December 2022 Texas Dental Journal

Anesthesia Education & Safety Foundation

be a post-test after the online course concludes, so you will receive immediate CE credit for attendance 4. With the webcast, you can enjoy real-time interaction with the course instructor, utilizing a question and answer format

OUR MISSION STATEMENT: To provide affordable, quality anesthesia education with knowledgeable and experienced instructors, both in a clinical and academic manner while being a valuable resource to the practitioner after the programs. Courses are designed to meet the needs of the dental profession at all levels. Our continuing education programs fulfill the TSBDE Rule 110 practitioner requirement in the process to obtain selected Sedat ion permits. AGD Codes for all programs: 341 Anesthesia & Pain Control; 342 Conscious Sedation; 343 Oral Sedation This is only a partial listing of sedation courses. Please consult our www.sedationce.com for updates and new programs. Two ways to Register: e-mail us at sedationce@aol.com or call us at 214-384-0796

FEATURES

723 “X” MARKS THE SPOT! A SUSPICIOUS AND MYSTERIOUS HOMICIDE

CASE IN TEXAS

Kathleen A Kasper, DDS, D-ABFO

On some occasions I am privy to information that goes beyond just the “teeth” which makes a case so much more tantalizing than usual. The selected homicide case is one that stands out above all others for reasons that will be made clear as you read on.

733 THE JFK ASSASSINATION FROM A DENTAL PERSPECTIVE: AN INTERVIEW WITH AN ORAL AND MAXILLOFACIAL SURGEON — JACK BOLTON, DDS, MSD

T. Campbell Bourland, DDS, MS

The 50th anniversary of the assassination of President John F. Kennedy occurred in November 2013. This article recounts one oral and maxillofacial surgeon’s experience on that fateful day, as the mortally wounded President was treated at Parkland Hospital in Dallas. Originally printed in the March 2014 Texas Dental Journal.

HIGHLIGHTS

717 Editor’s Note

718 TDA Notice of Grant Availability 719 President’s Message

740 Oral and Maxillofacial Pathology Case of the Month 743 Calendar of Events 743 In Memoriam 744 Value for Your Profession: TDA Perks Program Hopes It Made a Big Impact on Your Life in 2022

748 Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management 750 Classifieds 758 Index to Advertisers

Cover Credit:Mohammed Haneefa Nizamudeen, iStock

Editorial Staff

Jacqueline M. Plemons, DDS, MS, Editor

Paras B. Patel, DDS, Associate Editor

Nicole Scott, Managing Editor

Barbara Donovan, Art Director

Lee Ann Johnson, CAE, Director of Member Services

Editorial Advisory Board

Ronald C. Auvenshine, DDS, PhD

Barry K. Bartee, DDS, MD

Patricia L. Blanton, DDS, PhD

William C. Bone, DDS

Phillip M. Campbell, DDS, MSD

Michaell A. Huber, DDS

Arthur H. Jeske, DMD, PhD

Larry D. Jones, DDS

Paul A. Kennedy Jr, DDS, MS

Scott R. Makins, DDS, MS

Daniel Perez, DDS

William F. Wathen, DMD

Robert C. White, DDS

Leighton A. Wier, DDS

Douglas B. Willingham, DDS

The Texas Dental Journal is a peer-reviewed publication. Established February 1883 • Vol 139 | No. 8

Texas Dental Association

1946 S IH-35 Ste 400, Austin, TX 78704-3698 Phone: 512-443-3675 • FAX: 512-443-3031

Email: tda@tda.org • Website: www.tda.org

Texas Dental Journal (ISSN 0040-4284) is published monthly (one issue will be a directory issue), by the Texas Dental Association, 1946 S IH-35, Austin, TX, 78704-3698, 512-443-3675. Periodicals Postage Paid at Austin, Texas and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S IH 35, Austin, TX 78704. Copyright 2022 Texas Dental Association. All rights reserved.

Annual subscriptions: Texas Dental Association members $17. Instate 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. Electronic submissions are required. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. For more information, please refer to the Instructions for Contributors statement printed in the September Annual Membership Directory or on the TDA website: tda. org. All statements of opinion and of supposed facts are published on authority of the writer under whose name they appear and are not to be regarded as the views of the Texas Dental Association, unless such statements have been adopted by the Association. Articles are accepted with the understanding that they have not been published previously. Authors must disclose any financial or other interests they may have in products or services described in their articles.

Advertisements: Publication of advertisements in this journal does not constitute a guarantee or endorsement by the Association of the quality of value of such product or of the claims made of it by its manufacturer.

editor’s note

The end of the year is always a special time—from haunted houses to pumpkinspiced everything to brightly lit decorations, it’s a time of celebration. We say goodbye to one year and welcome the new year filled with promise and opportunity.

This month, the TDA is celebrating a special opportunity from 2022—the reimagining of the Texas Dental Journal. After months of data gathering, targeted discussions, research, market analysis, and listening carefully to TDA members’ needs, the December issue of the Journal shows much of the fruit of that effort.

Jacqueline Plemons, DDS, MS

Some changes are obvious and others more subtle, but all are designed to insure the Journal remains relevant and a valued member benefit. Starting with the design and colors on the cover, you can begin to feel the changes. You’ll be lead as you explore the Journal by nuances in things like layout, font size, and graphics. Content is reflective of our members’ desires and needs based on surveys and small focus groups, with targeted sections on practice management, technology, and a “softer” kind of science.

The December issue of the Journal highlights true-crime cases that include forensic dentistry. It’s been said that what’s left behind at a person’s death is their last form of communication to those who remain. We hope you enjoy these true-crime cases solved in part by local and national forensic dentists.

true crime

Facts and Stats

For many of us, it’s our guilty pleasure. True crime podcasts allow us to help solve the literal mystery of a crime and figurative mystery of the human psyche. What makes us tick? Why do some of us commit crime? Here are some interesting statistics on true crime podcasts that we came across:

• Half of Americans say they enjoy the genre of true crime, including 13% who say it’s their favorite genre. One in 3 (34%) say they don’t enjoy it, and 13% say it’s their least favorite genre.1

• The target audience of thrillers, particularly crime thrillers, is the 15-21 age group.2

• 61% of the Top 25 True Crime podcast listeners are women. The average median age of the top True Crime podcasts is 29.6. More men than women listen to MrBallen Podcast: Strange, Dark & Mysterious Stories, Park Predators, and Darknet Diaries. Darknet Diaries has the oldest average median listeners at 35.7 years old.3

Popular Picks

True Crime Genre Recommendations from Members and Staff:

TDA Director of Member Services Lee Ann Johnson recommends the podcasts Gone Cold Texas, Crime Junkies, and Tom Brown’s Body.

TDA Secretary-Treasurer Dr Carmen P Smith and Senior Policy Manager Diane Rhodes recommend the TV series Snapped.

Board Member Dr Richard Potter recommends the TV series 48 Hours.

Board Member Dr Teri Lovelace and dental student Julia Lovelace recommend the TV series The Jinx.

Continued on page 725

TEXAS DENTAL ASSOCIATION NOTICE

OF

GRANT

AVAILABILITY 501(C)(3) NON-PROFIT DENTAL ORGANIZATIONS

The Texas Dental Association (TDA) announces availability of financial assistance for qualifying 501(c)(3) non-profit organizations affiliated with dentistry. The monies are derived from TDA Relief Fund interest income earned over the 2022 fiscal year. Grantees will be determined by the TDA Board of Directors.

Board of Directors Texas Dental Association

PRESIDENT Duc “Duke” M. Ho, DDS 281-395-2112, ducmho@sbcglobal.net

PRESIDENT-ELECT Cody C. Graves, DDS 325-648-2251, drc@centex.net

PAST PRESIDENT Debrah J. Worsham, DDS 936-598-2626, worshamdds@sbcglobal.net

VICE PRESIDENT, SOUTHEAST Glenda G. Owen, DDS 713-622-2248, Dr.owen@owendds.com

VICE PRESIDENT, SOUTHWEST Carlos Cruz, DDS 956-627-3556, ccruzdds@hotmail.com

Eligibility: Grantees must be 501(c)(3) non-profit organizations affiliated with dentistry.

Application: Letters of interest detailing the proposed project(s), including a budget, should be mailed to:

TDA Board of Directors

C/O Mr Terry Cornwell

1946 S IH 35, Ste 400 Austin, TX 78704

Deadline: Letters of Interest must be postmarked or emailed (tcornwell@tda.org) no later than January 31, 2023.

Approval: All letters of Interest will be reviewed and considered by the TDA Board of Directors no later than its March 2023 meeting.

Notification: All recipients will be notified in writing on or before May 15, 2023.

Previous Recipients: In 2022, grants totaling $12,000 were awarded to the following organizations in Texas for charitable patient care: The Family Place (Dallas), First Refuge Ministries (Denton), Greater Killeen Community Clinic (Killeen), Network of Community Ministries (Richardson), Rotary Club of Grand Prairie Saving Smiles Program (Grand Prairie), and San Jose Clinic (Houston).

