AL IC UE I EC ATR ISS P S I RY D PE IST rt 1I T Pa N DE
December 2010
Journal TEXAS DENTAL
Southwest Dental Conference January 13 – 15, 2011 Dallas Convention Center
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Texas Dental Journal l www.tda.org l December 2010
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Contents
TEXAS DENTAL JOURNAL n Established February 1883 n Vol. 127, Number 12, December 2010
ON THE COVER
Southwest Dental Conference • January 13–15, 2011 Dallas Convention Center, Dallas • swdentalconf.org
The Dallas County Dental Society (DCDS) holds its annual session, the Southwest Dental Conference (SWDC), January 13–15, 2011, at the Dallas Convention Center, in Dallas, Texas. For more information, please visit swdentalconf.org. Pictured left to right are: 2013 SWDC Chairman Dr. Robert Hamilton, 2012 SWDC Chairman Dr. Danette McNew, 2011 SWDC Chairman Dr. Jacqueline Plemons, and DCDS President Dr. Wayne Woods. Photo by Wade Barker.
ARTICLES
This issue is the second of two special issues on pediatric dentistry. The authors present studies on dental trauma in children with disabilities compared to otherwise healthy children, the complex process of creating a treatment plan for pediatric patients, and the preparedness of a Texas county to treat underserved children.
1265 Dental Trauma in Children and Adolescents with Mental and Physical Disabilities
Bhavini S. Acharya, B.D.S., M.P.H. Priyanshi Ritwik, B.D.S., M.S. Sanford J. Fenton, D.D.S., M.D.S. Gisela M. Velasquez, D.D.S., M.S. Joseph Hagan, M.S.P.H.
The authors determine the occurrence of dental trauma in children with special needs versus otherwise healthy children.
1275 Treatment Planning for the Pediatric Patient
Alton G. McWhorter, D.D.S., M.S.
The author discusses the treatment planning process for pediatric patients, a complex process of risk assessment and behavior evaluation.
1283 Bexar County’s Dental Safety Net for Children: An Estimate
of Our Capacity and Need
Carlos N. Mohamed, D.D.S., M.P.H. William Spears, Ph.D.
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As uninsured children experience difficulty in obtaining dental care, the authors present a study on a Texas county’s preparedness for this underserved population.
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MONTHLY FEATURES
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President’s Message
Diagnosis and Management
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BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION
Guest Editorial Thanks to the Journal Reviewers Notice of Grant Availability TDA 140th Annual Session 2010 TEXAS Meeting Photo Contest Texas Dental Journal 2010 Index of Feature Articles TEXAS Meeting Preview In Memoriam / TDA Smiles Foundation What’s on tda.org? Value for Your Profession Calendar of Events Oral and Maxillofacial Pathology Case of the Month Oral and Maxillofacial Pathology Case of the Month Advertising Briefs Index to Advertisers
EDITORIAL STAFF
Texas Dental Journal (ISSN 0040-4284) is published monthly, one issue will be a directory issue, by the Stephen R. Matteson, D.D.S., Editor Texas Dental Association, 1946 S. IH-35, Austin, Texas, 78704-3698, (512) 443-3675. Periodicals Nicole Scott, Managing Editor Postage Paid at Austin, Texas and at additional mailBarbara S. Donovan, Art Director ing offices. POSTMASTER: Send address changes Paul H. Schlesinger, Consultant to TEXAS DENTAL JOURNAL, 1946 S. Interregional Highway, Austin, TX 78704. EDITORIAL Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, ADVISORY BOARD Out-of-state ADA Affiliated $49.50. In-state NonRonald C. Auvenshine, D.D.S., Ph.D. ADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA AffiliBarry K. Bartee, D.D.S., M.D. ated, $17 Non-ADA Affiliated, September issue $17 Patricia L. Blanton, D.D.S., Ph.D. ADA Affiliated, $65 Non-ADA Affiliated. For in-state William C. Bone, D.D.S. orders, add 8.25% sales tax. Phillip M. Campbell, D.D.S., M.S.D. Contributions: Manuscripts and news items of interest to the membership of the society are solicited. The Tommy W. Gage, D.D.S., Ph.D. Editor prefers electronic submissions although paper Arthur H. Jeske, D.M.D., Ph.D. manuscripts are acceptable. Manuscripts should be Larry D. Jones, D.D.S. typewritten, double spaced, and the original copy should be submitted. For more information, please Paul A. Kennedy, Jr., D.D.S., M.S. refer to the Instructions for Contributors statement Scott R. Makins, D.D.S. printed in the September Annual Membership DirecRobert V. Walker, D.D.S. tory or on the TDA website: www.tda.org. All statements of opinion and of supposed facts are published William F. Wathen, D.M.D. on authority of the writer under whose name they Robert C. White, D.D.S. appear and are not to be regarded as the views of the Leighton A. Wier, D.D.S. Texas Dental Association, unless such statements Douglas B. Willingham, D.D.S. have been adopted by the Association. Articles are accepted with the understanding that they have not The Texas Dental Journal is a been published previously. Authors must disclose any financial or other interests they may have in products peer-reviewed publication. or services described in their articles. Advertisements: Publication of advertisements Texas Dental Association in this journal does not constitute a guarantee or 1946 South IH-35, Suite 400 endorsement by the Association of the quality of Austin, TX 78704-3698 value of such product or of the claims made of it by Phone: (512) 443-3675 its manufacturer. FAX: (512) 443-3031 E-Mail: tda@tda.org Texas Dental Journal is a member of the aa Website: www.tda.org American Association of Dental Editors.
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PRESIDENT Ronald L. Rhea, D.D.S. (713) 467-3458, rrhea@tda.org PRESIDENT-ELECT J. Preston Coleman, D.D.S. (210) 656-3301, drjpc@sbcglobal.net IMMEDIATE PAST PRESIDENT Matthew B. Roberts, D.D.S. (936) 544-3790, crockettdental@gmail.com VICE PRESIDENT, SOUTHEAST R. Lee Clitheroe, D.D.S. (281) 265-9393, rlcdds@windstream.net VICE PRESIDENT, SOUTHWEST John W. Baucum III, D.D.S. (361) 855-3900, jbaucum3@msn.com VICE PRESIDENT, NORTHWEST Kathleen M. Nichols, D.D.S. (806) 698-6684, toothmom@kathleennicholsdds.com VICE PRESIDENT, NORTHEAST Donna G. Miller, D.D.S. (254) 772-3632, dmiller.2thdoc@grandecom.net SENIOR DIRECTOR, SOUTHEAST Karen E. Frazer, D.D.S. (512) 442-2295, drkefrazer@att.net SENIOR DIRECTOR, SOUTHWEST Lisa B. Masters, D.D.S. (210) 349-4424, mastersdds@mdgteam.com SENIOR DIRECTOR, NORTHWEST Robert E. Wiggins, D.D.S. (325) 677-1041, robwigg@suddenlink.net SENIOR DIRECTOR, NORTHEAST Larry D. Herwig, D.D.S. (214) 361-1845, ldherwig@sbcglobal.net DIRECTOR, SOUTHEAST Rita M. Cammarata, D.D.S. (713) 666-7884, rmcdds@sbcglobal.net DIRECTOR, SOUTHWEST T. Beth Vance, D.D.S. (956) 968-9762, tbeth55@yahoo.com DIRECTOR, NORTHWEST Michael J. Goulding, D.D.S. (817) 737-3536, mjgdds@sbcglobal.net DIRECTOR, NORTHEAST Arthur C. Morchat, D.D.S. (903) 983-1919, amorchat@suddenlink.net SECRETARY-TREASURER Ron Collins, D.D.S. (281) 983-5677, roncollinsdds@hotmail.com SPEAKER OF THE HOUSE Glen D. Hall, D.D.S. (325) 698-7560, abdent78@sbcglobal.net PARLIAMENTARIAN Michael L. Stuart, D.D.S. (972) 226-6655, mstuartdds@sbcglobal.net EDITOR Stephen R. Matteson, D.D.S. (210) 277-8595, smatteson@satx.rr.com EXECUTIVE DIRECTOR Ms. Mary Kay Linn (512) 443-3675, marykay@tda.org LEGAL COUNSEL Mr. William H. Bingham (512) 495-6000, bbingham@mcginnislaw.com
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President’s Message Ronald L. Rhea, D.D.S., TDA President
I am excited to introduce this second of two Texas Dental Journal issues with a focus on pediatric dental care. Certainly Texas dentists must be concerned that all Texas children receive the dental care that they need. Drs. Mohamed and Spears present an article discussing the Dental Safety Net System in Bexar County and the care delivered by this system versus the dental needs in the county. This data cannot be extrapolated to the entire state, however, for Bexar County, about one sixth of the indigent children needs can be met by the safety net system as the authors define it. In addition to the ongoing efforts of private practicing dentists to treat patients traditionally seeking services through the Dental Safety Net System, the TDA, as directed by the House of Delegates, will continue advocating for comprehensive oral health services by strengthening the public health infrastructure and increasing funding for public health programs. Pediatric dental care is of course a specialty. Not all dentists are competent or confident to do all phases of pediatric dentistry. Dr. McWhorter’s article on treatment planning for the pediatric dental patient gives some guidelines to help in this complex endeavor. One of the most complex care areas, the treatment of traumatic dental injuries in pediatric patients with mental and physical disorders, is discussed by Dr. Acharya et al. As dentists, we can all agree there are children in Texas who do not receive the amount of dental care that we believe to be ideal. But why they do not receive this care and what are the solutions to see that they do, is often a highly emotional and politically charged discussion. It is very important now when so many decisions are being made about the future of dentistry that we clearly understand the problem. First we must not confuse access with utilization. Even the children from financially secure, well-educated families do not always receive recommended dental care. They have complete access which, for one reason or another, they do not utilize. The decision not to seek care even when it is readily available certainly also occurs in indigent populations.
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Add to this the need to understand the ways by which care can be accessed when finances are short and the cultural impediments to seeking care and it is easy to see why dental care is underutilized. It may be an un-caring or uneducated parent that is the main barrier to the child receiving dental care. In Texas, we can be very proud of the positive effects the Head Start Dental Home Initiative and First Dental Home Program have had on very young dental patients and their parents. Dr. Fenton’s guest editorial praises these programs and relays to us some statistics about the utilization problem in Texas. From Dr. Fenton’s statistics we can see that much analysis remains to be done. If 23 percent of Texas children live in poverty, and 27 percent of Texas children are enrolled in Medicaid, but 46.2 percent of Texas Medicaid eligible children did not receive any dental care, why not? Did the funding run out? Was it that no dentist was willing to see them? Was it because they didn’t think they needed to see a dentist because they had no pain? Was the distance to a provider further than they wanted to travel or had means to travel? Is it because no parent or adult care giver could work the time for the child’s dental visit into their schedule? Is this an access problem or a utilization problem? Is it a funding problem? The answer: it is some of each of these things. Most Texas dentists have open appointment times in their schedules and many are willing to see indigent children for no fee during these times. How can we coordinate and use these times? Finally, we must be very skeptical when some would have us delegate this most complex area of dental specialty care to a lesser trained, minimally supervised DHAT or other individual. Managing the delivery of pediatric dental care is often a difficult and daunting task. While work remains to be done, you can be proud of the progress in the access to care arena that has occurred over the last several years. Please enjoy your issue of the Texas Dental Journal.
Peer Review: Process Snapshot Peer review is organized dentistry’s dispute resolution process that generally handles complaints from patients against dentists regarding the quality or appropriateness of clinical dental treatment received.
Need a peer review sign for your office? You may print a copy of the peer review sign from the Resources section of the members homepage on the TDA Website (tda.org).
For more information about peer review please contact the Council on Peer Review via Cassidy Neal at 512-443-3675 ext. 152.
Guest Editorial
Improving the Oral Health of Texas Children, but...
Sanford J. Fenton, D.D.S., M.S., Professor and Chair, Department of Pediatric Dentistry, University of Texas Dental Branch, Houston, Texas
I
t is a recognized fact that dental decay is the most common chronic disease of childhood affecting, for example, 5 times more children than asthma (1). It is also well documented that 80 percent of the disease is found in 20-25 percent of the population with most vulnerable children residing in impoverished inner city neighborhoods or rural communities. Relative to federal child poverty level statistics, Texas ranks 43 among the states with 23 percent of Texas children living in poverty (2). Compounding the problem, Texas has had the highest number (years 2003-2008) and percentage of children (years 1998-2008) ages 0-17 years that did not have health coverage through either private or public insurance in the country over the last several years (3). Many children and their parents rely on public funding assistance such as Texas Medicaid for necessary pediatric dental care to prevent or treat oral pain and infection. Over 2.8 million Texas children are
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currently enrolled in Medicaid or the Children’s Health Insurance Program (CHIP). The percentage of children (0-18 years) enrolled in Texas Medicaid was 27.2 percent in 2007 (4). Texas has made some significant strides to improve the oral health of its children since 2007. For example, it was reported at the October 8, 2010, Medicaid Stakeholder’s Meeting in Austin, Texas, that 53.8 percent of the Medicaid eligible children had at least one dental appointment in 2009 which placed Texas third among all the states in access to dental services for these most vulnerable children (5). This noteworthy landmark was achieved through the efforts of many professional organizations and their leadership including the Texas Dental Association and Texas Academy of Pediatric Dentistry, Texas state governmental agencies and officials, and most importantly, the many local community dentists who welcomed Medicaid eligible children into their practices. Other recent state dental programs that have had a significant positive impact on the oral health of Texas children include the Head Start Dental Home Initiative and First Dental Home Program. Establishing 6 months of age for the first dental visit will help to reduce early childhood caries for infants at high risk by stressing anticipatory guidance through the counseling of parents about prevention concepts including establishing good nutrition habits and daily oral hygiene practice while professionally assessing the infant’s risk for tooth decay and providing a dental prophylaxis and topical fluoride varnish application with the potential for 10 infant oral health dental appointments until the child reaches 35 months of age. The Head Start Dental Home Initiative, developed by the American
Academy of Pediatric Dentistry in conjunction with Texas dental leadership, targets Head Start children and their families who have not established a relationship with a private dental practitioner in their local community. This program encourages pediatric and general dentists to welcome these often at-risk children into their practices for comprehensive oral rehabilitation with continued periodic monitoring to minimize a recurrence of significant oral disease. Recent graduates from dental school are taking advantage of the innovative, albeit highly competitive, Children’s Medicaid Loan Repayment Program (CMLRP) administered through the Texas Department of State Health Services which can grant up to $140,000 over 4 years to those recent graduates who provide dental care for a significant number of Medicaid eligible children in their dental offices. This program gives priority to dentists establishing practices in recognized dentally underserved communities across the state. It is so timely that the editor of the Texas Dental Journal has chosen Pediatric Dentistry to be the theme for both the November and December 2010 issues. Providing comprehensive dental care for all children including those who live in poverty, have a significant medical condition or developmental disability, or reside in a rural community setting should be a major goal for any statewide dental healthcare program. The Texas Legislature will convene in January 2011 to address the serious budget shortfall that is anticipated over the next 2 years. Difficult budget decisions including inevitable spending cuts will be deliberated and enacted during the upcoming legislative session. While the present Texas Medicaid Program commend-
ably funded dental care for 53.8 percent of enrolled children in 2009, the fact remains that 46.2 percent of Medicaid eligible children were not so fortunate. Whatever public dental healthcare funding system is finally adopted, it must at least preserve the current level of access to comprehensive dental services for these most vulnerable children and if possible expand access to include the 46.2 percent of un-served children. The views expressed in this editorial are those of the author and do not reflect the opinions of the University of Texas Dental Branch at Houston, the University of Texas Health Science Center, or the Texas Dental Association. References 1. US Dept of Health and Human Services. Oral health in America: A report of the Surgeon General. Rockville, MD: US Dept of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. 2. Children in Poverty, Kids Count Data Center, The Annie E. Casey Foundation, http://datacenter.kidscount.org/, accessed November 22, 2010. 3. Data Across States, Kids Count Data Center, The Annie E. Casey Foundation, http:// datacenter.kidscount.org/ data/acrossstates/Rankings. aspx?ind=31, accessed November 22, 2010. 4. Children Enrolled in Texas Medicaid, Kids Count Data Center, The Annie E. Casey Foundation, http://datacenter.kidscount. org/data/bystate/Rankings. aspx?state=TX&ind=3138, accessed November 22, 2010. 5. 2009 CMS Data reported at Texas Medicaid Stakeholder’s Meeting, Austin, Texas, October 8, 2010.
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Recently Retired? As a retired member, you still receive the same amazing member benefits. Please contact Rachael Daigle at (512) 443-3675 or rachael@tda.org to let us know if you have retired.
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Thanks to the Journal Reviewers Stephen R. Matteson, D.D.S., Editor
The editor of the Texas Dental Journal, on behalf of the Texas Dental Association, wishes to express his sincere appreciation to the manuscript reviewers for 2009-2010. The quality of clinical science articles is largely dependent on the judgment and advice provided by these individuals. Below is the list of reviewers for 2009-2010. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr.
Hoda M. Abdellatif Bhavini S. Acharya Peggy P. Alexander Barry K. Bartee Richard D. Bebermeyer Steven D Bender Joseph M. Berrong Kenneth A. Bolin James S. Bone John P. Brown David P. Cappelli Jarvis T. Chan J. Preston Coleman S. Thomas Deahl II William W. Dodge Ingrid Duebbert Arlet R. Dunsworth Sanford J. Fenton Kevin M. Gureckis
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Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr.
Texas Dental Journal l www.tda.org l December 2010
Steven P. Hackmyer Aya Hamao-Sakamoto Timothy B. Henson Stefan Hienz Michaell Huber Arthur H. Jeske Archie Jones Daniel L. Jones John D. Jones Larry D. Jones Karl Keiser Kavin Kelp Paul A. Kennedy, Jr. Raymond Koeppen Sam Nesbit Patrick Mattie Howard S. McGuff Alton McWhorter Barry K. Norling
Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr.
J.D. Overton Raghu Puttaiah Ryan Quock H. Ralph Rawls Terry Rees Issa S. Sasa N. Sue Seale Jordan Schweitzer Bjorn Steffensen Charles F. Streckfus James Summit Peter Triolo Karen Troendle Charles Wakefield Robert V. Walker William F. Wathen Robert C. White Leighton A. Wier Douglas B. Willingham
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Texas Dental Association Notice of Grant Availability 501(c)(3) Non-Profit Dental Organizations
T
he Texas Dental Association (TDA) announces availability of financial assistance for qualifying 501(c)(3) non-profit organization affiliated with dentistry. The monies are derived from TDA Relief Fund interest income earned over the previous fiscal year. Grantees will be determined by the TDA Board of Directors.
Not Certified by the Texas Board of Legal Specialization
Eligibility: Grantees must be 501(c)(3) nonprofit organizations affiliated with dentistry. Application: Letters of interest detailing the proposed project(s) and including a budget(s) should be mailed to: TDA Board of Directors Attn.: Mr. Terry Cornwell 1946 S. IH 35, Ste. 400, Austin, TX 78704 Deadline: Letters of Interest must be received no later than January 31, 2011. Approval: Letters of Interest will be reviewed and considered by the TDA Board of Directors at its April 2011 meeting.
