by either brushing or ultrasonic cleaning. Ultrasonic cleaning is much safer than hand-scrubbing because it decreases the risk of puncture wounds. Ultrasonic cleaning can also be an effective and timesaving method of cleaning instruments, although it is not capable of removing all con-tamination (2, 3). The ultrasonic cleaner uses vibratory energy, carried as sound waves in the fluid, to create suction which in turn removes biologic matter from instruments (6). Following any cleaning process, instruments should be given a final rinse to remove any debris left over from the cleaning solution (2). The instruments are then ready for sterilization. Three methods of sterilization are currently in use: application of steam under pressure in a steam autoclave, application of dry heat in a sterilizing oven and sterilization by chemical

vapour (1). All of these methods have advantages and disadvantages. Steam sterilization is one of the most effective and safe methods. Steam sterilization can be used on pack-aged items because it penetrates fabric and paper, but it cannot be used on items that cannot tolerate heat or moisture. Both the dry heat and chemical vapour methods of sterilization can be used on packaged items with no risk of rust or corrosion, leaving the instruments dry upon completion (1). Dry heat requires a lengthy sterilizing cycle and tends to damage most plastic items. Dry heat sterilizing equipment operates at extremely high temperatures and cannot be used to sterilize handpieces (1). This study had 2 main objectives. The first objective was to investigate the effectiveness of various sterilization procedures commonly applied to used burs and endodontic files. The second objective was to determine the sterility of new, unused burs and endodontic files.

MATERIAL AND METHODS The sterility of new and used dental burs and endodontic files before and after sterilization procedures was analyzed. Previously used burs and files were gathered from 4 different dental offices after they had been packaged and sterilized for reuse. Sterilization was conducted by the staff of these clinics. Sterilization procedures were carried out according to the protocols employed by each office, as the goal of this study was to see if the techniques currently being used are effective. The following groups of instruments were tested in this study: new, unused and sterilized burs and files; new, unused and unsterilized burs and files; and used burs and files sterilized using a variety of techniques (Tables 1 and 2). Each group consisted of 40 items. There were many differences between the groups, such as methods of precleaning, type of packaging, length of sterilization cycle and type of sterilizer. Once collected, the sterilized items were stored at room temperature in dry conditions for no longer than 7 days before incubation. The burs and files were then transferred, using sterile technique, into individual sterile test tubes containing 3 mL of Toddâ&#x20AC;&#x201C;Hewitt

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Sterilization Procedures Effective? Table 1. Treatments applied for five groups of burs Group Ultrasonic

Other treatment

Sterilization

Packaging

Sterilizer

Cycle

New burs 5 min Neutra-Cleana NA B1 Bagged bur block Harvey Chemiclave 6000 autoclave (Alfa Medical, Hempstead, NY)

20 min, 138 kPa, 132°C

B2 (untreated) NA

Individual bags

Used burs 5 min Neutra-Clean Visible debris Bagged bur block Harvey Chemiclave 6000 B3 brushed off autoclave (Alfa Medical)

20 min, 138 kPa, 132°C

B4 15 min Enzymaxb NA Individual bags

Statim Steam Sterilizer (SciCan, Toronto, ON)

6 min, 130°C

10 min Enzymax NA Bulk bags B5

Pelton & Crane Delta XL steam autoclave (Pelton & Crane, Charlotte, NC)

12 min, 216 kPa, 134°C

NA = not applicable; Neutra-Clean (Borer Chemie AG, Zuchwill, Switzerland); Enzymax (Hu-Friedy Manufacturing Co. Inc., Chicago, Ill.) a Sodium dodecylbenzenesulphonate. bBacterial protease and amylase.

Table 2. Treatments applied for four groups of files Sterilization

Group

Precleaning

Packaging

Sterilizer

Cycle

Dry heat sterilizer (Henry Schein, Ottawa, ON)

30 min, 149°C

Dry heat sterilizer (Henry Schein)

30 min, 149°C

Statim steam sterilizer (SciCan)

6 min, 130°C

New files F1

Disinfected with Pathexa Bulk bags and visible debris brushed off

F2 (untreated) NA

Packaged in cassettes with other new files

Used files F3

Disinfected with Pathex and Bulk bags visible debris brushed off

F4 Wiped with Preseptb Individual bags

NA = not applicable; Pathex (Certol International Inc., Commerce City, CO); Presept (3M, St. Paul, MN) o-Phenylphenol. b Sodium dichloroisocyanurate.

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

297

Dental Burs and Endodontic Files: Are Routine broth. The samples were incubated at 37Â°C. The test tubes were examined every 24 hours for a total of 72 hours, and any signs of bacterial growth were documented. A colour change, cloudy broth and visible precipitate in the test tube were all considered indicative of bacterial growth. If the solution remained clear throughout the incubation period, the sample was considered sterile (Figure 1). Data were collected and tested for significant differences using Fisherâ&#x20AC;&#x2122;s exact test.

Figure 1. Presence of bacterial growth denoted by cloudy broth (left); sterile sample indicated by clear broth (right).

RESULTS New items, as packaged by the manufacturer, were not sterile (Tables 3 and 4). However, sterilization procedures were 100 percent effective for unused burs (group B1) and unused files (group F1); no item in either of these groups showed contamination following the 72-hour incubation period. All sterilization procedures performed on previously used burs and files were less than 100 percent effective (Tables 3 and 4). Of the burs in group B3, used burs that were resterilized using a Harvey Chemiclave, 15 percent were contaminated (p = 0.01). Among the endodontic files in group F3, treated with disinfectant and dry heat sterilization, 58 percent

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

Table 3. Results of testing for contamination of burs

Group

No. (%) burs contaminated

0 (0)

17 (42)

6 (15)

14 (35)

21 (52)

See Table 1 for description of groups.

Table 4. Results of testing for contamination of files Group No.

(%) files contaminated

0 (0)

18 (45)

23 (58)

5 (12)

See Table 2 for description of groups.

Sterilization Procedures Effective? showed contamination (p < 0.001). Several samples of bacterial growth from used and resterilized burs were subjected to gram staining; the resultant staining and bacterial structure appeared consistent with Staphylococcus (Figure 2).

Figure 2. Gram staining demonstrates bacterial growth on a used bur that was resterilized.

DISCUSSION The goal of instrument sterilization in dentistry is to protect patients from cross-contamination via instruments (2). Careful consideration is required when devising a sterilization protocol for endodontic files and dental burs, and some have suggested that these instruments be considered single-use devices (5). A single-use device is an instrument designed to be used on one patient only, and the packages for such devices carry a clear label stating that they are not to be resterilized (4). In a recent study conducted in a hospital setting, the authors determined that the cleaning protocol was not entirely effective for some of the instruments used in an oral and maxillofacial surgery clinic (4). High rates of bacterial contamination were discovered following resterilization of bone burs by gas sterilization (4). If sterilization in a hospital setting is not completely effective, then sterilization in dental offices may not be as adequate as once thought. In the United Kingdom, concern has been raised over the potential transmission of prions by endodontic files because these devices come into contact with the peripheral branches of the trigeminal nerve. Of particular concern is the iatrogenic transmission of variant Creutzfeldt-Jakob disease, one of the transmissible spongiform encephalopathie (5, 7). The risk of transfer of this disease in dentistry is currently unknown; however, animal studies have shown that these prions can be transmitted via the oral cavity (7). Even if the risk of disease transmission is minimal during endodontic procedures, the high frequency of root canal treatments could in-crease the possibility of an adverse event (5, 8, 9). This is one example of why it is so important to ensure that resterilization procedures are effective. Treating endodontic files as single-use devices would eliminate this potential risk. Smith and others found that a large number (76 percent) of files collected from the U.K. dental community remained visibly contaminated after completion of the sterilization process (5). This is additional proof of unsatisfactory sterilization methods. The results obtained in the current study reinforce the conclusion that several of the methods of resterilization employed in the dental community are unsatisfactory. In this experiment, 5 techniques of resterilization were tested and found to be inadequate. Rates of contamination ranged from 15 percent of the items in group B3 to 58 percent of those in group F3. There are many variables to consider with each resterilization technique, and these variables account for the differences in results. Given the many variables, it is, for the most part, impossible to directly compare the techniques. However, the goal of this study was not to determine which technique was Texas Dental Journal l www.tda.org l March 2010

299

Dental Burs and Endodontic Files Sterilization most effective and why; rather, the aim was to determine if the techniques being used today are effective. The sterilization techniques were 100 percent effective for only 2 groups: the new burs and files that were sterilized before first use (groups B1 and F1, respectively). Group B1 can be directly compared with group B3 (used burs), because the sterilization technique used was the same, the only difference being that the used items in group B3 had visible debris and were brushed manually before packaging. None of the items in group B1 were contaminated following sterilization, but 15 percent of the burs in group B3 were contaminated following the same procedure (p = 0.01). Similarly, group F1 can be directly compared with group F3 (used files), for which the identical sterilization technique was used. In group F1, none of the items were contaminated, but in group F3, 58 percent of the items were contaminated after the resteriliza-tion procedure (p < 0.001). By comparing these groups, it becomes apparent that perhaps the problem with the sterilization procedures is the method employed to remove gross debris from the burs and files, rather than the method of sterilization. This relates back to the small size and complex surface architecture of these items. If the organic debris can be physically removed from these items, it is possible to sterilize them. Groups B1 and F1 had no organic contaminating debris and were rendered 100 percent sterile by the procedures outlined in Tables 1 and 2. The other objective of this study was to determine if new burs and files are sterile when they are purchased from the manufacturer. To satisfy this objective, new burs and files (groups B2 and F2, respectively) were incubated in nutrient broth using the same technique as for the other groups. Following incubation, 42 percent of the burs in group B2 were contaminated, and 45 percent of the files in group F2 were contaminated. This indicates that these instruments are not sterile at time of purchase and should be sterilized before first use.

CONCLUSIONS Sterilization procedures were successful for burs and files that had not been previously contaminated by organic debris. This was demonstrated by the groups of new burs (B1) and new files (F1) that were sterilized before first use. However, dental burs and endodontic files are not sterile when purchased and should be cleaned and sterilized before use. Routine sterilization procedures for previously used burs and files were not effective, and further research is warranted to devise an effective sterilization protocol. Future studies should focus on determining the best method of precleaning these devices. If such procedures cannot be devised, perhaps the instruments should be considered single-use devices. This would reduce the risk of transmission of all infectious agents, including prions (5).

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References 1. Woods R. Sterilization: Part 1. Instrument preparation. FDI World 1996; 5(2):7–10. 2. Miller CH. Sterilization. Disciplined microbial control. Dent Clin North Am 1991; 35(2):339–55. 3. Whitworth CL, Martin MV, Gallagher M, Worthington HV. A comparison of decontamination methods used for dental burs. Br Dent J 2004; 197(10):635–40. 4. Hogg NJ, Morrison AD. Resterilization of instruments used in a hospital-based oral and maxillofacial surgery clinic. J Can Dent Assoc 2005; 71(3):179–82. 5. Smith A, Dickson M, Aitken J, Bagg J. Contaminated dental instruments. J Hosp Infect 2002; 51(3):233–5. 6. Bentley EM. The value of ultrasonic cleaners in dental practice. Br Dent J 1994; 177(2):53–6. 7. Bagg J, Sweeney CP, Roy KM, Sharp T, Smith A. Cross infection control measures and the treatment of patients at risk of Creutzfeldt Jakob disease in UK general dental practice. Br Dent J 2001; 191(2):87–90. 8. Taylor DM. Inactivation of prions by physical and chemical means. J Hosp Infect 1999; 43 Suppl:S69–76. 9. Ingrosso L, Pisani F, Pocchiari M. Transmission of the 263K scrapie strain by the dental route. J Gen Virol 1999; 80(Pt 11):3043–7. 10. Adams DH, Edgar WM. Transmission of agent of Creutzfeldt-Jakob disease. Br Med J 1978; 1(6118): 987.

EXPRESS

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2009 Financial Report Texas Dental Association

Prepared by J. Preston Coleman, D.D.S., TDA Secretary-Treasurer

Financial Summary

2009 Financial Report

Although 2009 was a very challenging year for the Texas Dental Association (TDA) with the severe economic down turn, the TDA continued to be in excellent financial condition. The total revenues for 2009 were $6,453,918 or 1 percent above budget. The total expenses for 2009 were $5,950,049 or 7 percent below 2009 budget. This combination provided a surplus form operation in 2009 of $503,868. This amount plus funds unexpended from prior years gave support for the 2011 budget in addition to providing needed funds for 2010 operation which could not be anticipated when Budget 2010 was formulated. The 2011 proposed budget will require no dues increase.

Revenues

The 2009 interest on the TDA extension was paid from the 2008 surplus. In April 2010 the loan on the TDA extension will be reduced by 50 percent. The Building Committee has made some improvements on the building in 2009. The committee and the TDA Board have begun the process of vetting the renovation of the extension by reviewing architectural and engineering studies. The plan is to construct a facility that has state-of-the-art audio-visual facilities and meeting rooms for TDA purposes as well as for rental for groups needing facilities to accommodate 100-120 people. The TDA Board continues to be very concerned about the economic situation that has continued since late 2008. Last year the TDA Board allowed the budgeted expenses to increase only 2.18 percent from 2009 budget to 2010 budget. This year the Board is proposing a 3.5 percent decrease in expenses from 2010 budget to 2011 budget. The value of our reserves at the end of 2009 was $2,316,353. That is about $86,000 greater than at the end of 2007 before the recession began. There have been additional funds placed in the reserves during this time so we have not yet recovered fully.

Expenses

The TEXAS Meeting accounted for the largest portion of non-dues revenue in 2009 with $458,106. This was 1 percent above projection for 2009. The TDA Member Benefits Ltd., (MBL) and TDA Financial Services, Inc., (FSI) partnership realized $351,614 in revenue for TDA. This was 6 percent below projection. Earnings on short-term investments are primarily in Money Market Funds that have paid little return in 2009 because of the economic crisis. These earnings were $6,573 — 95 percent below the projection for 2009 that was made before the financial crisis began. As a result the sweep account was closed because leaving the funds in the accounts reduced the bank charges more than the earnings in the sweep account. In 2009 these income sources accounted for 12.7 percent of total revenue of the TDA. The 2009 surplus was $503,868. This was less than 2008 but adequate to fund a “Cash Carry Over” of $469,008 for the 2011 budget.