For more information, please contact Mr. Terry Cornwell, TDA Governance Manager, (512) 443-3675, Ext. 146, or email tcornwell@tda.org.

VICE PRESIDENT, NORTHWEST Teri B. Lovelace, DDS 325-695-1131, lovelace27@icloud.com

VICE PRESIDENT, NORTHEAST Elizabeth S. Goldman, DDS 214-585-0268, texasredbuddental@gmail.com

SENIOR DIRECTOR, SOUTHEAST Shailee J. Gupta, DDS 512-879-6225, sgupta@stdavidsfoundation.org

SENIOR DIRECTOR, SOUTHWEST Richard M. Potter, DDS 210-673-9051, rnpotter@att.net

SENIOR DIRECTOR, NORTHWEST Summer Ketron Roark, DDS 806-793-3556, summerketron@gmail.com

SENIOR DIRECTOR, NORTHEAST Jodi D. Danna, DDS 972-377-7800, jodidds1@gmail.com

DIRECTOR, SOUTHEAST Laji J. James, DDS 281-870-9270, lajijames@yahoo.com

DIRECTOR, SOUTHWEST Krystelle Anaya, DDS 915-855-1000, krystelle.barrera@gmail.com

DIRECTOR, NORTHWEST Stephen A. Sperry, DDS 806-794-8124, stephenasperry@gmail.com

DIRECTOR, NORTHEAST Mark A. Camp, DDS 903-757-8890, macamp1970@yahoo.com

SECRETARY-TREASURER*

Carmen P. Smith, DDS 214-503-6776, drprincele@gmail.com

SPEAKER OF THE HOUSE*

John W. Baucum III, DDS 361-855-3900, jbaucum3@gmail.com

PARLIAMENTARIAN**

Glen D. Hall, DDS 325-698-7560, abdent78@gmail.com

EDITOR** Jacqueline M. Plemons, DDS, MS 214-369-8585, drplemons@yahoo.com

LEGAL COUNSEL

Carl R. Galant

*Non-voting member **Non-voting

DENTIST to DENTIST

RELATIONSHIP. MENTORSHIP. COMMUNICATION.

Duc “Duke” M. Ho, DDS, FAGD TDA President

This time of the year is always very exciting as I am reminded of the many blessings of friends and family that have come my way while eagerly awaiting the surprises of the upcoming year.

Although only halfway into my term, I’ve had the pleasure of visiting so many local components (most recently, Brazos Valley, Dallas, Abilene, and soon, McAllen) and getting to know their members, while seeing so many familiar, warm faces. We truly are family and though we may always not agree, there’s room for everyone because we have far more in common than our differences!

So, I am most thankful for each of you who are willing to give and support this amazing Association and profession. It’s our turn to continue working and giving back to you.

Things I’m Thankful For

• First and foremost, I’m thankful for an awesome family, great mentors, and an amazing team—at my practice and at the Association—that supports and allows me to serve you;

• That your Council on Membership, New Dentists, and Students met in late November to continue developing its Leadership Program, which teaches young dentists how to be better leaders in their community, offices and in organized dentistry;

• That they, along with TDA Perks (the for-profit arm of the TDA), had healthy conversations on how we can bring everyday value to all our members and their families;

• That the Massachusetts Medical Loss Ratio ballot initiative passed and that we’re discussing how such may influence both our short- and long-term plans with third party payers in Texas.

Things I Am Excited About

• I’m excited that your Council on Legislative, Regulatory, and Governmental Affairs had met to finalize our agenda and strategy prior to the start of the upcoming session;

• That your Association will continue to advocate for issues at the capitol that are important to dentists including insurance reform, increased reimbursements for dental Medicaid providers, and dental education loan repayment program, just to name a few;

• That your Council on Professions and Trends is working on AI, developing a toolkit to address mental health, as well as one to meet the needs of members or their families if a dentist was unable sustain his or her practice.

Of course, so much more is happening, even as the year begins to wind down. I would be remiss if I didn’t remind you of some important upcoming dates.

Save the Dates

• TDA Legislative Day, February 15, 2023, Austin, TX

• ADA Lobby Day, March 5-7, 2023, Marriott Marquis, Washington, DC

Thank you again for allowing me to serve you and know that I am always available. Happy Hanukkah, Merry Christmas, and Happy Kwanzaa from all of us at your Texas Dental Association.

“There’s room for everyone on the Nice List!”

—Buddy (Will Ferrell), “Elf”

forensic professionals do this work as a calling, and we see the best of humanity and the worst of humanity, often simultaneously.

“X” MARKS THE SPOT! A Suspicious and Mysterious Homicide Case in Texas

By Kathleen A Kasper, DDS, D-ABFO

In my forensic dental career, I have had the privilege to work with multiple medical examiners in the great State of Texas and have made dental identifications on countless individuals. On some occasions I am privy to information that goes beyond just the “teeth” which makes a case so much more tantalizing than usual. The selected homicide case is one that stands out above all others for reasons that will be made clear as you read on. I became involved in the case on April 6, 2004.

The Texas Rangers and the Colleyville, Texas, Police Department received informant information in 2003 that the husband of Peggy Tubbleville was murdered and buried in the backyard of her home in or around August of 1996. Through tax records on the home, police investigate Limal Tubbleville as the victim and discover that he died in an automobile accident in Oklahoma and closed the case. Now you would think the story ends here; however, approximately one year later a relative comes forward and says that the grandfather was killed and buried in the yard. Investigators say that they have already investigated this case and closed it. The new informant states that they looked at the “wrong” husband. The victim Patrick Cunningham was married to Peggy Tubbleville when he was allegedly murdered in 1996. The informant said that Kevin Rotenberry allegedly claimed to have murdered his step-grandfather and buried the body in the yard of the family residence. The Texas Rangers found that Patrick Cunningham had last been seen at his job in August 1996 and his Texas driver license expired in October 1999. Peggy Cunningham filed for divorce in November of 1996 stating that her husband abandoned her in August 1996. It is interesting to note here that a missing person’s report on Patrick Cunningham was never filed with the police in this case. Peggy Tubbleville Cunningham died in 2000 when a lawn tractor fell on her. Let it be said that her side of this story and her involvement in the death of Patrick Cunningham will never be revealed. The second informant also claimed that Patrick Cunningham’s body was cut up, buried, dug up by the family dog, and then was reburied deeper. The investigators obtained a warrant to search the property; however, prior to the actual search of the premises, police decided to interview Kevin Rotenberry on the morning of the planned dig and hoped that he would show them the exact location of the remains. If he was non-cooperative, then areas of disturbances would be identified through surveying procedures, ground penetrating radar, and/or probing and cadaver dog scenting. Mr Rotenberry, after being

read his rights, admitted to placing the body in the yard and claimed that his grandmother, Peggy Tubbleville Cunningham, killed him. She allegedly poisoned and smothered him as a result of abuse and then called Rotenberry to help her dispose of the body.

Mr Rotenberry proceeded to mark a spot in the dirt and grass near the rear of the house with his boot and stated that a septic tank is under that spot and he put a body in it. It is important to note that this septic tank had not been used in over 30 years. This site in the ground that was marked with an “X” was initially probed and a hard resistance was felt at 1 foot below the surface. Digging in this area revealed a round concrete feature with a concrete lid and a metallic handle. Upon removing the lid, bones were observed that were determined to be human. Bones were scattered throughout the root mat which was consistent with the story given by the informant. Now forensic scientists needed to determine this decedent before charges could be filed.

At the time, the forensic anthropologist Dana Austin, PhD, determined that this individual was an older adult, Caucasian male. Several features from the recovered skull including

true crime

Facts and Stats

• US listeners dominate the Top 25 True Crime podcasts, except for Canadian True Crime, where they come in second after Canadian listeners.3

• True Crime podcasts are popular in the US, UK, Canada, Australia, Ireland, Brazil, the Philippines, and India.3

• Top listener occupations include nurses, managers, authors/ writers, journalists/reporters, and directors.3

• True crime podcasts are also popular with marketers, editors, teachers, and software engineers. Top employers include Starbucks, Target, McDonald’s, Walt Disney, Walmart, the US Army, and Apple.3

• True Crime podcast listeners like include Instagram, Disney, Google AdWords, Funny or Die, Associated Press, Starbucks, YouTube, and NPR.3

Continued on page 736

Popular Picks

True Crime Genre

Recommendations

from Members and Staff:

Council on Membership Chair

Dr Sarah Tovar recommends the podcasts Up and Vanished and That Chapter (videos on YouTube).

TDA President Dr Duc “Duke” Ho recommends the podcast The Case (a podcast where they actually solved the crime!).

Dr Sarah Poteet recommends the podcast S-Town by Serial Podcast series.

Strategic Affairs Committee Chair Dr Akshay Thusu recommends the TV series

House of Secrets: The Burari Deaths (Netflix).