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Notification: All applicants will be notified in writing by May 15, 2011. Previous Recipients: In 2010, grants were awarded to Christian Community Action in Lewisville, Community Health Center of Lubbock, Dentists Who Care in the Rio Grande Valley, and the HOPE Clinic in Alvin. For more information, please contact Mr. Terry Cornwell, TDA, (512) 443-3675 or terry@tda.org.
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Dental Trauma in Children and Adolescents with Mental and Physical Disabilities Bhavini S. Acharya, B.D.S., M.P.H. Priyanshi Ritwik, B.D.S., M.S. Sanford J. Fenton, D.D.S., M.D.S. Gisela M. Velasquez, D.D.S., M.S. Joseph Hagan, M.S.P.H.
Introduction Children with special needs face numerous challenges in their daily lives, and in recent years there has been increased sensitivity to these challenges. The risk of injury however has received little attention and epidemiology has not been adequately studied (5). Traumatic dental injuries, as with other oral health conditions are preventable, but preventive measures can be applied only if factors contributing to these injuries can be identified (2). It has been acknowledged that although the amount of dental disease in children with disabilities may not be markedly different from that identified in otherwise healthy children, the level of untreated disease is higher in the children with special needs and so is untreated trauma (9).
Acharya Dr. Acharya is an assistant professor, Department of Pediatric Dentistry, University of Texas Dental Branch, Houston, Texas. Dr. Ritwik is an associate professor and Program Director, Department of Pediatric Dentistry, Louisiana State University School of Dentistry, New Orleans, Louisiana. Dr. Fenton is a professor and chair, Department of Pediatric Dentistry, University of Texas Dental Branch, Houston, Texas. Dr. Velasquez is an assistant professor, Department of Pediatric Dentistry, University of Texas Dental Branch, Houston, Texas. Dr. Hagan is an instructor, Department of Biostatistics, Louisiana State University School of Public Health, New Orleans, Louisiana. Corresponding Author: Dr. Acharya, Department of Pediatric Dentistry, University of Texas Dental Branch, 6516 M.D. Anderson Blvd., office #359, Houston, TX 77030. Phone: (713) 500-4178; Email: Bhavini.s.acharya@uth.tmc.edu. This article has been peer reviewed.
Abstract Aim: to determine the occurrence of dental trauma in children and adolescents with a mental and/or physical disability compared to otherwise healthy children, and to assess factors associated with and mechanism of such trauma. Methods: Eighty-six subjects consisting of 43 special needs and 43 otherwise healthy children between the ages of 8 and 15 years were chosen from the patient pool at Special Children’s Dental Clinic within Children’s Hospital, New Orleans. The study utilized a parent interview questionnaire and a clinical exam of the patient. Results: Although healthy children had a higher number of injuries than children with special needs on average, the difference was not statistically significant. Neither healthy children nor children with special needs exhibited a significant correlation between the number of injuries and the size of the overjet (mm) (p=0.722, 0.712). There was not a significant difference in the number of injuries for children with different oral profiles (p=0.949), or adequate versus inadequate lip coverage (p=0.940). Conclusion: In this study population, the children with special needs living at home may have had the same amount of trauma as the otherwise healthy children and studies with larger sample sizes may be needed to further explore this possibility. Excessive overjet, type of facial profile, and adequacy of lip coverage did not seem to increase the amount of trauma noted in our study population. Key woRDS: Special needs, disability, trauma, injury risk Tex Dent J 2010; 127(12):1265-1272. Texas Dental Journal l www.tda.org l December 2010
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Dental Trauma
First, exposure to injury risk of children with special needs is reduced because of decreased mobility and presumably increased precautions (5). Conversely, their injury risk for a given environmental exposure may be amplified because of compromised adaptability to external hazards (5).
As cited in the study by Petridou et al., there are two special factors that tend to alter the epidemiological profile of injuries among children with disabilities. First, exposure to injury risk of children with special needs is reduced because of decreased mobility and presumably increased precautions (5). Conversely, their injury risk for a given environmental exposure may be amplified because of compromised adaptability to external hazards (5). Several studies have been conducted in different parts of the world that have shown a higher incidence and prevalence of trauma in children with special needs (1, 2, 4, 6, 9). However, none of those studies included special needs as one group; instead they had children with specific conditions such as visual or hearing impairment, Down syndrome, autism, cerebral palsy, etc. A study by Shyama et al. in 2001 showed that children with sensory deficits, particularly children who were blind, suffered the highest number of traumatic injuries (1). Her study population included children with sensory deficits, physical handicaps, and developmental disorders. This study also found that injuries increased with age with a clear increase between ages 8-9 and 12-13. The age range chosen for our study population was 8-15 years in order to include these two specific age ranges. A study by Ohito et al. on traumatic dental injuries in handicapped and normal school children in Nairobi, Kenya, included an age range of 5-15 years (2). In this study more handicapped children had injuries compared to normal children (18 percent). Falls alone accounted for 77 percent of all injuries in this group
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of 449 handicapped children. Other studies also found falls to be the most common cause of injury in the handicapped children (3, 5, 6, 7, 8). None of the studies looked for any differences based on where the child spent most of his/her time (homecare or institution). The purpose of this study was to: 1) determine the occurrence of dental trauma in children and adolescents with a mental and/ or physical disability compared to otherwise healthy children; and 2) assess factors associated with and mechanism of such trauma.
Methods and Materials This case control study consisted of 86 children including 43 with special needs (cases) and 43 otherwise healthy (controls). The first 43 patients that met the study criteria in each group and consented to participate were included. All children were between the ages of 8 and 15 years and were chosen from the recall and new patient pool at the Special Children’s Dental Clinic within Children’s Hospital in New Orleans. This clinic caters to healthy as well as children with special needs with most of them having Medicaid as their primary insurance provider. IRB approval was obtained to conduct the study. The cases consisted of children with varying degrees of intellectual disability due to conditions such as, but not limited to, autism, cerebral palsy, or other developmental disturbances as-
sociated with various syndromes. The study subjects included ambulatory children, as well as children who used wheelchairs, but was limited to those children whose disability was severe enough to need constant adult supervision from a family member or other caregiver. For example, children with mild ADHD or autism were not included in the study. Due to institutional regulations, we were unable to obtain consent for those children with special needs who were living in institutions. Therefore, our cases were limited to patients that lived at home and were brought in by parents who were the primary caregivers. Due to this factor, we were unable to compare trauma in homecare versus institutionalized patients. To participate in the study, all patients needed to have their anterior permanent teeth present or, if absent, they should have been lost from trauma only. The controls consisted of children that were otherwise healthy (ASA I) with development appropriate for their age with no physical or mental disabilities. Informed consent was obtained from all parents to perform an exam on their children for the purpose of our study. The study was verbally explained to the otherwise healthy children and they were asked to read and sign assent forms that explained the study in simple terms on one page. In the case of children with special needs, only parental consent for the exam was obtained as the children were unable to read and sign the forms. Interview questionnaires were given to parents for them to review, but were completed by
the examining dentist during the interview process with the parent. The interview questionnaire consisted of questions on patient demographics and medical history. It also included questions on mobility (e.g., wheelchair use) and caretaking needs of the child, such as, how many times the child had been seen by a dentist, and how many times they had been to the emergency room (ER). The history of trauma consisted of questions on how traumatic injury occurred, if treatment was sought immediately, and whether it was in a dental clinic or ER. Also, questions on how, where, and during what activity the trauma occurred and how many times the child had suffered an injury to his or her teeth were asked. A clinical exam of the child was completed by the primary investigator after the interview with the parent. The exam was completed in the dental clinic either in the dental chair or in the wheelchair if required with the use of a dental light, a mirror, and an explorer. The clinical exam included examination of the upper and lower anterior teeth (canine to canine) for signs of trauma. The presence of fractured, discolored, missing and/ or restored anterior teeth due to trauma was noted. Also noted were hypoplastic spots on permanent anterior teeth caused by trauma to primary predecessors and facial or chin scars. Aside from dental trauma, the child’s facial profile and dental overjet were recorded. A plaque and calculus grading was also completed to assess oral hygiene. The findings of the clinical exam were entered into a questionnaire by a dental assistant and reviewed by the primary inves-
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tigator upon completion of the exam. Due to the inability of most of the participants to cooperate for radiographs in the case group, radiographic examination for trauma was not included in this study. The interview and the clinical exam were both performed by the primary investigator to avoid examiner variance that could lead to a bias.
Statistical Analysis The Wilcoxon-Mann-Whitney U was used to determine if there were differences in the number of injuries for healthy children compared to children with special needs and within the group with special needs, to determine if there were differences in the number of injuries for children who needed no aid for mobility versus children who used a wheelchair. The WilcoxonMann-Whitney U was also used to determine if there were differences in the number of injuries for children with different oral profiles, inadequate lip coverage, severity of plaque and calculus, or number of emergency room visits for healthy children versus children with special needs. Spearman’s correlation was used to examine the relationship between the number of injuries and the size of the overjet. The chi-square test was used to determine if there were differences
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in the type of dental fracture for healthy children versus children with special needs. Odds ratios were used to examine the association between being a child with special needs (the “exposure”) and having inadequate lip coverage. Likewise, odds ratios were used to examine the association between being a child with special needs and having plaque buildup. The p-values for the odds ratios were calculated using Fisher’s exact tests. Fisher’s exact test was also used to determine if there was a significant association between being a healthy child versus a child with special needs and the odds of dental trauma, reported past dental injury and clinical signs of dental trauma. Likewise, Fisher’s exact test was used to determine if there was a significant association between being a healthy child versus a child with special needs and the odds of gingival inflammation. A significance level of 0.05 was used for all statistical tests.
Results Data were obtained on 86 children. There were 43 healthy children and 43 children with special needs. The average age in the special needs group and the otherwise healthy group was 12.1 years and 11.5 years, respectively. In the special needs group, 58.1 percent were males and 41.9 percent were females, and in the healthy group, 53.5 percent were males and 46.5 percent were females. The subjects were predominantly African American (Table 1). All except three of the children with special needs displayed intellectual disability. Ten had autism, 11 had cerebral palsy with intellectual disability, nine had seizure disorder, five had Down syndrome, two had spina bifida, and two had Cornelia de Lange syndrome. There were others that had rare syndromes with associated mental and physical disabilities. Fifteen of the 43 children with special needs had trauma, 11 out of the 15 had reported
Table 1. Ethnicity of subjects.
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Ethnicity
Frequency (Percent)
African American
57 (66.3 percent)
Caucasian
25 (29.1 percent)
Hispanic
4 (4.7 percent)
Table 2. Number of injuries for healthy and special needs children. Group
N
Mean (SD) Number of Injuries
Healthy
43
0.414 (0.517)
Special Needs
43
0.262 (0.497)
trauma, and nine had signs of trauma. Five out of the 11 children with reported trauma by the parent still had signs of untreated trauma. Twenty one of the 43 otherwise healthy children had trauma, 16 had reported trauma, and 12 had signs of trauma. Seven out of the 16 children with reported trauma by the parent still had signs of untreated trauma. These findings did not demonstrate a significant difference in the overall trauma experience between the special needs and otherwise healthy children.
Although healthy children had a higher number of injuries than children with special needs on average, the difference was not statistically significant (Table 2). Children with special needs had about half the odds of injury compared to otherwise healthy children but these findings were not statistically significant (OR = 0.488, 95 percent CI = 0.189 – 1.260, p = 0.160) The number of injuries was based on history of trauma given by parent. The signs of trauma were not counted as injuries as one episode of injury may have
p-value 0.154
caused more than one sign of trauma. Data regarding mobility were obtained for all children with special needs except one. There was no significant difference in the number of injuries for children using a wheelchair compared to children that use no aid for mobility (Table 3). Neither healthy children nor children with special needs exhibited a significant correlation between the number of injuries and the size of the overjet (mm) (Table 4).
Table 3. For children with special needs, the number of injuries for children using a wheelchair compared to children using no aid for mobility. Group
N
Mean (SD) Number of Injuries
Wheelchair
16
0.200 (0.414)
No Aid
26
0.308 (0.549)
p-value 0.602
Table 4. Spearman correlation between the number of injuries and the size of the overjet (mm) for healthy and children with special needs. Group N
Correlation Between Number of Injuries and Size of Overjet (mm)
p-value for Significance of Correlation
Healthy 43 -0.057
0.722
Special Needs
0.712
43
0.062
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Table 5. Comparison of the number of injuries for children with different oral profiles. Oral profile
N
Mean (SD) Number of Injuries
Convex
50
0.34 (0.52)
Concave
4
0.25 (0.50)
Straight
31
0.35 (0.55)
There was no significant difference in the number of injuries for children with different oral profiles (Table 5).
children, but the difference was not statistically significant (OR = 0.474, 95 percent CI = 0.184 – 1.219, p = 0.158).
Children with special needs had significantly higher odds of inadequate lip coverage compared to the otherwise healthy children (OR = 3.41, 95 percent CI = 1.09 – 10.64, p = 0.036). However, there was no significant difference in the number of injuries for children with inadequate lip coverage compared to those with adequate lip coverage (p = 0.940).
Fewer children with special needs (9.3 percent) had clinical signs of trauma (i.e., discolored anterior teeth from trauma or restorations due to trauma) compared to healthy children (14.0 percent) but this difference was not statistically significant (p = 0.507).
There was also no significant difference in the type of dental fracture observed in healthy children compared to children with special needs (p = 0.894). Children with special needs had more than four times the odds of gingival inflammation than otherwise healthy children (OR = 4.51, 95 percent CI = 1.76 – 11.58, p = 0.002). Children with special needs had lower odds of reported injury to the face or teeth in the past compared to otherwise healthy
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Children with special needs had significantly higher levels of plaque (p = 0.020) compared to healthy children but there was no significant difference in the level of calculus (p = 0.626). To examine the odds ratios for children with special needs developing plaque, one could arbitrarily choose any of three cut-points to classify “disease” versus “no disease”: For this study cut-point #1 was defined as “any plaque or Grade I,” cut-point #2 as “moderate to severe plaque or Grade II,” and cut-point #3 as “severe plaque or Grade III.” The grades were based on the amount of the
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p-value
0.949
facial surfaces of the upper and lower anterior teeth that were covered with plaque. The facial surfaces of the 12 anterior teeth were divided into thirds; gingival, middle, and incisal third and graded as I, II, and III, respectively. The average of the grades on the 12 teeth was calculated and one grade recorded for each individual participant. The odds ratios for plaque development was computed using each of these three cut-points for disease vs. no disease and considering children with special needs as “exposed” (Table 6). Although children with special needs had a higher number of emergency room visits on average, this difference was not quite statistically significant (p = 0.069).
Discussion Studies performed in various countries have shown that a child with special needs suffers more dental trauma compared to an otherwise healthy child. Shyama et al. in 2001, studied
Table 6. Odds ratios for children with special needs having plaque buildup. Plaque Cut-point
Odds Ratios (95 percent CI)
p-value
(1) any plaque
2.59 (0.967 – 6.95)
0.091
(2) moderate to severe plaque
3.125 (1.25 – 7.95)
0.024*
(3) severe plaque
1.48 (0.43 – 5.08)
0.757
*statistically significant, a = 0.05
malocclusions and traumatic injuries in disabled children in Kuwait aged 3-20 years with sensory deficits (vision or hearing impaired), physical handicaps, and developmental disorders (1). This study found that the highest number of traumatic injuries was seen in blind children (nearly 25 percent of the blind children had dental trauma). They also found that injuries increased with age with a clear increase between ages 8–9 and 12–13. The age range chosen for our study population was 8–15 years in order to include the two specific age ranges with an identified increase in injuries as previously reported by Shyama et al. and to increase the number of children with special needs who could be enrolled as participants in our study. Our results show that children who were otherwise healthy had more dental trauma than those with special needs, although the results were not statistically significant. On the other hand, the lower number of injuries in the special needs population could be attributed to the fact that they were cared for at home by their parents who may have been very protective. The study by Shyama et al. assessed the prevalence of malocclusion and found it to be highest among children with Down syndrome and was shown to be related to
traumatic injuries to the teeth. Traumatic injuries were more common in children with severe malocclusion than with none or slight malocclusion. Other studies however show no statistically significant association between malocclusion and risk of traumatic injury (10). In our study neither healthy children nor children with special needs exhibited a significant correlation between the number of injuries and the size of the overjet, nor was there a significant difference in the number of injuries for children with different oral profiles (Convex, Concave or Straight). A study by D. M. O’Mullane on the relationship between prevalence of injuries to permanent incisor teeth and incisor protrusion and lip coverage showed that the prevalence of injuries to permanent incisor teeth was significantly higher in subjects with protruding incisors and inadequate lip coverage (11). To the contrary, a case control study by Stokes et al. suggested that overjet was not a positive correlate with traumatic dental injury for their study population (10). In our study 12 out of 43 children with special needs had overjets of more than or equal to 5mm but only three of those children reported any injury to their teeth and only three of
the 12 had any signs of trauma (fractured teeth). Also, in our otherwise healthy group, 19 out of 43 children had overjets more than or equal to 5mm but only four of those children reported injury to their teeth and only three of the 19 had signs of trauma. Our findings are consistent with Stoke’s study, wherein increased overjet was not related to increased number of injuries and this was true for both of the groups. Several studies report falls to be the most common cause of injury in children with disabilities (3, 5, 6, 7, 8). A study by Ohito et al. on traumatic dental injuries in handicapped and normal school children in Nairobi, Kenya, had 5-15 year olds where more handicapped children had injuries compared to normal children (18 percent) (2). In this study falls alone accounted for 77 percent of all injuries. Although our findings on this variable were not very significant due to sample size, the handful of parents that recalled and reported any trauma, said it was exclusively caused by falls. As far as treatment considerations, more dental trauma went untreated in children with special needs versus otherwise healthy children as sudden acute episodes of illness in such
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children could naturally allow dental care to assume a low priority (9). In all of our cases, the parents who reported dental trauma reported seeking care in a dental clinic at a later time versus the emergency room immediately. As mentioned earlier, exposure to injury risk for children with special needs is reduced because of decreased mobility and presumably increased precautions (5). Considering the fact that our special needs population was cared for at home, the increased precautions may have led to the lower than expected injuries among this population.
Conclusions •
•
•
•
Children with special needs had about half the odds of injury compared to healthy children but these findings were not statistically significant. Children with special needs had lower odds of reported injury to the face or teeth in the past compared to healthy children, but the difference was not statistically significant. Neither healthy children nor children with special needs exhibited a significant correlation between the number of injuries and the size of the overjet (mm). Children with special needs had more than four times the odds of gingival inflammation
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•
•
•
than healthy children. Children with special needs had significantly higher levels of moderate to severe plaque (p = 0.020) compared to healthy children but there was not a significant difference in the level of calculus. No gender differences were noted in the amount of trauma in either group. Therefore, in this study population, it can be speculated that children with special needs living at home may have the same amount of trauma as the otherwise healthy children but further studies with a larger sample size may be needed.