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

In 2009 the total revenues were above projection by $56,005 (.0088 percent increase). The following were the significant variances: • Annual Session — 5.1 percent above budget • Publications/Website — 8.3 percent above budget • Building Leases — 11 percent below budget • Membership Dues — 1.6 percent above budget • Interest & Dividends — 95 percent below budget • Miscellaneous — 135 percent above budget • Dental Assistant Training — 474 percent above budget • MBL Partnership — 6 percent below budget

During 2009, the actual expenses of $5,950,049 were 7 percent below the budget. The following are the significant variances: • Annual Session — 6.2 percent above budget • Publications/Website — 7.8 percent below budget • Building — 7.7 percent above budget • Capital Improvements — 3.5 percent below budget • Contingency — 78 percent below budget • Central Office Department — 6.8 percent below budget • Board of Directors — 23 percent below budget • Committees — 32 percent below budget • Councils — 9.2 percent below budget • ADA/National Organization — 17 percent below budget • House of Delegates — 11.2 percent above budget • Federal Taxes — 71 percent above budget

Utilization of Surplus

At the conclusion of business in 2008, the unused surplus was $37,426 from 2008 surplus. The Board chose not to continue funding for two projects, which either had not fully used the allotted funds or had never gotten started. The total was $5,372. The 2009 surplus was $503,868. The total available surplus at the end of 2009 was $546,666. The Board of Directors approved the following funding: Funding For 2010: Staff Dental Reimbursement Plan, 2010 AAPD Head Start Grant — Unused in 2009 Additional Directors & Officers Insurance Premium for 2010 Funding for 2011: Cash Carry Over Unallocated Surplus Funds

$4,975 $11,255 $14,774 $469,008 $46,655

2011 Proposed Budget REVENUES

In 2011 the total projected revenue is $6,309,055. This is a decrease of 3.5 percent from 2010. The revenue from The TEXAS Meeting is projected to be $1,908,650, a 2.1 percent increase. The leases from the TDA building are projected to decline 22 percent in 2011. Interest and Dividends for 2011 have been reduced 91 percent due to expectations of a poor banking outlook. The MBL, managed by FSI, is projected to produce $415,000 in non-dues revenue. The “Cash Carry Over” for 2011 is $469,008.

EXPENSES

Our past and present investments in staff communications, leadership, and team building continue to strengthen our staff, our most valuable asset. Reorganization of the staff and consolidation of duties by our Executive Director Ms. Mary Kay Linn has allowed a 4 percent reduction in the cost of salaries in 2011. These changes along with some attrition have provided advancement for some of our brightest and most deserving staff members. Salaries, payroll taxes, health care costs, and retirement benefits represent 33 percent of the expenses budgeted for 2011. We are fortunate to have such a dedicated staff at the TDA. We have budgeted $35,000 for capital improvements. In keeping with the plan to keep expenses as low as possible, central office operations will increase 3.1 percent for 2011. Additional cost of insurance is the reason for the increase. Contracted services are projected to decline 2.5 percent in 2011. These services include lobby consultants, audit and tax services, bank charges, and payroll services. Bank charges continue to rise substantially and presently there is no relief in sweep accounts. The Board Docs electronic board book services were dropped at the end of the first year of use because the perceived convenience and savings were not realized. Alternative methods of electronic board document generation are being examined to accomplish the savings of cost and staff time. The Council on Membership’s Dental Student Extern Program was very successful again in 2009, its second year. The pursuit of good leaders by nurturing dental students and new dentists is an investment in the future of the TDA. In 2011, the 82nd Texas Legislature will convene. In anticipation of vigorous pursuit of the TDA legislative agenda, the 2011 Budget for Council on Legislative and Regulatory Affairs (CLRA) has been increased by 34 percent. The Council on Dental Education, Trades and Ancillaries (DETA) budget will be increased by 69 percent. DETA has several projects on their agenda. Two of the projects involve the Dental Assistant Training Program and the printing and mailing of the books for the course. There is a revenue balance that defrays some of the cost. The Council on Membership will expand the Student Extern Program. The 15th District Texas Delegation to the

ADA continues to be a guiding force in the governance of the American Dental Association (ADA). The TDA is well represented in the councils and committees of the ADA. The TDA extension expenses are budgeted at $57,425 that includes the estimated interest expense on the loan that will be substantially reduced by 2011. Any renovation projects will be financed by a line of credit included in the loan up to the loan limits.

THE FUTURE

For the year 2009, the actual expenses were 7 percent below the 2009 budget. Income from The TEXAS Meeting and MBL, as well as the profit realized from the TDA publications and website of $106,127, provided $915,847 in non-dues revenue or 14 percent of total revenues. Dues in 2009 constituted 41 percent of total revenues. The 2009 non-dues revenue represents a dues increase of about $152 per full dues paying member. Non-dues revenues are strategic to keeping dues as low as possible. The TDA Board of Directors and the TDA staff are committed to the fiscal responsibility of your Association. The TDA is very sensitive to the members concerns in the economic times we are living in today. The TDA is working hard to see to it that all members can afford to maintain their TDA membership. The public image of the TDA and the dental profession has received immeasurable benefits from the TDA Smiles Foundation (TDASF) and its Texas Missions of Mercy and Donated Dental Services. Besides providing needed care to those in need, these programs have provided the TDA another way to put the profession’s best foot forward. The Board of Directors and the TDASF staff are to be commended. The financial strength of TDA has remained apparent in the adverse economic times of 2009. The service to the members and the patients we serve has continued thus far without a dues increase or a cut in services. The Texas Dental Association continues to be the “Voice of Dentistry in Texas”.

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

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2011 Proposed Budget Texas Dental Association

Revenues Annual Session PUBLICATIONS/WEBSITE

BUILDING

OPERATIONS

Expenses

2009 Actual

2009 2010 2011 Budget Budget Proposed

1. Annual Session 1,844,659 1,755,800 1,869,850 2. Journal 411,912 377,240 457,301 38,265 37,600 39,265 3. TDA Today 4. TDA Website 20,985 20,220 24,950 Total Publications/Website 471,162 435,060 521,516 5. Building a. Building Leases 185,726 213,469 219,873 b. Building Extension Leases 4,022 0 23,352 Total Buildings 189,748 213,469 243,225 6. Operating a. Dues 2,651,486 2,608,778 2,651,113 b. Interest & Dividends 6,573 136,500 132,500 c. Miscellaneous 17,659 7,500 7,500 d. Contributions — Grants — AAPD 14,000 0 0 e. Dental Assistant Training 34,411 6,000 8,000 f. Seminars 12,800 0 0 g. Affiliates Administration 84,806 84,806 86,502 h. MBL Partnership 351,614 375,000 415,000 i. Cash Carry Over 775,000 775,000 605,445 Total Operating 3,948,349 3,993,584 TOTAL REVENUES 6,453,918 6,397,913

1,908,650 475,527 39,655 20,400 535,582 186,327 4,500 190,827 2,626,912 12,000 7,500 0 47,042 0 96,534 415,000 469,008

3,906,060

3,673,996

6,540,651

6,309,055

7. Annual Session 1,386,553 1,305,965 1,374,700 PUBLICATIONS/WEBSITE 8. Journal 295,683 323,850 331,500 48,645 50,100 60,100 9. TDA Today 10. TDA Website 21,323 22,660 20,685 Total Publications/Website 365,651 396,610 412,285 BUILDING 11a. Building Leases 233,286 245,422 252,122 46,434 57,490 84,700 11b. Building Extension Leases Total Buildings 279,720 302,912 336,822 CAPITAL IMPROVEMENTS 12. Capital Improvements 68,802 66,500 35,000 CONTINGENCY 13. Non Budgeted Contingency 8,680 40,000 40,000 2,951,602 3,165,568 3,233,209 CENTRAL OFFICE 14. Central Office Departments 195,440 253,670 254,195 BOARD OF DIRECTORS 15. Board of Directors COMMITTEES 16. Committees 63,839 94,496 93,600 331,799 365,442 330,610 COUNCILS 17. Councils ADA/NATIONAL 18. ADA /National Organizations 216,762 261,760 279,640 Annual SESSION

1,376,796 347,845 61,100 20,510 429,455 241,560 57,425 298,985 35,000 40,000 3,155,213 250,220 71,231 356,475 190,990

ORGANIZATIONS HOUSE OF DELEGATES

19. House of Delegates

57,702

64,990

65,590

54,690

FEDERAL INCOME TAX

20. Federal Income Tax

23,500

80,000

85,000

50,000

TOTAL EXPENSES 5,950,049 6,397,913 6,540,651 6,309,055 REVENUE OVER EXPENSE 503,868 0 0 0

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

Central Office Departments PERSONNEL

EXECUTIVE DIRECTOR

OFFICE OPERATIONS

SERVICES

OTHER EXPENSES

2011 Proposed Budget Texas Dental Association 2009 Actual

2009 2010 2011 Budget Budget Proposed

14.

Central Office Departments Personnel a. Regular Salaries 1,415,374 1,563,688 1,622,583 b. Salaries — Temporary 15,301 1,000 1,000 c. Payroll Taxes 124,934 136,280 145,974 d. Dental Reimbursement-Employee 10,777 15,752 13,639 e. Health Insurance 133,098 165,919 187,890 f. Retirement 138,171 162,531 168,825

1,556,409 1,000 140,879 16,537 204,803 162,981

Total Personnel

2,139,911

2,082,609

Executive Director: g. Salary 139,809 139,809 146,799 h. Auto Allowance 6,000 6,000 7,200 i. Health Insurance 6,835 7,542 8,169

151,217 7,200 8,687

Total Executive Director

162,168

167,104

Office Operations: j. Insurance — Directors/Officers 23,415 50,282 35,226 k. Maintenance 32,208 39,641 42,330 l. Postage & Couriers 27,664 32,022 34,384 m. Printing 13,220 11,100 11,200 n. Supplies — Office 13,576 21,450 22,475 o. Taxes — State & Local 1,903 2,211 2,432 p. Telephone 29,200 32,093 32,200

50,000 36,328 35,804 12,100 16,700 2,675 32,225

Total Office Operations

180,247

185,833

Services: q. Accounting Services — Payroll 3,977 3,592 3,951 r. Accounting & Auditing Services 33,121 29,986 32,985 s. Bank Charges 15,418 8,936 11,618 t. Consultants 185 0 0 u. Human Resources 62,253 40,000 40,000 v. Legal Services 129,409 123,000 123,000 w. Lobbying 281,581 267,600 275,100 x. Gifts and Memorials 2,244 1,700 2,200

4,346 34,634 15,104 0 0 123,000 297,600 2,200

Total Services

476,883

1,837,655

152,643

141,187

528,188

2,045,170

153,351

188,799

474,814

488,853

Other Expenses: y. Contributions 150,825 150,825 100,000 z. Dues Processing 78,161 63,868 70,255 aa. Education & Organizational Development 4,663 18,300 16,750 bb. Meetings 13,425 11,007 11,528 cc. Professional Dues & Memberships 4,830 5,140 5,660 dd. Subscriptions — Publications 3,787 2,957 3,155 ee. Recruiting 95 700 1,500 ff. Travel 36,143 50,637 53,182 Total Other Expenses 291,929 303,434 262,030 Total Central Office 2,951,602 3,165,568 3,233,209

100,000 65,000 16,000 12,651 4,160 3,473 1,500 40,000 242,784 3,155,213

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

305

2011 Proposed Budget Texas Dental Association

Board of Directors, Councils, Committees, ADA, HOD BOARD OF DIRECTORS

COMMITTEES

COUNCILS

ADA/NATIONAL ORGANIZATIONS

HOUSE OF DELEGATES

FEDERAL INCOME TAX

306

2009 Actual

2009 2010 2011 Budget Budget Proposed

15.

Board of Directors: a. President 25,095 33,230 33,230 b. President — Stipend 30,000 30,000 30,000 c. President Elect 14,851 11,425 11,915 d. President Elect — Stipend 8,400 8,400 8,400 e. Past President 9,826 8,450 8,450 f. Secretary Treasurer 4,305 7,185 7,185 g. Secretary Treasurer — Stipend 8,400 8,400 8,400 h. Editor 6,155 11,810 11,950 i. Editor — Stipend 6,097 8,400 8,400 j. Vice Presidents 18,730 29,660 29,660 k. Senior Directors 16,714 25,700 25,700 l. Directors 19,362 24,700 24,700 m. Other Officers 10,692 12,075 12,250 n. Board Meetings 16,814 24,235 23,955 o. Board Docs 0 10,000 10,000

Total Board of Directors

254,195

250,220

16.

Committees: a. Access to Care 9,066 8,345 8,640 b. Assets Management 92 2,410 2,410 c. Awards 22,029 23,450 26,450 d. Budget 4,347 5,512 5,526 e. Building 216 724 524 f. Communications 494 7,635 8,185 g. Finance and Audit 1,358 4,080 2,100 h. New Dentist 12,100 15,210 15,420 i. Personnel & Prof Affairs 50 200 200 j. Future Focus 14,086 26,930 24,145

8,640 1,410 20,500 5,026 425 2,000 3,830 13,915 200 15,285

Total Committees

93,600

71,231

17.

Councils: a. Annual Session 20,393 30,545 23,725 b. Legislative and Regulatory Affairs 147,897 164,576 124,276 c. Constitution and Bylaws 10,815 4,311 4,311 d. DENPAC 46,500 73,710 65,000 e. Dental Economics 11,153 10,900 13,350 f. Dental Education, Trade and Ancillaries 34,245 17,255 26,515 g. Ethics and Judicial Affairs 6,514 10,890 11,590 h. Membership 37,893 39,765 45,503 i. Peer Review 16,389 13,490 16,340

27,425 166,311 4,311 50,000 10,350 44,690 8,590 28,458 16,340

Total Councils

330,610

356,475

ADA /National Organizations: a. ADA Delegates 165,420 208,610 225,390 b. ADA 15th Trustee Headquarters 15,818 17,000 17,600 c. ADA Texas Reception 35,524 36,150 36,650

134,740 17,600 38,650

18.

195,440

63,839

331,799

216,762

253,670

94,496

365,442

261,760

33,230 30,000 13,915 8,400 10,200 7,185 8,400 13,225 8,400 29,660 25,700 25,200 12,250 24,455 0

Total ADA /National

279,640

190,990

19.