Board Member Dr Krystelle Anaya recommends the book I’ll Be Gone in the Dark by Michelle McNamara.

Root Mat Containing Scattered Human Bones

the entire maxilla and mandible along with other bones assisted her in making this determination. She also determined there were multiple antemortem (before death) fractures of the nasal bones, right wrist, right kneecap, and right ankle.

In the forensic world, a positive identification (ID) is accomplished legally by visual means, latent print analysis (finger and palm prints), dental means, DNA, or medically implanted devices which have a serial number. Since this decedent had no soft tissue or any medically implanted devices, visual means, latent prints, and medical devices could not be used to make a positive identification. This left dental means and DNA. Dental identification is cheap, fast, and an uncomplicated process for most cases depending on the evidence received. I was contacted as a second opinion for the dentals because the first forensic dentist was unable to positively identify this individual through teeth and available dental records. I came to the same conclusion! There are limited reasons a positive dental identification cannot

Skeleton Recovered at Scene

Clean Skeleton in Forensic Lab

be accomplished by dental records. Most dental identifications cannot be accomplished if there is an insufficient or lack of enough antemortem (before death) dental records and/or postmortem (after death) remains/evidence. In this case the only antemortem dental records obtained for Patrick Cunningham were written records and charts that were dated January 14, 1959—he died in 1996! I was able to identify several antemortem and postmortem dental features that were consistent; however, this was not adequate enough to establish a positive identification through dental means. Dental radiographs are the “gold standard” in dental IDs and there were none available for antemortem records. My dental conclusion was this information allowed only a “possible” dental ID. Patrick Cunningham was eventually positively identified by DNA.

Presently in 2022, technical advances in computer databases for forensic dentistry have taken off by leaps and bounds. Kenneth W. Aschheim, DDS, D-ABFO, and Bradley J. Adams, PhD, D-ABFA, developed OdontoSearch, which is a database that creates a means of using dental charts and notes in the absence of dental radiographs for identification purposes on adults 14 to 90 years. It is a computer program that provides an objective means of assessing the frequency of occurrence of dental treatment. It produces statistical values for quantifying the relative frequency that a dental pattern occurs in the general population. The program works by comparing an individual’s pattern of missing, filled, and unrestored teeth to a large, representative sample of a US population. (This database is currently at 107,000 records which is expected to increase to over 250,000 in future years). OdontoSearch simply provides a statistical value that quantifies the strength of the observed dental pattern with an unidentified individual. The rationale and methodology behind OdontoSearch are remarkably similar to procedures that have been established for mitochondrial DNA (www.odontosearch.com).

Recovered Skull from the Septic Tank

Therefore, today when I run through OdontoSearch 3.2 the dental features that are the same in the antemortem written dental records for Patrick Cunningham and the postmortem evidence in this case, I could state that there were 0 pattern matches out of 107,002 records suggesting the selected pattern would occur in 0.00093% of the target population base. This information could possibly corroborate with other scientific evidence to arrive at a positive ID.

For his responsibility in the death of Patrick Cunningham, Kevin Rotenberry was convicted of dumping and concealing the body of his step-grandfather in a septic tank and sentenced to 10 years probation literally hours after a Tarrant County jury convicted him of tampering with evidence. This occurred on March 22, 2006, about 10 years after the disappearance of Patrick Cunningham. No one has been convicted for Patrick Cunningham’s actual death.

In conclusion, forensic professionals do this work as a calling, and we see the best of humanity and the worst of humanity, often simultaneously. Regardless, we are all in it to help people find peace with whatever the circumstance and arrive at closure. This can be a daunting task that is almost always done behind the scenes for forensic dentists.

antemortem Dental Record postmortem Dental Record

we are all in it to help people find peace with whatever the circumstance and arrive at closure. This can be a daunting task that is almost always done behind the scenes for forensic dentists.

DENTAL

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Mark

The 50th anniversary of the assassination of President John F. Kennedy occurred in November 2013. This article recounts one oral and maxillofacial surgeon’s experience on that fateful day, as the mortally wounded President was treated at Parkland Hospital in Dallas.

The JFK ASSASSINATION From a Dental Perspective: An

Interview With an Oral and Maxillofacial Surgeon —

Jack Bolton, DDS, MSD

T. Campbell Bourland, DDS, MS

Originally printed in the March 2014 Texas Dental Journal.

Over a year ago, I found myself in a precarious position that many associates in a group practice discover. I needed a new place to call home and find a community to establish myself in as a competent oral surgeon, eagerly waiting to serve the local patient population. As I looked around the Dallas-Fort Worth metroplex for a place to land, I heard a surgeon on my side of town might be looking to retire. He was a cornerstone of the East Dallas community and a vast contributor to the field of dentistry especially the division of oral maxillofacial surgery. I had crossed paths once with Dr Jack Bolton and mercifully it was not when he was a Texas State Board Dental Examiner. As an oral surgery resident at Baylor, I saw Dr Bolton in the audience when the former Parkland Oral Surgery Chairman Dr Robert Walker gave the dental students and residents a 45-minute synopsis of the President John F. Kennedy assassination nearly half a decade earlier as he witnessed it. Dr Bolton was in attendance because he was one of the oral surgery interns at Parkland under Dr Walker’s tutelage when JFK was rushed to the hospital. Dr Walker’s lecture was fascinating. I found myself with many more questions than answers. I vowed that one day I would find the time to interview Dr Walker personally with my inquiries, which I tragically missed due to his untimely passing. When I met Dr Bolton personally to discuss the possible sale of his practice, I knew I had living history in front of me. I found Dr Bolton to be one of the most agreeable gentlemen I have ever met. His demeanor was commanding and steadfast. Through our conversation, I could see his dedication to the East Dallas community and the profession of dentistry. He illustrated all the characterizations of a successful practitioner. During our conversation, we consistently wandered from discussing the practice transition and landed on the topic of Dr Walker’s lecture and the JFK assassination. He provided many details unlike any I have heard before. I knew I had an opportunity again to obtain front line answers to history that I had to put on paper to share with all generations. With 20 questions, I hope I provide a unique perspective to November 22, 1963, through the eyes of an oral surgery intern.

1. Dr Bolton, what year were you in training when in the fall of 1963 at Parkland?

I was an intern during the fall of 1963. I graduated from Baylor College of Dentistry in the spring of 1962, and I spent a year after I graduated getting a master’s degree.

2. What percentage of facial trauma was treated by oral surgery at the time compared to ENT and plastics?

Oral surgery treated all of facial trauma. There was no plastic surgery residency at the time. ENT existed but they did not do much with facial trauma.

3. How many oral surgery residents were at Parkland at the time?

There were 6 residents total. We had 2 interns, 2 first-years, and 2 second-years. We rotated on anesthesia for 6 months, pathology for 3 months, medicine and infectious disease for our intern year.

4. Where were you at Parkland when you heard the news the President was shot and headed to the Parkland ER?

That morning, Don Curtis and I (Don was a year ahead of me) had operated and we finished just after 11:00 AM. We had a full clinic we had to go take care of. We usually had 45-50 patients. We were in the clinic working and we were used to hearing sirens because the ambulance dock was right behind our reception area. These sirens kept going on and on and on. Don was in one operating area and I was in another and he

After I walked around the table and saw that injury, I knew he was gone.

came by me and said, “Jack, there is something going on. I am going to go by the major surgery area. There is something happening.” Don left, and I continued to see patients. Miss Hickman, our clinic nurse told me, “Don never came back.” I told her I would go over and see what is happening. So I put a coat on and went over to the major surgery area. Back then, they just started the trauma teams at Parkland. The emergency room was split up into minor emergency, minor medicine, major surgery, and major medicine. In the major surgery area we had a trauma room set up that was ready to go at all times. So I went into the major surgery area and I went around the corner and I saw (Dr Jim) Carrico. He was the resident that was head of the trauma team that was on call. Don Curtis was there and 2 or 3 other people at the time. I think it was Don who said, “They’ve shot the President, Jack.” The hair on the back of my neck stood out. There on this table lay the President. I walked around. I cannot remember who else was in the room but I walked around to the head of the table and it looked to me like the whole right occipital area of the President’s head was gone. There was a lot of blood. I stood there for a minute and thought to myself, “I don’t have anything I can do so I am going to get out of here.” Just about the time I left the room they took Lyndon Johnson, Lady Bird Johnson, and Jackie Kennedy down the hallway by the trauma rooms and sequestered them so nobody could get to them. And that is when I thought to myself, “My gosh! This is really something.”