References 1. Shyama M, Al-Mutawa SA, Honkala S. Malocclusions and Traumatic Injuries in disabled school children and adolescents in Kuwait. Spec Care Dentist 21(3): 104-108, 2001. 2. Ohito FA, Opinya GN, Wang’ombe J. Traumatic Dental Injuries in Normal and Handicapped Children in Nairobi, Kenya. E Afr Med J. 69: 680-2, 1992. 3. Holan G, Peretz B, Efrat J, Shapira J. Trauamtic injuries to the teeth in young individuals with cerebral palsy. Dent Traumatol 21: 65-69, 2005 4. AlSarheed M, Bedi R, Hunt NP. Traumatized permanent teeth in 11-16 year old Saudi Arabian children
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with a sensory impairment attending special schools. Dent Traumatol 19: 123125, 2003 5. Petridou E, Kedikoglou S, Andrie E, Farmakakis T, Tsiga, Angelopoulos AM, Dessypris N and Trichopoulos D. Injuries among disabled children: A study from Greece. Inj. Prev. 9: 226230, 2003 6. Ramirez M, Peek-Asa C, Kraus JF. Disability and risk of school related injury. Inj Prev 10: 21-26, 2004 7. Ann P. Limbos M, Ramirez M, Park LS, Peek-Asa C, Kraus JF. Injuries to head among children enrolled in Special Education. Arch Pediatr Adolesc Med. 158: 1057-1061, 2004 8. Onetto JE, Flores MT, Garbarino ML. Dental Trauma in children and adolescents in Valparaiso, Chile. Endod Dent Tramatol. 10: 223-227, 1994 9. Nunn JH, Murray JJ. The dental health of handicapped children in Newcastle and Northumberland. British Dental Journal 162:, 1987 10. Stokes AN, Loh T, Teo CS, Bagramain RA. Relation between incisal overjet and traumatic injury: a case control study. Endod Dent Traumatol. 11: 2-5, 1995 11. O’Mullane DM. Some factors predisposing to injuries of permanent incisors in school children. Brit. Dent. J. 1973, 134, 328.
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Treatment Planning for the Pediatric Patient Alton G. Mcwhorter, D.D.S., M.S.
Introduction Treatment planning for the pediatric patient is the most important, and probably the most interesting, aspect of patient care. The patients are growing and constantly changing as they develop, not only dentally, but also physically, mentally, and psychologically. The complex process of deciding what needs to be done for each patient while considering the stage of development becomes even more complicated for pediatrics when one has to consider reconciling the child’s behavior and the parents’ expectations. Treatment planning decisions for children are multifactorial. One has to consider the size and location of the carious lesion, and decide what is the best treatment for this tooth, in this child, in this family. When we think of treatment planning for pediatric patients, there are three big decisions that must be made: what is the child’s caries risk status; given that information, what is the best treatment choice; and finally, given the constraints of the child’s behavior (or lack thereof), how will the care best be accomplished? Because children are completely dependent on others for all
Abstract Treatment planning for pediatric dental patients is a multifactorial, complex process that requires careful consideration of three distinct areas: the patient’s caries risk status, the available treatment options and the child’s behavior. Components of a caries risk assessment include: a review of the child’s medical and dental history in combination with the findings of the clinical and radiographic examination. All decisions regarding appropriate treatment options for the patient are guided by the outcome of the caries risk assessment. The child’s behavior is another overriding consideration as it determines how the treatment can be rendered. Information obtained through careful evaluation of each area results in a treatment plan specifically designed for each child’s circumstance.
Key woRDS: treatment
planning, caries risk assessment, pediatrics McWhorter Dr. McWhorter, chair, Department of Pediatric Dentistry, Baylor College of Dentistry — Texas A&M Health Science Center, Dallas, Texas. Correspondence to: Alton G. McWhorter, D.D.S., M.S., 3302 Gaston Avenue, Dallas, Texas 75246; Phone: (214) 828-8131; Fax: (214) 874-4562.; E-mail: amcwhorter@bcd.tamhsc.edu. This article has been peer reviewed.
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Treatment Planning
…you can have the same tooth with the exact same lesion in three different patients, and depending on the child’s caries risk status, could be treated three completely different ways.
of their needs including health care, all treatment planning decisions must then be finalized while considering the parents’ expectations and their ability or willingness to comply with home care, diet, transportation to appointments, etc.
Caries Risk Assessment Determining the child’s caries risk status is the first step in the treatment planning process, and all other treatment planning decisions are based on the information gained from this process. Previous caries experience is the best indicator of
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future activity in the primary teeth (1). Two other powerful indicators are the parent’s level of education and the family’s socioeconomic status (2, 3). The American Academy of Pediatric Dentistry has developed the Caries-risk Assessment Tool (CAT) to help organize information regarding the child and identify the level of risk in order to treatment plan appropriately for each child. According to the CAT, certain findings from the child’s history will place them in the high-risk category. These include: the presence of caries in the parents or siblings; a medically compromising condition that impacts motor coordination or coop-
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eration; the establishment of a dental home and regular visits; fluoride exposure; and diet. CAT findings, coupled with the clinical findings, are then used to determine if the child is at high, moderate, or low risk. A patient in the high-risk category will be evaluated and treatment planned more aggressively than a child in the low-risk group. This assessment needs to be reapplied periodically to determine changes in the patient’s risk status. A more in depth description and an example of the CAT are available in the November 2010 issue of the Texas Dental Journal in the article entitled “Infant Oral Exam and First Dental Home” by Dr. Kavitha Viswanathan.
Treatment Choice Many teeth will require restoration, and dentists have a small arsenal of choices (sealants, composites, amalgams, stainless steel crowns, pulp therapies, and extraction) that will accommodate virtually all restorative requirements. The challenge is to determine which one is appropriate for each patient situation. For example, you can have the same tooth with the exact same lesion in three different patients, and depending on the child’s caries risk status, could be treated three completely different ways. If the tooth in question is the first primary molar with a radiographically demonstrable distal lesion 75 percent of the way to the dentoenamel junction (DEJ), the lesion can be watched in one child, a Class II amalgam or composite might be placed in another, and a stainless steel crown (SSC) could be recommended for the third. While this appears to represent extremes in management, there is sound reasoning for each (Figure 1).
is an increase in size of the lesion at any point in the future, it can be restored at that time. In this situation, two things happen: first, the parent has been given the opportunity to take part in the child’s treatment, and second, the child has grown up in the practice. For some parents, having them actively participate in the preventive aspect of the care makes it easier to hear that the child needs a restoration. If it is decided that the tooth will need restoration in the future, the child has been coming regularly to the office and is used to the surroundings. They have become an older, more comfortable patient and will usually be well-behaved and easily treated. With the advent of remineralization therapy and the understanding that certain lesions can be arrested, we have been able to watch lesions over time. Teeth should only be restored if the lesion progresses. If the lesion remains stable over time, the lesion has become arrested. In another situation, the patient has the same lesion (Figure 1), and is slightly older, 6-8 years of age. For this patient, assume that this is the child’s first visit to the dentist, and the lesion is the smallest of six to eight others that are already well into dentin. The older age for the first dental visit coupled with the increased number of lesions places this child in the moderate caries risk category. The recommendation for a Class II composite or amalgam is a good choice because the lesion is small, the preparation will be ideal, and the tooth will only be in the mouth for approximately 3 more years.
Figure 1. First primary molar with a distal carious lesion approaching the dentoenamel junction (DEJ).
If the lesion described is the only lesion in a low caries risk 3-year-old from a family that has been coming regularly to your office and you are confident that you will have access to the patient and the ability to follow him or her over time, watching this lesion and recommending frequent in-office fluoride varnish along with aggressive home fluoride use is an appropriate choice. Monitoring the lesion radiographically over time is a viable option. If there Texas Dental Journal l www.tda.org l December 2010
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Treatment Planning A conservative Class II restoration of a small lesion in this case can be justified. The final patient is very young (2.5 years old), severely developmentally delayed, and has multiple other large lesions that will require pulp therapy followed by an SSC. Due to the developmental delay and inability to cooperate for treatment in the office, they are being treated in the operating room under general anesthesia. An SSC is an appropriate choice for this child of high caries risk who has a small interproximal lesion on the first primary molar. The crown would be best for this patient, because as the child ages, the behavior will not improve due to the developmental delay. If a Class II restoration fractures or there is recurrent caries, treating the child in a clinical setting will be difficult and possibly dangerous. Of all the restorative options available for the primary dentition, the SSC offers the most advantages; however, it has one major drawback — its lack of esthetics. Indications that make the SSC an appropriate treatment recommendation include: caries diagnosed in the primary dentition that undermines the buccal or lingual surface; proximal caries crossing the line angles or caries on three or more surfaces of a primary tooth; following pulp therapy; if cusps are fractured; or when the tooth is hypoplastic (4). The SSC is extremely durable, relatively inexpensive, subject to minimal technique sensitivity during placement, and offers the advantage of full coronal coverage (5). The parent may reject the SSC for a more esthetic posterior restoration. With the improvement of restorative materials over recent years, there is some latitude and flexibility among material choices. As a result, many times a desire for an esthetic result can be accommodated without providing a substandard final restoration; sometimes, it cannot. The parent is making a decision based on one aspect (esthetics) of the restoration, while practitioners have to consider all factors involved. Parents’ demands for esthetics cannot be allowed to persuade one to abandon appropriate, standard of care treatment choices.
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Pulp therapy for the primary dentition is relatively simple once the appropriate diagnosis of pulpal status is made. The determination that the pulp is vital indicates that either the 5-minute formocresol pulpotomy or an Indirect Pulp Treatment (IPT) is an appropriate choice. The pulpotomy is the most frequently used pulp treatment for cariously involved primary teeth. If the pulp is nonvital, a pulpectomy is required or the tooth should be extracted. For more information on primary tooth pulp treatment, refer to the article in the November 2010 Texas Dental Journal entitled “Indirect Pulp Therapy: An Alternative to Pulpotomy in Primary Teeth” by Dr. N. Sue Seale.
Behavior Management Considerations It seems there are two principle reasons that will result in a child being referred to the pediatric dentist: one is the child’s behavior and the other is the amount of treatment. The child’s behavior does have to be considered in all treatment planning decisions, and it is sometimes a factor in the restoration choice, as mentioned earlier for the child with the small lesion who is being treated in the operating room. More commonly and more importantly, behavior determines how the treatment will be accomplished. The goals of behavior management are communication and education. The child learns about the dental environment through interaction with the dentist and staff. The objectives of behavior management are for the dentist to get the treatment done effectively and efficiently, and leave the patient with a positive attitude about the experience. Behavior management style for a practitioner is similar to treatment planning style in that it develops over time. There is a spectrum of behavior management tools available to select from that begins with the communicative forms of behavior management on one end and goes to general anesthesia on the other. During the examination of the child and interaction with the parent, the practi-
tioner has to decide where along this spectrum to start. It may be determined that the child will be manageable with only the communicative forms of behavior management such as the use of age appropriate language, euphemisms, tell-show-do, directive guidance, and positive reinforcement. All are forms of communication that help to mold children’s behavior by setting limits and educating them about the dental environment at a level they can understand. Most of the children seen in a practice want to behave and are capable of doing so. Typically, they are good patients and easy to treat in the office setting. There are some children who are lacking cooperative ability: the very young, the child with developmental delay or the child with a physical handicap that prevents him/her from sitting still, e.g. cerebral palsy.
Very young children (< 2.5 years) are unable to cooperate because they cannot understand what is happening and no amount of explanation will make them understand. For children who can be expected to understand (> 3 years), speaking in age-appropriate language and the use of euphemisms are two basic behavior management tools. An 18-month-old child has a vocabulary of about 10 words, and a 36-month-old has about 1,000 words. When treating a 3-year-old child, we have more words to use to communicate with them, but the words still have to be chosen carefully. Telling the child, “I’m going to place a Class II amalgam restoration under rubber dam isolation” won’t be understood. The use of euphemisms, such as, “I’m going to put a raincoat on your teeth, and then chase away the cavity bugs and put a sliver star on
your tooth” will be a more effective form of communicating that describes the procedures in terms that the child can understand. Euphemisms allow the dentist to explain potentially frightening experiences in a less threatening way so that the child understands. Thus, dentists talk about “blowing bubbles” and the “tooth whistle” rather than “injections” and the “highspeed handpiece.” The translation into euphemisms allows the child to understand exactly what is going to happen and what is expected. If it is determined that the child will need to be managed with more than the communicative tools, other choices from the spectrum include restraint, nitrous oxide, conscious sedation, IV sedation, or general anesthesia. Restraint, e.g. the papoose board, is a recognized behavior management tool, but it only has
It seems there are two principle reasons that will result in a child being referred to the pediatric dentist: one is the child’s behavior and the other is the amount of treatment.
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Treatment Planning limited appropriate indications for use with a healthy, mentally normal child. It should not be used to provide a large amount of treatment on a child solely for the convenience of the practitioner (6). Restraint for a single, small procedure for a very young child or for an emergency treatment on a young child is the only appropriate use. The combination of nitrous oxide with the communicative forms of management will provide enough behavior modification that most children can be successfully treated in the office. Nitrous oxide is an excellent and safe agent for three reasons: it has a quick onset, it’s easy to titrate and there is a quick and complete recovery (7). While all three are important, the ability to titrate for the desired effect adds flexibility not available with other pharmacological agents. If the behavior isn’t improved enough to safely treat the child, the flow of nitrous can be increased; if the child receives too much and becomes anxious, the flow can be reduced. The result of the increase or decrease in flow will be seen virtually immediately. The agent’s effect on the child is good for two reasons: it obtunds the gag reflex while it reduces the child’s anxiety (7). Each child responds to the agent differently and the effect has to be monitored carefully. Leaving a child on a high concentration of nitrous for an extended period of time will have the opposite effect, and the child may ex-
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perience nausea and vomiting without warning (8). Behavior modification agents such as nitrous oxide alone or in combination with sedative drugs serve to reduce the child’s anxiety. The goal of the use of these is to reduce the anxiety enough so that the child will be receptive to the communicative forms of management. Neither can make a child lacking cooperative ability (the child younger than 2.5 years old or who is severely developmentally delayed) behave. The only two behavior management tools that can overcome a child’s behavior, when it deteriorates to combative, are IV sedation and general anesthesia. Careful consideration of the three factors discussed, caries risk assessment, treatment choice, and the child’s behavior will result in an appropriate plan of action for each patient. Finally, one must reconcile the plan with the parents’ expectations. This may result in a modification of a treatment plan that we feel is optimum; however, one should not be influenced to abandon the standard of care to accommodate an unrealistic expectation of the parent. Appropriate selection of available treatment choices and behavior management options should result in a successful treatment that serves the child for the life expectancy of the tooth while at the same time providing the patient with the tools to be an excellent patient in the future.
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References 1. Zero D, Fontana M, Lennon AM. Clinical applications and outcomes of using indicator of risk in caries management. J Dent Educ 2001;65(10):1126-32. 2. Demers M, Brodeur JM, Mouton C, Simard PL, Trahan L, Veilleux G. A multivariate model to predict caries increment in Montreal children aged 5 years. Comm Dent Health 1992;9(3):273-81. 3. Isokangas P, Alanen P, Tiekso J. The clinician’s ability to identify caries risk subjects without saliva tests-A pilot study. Comm Dent Oral Epidemiol 1993;21(1):8-10. 4. Dentistry for the Child and Adolescent. McDonald RE, Avery DR, Dean JA, eds. 8th ed. St. Louis: Mosby, Inc.; 2004:379 5. Seale NS. The use of stainless steel crowns. Pediatr Dent 2002;24:501-05. 6. Dentistry for the Child and Adolescent. McDonald RE, Avery DR, Dean JA, eds. 8th ed. St. Louis: Mosby, Inc.; 2004:534. 7. American Academy of Pediatric Dentistry. Guideline on appropriate use of nitrous oxide for pediatric dental patients. Pediatr Dent 20092010 (suppl):148. 8. Paterson SA, Tahmassebi JF. Pediatric dentistry in the new millennium: Use of inhalation sedation in pediatric dentistry. Dent Update 2—3:30(7):350-6, 358.
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Bexar County’s Dental Safety Net For Children: An Estimate of Our Capacity and Need Carlos N. Mohamed, D.D.S., M.P.H. william Spears, Ph.D. This manuscript is compiled from a dissertation submitted in May 2007. To view the dissertation in its entirety, please visit http://digitalcommons.library. tmc.edu/dissertations/AAI1444053/.
Introduction Problem Many uninsured and poor children are not receiving dental care due to limited access to care and other barriers to oral health. Without appropriate oral health, these children may fail to thrive, endure pain and discomfort, have infections, and face eventual tooth loss. In addition, children with dental pain are unlikely to reach their potential in the classroom and will be more likely to miss school days due to emergency dental visits than children with good oral health. Poor oral health has been linked to systemic diseases, thus it is critical to treat oral disease.
Mohamed
Spears
Dr. Mohamed, currently in private practice, Edinburg, Texas; previously a graduate student, University of Texas School of Public Health San Antonio Regional Campus, San Antonio, Texas. E-mail: carlosmohamed@hotmail.com. Dr. Spears is an associate professor at the Center for Healthy Communities, Dayton, Ohio. E-mail: william.spears@wright.edu. Send correspondence to: Dr. Carlos N. Mohamed, 2821 Michaelangelo Dr., Suite 202, Edinburg, Texas 78539. This article has been peer reviewed.
Abstract Background: It has been well established that poor uninsured children lack access to dental care and have greater dental needs than their insured counterparts. Objective: To assess the capacity of the Bexar County dental safety net to treat children. To assess the dental needs of Bexar County children ages 0-18 who are uninsured or are Medicaid or Texas Children’s Health Insurance Program (CHIP) recipients. Methods: Dental clinics that treat children ages 0-18 and act as the safety net were identified in order to assess their capacity to treat children. Clinic directors were contacted to request data on the number of child patient encounters per clinic for 2005. Data from the census, NHANeS and other sources were used to establish an estimate of the dental needs of the uninsured and Medicaid/CHIP children. The dental needs of this population were calculated as maximum possible number of patient encounters per year. Results: The capacity of the current safety net to treat children is 33,537 patient encounters per year. The dental needs of the community are 227,124 patient encounters per year. Conclusion: The results of the study suggest that the Bexar County is not prepared to treat the dental needs of the underserved children in San Antonio.
Key woRDS: Dental safety net, barriers to oral health, children’s oral health needs Tex Dent J;127(12):1283–1291. Texas Dental Journal l www.tda.org l December 2010
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Dental Safety Net for Children Public Health Significance
A large number of low income and uninsured children make the dental safety net a critical component of health promotion efforts. Although San Antonio and the surrounding area have an established dental safety net for children’s dental needs, a better understanding of the capacity is required to determine whether there are sufficient resources to meet the demand for services.
