July 2010

Page 1

July 2010

Journal TEXAS DENTAL

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Texas Dental Association 140th Annual Session 2010 TEXAS Meeting Photo Contest Award: Best of Show Photographer: Dr. Roy Tiemeyer Title: “Skimmers” For information on entering your photo in the 2011 TEXAS Meeting Photo Contest, please visit texasmeeting.com.

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Contents

TEXAS DENTAL JOURNAL n Established February 1883 n Vol. 127, Number 7, July 2010

ON THE COVER

The cover photo, “Lazy Day on the Guadalupe,” is a refreshing view of summer and was taken by Ms. Tessa Kolodny, RDH, of Arlington. It won Honorable Mention in the Sports/ Human Endeavor category at the May 2010 TEXAS Meeting Photo Contest in San Antonio. Ms. Kolodny took the photo in July 2009 about 5:00 PM from the top of the main bridge in New Braunfels that overlooks the Guadalupe River. Ms. Kolodny works her with husband, Carter Kolodny, DDS, at their dental practice in Arlington. For more information on the 2011 TEXAS Meeting Photo Contest, please visit texasmeeting.com or call the TDA central office, (512) 443-3675.

ARTICLES

651 Current Development of Saliva/Oral Fluid-based Diagnostics

Chih-Ko Yeh, Ph.D.; Nicolaos J. Christodoulides, Ph.D.; Pierre N. Floriano, Ph.D.; Craig S. Miller, D.M.D., M.S.; Jeffrey L. Ebersole, Ph.D.; Shannon E. Weigum, Ph.D.; John McDevitt, Ph.D.; Spencer W. Redding, D.D.S., M.S.E.D.

Researchers in Texas and Kentucky discuss the current consensus on development of saliva/oral fluid-based diagnostics.

665 Weekly Monitoring of the Water Fluoride Content

in a Fluoridated Metropolitan City — Results After 1 Year

Ryan L. Quock,D.D.S. Jarvis T. Chan, D.D.S., Ph.D.

The authors discuss a study to determine the extent of fluctuation of water fluoride concentration in samples from Houston, Texas, over 1 year.

677 Dental Unit Waterline Contamination — A Review

Nuala Porteous, B.D.S., M.P.H.

The author discusses the positive responses from manufacturers of dental units to the American Dental Association’s and the Center for Disease Control and Prevention’s challenges to deliver patient treatment water that is at least as pure as drinking water.

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MONTHLY FEATURES

640 644 648 688 690 694 696 698 702 704

President’s Message

707 722

Advertising Briefs

BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION

The View From Austin Guest Editorial What’s on tda.org? Value for Your Profession In Memoriam / TDA Smiles Foundation Calendar of Events Oral and Maxillofacial Pathology Case of the Month Dental Artifacts Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management

Index to Advertisers EDITORIAL STAFF

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

EDITORIAL ADVISORY BOARD Ronald C. Auvenshine, D.D.S., Ph.D. Barry K. Bartee, D.D.S., M.D. Patricia L. Blanton, D.D.S., Ph.D. William C. Bone, D.D.S. Phillip M. Campbell, D.D.S., M.S.D. Tommy W. Gage, D.D.S., Ph.D. Arthur H. Jeske, D.M.D., Ph.D. Larry D. Jones, D.D.S. Paul A. Kennedy, Jr., D.D.S., M.S. Scott R. Makins, D.D.S. Robert V. Walker, D.D.S. William F. Wathen, D.M.D. Robert C. White, D.D.S. Leighton A. Wier, D.D.S. Douglas B. Willingham, D.D.S. The Texas Dental Journal is a peer-reviewed publication. Texas Dental Association 1946 South IH-35, Suite 400 Austin, TX 78704-3698 Phone: (512) 443-3675 FAX: (512) 443-3031 E-Mail: tda@tda.org Website: www.tda.org

Texas Dental Journal (ISSN 0040-4284) is published monthly, one issue will be a directory issue, by the Texas Dental Association, 1946 S. IH-35, Austin, Texas, 78704-3698, (512) 4433675. Periodicals Postage Paid at Austin, Texas and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S. Interregional Highway, Austin, TX 78704. Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, Out-of-state ADA Affiliated $49.50. In-state Non-ADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA Affiliated, $17 Non-ADA Affiliated, September issue $17 ADA Affiliated, $65 Non-ADA Affiliated. For in-state orders, add 8.25% sales tax. Contributions: Manuscripts and news items of interest to the membership of the society are solicited. The Editor prefers electronic submissions although paper manuscripts are acceptable. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. For more information, please refer to the Instructions for Contributors statement printed in the September Annual Membership Directory or on the TDA website: www.tda.org. All statements of opinion and of supposed facts are published on authority of the writer under whose name they appear and are not to be regarded as the views of the Texas Dental Association, unless such statements have been adopted by the Association. Articles are accepted with the understanding that they have not been published previously. Texas Dental Journal is a member of the American Association of Dental Editors.

aa de

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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“The Aesthetic Restorative Series at C.A.R.D. had the most effect on me and my practice than any other course I have taken in my 32 years of practice.” RON BOSHER, D.D.S., GARLAND, TX “In my opinion, The Aesthetic Restorative Series is the best kept secret in continuing education. After taking these courses, my practice is a different place!” JERRY HERRINGTON, D.D.S., CONROE, TX “C.A.R.D. has provided for me an ‘extreme makeover’ for my attitude toward my profession of dentistry. Through five individual courses over the span of one year, I have come to realize what dentistry can provide in the way of contentment, prosperity and self respect. If you want to know what it means to be a true professional, Dr. Cutbirth can show you. He is there for dentists who want to be great, not just ok.” EDDIE PRUITT, D.D.S., HOUSTON, TX “It is rare in our profession to find a master technical dentist who also possesses exemplary skills in practice systems that lead to high profitability in a dental practice. Steve Cutbirth symbiotically blends both areas to allow each attendee of this seminar to vastly improve their level of success. I strongly recommend that dentists at all stages of their practice attend this seminar.” TOM MCDOUGAL, D.D.S., RICHARDSON, TX “Dr. Cutbirth’s series is a must for any dentist seeking a ‘top tier’ practice. His courses really helped ‘fill in the gaps’ when it comes to complex restorative cases, i.e., occlusion, changing vertical and facial pain. If you seek excellence, as Steve most certainly does, in the quality of your work and the way you run your office then I highly recommend this series.” MARK SIVLEY, D.D.S., ABILENE, TX “To take your dentistry to the next level, this is the clearest and most concise presentation of advanced aesthetic restorative studies that you’ll find! I am now, confidently and successfully, doing the dentistry that, just two years ago, I thought was relegated to ‘those guys’ on the lecture circuit.” DARREN DICKSON, D.D.S., PLANO, TX “In one wordTERRIFIC! What makes this series different: 1. The small class size encourages interaction. 2. Dr. Cutbirth’s straight forward approach and his willingness to share all his knowledge and experiences.” MICHEAL W. SCOTT, D.D.S., LUBBOCK, TX

reach the highest level of technical excellence and bottom line productivity Advanced Restorative Series Hands-on Training Double, triple, quadruple your practice production while slashing overhead! • Learn the secrets of highest productivity with

lowest overhead. • Master the highest levels of dentistry. • Learn to restore any case that presents in your office—including complex esthetics cases, severe wear and facial pain. • Never “sell.” • Patients diagnose themselves and request the treatment. • 5 weekends in Dallas. Morning lectures with afternoon hands-on laboratory.

steven t. cutbirth, d.d.s. director of c.a.r.d.

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Texas Dental Journal l www.tda.org l June 2010 July 2010

register on line at www.centerforard.com


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President’s Message Ronald L. Rhea, D.D.S., TDA President

This issue of the Texas Dental Journal has been internally titled the Fluoride/Water Issue. Articles enclosed revisit two subjects long familiar to Texas dentist — fluoride in the water and from other sources and its effect on tooth enamel and contamination of the waterlines in dental units. The third subject, salivary diagnostics of systemic disease, is one of the newest and most exciting to emerge in dentistry.

tistry. The potential for early screening and diagnostics could indeed save countless lives with dentistry at the forefront of early detection and referral. The discovery of disease specific salivary biomarkers combined with nanotechnology allows for rapid, multiplex and miniaturized analytical assays. Dr Chih-Ko Yeh writes for us on current developments in this newest diagnostic modality.

Fluoridation of the water supply along with supplements in toothpaste and mouth rinses have markedly reduced tooth decay in treated municipalities in this country. Drs. Ryan Quock and Jarvis Chan examine the fluoride levels in a Texas city and finds variations that we all must consider in treating our patients. Patients could easily be under fluoridated and be underprotected from caries, or overfluoridated and potentially develp fluorosis.

***

Dr. Nuala Porteous reviews the dental unit waterline contamination issue and reports on the improvement in equipment to combat this problem. A challenge from the American Dental Association and guidelines issued by the Centers for Disease Control have influenced the dental equipment manufacturers to step up and provide dental units with the features needed to eliminate this problem. Salivary diagnostics of systemic diseases is one of the most exciting developments in medicine and den-

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As we celebrate the landmark events of the Texas summer — Memorial Day, Fathers Day, July 4th, and Labor Day — I hope that each of you took or take these opportunities for holiday recreation. After all, it is through recreation that we are restored and again can be the productive individuals and families that make Texas great. Summer opportunities in Texas to sharpen our skills as dentists are many: The Lone Star Dental Conference, the Dentists Who Care Conference, and the El Paso Dental Conference just to name a few. Combined with a getaway, for example a visit to South Padre Island or Galveston or the Hill Country, the whole family can be recreated. Just pick one of these great meetings, and I will see you there!


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This organization receives financial support for allowing Liberty Mutual to offer this auto and home insurance program. *Figure based on a February 2008 sample of auto policyholder savings when comparing their former premium with those of the Liberty Mutual Advantage program. Individual premiums and savings will vary. **Discounts and savings are available where state laws and regulations allow, and may vary by state. Certain discounts apply to specific coverages only. ***Emergency Roadside Assistance is available anywhere in the U.S. and Canada. With the purchase of our optional Towing & Labor coverage, the cost of towing is covered, subject to policy limits. †Accident Forgiveness coverage subject to terms and conditions of Liberty Mutual’s underwriting guidelines and is not available in all states. Coverage provided and underwritten by Liberty County Mutual Insurance Company and its affiliates, 2100 Walnut Hill Lane, Irving, TX. A consumer report from a consumer reporting agency and/or a motor vehicle report, on all drivers listed on your policy, may be obtained where state laws and regulations allow. Please consult a Liberty Mutual specialist for specific details. ©2008 Liberty Mutual Insurance Company. All Rights Reserved.

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


The Texas Dental Association’s ADA Golden Apple award-winning website is the official website of the Texas Dental Association. Log in using your ADA # with dashes (123-45-6789) and TX + license number for your password, with TX in caps (TX1234) The member side is for TDA member dentists and Texas dental students. It includes top stories and TDA news, an online job board, upcoming meetings and events, the online discussion group “Ask a Colleague,” online member dues, TDA publications and references, component society web pages, personal web pages, a searchable member directory and contact information. Members can also update their personal contact information online. The public side of TDA’s website is for patients and the public, non-member dentists and non-dentist dental professionals. It includes information about TDA, how to join TDA, general oral health information, resources for dental insurance, financial help, charitable activities, careers in dental health, TDA contact information, and a “Find a Dentist” search function.

Home

Current Issues

Membership Info UPDATE PROFILE Change your home or office address, phone, fax or e-mail.

CONTACTS Member Directory TDA Contacts Components Personal Web Pages Dental Websites

Special Events

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Check out the TDA Express

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Travel

How to Obtain an NPI

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Internet Portal! Course Now Available!!

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FEATURES

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Recall - Firm Press Releases Dental Student Info

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DENTAL STUDENT INFO

Educations

TDA 2009

TDA Dental Assistant PAY DUES Pay 2008 dues online.

Resources

General Info

To go to a specific page on an affiliate website, simply mouseover the website name and a menu will appear. You can always get back to the homepage, by clicking on “Home” under each menu.

ARCHIVES Dr. John Findley Elected ADA President-elect New TDA Website!