Moments after the president was shot. Photo courtesy of the Library of Congress

Evidence indicates that shots were fired from the sixth floor of the Texas School Book Depository in Dallas, and its employee Lee Harvey Oswald was charged with the President’s murder.

true crime

Facts and Stats

• Data compiled by Spotify showed that female listeners of the true crime podcast genre grew 16% in 2019.4

• The most popular and commonly accepted explanation for why women love true crime is because they feel, consciously or subconsciously, that they might learn something from it. This may be because women often see themselves (quite literally) in true crime stories.5

• True crime content helps women understand a criminal’s mindset, and promotes a sense of justice.6

References

1. Orth, Taylor. Half of Americans enjoy true crime, and more agree it helps solve cold cases. Accessed 12/9/22. https://today.yougov.com/topics/entertainment/articlesreports/2022/09/14/half-of-americans-enjoy-true-crime-yougov-poll

2. Thye, Lee Lam. Parlia. Crime thrillers are like the Pied Piper to the young and the impressionable of the society. Accessed 12/9/22. https://www.parlia.com/a/young-audience#reference-1

3. Parisyan, Lea. True Crime Podcast Statistics That Will Blow Your Mind. Podchaser. Accessed 12/9/22. https://www.podchaser.com/articles/podcast-insights/true-crime-podcast-statisticsthat-will-blow-your-mind

4. Hale, Tenley. Study shows women are more likely to listen to true crime podcasts than men. The Daily Universe. Accessed 12/9/22. https://universe.byu.edu/2022/09/24/why-womenare-more-likely-to-listen-to-true-crime-podcasts/#:~:text=Data%20compiled%20by%20 Spotify%20showed,daily%20life%20than%20men%20do.

5. Gordon, Eden Arielle. Research Reveals Why Women Love True Crime. Magellan. Accessed 12/9/22. https://www.magellantv.com/articles/research-reveals-why-women-love-true-crime

6. Sharma, Megha. This might be the reason why women are obsessed with true crime stories. Vogue. Accessed 12/9/22. https://www.vogue.in/culture-and-living/content/why-arewomen-obsessed-with-true-crime-stories#:~:text=True%20crime%20content%20helps%20 women,the%20thought%20processes%20of%20criminals.

Popular Picks True Crime Genre Recommendations from

Members and Staff:

Board Member Dr Jodi Danna recommends the podcasts Crime Junkie, Killed, Morbid, Counter Clock, ID.

Director of Meetings and Continuing Education Shannan Cook CMP recommends the TV series Dirty John.

Managing Editor Nicole Scott recommends the podcast Devil Town.

Council on Membership Dr Ensy Atarod recommends the podcast Sword and Scale It describes the dark side of humanity and that the worst monsters are real. Warning it can be pretty graphic at times.

Council on Membership Dr Gabrielle Dizon recommends the podcast Dirty John.

Board Member Dr Elizabeth Goldman recommends the podcast RedHanded.

5. When you were on for facial trauma, did the oral surgery resident always take part in the trauma workup or was the patient stabilized by other services and then you consulted?

Oral surgery was always around. Don Curtis did a cut down on the President, and another oral surgery resident assisted with general anesthesia on Lee Harvey Oswald when he was brought in. The way that it would work is the trauma team would do the work and they would give us a call if there were facial injuries. We had a very good rapport with trauma service. Back then, we did not have seatbelts and airbags, so we did a lot of midface trauma. Trauma was our major function at Parkland.

6. How many residents versus attending physicians did you see in Trauma Room 1 when the President was brought in? I saw no attendings in the room.

7. How about Governor Connally?

Coincidentally, across the hall from President Kennedy was Governor Connally. He had a chest injury. When the feds left, the Secret Service turned things over to the Texas Rangers. Contrary to today, where you have to use a card to get in and out of doors; we had nothing like that. They had a Texas Ranger at each exit of Parkland by the next morning. You had to identify yourself and they had to look you up to get in. They kept Connally in the recovery room. Every time you did a case and you would have to go to the recovery room, there was a bed over on the side with 2 Texas Rangers sitting there where Connally was until they could get him to a private room. It was a very emotional time for everyone. Something I will never forget.

8. Did the President have any vital signs at all?

They had already stripped him down. I don’t have any knowledge of that.

9. Was any type of imaging done during the resuscitation effort like a chest x-ray or plain film of his skull? None to my knowledge.

10. How long did the resuscitation efforts continue?

I am not aware how long.

11. Supposedly, one of the criticisms from the Warren Commission Report was that a “dentist” placed a central venous catheter in the President? Was this true?

Don Curtis did the cut down on the President. I am sure Jim Carrico, the surgery resident, told Don that he needed a line and so Don started that cut down. I do not remember seeing anything hanging (fluids) when I went in. Don was focusing on the left leg, as I remember.

12. Can you describe the wounds you saw on the President?

Supposedly the President had a neck injury too. I never did see it. All I could see was the occipital injury on the right side.

Oral surgery was always around.

Don Curtis did a cut down on the President, and another oral surgery resident assisted with general anesthesia on Lee Harvey Oswald when he was brought in. The way that it would work is the trauma team would do the work and they would give us a call if there were facial injuries.

There has been

13. Here are the copies of his autopsy photos from the internet. Is this how he looked to you?

That is it right there. The significant injury to the President’s head. The only injury I saw was to the occipital area. There was a lot of brain tissue hanging out of there.

bullets, the angle of the bullets. I could not speak to any of that. All I saw was that he had a severe head injury. I am not a forensic pathologist, but I thought exit wounds were pretty good size wounds as opposed to entrance wounds and that was a pretty small wound in his throat as compared to what was on the back of his head.

14. Did the wounds indicate to you that there were multiple shooters?

I could not say.

15. Did you wonder if oral surgery was going to have any part in his care if he survived or was it evident that the resuscitation efforts were futile?

After I walked around the table and saw that injury, I knew he was gone.

16. Did you have any interactions with the Secret Service?

I started walking out of the major surgery area. There was a door going into radiology and there was a man standing there at the door. He asked me, “Do you have official duties here?” I said to him, “Yes, sir, I do.” He said, “Well, let me ask you to do this. You stand here at this door and do not let anyone in here until I get back.” I said okay. I am standing here in that door between radiology and surgery. I stood there for about 5 or 10 minutes. The next thing I see is Dr Walker comes out of the area where the trauma room is and he has got tears in his eyes. Dr Walker does not ever have tears in his eyes, and he says to me, “My God, Jack. They’ve killed the President.” That just shook me to my toe nails. Dr Walker walked off back to our clinic. I stood there for a short period of time. There were 4 Secret Service agents who had had Lyndon Johnson, Lady Bird Johnson, and Jackie Kennedy, and each one of the agents had machine guns. Back in those days, we did not see people or police walking around with machine guns. That was really an eye-opening experience for me to see that in public. They brought a car around, and I was standing on the ambulance dock where the ambulance was. Then, out comes Mr and Mrs Johnson, and the Secret Service pulled up in one of those Lincoln Town Cars. They opened the back door on one of those cars and put Mr and Mrs Johnson on the floor board, and those Secret Service agents got in on top of them as a human shield. I thought, “Boy, you better remember this, Jack. This is serious when you are in the United States, and you are worried you might be shot by a sniper driving down the street.” That is exactly what they were thinking.

17. How about the First Lady? They took the 3 of them off (Jackie Kennedy, Lyndon Johnson, and Lady Bird Johnson) to another part of the hospital to sequester them, and I knew that this was serious business and that we were seeing history made. I stood there for another 5 minutes, and the guy never came back.

18. Did she seem coherent or was she in total shock? They left and it was a short time later they brought President Kennedy out. They had put him in a coffin. They had an ambulance backed up to the dock. They took the casket and put in the back of the car, and Mrs Kennedy was following right behind the casket wearing that pink suit. She had blood all over her. She got in the back with them and that is when they left Parkland and went out to Love Field. Back then communications were entirely different. On the ambulance dock they had probably 20 pay telephones stretched out for the press to phone in their stories.

a lot of controversy over how many

19. Many of the doctors who were present have written books, done interviews, and publicized the President’s treatment at Parkland. Do you think the espousing of all this information violates HIPAA regulations?

You would now! I never said a whole lot about it because there were so many books. I think they interviewed Dr Jenkins. Crenshaw wrote a big book about it. I do not remember seeing Chuck there. Everybody who had anything to do with it was interviewed.

20.

There has been a lot of controversy over how many bullets, the angle of the bullets. I could not speak to any of that. All I saw was that he had a severe head injury. I am not a forensic pathologist, but I thought exit wounds were pretty good size wounds as opposed to entrance wounds and that was a pretty small wound in his throat as compared to what was on the back of his head. Let us just say this … as many gunshot wounds as we saw out there during that time, those guys knew what they were talking about. I would put them (the doctors) up against anybody as far as treating and recognizing trauma. Gunshot wounds were a run-of-the-mill injury at the time out there.