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Oral health has been identified as a critical component of overall general health (1). In the health promotion model, we strive to encourage people to improve their lifestyles to create a state of optimal health. This has been found to be more difficult with those who are uninsured or have low incomes (2). Barriers to oral health limit access, and elimination of these barriers should improve opportunities to advance oral health. Examples of barriers include lack of awareness, lack of transportation, lack of disposable income, lack of perceived need, cultural and language barriers (1). Lack of awareness and perceived need is a problem when poorly educated individuals do not understand the principles of oral health, oral hygiene, and caries prevention. To improve the oral health status of uninsured and low-income children, we must rely on dental clinics established and funded by the volunteer and public sectors. Many who are unable to pay for treatment in the private sector can rely on these clinics. This network of clinics is often referred to as the “dental safety net.” This term describes clinics that provide treatment to those who would otherwise not have the means to obtain care. Thousands of uninsured children would be living with tooth decay if it were not for these safety net dental providers. San Antonio, the seventh largest city in the nation, has a population that is nearly 60 percent Hispanic (3). San Antonio has one of the highest uninsured rates in the nation — 24 percent of the population does not have health insurance (3). Approximately 100,000 children under the age of 17 live below the federal poverty level, and this accounts for nearly 24 percent of the county’s children (4). A large number of low income and uninsured children make the dental safety net a critical component of health promotion efforts. Although San Antonio and the surrounding area have an established dental safety net for children’s dental needs, a better understanding of the capacity is required to determine whether there are sufficient resources to meet the demand for services.
Methods Estimating the Community’s Need The community’s need for the dental safety net system are defined in terms of the number of annual patient encounters necessary to achieve and maintain optimal oral health. Optimal oral health is defined as a caries free state in which the oral and soft tissues are free from disease. The community is defined as children ages 0-18. The current study uses scientific methods to estimate the number of uninsured and low-income children in the San Antonio area. In October 2005, the Texas Health and Human Services Commission reported that 209,304 Bexar County children were enrolled in Medicaid (5). Of that number, 138,782 enrollees were between the ages of 0 and 18. In addition, 21,000 Texas Children’s Health Insurance Program (CHIP) enrollees between the ages of 0 and 18 were identified during the month of October 2005 (6). This brings the total of Medicaid and CHIP enrollees under the age of 18 to 159,782. The Texas Department of Health and Human Services reports that the number of children in Bexar County without dental health insurance who live on family incomes below 200 percent of the Federal Poverty Level (FPL) was found to be 29,005 (4). It is unlikely that a significant number of these uninsured children are treated in the private sector.
Private practitioners typically will not see these patients due to their inability to pay for services. As a result, these patients must rely on the dental safety net to receive care. Dr. Kevin Donly*, a highly respected pediatric dentistry academician, was consulted to estimate the percentage of uninsured children treated by the dental safety net. Dr. Donly believes that 100 percent of these uninsured children fall through the cracks and into the dental safety net. Some children who are publicly insured, i.e. Medicaid recipients, will visit a dentist in the private practice setting. In a Connecticut study, it was found that 28 to 33 percent of low income children received care in safetynet clinics (7). For this study 30 percent is used to estimate the proportion of low income children who may seek dental care in a safety net clinic. Of the 159,782 Bexar County Medicaid enrollees, only 47,935 are likely to seek treatment at a safety net clinic. The next step in assessing the community’s needs for a safety net clinic is to estimate how many dental visits will be required. In addition to the recommended biannual dental exams, the average number of additional dental visits is based upon the presence and extent of dental decay. If children have many decayed teeth, they will require more dental visits than those with only one or two decayed teeth. The number of visits required for restoration will depend on the number of decayed teeth.
*Personal communication with Dr. Kevin Donly on November 10, 2007. Dr. Donly is a professor and chair, Department of Developmental Dentistry, University of Texas Health Science Center at San Antonio Dental School, San Antonio, Texas. In addition, he has more than 20 years of clinical as well as teaching experience. Dr. Donly has been actively involved in research and has been a strong contributor to the profession’s literature.
The National Institute of Dental Research estimates that more than 80 percent of children are affected by dental caries by age 17 (8). Data from National Health and Nutrition Examination Survey III (NHANES III) provides more age and income specific data regarding tooth decay (9). The percentage of children with decayed teeth and the mean number of decayed teeth per child are listed in Table 1. For this study, based on data presented in Table 1, it is estimated that children will have an average of 2.15 decayed, missing, or filled primary or permanent teeth. This is the “dft” for children at or below 133 percent of FPL ages 6-12 with primary teeth. The average percentage of children with untreated dental caries was found to be 47.6 percent. This was calculated by averaging the “percent d/dft” for children ages 6-12 with primary teeth at all three income levels. This means that 47.6 percent of children nationwide have untreated decay and are in need of dental treatment. Estimates of the magnitude of dental need in the community are based on these values. A statewide Texas survey found that 66 percent of 8-year-old and 53 percent of 14-year-old schoolchildren had experienced dental caries (10). In addition, the survey results indicate that 44 percent of 8-year-old schoolchildren had untreated dental caries (10). This 44 percent of Texas school children with untreated caries is similar to the 47.6 percent utilized in the study. To ascertain how many dental visits would be required to treat 2.15 decayed teeth for 47.6 percent of children, three pediatric dentists who are faculty members at the University of Texas Health Science Center at San Antonio were consulted. The three
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Dental Safety Net for Children Table 1. Percentage of Decayed Primary and Permanent Teeth by Federal Poverty Level Percentage of Decayed Primary Teeth
Income Level
(% of FPL)
2 to 5
Years
dft
Percentage of Decayed Permanent Teeth
6 to 12
6 to 14
Years
Years
15 to 18 Years
% % % %
d/dft*
dft
d/dft*
DMFT
D/DMFT*
DMFT D/DMFT*
At or below 100%
1.49
78.8
2.30
51.3
1.08
40.5
3.69
26.0
At or below 133%
1.56
77.5
2.15
48.7
1.02
39.6
4.03
28.2
At or below 200%
1.44
77.2
2.04
44.3
1.11
35.1
3.90
24.1
dft: Decayed and filled primary teeth DMFT: Decayed, missing, filled permanent teeth FPL: Federal Poverty Level *Percentage of dft or DMFT represented by decayed teeth Table adapted from Vargas,C.M.; Crall,J.J.; Schneider, D.A. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988-1994 J.Am.Dent.Assoc., 1998, 129, 9, 1229-1238, UNITED STATES
consultants were interviewed independently to ensure that an unbiased estimate of the number of visits required was obtained.* The three dentists concurred that two visits to restore 2.15 decayed teeth would be an accurate estimate based on their experience and observation.
The two visits are in addition to the two annual dental visits for routine oral examination. A total of four visits will be necessary to treat the 47.6 percent of Medicaid, CHIP and uninsured children who have decay. The remainder of this population who are free of dental caries, 52.4 percent, will require only the recommended two annual visits.
*Personal communications with Dr. Kevin Donly on December 11, 2006. and Dr. Adriana Segura and Dr. Timothy Henson on January 25, 2007.
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Estimating the Communityâ&#x20AC;&#x2122;s Capacity The number of child patient encounters in safety net clinics during 2005 provides an estimate of the capacity. For this study, it is assumed that the dental safety net clinics are working at capacity. The sum of the capacity across all clinics
provides an estimate of the number of uninsured and insured children that can be seen in Bexar County in a year. To assess the capacity of Bexar County’s safety net, clinics were classified into the following categories: community health centers, community hospitals, and dental schools. School based dental clinics, such as those found at elementary schools, are not included because they do not render a significant number of restorative services. These clinics serve to primarily screen and refer children with caries to a dentist. Hospital emergency room dental visits are also excluded because they deliver a small number of encounters. Information was collected from study clinics to identify the number of daily patient encounters for 2005. Clinic directors were contacted to request a copy of their annual clinic reports. Clinic reports are typically available on a monthly and annual basis and are easily accessible and are commonly used for measuring clinic performance.
Identification of safety net clinics in Bexar County was the first step in the process. The dental safety net is comprised of Federally Qualified Health Centers (FQHC), dental clinics in hospitals, state/county/city clinics, and dental schools are the types of clinics. A list of community clinics was obtained based on personal knowledge, and information provided by local pediatric dentists. To be included, the clinic must be within Bexar County and treat children ages 0 to 18. Clinic directors were contacted to request data on the number of daily patient encounters for 2005.
Results The results of the study indicate that the Bexar County dental safety net for children currently has the capacity to handle 33,537 patient visits. Although many children are being treated, it is estimated that 227,124 patient encounters may be necessary to treat the estimated child population that may utilize the Bexar County dental safety net.
Estimating the Community’s Capacity A total of 14 clinics met the inclusion criteria. These 14 clinics compose the dental safety net in Bexar County and are run by the following seven organizations: San Antonio Metropolitan Health District, CentroMed, Communicare, Wesley Community Centers, Ricardo Salinas Clinic, Christus Santa Rosa, and The University of Texas Health Science Center. The capacity of Bexar County’s dental safety net was found to be 33,537 patient encounters per year. Table 2 lists the seven organizations with their corresponding number of clinics. The capacity of Bexar County’s dental safety net clinics to provide dental care for children was identified to be 33,537 encounters in 1 year. Table 3 details the number of patient encounters each organization delivers in 1 year.
Table 2. List of Participating Organizations and Clinics that Treat Children Ages 0-18 Organization’s Name San Antonio Metropolitan Health District
Number of Clinics 4
CentroMed 3 Communicare 2 Wesley Community Centers
2
Ricardo Salinas Clinic
1
Christus Santa Rosa
1
University of Texas Health Science Center
1
TOTAL 14
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Dental Safety Net for Children Table 3. List of Organizations and Number of Annual Patient Encounters Organization’s Name
Number of Encounters
San Antonio Metropolitan Health District
5,061
CentroMed 7,675 Communicare 4,298 Wesley Community Centers
250
DePaul Community Center
N/A
Ricardo Salinas Clinic
5,105
Christus Santa Rosa
4,805
University of Texas Health Science Center
5,143
TOTAL 33,537
Estimating the Community’s Need Texas Department of Health and Human Services statistics show that Bexar County had 159,782 Medicaid and CHIP enrollees and an estimated 29,005 uninsured children ages 0 to 18. Figure 1 provides a flow diagram that details the demand for safety net dental encounters if all these children were to receive needed dental care. Approximately 30 percent (47,935) of Medicaid and CHIP enrollees will seek treatment in a community clinic. Reports from NHANES III establish that an estimated 47.6 percent (22,817) of these enrollees will have an average of 2.15 decayed teeth. This group will require four annual dental visits; two visits for treatment,
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and two visits for routine examination and cleaning. Providing care for these children would put a demand for an estimated 91,267 visits on the dental safety net. The remaining 52.4 percent (25,118) of enrollees who have no decay will need only two routine examinations per year. Providing care for these children will require approximately 50,235 visits.
cent (15,198) will only require two annual visits for routine examinations for a total of 30,396 encounters.
The uninsured population unable to obtain treatment from private providers will rely on the dental safety net for treatment. Bexar County has an estimated 29,005 uninsured children ages 0 to 18. Of these children 47.6 percent (13,806) will need two visits to treat decay and caries and two annual examinations requiring 55,226 dental encounters. The remaining 52.4 per-
Discussion
Texas Dental Journal l www.tda.org l December 2010
The estimated need in Bexar County is for 227,124 child dental visits. This is the estimated number of dental visits needed to maintain the oral health of children who rely on Bexar County’s dental safety net.
The Bexar County’s dental safety net clinics provide about 33,550 patient encounters per year. This study uses information from research studies to identify the need for dental services and establishes reasonable levels of utilization of safety net services by children from
Figure 1. Flow Diagrams Detailing the Total Number of Patient Encounters Needed
159,782 Medicaid/CHIP enrollees 70%
29,005 Uninsured children 30%
100%
Private Practice 111,847
Dental Safety Net 29,005
47,935
76,940 52.4% caries free
40,316 requiring a total of two visits
47.6% with caries
36,623 requiring a total of four visits
227,124 total visits
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Dental Safety Net for Children low-income families. Based on the number of children enrolled in Medicaid and CHIP enrollees and the approximate number of uninsured children it was calculated that to provide adequate dental care for this population that safety net providers should be prepared to provide approximately 227,000 patient encounters per year. These results indicate that Bexar Countyâ&#x20AC;&#x2122;s existing dental safety net for children is not sufficient to treat the estimated dental needs. If all the children who rely on the safety net requested dental services, there would be a large portion whose treatment needs would go unmet. The current capacity of the safety net only allows for treatment of about 15 percent of the potential patients. Under this scenario, 85 percent of the children in question would receive delayed treatment at best. One suggestion for improving the number of children who are treated in the safety net is to increase the number of dental facilities. Having more clinics in poor neighborhoods would expand the safety net. A critical component of any safety net dental clinic is the dentist. Although the work is gratifying, many dentists choose not to work at a community clinic because they can earn more money in the private sector. Perhaps increasing the salary of the dentists will drive more dentists to seek employment in community clinics. Often, it is difficult to find dentists to staff these community clinics.
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In a study to define the current capacity and the potential for expansion Bailit, et. al. found that the national safety net system has a limited capacity and can only treat about 10 percent of the potential safety net (11). Proposed ideas for expansion include increased funding for staffing, mandated 1-year residency training in community clinics, or a required 60-day community clinic rotation by dental students. While all these ideas work, they require years to mature and have an impact. Although it is difficult to establish and employ these ideas, there is evidence to suggest they work. In another safety net study carried out in Connecticut, authors found that about 28 percent of publicly insured patients can be treated within the safety net (7). This means that approximately 72 percent of publicly insured children are not receiving care. These results are similar to those observed in Bexar County. The authors in the Connecticut study suggest increasing the use of allied dental personnel to improve the capacity. This idea may work in Bexar County, but improved salaries are required to recruit, train, and retain employees who are capable of carrying out expanded duties. Having two to three assistants per dentist may alleviate the shortcomings of the current safety net. To increase the capacity of the safety net, some argue that the state should allow assistants to carry out expanded duties. This
Texas Dental Journal l www.tda.org l December 2010
would allow assistants to clean teeth and carry out other minor procedures under the close supervision of a dentist. Colorado and several other states allow for expanded duty dental assistants, permitting the dentist to see many more patients per year. There are several ways of increasing the safety netâ&#x20AC;&#x2122;s capacity, all of which rely heavily on funding. Any significant improvement in the access to care for the uninsured and Medicaid/CHIP population can only be done through improving infrastructure. An increase in funding would allow for more staff and facilities to serve the children. Although there has been a recent expansion of the dental safety net, Bexar County falls short of providing adequate dental treatment to children who rely on it.
References 1. American Dental Association. Increasing access to Medicaid dental services for children through collaborative partnerships. Innovations in dental Medicaid. Chicago: American Dent Association 2004. 2. Bailit H. Dental care for the underserved: A growing problem. Josiah Macy Jr. Foundation, New York 2003; 147. 3. U.S. Census 2006. 4. Texas Department of State Health Services, Center for Health Statistics. Selected health facts 2002, Bexar County.
5. Texas Health and Human Services Commission, Texas Medicaid enrollment statistics (October 2005b). Retrieved 1/15 2007 from http://www.hhsc.state.tx.us/research/dssi/ medicaid/cntysearch.asp 6. Texas Health and Human Services Commission, Texas CHIP enrollment, renewal and disenrollment rates by county (October 2005a). Retrieved 1/15 2007 from http:// www.hhsc.state.tx.us/research/CHIP/ monthlyEnrollment/05_10.html 7. Beazoglou, T., Heffley, D., Lepowsky, S., Douglass, J., Lopez, M., & Bailit, H. The dental safety net in Connecticut. J Am Dent Assoc 2005; 136(10): 1457-1462. 8. National Institute of Dental Research. Oral Health of the United States children: 19861987. No. 89-2247. Bethesda, Md, National Institutes of Health, 1989. 9. Vargas,C.M.; Crall,J.J.; Schneider,D.A. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988-1994. J.Am. Dent.Assoc., 1998, 129, 9, 1229-1238. 10. Brown, J., Steffensen, J., & McMahon, D. “Make Your Smile Count”; Report of the Texas Dental Health Survey. Retrieved 7/30 2007 from http://www.oralhealthsa.org/ Dental_Public_Health_San_Antonio/Oral_&_ Dental_Public_Health_Research_by_Faculty_ files/MakeYourSmileCount.pdf 11. Bailit, H., Beazoglou, T., Demby, N., McFarland, J., Robinson, P., & Weaver, R. Dental safety net: Current capacity and potential for expansion. J Am Dent Assoc 2006; 137(6): 807-815.
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Texas Dental Association 140th Annual Session 2010 TEXAS Meeting Photo Contest Category: Black & White/Abstract/Artistic • Award: 2nd Place Photographer: Dr. Steven M. Aycock of San Marcos Title: “At the Silo” For information on entering your photo in the 2011 TEXAS Meeting Photo Contest, please visit texasmeeting.com.
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Texas Dental Journal 2010 Index of Feature Articles (By Author) Adibi, Shawn, D.D.S., Bebermeyer, Richard D., D.D.S., M.B.A.; Conflicts of Interest in Research: Is Clinical DecisionMaking Compromised? An Opinion Paper; August 2010; Vol. 127, Number 8:735. Acharya, Bhavini S., B.D.S., M.P.H., Ritwik, Priyanshi, B.D.S., M.S., Fenton, Sanford J. , D.D.S., M.D.S., Velasquez, Gisela M., D.D.S., M.S., Hagan, Joseph, M.S.P.H.; Dental Trauma in Children and Adolescents with Mental and Physical Disabilities; December 2010; Vol. 127, Number 12:1265-1272. Austin, Joshua A., D.D.S.; Legacy of Leadership: Leading My New Dental Team; February 2010; Vol. 127, Number 2:186. Alexander, C. Moody, D.D.S.; Legacy of Leadership: Mentoring Professionalism: Great Expectations; February 2010; Vol. 127, Number 2:202. Alexander, Roger E., D.D.S., Limes, Sharon Limes, R.N., COHN-S; Is Your Office Prepared for an Accidental Needlestick or Other Unexpected Exposure Incident? January 2010; Vol. 127, Number 1:15. Birdwell, William, D.D.S.; Legacy of Leadership: A HIgher Purpose; February 2010; Vol. 127, Number 2:182.
Blanton, Patricia L., D.D.S., Ph.D.; Power in the “Present”; January 2010; Vol. 127, Number 1:38.
Felton, David A. , D.D.S., M.S.; Edentulism and Comorbid Factors; April 2010; Vol. 127, Number 4:389.
Blanton, Patricia, D.D.S., Ph.D.; Legacy of Leadership: Dentistry’s Critical Compass — Leadership; February 2010; Vol. 127, Number 2:168.
Finn, Maxwell D., D.D.S.; Legacy of Leadership: Leadership Happens; February 2010; Vol. 127, Number 2:200.
Chandler, John, D.D.S.; Legacy of Leadership: Serious Leadership; February 2010; Vol. 127, Number 2:194. Cooley, Ralph A., D.D.S.; Legacy of Leadership: The Qualities in Outstanding Dental Leaders; February 2010; Vol. 127, Number 2:176. Dietrich, Andrew M., D.M.D., English, Jeryl, D.D.S., M.S., McGrory, Kathleen, D.D.S., M.S., Ontiveros, Joe, D.D.S., M.S., Powers, John M., Ph.D, Bussa, Harry I. Jr., D.D.S., M.S., Salas-Lopez, Anna, D.D.S., M.S.; A Comparison of Shear Bond Strengths on Bleached and Unbleached Bovine Enamel; March 2010; Vol. 127, Number 3:285.