In Memoriam

The DENPAC website (denpac.org) offers general information about DENPAC, legislative, leadership, and contact information, news articles and membership information. Users can also sign up as DENPAC club member online. The TDA Smiles website (tdasf.org / tdasmiles.org) includes program information on oral health education, Texas Mission of Mercy (TMOM), and Donated Dental Services (TXDDS). It also includes a calendar of upcoming events, history, and contact information. Users can also sign up for upcoming events and make contributions online. The Freedom-of-Choice Dental Plan website (freedom-of-choicedental.com / paiddental.com) offers detailed information on Direct Reimbursement and Paid Dental. The TDA Perks Program website (tdaperks.com / tdamemberbenefits.com) includes links to all TDA Member Benefits Endorsed Vendors, Board of Directors contact information, and additional helpful articles. The TEXAS Meeting website (texasmeeting.com) allows users to register for courses and housing for the TEXAS Meeting, as well as access general information, education, travel, special events, exhibits, and governance information. Contact: Stefanie Clegg (512) 443-3675 or stefanie@tda.org


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

Beginning with this July issue of the Journal, photographs from the photo contest held at the annual meeting of the Texas Dental Association will be published. One photograph will be printed on the cover of the July issue and other photographs will be printed in the pages of the Journal throughout the year. I have always found the displayed photos at the annual meeting to demonstrate the creativity and high photographic skills of our dental colleagues. The contest is judged by noted photographer Kevin Stillman who has more than 30 years experience as a professional photographer and is a graduate of the Art Institute of Pittsburg. He has served as aTexas Highways magazine photographer, worked as photographer for the Texas Department of Transportation for 20 years, and, in 2002, received the Texas Department of Transportation’s Lone Star Award for service to the Texas travel industry. The winners of this years contest are listed to the right. Congratulations to all involved.

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Best of Show

Dr. Roy Tiemeyer

Portrait: People & Animals

1st: Dr. Patrick E. Daniels 2nd: Dr. Patrick E. Daniels 3rd: Ms. Leanna R. Sims-Gowan Honorable Mention: Dr. Alex Gonzalez

Sports/Human Endeavor

1st: Dr. Patrick E. Daniels 2nd: Dr. Alex Gonzalez 3rd: Dr. C. Doug Foster Honorable Mention: Ms. Tessa Kolodny, RDH

Built Environment

1st: Dr. Steven M. Aycock 2nd: Ms. Leanna R. Sims-Gowan 3rd: Dr. Mark Peppard Honorable Mention: Dr. Edwin W. Roberts

Black & White/Abstract/Artistic

1st: Leanna R. Sims-Gowan 2nd: Dr. Steven M. Aycock 3rd: Dr. C. Doug Foster Honorable Mention: Dr. Mark Peppard

Natural Wonders

1st: Tessa Kolodny, RDH 2nd: Dr. Steven M. Aycock 3rd: Dr. Roy Tiemeyer Honorable Mention: Ms. Sarah Shoot Honorable Mention: Juan D. Villareal


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Texas Dental Association 140th Annual Session 2010 TEXAS Meeting Photo Contest Category: Sports/Human Endeavor Award: 2nd Place Photographer: Dr. Alex Gonzalez of El Paso Title: “Backstroke Frenzy” For information on entering your photo in the 2011 TEXAS Meeting Photo Contest, please visit texasmeeting.com.

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SOUTHERN DENTAL ASSOCIATES EMPLOYMENT OPPORTUNITIES

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Full or Part Time employment opportunities for experienced dentists and dental hygienists and for recent graduates. Visit our web site: www.southern-dental.com for more information. To schedule a confidential interview, contact: Dr. David Lewis - Southern Dental Associates P. O. Box 924049 • Houston, TX 77292 Telephone: (713) 681-7920 • Fax: (713) 263-0132 • Email: DRLSDA@AOL.COM Texas DenTal Journal H January 2009 H 23

TexasTexas Dental Journal l Journal www.tda.org l July 2010 Texas Dental l May 2009 Dental Journal l February

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Guest Editorial Wealth and Happiness Never Seem to Add Up Wayne Radwanski, D.D.S., President, Capital Area Dental Society (District 10), 2008-09 This article is reprinted with permission from the Capital Area Dental Society. It originally appeared in the April 2009 issue of the Star newsletter.

There’s a lot of evidence that we Americans are very much on a quest to be happier. Shortly before the current recession, an article in Financial Times titled “Why Happiness is Priceless” documented that Americans are both unhappier and richer than ever. This anxiety of affluence has prompted many sociological studies that document what we always knew — or thought we knew — that higher incomes do not translate automatically to increased happiness. In fact, something of the reverse seems to happen. The more we have, the unhappier we become. Now, the article is careful not to glamorize poverty. Rich people may be stressed and anxious, but not as much as the poor. I remember happiness in a three bedroom home with one bath; with closets deep enough for clothes, but no deeper. And this was with a family of six kids! I suspect many of you too can remember happiness in a simpler time — a simpler place. We have all paid a high price in stress, anxiety, family, and marital dysfunction for our affluence, and perhaps the most important task in front of us is to determine how it is to be maintained in the frantic, harried, and almost out-of-control work and lifestyle it has created without losing something precious about our humanity. Randy Pausch, the professor and author from Carnegie Mellon, who authored The Last Lecture and recently died of pancreatic cancer, said it best, “It’s not the things we do in life we regret, it’s the things we don’t do.” He goes on to say, “You will not find your passion in money because the more things and the more money you have, the more you will use that as a metric, and there will always be someone with more money and things.” If dentistry is our passion, then we will want to learn and grow more and more in its knowledge so we can serve others the very best we can. If you talk to those that have retired from the dental profession, they will most likely tell you, “those were the best years of my life.” Their wealth has been measured not by the dollars but by the love and service to those in need. Serve on, my fellow dental professionals. It’s where we will find real wealth and happiness.

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2010September Lone Star9 -Dental Conference 11 • Austin, Texas AT&T Executive Education Conference Center

Your Future

Space is limited in all courses so be sure to register today! Friday Course • September 10 • 8:00am - 4:00pm NEW ASPECTS OF DENTISTRY - 2010 Presented by Dr. Gordon Christensen Open to the entire dental team 7 hours lecture credit • AGD Code: 250

Topics will include: • • • •

This brand new, full-day program includes many of the new concepts in restorative dentistry compared to the long proven products and techniques. The morning session is a comparison of porcelain-fused-to metal restorations and the several competing types of all-ceramic crowns and fixed prostheses. The afternoon session is a multi-topic discussion and comparison of the many techniques and materials used in fixed prosthodontics.

Criteria for crowns vs. direct restorations in view of new superior direct restorative materials Building-up teeth rapidly and well The best posts and cores compared Air vs. electric handpieces for fixed prosthodontics

• • • •

Conventional and digital impressions. Which is best? The best cements for specific situations Many everyday dilemmas and solutions And much more!

Saturday Workshops • Stain & Glaze Made Easy Presented by Dr. Todd Ehrlich 8:00 a.m.- 12:00 p.m.

4 hours hands-on credit AGD Code: 610 & 780 Sponsored by Ivoclar Vivadent Inc.

September 11 How to Use Digital The Abused Mouth Imaging to Improve Your Presented by Case Acceptance Presented by Presented by Dr. Mike Malone 8:00 a.m. - 12:00 p.m.

4 hours hands-on credit AGD Code: 130 & 730 Sponsored by PracticeWorks / Kodak Dental Systems

Dr. Jerry Bouquot 8:00 a.m. - 12:00 p.m.

4 hours hands-on credit AGD Code: 730 & 750 Sponsored by the Jack T. Clark Foundation

First Dental Home Training Presented by Dr. Linda Altenhoff 9:00 a.m. - 11:00 a.m.

2 hours lecture credit AGD Code: 430 Provided by the Texas Department of State Health Services

2010 LSDC Events Thursday • September 9 TAGD Leadership Reception

All LSDC attendees are invited to the Leadership Reception on Thursday night where we celebrate the achievements of our local state components as well as local leaders who have demonstrated their commitment to dental excellence through education. TAGD will also announce its second New Dentist of the Year recipient at this event. Attendance is complimentary, guests are welcome, just RSVP with the TAGD office.

Friday • September 10

Texas Dentist of the Year Gala™

The 2010 Texas Dentist of the Year Gala™ celebrates dentists throughout the state who exhibit a commitment to continuing dental education, service to the community and activism in the dental profession. Nominees are selected by their colleagues from dental societies and local components around the state. Tickets are $95. This is a

formal, black tie event.

To register or for more information visit www.tagd.org or call the TAGD office at 512.244.0577 (toll-free 877.464.8243)

# 219328 1/1/06 - 12/31/10

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Current Development of Saliva/ Oral Fluid-based Diagnostics

Abstract

Chih-Ko Yeh, Ph.D.; Nicolaos J. Christodoulides, Ph.D.; Pierre N. Floriano, Ph.D.; Craig S. Miller, D.M.D., M.S.; Jeffrey L. Ebersole, Ph.D.; Shannon E. Weigum, Ph.D.; John McDevitt, Ph.D.; Spencer W. Redding, D.D.S., M.S.E.D.

Introduction Saliva, or oral fluid, has long been of interest as a substitute for blood and other body fluids for disease diagnosis and disease/drug monitoring because it is readily accessible, as it can be obtained non-invasively. However, saliva diagnostics are not widely used due to the lack of well-defined salivary biomarkers for specific diseases, appropriate technologies for low sample volume analysis, and social and medical professional acceptance (1, 2).

Yeh

Christodoulides

Ebersole

Weigum

Floriano

McDevitt

Miller

Redding

Dr. Yeh is a professor and geriatric/research dentist, Department of Dental Diagnostic Science, University of Texas Health Science Center at San Antonio; Geriatric Research, Education and Clinical Center (GRECC), Audie L. Murphy Division, South Texas Veterans Health Care System, San Antonio, TX. Dr. Christodoulides is a senior scientist, Department of Bioengineering, BioScience Research Collaborative. Dr. Floriano is a senior scientist, Department of Bioengineering, BioScience Research Collaborative; www.tastechip.com. Dr. Miller is a professor, Oral Medicine, University of Kentucky College of Dentistry, Lexington, KY; http://www. mc.uky.edu/microbiology/miller.asp. Dr. Ebersole is an Alvin L. Morris professor/director/associate dean for research, Center for Oral Health Research, University of Kentucky College of Dentistry, Lexington, KY. Dr. Weigum is a postdoctoral fellow, Department of Bioengineering, Rice University, BioScience Research Collaborative, Houston, TX. Dr. McDevitt is a Brown-Wiess professor, Departments of Bioengineering & Chemistry, Rice University BioScience Research Collaborative; http://www.tastechip.com. Dr. Redding is a professor and chair/Castella Dental Chair, Department of Dental Diagnostic Science, University of Texas Health Science Center at San Antonio, San Antonio, TX.

Saliva can be easily obtained in medical and non-medical settings, and contains numerous bio-molecules, including those typically found in serum for disease detection and monitoring. In the past two decades, the achievements of high-throughput approaches afforded by biotechnology and nanotechnology allow for disease-specific salivary biomarker discovery and establishment of rapid, multiplex, and miniaturized analytical assays. These developments have dramatically advanced saliva-based diagnostics. In this review, we discuss the current consensus on development of saliva/ oral fluid-based diagnostics and provide a summary of recent research advancements of the Texas-Kentucky Saliva Diagnostics Consortium. In the foreseeable future, current research on saliva based diagnostic methods could revolutionize health care.

Key words:

Point of care, multiplexed test, biomarkers, salivary diagnostic, lab-on-a-chip, AMI, cancer.

Address correspondence and reprint requests to Dr. Yeh, Geriatric Research, Education and Clinical Center (182), Audie L. Murphy Division, South Texas Veterans Health Care System, 7400 Merton Minter Boulevard, San Antonio, Texas 78229-4404; Phone: (210) 617-5300, ext. 16684; Fax: (210) 617-5312.

Tex Dent J;127(7):651-661.

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Saliva/Oral Fluid-based Diagnostics To fully realize the potential of saliva as a diagnostic fluid, the National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH) has recently invested in research efforts aimed at discovering and validating salivary biomarkers of disease, as well as in the development of dedicated technologies for their measurement. In the past few years, these efforts have fostered interdisciplinary research projects that allow clinicians, biologists, chemists, physicists, engineers, and commercialization partners to collaborate, investigate, discover, and translate the potential of saliva to diagnose systemic disorders, such as neoplastic, cardiovascular, metabolic, infectious, and neurological diseases. Based on the reported results of these initial efforts, it may be envisioned that in the foreseeable future, saliva-based diagnostic testing can become a component in routine medical practice in doctors’ offices and/or in the field for disease diagnosis, prevention, screening, and monitoring. Dental professionals who encounter saliva/oral fluid in their daily professional life are perceived as saliva experts in the medical field and can thus play an important role in the future of salivary diagnostics for dental and systemic diseases. This brief review provides a description of salivary physiology and provides an update on current advances in salivary biomarker discovery and validation derived from the combined efforts of the Texas/Kentucky Saliva Diagnostic Consortium including the University of Texas Health Science Center at San Antonio, the University of Kentucky, and Rice University. Further, herein described is the development and application of a powerful point of care nano-bio-chip (NBC) technology that hosts saliva-based tests for the measurement of biomarkers for local and systemic diseases.