House of Delegates: a. HOD 50 Year and Life Luncheon 3,784 3,800 4,000 b. HOD Headquarters 52,060 59,390 59,390 c. HOD Past President’s Breakfast 1,858 1,800 2,200

4,100 48,390 2,200

Total House of Delegates

57,702

64,990

65,590

54,690

20. Federal Income Tax

23,500

80,000

85,000

50,000

23,500

80,000

85,000

50,000

Total Miscellaneous

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

2011 Proposed Budget Texas Dental Association 2009 Actual

2009 2010 2011 Budget Budget Proposed

Annual Session ANNUAL SESSION REVENUE

ANNUAL SESSION EXPENSE

Annual Session Revenue a. Advertising 3,900 6,500 9,500 b. Clinics for Continuing Education 972,417 800,000 900,000 c. Classes 2,030 4,500 4,500 d. Contests — Photo 170 300 350 e. Exhibits 618,199 700,000 700,000 f. Merchandise Sales — Logo Shop 3,342 6,000 6,000 g. Miscellaneous 299 1,500 1,500 h. Other Groups 93,527 90,000 100,000 i. Registration 67,000 62,000 60,000 j. Sponsorships 83,775 85,000 88,000

6,500 941,000 4,500 350 700,000 3,000 300 100,000 65,000 88,000

Total Annual Session Revenue

1,869,850

1,908,650

7. Annual Session Expense a. Audio-Visual 170,683 145,000 148,000 b. Bank Charges 45,565 40,000 40,000 c. Classes — Cooking 1,890 4,500 4,500 d. Clinician Handouts 11,457 20,000 15,000 e. Clinician Honorariums 304,900 260,000 300,000 f. Clinician Support 201,681 160,000 175,000 g. Clinics — Other 0 500 0 h. Council /Board Dinner 4,676 4,000 4,500 i. Education 0 0 0 j. Exhibits 165,994 160,000 160,000 k. Hospitality Suite 27,307 35,000 40,000 l. Logo Shop 6,828 7,500 6,000 m. Meetings 45 0 0 n. Miscellaneous 4,487 4,000 4,000 o. Onsite Program 30,356 35,000 35,000 p. Other Groups 55,007 65,000 70,000 q. Photo Contest 4,346 4,000 4,000 r. Postage 18,064 18,000 15,000 s. President’s Reception 1,278 2,000 2,000 t. Printing 0 0 0 u. Promotion 55,168 40,000 50,000 v. Red Coats’ Breakfast 332 450 450 w. Registration 137,554 127,500 135,000 x. Shuttle Services 7,747 5,000 8,500 y. Stipends 19,250 19,250 19,250 z. Supplies — Office 1,908 5,000 5,000 aa. Temporary Salaries 544 500 500 bb. Texas Party 43,129 45,000 45,000 cc. Tours 1,779 0 0 dd. Travel 35,488 73,765 60,000 ee. VIP Reception 29,088 25,000 28,000

155,000 40,000 4,500 10,000 300,000 175,000 500 4,500 0 160,000 40,000 1,500 0 4,000 35,000 70,000 4,000 18,000 2,000 0 50,000 450 135,000 8,500 19,750 3,000 500 45,000 0 60,596 30,000

1,305,965

1,374,700

1,376,796

449,835

495,150

531,854

Total Annual Session Expense

Annual Session Net Revenue

1,844,659

1,386,553 458,106

1,755,800

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307

2011 Proposed Budget Texas Dental Association 2009 Actual

Publications/Website JOURNAL REVENUE

JOURNAL EXPENSE

TDA TODAY REVENUE

TDA TODAY EXPENSE

WEBSITE REVENUE

WEBSITE EXPENSE

308

2009 2010 2011 Budget Budget Proposed

TDA Journal Revenue a. Advertising 288,229 262,000 336,000 b. Single Issue Purchases 214 500 500 c. Subscriptions 123,409 114,740 120,801 d. Miscellaneous 60 0

354,400 500 120,627 0

Total TDA Journal Revenue

457,301

475,527

TDA Journal Expense a. Meetings 191 100 100 b. Postage & Couriers 48,008 43,000 50,000 c. Printing & Production 247,102 280,350 280,800 d. Supplies — Office 129 300 500 e. Travel 252 100 100

100 57,000 290,345 300 100

Total TDA Journal Expense

331,500

347,845

TDA Today Revenue a. Advertising 3,855 4,000 5,000 b. Subscriptions — Membership Dues 34,410 33,600 34,265

5,500 34,155

411,912

295,683

377,240

323,850

Total TDA Today Revenue 38,265 37,600 39,265 9. TDA Today Expense a. Postage 20,527 19,000 24,000 b. Printing & Production 28,117 31,000 36,000 c. Supplies — Office 0 100 100

39,655

Total TDA Today Expense 48,645 50,100 60,100 4. TDA Website Revenue a. Advertising and Merchandise Sales 16,235 11,220 16,950 b. Sponsorships 3,250 7,000 5,000 c. TDA Affiliates Support 1,500 2,000 3,000

61,100

Total TDA Website Revenue 20,985 20,220 24,950 10. TDA Website Expense a. Education & Organization Development 0 350 600 b. Postage 0 50 25 c. Promotion 3,431 3,000 1,000 d. Repairs and Maintenance 0 0 0 e. Software and Software Support 122 400 350 f. Subscriptions — Publications 10 50 50 g. Supplies — Office 117 250 150 h. Travel 970 1,560 1,510 i. Website Engineering 462 1,000 1,000 j. Website Hosting 5,413 5,000 5,000 k. Website Services — TDA Express 10,800 11,000 11,000

20,400

Total TDA Website Expense 2-4 Total Public/Web Revenues 8-10 Total Public/Web Expense

21,323

22,660

20,685

20,510

471,162 365,651

435,060 396,610

521,516 412,285

535,582 429,455

105,511

38,450

109,231

106,127

Communications Net Revenue

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

24,500 36,500 100

17,400 0 3,000

600 25 1,000 0 200 25 150 1,510 1,000 5,000 11,000

2011 Proposed Budget Texas Dental Association 2009 Actual

Buildings BUILDING REVENUE

BUILDING EXPENSE

2009 2010 2011 Budget Budget Proposed

TDA Building Revenue a. Lease Income 185,726 213,469 219,873

186,327

Total TDA Building Revenue

219,873

186,327

11. TDA Building Expense a. Building Tenants 1,098 1,400 1,400 b. Gifts & Memorials 239 1,000 500 c. Insurance — Operating 16,964 24,000 24,000 d. Meetings 0 0 0 e. Postage 0 0 0 f. Repairs & Maintenance — Equipment 17,559 2,000 2,000 g. Service Contracts 76,953 86,000 88,000 h. Supplies — Office 4,546 11,000 9,000 i. Taxes — State & Local 56,084 55,000 57,200 j. Telephone 675 750 750 k. Utilities 59,169 64,272 69,272

1,400 500 22,000 0 0 3,500 89,760 5,000 59,000 400 60,000

185,726

213,469

Total TDA Building Expense 233,286 245,422 EXTENSION REVENUE

252,122

241,560

TDA Extension Revenue b. Lease Income 4,022 0 23,352

4,500

Total TDA Extension Income 4,022 0 EXTENSION EXPENSE

BUILDING MAINTENANCE FUND

23,352

4,500

11.

TDA Extension Expense l. Capital Expenditures 5,900 0 0 m. Insurance — Operating 0 2,500 2,500 n. Interest Expense 0 0 29,500 o. Legal Fees 0 0 0 p. Repairs & Maintenance — Equipment 1,225 8,490 8,500 q. Service Contracts 8,795 7,500 7,800 r. Taxes — State & Local 15,599 27,000 19,000 s. Telephone 7,056 0 4,400 t. Utilities 7,859 12,000 13,000

0 2,500 11,525 0 4,000 5,000 21,000 5,000 8,400

Total TDA Extension Expense

84,700

57,425

TDA Building Maintenance Fund Building Maintenance & Repair 0 31,081 17,473

2,493

46,434

57,490

(1) By House Resolution 132-1997-H, building repairs are funded from the interest generated from the Building Maintenance Fund from 2 years previous to the current year. The 2011 budgeted amount for these lines is the interest earned in the year 2009 by the Building Maintenance Fund.

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309

Texas Dental Association 2011 Budget Explanation 1a. Income from vendor advertising in the Annual Session program brochures. 1b. Income from ticketed clinician classes and events. 1c. Income from classes such as cooking and painting. 1d. Fees from Photo Contest. 1e. Income from exhibit booth spaces. 1f. Income from sale of TDA logo items. 1g. Other income associated with the TDA Annual Session. 1h. Fees from alumni lunches and other professional groups’ events. 1i. Pre-registration and on-site registration fees. 1j. Income from corporate sponsorships. 2a. Income from sale of classified and display advertising in Texas Dental Journal. 2b. Sale of single issues. 2c. Income from sale of Journal subscriptions, including allocations of dues of $17 per dues-paying member. 2d. Fees from continuing education offering. 3a. Income from advertising in TDA Today. 3b. Member subscriptions allocated from dues at $5 per dues-paying member. 4a. Income from advertising on the TDA Website. 4b. Vendor support for web related promotion. 4c. Payment from affiliates for portion of website development and maintenance costs. 5a. Income from leased space in the TDA building. 5b. Income from leased space in the TDA building extension. 6a. Dues income available for operations after allocation of $22 per member for Texas Dental Journal and TDA Today. 6b. Money earned from various short-term investments of dues collected and any interest income from current revenue.

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

6c. Legislative Day and other income associated with the operating fund. 6d. American Academy of Pediatric Dentistry DHI Grant. 6e. Income from dental assistant training program. 6f. Income from sponsored seminars. 6g. Payment from the for-profit affiliates, FSI and PDBI, for administrative support of staff and equipment provided by the TDA. This amount is decreased due to the decreased activity of PDBI. 6h. Distribution of 90 percent of the partnership income from TDA Member Benefits, Ltd, in which TDA is the limited partner. 6i. Surplus carried over from 2008. 7a. Audio-visual for clinicians. 7b. Charges in connection with the Annual Session bank accounts and credit card charges. 7c. Costs of classes, such as cooking and painting. 7d. Printing of clinicians’ handouts. 7e. Cost of honoraria, hotel, and travel. 7f. Course supplies, electrical, and gifts for clinicians; convention center meeting rooms; and signs. 7g. Other costs associated with clinics. 7h. Costs of Council/Board Dinner. 7i. Costs associated with education. 7j. Exhibit hall costs, printing of exhibitors’ prospectus, refreshments, electric/ decorating for exhibitors and security. 7k. Cost of catering for speakers, staff and A/S Council during Annual Session. 7l. Cost of merchandise sold at the Annual Session. 7m. Staff meetings associated with Annual Session 7n. Charges for other costs associated with the Annual Session.

7o. Cost of printing on-site program. 7p. Alumni luncheons and CPR classes. 7q. Costs associated with the Photo Contest. 7r. Postage used for Annual Session. 7s. Costs associated with the President’s Reception. 7t. Costs associated with printing materials. 7u. Mass mailings, promotional items, and advertising. 7v. Cost of A/S Council and A/S staff breakfast during meeting. 7w. Cost for registration firm for the Annual Session, as well as on-site setup cost, electrical, and staffing. 7x. Cost of shuttle transportation around downtown for attendees. 7y. Stipends paid to the San Antonio Dental Society, TDA Alliance, and the Dental Assistants Association. 7z. Supplies purchased for use at the Annual Session. 7aa. Temporary help hired specifically for the Annual Session. 7bb. Catering, music and space rental for The Texas Party. 7cc. Tours. 7dd. Annual Session staff travel and Annual Session Council travel to scout other dental meetings. 7ee. Catering, music and space rental for the VIP Reception. 8a. Cost of meetings held in connection with Journal business. 8b. Cost of mailing the Texas Dental Journal to all members. 8c. Cost of printing, typesetting and artwork for the Texas Dental Journal. 8d. Supplies used for the Texas Dental Journal. 8e. Staff travel in connection with Journal business. 9a. Cost of mailing newsletter, TDA Today. 9b. Cost of printing newsletter, TDA Today.

9c. Supply costs associated with TDA Today. 10a. Educational programs for website staff. 10b. Cost of postage for mailing to potential website advertisers. 10c. Costs on site at the Annual Session to promote the website. 10d. Maintenance costs for website specific software. 10e. Costs associated with software and support for the website. 10f. Professional publications related to the website. 10g. Supply costs for the website. 10h. Travel costs for staff to promote the website to the membership at the Annual Session. 10i. Costs for maintaining updates and enhancements to the website. 10j. Costs to design, implement and host website. 10k. Software service costs to maintain TDA Express. 11a. Expenses allotted to maintain the tenant relations. 11b. Gifts of appreciation for service vendors and memorials for building display. 11c. Premiums paid for insurance associated with the TDA Building. 11d. Staff meetings associated with the building. 11e. Postage used for mailing building information. 11f. Cost of equipment maintenance for the building. 11g. Service contracts associated with building such as the elevator service, security, HVAC, landscaping, etc. 11h. Supplies used to maintain the building. 11i. Property taxes paid on building. 11j. Telephone expense allocated to the building. 11k. Gas, water and electricity expenses. 11l. Capital Improvement needs are reviewed and prioritized, and estimated costs are projected.

11m. Premiums paid for insurance associated with the TDA Extension. 11n. Interest paid for building extension term note. 11o. Legal Fees associated with the building extension. 11p. Repairs and maintenance required above and beyond the service contracts. 11q. Service contracts associated with building such as the janitorial service, security, HVAC, landscaping, etc. 11r. Property taxes paid on the TDA Extension. 11s. Telephone expense allocation to the TDA extension. 11t. Gas, water and electricity expenses. Building Maintenance Fund uses interest earnings for remodeling and major repair costs. The budgeted expense amount is based on the interest earnings for the year ended 2 years prior to the budget year. 12. Capital improvement needs are reviewed and prioritized, and estimated costs are projected. 13. Contingency for approved expenditures by the Board of Directors. 14a. Full- and part-time salaries and year-end bonus (one week’s salary). The amount for 2011 reflects maintaining current staffing levels with annual salary adjustments. 14b. Temporary help for the TDA Central Office. 14c. Employer’s portion of FICA and Medicare based on 7.65 percent plus state and federal unemployment tax. 14d. Direct Reimbursement Dental Plan for employees. 14e. Medical insurance for employees. 14f. Payments to retirement plan for all eligible employees. 14g. Salary for the Executive Director. 14h. Car allowance for the Executive Director. 14i. Health insurance for the Executive Director.