Giesler, Michael L., D.D.S.; Legacy of Leadership: The Art of Leadership; February 2010; Vol. 127, Number 2:172. Giglio, James A., D.D.S., M.Ed., Lanni, Susan M., M.D., Laskin, Daniel M., D.D.S., M.S., Giglio, Nancy W., C.N.M.; Oral Health Care for the Pregnant Patient; October 2010; Vol. 127, Number 10:1061. Hackmyer, Steven, D.D.S.; Donly, Kevin J., D.D.S., M.S.; Restorative Dentistry for the Pediatric Patient; November 2010; Vol. 127, Number 11:1165. Haveman, Carl, D.D.S., M.S., Huber, Michaell, D.D.S.; Xerostomia Management in the Head and Neck Radiation Patient May 2010; Vol. 127, Number 5:487.
Doerre, David L., D.D.S.; Legacy of Leadership: Personal Leadership; February 2010; Vol. 127, Number 2:171.
Hildebrand, Sloan, D.D.S.; Legacy of Leadership: Serving Without Compromise — Honoring Dr. David C. Hildebrand; February 2010; Vol. 127, Number 2:190.
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TDA 2010 Journal Index of Articles Jones, John D., D.D.S.; Turkyilmaz, Ilser, D.D.S., Ph.D.; Garcia, Lily T., D.D.S., M.S.; Removable Partial Dentures — Treatment Now and for the Future; April 2010; Vol. 127, Number 4:365. Long, S. Jerry, D.D.S.; American Dental Association 15th District Trustee’s Address, May 6, 2010; June 2010; Vol. 127, Number 6:568. McWhorter, Alton G., D.D.S., M.S.; Treatment Planning for the Pediatric Patient; December 2010; Vol. 127, Number 12:1275-1280. Meru, Michael, D.D.S.; Following Your Moral Compass; January 2010; Vol. 127, Number 1:28.
Overton, J. D., D.D.S.; What is Different in Operative Dentistry?; March 2010; Vol. 127, Number 3:277.
Rhea, Ronald L., D.D.S.; Incoming President’s Address, May 9, 2010; June 2010; Vol. 127, Number 6:576.
Perez, Daniel, D.D.S., Leibold, David, D.D.S., M.D., Liddell, Aaron, D.M.D., M.D., Duraini, Mazen, D.D.S., M.D.; Vascular Lesions of the Maxillofacial Region; October 2010; Vol. 127, Number 10:1045.
Roberts, Matthew B., D.D.S.; Outgoing President’s Address, May 6, 2010; June 2010; Vol. 127, Number 6:562.
Porteous, Nuala, B.D.S., M.P.H.; Dental Unit Waterline Contamination — A Review; July 2010; Vol. 127, Number 7:677. Quock, Ryan L., D.D.S., Chan, Jarvis T., D.D.S., Ph.D.; Weekly Monitoring of the Water Fluoride Content in a Fluoridated Metropolitan City — Results After 1 Year; July 2010; Vol. 127, Number 7:665.
Mohamed, Carlos N., D.D.S., M.P.H., Spears, William, Ph.D.; Bexar County’s Dental Safety Net For Children: An Estimate of Our Capacity and Need; December 2010; Vol. 127, Number 12:1283-1291.
Quock, Ryan L., D.D.S., Warren-Morris, Donna P., R.D.H., M.Ed.; Fluoride Varnish: The Top Choice for Professionally Applied Fluoride; August 2010; Vol. 127, Number 8:749.
Morrison, Archie, D.D.S., M.S., FRCD(C); Conrod, Susan, D.D.S.; Dental Burs and Endodontic Files: Are Routine Sterilization Procedures Effective?; March 2010; Vol. 127, Number 3:295.
Rankin, K. Vendrell, D.D.S., C.T.T.S., Jones, Daniel L., Ph.D., D.D.S., Benton, Elain, R.D.H., B.S., C.T.T.S.; Smokeless Tobacco: Challenges, Products, and Cessation; June 2010; Vol. 127, Number 6:589.
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Seale, N. Sue, D.D.S., M.S.D.; Indirect Pulp Therapy: An Alternative to Pulpotomy in Primary Teeth; November 2010; Vol. 127, Number 11:1175. Schubert, Mark M. , D.D.S., M.S.D., Jones, Daniel L. , Ph.D., D.D.S.; Management of Oropharyngeal Mucositis Pain; May 2010; Vol. 127, Number 5:463. Scott, Nicole; The 2010 Gold Medal for Distinguished Service — Dr. John S. Findley; November 2010; Vol. 127, Number 11:1156. Steinhauer, William D., D.D.S.; Texas Medicaid — TDA Dentists Making a Difference; August 2010; Vol. 127, Number 8:767. Stephan J. Haney, D.D.S, Roxanna Nicoll, D.D.S., Michael Mansueto, D.D.S., M.S.; Functional Impressions for Complete Denture Fabrication; April 2010; Vol. 127, Number 4:377.
TDA 2010 Journal Index of Articles Stamboulieh, Jason N., D.D.S.; Neagle, Jack M., D.D.S.; Throndson, Roger, D.D.S.; Orthognathic Correction of a Craniofacial Deformity in a Patient with a Mutilated Dentition: A Case Report; June 2010; Vol. 127, Number 6:599. Velasquez, Gisela M., D.D.S., M.S.; Fenton, Sanford J. , D.D.S., M.D.S., CamachoCastro, Laura, C.D., D.M.D.; Acharya, Bhavini S., B.D.S., M.P.H.; Sheinfeld, Aaron, D.D.S., D.M.D.; Comprehensive Oral Rehabilitation with General Anesthesia and Prosthetic Care in the Primary Dentition: A Case Report; November 2010; Vol. 127, Number 11:1187. Viswanathan, Kavitha, D.D.S., Ph.D.; Infant Oral Exam and First Dental Home; November 2010; Vol. 127, Number 11:1195. Woods, Wayne, D.D.S.; Legacy of Leadership: Say Yes!; February 2010; Vol. 127, Number 2:166. Wright, Stephen R., D.D.S.; Legacy of Leadership: Five to Be Aware Ofâ&#x20AC;Ś; February 2010; Vol. 127, Number 2: 208.
Notice of Grant Availability; December 2010; Vol. 127, Number 12:1263.
Yeh, Chih-Ko, Ph.D., Christodoulides, Nicolaos J., Ph.D.; Floriano, Pierre N., Ph.D.; Miller, Craig S., D.M.D., M.S.; Ebersole, Jeffrey L., Ph.D.; Weigum, Shannon E., Ph.D.; McDevitt, John, Ph.D., Redding, Spencer W., D.D.S., M.S.E.D.; Current Development of Saliva/Oral Fluid-based Diagnostics; July 2010; Vol. 127, Number 7:651.
Official 2010-2011 Directory of Members; September 2010; Vol. 127, Number 9. Official Call for Secretary/Treasurer Nominations; January 2010; Vol. 127, Number 1:12; March 2010; Vol. 127, Number 3:269; April 2010; Vol. 127, Number 4:361.
Other
Official Call to the 2010 TDA House of Delegates; February 2010; Vol. 127, Number 2:157; March 2010; Vol. 127, Number 3:264; April 2010; Vol. 127, Number 4:357.
ADA Appointive/Elective Positions; June 2010; Vol. 127, Number 6:559. American Dental Association Caucus Notice; March 2010; Vol. 127, Number 3:269. American Dental Association Caucus Notice; April 2010; Vol. 127, Number 4:361; May 2010; Vol. 127, Number 5:484. El Paso Dental Conference; June 2010; Vol. 127, Number 6:583. Notice of Grant Availability; January 2010; Vol. 127, Number 1:12. Notice of Grant Availability; November 2010; Vol. 127, Number 11:1153.
Special Legislative Section to the Texas Dental Association; 2011 Legislative Landscape; October 2010; Vol. 127, Number 10:1073. Texas Dental Association 2009 Financial Report, 2011 Proposed Budget, and 2011 Budget Explanation; March 2010; Vol. 127, Number 3:302. The TEXAS Meeting â&#x20AC;&#x201D; The 140th Annual Session of the Texas Dental Association; January 2010; Vol. 127, Number 1:41.
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r P
w e i v e
Dental Office Design
Michael Unthank, D.D.S., Architect and Geri True, ASID Unthank Design Group
At some time in the life of virtually every dental practice, there is a need to ask the question: “Is the office helping to reach prac-
tice goals, or is it holding the practice back?” The office environUnthank
True
Dental Office Design: Plan for Success Part I Michael Unthank, D.D.S. Thursday, May 5, 2011 1:00 PM ─ 4:00 PM Course Code: # T69 Dental Office Design: Plan for Success Part II Michael Unthank, D.D.S. Friday, May 6, 2011 8:00 AM ─ 11:00 AM Course Code: # F99 Technology Roundtable — One-On-One With The Experts Paul Feuerstein, D.M.D., Dale Miles, B.A., D.D.S., M.S., and Michael Unthank, D.D.S. Friday, May 6, 2011 1:30 PM ─ 4:30 PM Course Code: # F36
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ment is the ultimate reflection of one’s skills as a dentist and the professionalism of the practice’s staff. Take a look around the
office, or better yet, take photos, and review the results. What does it say about you, the practice, and the team?
As practices evolve many become limited by the facilities for various reasons. The most frequent of which are: 1) A lack of treatment rooms, including hygiene; 2) A business area that is poorly planned; 3) An overall “practice image” that is not in keeping with quality of services or the type of patient desired; 4) The area or neighborhood surrounding the practice has degraded; or 5) The doctor has simply inherited an outmoded office from a bygone era. In patients’ eyes the dental practice’s facility is the physical representation of the quality of care provided within. It must communicate that quality and thereby inspire patients’ confidence (Figure 1). A professional “image” encourages patients to tell their friends about the practice and keeps providers and staff enthusiastic, efficient and productive. If the facility is lacking in any aspect, change must occur. If the space is worn, tattered, cluttered, and generally poorly organized, patients may transfer that perception to the quality of the services provided. The office should communicate that patients will receive the finest of care in an attractive, state-ofthe-art facility. Does this mean improving the existing office, or relocation? An obvious advantage of staying in place is that patients of record know where to find the practice. If the office needs only a “freshening up,” minor remodeling and/or redecorating can be easily accomplished over two or three weekends (Figures 2 & 3). Keep in mind: one office alone cannot “refresh” the community immediately surrounding a given location. If the neighborhood has eroded, it may be time to move on. The decision to build a new facility (whether as a free-standing building, condominium, or leasehold space) or remodel an existing space is impacted by a number of issues. The availability of land, desirability of location, accessibility and
Texas Dental Journal l www.tda.org l December 2010
visibility by the public are all key considerations. When land is too costly or not available in the desired area, it is often preferable to remain in the current space and expand (if possible), or remodel within the existing facility’s boundaries. Beyond simply redecorating, remodeling brings with it an array of potential complications. Rather than affecting one small component of the office, the changes desired typically impact various areas, spreading construction throughout the office. Construction is a literal mess not in keeping with the asepsis required in our profession. When tearing into existing construction, dust permeates the entire office. Structural and utility surprises are contained within the walls of the office and can truly complicate an otherwise apparently straightforward project. Attempting to practice in the midst of remodeling is extremely difficult, and heaps unnecessary stress upon doctors, staff, and patients (Figure 4). So as to not negatively impact production, the general contractor and subcontractors will need to work around the office’s schedule (during evenings and weekends). This billable time is termed “offhours” and comes at a premium. The overall period of construction is drawn out as the project is broken into small inefficient increments of actual work. After each period of construction the contractor must clean up and assure that the “construction zone” is adequately isolated from the remainder of the space. There typically will come a point during remodeling when some aspect of the planned changes requires “the mandatory 2 week vacation”. The office is closed. A key difficulty is identifying in advance exactly when this will occur. Depending on the degree of remodeling, one may have to vacate the office for the entire construction process. Loss of production can become a significant portion of the actual cost of remodeling. If the project entails expanding into an adjacent space, construction can be “phased,” completing sections of the office in sequence, then moving functions into the completed areas. This requires a great deal of orchestration on the part of the contractor and office staff as equipment, records, etc., are moved multiple times in the course of demolition and construction. When remodeling and/or expanding, it is human nature to try and save some of what exists. This approach limits the potential to develop a successful office plan. Rarely do the relationships of existing rooms and functions dovetail with the goals of the changes desired. By comparison, constructing a new office within a leasehold or condominium space or building a new building means starting with a blank slate. The plan can be tailored to exact needs without compromise, the contractor can complete the project in an expeditious manner without interruptions during normal working hours, and the fresh new space can be occupied over a 3-day weekend without any loss of productive time. Consider the full spectrum of “pros” and “cons” when deciding whether to redecorate, remodel or relocate. Each unique situation will determine the extent of changes required, and whether improving the existing office is more appropriate than relocating. If the changes desired are possible within the existing parameters, if the end result is appropriate for the practice goals, if the image to be conveyed can be achieved in the current location, if there is flexibility to schedule around the contractor, and if the possibility of a surprise mandatory vacation is not problematic, then remodeling may be the correct choice. Whether planning to build a new office or remodel an existing space, it is likely that it will be done only once. Make sure to avoid re-creating the same traps the practice is struggling to escape. Initially, it costs just as much to build it wrong as it does to build it
Figure 1. An attractive reception area communicates the quality of your care.
Figure 2. The greeting area prior to remodeling.
Figure 3. The greeting area following remodeling.
Figure 4. Construction and asepsis do not successfully coexist. Texas Dental Journal l www.tda.org l December 2010
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right, and, over the life of the practice, it costs more due to functional inefficiencies and increased stress. Before undertaking the most expensive single investment to be made in the practice, take two critical steps in planning in order to save dozens of missteps in design: 1. Remind yourself daily that you are a dentist, not an architect. Choose a team of qualified professionals to assist in realizing the dream. It is important to engage experts who have designed dental offices and are intimately familiar with the challenges of running a dental practice. Ideally, this is a design professional that has walked in “dental shoes”. Although the practice owner is the ultimate decision-maker, a qualified design team will prevent a string of costly mistakes. 2. Develop a Design Program. This is the “treatment plan” for the practice’s ideal office. The Design Program identifies what is wanted and not wanted in the new facility. It is an exhaustive list of practice needs, desires, and goals and essentially defines how one intends to practice. This, understandably, may vary from the status quo. The Design Program clearly spells out all office functions and what essential elements are necessary to ensure that those functions are carried out effectively. This ranges from greeting patients and managing the schedule to diagnosing, treatment planning and case presentations, financial arrangements and collections, to delivering treatment. The Design Program is not simply a reflection of where the practice is today, but also a blueprint for where the practice needs to go in the future. The Design Program forms the written foundation from which the office design will be developed. The functional spaces in the office are considered zones, and effective zones take into consideration numerous elements, from equipment and ergonomic considerations to privacy to lighting to technology. Key issues include: 1. Private areas should never be on public display. Position treatment areas so that they are not visible from the public areas such as the greeting and reception areas. 2. Create a reception area that enables the receptionist to turn 90 degrees to welcome the patient and turn 90 degrees away from the patient to conduct other business. This ensures that private conversations or transactions conducted in the payment zone do not become public information to those sitting in the waiting room (Figure 5). 3. Ensure that patients and staff never are left to negotiate fees within earshot of other patients in the office, whether in person or on the phone. 4. Designate private office and break room space away from the patient-activity areas of the practice. 5. Equip all treatment rooms similarly so every room is the “doctor’s favorite room.” 6. Integrate technology throughout the treatment area for practice management, education, treatment co-diagnosis, and, if desired, entertainment during procedures (Figure 6). 7. Allow for technology growth and expansion in the future.
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Figure 5. Position the receptionist 90 degrees to the reception area.
8. Involve patients in the excitement by including materials which promote the project in the reception area of the office and illustrate the state-of-the-art dental care the practice will soon provide them. 9. Before changing the office environment, take a seminar on office planning and design. The office needs to be the ultimate blend of form and function. Ultimately, the goal of successful office planning is to be able to finish each day with more money in the bank, less stress in life, and with all members of the practice looking forward to returning the next morning. Dental offices must satisfy a range of diverse needs; they must be welcoming, yet function clinically. They must exude professionalism, yet not appear ostentatious. All this needs to occur on a budget that makes sound financial sense. Allowing adequate time to make the right decisions will impact the practice positively for the rest of its existence. From the onset of planning, be sure everything will work as it needs to. If it does, the office may never have to be amended again. If it doesn’t, costly errors will haunt the practice continuously, affecting the efficiency and the morale of the entire office team. Remember, it costs more to build it wrong than to build it right.
Figure 6. Technology positioned for co-diagnosis.
In Memoriam Those in the dental community who have recently passed
Smith, Ray A. Dallas, Texas December 19, 1948 – October 16, 2010 Good Fellow, 2000
Memorial and Honorarium Donors to the Texas Dental Association Smiles Foundation
In Memory of: Cleo Keller By Drs. Jamie and Jennifer Bone John Evans By Dr. Robert Cody Robert Collins By Eric, Amy, Marj, Deanna, Tracey, and Griselda Your memorial contribution supports:
Smith, Robert Aaron Nacogdoches, Texas May 28, 1940 – September 29, 2010 Good Fellow, 1992 Life, 2006
• educating the public and profession about oral health; and • improving access to dental care for the people of Texas.
Please make your check payable to:
TDA Smiles Foundation, 1946 S IH 35, Austin, TX 78704
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Stefanie Clegg, TDA Web & New Media Manager Department of Member Services & Administration
Check out the Texas Dental Journal EZ Flip on 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. Advertising / Publication Questions? Please contact Nicole Scott at (512) 443-3675 or nicole@tda.org.
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treatment plans” for practice transitions Creating “treatment for more than 23 years… L. Norton Hindley III, A.S.A. Purchase/Sale of Practice • Negotiations and Closing Documents • Purchaser Representation Practice Mergers and Reformations • Associate Buy-in and Partnership Agreements Practice Valuations Leading to Merger and Acquisition • Banking: Loan Packages and Origination of Loans
The Hindley Group, L.L.C. 2202 Timberloch Place, Suite 218 • The Woodlands, Texas 77380 281-367-1955 • 800-856-1955 norton@thehindleygroup.com www.thehindleygroup.com
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Provided by TDA Perks Program
value for your
profession
How to Make Patients Irate: Don’t Answer the Phone
Kathleen M. Roman, M.S., Medical Protective Company Office receptionist: We sure are busy this morning. I’m so glad that we have our answering system. I can get a lot of my paperwork completed before returning calls. Then, right before lunch, I call everyone back. If they’re there, great. If not, I leave a message. I do the same thing again in the afternoon; it helps me stay organized. Patient: I like this doctor and her office is close to our home, but I’m getting ready to change dentists. You can never talk with a human being when you call them. The last time I called, it took 2 days and several rounds of phone tag just to get an appointment to have my teeth cleaned. This is just silly. Technology advances have significantly increased the speed at which people can send and receive information. But technology can’t take the place of some of the more mundane aspects of communication. As noted in the example above, there are times when a caller wants to speak with a person; without having to hear, “our menu has changed,” wander through a maze of numeric choices, be instructed to leave a message, and be told that, “someone will get back to you.”