Saliva/oral fluid physiology Oral fluid is usually referred to as whole saliva that includes secretions from salivary glands, upper gastrointestinal and respiratory tracks, and the gingival sulcus (crevicular fluid). Human salivary glands produce about 500-1000 mL of saliva per day by three distinct major salivary gland

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pairs, i.e., parotid, submandibular and sublingual glands, and numerous minor salivary glands in oral palatal, buccal, and labial mucosa. Glandular, parotid, and submandibular/sublingual saliva can be collected non-invasively. Microscopically, a salivary gland secretory unit consists of acina and a ductal system. There are two types of acinar cells, i.e., serous and mucous, depending on protein produced. The ductal system consists of intercalated, striated, and excretory ducts. Salivary secretion is tightly controlled by the autonomic nervous system through a two stage secretion — primary saliva produced by acinar cells, followed by ductal system modification — resulting in a hypotonic solution when it reaches the mouth. Saliva is known to play essential roles in lubrication, digestion, and host defense since it contains electrolytes (e.g., Na+, K+, Cl-, Ca2+, HCO3-, PO43-), digestive enzymes (e.g., amylase, lipases, proteases and DNAse/RNAse, etc.), antimicrobial proteins (e.g., lysozyme, IgA, lactoferin, defensin, peroxidase, histatins, etc.), and other major proteins (e.g., mucins, proline-rich proteins, statherin, etc.). While salivary gland cells synthesize and secrete many salivary components, serum contents such as cytokines, antibodies, hormones, and drugs can also be transferred to saliva by passing through capillary walls in salivary gland tissues. These molecules travel though the basement membrane and salivary cell barriers to enter saliva involving possible mechanisms of passive transcellular diffusion, paracellular ultrafiltration, energy dependent active transport, and/ or pinocytosis (3-5). The relationship of salivary molecule concentration to blood (or saliva/plasma ratio; S/P) is influenced by serum/saliva pH, molecular pKa, molecular weight, lipophilicity, and protein binding. Serum components can also be transported to whole saliva via gingival fluids or mucosal cells. Additionally, normal human whole saliva contains numerous normal and pathogenic microorganisms (e.g., bacteria, fungi, or viruses) and their metabolites, as well as multiple cell types shed or migrated from oral mucosa or gingival crevices. Therefore, saliva provides a large number of analytes that are comparable to blood for disease diagnosis and monitoring (Table 1).


Saliva/oral fluid as diagnostic fluid Saliva provides biological materials, e.g., mammalian and microorganism proteins, DNAs, and cells for potential medical and law enforcement use. Dentists and oral biologists have utilized the culture counts of Streptococcus mutans and lactobacillus from saliva to predict caries risk (6). It is well known that saliva samples have been used for forensic DNA testing. The development of salivary/ oral fluid-based diagnostics has focused on testing hormones, drugs, and antibodies with some success in the past few decades. For example, commercialized saliva based testing systems have been used for detection of HIV antibodies with high specificity and sensitivity similar to blood testing (7). Antibodies to hepatitis B, C, and several other infectious pathogens (e.g., rubeola and dengue) can also be detected in saliva (8). Further direct detection of local or systemic infectious pathogens in saliva such as bacteria, viruses, and fungi is also possible by using salivary culture and/or polymerase chain reaction (PCR). The salivary/oral fluid based home testing system of estradiol has been used to predict premature birth. Changes in salivary levels of estrogen, testosterone, progesterone, and electrolytes have been used for monitoring or assessing

Table 1. Biomarker Discovery and Strategies for Saliva/Oral Fluid Diagnostics Potential Biomarkers

Strategies of Saliva Diagnostics

Electrolytes: Na+, K++, HCO3-, Ca2+, P043-

Multiplex: Multiple samples Multiple analyses

Proteins (Proteome) Salivary proteins Salivary serum components Transcriptome mRNA and miRNA profiles DNA: mammalian cells (epithelial and inflammatory cells and microorganisms (e.g., bacteria, fungi, viruses)

High sensitivity and specificity Miniaturization: Portable Nanotechnologies: lab-on-a- chip (LOC) Automated and self-powered Point of care (POC)

female reproductive cycles and overall health (3, 4). It is also well accepted to assess a subject’s stress level by measuring salivary cortisol level in psychological studies (4, 9). The salivary steroid hormone levels are preferred by many investigators because hormones in saliva are in free form (active form) in contrast to in serum where most hormones are protein bound which complicates the estimation of true activity. Saliva has been widely studied as a medium for pharmacokinetic and therapeutic drug monitoring (2, 3). The usefulness of saliva for drug monitoring is dependent on the saliva/plasma (S/P) ratio that has already been established for numerous drugs, a list which is continually expanding. In recent years, there has been vast interest from law enforcement agencies to develop oral fluid based point of detection methods for illegal drugs and/or legal intoxication limits, resulting in an international cooperative study for roadside testing (e.g., European Commission on Roadside testing assessment (Rosita)) (3, 10, 11). In this study, a large number of recreational and illicit drugs (e.g., amphetamine, opium, alcohol, lysergic acid diethylamide, marijuana, and phencyclidine, etc.) and their metabolites have been evaluated in saliva samples in comparison to their serum counterparts. In addition, the various commercial oral testing prototypes for drug detection will be evaluated with laboratory validation. Salivary cotinine and thiocyanate contents are also commonly used for documenting tobacco use and second-hand smoke exposure. A summary of current and potential saliva/oral fluid diagnostics is listed in Table 2. The future application of saliva/oral fluid diagnostics for medical use, epidemiological studies, and law enforcement is dependent on the availability of reliable point-of-care systems.

Current challenges and advances in salivary/ oral fluid diagnostics The challenge for successful use of saliva for medical diagnostics resides in maximizing the advantages and overcoming the disadvantages of using saliva/oral fluids. Compared to serum samples, the volume of Texas Dental Journal l www.tda.org l July 2010

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Saliva/Oral Fluid-based Diagnostics Table 2.

saliva that can be obtained is relatively limited and disease-specific salivary biomarkers are still largely unknown. However, saliva can be obtained by patients themselves or by personnel with little medical training. Furthermore, saliva collection is associated with less stress and discomfort to the patient/donor. Therefore, saliva-based diagnostics can be applied in medically disadvantaged areas or non-conventional medical settings, such as in developing or underdeveloped countries, remote rural areas, patients’ homes, as well as in the dentist’s office or neighborhood pharmacy. Recent studies have demonstrated improvement of sensitivity and specificity using a combination of multiple biomarkers instead of a single biomarker in disease detection (12, 13). Therefore, a successful saliva/oral based diagnostic should provide accurate, non-invasive, diseasespecific, multi-analyte and rapid outcome measurements, as well as be portable and cost-effective. Current efforts emphasize the discovery and validation of disease biomarkers in saliva, the development of multiplexed nanotechnologies (lab-on-a-chip) for point-of-care, and their ultimate translation into the real world through an industrial partner (Table 1).

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Current and Potential Use of Strategies for Saliva/Oral Fluid Diagnostics Current existing assays with active Potential use in near future development of new detection systems Pharmacological monitoring (11) Therapeutic drugs Law enforcement applications Drug intoxication Illicit drugs Forensics Smoking exposure Cotinine and thiocyanate Steroid hormones (4) Cortisol, estrogen, testosterone, and progesterone Infectious diseases (35) Antibody testing: HIV, HCV and HBV Antigen detection: Bacterial, Viral, Fungal DNA/RNA/Protein Microorganism recovery: Bacterial, Viral, Fungal cultures

Autoimmune diseases (22, 23) Autoantibodies: Sjögren’s syndrome Allergic markers Cardiovascular diseases (13) Acute myocardial infarction Cardiac risk Cancer screening and diagnosis (19, 36-38) Oral cancer Breast cancer Cancer-specific markers Periodontal diseases (20, 39)

Development of analytical technologies in the post genomic era has allowed for large scale identification of proteins/peptides (proteome) and ribonucleic acids (RNA; transcriptome), and their functions/structures in cells and fluids. The high throughput proteomic studies have catalogued at least 1,166 proteins in the major salivary gland secretions, of which 914 are recovered from parotid and 917 from submandibular/ sublingual ductal saliva, with 57 percent of these proteins present in both glandular saliva (14). The proteome of human minor salivary gland secretion showed 56 proteins, 12 of these proteins have never been indentified in the glandular saliva (15). Analysis of human whole saliva and plasma has identified a total of 1,939 proteins in whole saliva, with 740 proteins in glandular saliva proteomes and 597 saliva proteins in plasma (16). More surprisingly, the salivary transcriptome (RNAs) has been discovered using microarray profiling in recent years. It is estimated that approximately 3,000 messenger RNAs (mRNAs) have been identified in cell-free whole saliva. Most recently, the presence of microRNA (miRNA; -50) was also discovered in whole saliva. Unlike mRNA, miRNA consists of 18-24 nucleotides transcribed from non-protein coding genes and regulates protein translation through an RNA-induced silencing complex (RIST) (17). These advances have provided a large number of salivary molecular targets, e.g., proteins and RNAs, for disease biomarker discovery. Several investigators have already attempted to use high throughput technologies and current salivary proteomic and transcriptomic knowledge for biomarker dis-

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covery in the areas of oral cancer, breast cancer, periodontal diseases, cardiovascular disease, and Sjögren’s syndrome (13, 17–23). In the past few years, multiplex biomarker detection systems have emerged through remarkable progress in the development of lab-on-a-chip (LOC) and point-of-care (POC) technologies (24). The goal of these efforts is to build automated, miniaturized, and multiplexed platforms for rapid assays and readout. In general, the principles of conventional enzyme-liked immunosorbent assay (ELISA) and/or nucleic acid hybridization are applied often with either electrochemical sensors or a microbead reactor (12, 13, 25). The electrochemical approach uses gold electrode arrays (multiplex chips) in which one set of electrodes (i.e., working, counter, and reference electrodes) is used for one analyte measurement applied with the cyclic square wave electrical field to facilitate chemical reaction, followed by amperometric readout (12). The UCLA School of Dentistry “UCLA Collaborative Oral Fluid Diagnostic

Research Center” is the leading institute for this nano/micro-electrical-mechanical development. Alternatively, the microbead reactor system developed by the Texas-Kentucky Saliva Diagnostic Consortium consists of porous bead sensors consisting of a nano-net of agarose fibers serving as a chemical reaction matrix sequestering and concentrating analytes. The beads are placed in a microchip holder with each bead serving as a 3-dimensional reactor. Multiple beads can be placed in the holder with modulation of their analyte specificity through the capturing antibody they are conjugated to, providing a multi-analyte testing platform. The reaction reagents are delivered through a self-contained microfluidic infrastructure and the measurement is reported by nano-particle fluorescent particles or dyes that are conjugated to detecting antibodies. This approach results in increased signal to noise ratios and amplification several orders above conventional assays (24) (Figure 1).

Figure 1. Microbead-based reactor systems: Agarose microbeads that serve as single enzyme-linked immunosorbent assay (ELISA) reactor sensors (a) are arrayed in microchips (b) assembled into a disposable microfludic cassette that can be inserted into an analyzer (d) for automated assay execution and processing of image data acquired within this optical sensor (Modified from Jokerst et al. Nanomedicine, 2010 (24)). Texas Dental Journal l www.tda.org l July 2010

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Saliva/Oral Fluid-based Diagnostics The Texas/Kentucky Saliva Diagnostics Consortium is in the forefront of developing 3-D bead saliva/oral fluid diagnostics for cardiovascular, cancer, and periodontal diseases (13, 26, 27). As compared to other systems, this approach is cost-effective and more flexible than any other LOC system reported in the literature. For example, the bead reactor can be replaced with a thin-polymeric membrane for analyzing cell isolation/trapping from saliva or serum or oral brush biopsy samples, e.g., oral cancer cell studies. Current efforts to develop a saliva-based nanobiochip test for acute myocardial infarction (AMI) at the-point-of-care, particularly in the emergency settings, and for cytological diagnosis of oral cancers are briefly described below.