14j. Liability coverage for TDA Officers and Component Society Officers, personal property coverage and workers’ compensation insurance. 14k. Maintenance contracts for office and computer equipment and general office operations. 14l. Postage, metering equipment and maintenance, and UPS and Federal Express charges. 14m. All printing jobs done outside office such as stationery, business forms, office forms, and dues statements. 14n. General office, printing and copy machine supplies. 14o. Personal property taxes of the Central Office furniture and equipment. 14p. Eight incoming WATS and business lines for Central Office using XO Communications, facsimile charges, and cellular phones. 14q. Cost of payroll service used by TDA. 14r. Accountant fees for annual audit, consulting services, and tax return preparation. 14s. Charges for transaction fees and returned checks. 14t. Expenses associated with outside consulting firms. 14u. Cost of out-sourced human resource service. 14v. Retainer for legal counsel and related legal expenses. 14w. Expenses associated with consulting firms engaged for legislative lobbying services. 14x. Flowers for funerals, special gifts to VIP’s, members, and their families. 14y. Funding for the operating costs of the Texas Dental Association Smiles Foundation. 14z. Credit card processing fees and other bank charges for processing dues payments. 14aa. Continuing education and organizational development costs for TDA staff members. 14bb. Meals and supplies not directly related to a specific council, committee, or board meeting that occurs at the TDA Central Office. Texas Dental Journal l www.tda.org l March 2010

311

Budget Explanation, continued

14cc. Memberships to the Austin Club, TSAE, ASAE and other licensing requirements for TDA staff. 14dd. Press clippings and other subscriptions used in the Central Office. 14ee. Advertising cost for open staff positions. 14ff. Travel expenses for Executive Director and TDA staff not related to a council or committee. 15a. Travel reimbursement for the President while on TDA business. 15b. Stipend paid to the President. 15c. Travel and per diem reimbursement for the President-Elect while on TDA business. 15d. Stipend paid to the PresidentElect. 15e. Travel and per diem reimbursement for the Past President, previously included in the Other Officers line. 15f. Travel and per diem reimbursement for the Secretary-Treasurer while on TDA business. 15g. Stipend paid to the SecretaryTreasurer. 15h. Travel expenses for the Editor. 15i. Stipend paid to the Editor. 15j. Travel and per diem reimbursement for the four Vice Presidents while on TDA business. 15k. Travel and per diem reimbursement for the four Senior Directors while on TDA business. 15l. Travel and per diem reimbursement for the four Directors while on TDA business. 15m. Travel and per diem reimbursement for the Speaker of the House and Parliamentarian while on TDA business. 15n. Costs associated with conducting Board meetings such as coffee, soft drinks, lunches, Board dinners (the cost of the Board lunch and dinner is deducted from BOD per diem), mailing and printing of Board-approved

312

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

communications and conference calls. 15o. Costs for board.docs, an electronic governance software. 16a. Meeting and travel costs for the Committee on Access to Care Medicaid and CHIP which monitors access to care and state funding issues. 16b. Meeting costs and travel reimbursement for committee that oversees the investments of the Reserve Fund and the TDA Relief Fund. 16c. Cost of awards presented by the TDA, including meeting and travel reimbursement costs for committee. 16d. Meeting costs and travel reimbursement for committee that formulates initial budget recommendations for the Board of Directors. 16e. Meeting costs and travel reimbursement for committee that administers Building Fund and is responsible for oversight of the building. 16f. Meeting costs, travel reimbursement, and projects of the Communications Committee. 16g. Meeting costs and travel reimbursement for committee that monitors the TDA financial functions. 16h. Meeting costs, travel reimbursement, G.O.L.D. Reception, and projects of the New Dentist Committee. 16i. Meeting costs to discuss personnel issues. Minimal costs are budgeted as this committee meets in conjunction with Board Meetings or by telephone conference. 16j. Oversight of the strategic plan is accomplished through the Future Focus Committee. 17a. Reimbursement for travel, meeting costs, and council projects for the Council on Annual Session. 17b. Reimbursement for travel, meeting costs, and council projects for the Council on Legislative and Regulatory Affairs. 17c. Reimbursement for travel, meeting costs, and council

projects for the Council on Constitution and Bylaws. 17d. Administrative support for DENPAC. 17e. Reimbursement for travel, meeting costs, and council projects for the Council on Dental Economics. 17f. Reimbursement for travel, meeting costs, and council projects for the Council on Dental Education, Trade, and Ancillaries. 17g. Reimbursement for travel, meeting costs, and council projects for the Council on Ethics and Judicial Affairs. 17h. Reimbursement for travel, meeting costs, and council projects for the Council on Member Services. 17i. Reimbursement for travel, meeting costs, and council projects for the Council on Peer Review plus training sessions for component officers. 18a. Reimbursement for travel and hotel for 43 Delegates and Alternates to attend the ADA Annual Session and Pre-Caucus, and meeting costs of printing, postage and supplies. 18b. Printing, supplies, meeting rooms and general expenses associated with the 15th Trustee District Headquarters at the ADA Annual Session. 18c. Reception given by the TDA at the ADA Annual Session. 19a. Costs of luncheon for 50 Year and Life Members at the TDA Annual Session. 19b. Costs associated with meetings of the TDA House of Delegates, including reference committees. 19c. Costs for breakfast for Past Presidents and Past Vice Presidents at Annual Session. 20. Estimated costs for federal income taxes for non-related business income.

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

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w e i v e r

Technology’s Impact on Practice Busyness Charles Blair, D.D.S.

Stay Out Of Jail: The Top Coding Errors Thursday, May 6, 2010 8:30 AM – 11:30 AM Practice Booster — Dentistry’s Answer To Intensify Clinical Treatment 1:30 PM – 4:30 PM A Clinical Pathway In Progressive Diagnosis And Treatment Of Periodontal Disease And The Opportunity Cost Of The UnderDiagnosis Of Periodontal Disease Charles Blair, D.D.S., and Casey Hein, BSDH, M.B.A. Friday, May 7, 2010 8:30 AM – 3:30 PM The TDA makes every effort to present high caliber speakers in their respective areas of expertise at the TEXAS Meeting. Speakers presented by TDA are offered for the purpose of providing information only and not as dental, ﬁnancial, accounting, legal, or other professional advice. Attendees must consult their own professional advisors for such advice. The ideas and comments expressed during the seminars and the articles presented herein are not necessarily endorsed by, or those of, the TDA. Programs actually presented at the TEXAS Meeting may be subject to change by the TDA.

314

entists with “busyness” problems always think they have “new patient flow” problems. They think the obvious solution is to advertise more or join numer-

ous PPO plans which cuts profitability. While doing that may be the easy way out, they are dead wrong. Doctor busyness is derived from six critical components: new patient flow, quantity of hygiene checks, procedure mix breadth, emergency treatment, case acceptance and clinical treatment intensity (how many crowns, etc.). In reality, each component is important and contributes to overall busyness!

What tool can be used to enhance busyness yet works with the current new patient flow? Technology comes charging to the forefront. Technology directly affects the previously mentioned components that drive doctor busyness. For instance, acquiring a soft tissue laser may add seven procedures to the service mix breadth (average practice does 94 different coded procedures) while improving crown and bridge impression-taking. Acquiring an intraoral camera, digital camera, and converting over to digital X-ray and pan will immediately affect the quality of diagnosis and case acceptance with the current new patient flow, while improving clinical and insurance documentation, which helps defend malpractice actions. Digital pans can now be done in eight seconds, versus the time required for a full series. Patient education software such as Guru and Casey, along with third party financing such as CareCredit contribute to better case acceptance. The E4D/Cerec 3D technology allows a percentage of the current composites to be converted to higher-fee crowns. It also provides the capacity to add an extra crown or onlay to the day’s schedule utilizing the always available unbooked op-

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

eratory. An unbooked operatory is one that is used for “spillover” and adds the capacity to work-in “same day dentistry”. Now that’s improving the clinical treatment intensity! The VELscope facilitates oral cancer detection while expanding the procedure mix and yields a nice “return on investment” if used in volume. The DIAGNOdent or Spectra Caries detector facilitates x-ray diagnosis and can increase the count of single surface fillings resulting in a substantial ROI. With the implant market growing 25 percent or more a year, Cone Beam CT is getting traction and increasingly is considered the stan-

dard of care for implant surgery. What is even more exciting is that Cone Beam CT and CAD/CAM are marching forward to a restorative marriage. Patient contact software, such as DemandForce, enables the practice to decrease broken appointments, maintain the viability of the recall system, and enhance patient communication and retention. In this economy, staying “close to the patient-customer” is all important and patient contact software fits the bill. Technology drives the doctor’s busyness and plays a key role in diminishing the need to advertise or participate in PPO plans. Bot-

Doctor busyness is derived from six critical components: new patient ﬂow, quantity of hygiene checks, procedure mix breadth, emergency treatment, case acceptance, and clinical treatment intensity.

tom line, technology increases profitability while vastly improving patient care. Dr. Charles Blair is a contributing editor of Dental Economics magazine and president of Dr. Charles Blair & Associates, Inc. in Mt. Holly, North Carolina. His Revenue Enhancement Program includes fee consulting, clinical procedure protocols analysis, and proper insurance coding guidance, which averages over $85,000 increase in net profi ts annually per practice consulted. Thousands of offi ces have gone through the program. Call (866) 858-7596 or contact Dr. Charles Blair and Associates, Inc. by email at info@drcharlesblair. com or further information on this unique program and his insurance coding manual, Coding with Confi dence: The Go-To Dental Insurance Guide for CDT-2009/2010.

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

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In recognition of the Beverly Bane Lectureship Fund, the TDA Smiles Foundation is proud to support the following lectures:

Thomas Dawson, DDS & Jack Shirley, DDS Thursday, May 6, 2010 8:30 AM - 11:30 AM Has Your Practice Ceased To Function? Course Code: #T20

1:30 PM - 4:30 PM Tough Cases Made Simply Beautiful Course Code: #T21

Founded in 1990 as the nonprofit, philanthropic arm of the TDA, the TDA Smiles Foundation seeks to improve patient care in Texas through the support of education and research. To forward these efforts, the TDA Smiles Foundation hosts the Beverly Bane Honorary Lectureship, which fosters continuing education to broaden the scope of Texas dentists and enables them to better serve their patients.

Oral and Maxillofacial Pathology Case of the Month

Clinical History This 68-year-old male was referred to the oral surgeon by his general dentist for extraction of #15 due to severe periodontal disease. The patient’s medical history was unremarkable except for high blood pressure treated with enalapril. On clinical examination the patient had severe periodontal disease of #15, with some mobility. There was no exudate on probing and he related no pain or discomfort. The panoramic radiograph showed severe bone loss of #15 (Figure 1). The extraction was performed without complications and the patient was followed up 2 weeks later. At this point the extraction site was healing normally. Three to 4 weeks after the initial follow up, the patient called the oral surgeon because he was feeling some pain at the extraction site and there was a “growth”. The patient returned to the oral surgeon and the intraoral exam revealed a large pink and bluish, multinodular mass growing out of the extraction socket of #15 (Figure 2). The patient reported pain and bleeding from the area. A panoramic radiograph was taken and showed some bone loss, but no obvious bone changes (Figure 3). At this time, the oral surgeon decided to remove the mass and submit the tissue for histologic evaluation. Histologic examination revealed a mass composed of a sheet-like proliferation of large cells with abundant cytoplasm, round to oval nucleus and prominent nucleoli in some cases and some scattered mitoses. The large cells infiltrate diffusely in between the connective tissue and deep tissues.

What is your diagnosis? See page 322 for the answer and discussion.

Juliana Robledo, D.D.S. South Texas Oral Pathology San Antonio, TX Bryan Roach, D.D.S. Sonterra Oral Surgery San Antonio, TX

Robledo

Roach

Figure 1. Panoramic radiograph taken before extraction of tooth 15. The bone loss is consistent with periodontal disease.

Figure 2. Large red and bluish multinodular mass, emanating from socket of tooth 15.

Figure 3. Panoramic radiograph taken after the patient returned with the mass, there is bone loss affecting the teeth adjacent to the area of the mass. Texas Dental Journal l www.tda.org l March 2010

317

In Memoriam Those in the dental community who have recently passed

Asher, Tipton J. Dallas, Texas July 10, 1942 – January 18, 2010 Good Fellow, 1999 Life, 2008

Bradley, Oscar Clyde, Jr. Hughes Springs, Texas November 18, 1925 – January 14, 2010 Good Fellow, 1978 Life, 1990 Fifty Year, 2003

Memorial and Honorarium Donors to the Texas Dental Association Smiles Foundation

In Honor of: Dr. Kent Macaluay By Brad and Shelli Lankford Dr. and Mrs. T.J. Randers By Dr. and Mrs. Barry J. Currey Dr. and Mrs. Russell Owens By Stephanie and Fred Spradley Lewis T. Stevens By Dr. and Mrs. Russell Owens Your memorial contribution supports: • educating the public and profession about oral health; • enhancing the public image of dentistry; and • improving access to dental care for the children of Texas.

Corbett, Edward Kimball Dallas, Texas January 27, 1938 – January 1, 2010 Life, 2004

Cunningham, James Stier Houston, Texas February 22, 1926 – January 13, 2010 Good Fellow, 1974 Life, 1991 Fifty Year, 1999

Helm, Lee Walker, Jr. Woodway, Texas January 14, 1922 – January 16, 2010 Good Fellow, 1980 Life, 1987

Williams, John L. Houston, Texas December 31, 1937 – January 26, 2010 Good Fellow, 2004 Life, 2004

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

Please make your check payable to:

TDA Smiles Foundation, 1946 S IH 35, Austin, TX 78704

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Staff Meetings: Their Impact on Dental Practice Kathleen M. Roman, MS; The Medical Protective Company A successful dental practice is never an accident. Key elements of a wellrun dental office include clinical excellence, effective business processes, and patient-centered communication. Of the three, communication is most easily overlooked. Since most dental offices employ fewer than 20 people, doctors and staff may assume that communication should occur often and freely within the team. But in the course of a busy office day, important elements of good communication can get lost in the shuffle â&#x20AC;&#x201D; unless they are part of the culture of the organization. These losses may result in errors â&#x20AC;&#x201D; and even the smallest errors can have a negative impact on efficiency, expenses, and team morale. Some errors also have the potential to anger patients or even to cause them harm. If communication is an effective means of preventing these problems, then communication skills should be modeled and reinforced. They should be central to all of the activities that take place in the practice. And they should occur within a framework. A good example of this type of communication is the office staff meeting. It provides an opportunity, away from the ongoing interactions with patients, for doctors and their staffs to answer questions, address challenges, formulate plans, and improve team effectiveness and satisfaction. For example, during a series of recent risk management seminars, dentists were asked how many of them held staff meetings. Overall, 48 percent reported that they did have staff meetings. However, only 38 percent stated that they schedule staff meetings at least quarterly. Of those reporting regularly-scheduled meetings, 55 percent reported monthly staff meetings as part of their regular team updates. However, of that group, four percent of doctors confessed that they themselves might not always attend the staff meetings.