Another interesting part of Dr Bolton’s story is watching Dr Clark from Neurosurgery sign the President’s death certificate. As soon as Dr Clark put the pen down, it was immediately swiped since the perpetrator knew that the pen would be a valuable keepsake. Also, Dr Bolton describes the entire procession of dignitaries that followed the

X on the road where President John F. Kennedy was assassinated in Dallas, Texas. Bigstock/copyright: f11photo

Presidential limo and the mortally wounded President to the hospital. Dr Bolton went out to the limo and offered Mayor Cabell’s wife a glass of water while she looked around in shock trying to digest the events. The first-hand account of the Presidential assassination yielded details unlike I have ever heard. I was gratified to know that oral surgery played such a unique role in the trauma work up and the resuscitation effort.

Tom Brokaw’s book, The Greatest Generation, aptly describes the character of men like Dr Jack Bolton. As the transition takes place in his practice, I hope Dr Bolton will stay around for as long as I can convince him. The good doctor deserves a parade the last time he walks out of the door in his practice. I am sure he will lay low and go quietly, much as the oral surgery residents and staff did during those tumultuous days back in November 1963. I hope he will at least pat himself on the back and say to himself, “Job well done.”

Does anything you saw make you think there was a conspiracy or cover up?

ORAL and

maxillofacial pathology case of the month

AUTHORS

Clinical History

A 55-year-old Caucasian male with a chief complaint of a toothache and severe pain in the mandibular anterior gingiva for 6 weeks was referred to a periodontist for evaluation. He had used over the counter Orajel in the area but felt no relief. The patient then went to his dentist and was managed with amoxicillin and scaling of the teeth but showed no improvement. He reported a migraine headache and short episodes of fever at the time of the toothache. No other systemic disease was reported, and he was not taking any medications other than amoxicillin. There was no history of trauma to the area of his chief complaint. Clinical examination revealed generalized advanced periodontitis with most of his teeth showing clinical attachment loss over 5mm as well as bleeding upon probing. A large, ulcerated lesion with erythema was also noted in mandibular anterior buccal and lingual gingiva (Figure 1A-F). A biopsy was performed of the mandibular anterior gingiva, and it showed non-caseating, chronic granulomatous inflammation within the lamina propria (Figure 2A). The inflammatory cell infiltrate was a mixture of lymphocytes, and sheets of histiocytes as well as plasma cells (Figure 2B). Small round microorganisms were seen in the cytoplasm of the histiocytes or in the extracellular matrix (Figure 2C, green arrows). These micro-organisms showed a halo around them. A PAS fungal stain was performed and these micro-organisms stained positive for PAS stain. (Figure 2D, black arrows).

What is your diagnosis?

See page 748 for the answer and discussion.

Yi-Shing Lisa Cheng, DDS, MS, PhD Oral Pathology Associates, Dallas, Texas

David Wong, DDS, MDS Private practice, Richardson, Texas

Figure 1. Clinical presentation of the case

A: Left lateral view showed generalized swelling in left maxillary and mandibular quadrants, gingival recession on #10 and #11, and cervical abrasion of #11 and #22 (mirror image);

B: Maxillary front view showed gingival recession and cervical abrasion on #6 and #11;

C: Mandibular front view showed generalized gingival recession with bone loss in mandibular anterior teeth, and redness with swelling and linear ulcerations on gingiva of #22-26;

D: Mandibular lingual view also showed ulcerations in #22-#27 lingual gingiva;

E: Right lateral view showed generalized swelling in both maxillary and mandibular gingiva (mirror image);

F: Palatal view showed generalized gingival swelling but no ulceration.

ORAL

and maxillofacial pathology continued

Figure 2. Histological features of the case

A: A non-caseating, chronic granulomatous inflammation was seen in the lamina propria (H&E stain, original magnification 20);

B: The infiltrate was a mixture of lymphocytes, histiocytes and plasma cells (H&E stain, original magnification x100);

C: Groups or single small round micro-organisms (black arrowheads) were seen in the pale-stained cytoplasm of the histiocytes (H&E stain, original magnification x200);

D: The micro-organisms (black arrowheads) stained positive for PAS fungal stain and showed a halo around them (Periodic-Acid-Schiff stain, original magnification x200).

calendar

Calendar of Events

End-of-Year Giving: November Through December 31, 2022

TDA Legislative Day: Wednesday, February 15, 2023

TMOM 2023 Events

TMOM Marble Falls: February 24-25, 2023

TMOM Bonham: April 14-15, 2023

TMOM Abilene: July 14-15, 2023

TMOM McAllen: September 15-16, 2023, or September 22-23, 2023 (TBD by venue)

Due to COVID-19, please check each meeting’s website for up-to-date information related to cancellations or rescheduling.

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

in memoriam

Those in the dental community who have recently passed

Samuel

E Cress

Houston

November 1, 1963–November 1, 2022

Good Fellow: 2019

Ronald Kent Stobaugh

Houston

October 8, 1942–November 4, 2022

Good Fellow: 1998 • Life: 2007 • Fifty Year: 2022

B Brooks Goldsmith Austin

January 27, 1934–November 14, 2022

Good Fellow: 1985 • Life: 2000 • Fifty Year: 2010

Lesslie G Moore

Plano

October 13, 1945–July 9, 2022

Good Fellow: 2005 • Life: 2010

value for your

TDA Perks Program Hopes It Made a BIG IMPACT on Your Life in 2022

By TDA Perks Program

Does your phone have the TDA DENTAL CONCIERGE app installed on it? Or does your bank account have a sizable (perhaps very sizeable) addition to it, with the assistance of ERC Specialists?

If you enjoyed these yields from TDA Perks Program’s 2022 crop of goodies for TDA members, we’re very glad and hope they’ve enriched your life. You can read on for updates on the programs.

If not, we’d like to present for your review the 2 achievements of 2022 we’re most proud of—our gifts to you— in the hope you don’t pass them over.

profession

Provided by: PERKS P R O G R A M

App and Learning Management System, TDA Dental Concierge, is making these tasks easy.

Sometime in mid-2020, TDA Financial Services, Inc.’s board of directors (which manages TDA Perks Program) homed in on a challenge Texas dentists face: staying on top of Texas State Board of Dental Examiners (TSBDE) CE requirements.

The Board worked to find a solution to what it noted was a messy and stressful endeavor, which led to TDA Perks Program and TDA commissioning TDA Dental Concierge.

Released in February 2022, the app and learning management system (LMS) provides an easy way to keep track of completed CE courses and outstanding requirements, offers high quality CE courses at low cost, and makes submitting CE documentation to TSBDE easy in the event of an audit.

In just a few months, it garnered more than 1,800 registered users who completed more than 1,000 live and on-demand courses (offered in the LMS). Here’s a rundown of three key functions it performs for you.

Tracks and Organizes Your CE Hours

The app organizes all CE completion documentation for you, sorting them into appropriate requirement categories and storing them in a digital vault until needed. If you take CE courses offered through TDA Dental Concierge’s LMS, the sorting and organizing is performed automatically.

For courses completed outside the app, information must be entered manually. You simply upload a photo of the completion certificate, check the box for the requirement it applies toward, and enter the completion date.

Progress toward meeting requirements is charted via a color-coded dashboard where you can see which courses and categories need to be completed and/or are fulfilled. As deadlines approach, reminders are sent via app alerts or emails at a frequency customized by you.

Meeting TSBDE CE requirements, audit submissions are no longer a chore.

Simplify CE for the whole team.

Dentists, hygienists, and RDAs can track and submit CE hours with the TDA Dental Concierge app.

And you can start right now.

Scan here:

Provides Quality CE Courses at Low Cost

The second key function of TDA Dental Concierge is to offer an ever-growing collection of high-quality CE courses— live and pre-recorded—at a lower cost to TDA members.

Among the courses added to TDA Dental Concierge its inaugural year were:

• A controlled substance course that enables dentists to meet all controlled substance CE requirements. This popular 4-hour live course, “Safe and Effective Pain Management When Ethically Prescribing Opioids and Other Controlled Substances to Dental Patients,” will continue to be offered on select dates through February 2023.

• Self-study courses from prestigious The Pankey Institute, available ondemand. These provide 2–3 hours of CE credit each.

Note: TDA is an ADA CERP Recognized Provider.1

Keeps You Ever-Ready

For an Audit

The app’s third key function is to make submitting CE documentation to TSBDE a snap. TDA Dental Concierge’s digital vault will store your CE documentation—organized and at-theready for submission—should an audit notice arrive in the mailbox.

For Your Team

TDA Dental Concierge is also available for your team. The app debuted its RDH and RDA modules in late May, enabling team members to access the same features available to you: track completed CE and what’s lacking, provide access to quality CE, and simplify the license-renewal process.

You can sign up your staff and gift it to them, or simply share the information with them. Staff pricing is $4.99/month.

TDA Dental Concierge is available for download through Google Play and the Apple App Store free of charge for TDA members. The app is available to non-TDA members for a monthly fee of $9.99. You can learn more and browse through courses at tdadentalconcierge.com.

tdadentalconcierge com

Many dentists were incorrectly told they didn’t qualify for the ERC (Employee Retention Credit)—a significant, fully-forgiven stimulus. A large number of TDA members were not aware that changes to IRS rules made many of them eligible for a significant tax credit.