Oral fluid-based lab-on-a-chip testing for detection of acute myocardial infraction (AMI) in pre-hospital settings Cardiovascular disease remains the leading cause of death in developed countries, including the United States. Coronary artery disease (CAD), a major component of cardiovascular diseases, caused one of every five deaths in the United States in 2004, while CAD mortality was at 451,326. In 2010, an estimated 785,000 Americans will have a new coronary attack, and about 470,000 will have a recurrent attack. It is estimated that an additional 195,000 silent first myocardial infarctions occur each year. Every 26 seconds, an American will have a coronary event, and about every minute someone will die from it (28). The survival of AMI is dependent on how soon intervention can be initiated. Early diagnosis and early intervention is the key for a good patient prognosis. Currently, electrocardiogram (EKG or ECG) is standard equipment in the emergency medical services (EMS) ambulance setting and is used as a diagnostic standard for emergency triage of patients with chest pain and/or unconsciousness. A typical EKG abnormality for an AMI is a ST segment elevation (STEMI). Unfortunately,

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EKG alone only identifies ~35 percent of all AMI cases admitted to the emergency department (ED) and misses the remaining 65 percent (NSTEMI) that do not exhibit the characteristic EKG changes. The triage of potential AMI cases in the ED depends on supplemental blood testing that often includes cardiac troponins T and I (cTnT, cTnI), creatine kinases-MB (CK-MB), total CK and myoglobin (MYO) (13). However, these tests are, for the most part, limited to the clinical laboratory setting and the few that have been developed for point of care testing lack the analytical and clinical sensitivity and specificity to efficiently diagnose AMI (29). Furthermore, the invasive nature of blood testing and the absence of a sensitive enough test on a point of care instrument that could perform such a test preclude use of a blood test in an ambulance setting. There is indeed a need to have a non-invasive test with the required analytical and clinical performance that could be used in an ambulance setting to minimize the time from diagnosis to treatment of AMI patients. Saliva presents itself as an ideal fluid in this situation (Figure 2). To achieve this goal, our collaborative research group has first evaluated the potential use of AMI biomarkers in saliva. Unstimulated whole saliva was collected within 48 hours from more than 80 patients with a definitive diagnosis of AMI and from more than 80 healthy controls. Samples were assayed for 21 cardiac related proteins using conventional methodologies, such as LUMINEX, ELISA and Beckman Access instrumentation. Data gathered demonstrated cardiac biomarkers/proteins such as C-reactive protein (CRP), myeloperoxidase (MPO), interleukins, matrix metallo-perteinase-9 (MMP-9), and cellular adhesion molecule-1 (sICAM-1), can be detected in saliva samples but, most importantly, demonstrated a capacity to differentiate healthy controls from AMI patients. Strikingly, the logistic regression and receiver operating characteristics (ROC) analysis shows that AMI diagnosis was greatly improved with combination of EKG and the AMI proteins in saliva (13). For example one model has shown that the area under the ROC curve (AUC) was improved from 0.75 to 0.94 if the EKG readout was combined with salivary markers CRP and MPO 13 (Figure 2).


In parallel to discovering salivary AMI biomarkers, the critical steps for salivary marker measurement using NBC technology include ambulance sample collection, temperature, humidity, reagent stability, mechanical disturbance of the instrument, compromised light source, and sample contamination are being developed and standardized. Here, the NBC-based sensor system is in development as a portable, modular device dedicated to saliva-based diagnosis of AMI (Figure 1) (24). In Figure 1, an example of a fluorescence micrograph of a LOC multiplex assay for salivary CRP, IL-1ß, MYO, and MPO in healthy control, NSTEMI, and STEMI patients is shown (13). The results demonstrate the increased expression of AMI biomarkers in saliva from NSTEMI and STEMI cardiac subjects as compared to a healthy control. This promising evidence suggests that saliva-based tests using the NBC system could provide a more convenient rapid screening method for initial and subsequent cardiac events in pre-hospital stage AMI patients.

Exfoliative cytology based on nano-bio-chip sensor platform for oral cancer detection Oral cancer is a global health problem afflicting more than 300,000 people worldwide each year. In the United States, greater than 35,000 new cases and nearly 7,600 deaths were estimated in 2009 (30). Despite surgical and therapeutic advances in the treatment of oral cancer, the 5-year survival rate (approximately 50 percent remains among the lowest for all major cancers. At the present time, early diagnosis and intervention is the key for a better prognosis underscoring the value of advanced screening and diagnostic techniques for oral cancer and, more importantly, pre-cancerous lesions. As compared to the conventional surgical biopsy procedure, an approach that is rapid and less invasive is desirable for early detection and screening. Recently, non-invasive exfoliative cytology using OralCDx® Brush Test (OralScan Laboratories, Suffern, NY) has been widely promoted for oral cancer screening. This technique is based on quantitative cytomorphometry and DNA aneuploidy with computer-assisted analysis (31). However, the limited specificity of current cytology-based analysis is still a major hindrance

for early oral cancer detection and intervention (32, 33). Since exfoliative cytology also gathers cellular DNA, RNA, and protein biomarkers, new diagnostic techniques targeting early tumor biomarkers and molecular transformation could enhance the role and utility of oral cytology in clinical diagnostics. Addressing this clinical need, research groups at Rice and the University of Texas Health Science Centers at San Antonio and Houston have adapted the bead-based NBC sensor system to establish a platform for whole cell analysis of tumor biomarkers in oral exfoliative cytological specimens (34). The cellular-NBC sensor replaces the microbead array, found in the saliva-based NBC design, with a porous membrane that functions as a micro-sieve to capture and screen cells from a cytology suspension (Figure 3). Once captured, “on membrane” immunofluorescent assays reveal the presence and isotype of interrogated cells via automated microscopic imaging and analysis. This technique and its potential in oral diagnostics were recently described in a pilot study examining both molecular and morphological biomarkers associated with oral dysplasia and malignancy (34). Here, the oral epithelial cells (<10μm) were captured on a membrane filter (0.4μm pore size) followed by immunofluorescent labeling for the well-known epidermal growth factor receptor (EGFR) biomarker. Concurrently, the cytoplasm and nuclei were stained with fluorescent dyes Phalloidin and DAPI, respectively, for cytomorphometric measurements (Figure 3). The nuclear area, nuclear diameter, N/C ratio, and EGFR expression were found to be significantly altered in malignant and dysplastic oral lesions as compared to normal control epithelial cells. Logistic regression and ROC curve analysis further identified the morphological features as the best predictors of disease individually, AUC ≤ 0.93 (97-100 percent sensitivity and 86 percent specificity), while a combination of morphometric and EGFR biomarker expression further enhanced discrimination power between cancerous/precancerous and healthy conditions to an AUC 0.94 (97 percent sensitivity and 93 percent specificity; Figure 3). These results suggest that the combined cytomorphometry and EGFR panel likely holds the greatest potential for cancer detection and diagnosis. Yet, the true diagnostic need lies not in the identification of oral cancer but in the identification of dysplastic, premalignant lesions. Texas Dental Journal l www.tda.org l July 2010

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Figure 2 Saliva AMI testing in ambulance: (a) 12 lead EKG used by paramedics to transmit initial findings to emergency room physicians (left). The portable saliva-based diagnostics NBC platform can complement EKG for the identification of AMI cases. (b) Logistic regression and ROC analysis using serum and salivary biomarkers in conjunction with EKG exhibited improvement of diagnosis of AMI. The EKG and AMI biomarkers of 42 healthy controls, 46 AMI (23 NSTEMI and 23 STEMI) are measured and compared. In serum, the ROC curve was improved from 0.81 to 0.92 in triage biomarkers (cTnI, myoglobin and CK-MB) were used as diagnostic indexes (left). However, the combined use of salivary CRP and MPO in conjunction with EKG (right), produced an excellent ROC 0.94 (i.e., >90 percent specificity and sensitivity of AMI diagnosis). (c) Multiplex lab-on-a-chip (LOC) for AMI biomarker antigens screening. Examples of fluorescence micrographs of a LOC multiplex assay for CRP, IL-1Ă&#x;, MYO and MPO are shown for non-AMI control, (d) NSTEMI and (e) STEMI patients. NEG, negative; CAL, calibrator (Modified from Floriano et al. Clin Chem, 2009 40).

An 850-patient clinical study targeting oral dysplasia using an expanded biomarker panel is currently underway and aims to further validate the clinical utility of the NBC system for early detection of high-risk premalignant oral lesions. With continued advances in cancer biomarker discovery and sensor technology, rapid and POC screening for cancer is likely achievable.

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Conclusion Saliva and oral fluids contain multiple biomarker materials that can be readily obtained in conventional and non-conventional medical or medical laboratory settings. With current advancements in the development of nano-bio-technology, saliva is now closer to meet its full capability to be used as a diagnostic fluid at the point of care. While oral fluid/saliva-based diagnosis of AMI is


Figure 3. Application of the cell-based NBC sensor system for cytological assessment of healthy and cancerous oral mucosa. (a) Exfoliative cytology specimens were obtained using the OralCDxÂŽ cytobrush (http://www. sopreventable.com/ How2Use.htm); (b) Next, cells were captured on the membrane filter (panel i) followed by EGFR immunolabeling (panel ii, green) and staining of the cell cytoplasm (red) and nuclei (blue) for morphometric measurement; (c) Representative images of healthy epithelia (panel i) and a cancerous lesion (panel ii) examined using the NBC sensor illustrate the increase in EGFR expression and nuclear-to-cytoplasm ratio associated with disease progression; and (d) Logistic regression and ROC analysis of individual and combined biomarkers (adapted from Weigum et al. Cancer Detect. Prevent, 2010 34).

demonstrated, use of a saliva-based test is not intended to replace current serum based diagnosis, but simply to complement it. Current major challenges are discovery of disease specific markers, determinations of specificity and sensitivity of the specific tests, and standardization of saliva collection methods and holding solutions. Once these challenges are met, saliva-based diagnostics can be validated within the context of large clinical studies en route to final approval by the Food and Drug Administration (FDA) for ultimate clinical/field application. While still several years away from achieving this goal, practicing dentists, as a part of the health care team, should be kept updated about developments in the field of saliva/oral fluid diagnostics for oral and systemic diseases.

Acknowledgements This review was supported by NIDCR/NIH U01 DE017793 grant which funded the program entitled “Development of a Lab-on-a-chip System for Saliva-Based Diagnostics.� References 1. Tabak LA. A revolution in biomedical assessment: the development of salivary diagnostics. J Dent Educ 2001; 65(12):1335-1339. 2. Mandel ID. The diagnostic uses of saliva. J Oral Pathol Med 1990; 19(3):119-125. 3. Choo RE, Huestis MA. Oral fluid as a diagnostic tool. Clin Chem Lab Med 2004; 42(11):1273-1287. 4. Groschl M. Current status of salivary hormone analysis. Clin Chem 2008; 54(11):1759-1769. Texas Dental Journal l www.tda.org l July 2010

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tein detection: determinations of cancer biomarkers in serum and saliva using quantum dot bioconjugate labels. Biosens Bioelectron 2009; 24(12):3622-3629. 27. Christodoulides N, Floriano PN, Miller CS et al. Lab-on-a-chip methods for point-of-care measurements of salivary biomarkers of periodontitis. Ann N Y Acad Sci 2007; 1098:411-428. 28. Lloyd-Jones D, Adams RJ, Brown TM et al. Heart Disease and Stroke Statistics--2010 Update. A Report From the American Heart Association. Circulation 2009. 29. Fermann GJ, Suyama J. Point of care testing in the emergency department. J Emerg Med 2002; 22(4):393-404. 30. American Cancer Society. Cancer Facts and Figures 2009. 2009. American Cancer Society. 31. Sciubba JJ. Improving detection of precancerous and cancerous oral lesions. Computer-assisted analysis of the oral brush biopsy. U.S. Collaborative OralCDx Study Group. J Am Dent Assoc 1999; 130(10):1445-1457. 32. Poate TW, Buchanan JA, Hodgson TA et al. An audit of the efficacy of the oral brush biopsy technique in a specialist Oral Medicine unit. Oral Oncol 2004; 40(8):829-834. 33. Scheifele C, SchmidtWesthausen AM, Dietrich T, Reichart PA. The sensitivity and specificity of the OralCDx technique: evaluation of 103 cases. Oral Oncol 2004; 40(8):824-828. 34. Weigum SE, Floriano PN, Redding SW et al. Nano-

bio-chip sensor platform for examination of oral exfoliative cytology. Cancer Detect Prevent 2010; 3(4):518-528. 35. Malamud D, Abrams WR, Bau H et al. Oral-based techniques for the diagnosis of infectious diseases. J Calif Dent Assoc 2006; 34(4):297-301. 36. Hu S, Arellano M, Boontheung P et al. Salivary proteomics for oral cancer biomarker discovery. Clin Cancer Res 2008; 14(19):6246-6252. 37. Weigum SE, Floriano PN, Christodoulides N, McDevitt JT. Cell-based sensor for analysis of EGFR biomarker expression in oral cancer. Lab Chip 2007; 7(8):9951003. 38. Jokerst JV, Raamanathan A, Christodoulides N et al.

Nano-bio-chips for high performance multiplexed protein detection: determinations of cancer biomarkers in serum and saliva using quantum dot bioconjugate labels. Biosens Bioelectron 2009; 24(12):36223629. 39. Christodoulides N, Floriano PN, Miller CS et al. Lab-on-a-chip methods for point-of-care measurements of salivary biomarkers of periodontitis. Ann N Y Acad Sci 2007; 1098:411-428. 40. Floriano PN, Christodoulides N, Miller CS et al. Use of saliva-based nanobiochip tests for acute myocardial infarction at the point of care: a feasibility study. Clin Chem 2009; 55(8):1530-1538.

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Weekly Monitoring of the Water Fluoride Content in a Fluoridated Metropolitan City — Results After 1 Year Ryan L. Quock, D.D.S., Jarvis T. Chan, D.D.S., Ph.D.