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Staff meetings are an important means of building a successful dental practice. Their numerous benefits have been reported by human resources experts, clinical consultants, and business schools. Following is a sampling of benefits that have relevance for dental offices: 1. Everyone is on the same page. Staff meetings keep members of the team apprised of the ongoing activities of the practice while providing a forum for identifying and addressing changes, questions, or concerns. Staff meetings also enable the group to take action by: a. b. c.

Formulating multiphase action plans; Broadening the forum for ideas, suggestions, and research. Preventing and/or addressing misunderstandings, deviation from group policies, and unpleasant surprises.

2. The group has a forum. Rather than using a shotgun approach to address questions and concerns, staff meetings provide a framework that should prevent important issues from being overlooked, forgotten, or decided in haste without thorough review and discussion. Here’s an example. On a busy day, a clinic employee suddenly has a brainstorm about how to solve a particular problem. She plans to share her idea with the practice administrator at her first opportunity. But by the next day she’s forgotten all about it. If the practice had set up an electronic or paper file for the meeting agenda, the employee’s good idea could have been preserved and discussed at the next meeting. 3. The better the team, the better the leader. Staff meetings are inclusive activities. They encourage openness and participation. They help to prevent inadvertent communication errors, and they help identify and resolve misunderstandings and disagreements. In offices that don’t encourage the sharing of information, the doctor is often the last one to know when something isn’t going as planned. Unaware, the doctor loses the chance to suggest resolutions. And from a risk management perspective, what the doctor doesn’t know may be a matter of practice error, patient safety, and potential liability. A dental practice is a business. Its leader/s must exemplify business skills and people skills as well as clinical skills. Team meetings provide benefits for each of these important areas. 4. The better the team, the better the employee satisfaction. Numerous industry and human resources experts report that employees’ sense of inclusion and value as part of a team is the single most important factor in the retention of an outstanding workforce. Staff meetings comprise one of several effective tools that doctors can use to build collaborative and professional teams. Outstanding teams also have a remedial effect on employees who may be struggling to complete their assigned duties, recall office policies and procedures, or have inter-office issues. The employees of a dental practice may note the strengths and weaknesses of a new employee before the doctor notices them.

5. A highly-professional staff reduces the doctor’s workload — and may also help reduce the doctor’s liability exposures. In a busy practice, it’s impossible for the dentist to monitor everything at once. The only way to develop a trustworthy team is for the group to rely on one another. As staff members assume personal accountability for various duties, the doctor will have to be less involved with oversight and more involved with coaching and leadership. The American Dental Association (ADA) provides a variety of educational materials and information about the importance of training and mentoring for dental office employees. Professional liability insurance companies and healthcare business consultants are also good resources for information about team-building in small businesses. Regardless of the environment, regularly-scheduled, results-focused meetings help the team stay on target. They encourage proposals, evaluation, and discussion of topics that are directly related to the group’s mission statement.

Conclusion Team meetings help establish esprit de corps. They enable doctors and their employees to model inclusivity, teamwork, and patient partnerships. Team meetings help prevent misunderstandings and errors. They can help improve efficiency, reduce costs, and lower liability exposures. For more information about the management of team meetings, dentists are encouraged to contact their professional liability carriers. Use the following checklist to see if you’re getting the most benefit from your team meetings.

True/False: ___ Our team has staff meetings at least once per quarter. ___ Everyone on the staff attends. ___ Our dentist/s always attend our staff meetings. ___ We establish an agenda in advance. Anyone can propose a topic. ___ We use our staff meetings as a platform for identifying problems. ___ We use our staff meetings as a platform for providing information and updates. ___ Every staff meeting has an educational component. ___ We use staff meetings to build team effectiveness and good will. ___ Our staff meeting allows time for questions and answers. Kathleen M. Roman is Risk Management Education Leader for Medical Protective, a TDA Perks Program partner, and the nation’s oldest professional liability insurance company, serving healthcare since 1899. Kathleen welcomes readers’ comments and questions. She can be reached at: kathleen. roman@medpro.com. For more information regarding other TDA Perks programs, please visit tdaperks.com; or call (512) 443-3675.

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Oral and Maxillofacial Pathology Diagnosis and Management

Diffuse Large B-cell Lymphoma of the Oral Cavity Oral and Maxillofacial Pathology Case of the Month (from page 317)

Discussion

aggressive but treatable with a variable clinical presentation and progression (7).

Lymphomas have been divided into two major subtypes: Hodgkin’s lymphoma and Non-Hodgkin’s lymphoma. Hodgkin’s lymphoma present most frequently as nodal disease, with predilection for the head, neck and mediastinal nodes. Non-Hodgkin’s lymphoma (NHL) is a heterogeneous group of malignancies with a predilection to involve extranodal tissues (1–4). One third of NHL arises in tissue other than the lymph nodes, spleen, Waldeyer’s ring and thymus. The gastrointestinal tract is the most frequent site of extranodal lymphoma (4–20 percent) followed by the head and neck (15 percent). NHL presenting with oral symptoms is uncommon and lesions of the oral cavity and jaws represent only about 2 percent of all NHL (5). Clinical and radiographic features of NHL in the oral cavity and jaws can be nonspecific and mimic inflammatory and reactive disorders. NHL in the oral cavity has been reported to be predominately of the diffuse large B-cell lymphoma (DLBCL) subtype (3, 5). Diffuse large B cell lymphoma represents about 30–40 percent of all NHL and up to 40 percent of these arise in extranodal sites and this may explain its tendency to predominate in the oral cavity (3–5). This subtype is considered to be

Clinical and Radiographic Features

Figure 4. Microphotograph (4X) Sheet-like proliferation of large cells, diffusely invading the connective tissue. Surface mucosa appears normal.

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Diffuse large B-cell lymphoma most likely occurs in patients in the sixth and seventh decades of life with a slight male predominance. Clinically, they may present as a rapidly growing pink, red or bluish-red mass that may or may not be ulcerated. They are usually asymptomatic; however there may be slight pain and numbness in larger lesions (1, 3–5). Our patient had a large red to blue, somewhat ulcerated mass, emanating from the socket of tooth #15. There may or may not be bone involvement and it may present as an ill-defined radiolucent lesion or as non-specific bone loss as seen in periodontal disease (4, 6). In our case, the changes in the bone were characteristic of periodontal disease, and not initially suspicious for neoplasia. Jaw involvement by NHL is rare, but among jaw lesions, the maxilla is more frequently involved than the mandible (6). In the oral cavity lymphomas will arise more commonly in the tonsil and Waldeyer’s ring, however the tongue, palate, gingiva, and lip have also been reported (3, 5).

Figure 5. Microphotograph (10x) Large cell proliferation with multiple tingible body macrophages.

Histology

References

Diffuse large B cell lymphoma is characterized histologically by a sheet-like proliferation of large lymphoid cells with abundant cytoplasm and large oval nuclei with prominent nucleoli. Immunohistochemically, these cells express B cell markers CD20 and CD79a. Also they will demonstrate variable staining with the germinal center cell markers CD10 and Bcl-6 (2, 3, 5).

1. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. Third Edition. St. Louis, MI. 2009, 2002 SAUNDERS ELSEVIER. 2. Jaffe E, Harris N, Stein H, Vardiman J, World Health Organization classification of tumours. Pathology and genetics of tumours of the hematopoietic and lymphoid tissues. Lyon (France): IARC Press; 2001. 3. Kemp S, Gallagher G, Kabani S, Noonan V, O’Hara C. Oral Non-Hodgkin’s lymphoma: review of the literature and World Health Organization classification with reference to 40 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105: 194-201. 4. Kolokotronis A, Konstantinou N, Christakis A, Zaraboukas T, Antoniades D. Localized B cell nonHodgkin’s lymphoma of oral cavity and maxillofacial region: A clinical study. Oral surg Oral Med Oral Pathol Oral Radiol Endod 2005; 99: 303-310. 5. Takahashi N, Tsuda N, Tezuka F, Okabe H. Primary non-Hodgkin’s lymphoma of the oral region. J Oral Pathol Med 1989; 18:84-91. 6. Kini R, Saha A, Naik V. Diffuse Large B-cell lymphoma of mandible: A case report Med Oral Patol Oral Cir Bucal. 2009 Sep 1; 14 (9):e421-4. 7. Epstein JB, Epstein JD, Le ND, Gorsky M. Characteristics of oral and paraoral malignant lymphoma: a population-based review of 361 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 92:519-25. 8. Someya M et al. Three cases of diffuse large B cell lymphoma of the mandible treated with radiotherapy and chemotherapy. Radiation Medicine 2005; 23, 4: 296-302

In our case, histologic examination revealed a large nodular mass composed of large lymphoid cells that infiltrated diffusely and in groups between the connective tissue. Most lymphocytes were large and appeared centroblastic to immunoblastic and occasionally plasmacytoid (Figure 4). Some mitotic figures and tingible body macrophages were also present (Figure 5). The neoplastic cells were positive for CD20 (Figure 6) and CD79a (Figure 7).

Treatment and Prognosis Treatment of NHL is based on several factors, such as grade and stage of the lymphoma (2). Diffuse large B cell lymphoma is usually an intermediate to high grade malignancy, however it tends to remain localized, and most of the cases presenting in the oral cavity are stage I or II (3, 4, 6, 7). Surgery is not a treatment of choice when histology has been confirmed. With localized disease the treatment of choice consists of radiation and chemotherapy, which will provide local control. With more disseminated disease, chemotherapy alone is usually performed. Radiation therapy alone is not sufficient for tumor control of stage I and II NHL and additional treatment with chemotherapy may be necessary (7–8). Our patient was referred to a multidisciplinary institution for final staging and treatment.

Figure 6. Microphotograph (4X) CD20 Immunoperoxidase stain. Neoplastic cells are positive for CD20 confirming B-cell origin.

Figure 7. Microphotograph (4X) CD79a Immunoperoxidase stain. Neoplastic cells stain positive.

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Calendar of Events 324

April 2010

10 The TDA Smiles Foundation will hold the Fluoride Fest in Goliad. For more information, please contact the TDA Smiles Foundation, 1946 S. IH 35, Ste. 300, Austin, TX 78704. Phone: (512) 448-2441; Web: tdasf.org. 12 – 14 The American Dental Association Washington Leadership Conference will be held in Washington, D.C. For more information, please contact Ms. Cynthia Taylor, ADA, 1111 14th St., NW, Suite 1200, Washington, D.C. Phone: (202) 789-5172; FAX: (202) 898-2437; E-mail: taylorc@ada.org. 15 – 17 The Greater Houston Dental Society will hold the Star of the South Dental Meeting at the George R. Brown Convention Center in Houston, TX. For more information, please contact Ms. Charlotte Bolls, GHDS, 1001 Avenida de las Americas, Houston, TX 77010. Phone: (713) 961-4337; FAX: (713) 9613617; E-mail: cbolls@ghds.org; Web: starofthesouth.org. 15 – 17 The American Society of Dental Anesthesiologists will hold its Annual Scientific Session and House of Delegates at the Fairmont Olympic Hotel in Seattle, WA. For more information, please contact Ms. Amy Brown, ASDA, 6038 Callaway Court, Centreville, VA 20121. Phone: (703) 266-2335; FAX: (703) 2663114; E-mail: asda@asdahq.org; Web: asdahq.org. 27 – May 1 The American Academy of Cosmetic Dentistry will hold its annual scientific session, Excellence in Cosmetic Dentistry 2010, at the Gaylord Texan Resort & Convention Center in Grapevine, TX. For more information, please contact Ms. Kelly Radcliff, AACD, 540 World Dairy Dr., Madison, MI 53718. Phone: (800) 543-9220; FAX: (608) 222-9540; E-mail: kelly@aacd.com; Web: aacd.com. 29 – May 1 The American Dental Society of Anesthesiology will hold its annual meeting at the Ritz Carlton Key Biscayne in Key Biscayne, FL. For more information, please contact Mr. R. Knight Charlton, ADSA, 211 E. Chicago Ave., Ste. 780, Chicago, IL, 60611. Phone: (312) 664-8270; FAX: (312) 642-9713; E-mail: adsahome@mac.com; Web: adsahome.org. 30 – May 4 The American Association of Orthodontists will hold its annual session at the Washington Convention Center in Washington, D.C. For more information, please contact Ms. Pam Hoffman, AAO, 401 N. Lindbergh Blvd., St. Louis, MO 63141. Phone: (314) 993-1700; FAX: (314) 997-1745; E-mail: phoffman@aaortho.org; Web: aaomembers.org.

May 2010

6–9 The Texas Dental Association will hold its 140th annual meeting, The TEXAS Meeting, at the San Antonio Convention Center in San Antonio, TX. More than 530 booths will be on exhibit. For more information, please contact Ms. Sandy Blum, TDA, 1946 S. IH35, Ste. 400, Austin, TX 78704. Phone: (512) 443-3675; FAX: (512) 443-3031; E-mail: sblum@tda.org; Web: texasmeeting.com. 22 The TDA Smiles Foundation will hold a Smiles on Wheels in Goliad. For more information, please contact the TDA Smiles Foundation, 1946 S. IH 35, Ste. 300, Austin, TX 78704. Phone: (512) 448-2441; Web: tdasf.org. 20 – 23 The Society of American Indian Dentists will hold its annual conference at the Embassy Suites in Omaha, NE. For more information, please contact Dr. Tamana Begay, Society of American Indian Dentists, 4212 N. 16th St., Phoenix, AZ 85016. Phone: (602) 263-1200; E-mail: doctorbegay@hotmail.com. 27 – 30 The American Academy of Pediatric Dentistry will hold its 63rd annual session at the Hilton Chicago in Chicago, IL. More than 120 booths will be on exhibit. For more information, please contact Ms. Kristin Olson, AAPD, 211 E. Chicago Ave., Ste. 1700, Chicago, IL 60611-2663. Phone: (312) 337-2169; FAX: (312) 337-6329; E-mail: kolson@aapd.org; Web: aapd.org.