The Employee Retention Credit (ERC)— created under the Coronavirus Aid, Relief and Economic Security (CARES) Act—allows qualified small businesses to claim up to $26,000 per employee as a fully-forgiven tax credit for 2020 and 2021—even if they received Paycheck Protection Program (PPP) funding.

When it was introduced, there were many restrictions attached, and business owners were often inaccurately told by their accountants they didn’t qualify for it. (Note: If you haven’t applied for the credit, you still have time. In general, your practice qualifies if it was able to retain your employees during 2020-2021; and if it experienced one or more of the following: revenue reduction, supply chain disruptions, or full or partial shutdowns.)

The ERC’s confusing qualifications and complex tax code meant many accountants may not have known how to maximize the credit or had only a partial understanding of it. It also meant that had small business owners filed on their own, they might have missed out on funds they were entitled to receive.

In mid-May, TDA Perks Program partnered with ERC Specialists, a specialty payroll company exclusively dedicated to simplifying the complex filing process and helping businesses maximize their credit. The company’s team of CPAs, Certified Payroll Providers (CPPs), and tax lawyers oversaw their clients’ credits to maximize them while ensuring they were staying within the guidelines of the program.

By mid-October (the time of this writing), 407 TDA members started the process of filing through ERC Specialists. Roughly half had refund amounts estimated, with the collective amount exceeding $11 million.

For more information on the ERC Specialists program, visit tdaperks.com (Financial: ERC Specialists). You can contact ERC Specialists at (281) 229-4918.

TDA Perks Program sincerely hopes that its 2022 efforts touched you in tangible ways as it continues its mission to provide value to you and for your profession.

References

1. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

2. Current figure at the time of this article’s writing in mid-October 2022. The figure will likely be substantially higher at publication.

The Employee Retention Credit (ERC)—created under the Coronavirus Aid, Relief and Economic Security (CARES) Act—allows qualified small businesses to claim up to $26,000 per employee as a fully-forgiven tax credit for 2020 and 2021—even if they received Paycheck Protection Program (PPP) funding.

More than $11 million was scheduled to be refunded to TDA members with the help of a TDA Perks Program2

ORAL

and maxillofacial pathology diagnosis and management—from page 740

Diagnosis: Histoplasmosis

Additional Follow Up Information

After the diagnosis was established, the patient was referred to an infectious disease specialist and was managed by oral itraconazole for two months. His oral pain and ulceration resolved and he was disease-free for a few months, although he still complained of lingering headaches during this time. The disease then recurred, and he was admitted to an emergency room and managed by itraconazole for another 6 months. Currently he is undergoing a nasal surgery and further systemic evaluation of his overall health.

Discussion

This case illustrates the clinical challenge of a non-healing ulcerated lesion on the gingiva that did not respond to conventional periodontal therapy and antibiotics. Generally speaking, biopsy is necessary for an oral ulceration that shows no sign of healing for longer than two weeks. In this case, a biopsy is even more important as the possibility of dental plaque-associated gingivitis/periodontitis, including necrotizing gingivitis/periodontitis, had been excluded. The ulcer persisted for weeks and was considered chronic. Although there are other oral diseases in the differential diagnosis (see below), malignancy is the most serious concern for a chronic nonhealing ulcer, and that is the reason why a biopsy is necessary for any chronic nonhealing oral ulceration lasting longer than 2 weeks.

The clinical differential diagnosis for a localized, chronic, non-healing oral ulcerated lesion include: 1) traumatic granuloma (traumatic ulcerative granuloma with stromal eosinophilia); 2) infection (bacterial, viral or deep fungal infection); and 3) malignancies such as oral squamous cell carcinoma. The traumatic granuloma is caused by deep-seated inflammation associated with a traumatic ulcer.1 It most commonly affects the lateral border of tongue and buccal mucosa, which are areas prone to bite trauma. These lesions can last for weeks or months. Traumatic granuloma was less likely in this case, as gingiva is an uncommon site for this lesion and there was no history of trauma.

In the category of infection, tuberculosis (TB) is the most common bacterial infection that can present as a nonhealing oral ulceration. It is caused by Mycobacterium tuberculosis and the lung is the most common organ affected by this disease.2 Oral TB is uncommon, and most often represents a secondary infection from the initial infection in the lungs. The most common presentation is a non-healing ulcer involving the tongue.

Cytomegalovirus (CMV, HHV-5) infection and EBV-associated mucocutaneous ulceration, a newly described entity, are two examples of viral infections that may present as chronic oral ulcerations. Both CMV-associated oral ulceration and Epstein-Barr Virus (EBV)associated mucocutaneous ulcerations usually occur in immunocompromised individuals.3-5 Almost 90% of CMV infections are asymptomatic.6 In symptomatic cases, the patients show cardinal signs of infection (fever, chills, headache, fatigue), sore throat and less commonly joint and muscle pain, or abdominal pain. Like other herpesviruses, CMV remains latent after initial infection, and can be reactivated when a person’s immune function is suppressed. EBV-associated mucocutaneous ulceration is a B-cell lymphoproliferative disorder typically occurring in elderly or immunosuppressed patients due to medication, organ transplant, or HIV infection.7 The most common immunosuppressive medication that causes an EBV-associated mucocutaneous ulceration is methotrexate, followed by azathioprine, cyclosporine, imatinib, and others.5,7 EBV–associated mucocutaneous ulceration typically presents as a circumscribed, isolated and indurated ulcer. Other than the symptoms related to the ulcer, patients are

otherwise asymptomatic. Although these lesions mimic malignancies both clinically and histopathologically, EBVassociated mucocutaneous ulcerations are usually self-limiting or show an indolent course. Most cases regress spontaneously or respond to reduction of immunosuppression.7 Rituximab has been used for treating elderly patients without known immunosuppression with excellent results.

The most common deep fungal infection seen in the oral cavity is histoplasmosis, and it typically presents as a nonhealing oral ulceration. Histoplasmosis is caused by Histoplasma capsulatum.8 It grows in a yeast form in the human body and a mold form in its natural environment, which includes primarily humid areas and soil enriched with bird or bat excrement. The Ohio and Mississippi River valley in the US are the endemic areas. Humans get infected by inhaling the airborne spores of H. capsulatum with the lungs being the primary organ of infection. The outcome of any infection typically depends on three factors: the host immune status, quantity of infectious agent the host encountered, and the ability of the infectious agent to make the host sick (virulence). The outcome of histoplasmosis also depends on the patient’s immune status, quantity of spores the patient is exposed to, and the strain of the organism. Most cases of histoplasmosis are asymptomatic or present with mild flu-like symptoms for which the patient may or may not seek medical help.. In symptomatic patients, histoplasmosis may present as three different clinical forms: 1) acute pulmonary form, 2) chronic pulmonary form, and 3) disseminated form, in which the infection progressively spreads to extra-pulmonary sites such as oral cavity. The disseminated form usually occurs in older, debilitated or

immunosuppressed individuals. In the present case, there was no known history of debilitating disease or known immunosuppression at the time of biopsy. However, based on the available follow-up information, the possibility of a yet-undiagnosed debilitating disease is certainly considered. The most common oral presentation for histoplasmosis is a solitary non-healing ulceration with a variable degree of pain persisting for several weeks. Although the most common reported sites for oral histoplasmosis are the tongue, palate, and buccal mucosa, we have seen multiple cases involving the gingiva, including the present case.8

Oral squamous cell carcinoma (OSCC) is the most common malignancy in the oral cavity, and accounts for more than 90% of all oral cancer cases.9 OSCC most often involves the lateral, ventral tongue and floor of mouth, and the clinical presentation depends on the stage. In early-stage disease, OSCC often presents as a localized, red and white plaque with or without ulceration. The patient is usually asymptomatic. In advanced stage disease, OSCC often presents as an ulcerated mass with heterogeneous color (intermixed with red and white) and an irregular surface (pebbly, cobblestone, or verrucous/ papillary). Pain is typically associated with advanced OSCC. The ulceration in OSCC is caused by necrosis of the surface epithelium. The rapidly growing neoplastic cells invade the underlying lamina propria, taking up nutrients and oxygen diffused from the blood vessels before they reach the surface epithelium. Without these nutrients and oxygen, the surface squamous epithelial cells die, and ulceration forms. OSCC orchestrates its microenvironment to benefit its own growth and to allow further spread.10 Therefore, proper wound healing cannot happen, and

the clinical ulceration persists. Like any type of cancer, early detection and early diagnosis are key to patient survival; and early detection of oral cancer is through a comprehensive oral examination by a dentist or oral healthcare provider.

In summary, a localized, chronic, non-healing oral ulcerated lesion can be caused by deep seated trauma, infection, or malignancy. It is important to note that a biopsy is essential to establish the definitive diagnosis.