Introduction The fluoridation of community drinking water raises many questions and continues to be a source of controversy (1, 2). In the United States, the Centers for Disease Control and Prevention (CDC) is a strong proponent of drinking water fluoridation for the prevention of dental caries (3). Furthermore, it has been a stated goal of the United States Department of Health and Human Services that by the year 2010, 75 percent of the United States population would have access to fluoridated drinking water, with fluoride concentrations falling in the range of 0.7-1.2 parts per million (ppm) (4, 5).

Abstract It continues to be the goal of the United States Department of Health and Human Services to fluoridate community water supplies to prevent dental caries. In Houston, Texas, where community water is assumed to contain in the range of 0.7-1.2 ppm fluoride, water samples were taken from the same source on approximately a weekly basis over a period of 52 weeks. The purpose of this study was to determine the extent of fluctuation of water fluoride concentration in these samples. Water fluoride analysis with an ion-specific electrode and millivolt meter of the data set showed a range of 0.33 to 1.00 ppm fluoride, with a mean of 0.70 ppm and a standard deviation of 0.15. This wide range of fluoride concentrations may create a risk for fluorosis in pediatric patients who are prescribed dietary fluoride supplements.

KEY WORDS: Quock Chan Dr. Quock is an assistant professor, Department of Restorative Dentistry & Biomaterials, University of Texas at Houston Dental Branch Dr. Chan is a professor, Department of Integrative Biology & Pharmacology, University of Texas at Houston Medical School; and adjunct professor, Department of Pediatric Dentistry, University of Texas at Houston Dental Branch Address correspondence and reprint requests to Dr. Ryan Quock, Department of Restorative Dentistry & Biomaterials, University of Texas Dental Branch, 6516 M. D. Anderson Blvd., Ste. 493, Houston, TX 77030; Phone: (713) 500-4276; Fax: (713) 500-4108; E-mail: Ryan.Quock@uth.tmc.edu.

Community drinking water, fluoride supplements, fluorosis, tap water Tex Dent J;127(7):665-671.

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Following this trend at the federal level, states like Louisiana and cities like San Diego have recently taken action to fluoridate their respective public water supplies (6, 7). A primary health risk of consumption of fluoride is dental fluorosis. Dental fluorosis is a disruption of enamel formation whose manifestation can range from white spots or streaks to brown pits and stains (8, 9). Fluorosis related to the consumption of drinking water with high levels of fluoride has been well documented in the literature (10, 11, 12). Recently, a study of drinking water samples collected over a 10-year period from various zip codes in the Houston metropolitan found a wide variance in water fluoride concentration, even within the same zip code area (13). Considering the proposed dental caries preventive purpose of water fluoridation, as well as the evident risk for fluorosis, it would be beneficial to further examine the relative consistency of fluoride concentration in community drinking water sources. The purpose of this study was to look for trends in the fluoride content of tap water from a common source in Houston over a 1-year period of time, with the hypothesis that the study’s findings would be comparable to those reported by the Houston’s Department of Public Works & Engineering for the calendar year 2008 — average water fluoride concentrations of 0.54 ppm with a maximum concentration of 0.74 ppm (14).

Materials and Methods During the period between July 17, 2008, and July 7, 2009, a 10 mL sample of tap water was taken from the same source in U.S. postal zip code 77030 at a frequency of once per week. The tap was allowed to run for 5 minutes before each water sample was collected in a Falcon 15 mL polystyrene conical tube (Becton Dickinson, Franklin Lakes, NJ). After each sample was collected, the conical collection tube was sealed with the accompanying cap and stored at room temperature. Upon collection of the entire set of samples, any water that had evaporated over the course of the year was replaced with deionized and distilled water. An Orion fluoride-specific electrode and millivolt meter (Orion model 701A and 720A+, Thermo Orion, Beverly, MA) was used for water fluoride analysis. Water samples were thoroughly mixed in a 1:1 ratio with total ionic strength adjustment buffer (TISAB) II, in accordance with manufacturer instructions prior to measurement for fluo-

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ride. After fluoride concentrations for all samples were determined, the following analyses of the data set were performed: mean fluoride concentration, standard deviation, 95 percent confidence interval, and median fluoride concentration.

Results Fifty water samples were analyzed for fluoride concentration in this study. Fluoride concentrations ranged from 0.33 to 1.00 ppm for the data set (Table). Mean fluoride concentration for 50 water samples was 0.70 ppm (95 percent CI = 0.41 to 0.98 ppm). Median fluoride concentration for the data set was 0.68 ppm.

Tap Water Fluoride Measurements (Samples Collected July 17, 2008 - July 7, 2009) Week 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

Date of Collection 7/17/08 7/24/08 7/31/08 8/7/08 8/14/08 8/21/08 8/28/08 9/4/08 9/11/08 9/18/08 9/25/08 10/2/08 10/9/08 10/16/08 10/23/08 10/28/08 11/6/08 11/13/08 11/20/08 11/26/08 12/4/08 12/11/08 12/18/08 12/23/08 12/31/08 1/7/09

Measured ppm 0.84 0.85 0.93 0.94 0.93 0.93 0.87 0.87 0.86 * 0.39 0.48 0.70 0.86 0.81 0.80 0.61 0.56 0.61 0.58 0.73 0.75 0.72 0.73 * 0.68

Week 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

Date of Collection 1/13/09 1/22/09 1/28/09 2/4/09 2/11/09 2/18/09 2/25/09 3/4/09 3/11/09 3/19/09 3/25/09 4/1/09 4/8/09 4/15/09 4/22/09 4/29/09 5/6/09 5/13/09 5/20/09 5/28/09 6/4/09 6/10/09 6/18/09 6/25/09 7/2/09 7/7/09

Measured ppm 0.64 0.70 0.33 0.53 1.00 0.45 0.85 0.76 0.56 0.60 0.64 0.62 0.56 0.60 0.66 0.65 0.52 0.61 0.63 0.73 0.62 0.68 0.71 0.68 0.67 0.68

*Sample not collected. Mean = 0.70, SD = 0.15

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Water Fluoride Content

Discussion The United States Environmental Protection Agency (EPA) has designated the range of 0.7-1.2 ppm as the optimal level of fluoride concentration in drinking water for the prevention of dental caries (5). Additionally, the EPA has set 2.0 ppm as a suggested maximum water fluoride concentration, and 4.0 ppm is the enforceable maximum water fluoride concentration (15,16). Twenty-seven out of 50 samples (54 percent) in this study had water fluoride concentrations lower than 0.7 ppm, and no samples had fluoride concentrations greater than 1.2 ppm. However, the mean water fluoride concentration for this study approximated the U.S. government recommended concentration for the Houston area (0.70 ppm), with a maximum recorded fluoride concentration of 1.0 ppm (17). These figures are higher than those reported by the City of Houston for the calendar year 2008 (14).

Figure 1.

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Although risk for fluorosis may be minimal with regard to consumption of tap water measured in this study, the range of fluoride concentrations does exhibit regular fluctuation in water fluoride concentration (Figure 1). Fluoride concentrations varied from the target concentration of 0.70 ppm by as much as 52.9 percent on the lower end (0.33 ppm) and by as much as 42.9 percent (1.00 ppm) on the upper end of the range. Furthermore, four out of 50 samples deviated from the target concentration of 0.70 ppm by at least 30 percent on the lower end (≤0.49 ppm), and five out 50 samples deviated from the target concentration of 0.70 ppm by at least 30 percent at the upper end (≥0.91 ppm). Thus, 18 percent of the samples in the study deviated from the target fluoride concentrations by at least ± 30 percent. Even though the mean fluoride concentration for

Chart of Tap Water Fluoride Measurements (Samples Collected July 17, 2008 - July 7, 2009)

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samples in this study approximated the target concentration as established by the U.S Department of Health and Human Resources, it might be desirable to reduce the occurrence and magnitude of fluctuation from this target fluoride concentration. The wide range of fluoride concentrations observed in this study may also indicate a possible fluoride over-consumption risk. Ten out of the 50 water samples from this study had fluoride concentrations under 0.60 ppm. The American Dental Association, the American Academy of Pediatric Dentistry, and the American Academy of Pediatrics recommend dietary fluoride supplements for pediatric patients, depending on patient age and fluoride concentration of the patient’s community drinking water (Figure 2). The major water fluoride concentration thresholds for these recommendations are 0.3 and 0.6 ppm; if the patient’s community drinking water is above 0.6 ppm fluoride, then no

Figure 2.

The wide range of fluoride concentrations observed in this study may also indicate a possible fluoride overconsumption risk. supplementation is prescribed (18, 19, 20). Patient’s drinking water fluoride concentration is determined by requesting a tap water sample from the patient and then sending it to a laboratory for analysis. If tap water fluoride concentration remained the same over time, then this might be an acceptable way to determine whether dietary fluoride supplementation is warranted, according

to the guidelines. However, the data from this study suggests that if the patient’s water sample is taken on a day when the fluoride concentration happens to be under 0.6 ppm, fluoride supplementation may be unnecessarily prescribed. The mean water fluoride concentration for the entire data set was 0.70 ppm, suggesting that a patient drinking water from this source may derive, on av-

Dietary Fluoride Supplement Schedule (18, 19, 20)

Fluoride ion level in drinking water (ppm)* Age

less than 0.3 ppm

0.3 - 0.6 ppm

greater than 0.6 ppm

None

None

None

0.25 mg/day**

None

None

3 - 6 years

0.50 mg/day

0.25 mg/day

None

6 - 16 years

1.0 mg/day

0.50 mg/day

None

Birth - 6 months 6 months - 3 years

* 1 part per million (ppm) = 1 milligram/liter (mg/L) ** 2.2 mg sodium fluoride contains 1 mg fluoride ion. Approved by the American Dental Association, the American Academy of Pediatrics, and the American Academy of Pediatric Dentistry.

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Water Fluoride Content erage, an acceptable amount of fluoride from the tap water alone. At the same time, 20 percent of the collected samples had fluoride concentrations below 0.60 ppm, which could potentially result in an unnecessary prescription of additional fluoride, increasing the patient’s risk for fluorosis, among other effects. The authors recommend that, in order to minimize risk for fluorosis, practitioners following these fluoride supplementation guidelines analyze multiple water samples taken on different dates before making any fluoride supplementation decisions. Indeed, the supplementation of dietary fluoride for pediatric patients is a practice that may need to be examined more critically (21). It is the authors’ intent to present these findings to the local water authority, especially with regard to possible discrepancies between data collected by this study and by the city. Hopefully appropriate improvements could be identified to stabilize the fluoride level of the drinking water. To conclude, the water samples taken on a weekly basis for approximately a year in this study had a mean fluoride concentration of 0.70 ppm and a maximum concentration of 1.00 ppm; these values were higher than those reported by the City of Houston for the calendar year of 2008 — mean fluoride concentration of 0.54 ppm and maximum concentration of 0.74 ppm (14). There are a few limitations to this comparison. Although this study examined water samples taken on an approximately weekly basis, to the authors’ knowledge, there are no such weekly records available from the City of Houston for direct comparison. Also, for this study water samples were collected from July 17, 2008, and July 7, 2009, thus including data from two calendar years. City of Houston annual reports are published based on the calendar year, so the 2008 data from the City of Houston does not account for the entire time span of this study. It may be beneficial in the future to examine water samples taken during one calendar year, so that a more direct comparison can be made to City of Houston statistics. Finally, City of Houston annual water quality reports are organized with regard to source of water and not specifically by zip code. The majority of the geographical area served by the City of Houston utilizes the surface water main system; isolated ground water sources supply other areas. Thus, the zip code of the water

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…in order to minimize risk for fluorosis, practitioners following these fluoride supplementation guidelines analyze multiple water samples taken on different dates before making any fluoride supplementation decisions.