June 2010

10 – 13 The Organization for Safety & Asepsis Procedures will hold its annual Infection Prevention and Safety Symposium at the Hyatt Regency Tampa in Tampa, FL. For more information, please contact Ms. Therese Long, OSAP, PO Box 6297, Annapolis, MD 21401. Phone: (410) 571-0003; FAX: (410) 571-0028; E-mail: tlong@osap.org; Web: osap.org. 11 – 12 The TDA Smiles Foundation will hold a Texas Mission of Mercy in Williamson County, Taylor, Texas. For more information, please contact the TDA Smiles Foundation, 1946 S. IH 35, Ste. 300, Austin, TX 78704. Phone: (512) 448-2441; Web: tdasf.org.

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24 – 26 The ADA will hold its 24th New Dentist Conference in San Diego, CA. For more information, please contact Mr. Ron Polaniecki, ADA, 211 East Chicago Avenue, Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org. 24 – 26 The American Association of Women Dentists will hold its annual meeting, A Taste of Dentistry in Chicago, in Chicago, IL. For more information, please contact Ms. Deborah Gidley, AAWD, 216 W. Jackson Road, Ste. 625, Chicago, IL 60606. Phone: (800) 920-2293; Fax: (312) 750-1203; E-mail: info@aawd.org; Web: aawd.org.

July 2010

8 – 11 The Academy of General Dentistry will have its annual meeting at the Ernest Morial Convention Center in New Orleans, LA. For more information, please contact Ms. Rebecca Murray, AGD, 211 E. Chicago Avenue, Suite 900, Chicago, IL 60611-2616. Phone: (312) 440-3368; FAX: (312) 440-0559; E-mail: agd@ agd.org; Web: agd.org. 8 – 13 The American Dental Association Kellogg Executive Management Program will be held in Chicago, IL. For more information, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Avenue, Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org. 16 – 20 The National Dental Association will hold its 97th annual convention at the Hilton Hawaiian Village Resort in Honolulu, HI. For more information, please contact Ms. LaVette Henderson, NDA, 3517 16th Street NW, Washington, DC 20010-3041. Phone: (202) 588-1697; FAX: (202) 588-1244; E-mail: 1henderson@ ndaonline.org; Web: ndaonline.org. 22 – 24 The American Academy of Craniofacial Pain will have its 25th Anniversary International Clinical Symposium at the Grand America Hotel in Salt Lake City, UT. For more information, please contact Mr. Gary Shaw, AACFP, 1901 N. Roselle Rd., Suite 920, Schaumburg, IL 60195. Phone: (847) 885-1272; FAX: (847) 885-8393; E-mail: central@aacfp.org; Web: aacfp.org.

August 2010

3–6 The American Academy of Esthetic Dentistry will hold its 35th annual meeting at the Ritz-Carlton Kapalua in Maui, HI. For more information, please contact Ms. Jennifer Hopkins, AAED, 737 N. Michigan Ave., Ste. 2100, Chicago, IL 60611. Phone: (312) 981-6774; FAX: (312) 981-6787; E-mail: info@estheticacademy. org; Web: estheticacademy.org. 13 – 14 The TDA Smiles Foundation will hold a Texas Mission of Mercy in Waco. For more information, please contact the TDA Smiles Foundation, 1946 S. IH 35, Ste. 300, Austin, TX 78704. Phone: (512) 448-2441; Web: tdasf.org.

September 2010

10 – 15 The ADA will hold its Kellogg Executive Management Program (ADAKEMP) in Chicago, IL. For more information, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org. 27 – October 2 The American Association of Oral Maxillofacial Surgeons will hold its 92nd annual meeting at McCormick Place in Chicago, IL. For more information, please contact Dr. Robert C. Rinaldi, AAOMS, 9700 W. Bryn Mawr, Rosemont, IL 60018. Phone: (847) 678-6200; FAX: (847) 678-6286; Web: aamos.org.

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

Calendar of Events

18 – 19 The Southwestern Society of Oral Medicine will hold its 61st annual meeting, “Current Issues in Oral Radiology,” at the Marriott Plaza San Antonio Hotel in San Antonio, TX. For more information, please contact Dr. Ron Trowbridge, 2943 Thousand Oaks, Suite 4, San Antonio, TX, 78247. Phone: (210) 6537174; FAX (210) 653-8204.

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Confidential and experienCed LegaL RepResentation

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Representation before the Texas Medical Board, The Texas Medical Foundation and Medical Staff Peer Review. Medical Practice Act and Medical Board Actions (hearings, settlement conferences and licensure) • Personal Counsel in Medical Liability Cases • Probation Modification / Termination • Managed Care Exclusions • Licensure • Reinstatement • Medico-legal Issues • Expert Review • Telemedicine • Medicare/Medicaid Appeals • Medical Ethics Opinions • Physician Assistants. tony cobos*

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shaRp & cobos, P.C. Attorneys At LAw 4705 spicewood spRings Road • suite 100• austin, texas 78759 • 512 473 2265 • fax: 512 473 8525 • www.sharpcobos.com * Board Certified in Administrative Law by the Texas Board of Legal Specialization.

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Stefanie Clegg, TDA Web and New Media Manager Department of Member Services & Administration

Announcing the Texas Dental Journal EZ Flip on the new tda.org/tdapublications EZ Flip is a user-friendly, visually appealing online application program designed to make readers feel as if they are reading the Texas Dental Journal in its entirety. Benefits include: • • • • • •

Flip each page like you’re reading a book Print one page at a time or both facing pages at once Zoom in and out of each page Click on participating ads to access websites for more information Jump to specific pages or read cover to cover View all pages at once

The TDA publications site also includes archives, history, and awards for the Texas Dental Journal and TDA Today newsletter as well as advertising / subscription information and the editorial staff. NOTE: The new EZ Flip Journal on tda.org is an added benefit for TDA members. This does not replace the printed Journal you currently receive. Web Questions? Please contact Stefanie Clegg at (512) 443-3675 or stefanie@tda.org. Publication Questions? Please contact Nicole Scott at (512) 443-3675 or nicole@tda.org.

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g n i rtis

e v Ad IMPORTANT: Ad briefs must be in the TDA office by the 20th of two months prior to the issue for processing. For example, for an ad brief to be included in the January issue, it must be received no later than November 20th. Remittance must accompany classified ads. Ads cannot be accepted by phone or fax. * Advertising brief rates are as follows: 30 words or less — per insertion…$35. Additional words 10¢ each. If TDA box number is used, add $5 when figuring a cost. The JOURNAL reserves 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. All checks submitted by non-ADA members will be returned less a $20 handling fee. * Advertisements must not quote revenues, gross or net incomes. Only generic language referencing income will be accepted. Ads must be typed.

Briefs

Practice Opportunities MCLERRAN AND ASSOCIATES: NEW! AUSTIN: Quality, fee-for-service family practice located in affluent, quickly growing area of town. Practice grossed mid-six figures on part-time work schedule. Solid history of production, excellent retail location, and established patient base give this practice tremendous upside potential. NEW! AUSTIN: High grossing, family practice located in retail center with seven operatories was recently remodeled. Practice boasts solid, well-established patient base. AUSTIN: Five operatory general family practice with high quality fee for service patient base. State-of-the-art, all digital and paperless office is as attractive as they come. Grossing above mid-six figures with very low overhead. ID #103.

lent satellite office or starter practice. The doctor currently works 2 days per week. The practice is located in growing area with new subdivisions being built, is 20 minutes from Concan Country Club (a top rated new course in Texas) and is in an excellent retirement area. ID #063. RIO GRANDE VALLEY: Excellent four operatory, 20-year-old general practice. Modern, new finish out in retail location with digital radiography. Fee-for-service patient base and very good new patient count. Great numbers. Super upside potential. ID #093. RIO GRANDE VALLEY: Three op Medicaid oriented practice grossing high six figures on part-time work week. Excellent opportunity. ID #100. SAN ANTONIO AREA: Three operatory offices in small town with no competition. Very good income and low, low overhead. Priced to sell. ID #013.

CHILDRESS: Free-standing brick building in excellent location. All new equipment, 44-year-old practice, fee-for-service, excellent opportunity. ID #019.

NEW! SAN ANTONIO: Eight operatory, high grossing, fee-for-service family practice in historic free-standing building in affluent neighborhood.

CORPUS CHRISTI: Three operatory, feefor-service crown and bridge oriented family practice in a great location. The practice is grossing high six figures. ID #098.

SAN ANTONIO: High gross and net income general family practice located in high income area in very visible retail office center. The seven op office is in excellent condition, has a modern design, and is equipped with almost new equipment, all digital X-rays, and is fully computerized. Practice grossed seven figures last year. Price slashed! ID #094.

CORPUS CHRISTI: Doctor retiring, six op office with excellent visibility and access. Good numbers, excellent patient base, good upside potential. Excellent practice for starting doctor. Priced to sell. ID #023. HILL COUNTRY AREA: Well-established family practice located in desirable hill country town. Practice would be an excel-

SAN ANTONIO: Excellent four-chair general family practice in high traffic retail center across from busy mall location. Solid income on 30 hours a week. Ideal opportunity for doctor wanting a quick start in low overhead operation. ID #086. Texas Dental Journal l www.tda.org l March 2010

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in s i t r e dv

Briefs

SAN ANTONIO — Prosthodontic practice with almost new equipment and build out. Doctor wants to sell and continue to work as associate. Beautiful office! Perfect for stand alone or satellite office. ID #060. SAN ANTONIO — Three operatory general practice in condominium located in highly desirable and conveniently located medical center area. This practice would be an excellent starter practice and has tremendous upside potential. The condo is also for sale. ID #084. SAN ANTONIO, NORTH CENTRAL — Small, two-op practice just off major freeway; perfect starter office. Terrific pricing. ID #009. SOUTH TEXAS BORDER: General practitioner with 100 percent ortho practice. Very high numbers, incredible net. ID #021. NEW! SAN ANTONIO: Solid, five op general family practice located in high visibility retail project in medical center. Good equipment, nice decor, and loyal patient base. SAN ANTONIO: Four operatory general family practice located in professional office building off of busy thoroughfare in affluent north central side of town. Very nice equipment and decor. Excellent opportunity. WACO AREA: Modern and high-tech, three op general family practice grossing in mid six figures with high net income. Office is well equipped for doctor seeking modern office. NEW! HILL COUNTRY: Four operatory, “bread and butter” family practice located in attractive, quickly growing hill country town near San Antonio. Practice is in beautiful, hill country style free-standing

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building with nice equipment. HILL COUNTRY; NORTH SAN ANTONIO: Doctor retiring from extremely successful general practice. Four operatory freestanding building. Excellent location, equipment, staff, and patient base. Located in a very desirable area. HOUSTON AREA PRACTICE OPPORTUNITIES! MCLERRAN & ASSOCIATES. HOUSTON/CONROE AREA — Associate to buy-in opportunity. Six operatory family practice with well-established patient base and high net income. Doctor retiring. Great opportunity. ID #041. HOUSTON — Three-year-old Medicaid/ insurance practice with nice build-out (three operatories with two equipped and room for expansion), digital X-rays (including panoramic), high traffic location. Ideal demographics and tremendous upside potential for a buyer willing to open more than 3 days per week. ID #092. GOLDEN TRIANGLE — Eight operatory general family practice grossing in the low seven figures. The office is in great shape and has a modern, open concept design. The practice is in a highly residential area, sees a healthy amount of new patients per month with a solid cash flow. ID #104. HOUSTON AREA — Highly profitable, multi-doctor, investor size practice. The office has more than 10 ops and presents multi-specialty opportunities for owning doctor. Great return on investment. HOUSTON — Galleria area practice with high visibility in a retail location. This well decorated office has hardwood floors and high ceilings and is bright and appealing. Practice has digital X-rays with computers in the treatment rooms. Operated as a satellite office, with strong new

patient flow, a full-time dentist can take this practice to the next level.

tions. See www.dental-sales.com for pictures and more complete information.

NEW! HOUSTON: 20-year-old crown and bridge oriented family practice inside 610 Loop in highly visible office. FFS practice has new equipment with digital X-rays, production in mid-six figures. Low overhead practice refers out a number of procedures, giving this office tremendous upside potential.