Reference

1. Neville BW, Damn DD, Allen CM, Chi AC. Traumatic ulcerations. In Chapter 8: Physical and Chemical Injuries. Oral and Maxillofacial Pathology. Fourth edition, Saunders Elsevier, 2016, p.260-2.

2. Neville BW, Damn DD, Allen CM, Chi AC. Tuberculosis. In Chapter 5: Bacterial Infections. Oral and Maxillofacial Pathology. Fourth edition, Saunders Elsevier, 2016, p.176-9.

3. Qari H, Pavelka J, and Cheng YSL. 2016, Oral and Maxillofacial Pathology Case of the Month: Cytomegalovirus associated oral ulceration. Texas Dental Journal 133(7):4067, 428-30.

4. Hart M, Thakral B, Yohe S, Balfour HH, Singh C, Spears M, McKenna RW. 2014. EBV-positive mucocutaneous ulcer in organ transplant recipients - A localized indolent posttransplant lymphoproliferative disorder. Am J Surg Pathol 38:1522–1529.

5. Naidu A, Kessler H, Pavelka M. 2014, Epstein-Barr virus–positive oral ulceration simulating Hodgkin lymphoma in a patient treated with methotrexate: Case report and review of the literature. J Oral Maxillofac Surg 72:724-729.

6. Neville BW, Damn DD, Allen CM, Chi AC. Cytomegalovirus. In Chapter 7: Viral Infection. Oral and Maxillofacial Pathology. Fourth edition, Saunders Elsevier, 2016, p. 231-2.

7. Quintanilla-Martinez L, Swerdlow SH, Tousseyn T, Barrionuevo C, Nakamura S, and Jafe ES. New concepts in EBV-associated B, T, and NK cell lymphoproliferative disorders. Virchows Archiv 2022 Oct 11. doi: 10.1007/ s00428-022-03414-4. Online ahead of print (https://doi.org/10.1007/s00428-022-034144).

8. Neville BW, Damn DD, Allen CM, Chi AC. Histoplasmosis. In Chapter 6: Fungal and Protozoal Diseases. Oral and Maxillofacial Pathology. Fourth edition, Saunders Elsevier, 2016, p.199-203.

9. Neville BW, Damn DD, Allen CM, Chi AC. Squamous cell carcinoma. In Chapter 10: Epithelial Pathology. Oral and Maxillofacial Pathology. Fourth edition, Saunders Elsevier, 2016, p.374-89.

10. Peltanova B, Raudenska M and Masarik M. 2019. Effect of tumor microenvironment on pathogenesis of the head and neck squamous cell carcinoma: a systematic review. Mol Cancer 18, 63. https://doi. org/10.1186/s12943-019-0983-5.

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Ads must be submitted, and are only accepted, via www.tda.org/Member-Resources/TDAClassified-Ads-Terms. By official TDA resolution, ads may not quote specific incomes or revenues and must be stated in generic terms (ie “$315,000” should be “low-to-mid-6 figures”). Journal editors reserve the right to edit and/or deny copy.

PRACTICE OPPORTUNITIES

ALL TEXAS LISTINGS FOR MCLERRAN & ASSOCIATES. TO REQUEST MORE INFORMATION ON OUR LISTINGS: Please register at www.dentaltransitions.com or contact us at 512-900-7989 or info@ dentaltransitions.com. AUSTIN-WEST (ID #539): 100% fee-for-service practice in the Texas hill country with strong hygiene recall (approximately 30% of total production) and an increasing revenue trend over the past 3 years. The practice is located in a freestanding building that features 3 fully equipped operatories, newly installed computers in each room, digital sensors, hand-held x-ray units, practice management software (Dentrix Ascend), and paperless charts. The real estate is also for sale. AUSTIN (ID #564): Turnkey GD office with a modern finish out in a highly desirable suburb of north Austin. This 2,100+ sq ft office featuring 6 total ops (4 fully equipped, 2 built out and plumbed), computers in operatories, digital radiography, intra oral cameras, paperless charts, and a digital pano. The practice revenue has been tracking at mid-

6 figures annually for the past several years on 3 doctor days per week with approximately 30% of total production derived from hygiene procedures. DALLAS/FORT WORTH (ID #558): Gorgeous general dentistry practice in a highly desirable and growing suburb of Dallas. Large 3,000 sq ft office that features 4 fully equipped operatories with 4 additional operatories builtout and ready to be equipped. The practice features computers in all operatories, digital radiography, digital sensors, a digital pano, a digital scanner, intra oral cameras and paperless charts. The office serves a FFS/PPO patient base with revenue of mid-6 figures annually and strong hygiene recall on 4 doctor days per week. EAST TEXAS (ID #486): Located in a growing east Texas community, this general practice caters to a dedicated multigenerational active patient base. The wellappointed 2,500 sq ft space contains 5 fully equipped operatories, digital pano, plumbed nitrous, and computers throughout. EAST TEXAS (ID #542): Large practice and real estate in east Texas with over 7 figures in revenue. The recently updated 2,400 sq ft facility features

5 fully equipped operatories with digital radiography, paperless charts, CBCT, digital Pano, and an iTero digital scanner. The practice serves a large FFS/PPO, multi-generational patient base with over 3,000 active patients and a stellar online reputation. The seller is open to providing a long-term transition period to the buyer. HOUSTON-NORTHEAST (ID #488): FFS/PPO practice + real estate, growing suburb 45 minutes NE of Houston. 1,800 total patients, steady flow of new patients, solid hygiene recall, and consistent revenue of high6 figures per year. The office contains 6 fully equipped operatories, plumbed nitrous, digital X-rays, CBCT, and computers throughout.

HOUSTON-SOUTHWEST (ID #565): Large, comprehensive GD practice in SW Houston. The spacious 3,200+ sq ft facility features 8 fully equipped ops (with 10 total operatories) with digital radiography, computers in operatories, a digital scanner and CBCT. The practice has realized revenue of over 7 figures in 2021 and is tracking for nearly the same in 2022 with over 40% profitability. This is a great opportunity for a highly trained clinician or group that is

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looking for a large office that they can continue to grow into. HOUSTON-SOUTHEAST (ID #566): GD office located in a growing suburb SE of Houston. PPO/Medicaid patient base, strong and consistent cash flow, a steady flow of new patients, and solid hygiene recall. The 1,950 sq ft, high visibility, retail space features 6 total operatories (5 equipped), a digital pano, paperless charts, an E4D digital scanner/milling unit, and computers throughout. With almost all expanded procedures being referred out, little to no marketing/advertising, and a stellar location, this practice is primed for future growth. HOUSTON-NORTH (ID #568): Turnkey GD practice in a rapidly growing suburb of Houston. The FFS/PPO office features a modern build out with 3 equipped operatories, computers in ops, digital radiography, intra oral cameras, paperless charts, and a digital pano. This is an ideal opportunity for a buyer who is interested in a start-up and is ready to take an office that is primed for growth to the next level!

MIDLAND/ODESSA (ID: 567): 100% FFS GD practice in Midland/Odessa. The 1,440 sq ft condo is well equipped with 3 fully furnished

operatories, digital radiography, intra-oral cameras, and a digital pano and CBCT. Dedicated, multi-generational patient base, a fantastic reputation, word of mouth referrals, consistent hygiene recall, low overhead, and strong cash flow. NORTHEAST TEXAS (ID #554): 100% FFS general dentistry practice in a desirable town in northeast Texas with 7 figures in revenue and strong net income. The turn-key practice features 4 fully equipped operatories with digital radiography, intra oral cameras, paperless charts, CBCT, and a digital scanner. SAN ANTONIO, ORTHODONTIC (ID #547): Rare opportunity to purchase a primarily FFS orthodontic practice in north central San Antonio. The facility has a modern feel and is equipped with a 3-chair open bay, 2 additional private treatment rooms, and digital radiography. In 2021, revenue was high-6 figures with strong net cash flow. The practice has been a staple in the community with over 40 years at its present location and is located near several highly desirable neighborhoods.

TO REQUEST MORE INFORMATION ON MCLERRAN & ASSOCIATES’ LISTINGS: Please

register at www.dentaltransitions.com or contact us at 512-900-7989 or info@ dentaltransitions.com.

BEAUMONT: GENERAL (REFERENCE

“BEAUMONT”). Small town practice near a main thoroughfare. 80 miles east of Houston. Collections in 7 figures. Country living, close enough to Houston for small commute. Practice in a stand-alone building built in 1970. The office is 1,675 sq ft with 4 total operatories, 2 operatories for hygiene and 2 operatories for dentistry. Contains, reception area, dentist office, sterilization area, lab area. Majority of patients are 30 to 65 years old. Practice has operated at this location for over 38 years. Practice sees patients about 16 days a month. Collection ratio of 100%. The Practice is a fee-for-service practice. Building is owned by dentist and is available for sale. Contact Christopher Dunn at 800-930-8017 or Christopher@DDRDental.com. HOUSTON (SHARPSTOWN AREA): GENERAL (REFERENCE “SHARPSTOWN GENERAL”). MOTIVATED SELLER. Well established general dentist with high-

6 figure gross production. Comprehensive general dentistry in the southwest Houston area focused on children (Medicaid). Very, very high profitability. 1,300 sq ft, 4 operatories in single building. 95% collection ratio. Over 1,200 active patients. 20% Medicaid, 45% PPO, and 35% fee-for-service. 30% of patients younger than 30. Office open 6 days a week and accepts Medicaid. Contact Christopher Dunn at 800-930-8017 or Christopher@

McLerran & Associates is the largest dental practice brokerage firm in Texas. When it’s time to buy or sell a practice, we’ve got you covered.