samples in this study, 77030, was one of many included in the surface water main system category — only one average fluoride level and maximum level was given for this category. To the authors’ knowledge, there is no publicly available data on fluoride concentrations in Houston water supplies organized by zip code. ACKNOWLEDGEMENT The authors would like to thank Cathy Quock, M.A., for her assistance in the preparation of this manuscript. References 1. Osmunson B. Water fluoridation intervention: dentistry’s crown jewel or dark hour? Fluoride 2007;40(4)214-221. 2. Connett P. Professionals mobilize to end water fluoridation worldwide. Fluoride 2007;40(3)155-158. 3. Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR 2001;50(No. RR-14). 4. US Department of Health and Human Services. Oral Health; 21-9: increase the proportion of U.S. population served by community water systems with optimally fluoridated water. In: Healthy people 2010: understanding and improving health. 2nd ed. Washington, DC: US Department of Health and Human Services: 2000. Available at: http://www.healthypeople.gov/document/ html/volume2/21oral.htm 5. Environmental Protection Agency. National

primary and secondary drinking water regulations: fluoride. Federal Register 1986;51:11396. 6. Louisiana law clears path for fluoridation. Chicago, IL: American Dental Association; 2008. Available at: http://www.ada/org/ prof/resources/pubs/ adanews/adanewsarticle. asp?articleid=3132 7. Crozier S. San Diego authorizes community water fluoridation. Chicago, IL: American Dental Association; 2008. Available at: http://www.ada.org/ prof/resources/pubs/ adanews/adanewsarticle. asp?articleid=3059 8. DenBesten PK, Thariani H. Biological mechanisms of fluorosis and level and timing of systemic exposure to fluoride with respect to fluorosis. J Dent Res 1992; 71:1238-43. 9. Fejerskov O, Manji F, Baelum V, Moller IJ. Dental fluorosis—a handbook for health workers. Copenhagen: Munksgaard, 1988. 10. Mandinic Z, Curcic M, Antonijevic B, Lekic CP, Carevic M. Relationship between fluoride intake in Serbian children living in two areas with different natural levels of fluorides and occurrence of dental fluorosis. Food Chem Toxicol. 2009 Jun;47(6):1080-4. 11. Srikanth R, Chandra TR, Kumar BR. Endemic Fluorosis in Five Villages of the Palamau District, Jharkhand, India. Fluoride 2008;41(3)206-211. 12. Akosu TJ, Zoakah AI. Risk factors associated with dental fluorosis in Central Plateau State, Nigeria. Com-

munity Dent Oral Epidemiol. 2008 Apr;36(2):144-8. 13. Quock RL, Chan JT. Water fluoride concentrations in and around the Greater Houston metropolitan area. Tex Dent J 2009 Feb;126(2):146-149. 14. City of Houston Department of Public Works and Engineering. Water Quality Report 2008. 15. US Environmental Protection Agency. 40 CFR Part 141.62. Maximum contaminant levels for inorganic contaminants. Code of Federal Regulations 1998:402. 16. US Environmental Protection Agency. 40 CFR Part 143. National secondary drinking water regulations. Code of Federal Regulations 1998;514-7. 17. US Department of Health and Human Services. Water fluoridation: a manual for engineers and technicians. 1986:19. 18. Meskin LH, ed. Caries diagnosis and risk assessment: a review of preventive strategies and management. J Am Dent Assoc 1995;126(suppl):1S-24S. 19. American Academy of Pediatric Dentistry. Special issue: reference manual 1994-95. Pediatr Dent 1995;16(special issue):1-96. 20. American Academy of Pediatrics Committee on Nutrition. Fluoride supplementation for children: interim policy recommendations. Pediatrics 1995;95:777. 21. Ismail AI, Hassan H. Fluoride supplements, dental caries and fluorosis: a systematic review. J Am Dent Assoc 2008 Nov;139(11):1457-68. Texas Dental Journal l www.tda.org l July 2010

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Dental Unit Waterline Contamination — A Review Nuala Porteous, B.D.S., M.P.H.

A Historical Perspective Contamination of patient treatment water and its reduction with chlorhexidene was first described in the British Dental Journal over 40 years ago (1). Ten years later, it was reported that bacterial levels in water emitted from highspeed handpieces, air/water syringes, and ultrasonic lines were as high as 2-3 million colony forming units per milliliter (CFU/mL) (2). Although the American Dental Association (ADA) issued a recommendation in 1978 that dental unit waterlines (DUWL) should be flushed with chemical germicides, they deferred to dental unit manufacturers on treatment methods at that time (3). National guidelines and recommendations were subsequently developed in the 1990’s and later revised, as illustrated in the following timeline (4-9).

Abstract Manufacturers of dental units have responded positively to the challenge from the American Dental Association (ADA) and the subsequent guidelines issued by the Centers for Disease Control and Prevention (CDC) to deliver patient treatment water that is at least as pure as drinking water. Dental units are now routinely manufactured with anti-retraction devices that are designed to control oral fluids from being aspirated into the lines during treatment and many units have water systems that isolate source water from municipal water supply. The dental industry has also produced an array of devices and cleaning/ disinfectant products to further facilitate the use of clean patient treatment water. Products that claim disinfectant efficacy must be registered with the Environmental Protection Agency (EPA). If they are not EPA-registered, they can be labeled as waterline cleaners only. Waterline treatment devices that are sold separately and require connection to dental units must be registered with the Food and Drug Administration (FDA) as medical devices. Patient treatment water quality can be monitored by using inoffice chairside kits or through commercial laboratory services..

KEY WORDS: Porteous Dr. Porteous is an associate professor, Department of Comprehensive Dentistry, University of Texas Health Science Center at San Antonio Dental School; Phone: (210) 567-6334; Fax: (210) 567-6348; E-mail: porteous@uthscsa.edu.

Dental unit waterline contamination, biofilm, dental unit waterline treatment products cessation Tex Dent J;127(7):677-685.

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Dental Unit Waterline Contamination CDC recommended infection-control practices for dentistry–1993. MMWR 1993;42(No. RR-8). • • •

Installation of and maintenance of anti-retraction valves to limit retraction of contaminated fluid Flushing lines between patients and beginning of each day Use of sterile irrigants for surgical procedures

CDC guidelines for infection control in dental health-care settings–2003. MMWR 2003;52(No. RR 17). “Use water that meets EPA regulatory standards for drinking water (<500 CFU/ mL) for routine dental treatment water output.”

1996 1993

2004 2003

ADA statement on DUWL:

ADA updated statement:

http://www.ada.org/1856.aspx

Industry and profession challenged to deliver patient treatment water <200 CFU/mL by Y2000.

Source of the problem Contamination of dental patient treatment water is caused by the presence of biofilms on the inner surfaces of DUWL, feeding a continuous source of bacteria to the water flowing through the lines (Figure 1). A biofilm may be defined as “bacterial populations adherent to each other and/or to surfaces or interfaces” (10). Biofilm bacteria predominate in all nutrient-sufficient ecosystems. They differ from free-floating (planktonic) microbes because adhesion to a surface triggers the production of an exopolysaccharide (slime layer) that encases and protects them. A mature biofilm consists of an efficient bacterial community with enhanced tolerance to disin-

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Figure 1. Biofilm mass on interior surface of DUWL tubing after 8 weeks of use.


fectants, causing a significant challenge for its elimination (10). DUWL tubing is usually composed of polyurethane or polyvinyl that is 1/16” or 2 mm in diameter, providing a surface area to volume ratio of approximately 6:1 (Figure 2). Flow rates in a dental unit are typically 60-100mL/min and occur intermittently throughout the day, allowing periods of water stagnation. Further, some water delivery lines, such as the ultrasonic line may be idle for days at a time, amplifying the contamination. The physical properties of the tubing, along with the fact that chemical additives in DUWL tubing can be an additional source of nutrition, provide an ideal, sometimes undisturbed environment for DUWL biofilm formation (11).

Types of flora recovered from DUWL Organisms are mainly derived from source water, comprised of heterotrophic (use organic carbon from another source), mesophilic (grow in moderate temperature) bacteria, predominantly gram-negative (gram -ve) species. These are generally termed heterotrophic plate count (HPC) bacteria. Opportunistic pathogens, such as Pseudomonas species that can grow readily in distilled water and in dilute disinfectants, e.g., chlorhexidene and iodophors; non-tuberculosis mycobacteria (NTM) that are present anywhere from 1-50 percent in the municipal water supply, depending on geographic location;

Figure 2. A. DUWL tubing 1/16” diameter, cut surface blackened. B. Tubing sectioned to expose narrow lumen (blackened).

and Legionnella (causative organism of Legionnaire’s disease and the milder Pontiac fever) species have all been isolated from DUWL (12-15). Fungi have also been found and even in air samples in dental offices, and studies have shown that levels decrease after disinfection of waterlines (16, 17). Oral organisms that enter the dental water system during patient treatment such as Streptococci and Porphyromonas gingivalis have also been isolated from DUWL (18, 19).

Who is at risk? HPC bacteria are found ubiquitously in all water systems and their level is used as a gauge of how well a water system is maintained (8). There is no correlation between the presence of controlled numbers of HPC bacteria in drinking water and human disease, as long as the entry water is biologically safe (20). Microbes of concern are the aforementioned opportunistic pathogens that are commonly isolated from stagnant water sources where biofilms proliferate. They are a known cause of disseminated disease and wound infections in immunocompromised patients and can also colonize respiratory tracts in healthy individuals without causing disease (21-24). In 1974, dental personnel were reported to have nasal Pseudomonas species corresponding to DUWL biofilm load, with the all the affected dentists reporting rhinitis, but confounding variables such as immune status and hypersensitivity were not reported (25). In the 1980’s, Martin et al. published a case report of medically compromised dental patients, who were infected with Pseudomonas aeruginosa that originated in DUWL. Texas Dental Journal l www.tda.org l July 2010

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Dental Unit Waterline Contamination A follow-up report concluded that the organisms were not a cause for concern in healthy individuals, as organisms could not be detected in the healthy patients 5 weeks after treatment with affected water, in spite of initial colonization (26). Other studies have shown a high prevalence of Legionnella seropositivity in dental personnel compared to non-dental workers, but no correlation with disease among personnel (27-29). In the medical literature, several studies have reported a significant association between the presence and severity of asthma and raised concentration of airborne gram -ve bacteria in the indoor environment (30, 31). The bacterial cell wall of gram -ve bacteria is a potent source of endotoxin and high levels have been found in DUWL (32). Matthew et al. observed a significant decrease in lung function in asthmatic children 30 minutes after receiving dental treatment (33). A cross-sectional multicenter survey of 265 dentists in practice concluded that the temporal onset of asthma may be associated with occupational exposure to DUWL because dentists who were exposed to DUWL >200CFU/mL were more likely to report symptoms of asthma since starting dentistry (34). On the other hand, a survey of 817 dental students in three dental schools concluded that the dental environment does not increase the risk for respiratory infection in healthy dental students (35). Pankhurst at al. reviewed the scientific evidence from 1966-2007 on DUWL as a source of occupational and acquired infections and concluded that the report by Martin et al. was the only one clinical case directly associated with dental procedures (26, 36). In the absence of epidemiological data from randomized control trials to show otherwise, we can conclude that the risk for healthy individuals appears to be low. Nevertheless, the documented presence of opportunistic pathogens in DUWL and their association with human disease poses a risk for immunocompromised individuals (21-24).

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Matthew et al. observed a significant decrease in lung function in asthmatic children 30 minutes after receiving dental treatment


In 2007, a dental patient filed a lawsuit claiming that her unprotected eye (no protective eyewear provided) was splashed with contaminated water during a dental procedure and resulted in chronic eye damage (37). The judge rejected the case, but this and other previously reported lawsuits reinforce the need for all dental offices to ensure vigilance with an office infection control policy that reflects laws, guidelines, and recommendations issued by federal state and local agencies (11). Furthermore it should include routine maintenance of patient treatment water at <500CFU/mL of HPC bacteria, in accordance with CDC recommendations (7).

How to reduce level of contamination The control of DUWL contamination is a two-part process consisting of biofilm removal and control, and reduction of planktonic microbes. Dental offices should consult with the dental manufacturers on treatment methods to ensure compatibility of products with equipment. They should also consult the owner’s manual or contact the manufacturer to determine whether testing or maintenance of devices, including anti-retraction valves is required, as these have been show to fail (6, 7, 38, 39). The CDC recommends that handpieces, ultrasonic scalers, or air/water syringes should be operated to discharge water and air for a minimum of 20–30 seconds after each patient to flush out patient material that might have entered the turbine, air, or waterlines (7). However, it must be noted that flushing alone is no longer considered a practical solution for the treatment of DUWL contamination, because of the lack of effect on biofilm (7). Autoclavable or single-use tubing systems that can deliver sterile water or other solutions to handpieces (Genesis Tech, Elmwood, WI) and ultrasonic scalers (Acteon Inc., Mt Laurel, NJ) are also available. Dental units are connected either directly to the municipal water supply, or have independent systems that allow the dental unit to be isolated from the municipal water supply. The self-contained bottle in an independent system is used to hold source water, with or without the addition of chemicals, for distribution throughout the

Figure 3. Confocal Imaging of biofilm inside DUWL tubing showing live and dead bacterial activity.

lines. Using untreated, unfiltered source water alone containing <500 CFU/mL of bacteria (e.g., tap, distilled, or sterile water) in an independent system does not eliminate bacterial contamination in treatment water if biofilms in the lines are not controlled (Figure 3).

Chemical treatment products for use with independent systems There is a wide range of chemical products on the market. Some common chemicals used are: sodium hypochlorite; hydrogen peroxide; chlorhexidene; chlorine dioxide; iodine; ozone; peracetic acid. These products claim to remove, inactivate, or prevent formation of biofilm, and reduce endotoxin levels from gram -ve bacteria. Products that carry germicidal claims for dental unit water system usage must be registered with the Environmental Protection Agency (EPA) and assigned a specific EPA number. Without EPA registration, products can be marketed as cleaners only, not disinfectants. To get the EPA registration for their products, manufacturers are required to submit their own efficacy data as standard efficacy testing methods have yet to be completed. Texas Dental Journal l www.tda.org l July 2010

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Dental Unit Waterline Contamination Chemical agents may be added to the source water in low concentrations and used continuously for patient treatment. The main effect of these continuous-use products is on planktonic bacteria with very little impact on mature biofilm. Agents that target biofilm can be used intermittently by adding a high concentration to the source water, running the product through, and leaving it in the lines for a brief period of time that can range from minutes to hours to overnight to weekend, and then flushed out for patient treatment. Products, utilizing a combination treatment method, requiring initial and periodic intermittent (shock) treatments, along with the routine use of a continuous-use product, are also available.