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Banking telephone calls in a message system may seem like a time saver, but business schools and customer-service experts suggest that banking calls may actually waste staffers’ time. If a receptionist answers a telephone call and schedules a patient’s appointment, the transaction usually takes less than 5 minutes. However, for every subsequent round of phone tag, additional documentation and information updates may be needed. For example, the receptionist might have to change the telephone message to inform the patient that the office is closing for lunch, and to call back after 2 p.m. The patient may have to expand on her previous message to explain that she’s away from home, and to request that she be contacted her on her cell phone. From an efficiency perspective, a telephone call promptly answered and correctly managed is the most effective transaction. Here’s why: • It requires the least amount of time, information, and documentation. • It has the lowest likelihood of error. • It gets a patient’s appointment onto the books, which increases income potential. • It reduces the likelihood that an office will receive complaints from irritated and busy patients. Speaking of patient satisfaction, in his excellent book, “Nine and a Half Things You Would Do Differently if Disney Ran Your Hospital,” Fred Lee makes a compelling case for the value of a promptly-answered telephone call, because it is the most common type of interaction with the organization, and because it should be one of the simplest and least expensive communication processes to “get right.” Lee strongly urges healthcare professionals to value service over attempts at perceived efficiency. This is a compelling idea, because it seems counterintuitive compared with how many organizations function. Dollar signs and organizational policies get in the way of the most dynamic organizations, and “by putting courtesy and service first, our problem with phony efficiency virtually disappears,” Lee says. Taking a quick survey may help doctors and their staffs identify opportunities to improve telephone management policies and procedures: 1. Do employees abide by a written telephone management policy? For example: a. The phone will ring no more than “x” number of times before a member of the team will answer. b. During busy periods, backup team members
will also answer the phone. c. Employee lunch hours or personal breaks will not interfere with telephone coverage throughout the entire business day. Even if the office is officially closed during the lunch hour, telephone calls will still be answered by an employee. 2. Do employee job descriptions specify that answering the phone (taking messages, scheduling appointments, helping patients obtain answers to questions, etc.) is a key accountability point, and takes precedence over other tasks? 3. Does the organization provide periodic updated training regarding customer service, including:
a. b. c. d. e.
Management of after-hours calls, Emergency calls, Dropped calls, On-hold policies, and Backup phone support during busy periods?
As the example patient at the beginning of this article pointed out, the inability to provide adequate phone management is perceived by the consumer as “silly.” That’s not a perception doctors want their patients to have. Additionally, telephone management isn’t just a customer service issue. Poor call management can also lead to patient-care issues, including lawsuits and state board complaints. For example, a state board complaint was recently filed by an irate patient who had a complication following a dental procedure. He called his dentist’s office, only to hear from a recording that the office was closed for lunch (his first call was placed at 3:00 PM), that he should leave a message, and that someone would return his call within 24 hours. Instead, he called another dentist’s office and was immediately seen and treated. Subsequently, he filed a complaint with the state board of dentistry regarding what he thought was poor care on the original dentist’s part. The state board agreed. Kathleen M. Roman is risk management education leader for Medical Protective Company, a TDA Perks Program partner and the nation’s oldest professional liability insurance company for healthcare professionals. Kathleen can be reached at: kathleen.roman@ medpro.com. For information regarding other TDA Perks Programs, visit www.tdaperks.com or call (512) 443-3675. © 2010, Medical Protective Company. All rights reserved. Texas Dental Journal l www.tda.org l December 2010
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Calendar of Events 1310
January 2011
13 – 15 The Dallas County Dental Society will hold the Southwest Dental Conference at the Dallas County Convention Center in Dallas, Texas. For more information, please contact Ms. Jane Evans, DCDS, 13633 Omega Dr., Dallas, TX 75244. Phone: (972) 386-5741; FAX: (972) 233-8636; E-mail: jane@dcds.org; Web: dcds.org 23 – 25 The American Dental Association will hold its Presidents Elect Conference in Chicago, IL. For more information, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org.
February 2011
3–5 The Greater Houston Dental Society will hold its 40th annual meeting, the 2011 Star of the South Dental Meeting, at the George R. Brown Convention Center in Houston, Texas. For more information, please visit starofthesouth.org or e-mail star@ghds.org. 4 The American Dental Association’s Give Kids a Smile Day occurs nationwide. For more information, please contact Ms. Lynne Mangan, ADA, 211 E. Chicago Ave., Chicago, IL 60611-2678. Phone: (312) 440-2500; FAX (312) 440-7494; E-mail: online@ada.org; Web: ada.org. 24 The American Equilibration Society will hold its 55th annual meeting at the Chicago Downtown Marriott in Chicago, IL. For more information, please contact Mr. Kenneth Cleveland, AES, 207 E. Ohio St., Ste. 399, Chicago, IL 60611. Phone: (847) 965-2888; FAX (609) 573-5064; E-mail: exec@aes-tmj.org; Web: aes-tmj.org.
March 2011
2–5 The Alliance of the American Dental Association will hold a conference in Richmond, VA. For more information, please contact Ms. Patricia Rubik-Rothstein, AADA, 211 E. Chicago Ave., Ste. 730, Chicago, IL 606112678. Phone: (312) 440-2865; FAX: (312) 440-2587; E-mail: manager@allianceada.org; Web: ada.org. 2–9 The American Academy of Dental Practice Administration will hold its annual meeting at the JW Marriott Resort in San Antonio, TX. For more information, please contact Ms. Kathy S. Uebel, AADPA, 1063 Whippoorwill Ln., Palatine, IL 60067. Phone: (847) 934-4404; FAX: (847) 934-4410; E-mail: executivedirector@aadpa.org; Web: aadpa.org. 2–5 The Academy of Laser Dentistry will hold its 18th annual conference and exhibition at the Loews Coronado Bay Resort in San Diego, CA. For more information, please contact Ms. Gail Siminovsky, ALD, 3300 University Dr., Ste. 704, Coral Springs, FL 33075. Phone: (954) 346-3776; FAX: (954) 757-2598; E-mail: laserexec@laserdentistry.org; Web: lasterdentistry.org. 3–5 The Academy of Osseointegration will hold its annual meeting, From Fundamentals to New Technologies for the Next 25 Years, at the Washington DC Convention Center in Washington, DC. For more information, please contact Ms. Gina Seegers, 85 W. Algonquin Rd., Ste. 550, Arlington Heights, IL 60005-4422. Phone: (847) 439-1919; FAX: (847) 439-1569; E-mail: ginaseegers@osseo.org; Web: osseo.org. 11 – 16 The Omicron Kappa Upsilon will meet in San Diego, CA. For more information, please contact Dr. Jon B. Suzuki, OKU, Temple University Dentistry, 3223 North Broad St., Philadelphia, PA 19140. Phone: (215) 707-7667; FAX: (215) 707-7669; E-mail: suzuki@dental.temple.edu; Web: oku.org. 11 – 16 The American Dental Education Association will hold its annual session and exhibition at the Manchester Grand Hyatt in San Diego, CA. For more information, please contact Ms. Michelle Allgauer, ADEA,
Texas Dental Journal l www.tda.org l December 2010
April 2011
11 – 13 The American Association of Public Health Dentistry will hold its National Oral Health Conference at the Hilton Pittsburgh in Pittsburgh, PA. For more information, please contact Ms. Pamela J. Tolson, CAE, 3085 Stevenson Dr., Springfield, IL 62703. Phone: (217) 529-6941; FAX: (217) 529-9120; E-mail: natoff@ aaphd.org; Web: aaphd.org. 13 – 16 The American Association of Endodontists will hold its annual session at the San Antonio Convention Center in San Antonio, TX. For more information, please contact Mr. James M. Drinan, AAE, 211 E. Chicago Ave., Ste. 1100, Chicago, IL 60611-2616. Phone: (312) 266-7255; FAX: (312) 266-9867; E-mail: jdrinan@ aae.org; Web: aae.org. 28 – 30 The American Dental Society of Anesthesiology will hold its annual meeting at the Westin Keirland Resort & Spa in Scottsdale, AZ. For more information, please contact Ms. Barbra Josephson, ADSA, 211 E. Chicago Ave., Ste. 780, Chicago, IL 60611. Phone: (312) 664-8270; FAX: (312) 642-9713; E-mail: barbra.josephson@mac.com; Web: adsahome.org.
May 2011
5–8 The Texas Dental Association will hold its 141st annual session, The TEXAS Meeting, at the Henry B. Gonzalez Convention Center in San Antonio, Texas. For more information, please contact TDA, 1946 S. IH 35, Ste. 400, Austin, TX 78704. Phone: (512) 443-3675; FAX: (512) 443-3031; Web: texasmeeting.com. 9 – 11 The ADA will hold its Washington Leadership Conference in Washington, D.C. For more information, please contact Mr. Brian Sodergren, ADA, 1111 14th St., NW, Ste. 1100, Washington, DC 20005. Phone: (202) 789-5168; FAX: (202) 789-2258; E-mail: sodergrenb@ada.org; Web: ada.org. 17 – 21 The American Academy of Cosmetic Dentistry will hold its annual scientific session at the Hynes Convention Center in Boston, MA. For more information, please contact Ms. Kelly Radcliff, AACD, 5401 World Dairy Dr., Madison, WI 53718. Phone: (800)543-9220; FAX: (608)222-9540; E-mail: kelly@aacd.com; Web: aacd.com. 26 – 29 The American Academy of Pediatric Dentistry will hold its 64th annual session at the Marriott Marquis New York in New York, NY. For more information, please contact Dr. John S. Rutkauskas, CAE, AAPD, 211 E. Chicago Ave., Ste. 1700, Chicago, IL 60611-2663. Phone: (312) 337-2169; FAX: (312) 337-6329; E-mail: jrutkauskas@aapd.org; Web: aapd.org.
June 2011
15 – 18 The ADA will hold its 25th New Dentist Conference in Chicago, IL. For more information, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org. 23 – 25 The ADA Council on Access, Prevention and Interprofessional Relations (CAPIR) will meet in Chicago, IL. For more information, please contact Ms. Carrie Campbell, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-2500; FAX: (312) 440-7494; E-mail: campbellc@ada.org; Web: ada.org. The Texas Dental Journal’s Calendar will include only meetings, symposia, etc., of statewide, national, and international interest to Texas dentists. Because of space limitations, individual continuing education courses will not be listed. Readers are directed to the monthly advertisements of courses that appear elsewhere in the Journal.
Calendar of Events
1400 K Street, NW, Ste. 1100, Washington, DC 20005. Phone: (202) 289-7201; FAX: (202) 289-7204; E-mail: allgauerm@adea.org; Web: adea.org.
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Oral and Maxillofacial Pathology Case of the Month Case History During an emergency appointment, a child was escorted by his father for evaluation of bleeding gums and an unusual appearing tongue. Except for these chief complaints, the patient was a healthy 11-yearold Hispanic boy. Although the father had been informed that his son had a â&#x20AC;&#x153;wrinkledâ&#x20AC;? tongue by a previous dentist, it appeared to be more exaggerated lately. He was most concerned about the generalized swelling of the gums and how easily they bled when eating or brushing the teeth. He was uncertain how long this problem had existed, but the child had complained about bleeding for the past 3 weeks. Clinically, there was generalized erythema and swelling of the anterior attached gingiva that was especially prominent in the maxilla. The brightly erythematous, but painless, tissues had a pebbly to velvety surface that bled freely when manipulated. Pseudopockets, measuring 3 mm in depth, were identified on several of the anterior teeth and there was bleeding on probing without purulence. The patient was in the mixed dentition stage with stainless steel crowns and abundant plaque accumulation noted on many of the teeth (Figure 1). In addition, the dorsal tongue was covered but multiple, deep grooves and circinate patches with white adherent borders. The tongue findings were consistent with both a fissured tongue and benign migratory glossitis (Figure 2). The child was not a mouth breather and exhibited normal lip closure. A diagnosis of plaque-related gingivitis was made and proper oral hygiene measures were demonstrated. At a 2-week follow-up visit, minimal resolution of the gingival lesions was noted, despite significant improvement in plaque control. Because a secondary bacterial infection was suspected, the child was instructed to rinse twice a day with chlorhexidine gluconate 0.12 percent rinse and to return in 2 weeks. Although there was resolution of some of the gingival lesions, the maxillary anterior lesions persisted and continued to bleed (Figure 3). The differential diagnosis included chronic hyperplastic gingivitis,
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Texas Dental Journal l www.tda.org l December 2010
Flaitz
Longoria
Catherine M. Flaitz, D.D.S., M.S., professor, Oral & Maxillofacial Pathology and Pediatric Dentistry, Department of Diagnostic Sciences, The University of Texas Dental Branch at Houston, Texas; and Julie M. Longoria, D.D.S, M.S., pediatric dentistry practice, Houston, Texas
plasma cell gingivitis, foreign body gingivitis, and gingivitis associated with systemic disease. Based on the variety of disorders that were included in the working diagnosis and the lack of response to treatment approaches, an incisional biopsy of the attached gingiva, adjacent to the left lateral incisor was performed. The microscopic findings revealed a soft tissue fragment covered by a mildly papillary surface of nonkeratinized stratified squamous epithelium with marked spongiosis and inflammatory exocystosis. The underlying stroma was fibrovascular with a dense acute and chronic inflammatory infiltrate (Figures 4, 5). Polarization of the sections did not demonstrate any birefringent particles. In addition, superficial bacterial colonies or fungal forms were not observed.
What is the final diagnosis? See page 1315 for the answer and discussion.
Figure 1 (upper left). Generalized gingival inflammation with the presence of plaque. Figure 2 (above). Benign migratory glossitis and fissured tongue in the same patient. Figure 3 (left). Persistent gingival lesions at 1-month follow up, despite improved oral hygiene.
Figure 4. Photomicrograph of a soft tissue nodule with a subtle papillary architecture and marked epithelial hyperplasia. (Hematoxylin-eosin stain, original magnification X33).
Figure 5. Photomicrograph showing epithelial hyperplasia with spongiosis, inflammatory exocytosis and a mixed inflammatory infiltrate of the lamina propria. (Hematoxylineosin stain, original magnification X66). Texas Dental Journal l www.tda.org l December 2010
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Oral and Maxillofacial Pathology Diagnosis and Management
Localized Juvenile Spongiotic Gingival Hyperplasia Oral and Maxillofacial Pathology Case of the Month (from page 1312)
Discussion Localized juvenile spongiotic gingival hyperplasia (LJSGH) is a newly described inflammatory lesion of the gingiva that was originally referred to as juvenile spongiotic gingivitis (1, 2). This disorder has specific clinical and microscopic features that mimic other gingival conditions in children, but it is not highly associated with plaque accumulation or hormonal changes related to puberty. This entity has a marked predilection for children with a mean age of 12 years-old, but it has been documented in adults (1, 2). Although the studies are limited, it appears to occur more frequently in females. Clinically, these lesions occur primarily on the anterior facial gingiva, in particular, the maxillary tissues. They present as solitary or multiple, brightly erythematous plaques or slightly elevated masses with papillary, granular, or velvety surfaces. About 20 percent of the cases have been reported to bleed easily and are painless. LJSGH is a persistent lesion that appears to be refractory to local debridement and professional polishing of the adjacent teeth or improved oral hygiene measures. Excisional biopsy is the recommended treatment with a recurrence rate that ranges from 6 to 29 percent (1, 2).
To date, no prospective study has evaluated the natural progression of this group of lesions or whether they are associated with other inflammatory mucosal or cutaneous diseases. However, spontaneous resolution of early lesions seems likely based on the location of the gingivitis and its predilection for children and adolescents. If these lesions were persistent and did not resolve without surgical intervention, it is likely that adults would be equally affected. When lesions are single in presentation in children, their clinical appearance mimics a pyogenic granuloma, peripheral giant cell granuloma, fibrous hyperplasia, squamous papilloma, and hemangioma. A diffuse or multifocal pattern is frequently interpreted as plaquerelated gingivitis, especially puberty gingivitis. The pathogenesis of LJSGH is unclear, but it has been described as being the oral counterpart of spongiotic dermatitis (1). This is a nonspecific, histopathologic term for a variety of cutaneous conditions, including contact dermatitis, atopic dermatitis, nummular dermatitis, seborrheic dermatitis, and acute pustular psoriasis. Although contact allergy gingivitis may present with a similar clinical pattern, a hypersensitivity reaction has not been identi-
fied as a contributing factor. Of interest, in the present case report, exacerbation of the fissured tongue and benign migratory glossitis were documented, along with the gingivitis. Whether these gingival lesions represent extraglossal presentation of benign migratory glossitis, another example of a spongiotic lesion, is not known and merits further investigation (3). Because of the age of the patients, female predilection and clinical presentation, this entity has similar features as puberty gingivitis. However, many of the examples of LJSGH developed prior to the onset of puberty and/or lacked sex hormone receptors in the affected epithelium when investigated in immunohistochemical studies (1). In contrast to this newly described condition, puberty gingivitis is defined as a plaque â&#x20AC;&#x201D; associated inflammatory lesion and the response to local irritation may be exuberant (4). The most interesting hypothesis was made by Chang and others that these lesions may arise from sulcular and junctional epithelium that has been exteriorized to the labial surfaces and that with time this epithelium matures into surface mucosal-type epithelium (2). Typically, sulcular/junctional epithelium is thinner and less keratinized, and
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Oral and Maxillofacial Pathology
therefore more likely to react to local irritants and become spongiotic. If this is the case, the eruption of teeth, lip incompetence, and minor trauma, including the placement of orthodontic appliances could contribute to these inflammatory changes. For those of us who routinely treat children, brightly erythematous plaques are frequently observed, especially on the maxillary facial gingiva in the mixed dentition. Overtime, the redness resolves and there is improved gingival contour as the teeth fully erupt, unless a focal lesion in the interdental papilla or marginal gingiva becomes more exophytic. To support these statements, natural history studies are needed to understand the inciting factors, lesion course and appropriate treatment options. Although excisional biopsy of isolated lesions is both prudent and practical for obtaining a definitive diagnosis, it may not be feasible or even appropriate for managing diffuse or multifocal lesions. In the present case report, only an incisional biopsy was obtained to establish a diagnosis. Reinforcement of oral hygiene and short-term use of topical antimicrobial agents have improved the secondary inflammation. At the present time, the child will be periodically monitored every 3 months to evaluate the gingival condition. The parents have been advised that gingival recontouring and/or laser treatment may be required, if this condition persists. The differential diagnosis for localized juvenile spongiotic gingival hyperplasia, when it is more wide-
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spread, as in this child, includes puberty gingivitis, plasma cell gingivitis, orofacial granulomatosis, foreign body gingivitis, and linear gingival erythema. Puberty gingivitis is a common plaque-related condition that is exacerbated by hormonal fluctuations and an alteration in subgingival microflora (5,6). Typically, the lesion involves the marginal gingiva with extension to the attached gingiva and interdental papillae. Females are at greater risk for developing this form of gingivitis and its distribution is often widespread. The removal of local factors by routine oral hygiene measures is critical for managing this condition (4). Plasma cell gingivitis is rarely seen in children and represents a hypersensitivity reaction. Cinnamon chewing gum, certain mints, herbal toothpastes, and peppers have been implicated in this unusual allergic reaction (7). Occasionally, no allergen can be identified. Sudden onset of a tender mouth and swollen gingival tissues are the classic findings. Both the free and attached gingival tissues are brightly erythematous and glossy with loss of stippling. The gingival involvement is widespread and may include the palate. Chapped lips, angular cheilitis, fissured tongue with or without depapillation and mild crenations of the lateral borders of the tongue may be present. Treatment is identification and elimination of the causative allergen. Topical or systemic steroids may be needed to manage the condition in severe cases.