GARY CLINTON — PMA: ABILENE / SAN ANGELO PRACTICES FOR SALE. A1-Abilene: Retiring dentist outright sale/PRN transition; great location on south side of Abilene. S1-San Angelo area: Perfect for recent graduate. Plenty of patients; exceptional value. S2-San Angelo: Excellent, well-established restorative practice. Very nice, newer equipment. Dentist relocation. Transitional/ outright sale. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 35 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to insure accuracy of appraisal (specialty and general). Our listings, no fee to buyers of our listings. Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

NEW! HOUSTON: Established, fee-forservice only, general family practice, beautiful new facility, digital X-rays, four operatories, grossing in mid-six figures. Located in one of Houston’s premier communities. ID #117. NEW! HOUSTON: Buy-in opportunity with premier group practice. Requires existing patient base close to Texas Medical Center area. Beautiful 12 operatory, high tech office with low overhead. Partner financed. ID #115. NEW; HOUSTON: General family practice located southwest of Houston, high visibility, grossing mid-six figures. Five operatories, two ready for expansion. Building and up to four acres of real estate ready for development included in sale. ID #116. NEW! HOUSTON: Established crown and bridge/removable practice with digital Xrays, great new patient flow, production in high six figures. PPO and fee-for-service only. Tremendous cash flow. ID #114. Contact McLerran Practice Transitions, Inc.: statewide, Paul McLerran, DDS, (210) 737-0100 or (888) 656-0290; in Austin, David McLerran, (512) 750-6778; in Houston, Tom Guglielmo and Patrick Johnston, (281) 362-1707. Practice sales, appraisals, buyer representation, and lease negotia-

GARY CLINTON TEXAS — THREE ORTHODONTIC PRACTICES ASSOCIATE/ TRANSITION AND OUTRIGHT SALES: O1-Within 90 miles of Austin: Flexible, will transition. Seven-figure practice, beautiful office. O2-West Central Texas midsized community: Professional referral based; traditional fee-for-service, referral, highly productive. Gorgeous building with room for two in this 50/50 partnership. O3-South Texas: Retiring orthodontist, transition flexible. Seven-figure practice collections; over 60 percent profits; lovely building. He is ready to spend time with grandchildren. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Texas Dental Journal l www.tda.org l March 2010

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Business Appraisers, Inc. “For over 35 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to insure accuracy of appraisal (specialty and general). Our listings, no fee to buyers of our listings. Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765. GARY CLINTON / PMA ORAL SURGERY PRACTICE FOR SALE, HOUSTON AREA: Northwest Houston (many referring dentists). Outright sale / transition as associate PRN. Seven figure gross. Seller will work 1-2 days as associate for purchaser PRN, phased retirement. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 35 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to insure accuracy of appraisal (specialty and general). Our listings, no fee to buyers of our listings. Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765. GARY CLINTON / PMA SOUTH TEXAS / BROWNSVILLE / HARLINGEN AREA: Excellent practice with flexible transition. Primarily fee-for-service and Delta Dental. High operating profits; more than seven figures in collections. Lovely office. Some ortho easily expanded to larger percentage of practice. Outright sale. Seller with transition / work for new owner as needed. We have the best sources for

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100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 35 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to insure accuracy of appraisal (specialty and general). Our listings, no fee to buyers of our listings. Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765. GARY CLINTON / PMA AMARILLO PRACTICE FOR SALE: Well established practice. Doctor relocating. High collections/net. Five operatory full hygiene; high productivity. Possible buy-out in future. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 35 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to insure accuracy of appraisal (specialty and general). Our listings, no fee to buyers of our listings. Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765. GARY CLINTON / PMA FRISCO / MCKINNEY / NORTH DALLAS AREA: Practice limited to orthodontics. Great location; mid-size practice. Expandable to more than 4,800 sq. ft. Dentist relocating to group practice. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 35

years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to insure accuracy of appraisal (specialty and general). Our listings, no fee to buyers of our listings. Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765. GARY CLINTON / PMA NORTH OF LUBBOCK PRACTICE FOR SALE. L-l Highly productive practice. Large growing patient base. Transitional phased retirement. He will work for purchaser as needed. Purchase building outright or leas/purchase. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 35 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to insure accuracy of appraisal (specialty and general). Our listings, no fee to buyers of our listings. Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765. GARY CLINTON / PMA BRYAN / COLLEGE STATION PRACTICE FOR SALE. Retiring dentist. Beautiful office; will transition as needed. Restorative practice. Well-established recall. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 35 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No con-

flict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to insure accuracy of appraisal (specialty and general). Our listings, no fee to buyers of our listings. Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765. GARY CLINTON / PMA NORTH OF DENTON PRACTICE FOR SALE. Grand practice for prosthodontist or experienced general dentist. Fast growing area. High income per capita. Excellent schools; down-home type community. Close to lakes/beautiful areas. Easy to get to DFW Metroplex. Cash cow with no Medicaid, seven figure gross with very high operating profits. Implant, cosmetic, restoration dentistry. Two parttime revenue producing specialists. This is an amazing 4-day-a-week practice. Owner will work 1-1.5 days as buyer’s associate. Pending offer. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 35 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to insure accuracy of appraisal (specialty and general). Our listings, no fee to buyers of our listings. Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765. SOUTHEAST HOUSTON GENERAL DENTAL PRACTICE — SALE: Incredible general dental practice with six operatories in a new facility. High revenues with excellent profit margin. Doctor relocating but is most interested in smooth transition. This is a wonderful opportunity to acTexas Dental Journal l www.tda.org l March 2010

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cumulate a substantial retirement “nest egg” with a low level of risk. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. CORPUS CHRISTI GENERAL DENTAL — SALE: Moderate revenues with a very healthy profit margin. Experienced and loyal staff. Totally digital and highly efficient facility layout. If you need to practice to refund your retirement but don’t want to fight the competitiveness of the city, come see this practice. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. EAST TEXAS ORAL & MAXILLOFACIAL SURGERY PRACTICE — SALE: Beautiful and spacious facility located in the heart of a rapidly growing Texas metropolis. Great opportunity for highly qualified surgeon with desire to assume responsibility for a wide spectrum of OMS procedures, expand surgical treatment, and dramatically increase income. Strong revenues and high profit margins; flexible acquisition terms! Must see opportunity! Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. SAN ANTONIO PROSTHODONTIC — SALE: Located inside the 410 loop, this 10-year-old practice produces moderate revenues on 3 days per week. Specializing in prosthodontics, the office could be expanded to a broader scope of restorative general dental treatment. Located in beautiful new offices, there are three treatment rooms with new equipment. Outstanding staff. Doctor must sell for health reasons but can transition over period of 3-6 months. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. HOUSTON ORAL SURGERY PRACTICE FOR SALE: Well-established 35-year-old

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practice with strong revenues and high profit margin due to limited competition. Outstanding mentor to transition. Wonderful staff. Practice building also available for sale. Whether you are just completing your residency or after 20 years in practice, you are tired of the snow, call us and come and meet this doctor. Contact The Hindley Group, (800) 856-1955. Visit us at www.thehindleygroup.com. GOLDEN TRIANGLE GENERAL DENTAL PRACTICE — SALE: Outstanding practice for sale developed by published mentor. Supported by outstanding staff and latest in dental equipment. Strong revenues and profit margin. Excellent new patient flow. Given high level of FFS revenues, doctor to transition to comfort level of purchaser. Come build your retirement in low competition community. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. CENTRAL EAST TEXAS — SALE: Outstanding practice for sale in beautiful East Texas. Moderate FFS revenues with three fully equipped operatories and an excellent staff. Doctor leaving for the mission field and interested in optimal transition. If you are an older doctor who needs to recomplete his retirement package after the stock market drop, and want to practice in a less competitive more relaxed environment, this is a must-see opportunity. Contact The Hindley Group at (800) 8561955. Visit us at www.thehindleygroup. com. NORTHWEST SAN ANTONIO GENERAL DENTAL PRACTICE — SALE: General dentistry practice with strong revenues and excellent new patient flow. Practice is located in highly visible location on well-traveled road. Four treatment rooms. Doctor is most anxious to facilitate strong transition. Contact The Hind-

ley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. DALLAS / FORT WORTH: Area clinics seeking associates. Earn significantly above industry average income with paid health and malpractice insurance while working in a great environment. Fax (312) 944-9499 or e-mail CJPatterson@kosservices.com. SOUTH OF HOUSTON GENERAL DENTAL PRACTICE — SALE: Outstanding practice with very high growth potential experiencing a strong new patient flow. Moderate revenues with a healthy profit margin on 4 days per week. Building also for sale. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. SUGAR LAND GENERAL DENTAL PRACTICE — SALE: Located at busy intersection with high traffic flow. Easy access to Houston. Strong revenues in high growth area. Excellent mentor to transition. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. NORTHWEST HOUSTON ORAL & MAXILLOFACIAL SURGERY PRACTICE — SALE: Well-established practice in growing area with strong revenues and excellent profit margin. Substantial referral base. Practice building also available for sale. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. NORTHWEST HOUSTON GENERAL DENTAL PRACTICE — SALE: Located near the intersection of 610 Loop and 290. Five-year-old practice with moderate revenues and healthy new patient flow on 3 days / week. Facilities include three operatories and three additional plumbed for expansion. Excellent oppor-

tunity for new grad. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. WEST HOUSTON GENERAL DENTAL PRACTICE — SALE: Wonderful opportunity in rapidly growing west Houston community. Strong revenue and profit margin. Wonderful staff. Practice has ortho emphasis, but seller will stay on to complete cases if necessary. Building also for sale. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. WACO PEDIATRIC DENTAL PRACTICE — SALE: Well-established practice with moderate revenues and high profit margin on 4 days per week. Due to limited competition and a large facility, there is ample room to grow in this community that is home to Baylor University. All ortho cases are being completed, unless purchaser would like to expand new cases. No Medicaid being seen, but good opportunity with enhanced state fee schedule. Experienced staff and steady new patient flow. Wonderful mentor. Building also available. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. NORTHWEST HOUSTON GENERAL DENTAL PRACTICE — SALE: new practice in growing area located near welltraveled Highway 290 and Jones Road. Two fully equipped treatment rooms with three others plumbed for expansion. Digital X-rays. Moderate revenues on 2.5 days / week. If you want to be in the rapidly growing northwest quadrant, this practice is for you. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. ASSOCIATESHIPS: SOUTH CENTRAL TEXAS PERIODONTAL: Wonderful pracTexas Dental Journal l www.tda.org l March 2010

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tice completing periodontal treatment seeks long-term associate who desires to be a partner within 1-2 years. Great location with strong new patient flow. Pre-determined purchase and partnership terms. Wonderful mentor looking for an “equally-yoked” individual. Excellent staff. DFW METROPLEX ORAL AND MAXILLOFACIAL SURGERY — Parkland trained surgeon seeking an “equally yoked” associate desiring to acquire the entirety of his practice within the next 3-5 years. Well-established practice enjoying 2008 revenues exceeding seven figures from two locations. Wonderful opportunity for a resident who has recently completed their program and who desires transition into practice ownership. You could not find a more superior partner! MIDLAND GENERAL DENTAL PRACTICE — Well established and growing practice with strong revenues and healthy profit margin on 4 days per week. Wonderful mentor with plenty of room to grow. SAN ANTONIO PERIODONTAL — Associateship with pre-determined buy-in for very active, multi-office periodontal practice. Outstanding mentor and cohesive staff. If you are the right person, this is an outstanding opportunity. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. HOUSTON SOUTHWEST GENERAL PRACTICE: Well-established general practice for sale with recent build out and equipment. Great merger candidate or stand-alone office. Call Jim Robertson, (713) 688-1749 or (713) 822-5705. HOUSTON CLEAR LAKE GENERAL PRACTICE: Small Clear Lake practice for merger opportunity or second office. Call Jim Robertson, (713) 688-1749 or (713) 822-5705. HOUSTON PASADENA ORTHO PRAC-

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TICE: Small ortho practice for merger opportunity or second office. Call Jim Robertson, (713) 688-1749 or (713) 822-5705. HOUSTON NORTHWEST ORTHO PRACTICE: Profitable, well-established ortho practice for sale. Call Jim Robertson, (713) 688-1749 or (713) 822-5705. ADS WATSON, BROWN & ASSOCIATES: Excellent practice acquisition and merger opportunities available. DALLAS AREA — Six general dentistry practices available (Dallas, North Dallas, Highland Park, and Plano); five specialty practices available (two ortho, one perio, two pedo). FORT WORTH AREA — Two general dentistry practices (north Fort Worth and west of Fort Worth). CORPUS CHRISTI AREA — One general dentistry practice. CENTRAL TEXAS — Two general dentistry practices (north of Austin and Bryan/College Station). NORTH TEXAS —One orthodontic practice. HOUSTON AREA — Three general dentistry practices. EAST TEXAS AREA —Two general dentistry practices and one pedo practice. WEST TEXAS — Three general dentistry practices (El Paso and West Texas). NEW MEXICO — Two general dentistry practices (Sante Fe, Albuquerque). For more information and current listings, please visit our website at www.adstexas.com or call ADS Watson, Brown & Associates at (469) 222-3200. DALLAS / FORT WORTH: Dental One is opening new offices in the upscale suburbs of Dallas and Fort Worth. Dental One is unique in that each office of our 60 offices has its own, individual name such as Riverchase Dental Care and Preston Hollow Dental Care. All our offices have top-of-the-line Pelton and Crane equipment, digital X-rays, and intra-oral cameras. We are 70 percent PPO, 30 percent full fee. We take no managed care or Medicaid. We offer competitive salaries and

benefits. To learn more about working for Dental One, please contact Rich Nicely at (972) 755-0836. HOUSTON DENTAL ONE is opening new offices in the upscale suburbs of Houston. Dental One is unique in that each office of our 50+ offices has its own individual name. All our offices have top-of-the-line Pelton and Crane equipment, digital Xrays, and intra-oral cameras. We are 100 percent FFS with some PPO plans. We offer competitive salaries, benefits, and equity buy-in opportunities. To learn more about working for Dental One, please call Andy Davis at (713) 343-0888. FULLY-EQUIPPED MODERN DENTAL OFFICE SPACE AVAILABLE FOR LEASE: Have four ops, current doctor is only using 2 days a week. Great opportunity to start up new practice (i.e. endo perio, oral surgery). Available days are Monday, Tuesday, and Thursday per week. Call (214) 315-4584, or e-mail ycsongdds@yahoo.com. TEXAS PANHANDLE: Well-established 100 percent fee-for-service dental practice for immediate transition or complete sale at below market price by retiring dentist. Relaxed work schedule with community centrally located within 1 hour of three major cities. The office building can be leased or purchased separately and is spaciously designed with four operatories, doctors’ private office and separate office rental space. This is an excellent and profitable opportunity for a new dentist, a dentist desiring to own a practice, or a satellite practice expansion. Contact C. Vandiver at (713) 2052005 or clv@tauruscapitalcorp.com. SUGAR CREEK / SUGAR LAND: General dentist looking for periodontist, endo, ortho specialist to lease or sell. Suite is 1,500

sq. ft. with four fully-equipped treatment rooms, lab, business office, telephone system, computers, reception and playroom; 5 days per week. If seriously interested, please call (281) 342-6565. PRACTICE OWNER IN LUBBOCK is searching for a full-time associate dentist. Ideal candidate is comfortable performing extractions, interest in implants is a plus. No nights or weekends. Full-time package includes: base salary, bonus potential; benefits to include: health, malpractice, CE, and a 401K plan with matching funds. Call or e-mail Mike to learn more: (800) 313-3863, mike.james@affordablecare.com. Practice visit and working interviews are available. The right dentist can start immediately. TOP OF THE HILL COUNTRY GENERAL PRACTICE FOR SALE. Beautiful freestanding building in growing Clifton medical/arts district. Well established, quality oriented, five ops, FFS. Easy proximity to Dallas, Austin, and Lake Whitney. Doctor relocating but willing to provide flexible transition terms. If you are tired of patient turnover and want to make a difference in patients’ lives, this it the opportunity you’ve been looking for. Call (254) 675-3518 or e-mail dnicholsdds@ earthlink.net. AUSTIN: Unique opportunity. Associateship and front-office position available for husband/wife team. Southwest Austin, Monday through Thursday. Option to purchase practice in the future. Send resume and questions to newsmile@onr. com. GALVESTON ISLAND: Unique opportunity to live and practice on the Texas Gulf coast. Well-established fee-for-service, 100 percent quality-oriented practice looking for a quality oriented associate. Texas Dental Journal l www.tda.org l March 2010