Source water treatment devices

Source water treatment devices, sometimes termed water purifiers, are retrofitted close to the junction box to treat incoming water from municipal water supply. Systems are designed to use a holding tank in a central location or they may be plumbed directly into the units. They also require FDA clearance as medical devices. There are numerous types on the market. Some systems continuously remove source water contaminants using de-ionization and sub-micron filtration. Others generate ozone from oxygen through exposure to ultraviolet light and the ozonated gas sterilizes water in the reservoir. They have no direct effect on biofilm inside DUWL; consequently patient treatment water quality may not improve without the addition of a biofilm-controlling agent. Some of these devices automatically introduce chemical agents.

Other approaches Researchers are currently studying innovative methods that interfere with biofilm formation through modification of the inner tubing surface

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to reduce microbial adhesion or to delay biofilm formation and some promising results have been published. A study that tested polyvinylidene fluoride tubing over 185 days showed it to be effective in preventing bacterial adhesion (40). Biofilmcontrolling functions have also been found with the incorporation of a rechargeable N-halamine compound into polyurethane tubing (41).

Literature review on chemical products Most published studies that have tested the efficacy of DUWL products have limitations, due to small sample size, lack of standardized testing methods, and short duration of testing time. Thus, it is difficult to do a comparative review of studies particularly when translating benchtop efficacy into clinical effectiveness. However, there is strong evidence to show that many chemical products will reduce contamination of output water temporarily, but not permanently, by reducing, but not removing biofilm (42, 43). DUWL chemical products may have disadvantages to their use and their effect on the bonding strength of dental materials has been researched in laboratory settings. A majority of those studies have shown no deleterious effect on dentin or enamel bonding agents when compared with controls (44-46). There is limited evidence to show that halogen-containing products may mobilize mercury from waste amalgam. Two studies that tested a number of disinfectants used in water delivery and evacuation lines concluded that chlorine-containing products released more mercury from amalgam waste than other cleaners, such as quaternary ammonium chloride products or deionized water (47, 48). Another study that tested a DUWL iodine-releasing device showed that iodine can mobilize mercury from amalgam particulate resulting in higher levels of mercury in wastewater (49). Dental offices should consider their amount of amalgam use and the active ingredients in products used to treat all lines (water delivery and evacuation lines) when choosing a suitable disinfectant.


Water quality monitoring The CDC recommends that waterline treatment schedules should include water quality monitoring, which should be performed as frequently as instructed by the product manufacturers (7). This can be done by simply taking a water sample and using one of two testing methods. In-office chairside kits (Millipore Corp., Billerica, MA) are available, but there is strong evidence to show that chairside kits underestimate bacterial counts when compared to standard methods and fail to grow certain phenotypes. Therefore, they should be considered screening tools for estimating bacterial counts in the range of 0-500 CFU/mL (50, 51). Although lower, results obtained with chairside kits have been found to be consistent, so it has been suggested that bacterial counts <500 CFU/mL may be corrected by a factor of 1.5 to get a more accurate reading (52). If chairside kits repeatedly show counts above 500 CFU/ mL, dental offices should consult with product manufacturers to ensure product is being used correctly. Alternative testing methods or treatment products should be considered if counts continue to be high. Laboratories across the U.S. offer mail-in testing services that can provide accurate testing readings. When mailing water samples to a commercial testing site, it is important that the samples should be stored at an average temp pf 4.5°C and sent immediately for processing, as variables such as time and temperature can affect results (53, 54). Information on these services and products are available on the ADA and Organization for Safety and Asepsis Procedures (OSAP) online websites (6, 55).

Conclusion In general, much progress has been made towards facilitating the delivery of patient treatment water that is consistent with EPA drinking water quality, in accordance with the CDC Guidelines. The source of the problem, biofilm, has been identified and products that target biofilm prevention and/or control have been developed. However, many questions remain unanswered; current treatment methods, products and devices have not been proven fail-safe; and further research on biofilm elimination is needed. Limited epidemiological reports suggest that the risk of disease transmission from contaminated DUWL for healthy individuals appears to be minimal, but the potential appears high for immunocompromised individuals. Dental offices should adhere to a strict infection control policy that includes routine treatment and monitoring of patient treatment water, regardless of speculation and lack of evidence of associated morbidity or mortality.

References 1. Blake GC. The incidence and control of bacterial infection in dental spray reservoirs. Br Dent J 1963;115:413-416. 2. Gross AG, Devine MJ, Cutright DE. Microbial contamination of dental units and ultrasonic scalers. J Periodontol 1976;47(11):670-673. 3. American Dental Association, Council on Dental Materials and Devices and Council on Dental Therapeutics. Infection Control in the dental office. J Am Dent Assoc 1978;97:673-677. 4. CDC. Recommended infection-control practices for dentistry -1993. MMWR 1993;42(No. RR-8). 5. ADA Statement on backflow prevention and the dental office. Available at: http://www.ada.org/1855.aspx. Accessed April 13, 2010. 6. ADA Statement on Dental Unit Waterlines Available at: http://www.ada. org/1856.aspx. Accessed April 13, 2010. 7. CDC Guidelines for infection control in dental health-care settings – 2003. MMWR 2003; 52(No. RR-17). 8. US Environmental Protection Agency. National primary drinking water regulations, 1999: list of contaminants. Washington DC: US Environmental Protection Agency, 1999. Available at http://www.epa.gov/safewater/contaminants/index.html. Accessed April 13, 2010. 9. American Public Health Association, American Water Works Association, Water Environment Foundation. In: Eaton AD, Clesceri LS, Greenberg AE, eds. Standard methods for the examination of water and wastewater. Washington, DC: American Public Health Association, 1999 10. Costerton JW, Lewandowski Z, Caldwell DE, Korber DR, Lappin-Scott HM. Microbial Biofilms. Annu Rev Microbiol 1995;49:711-45. 11. Mills SE. The dental unit waterline controversy: defusing the myths, defining the solutions. J Am Dent Assoc 2000;131:1427–1441. 12. Williams JF, Johnston AM, Johnson B, Huntington MK, Mackenzie CD. Microbial contamination of dental unit waterlines: prevalence, intensity and microbiological characteristics. J Am Dent Assoc 1993;124:59–65. 13. Barbeau J, Tanguay R, Faucher E, et al. Multiparametric analysis of waterline contamination in dental units. Appl Environ Microbiol 1996;62:3954– 3959.

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14. Singh R, Stine OC, Smith DL, Spitznagel JK, Labib ME, Williams HN. Microbial diversity of biofilms in dental unit water systems. Appl Environ Microbiol 2003 ;69(6) :3412-3420. 15. Porteous NB, Redding SW, Jorgensen JH. Isolation of non-tuberculosis mycobacteria in treated dental unit waterlines. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98(1):40-44. 16. Porteous NB, Redding SW, Thompson EH, Grooters AM, De Hoog S, Sutton DA. Isolation of an unusual fungus in treated dental unit waterlines. J Am Dent Assoc 2003;134(7):853-858. 17. Szymanska J. Evaluation of mycological contamination of dental unit waterlines. Ann Agric Environ Med 2005;12:153-155. 18. Petti S, Tarsitani G. Detection and quantification of dental unit waterline contamination by oral Streptococci Inf Control and Hosp Epidemiol 2006;27(5):504-509. 19. Montebugnoli l, Sambri Cavrini F, Marangoni A, Testarelli L, Dolci G. Detection of DNA from periodontal pathogenic bacteria in biofilm obtained from waterlines in dental units. The New Microbiol 2004;27:391-397. 20. Franco EL. Defining safe drinking water. Epidemiology 1997;8(6);607-609. 21. Walker JT, Bradshaw DJ, Bennett AM, Fulford MR, Martin MV, Marsh PD. Microbial biofilm formation and contamination of dental-unit water systems in general dental practice. Appl Environ Microbiol 2000;66:3363–3367. 22. Wallace JR, Swenson JM, Silcox VA, Good RC, Tschen JA, Stone MS. Spectrum of disease due to rapidly growing mycobacteria. Rev Infect Dis 1983;5:657-679. 23. Horsburg CR. Mycobacterium avium complex infection in the acquired immunodeficiency syndrome. N Engl J Med 1991;324:1332-1338. 24. Wayne LG, Sramek HA. Agents of newly recognized or infrequently encountered mycobacterial diseases. Clin Microbiol Rev 1992;5:125. 25. Clark A. Bacterial colonization of dental units and the nasal flora

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26.

27.

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35.

of dental personnel. Proceedings of the Royal Society of Medicine 1974;67:29-30. Martin MV. The significance of the bacterial contamination of dental unit water systems. Br. Dent J 1987;163(5):152-154. Fotos PG, Westfall HN, Snyder IS, Miller RW, Mutchler BM. Prevalence of Legionella-specific IgG and IgM antibody in a dental clinic population. J Dent Res 1988;64:1382-1385. Reinthaler FF, Mascher F, Stunzer D. Serologic examination for antibodies against Legionella species in dental personnel. J Dent Res 1988;67:942-943. Oppenhein BA, Sefton AM, Gill ON, Tyler GE, O’Mahony MC, Richards PL, et al. Widespread Legionella pneumophila contamination of dental stations in a dental school without apparent human infection. Epidemiol Infect 1987;99:159-166. Lawson JA, Dosman JA, Rennie DC, Beach J, Newman SC, Senthilselvan A. Relationship between indoor environment and asthma and wheeze severity among rural children and adolescents. J Agro Medicine 2009;14(2):277-85. Rennie DC, Lawson JA, Kirychuk SP, Paterson C, Willson PJ, Senthilselvan A, Cockcroft DW. Assessment of endotoxin levels in the home and current asthma and wheeze in school-age children. Indoor Air 2008;18(6):447-53. Schulze-Robbecke R, Feldmann C, Fischeder R, Janning B, Exner M, Wahl G. Dental units: an environmental study of sources of potentially pathogenic mycobacteria. Tuber Lung Dis 1995;76:318–323. Matthew T, Casamassimo PS, Wilson S. et al. Effect of dental treatment on the lung function of children with asthma. J Am Dent Assoc 1996;129:1120-1128. Pankhurst C L, Coulter WA. Do contaminated dental unit waterlines pose a risk of infection? J Dent 2007;35(9):712-720. Scannapieco FA, Ho AW, DiTolla M. Dentino AR. Exposure to the dental environment and prevalence of respiratory illness in dental student populations. J Can Dent Assoc 2004;70(3):170-174.

36. Pankhurst CL, Coulter W, Philpott-Howard JN, Surman-Lee S, Warburton F, Challacombe S. Evaluation of the potential risk of occupational asthma in dentists exposed to contaminated dental unit waterlines. Primary Dent Care 2005;12(2):53-59. 37. Barbeau J. Lawsuit against a dentist related to serious ocular infection possibly linked to water from a dental handpiece. J Can Dent Assoc 2007;73(7):618-622. 38. Berlutti F, Testarelli L, Vaia F, De Luca M, Dolci G. Efficacy of anti-retraction devices in preventing bacterial contamination of dental unit water lines. J Dent 2004;32(2):169-170. 39. Montebugnoli L, Dolci G, Spratt DA, Puttaiah R. Failure of antiretraction valves and the procedure for between patient flushing: a rationale for chemical control of dental unit waterline contamination. Am J Dent. 2005;18(4):270-4. 40. Yabune T, Imazato S, Ebisu S. Assessment of inhibitory effects of fluoride-coated tubes on biofilm formation by using the in vitro dental unit waterline biofilm model. Appl Environ Microbiol 2008;74(19):5958-64. 41. Sun Y, Sun G. Novel regenerable N-halamine polymeric biocides. I. Synthesis, characterization and antibacterial activity of hydantoincontaining polymers. J Appl Polym Sci 2001;80:2460-2467. 42. Kettering JD, Munoz-Viveros CA, Stephens JA, Naylor WP, Zhang W. Reducing bacterial counts in dental unit waterlines: distilled water vs. antimicrobial agents. J Calif Dent Assoc. 2002;30(10):735-41. 43. Meiller TF, DePaola LG, Kelley JI, Baqui A. Turng B-F, Falkler WA. Dental unit waterlines: biofilms, disinfection and recurrence. J Am Dent Assoc 1999;130(1):65-72. 44. Roberts HW, Karpay RI, Mills SE. Dental unit waterline antimicrobial agents’ effect on dentin bond strength. J Am Dent Assoc 2000;131(2):179-83. 45. Von Fraunhofer JA, Kelley JI, DePaola LG, Meiller TF. Effect of a dental unit waterline treatment solution on composite-dentin shear bond strengths. J Clin Dent 2004;15(1):28-32.