Texas Dental Journal l www.tda.org l December 2010
Foreign body gingivitis rarely occurs in children, unless they have had stainless steel crowns or orthodontic appliances with entrapment of cement or resin particles or the impaction of silica from polishing pastes, air abrasion, or toothpastes. The gingival lesions mimic the atrophic form of lichen planus and present as red, edematous macules that are tender (8). These single or multiple lesions usually involve the interdental papillae, but may include the marginal gingiva. Surgical excision is the treatment of choice for these persistent lesions (9). Another rare condition that may affect children is orofacial granulomatosis (OFG). The etiology of this condition appears to be multifactorial, including hypersensitivity to foods and food additives, oral infections, and hereditary factors (10). It may be associated with nonspecific gastrointestinal disease or an oral manifestation of Crohnâ&#x20AC;&#x2122;s disease in this age group (11). Although the lips are most frequently involved, the gingiva may demonstrate diffuse enlargement, erythema, erosions and pain. The patient may develop fissures, erosions and paresthesia of the tongue, along with taste alterations. Linear hyperplastic folds or a cobblestone pattern may develop in the buccal mucosa. Management includes identifying the cause. In children, searching for dietary allergens or evaluating for gastrointestinal disease is recommended (11). Treatment is challenging and involves the local and systemic use of immunosup-
Oral and Maxillofacial Pathology
pressive agents, especially corticosteroids. Lastly, linear gingival erythema (LGE) needs to be excluded in children who are immunocompromised, especially those with HIV infection. This form of gingivitis presents as a distinct linear band of erythema that affects multiple teeth and is not plaque-induced (12). LGE involves the free margin with extension up to 3 mm apically and exhibits either punctuate or diffuse redness of the attached gingiva. These lesions are frequently associated with oral candidiasis and may represent a specific manifestation of this fungal infection (13). Although Candida species have been implicated, another fungus, Saccharomyces cerevisiae, has been identified in the subgingival plaque of HIV positive individuals with LGE (14). Most lesions respond to systemic antifungal medications, while plaque control does not significantly improve the condition. Although plaque-related gingivitis is a very common disease in children, it is important to include other entities in the differential diagnosis when an atypical presentation is observed. This is particularly true in children, who have good oral hygiene but the inflammatory lesions persist. An incisional biopsy aids in the establishment of a definitive diagnosis so that everyone can move past the erroneous belief that improved toothbrushing will resolve the problem.
References 1. Darling MR, Daley TD, Wilson A, Wysocki GP. Juvenile spongiotic gingivitis. J Periodontol 2007;78:1235-40. 2. Chang JYF, Kessler HP, Wright JM. Localized juvenile spongiotic gingival hyperplasia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:411-8. 3. Neville B, Damm D, Allen C, Bouquot J. Oral & Maxillofacial Pathology. 3rd Edition, St. Louis: Saunders - Elsevier Inc. 2009, 779-81. 4. Oh T-J, Eber R, Wang H-L. Periodontal diseases in the child and adolescent. J Clin Periodontol 2002;29:400-10. 5. Mombelli A, Lang NP, Burgin WB, Gusberti FA. Microbial changes associated with the development of puberty gingivitis. J Periodontol Res 1990;25:331-8. 6. Nakagawa S, Fujii H, Machida Y, Okuda K. A longitudinal study from prepuberty to puberty of gingivitis. Correlation between the occurrence of Prevotella intermedia and sex hormones. J Clin Periodontol 1994;21:658-65. 7. Neville B, Damm D, Allen C, Bouquot J. Oral & Maxillofacial Pathology. 3rd Edition, St. Louis: Saunders - Elsevier Inc. 2009, 159-60. 8. Gordon SC, Daly TD. Foreign body gingivitis: clinical and microscopic features of 61 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:562-70. 9. Gravitis K, Daley TD, Lochhead MA. Management of patients with foreign body gingivitis: report of 2 cases with histologic findings. J Can Dent Assoc 2005;71:105-9. 10. Al-Johani K, Moles DR, Hodgson T, Porter SR, Fedele S. Onset and progression of clinical manifestations of orofacial granulomatosis. Oral Dis 2009;15:214-9. 11. Saalman R, Mattsson U, Jontell M. Orofacial granulomatosis in childhood â&#x20AC;&#x201C; a clinical entity that may indicate Crohnâ&#x20AC;&#x2122;s disease as well as food allergy. Acta Paediatr 2009;98:1162-7. 12. EC-Clearinghouse on Oral Problems Related to HIV Infection and WHO Collaborating Center on Oral Manifestations of the Immunodeficiency Virus. Classification and diagnostic criteria for oral lesions in HIV infection. J Oral Pathol Med 1993;22:289-91. 13. Grbic JT, Mitchell-Lewis DA, Fine JB, Phelan JA, Bucklan RS, Zambon JJ, Lamster IB. The relationship of candidiasis to linear gingival erythema in HIV-infected homosexual men and parenteral drug users. J Periodontol 1995;66:30-7. 14. Aas JA, Barbuto SM, Alpagot T, Olsen I, Dewhurst FE, Paster BJ. Subgingival plaque microbiota in HIV positive patients. J Clin Periodontol 2007;34:189-95.
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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. 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: AUSTIN: Associate to purchase. High grossing, family practice located in retail center with seven operatories was recently remodeled. Near major freeway. High growth area. Practice boast solid, well-established patient base. ID #108. AUSTIN: North, high grossing, five operatory practice in free-standing building. Plenty of room to expand. Fee-forservice patient base, good equipment. Owner wishes to sell and continue part-time as an associate. ID #115. MUST SEE! MUST SEE! AUSTIN NORTH: Beautiful five operatory (two equipped, all plumbed) family practice off busy thoroughfare grossing mid six figures. Digital X-ray, digital pano, floor-to-ceiling windows in all ops, solid patient base and cash flow at start-up price. Excellent opportunity. ID #107. NEW! CENTRAL TEXAS HILL COUNTRY: Quality, family practice located in the heart of the beautiful hill country. Three op practice grossed mid-six figures. Practice and real estate for sale. Don’t miss out on the chance to live in this growing yet laid back hill country town. ID #117. CORPUS CHRISTI: Three operatory, fee-for-service/crown and bridge oriented family practice in great location. High grossing practice on 3-day week! Doctor ready to retire. Make an offer. ID #098. CORPUS CHRISTI: Doctor retiring, six op office with excellent visibility
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and access. Good numbers, excellent patient base, good upside potential. Excellent practice for starting doctor. Priced to sell. ID #023. RIO GRANDE VALLEY: Excellent four operatory, 20-year-old general practice. Modern, new finish out in retail location with digital radiography. Feefor-service patient base and very good new patient count. Great numbers. Super upside potential. ID #093. SAN ANTONIO — Prosthodontic practice with almost new equipment and build out. Doctor wants to sell and continue to work as associate. Beautiful office! Perfect for stand alone or satellite office. ID #060. SAN ANTONIO, NORTH CENTRAL: Two-op practice just off major freeway; perfect starter office. Terrific pricing. ID #009. 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. ID #105. 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. ID #003. SAN ANTONIO: Well-established, endodontic specialty practice with solid referral base. Located in growing, upper middle income area. Contact for more information. ID #074. SAN ANTONIO: Oral surgery specialty practice. Very good referral base. Almost new build out, great location, and excellent equipment. Good gross
and net. Transition available. ID #113. SAN ANTONIO, NORTH CENTRAL: Six operatory general practice located in high growth area. All operatories have large windows with great views. Very nice equipment, solid patient base, great hygiene program. Priced to sell. ID #112. SAN ANTONIO, NORTH CENTRAL: Three operatory office in retail/office center with great visibility and access. New equipment and nice build out. Good solid numbers, very low overhead. ID #111. SAN ANTONIO: Six operatory practice with three chair ortho bay located in 3,400 sq. ft. building. Modern office with newer equipment. Free-standing building on busy thoroughfare. Practice has grossed in seven figures for last 3 years. Great location with super upside potential. ID #055. NEW! SAN ANTONIO, NORTH CENTRAL: Five operatory, state-of-the-art facility with new equipment. Located in a medical professional building in high growth, affluent area. Grossing seven figures with high net income. ID #106. SAN ANTONIO: Medical center, four operatory family practice in very nice professional building. Great picture window views. Very nice, modern office, good patient base. Perfect size for starting doctor. ID #67. SAN ANTONIO, NORTH CENTRAL: Very nice operatory office in retail center. Near freeway and large shopping areas. Good patient flow. Excellent pricing makes this attractive to starting doctor. ID #119.
SAN ANTONIO NORTH. WEST: Excellent, four-chair general family practice in high traffic retail center across from busy mall location. Solid gross income on 30 hours/week. Ideal opportunity for doctor wanting a quick start in low overhead operation. ID #086. NEW! SEGUIN: Three operatory, 30+-year-old practice with condo is priced very aggressively as doctor must sell. Call now to learn more about this great deal. ID #118. SOUTH TEXAS BORDER: General practitioner with 100 percent ortho practice. Very high numbers, incredible net. ID #021. WACO AREA: Modern and hightech, three op general family practice grossing in mid-six figures with high net income. Large, loyal patient base. Office is well equipped for doctor seeking a modern office. ID #107. Contact McLerran Practice Transitions, Inc.: statewide, Paul McLerran, DDS, (210) 737-0100 or (888) 6560290; in Austin, David McLerran, (512) 750-6778; in Houston, Tom Guglielimo and Patrick Johnston, (281) 362-1707. Practice sales, appraisals, buyer representation, and lease negotiations. See www.dentalsales.com for pictures and more complete information. HOUSTON AREA PRACTICE OPPORTUNITIES. MCLERRAN & ASSOCIATES: NEW! HOUSTON: General PPO/Medicaid practice located on the west side of Houston, five operatories, retail location, high traffic, great visibility. Seller only Texas Dental Journal l www.tda.org l December 2010
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working part time, practice poised for growth. #H125. NEW! HOUSTON: Well-established general and cosmetic practice located in highly visible, upscale location. Beautiful office with five+ operatories, production over seven figures, seller willing to transition. #H127. HOUSTON: General family practice located southwest of Houston, high visibility, grossing mid-six figures. Five operatories, two ready for expansion. Building and up to 4 acres of real estate ready for development included in sale. #H108. HOUSTON: This general, 100 percent fee-for-service practice has been established for more than 25 years. Produced near mid-six figures with retiring doctor only working 2 days per week. Spacious facility with three operatories, custom cabinetry throughout and great outside views can be expanded to four or five operatories. #H113. Contact McLerran & Associates in Houston: Tom Guglielmo and Patrick Johnston, (800) 747-3049 or (281) 362-1707. Practice sales, appraisals, buyer representation, and lease negotiations. See www. dental-sales.com for more complete information. ORAL SURGERY PRACTICE FOR SALE, HOUSTON AREA — GARY CLINTON, PMA: State-of-the-art practice. Fast growing location. Economy is strong in Texas. Many referring dentists for cosmetic and implant surgery. Outright sale; seven-figure gross. Seller relocating; will transition on limited basis. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the
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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 ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765. GARY CLINTON / PMA NORTHWEST OF DALLAS FARMERS BRANCH / CARROLLTON AREA PRACTICE FOR SALE: Well-established practice; exceptional recall; full general service practice with lots of crown and bridge. Retiring dentist. Will continue to work as needed 1 day per week. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” 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 ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765. WE NEED SELLERS! GARY CLINTON / PMA: Serving the dental profession since 1973: I have buyers! Sell your practice and travel while you have your health. In many cases, you can stay on to work 1-2 days per week if you wish. I need practices to sell/ transition as follows: Any practice in or near Austin, San Antonio, DFW and Houston areas, and other Texas locations. Have buyers for orthodontic, oral surgery, periodontic, pedodontic,
and general dentistry practices. Values for practices have never been higher. Tax advantages high for present time. One hundred percent funding available, even those valued at more than seven figures. Call me confidentially with any questions. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” 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 ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765. ORTHODONTIC PRACTICES FOR SALE / TRANSITION — GARY CLINTON / PMA TEXAS: O-1 West Central Texas mid-sized to larger community — Ideal transition; professional referral based; traditional fee-for-service, referral, highly productive. Gorgeous building with room for two in this planned 50/50 partnership; within 5 years complete buy-out with owner working 1-2 days as needed. O-2 South Texas — Retiring orthodontist; 100 percent buy-out / transition; seller will stay 1-2 days per week as needed. Seven figure practice collections; 60 percent profits; lovely building. He is ready to spend time with his grandchildren. O-3 Houston/Clear Lake/ South of Houston area — Very nice medium sized practice; doctor retiring; will transition; excellent operating profit. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc.
“For over 37 years, you’ve seen the name ... a name you can trust.” 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 ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765. GARY CLINTON / PMA MCKINNEY/ FRISCO AREA: MF-1 — Exceptional premier restorative practice; seven figure gross requiring experienced dentist. Newer equipment; attractive facility. MF-2 — Practice in the middle of high growth area off Dallas North Toll. Mid seven-figure gross. Newly equipped. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” 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 ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765. GARY CLINTON / PMA ARLINGTON PRACTICE FOR SALE: The place to be for young families. Well-established practice. Excellent recare program. Near seven figure gross. Garden style offices and operatories. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you
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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 ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765. GARY CLINTON / PMA GENERAL PRACTICE NORTH OF FORT WORTH NEAR DENTON: 3-4-day-aweek practice; excellent patient base; well-established recall; bread and butter practice. Very fast-growing area near Texas Motor Speedway. Average gross with excellent net. We have the best sources for 100 percent buyer funding. Gary Clinton is a senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” 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 ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765. GOLDEN TRIANGLE GENERAL DENTAL PRACTICE — SALE: Outstanding practice for sale developed by published mentor. Supported by outstanding staff and latest in dental equipment. Strong 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.
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SOUTH HOUSTON GENERAL DENTAL PRACTICE — SALE: Most attractive office located on busy thoroughfare in rapidly growing south Houston suburb. Six treatment rooms, five fully equipped. Two additional spaces plumbed. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com. WEST HOUSTON GENERAL DENTAL PRACTICE — SALE: new, wellappointed office space in fast growing west Houston. Three fully-equipped operatories with two additional rooms plumbed for future use. Strong new patient flow, excellent staff, and highly qualified mentor. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com. NORTH TEXAS GENERAL DENTAL PRACTICE — SALE: Small, well-established practice in mid-sized community in north Texas. Three fully-equipped operatories. Experienced staff with excellent skills. Doctor will assist with transition. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com. CORPUS CHRISTI GENERAL DENTAL — SALE: Moderate revenues with a very 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. 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.
WACO PEDIATRIC DENTAL PRACTICE — SALE: Well-established practice with moderate revenues and high profit margin on 4 days per week. Limited competition and a large facility. 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) 8561955. Visit us at www.thehindleygroup. com. SOUTH OF HOUSTON GENERAL DENTAL PRACTICE — SALE: Outstanding practice with very high growth potential experiencing a strong new patient flow. Moderate revenues and a healthy profit margin on 4 days per week. Building also for sale. Contact The Hindley Group, LLC, at (800) 8561955. Visit us at www.thehindleygroup. com. BRYAN/COLLEGE STATION GENERAL DENTAL PRACTICE —SALE: Wellestablished practice in mid-size town. Four operatories. Healthy revenues, excellent profit margin, and strong new patient flow. Doctor must transition due to health reason. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com. EAST TEXAS GENERAL DENTAL PRACTICE — SALE: Well-established practice in small town in hills in East Texas. Moderate revenues on 4 days per week; three operatories; excellent staff. Room to expand in adjusted space. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.
FORT WORTH ORTHODONTIC PRACTICE — SALE: Excellent opportunity for satellite office; general dentist wanting to add orthodontics to services offered; female dentist desiring part-time position while children in school; or older dentist wanting to utilize orthodontics as less physically taxing exit strategy. Doctor will mentor or assist with transition. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www. thehindleygroup.com. WEST TEXAS GENERAL DENTAL PRACTICE — SALE: Spacious office with five fully-equipped operatories; two additional spaces plumbed for future use. Strong revenues and profit margin. Excellent new patient flow. Eight hygiene days per week. Contact The Hindley Group. LLC, at (800) 856-1955. Visit us at www. thehindleygroup.com. ARLINGTON ORAL SURGERY PRACTICE — SALE: Highly successful practice with strong revenue history of more than seven figures. Selling doctor cut production in half due to back injury but will assist purchaser in rebuilding practice. Extensive referral pattern. Building also for sale. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com. ASSOCIATESHIPS: EAST TEXAS GENERAL DENTAL PRACTICE — Small but busy practice generating mid-range revenues on 4 days per week. Located in quaint small town with excellent access to forests and lakes for hunting, fishing, and boating. Excellent opportunity for dentists looking ahead to separation from the military. Pre-determined buyin terms. SOUTH CENTRAL TEXAS PERIODONTAL — Wonderful practice
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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. SAN ANTONIO PERIODONTAL AND ENDODONTIST ASSOCIATESHIPS — Periodontal associateship with pre-determined buy-in for very active, multi-office periodontal practice. Endodontist associate also needed in this practice. Outstanding mentor and cohesive staff. If you are the right person, this is an outstanding opportunity. WEST TEXAS GENERAL DENTAL PRACTICE — Associateship with pre-determined buy-in and partnership terms. Nine operatories. Strong mentor and experienced staff. Excellent revenues and profit margin. Large Medicaid component. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com. HOUSTON AREA PRACTICE FOR SALE: Profitable practice for sale. Well-established. Call Jim Robertson at (713) 688-1749. ADS WATSON, BROWN & ASSOCIATES: Excellent practice acquisition and merger opportunities available. DALLAS AREA — Six general dentistry practices available (Dallas, North Dallas, Highland Park, and 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 den-
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tistry 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-ofthe-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 X-rays, and intraoral 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, Thursday per week. If you are wanting an associate, please inquire. Call (214) 3154584 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) 205-2005 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. TOP OF THE HILL COUNTRY GENERAL PRACTICE FOR SALE. Beautiful free-standing 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 is 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-forservice, 100 percent quality-oriented practice looking for a quality oriented associate. Ideal for a new graduate or for an experienced dentist wanting to relocate and become part of an established practice with a reputation for providing comprehensive, quality dental care with a personable approach. Practice references available from local specialists. Contact Dr. Richard Krumholz, (409) 762-4522. ROWLETT DENTAL OFFICE seeks qualified pedodontist to work two to three times a week. We are looking for an honest, fun-loving pedodontist who enjoys working as a team. Please call (972) 412-2828. EXPERIENCED DENTIST IS NEEDED FOR AN ESTABLISHED PRIVATE GROUP PRACTICE LOCATED IN KATY. General dentistry practice with a comfortable and friendly atmosphere without administrative responsibilities. Full-time position with competitive compensation, benefits, and flexible schedule. Great opportunity for a quality oriented person. Please call Dr. Akerman at (832) 934-2044 or e-mail at yourhappydentist@aol.com. HOUSTON: General dentist with pediatric experience needed. Full-time position available. Excellent compensation. Please send CV to cvanalfen@ yahoo.com.