DSO C S PRACTICE SALES

Austin 512-900-7989

DFW 214-960-4451 Houston 281-362-1707

San Antonio 210-737-0100 South Texas 361-221-1990

PRACTICE APPRAISALS

Email: texas@dentaltransitions.com

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DDRDental.com. HOUSTON (BAYTOWN AREA): GENERAL (REFERENCE “BAYTOWN GENERAL”). MOTIVATED SELLER. Well established general practice with mid-6 figure gross production. Comprehensive general dentistry in Baytown on the east side of Houston. Great opportunity for growth! 1,400 sq ft, 4 operatories in single story building. 100% collection ratio. 100% fee-for-service. Practice focuses on restorative, cosmetic and implant dental procedures. Office open 3 - 1/2 days a week. Practice area is owned by dentist and is available for sale. Contact Christopher Dunn at 800-930-8017 or Christopher@DDRDental.com.

ready to retire! Upstairs rental spaces income for over 5 years: 5 figures per year. For info call 214-215-2525, Sandy Ward, Adm.

DALLAS: Hageman Family Dentistry, 9,900 sq ft building, on 2/3 acre. Prime location with easy access on and off Highway 67. 9 fully equipped operatories, digital x-rays, new computers in operatories, office and doctor’s offices. Cephalometric, laser, and Panorex machines.

Beautiful waiting room seats 20 patients comfortably; practice thriving for 50 years, 40 years in present location. Annual income for past 5 years: 7 figures. Dr David Hageman is

HOUSTON, COLLEGE STATION, AND LUFKIN (DDR DENTAL Listings). (See also AUSTIN for other DDR Dental listings and visit www. DDRDental.com for full details. LUFKIN: GENERAL practice on a high visibility outer loop highway near mall, hospital and mature neighborhoods. Located within a beautiful single-story, free-standing building, built in 1996 and is ALSO available for purchase. Natural light from large windows within 2,300 sq ft with 4 operatories (2 hygiene and 2 dental). Includes a reception area, dentist office, a sterilization area, lab area, and break room. All operatories fully equipped. Does not have a pano but does have digital X-ray. Production is 50% FFS and 50% PPO (no Medicaid), with collection ratio above 95%. Providing general dental and cosmetic procedures, producing mid-6 figure gross collections. Contact Christopher Dunn at 800930-8017 or Christopher@DDRDental.com

and reference “Lufkin General or TX#540”.

HOUSTON: GENERAL (SHARPSTOWN). Well established general dentist with high-6 figure gross production. Comprehensive general dentistry in the southwest Houston area focused on children (Medicaid). Very, very high profitability. 1,300 sq ft, 4 operatories in single building. 95% collection ratio. Over 1,200 active patients. 20% Medicaid, 45% PPO, and 35% fee-for-service. 30% of patients younger than 30. Office open 6 days a week and accepts Medicaid. Contact Chrissy Dunn at 800-930-8017 or chrissy@ddrdental.com and reference “Sharpstown General or TX#548”.

HOUSTON: GENERAL (PEARLAND AREA). GENERAL Located in southeast Houston near Beltway 8. It is in a freestanding building. Dentist has ownership in the building and would like to sell the ownership in the building with the practice. One office currently in use by seller. A 60 percent of patients age 31 to 80 and 20% 80 and above. Four operatories in use, plumbed for 5 operatories. Digital pano and digital x-ray. Contact Christopher Dunn at 800-930-8017 or christopher@ddrdental.com

and reference “Pearland General or TX#538”.

HOUSTON: PEDIATRIC (NORTH HOUSTON) This practice is located in a highly soughtafter upscale neighborhood. It is on a major thoroughfare with high visibility in a strip shopping center. The practice has 3 operatories for hygiene and 2 for dentistry. Nitrous is plumbed for all operatories. The practice has digital X-rays and is fully computerized. The practice was completely renovated in 2018. The practice is only open 3 - 1/2 days per week. Contact Christopher Dunn at 800930-8017 or christopher@ddrdental.com and reference “North Houston or TX#562”. WEST HOUSTON: MOTIVATED SELLER. Medicaid practice with production over 6 figures. Three operatories in 1,200 sq ft in a strip shopping center. Equipment is within 10 years of age. Has a pano and digital X-ray. Great location. If interested contact chrissy@ddrdental.com. Reference “West Houston General or TX#559”.

SAN ANGELO—#TX3082: 5 ops & low O/H. Highly profitable on a 4-day schedule/ wk. 100% FFS. Specialties referred. Room to

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grow. R/E available for purchase or lease. Contact Geremy Haseloff, geremy.haseloff@ henryschein.com, 806.777.4732. HOUSTON— #TX3114: Beautiful. Prosthodontic. Uptown/ West Oaks area. 3+1 Ops. Digital, Dentrix, digital pan and x-ray, i/o camera. Consistent 7 figures plus annual revenues past 5 years. Contact Josh Griebahn, josh.griebahn@ henryschein.com, 713.882.8485. CINCO

RANCH/KATY AREA—#TX3183: A gem startup opportunity! Beautiful 6 op practice in major hotspot. Digital, paperless, CBCT/with Ceph, all ADEC units with integrated electric handpieces, i/o cams. Contact Josh Griebahn, josh. griebahn@henryschein.com, 713.882.8485.

AMARILLO AREA—#TX3221: Profitable 7 figures GR. 41 yrs goodwill. Beautiful R/E available for purchase. >90% FFS, High patient numbers, great location, best equipment and tech. 12 equipped ops. Room for expansion! Contact Geremy Haseloff, geremy.haseloff@ henryschein.com. DALLAS— #TX3258: GP w/3 ops & equipment in nice shape. Great location on busy, main road with low O/H. Reasonable rent, affluent area. Seller to retire. 50+ years

of caring for area patients. Contact Geremy Haseloff, geremy.haseloff@henryschein.com.

SAN ANTONIO—#TX3284: Located in rapidly growing area, 4 ops pediatric, fully digital w/ real estate. 52 new patients/mo. Don’t miss this opportunity! Contact Josh Griebahn, 713-8828485 to discuss this opportunity! HOUSTON— #TX3297: 4 ops, Montrose area, amazing location. Dentrix, Dexis, CBCT, i/o cams & fantastic team. R/E for sale for tenant income. Net earnings are mid-6 figures on 3 days per week. Details? Contact Josh Griebahn at 713882-8485.

SAN ANGELO: To those desiring the perfect balance between work and play: Are you interested in taking over a successful readymade practice with a great salary low-to-mid 6 figures? Located in west central Texas, San Angelo is a city of 100,000+ but offers a small town feel and excellent quality of life. The city was named the Visual Arts Capital of Texas in 2021 and is alive with a vibrant mixture of arts and culture for children and adults. It is consistently ranked as one of the best

small cities for business and employment. San Angelo is home to award winning Angelo State University, 3 lakes, the beautiful Concho Riverwalk, an incredible nationally ranked Art Museum, and one of the best preserved forts in the nation, Fort Concho— all with numerous kid-involved programs. As a Texas friendly city, live music is offered almost daily at one of many venues and one-of-a-kind restaurants in town. The community is diverse, with an active young professional group, outstanding medical facilities, ranked sports teams, great hunting and fishing, and a low cost of living. Easy traffic takes you anywhere in the city within 10 minutes. It’s a great place to raise a family and a great place to live, work, and play. The 2,400 sq ft newly remodeled dental office, built to accommodate two dentists, is a free-standing building with natural light in each operatory. An extremely healthy hygiene program is in place with two hygienist. There are 6 operatory rooms—4 equipped. The majority of practice is FFS cash, with over 3,000 active patients. The practice has an excellent reputation in the local community. A bonus package is included for

preferred equipment needs. Contact Geremy Haseloff @ 806-777-4732 or geremy.haseloff@ henryschein.com.

WATSON BROWN PRACTICES FOR SALE:

Practices for sale in Texas and surrounding states, For more information and current listings please visit our website at www. adstexas.com or call us at 469-222-3200 to speak with Frank or Jeremy.

INTERIM SERVICES

HAVE MIRROR AND EXPLORER, WILL TRAVEL: Sick leave, maternity leave, vacation, or death, I will cover your general or pediatric practice. Call Robert Zoch, DDS, MAGD, at 512517-2826 or drzoch@yahoo.com.