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Ideal for a new graduate or for an experienced dentist wanting to relocate and become part of an established practice with a reputation for providing comprehensive, quality dental care with a personable approach. Practice references available from local specialists. Contact Dr. Richard Krumholz, (409) 762-4522. ROUND ROCK GENERAL PRACTICE FOR SALE. High visibility location. I want to move to my satellite office full-time. Only one PPO (Delta). E-mail inquiries to buyaroundrockdentalpractice@yahoo. com or call (512) 965-6725. IRVING PRACTICE FOR SALE: Long-established, four operatory (three equipped and one plumbed/unequipped) GP located in a popular and growing area of Irving. Efficient management systems, a trained staff, and stable patient base are in place for the next dentist to step in and begin practicing dentistry. The seller is retiring. Contact Practice Transition Partners at (888) 789-1085 or visit www. practicetransitions.com. EL PASO: FULL- OR PART-TIME ASSOCIATE NEEDED. Would be sole practitioner at location. Three operatories for DDS plus one for hygienist, equipment less than 1 year old. Past compensations up to 5-figures per week. No administrative responsibilities. Call (702) 510-7795 or email drartbejarano@gmail.com. ASSOCIATE NEEDED — NE TEXAS: Pittsburg is surrounded by beautiful lakes and piney woods. Well-established, quality-oriented, busy cosmetic and family practice. Associate to partnership opportunity. Call Dr. Richardson at (903) 856-6688. HOUSTON: Small group practice with three locations in and around Houston

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area seeking highly motivated general dentist to share in a fee-for-service, wellestablished private practice. High income potential with full doctor autonomy. Please send CV to amihuynh@yahoo.com. HOUSTON: General dentist with pediatric experience needed. Full-time position available. Excellent compensation. Please send CV to cvanalfen@yahoo.com. ASSOCIATE PARTNER, SOUTHEAST HOUSTON — WEBSTER: Excellent opportunity for a highly energetic, enthusiastic, hard working general dentist. Beautiful high-tech family practice is seeking an exceptional well rounded individual to take over existing adult patient base. Individual must be self motivated, experienced, and willing to work hard to obtain goals. Office is in great location with state-of-the-art equipment with the latest technology. The general dentist area has five treatment rooms with high production potential. Call (281) 488-2483 or fax resume (281) 488-3416. ASSOCIATE FOR TYLER GENERAL DENTISTRY PRACTICE: Well-established general dentist in Tyler with 30+ years experience seeks a caring and motivated associate for his busy practice. This practice provides exceptional dental care for the entire family. The professional staff allows a doctor to focus solely on the needs of their patients. Our office is located in beautiful East Texas and provides all phases of quality dentistry in a friendly and compassionate atmosphere. The practice offers a tremendous opportunity to grow a solid foundation for the doctor. The practice offers excellent production and earning potential with a possible future equity position available. Our knowledgeable staff will support and enhance your growth and earning potential

while helping create a smooth transition. Interested candidates should call (903) 509-0505 and/or send an e-mail to steve.lebo@sbcglobal.net.

well as performing all types of dentistry. Please send CV or contact Dr. John Bond at jbond@6daydental.com. Visit www.6daydental.com.

HOUSTON: Would you enjoy owning a well-established neighborhood dental practice in the Heights section of Houston? Located in a mixed use professional building, this practice has enabled the current owner to retire without financial stress. My client is ready to transition this great two operatory facility to the right dentist. It is priced right and ready to take you to the next level of your career. Call Jack Sayyah, (877) 905-1515.

ASSOCIATE NEEDED FOR NURSING HOME DENTAL PRACTICE. This is a non-traditional practice dedicated to delivering care onsite to residents of long term care facilities. This practice is centered in Austin but visits homes in the central Texas area. Portable and mobile equipment and facilities are used, as well as some fixed office visits. Patient population presents unique technical medical, and behavioral challenges, seasoned dentist preferred. Buy-in potential high for the right individual. Please toward CV to e-mail renee@austindentalcares.com; FAX (512) 238-9250; or call (512) 2389250 for additional information.

EXPERIENCED RESTORATIVE DENTIST (PANKEY/LVI TYPE) who enjoys aesthetics and full-mouth rehab needed to lead a first-class, full service practice. Unique practice model affords the opportunity to earn high income doing big cases and coordinating patient care with our specialty teams. Practice with the support of a veteran team in a beautiful practice. Contact Dr. John Bond at jbond@6daydental.com. 6 DAY DENTAL & ORTHODONTICS is an established group practice model, providing all dental services to our patients under one roof. Our general dentists and specialists work together to provide the most convenient and quality dental care possible. We are growing and have an immediate opportunity for a general dentist or prosthodontist with future partnership/equity opportunity. 6 Day Dental & Orthodontics just may be the premier feefor-service alliance of dental practices in the country. Our doctors earn more, see fewer patients, and have plenty of time off to enjoy a rich and healthy lifestyle. New grads and experienced dentists/prosthodontists welcomed. Our dentists earn in the top 10 percent of extractions, as

PEDIATRIC DENTIST: Pediatric Dental Wellness is growing and needs a dynamic dentist to work full time in our pediatric practice. The perfect complement to our dedicated staff would be someone who is compassionate, goal oriented, and has a genuine love for working with children. If you are a motivated self-starter that is willing to give us a long-term commitment, please apply. Salary plus benefits. Looking to fill position immediately. Send resumes and cover letters to candice. n.moore@gmail.com. WE ARE A PRIVATELY-OWNED PROFESSIONAL CORPORATION established in 1994, operating seven thriving dental practices in the greater Houston area with plans for expansion. We offer excellent career opportunities for highly motivated professionals interested in achieving strong, solid reputations in the dental community while building personal, caring patient relationships with excellent growth potential; 4.5-day work week, no Texas Dental Journal l www.tda.org l March 2010

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weekends; lucrative compensation package; unlimited earning potential; comprehensive benefit programs, paid holidays, 401K, CEU reimbursement, paid vacations, and more. We are currently seeking full-time general dentists to provide professional, chair-side dental procedures and advise patients on preventive, restorative, and surgical dental care. Will consider experience at various levels, including recent graduates. Contact Michael J. Carew, (281) 296-8600. GREAT OPPORTUNITY FOR A PEDIATRIC DENTIST OR GP to join our expanding practice. We are opening a new practice in the country (Paris, Texas), just 1 hour past the Dallas suburbs and our original location. The need for a pediatric dentist out there is tremendous, and we are the only pediatric office for 70 miles in any direction. We are looking for someone that is personable, caring, energetic, and loves a fast-paced working environment in a busy pediatric practice. We are willing to train the right individual if working with children is your ambition. This position is part-time initially, and after a short training period will lead to full-time. If you join our team, you will be mentored by a Board certified pediatric dentist and will develop experience in all facets of pediatric dentistry including behavior management using oral conscious sedation as well as IV sedation. For more information, please visit our websites at www.wyliechildrensdentistry. com and www.parischildrensdentistry. com. Please e-mail CV to allenpl2345@ yahoo.com. Office Space SPACE AVAILABLE FOR SPECIALIST. New professional building located southwest of Fort Worth in Granbury between elementary and junior high schools off of a state highway with high visibility

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and traffic. Call (817) 326-4098. HIGH TRAFFIC SHELL BUILDING IN ROUND ROCK, north of Austin, in one of the fastest-growing counties, Available at $155 / sq. ft. For more information, email jacque@rgtate.com or call (512) 8482509. DENTAL / MEDICAL OFFICE in Medical Center area. Nicely finished out; move-in ready; all bills paid. Up to 3,509 sq. ft. (1,608 sq. ft. and 1,892 sq. ft.) for $5,800 / month. Call Shannan Schnittger, broker, (210) 930-3700. DENTAL OFFICE SPACE AVAILABLE MARCH 2010 IN WIMBERLEY, a true “small town” in the heart of the Hill Country. Originally designed/built for a dentist; excellent location across the street from Wimberley High School and Middle School. Parking, ADA accessible, highspeed internet available, community water supply. Call Leslie Howe at (512) 8479361. SHERMAN — 1,750 SQ. FT. DENTAL OFFICE. Building has established general dentist and perio/implant dentist. Plumbed and ready to go. High traffic and visibility with lots of parking. Sherman is beautiful and growing town 50 miles north of Dallas and near Lake Texoma, the second largest lake in texas. It has great schools, a vibrant arts community, and is home to many, many Fortune 500 companies such as Texas Instruments and Tyson Foods. Call (760) 436-0446. DENTAL OFFICE FOR SALE / LEASE IN NORTHEAST TEXAS: A 2,800 sq. ft. six operatory office built 10 years ago is available in a town of 12,000 that needs a general dentist. Situated in an attractive professional park, this office features a large sterilization area, dual rear entry

operatories, dental cabinetry in five of the six ops, wood floors, and three bathrooms. A great opportunity for a mature dentist looking for good hunting and fishing in a small town environment, or a new grad wanting an instant patient pool and room to grow. Call Cheryl at (903) 649-8222 or (903) 753-2988 or e-mail buybuilding@ bachteldental.com. For Sale ESTABLISHED, FULLY EQUIPPED THREE OPERATORY LAB FOR SALE OR LEASE in Plainview. High visibility location. Seller retiring. Mentor to transition possible. Call (806) 293-2686 or (806) 292-3156.

Interim Services TEMPORARY PROFESSIONAL COVERAGE (Locum Tenens): Let one of our distinguished docs keep your overhead covered, your revenue-flow open wide, your staff busy, your patients treated and booked for recall, all for a flat daily rate not a percent of production. Nationâ&#x20AC;&#x2122;s largest, most distinguished team. Shortnotice coverage, personal, maternity, and disability leaves our specialty. Free, no obligation quotes. Absolute confidentiality. Trusted integrity since 1996. Some of our team seek regular part-time, permanent, or buy-in opportunities. Always seeking new dentists to join the team. Bread and

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in s i t r e dv

Briefs

butter procedures. no cost, strings, or obligations —ever’ work only when you wish. name your fee. Join online at www. doctorsperdiem.com. Phone: (800) 6000963; e-mail: docs@doctorsperdiem.com. OFFICE COVERAGE for vacations, maternity leave, illness. Protect your practice and income. Forest irons and Associates, (800) 433-2603 (Est). web: www.forestirons.com. “Dentists Helping Dentists since 1983. “

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Miscellaneous LOOKING TO HIRE A TRAINED DENTAL ASSISTANT? we have dental assistants graduating every 3 months in Dallas and Houston. to hire or to host a 32-hour externship, please call the national school of Dental Assisting at (800) 383-3408, www.schoolofdentalassisting-plano.com. ESTABLISHED DENTAL ASSISTING SCHOOL searching for general dental office to lease on 1 weekend day and 1 weeknight near Plano. ongoing 12-week course. Please call Dr. Peter najim, (800) 509-2864, pnajim@dentalassist.org.

ORAL & MAXILLOFACIAL, PLLC, has an opening in Fort Worth and Arlington for a clinical instructor to teach interns/ residents to diagnose, treat, and manage patients in a range of ambulatory oral and maxillofacial procedures involving adult and pediatric patients. Includes management of advanced traumatic injuries and pathologic conditions, orthognathic and dentoaveolar surgery, placement of implant devices, augmentations of hard and soft tissue and administration of general anesthesia and deep sedation. Provide a physical diagnosis history and physical exam course for new interns in July of each year. Be on call at least 1 week

of every month of employment. Requires Doctor of Dental Surgery (DDS) and Medical Doctor (MD) degree and completion of 6 years residency in oral and maxillofacial surgery which leads to an MD degree. Must be eligible for certification with the American Board of Oral and Maxillofacial Surgery. Must have legal authorization to work permanently in the U.S. EOE. Apply at oralmaxillofacialnetwork@gmail.com. Must reference â&#x20AC;&#x201D; lob code OMNCI.

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Your Patients Trust You. Who can YOU Trust? The Professional Recovery Network (PRN) addresses personal needs involving counseling services for dentists, hygienists, dental students and hygiene students with alcohol or chemical dependency, or any other mental or emotional difficulties. We provide impaired dental professionals with the support and means to confidential recovery. If you or another dental professional are concerned about a possible impairment, call the Professional Recovery Network and start the recovery process today. If you call to get help for someone in need, your name and location will not be divulged. The Professional Recovery Network staff will ask for your name and phone numbers so we may obtain more information and let you know that something is being done.

Statewide Toll-free Helpline 800-727-5152 Emergency 24-hour Cell: 512-496-7247 PRN Staff Donna Chamberlain, LCSW, CAS Director . . . . . . . . . . 512-615-9176 Paige Peschong, LMSW Social Worker . . . . . 512-615-9155 Courtney Bolin, MSW Social Worker . . . . . 512-615-9182 Professional Recovery Network 12007 Research Blvd. Suite 201 Austin, TX 78759 www.rxpert.org

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2011 save the

date

5-8

may

san antonio, tx

The Benefits.

The New Health Insurance Plan offers an array of benefits to fit your needs ... • $5 million lifetime

• • •

• •

maximum No exclusions or riders for covered conditions Vision coverage included 24/7 toll-free Health Line for confidential health questions staffed by RNs Online access of your health benefits Freedom to choose any provider in or out of network with no referrals

New Health Insurance Option for TDA Members and Staff Traditional and HSA Qualified Plans Available with Full Maternity Coverage Traditional Plan Features

HSA Qualified Plans

� Two Deductible Options � Prescription Drug Copay Card with Mail Order Option � Preventive Care Covered After Office Copay

� Three Individual or Family Deductibles � Preventive Care Covered at 100% In-network on HSA Plans Before Deductible

Questions? Visit www.TDAmemberinsure.com Or call, 1-800-677-8644

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