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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 on the needs of their patients. Our office is located in beautiful East Texas and provides all phases of quality dentistry in a friendly and compassionate atmosphere. The practice offers a tremendous opportunity to grow a solid foundation with the doctor. The practice offers excellent production and earning potential with a possible future equity position available. Our knowledgeable staff will support and enhance your growth and earning potential while helping create a smooth transition. Interested candidates should call (903) 509-0505 and/or send an e-mail to steve.lebo@ sbcglobal.net. ASSOCIATE NEEDED FOR 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. 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
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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. 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. SOUTHWEST FT. WORTH â&#x20AC;&#x201D; GENERAL DENTAL PRACTICE WITH BUILDING FOR SALE OR LEASE: This very successful, well-established practice has an excellent patient base with referrals from near and far. The seller is retiring immediately or will negotiate a comfortable transition. With a low overhead and excellent profit margin,
this practice makes a great investment for just the right person. Five treatment rooms, 3,200 sq. ft. plus 800 sq. ft. for additional expansion or rental space. The practice is located in a high visibility and stable economic community. With this practice comes an experienced staff, computers in all treatment rooms, nice equipment, imaging software, and much more. Get out of that associate position and be an owner! Appraisal performed by a CPA/CFP/CVA. Call (972) 562-1072 or (214) 697-6152 or e-mail sherri@ slhdentalsales.com. ASSOCIATE SUGAR LAND AND CYPRESS: Large well-established practice with very strong revenues is seeking an associate. Must have at least 2 years experience and be motivated to learn and succeed. FFS and PPO practice that ranks as one of the top practices in the nation. Great mentoring opportunity. Possible equity position in the future. Base salary guarantee with high income potential. Two days initially going to 4 days in the near future. E-mail CV to Dr. Mike Kesner, drkesner@madeyasmile.com. SEEKING ASSOCIATE DENTISTS. Dental Republic is a well-established general dental practice with various successful locations throughout the Dallas Metroplex. A brand new stateof-the-art facility in a bustling location will be opening soon. Join our outstanding and professional team in creating beautiful healthy smiles for all. Let us give you the opportunity to enhance your professional career with excellent hours, competitive salary/ benefits, and by forming long-lasting friendships with our patients and staff members. Please contact Phong at (214) 466-8450 or e-mail CV to phong@dentalrepublic.com.
CARE FOR KIDS, A PEDIATRIC FOCUSED PRACTICE, is opening new practices in the San Antonio and Houston area. We are looking for energetic full-time general dentists and pediatric dentists to join our team. We offer a comprehensive compensation and benefits package including medical, life, long- and short-term disability insurance, flexible spending, and 401(K) with employer contribution. New graduates and dentists with experience are welcome. Be a part of our outstanding team, providing care for Texasâ&#x20AC;&#x2122; kids. Please contact Anna Robinson at (913) 322-1447; e-mail: arobinson@amdpi.com; FAX: (913) 322-1459. THRIVING PRACTICE IN GALVESTON providing the best of both worlds ... the great outdoors and a laid back lifestyle, yet quick access to metropolitan Houston. This 15-year-old practice has three fully equipped operatories, private office, full-time hygienist, and a great staff. Ownership of free-standing building is available. Generating mid-six figure gross collections on only 3 days per week. Earn a six-figure income as the owner of one of the most well-known, well-respected practices in Galveston. Owner currently splits time with out-of-town practice and must sell. Call Jim Dunn at (800) 9308017. LUBBOCK â&#x20AC;&#x201D; GENERAL PRACTICE: Associate/partner. Growing group practice is looking for a motivated, long-term, career-minded dentist to provide quality care for our established and tremendous number of new patients. Experienced or new grad welcome. E-mail at dentist.lubbock@ gmail.com.
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SAN ANGELO, ABILENE: Associates — outstanding earnings. Historically proven at over twice the national average for general dentists; future potential even greater. Thriving, established practice in great location. Bright and spacious facility. Experienced, efficient, loyal staff. Best of all worlds; big city, earnings, small-town easy lifestyle, outstanding outdoor recreation. Contact Dr. John Goodman at john@ goodman.net or (325) 277-7774. ARLINGTON ORAL SURGERY PRACTICE — SALE: Oral and maxillofacial practice for sale in Arlington. It is located in a three unit professional office building and has two other dentists and an orthodontist. The building and office interior are very attractive and situated in a good area with a large referral base locally and the DFW area. This would be a great opportunity if you are seriously considering purchasing your own practice at an attractive price. If you would like any further information, call (817) 917-4536 or email at aosapa2010@gmail.com. A CASUAL COASTAL LIFESTYLE AND YEAR-ROUND GOLF, TENNIS, FISHING, AND OTHER WATER SPORTS are appealing parts of this compatible, quality-oriented group practice in Corpus Christi. If you are a general dentist interested in hassle-free dentistry in a busy, growing organization, this is an excellent opportunity to prosper. Please call Cathy at (361) 993-9551 or e-mail resume to apple4ccassels@sbcglobal.net. ASSOCIATE DENTIST NEEDED IN EULESS: Well-established general practice seeking full-time associate/ future partner. Cosmetic and full family practice. Please send resume to wendy.tcd@sbcglobal.net.
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TWO-YEAR DENTAL ASSOCIATESHIP — EL PASO: We are a quality children’s dental office employing general dentists and dental anesthesiologists. Pay per year for 2-year agreement equals generous six-figure income. Salaries on percentage based commissions. Will train in oral sedation. Ownership opportunities available. Send resume to info@ txkidsdental.com. Call (915) 858-6868. ESTABLISHED, SUCCESSFUL GENERAL PRACTICE AVAILABLE FOR OWNERSHIP with no personal financial investment. Niche market limited to removable prosthetics and related services. Guaranteed minimum salary plus unlimited potential from net profits. Full benefits package. Onsite lab. Monday through Friday, 8 a.m. to 5 p.m. Professional gratification, personal rewards. E-mail michele.cooke@ affordablecare.com. GREAT OPPORTUNITY FOR ORTHODONTISTS AND GENERAL DENTISTS to join our busy practices providing orthodontic care in the Rio Grande Valley area. We are looking for orthodontists to oversee all aspects of patient care and general dentists to work in coordination with our orthodontists to be able to provide the highest quality care for our patients. Be a part of our exceptional team helping the children of Texas get great smiles. Please contact Dr. Hal D. Lerman at (214) 789-4601 or e-mail to nflq21b@ swbell.net. AUSTIN — PEDIATRIC DENTISTS NEEDED FOR A VERY UNDERSERVED CITY. Established practice looking for associates leading to potential partnerships. Modern digital office. Please e-mail CV to cespilares@ sbcglobal.net.
KATY: Dr. Bui X. Dinh, D.D.S., M.S. is looking for a dentist right now with minimum 2 years experience. Please contact office manager Michelle, (832) 620-6982 or fax resume to (281) 579-6045. FOR SALE — GREAT 41-YEAR SUCCESSFUL PRACTICE IN SOUTH CENTRAL TEXAS. Owner retiring but will stay through transition period. Five operatories in beautiful building, Pan0, digital X-ray. Experienced long-term dependable staff. Room for multiple dentists. Please mail letter of interest to Box 1, TDA, 1946 S. IH 35, Ste 400, Austin, TX 78704. SEEKING ASSOCIATE: Established general dental office in Brownsville (30 minutes away from South Padre Island) is seeking a caring, energetic associate. We are a busy office providing dental care for mostly children. Our knowledgeable staff will support and enhance growth and earning potential allowing the associate to focus on patient dental care. Interested candidates should call (956) 546-8397. NEW, TYLER: Excellent opportunity, location, and lifestyle. Join an established doctor and share a 2-year-old, free-standing, award-winning building on busy south Tyler Street. Five of 10 ops and private office available. Share reception, lab, and sterilization. Equity position in property available or lease. E-mail dburrow@suddenlinkmail.com. TEMPLE DENTAL CENTER IN TEMPLE,TEXAS, IS FOR SALE: Doctor changing professions. Firesale! Four operatories, tons of equipment and instruments, three wall X-rays (film just needs sensors to convert), Panorex (also easily converted) Velopex processor. Call (254) 791-0977 and leave message. E-mail doctorbrown80@hotmail.com.
SAN ANTONIO NORTH WEST: Associate needed. Established general dental practice seeking quality oriented associate. New graduate and experienced dentists welcome. GPR, AEGD preferred. Please contact Dr. Henry Chu at (210) 684-8033 or versed0101@ yahoo.com. GREAT PRACTICE IN BEAUTIFUL EAST TEXAS. This fee-for-service practice was established by a prominent community-involved dentist with an excellent reputation for quality care. The office has 1,300 sq. ft. with four available treatment rooms and a large private office. Don’t miss the opportunity to become part of this stable economic town with an experienced staff and a growing patient base. Interested? Call (972) 562-1072 or e-mail sherri@slhdentalsales.com. EXPERIENCED DENTIST IS NEEDED FOR AN ESTABLISHED PRIVATE PRACTICE IN KATY. General dentist with extensive cosmetic dentistry background, preferably Invisalign certified. Full- or part-time position with lucrative compensation. Great opportunity for a quality oriented person without administrative responsibilities. Please call Dr. Akerman at (832) 934-2044 or e-mail yourhappydentist@aol.com. TEXAS — PEDIATRIC DENTAL ASSOCIATE NEEDED. Fast-growing pediatric dental practice is looking for a pediatric dentist to join our team. We are located north of San Antonio just 10 minutes from New Braunfels and 45 minutes from Austin. We offer a generous compensation package including paid time off and holidays. Experience is a plus, but new graduates are welcome. Please respond via e-mail to Sherri at velezluke@yahoo. com or by fax (210) 659-9436.
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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 and traffic. Call (817) 326-4098. ORTHODONTIST NEEDED NEXT TO DENTIST IN HIGH GROWTH, HIGH TRAFFIC AREA IN ROUND ROCK, north of Austin in one of the fastestgrowing counties. Available at $155/sq. ft. For more information, e-mail john@ herronpartners.com or call (512) 457-8206. 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. ALLEN: Prior dental, high end practice that relocated. Five plumbed and ready ops, reception, office, conference, two bath, some built-in cabinets, no equipment. High traffic visibility with lots of parking. Affluent residential, across the street from large grocer. Offering 5-7 years lease plus extensions. Levin Realty, (323) 9541934, levinrealty@sbcglobal-net. ROUND ROCK — DENTAL SPACE AVAILABLE FOR LEASE: 323 Lake Creek, 2,032 sq. ft. Lease rate is $18 PSF + $6.50. PSF NNN. Existing air lines and plumbing. Call Darren Quick, (512) 255-3000.
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ROUND ROCK — ORTHODONTIST SPACE FOR LEASE: On IH-35, between FM 620 and Hwy. 79. Call Darren Quick, (512) 255-3000. INGLESIDE DENTAL BUILDING FOR SALE! 1,700 sq. ft., two chairs plumbed. Rental side, near Corpus Christ!. Busy main street location. Vacant, no equipment. Landscaping, parking, owner/dentist, $124,900; financing, photographs. E-mail mbtex@ aol.com or call (702) 480-2236. ARLINGTON DENTAL OFFICE FOR LEASE: Current doctor is only using 1 day a week. Has four up-to-date operatories with HD TVs in each op, assistant computer, doctor computer, Casey educational system, digital X-rays, digital panoramic machine, electric handpiece, sterilization room, laboratory, and Cerec CAD/CAM technology. Perfect for new practice start up. Visit our website to view our office. Contact (817) 274-8667, info@docdds. com, www.docdds.com. NORTHWEST AUSTIN ESTABLISHED DENTAL SPACE below market, busy main street, many schools, and Rooftops nearby. Good signage, four ops, recently vacated, partially equipped, plumbed, and ready. Owner eager to lease, (512) 833-5300. AUSTIN / ROUND ROCK AREA: Three pad sites available at expanding dental park with thriving two-doctor general dentist practice. Wide frontage on four-lane boulevard with excellent traffic volumes. AREA DEMOGRAPHICS: Average income —$85,809; job growth — 45.15 percent (2000-2007); population growth — 8.2 percent (2008-2009); 47.5 percent of households have children under the age of 17. New high school opened nearby in fall 2010. Area has a shortage of specialty dentists. FINANCING is
available through a private investment group. Zero equity is required for land purchase and construction of custom ground-up practices. Doctors starting their first practice, tired of leasing, or looking to expand are encouraged to call. We understand the dental industry. Large college loans and associates low net worth are not a concern. CONTACT: Jim Ward, (512) 636-4286. I look toward to speaking with you. The Best Facility In Town Can Be Yours. We build free-standing dental offices throughout the state of Texas. One-hundred percent financing is available for all construction costs. Each facility is custom designed to your specifications by national award winning Fazio Architects. Are you currently leasing but want the advantages of ownership? We can make it happen. Are you having trouble getting financing as a first time owner? We can make that happen too. Call Jim at (512) 494-0643 or e-mail jim@fazioarchitects.com. ROUND ROCK: Property site available for dental/medical facility on Gattis School Road near the new high school. Good frontage with 25,000 cars passing by daily. Call Jim at (512) 494-0643 or e-mail jim@fazioarchitects.com. ROUND ROCK — OLD SETTLERS DENTAL PARK: Three pad sites available. Thriving 2-doctor general practice already on-site. High growth area has shortage of specialty dentists. Call Jim at (512) 494-0643 or e-mail jim@fazioarchitects.com. AUSTN — MCNEIL DRIVE DENTAL PARK: Successful general dentist with established practice has two pad sites available. Beautiful wooded area with good traffic volumes. Call Jim at (512) 494-0643 or e-mail jim@fazioarchitects. com.
THROUGHOUT TEXAS: Don’t let others persuade you to take a location that’s not the perfect fit for your new practice. We’ll help find the best location for YOU anywhere in the state and build a facility that exactly fits your vision. Don’t settle for less until you’ve evaluated the very best. Call Jim at (512) 494-0643 or email jim@fazioarchitects.com. WHITNEY: Free-standing vacant building for sale. Perfect location, 6 miles from the lake for any specialty start-up. Location near hospital complex, 2,600 sq. ft., no equipment, four bathrooms, private office, built 1978. Pictures are available. For more information call (972) 562-1072 or e-mail sherri@slhdentalsales.com DENTAL OFFICE SPACE AVAILABLE – SAN ANTONIO: Complete dental office containing 3,362 sq. ft. of area located in busy shopping center anchored by a 27,000 sq. ft. Dollar Tree store available on December 15, 2010. Location is at a busy intersection that includes Walgreen’s, HEB Grocery, McDonald’s, Whataburger, Big Lots, and Hallmark Cards. Some dental chairs and equipment may be purchased from existing dentist and shopping center owner will finance additional build-out if required. Current dentist has occupied this location for over 10 years and recently built his own building. Rent is $14/sq. ft. plus NNN charges of $3.60/sq. ft. Contact Cynthia Ellison at Grubb & Ellis Co. in San Antonio, (210) 804-4847. 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) 2932686 or (806) 292-3156.
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LARGE INVENTORY OF QUALITY REFURBISHED AIR DRIVEN DENTAL HANDPIECES. All have been repaired and tested by a qualified technician. All have new ceramic bearing turbines and all are fiberoptic. For sale — Star 430 SWL, $269; Kavo 640B, $279; Kavo 642B, $299; Kavo 647B, $299; Midwest Tradition push button or lever, $239; new Kavo multi-flex coupler five-hole, $249; new Kavo coupler six-hole, $149; new Star coupler five-hole, $145. Slow speed and implant handpieces available, too. Quality discounts are possible. I have been a TDA member for 25 years. If what you are looking for is not on this list, we stock a wide variety at wonderful prices, just inquire. Call (877) 863-4848 or visit our website, www. truespindental.com.
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. Nation’s largest, most distinguished team. Short-notice 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 butter procedures. No cost, strings, or obligations —
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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.”
a 1-week turnaround for slow speeds, ultrasonic sealers, and electrics. The Dental Handpiece Repair Guy wants to be your handpiece servicing facility of choice. We would appreciate a chance to earn your business! Call (800) 569-5245 or visit our website, www.thedentalhandpiecerepairguy.com.
Miscellaneous LOOKING TO HIRE A TRAINED DENTAL ASSISTANT? We have dental assistants graduating every 3 months in Dallas and Houston. To hire or to host a 32-hour externship, please call the National School of Dental Assisting at (800) 383-3408; Web: www. schoolofdentalassisting-northdallas.com. DOCTORSCHOICEGOLDEXCHANGE. COM: Try our high prices for dental scrap. Check sent 24 hours after you approve our quote. See why we have so many repeat customers. Visit www. DoctorsChoiceGoldExchange.com. THE DENTAL HANDPIECE REPAIR GUY, LLC. I’m pleased to inform you that we are now operating a full-service handpiece repair shop in Friendswood, Texas, where my father Dr. Ronald Groba has been practicing for over 35 years. I have been doing his handpieces for over 20 years and decided to provide this service to other dentists. First and foremost, we provide expert service for your precision instruments and are qualified to service nearly every make and model of high-speed, low-speed, and electric handpieces on the market. We use quality parts, take less time, and our costs are lower. We provide free pickup and delivery, warranties, and next-day service on most high-speed units and
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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 profesprofes sionals with the support and means to confidenconfiden tial recovery. If you or another dental professional are concon cerned about a possible impairment, call the Professional Recovery Network and start the recovery process today. If you call to get help for someone in need, your name and location will not be divulged. The Professional Recovery Network staff will ask for your name and phone numbers so we may obtain more information and let you know that something is being done.
Statewide Toll-free Helpline 800-727-5152 Emergency 24-hour Cell: 512-496-7247
Professional Recovery Network 12007 Research Blvd. Suite 201 Austin, TX 78759 www.rxpert.org
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Attract New Patients with a Professional Website. As the leading provider of dental website design, ProSites understands what your dental practice website needs to attract new patients and keep your existing patient base well informed. Each website compliments your professional image with impressive, high-quality color schemes and graphics, interactive features, patient-education content and more! TDA members save with special Perks pricing: just $1,875 for a site with unlimited pages!
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Insure wIth tDA FInAnCIAL serVICes InsurAnCe ProgrAm AnD the hArtForD running a successful dental practice isn’t easy. Attending to patients, handling paperwork, dealing with a hundred little details that need your attention – there are a number of challenges. Finding the right insurance shouldn’t be one of them. the tDA Financial services Insurance Property and Casualty Program features the hartford’s spectrum® business owners’ policy. In addition to financial strength, excellent service and dependable claim handling, the program includes the following features: • Electronic Funds Transfer • 12 Equal Payments (No large down payment!) If you don’t have your Property, Liability, or workers’ Compensation insurance placed through the tDA Financial services Insurance Program, there has never been a better time to switch. Contact us today at (888) 588-5420 or quotes@tdamemberinsure.com
the tDA Financial services Insurance Program is administered by the higginbotham & Associates brokerage firm.
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