46. Ritter AV, Ghaname E, Leonard RH. The influence of dental unit waterline cleaners on composite-to-denton bond strengths. J Am Dent Assoc 2007;138(12):985991. 47. Batchu H, Chou H-N, Rakowski D. The effect of disinfectants and line cleaners on the release of mercury from amalgam. J Am Dent Assoc 2006;137:14191425. 48. Roberts HW, Marek M, Kuehne JC, Ragain JC. Disinfectants’ effect on mercury release from amalgam. J Am Dent Assoc 2005;136(7):915-919. 49. Stone ME, Kuehne JC, Cohen ME, Talbott JL, Scott JW. Effect of iodine on mercury concentrations in dental unit wastewater. Dent Mat 2006;22(2):119-124. 50. Bartoloni JA, Porteous NB, Zarzabal LE. Measuring the validity of two in-office water test kits. J Am Dent Assoc 2006;137(3):363–371. 51. Smith RS, Pineiro SA, Singh, R, Romberg E, Labib ME, Williams HN. Discrepancies in bacterial recovery from dental unit water samples on R2A medium and a commercial sampling device. Curr Microbiol 2004;48:243– 246. 52. Cohen ME, Harte JA, Stone ME, O’Connor KH, Coen ML, Cullum ME. Statistical modeling of dental-unitwater bacterial test kit performance. J Clin Dent 2007;18:39–44. 53. Palenik CJ, Burgess K, Miller CH. Effects of delayed microbial analysis of dental unit waterline specimens. Amer J Dent. 2005;18:87–90. 54. Noce l. Giovanni D, Putnins EE. An evaluation of sampling and laboratory procedures fro determination of heterotrophic plate counts in dental unit waterlines. J Can Dent Assoc 2000;66:262. 55. Organization for Safety and Asepsis Procedures - Dental Unit Waterlines, available at: http://www.osap.org. Accessed April 13, 2010.

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SOUTHWEST DENTAL CONFERENCE Shaping the Future

Visit our Web site for more information: www.swdentalconf.org

A Commitment to Excellence

Sponsored by Dallas County Dental Society

January 13-15, 2011  Dallas Convention Center  Dallas, Texas

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exhibitors

sp nsors Their support is invaluable to the Texas Dental Association’s production of one of the largest dental meetings in the country. We appreciate their support and the important role they play in the success of the TEXAS Meeting. Visit texasmeeting.com to view the Sponsors and Exhibitors from the 2010 TEXAS Meeting.

s k n tha

2010 TEXAS Meeting


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

TDA Video Highlights on tda.org Due to the positive feedback and overall success with the TDA New Dentist Committee podcast series and the TDA Video Library on TDA Express, TDA has added a new TDA Video Highlights section on the homepage of tda.org. Members can browse through dozens of videos from TDA events, like the 2010 TEXAS Meeting. Listen to TDA members share their opinions on issues such as, “Why Join TDA” and “The Value of Membership.” Watch shout-outs from various events at the TEXAS Meeting like the House of Delegates, TDA GOLD Reception, or exhibit hall. Thank you to all the participants! We hope to include more footage in the future and welcome any feedback. Questions? Contact Stefanie Clegg, TDA web & new media manager, at (512) 443-3675 or stefanie@tda.org.

Join our Facebook group: groups.to/texasdental

Follow us on twitter.com/theTDA ®

Get LinkedIN at linked.com, search “Texas Dental Association”

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EXPRESS

The Texas Dental Association has integrated the existing TDA website (www.tda.org) into the “TDA Express” Internet portal. The TDA Express portal allows members to customize their homepage to show only the content in which they're interested.

Members can choose from existing links or add their own. TDA Express now includes a video library showcasing TDA videos and podcasts. Be sure to view the “Welcome” video by Mary Kay Linn, TDA Executive Director.

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Announcement Click HERE - TDA Express Feedback TDA Express has been enhanced! Along with a new look, TDA Express now has its very own TDA video library.

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Endodontics

TDA News TDA Committee on the New Dentist Podcast: Starting a New Practice The second installment of the TDA Committe on the New Dentist podacst series, conducted by Dr, Josh Austin.

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Five-year follow-up of a root canal filling material in the Oral Surgery, Oral Medicine, Oral Pathology, Oral ... 3/20/2009 10:21:05 AM

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Putative signaling action of amelogenin utilizes the Journal of Periodontal Research 3/19/2009 10:25:15 AM

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Top Section: Google search box (top-right corner), Helpful Tips, Contact Info (top-left), News scroll of top headlines, Local weather update Left-hand margin: RSS News Center, Calculators, Meetings/Planners, Weather Center, Announcements from TDA, Events Calendar, TDA News and TDA Perks Program highlights, List of TDA and affiliate websites, and World Indices Middle section (portlets) - Content divided into 7 sections: • Dental News & Videos: TDA video library, ADA Podcast Network, and dental specialty news. • News & Publications: Business and personal news, magazines, television, and Internet links. • Dental: Links related to the profession and dental office needs. • Personal: Links to travel, weather, people, sports, and other leisure interests. • Finance: Banking and finance related links, including investment, retirement, and bankruptcy. • Tools: Variety of helpful links such as office and tech tools, research, demographic, and people searches. • My Links: Links and categories created by the user. Contact: Stefanie Clegg (512) 443-3675 or stefanie@tda.org


Provided by TDA Perks Program

value for your

profession Get the Best Deal on Your Office Lease Evan Reynolds, The Reynolds Company

The vast majority of dental professionals will face the challenge of negotiating a lease for office space at some point in their careers. Leasing space in the right location at the right price is obviously critical to most practices. It can be a frustrating and confusing process, not to mention costly, if not approached in a strategic way. Fortunately, you can successfully negotiate a new lease by following a few key recommendations detailed below.

Start Early It typically takes approximately 6 months to complete the entire process of setting up a new dental office. This may include demographic analysis, competition studies, market research, lease negotiations, design and construction and many other items. The process can certainly take longer if you run into many unexpected delays. There may be delays in securing a construction permit or you may have to wait on the landlord to repair some items before you start your construction. It is best to establish a target occupancy date early in the process so that everyone understands your time objectives. This will also help you develop a

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time line for hiring staff, initiating your marketing plan, and other key start-up tasks. There may also be seasonal and tax considerations that will impact when you want to open your office, so you will need to plan accordingly.

Assemble Your Team Leasing an office space is not a oneperson job. You need a team of professionals that can assist you in all phases of the process. A real estate broker who specializes in working with dental professionals can help you with finding the right location and lease negotiations. Your attorney, fellow doctors, or dental equipment supplier may be able to steer you to such a professional. Real estate brokers exclusively represent your interests and are paid a standard commission by the building owner when the project is completed. You will need to meet with a lender in the early stages of the process to determine the amount of financing that you can secure. This will be important for everyone involved in the project. There are several dental specific lenders that have special programs to meet the unique needs of the dental professional. They are a good place to start. An architect or space planner should be another key member of your lease team. You need one to draft a tentative floor plan to determine how a particular space might work for your needs, as well as producing the final architectural documents. Most of the dental equipment vendors will provide this service at little or no cost if you purchase their equipment. In almost all cases, you will want to work with a dental equipment provider to help you establish a specific growth plan for your practice. You

will need to understand not only your initial equipment needs, but how your practice will grow and what you will need to purchase in the future. Another important member of your team is the general contractor that will build-out your space. It is critical that the contractor you choose has extensive experience in constructing dental office spaces. You will want to know not only what the cost will be, but how long it will take to complete the work. A contractor can tour you through recently completed projects, so you can view his work. Working with an inexperienced contractor can be one of the most expensive mistakes you can make. An experienced real estate attorney is another crucial team member. It is highly preferable if the attorney also has experience reviewing dental leases. The attorney needs to be comprehensive, but realistic and efficient in his lease review. The attorney can also help you with setting up a corporate entity or partnership, if you need it.

Develop a Vision You probably won’t have all the details nailed down as you start the process, but it is a good idea to think about what you want your practice to be and where you want it to be located. You need to think about where you want to live and work, who you want your patients to be and what type of procedures you want to perform. Think about whether this will be your only practice, or possibly the first of many locations. This information will help produce criteria that will enable your real estate broker to identify alternatives that best meet your needs. The broker can also play a big role in developing your vision by providing demographic information, competition studies, traffic

studies, etc. It is also helpful to think about the image of your practice. Do you want to be in a high-traffic retail location or in a lower-visibility professional office building?

Evaluate Your Options The key to successfully negotiating the terms of a new lease is having options. Your broker should play a vital role in developing a negotiating strategy that will maximize your options and consequently maximize your negotiating leverage. Having options produces a competitive environment which will put you in a position to make the best deal. You are not only negotiating the rental rate and improvement allowance, but also such items as: lease term, parking, signage, exclusivity, sublease and assignment, security deposit, and other key lease components. Most dental professionals dread dealing with office space issues. The process can be confusing, particularly if you are setting up an office for the first time. Fortunately, by following these key recommendations, you can find the right office space for your practice and successfully negotiate your lease. The author, Evan Reynolds, is president of The Reynolds Company, a healthcare real estate services firm and TDA Perks Program partner, that specializes in helping Texas dental professionals with their office space needs. The company is headquartered in Dallas, and has offices in Austin and Houston. For more information regarding The Reynolds Company, please visit: thereynoldscompany.com, or call: (972) 231-8900. For more information regarding other TDA Perks Programs, please visit tdaperks.com, or call (512) 443-3675.

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The Hindley Group, LLC, announces the release of

Getting Down to Business — Success in Each Stage of Your Dental Career

Your Practice is as unique as your thumbprint...

The Hindley Group, LLC We assist with acquisition terms and conditions, the financing process, and other practice transition issues in order to effect a timely and orderly transition. This resource and reference book, which draws on the experience and expertise of 12 collaborators, will help you evaluate your business practices and determine where you are and how to get where you want to be. Please visit www.yourpracticeasset.com for information and resources referenced in the book. For a listing of available practices and associateship opportunities, visit our website at www.thehindleygroup.com.

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L. Norton Hindley III, ASA 2202 Timberloch Place, Suite 218 The Woodlands, Texas 77380 281-367-1955 • FAX 281-363-9296 • 1-800-856-1955 norton@thehindleygroup.com http://www.thehindleygroup.com


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In Memoriam Those in the dental community who have recently passed

Alexander, Jack Willaford Lamesa, Texas October 30, 1917 – April 11, 2010 Good Fellow, 1971 Life, 1982

Memorial and Honorarium Donors to the Texas Dental Association Smiles Foundation

In Memory of: John Edwards By Don R. Deaver, D.D.S.

Fifty Year, 1993

Gerald Maikoetter By Charles A. Robertson, D.D.S.

Daggett, John Robert

Jim McNeill By Charles A. Robertson, D.D.S.

San Antonio, Texas September 10, 1937 – May 31, 2010 Life, 2003

Goettsche, Harley H. Amarillo, Texas May 5, 1915 – January 26, 2010 Good Fellow, 1973 Life, 1982

Billye Cooke By Charles A. Robertson, D.D.S. Ms. Joan Walters By Dr. & Mrs. Russell Owens Dr. Al Densmore By The Seventeenth District Dental Society Eddie Meyer By Robert C. Cody, D.D.S.

Fifty Year, 1988

Jim Pettus By Charles A. Robertson, D.D.S.

Golf, Jack

Kimmy Till By Charles A. Robertson, D.D.S.

Houston, Texas September 29, 1922 – April 28, 2010 Good Fellow, 1978 Life, 1987

In Honor of: Mr. Joe McComb By The Corpus Christi Dental Study Club

Fifty Year, 1998

Hill, Gary Rex Deer Park, Texas

Your memorial contribution supports: • educating the public and profession about oral health; and • improving access to dental care for the people of Texas.

August 22, 1946 – November 14, 2009 Good Fellow, 2000 Please make your check payable to:

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

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Calendar of Events 696

August 2010 3–6 The American Academy of Esthetic Dentistry will hold its 35th annual meeting at the Ritz-Carlton Kapalua in Maui, HI. For more information, please contact Ms. Jennifer Hopkins, AAED, 737 N. Michigan Ave., Ste. 2100, Chicago, IL 60611. Phone: (312) 981-6774; FAX: (312) 981-6787; E-mail: info@estheticacademy.org; Web: estheticacademy.org. 13 & 14 The TDA Smiles Foundation will hold a Texas Mission of Mercy in Waco. For more information, please contact the TDA Smiles Foundation, 1946 S. IH 35, Ste. 300, Austin, TX 78704. Phone: (512) 448-2441; Web: tdasf.org.

September 2010 10 – 15 The ADA will hold its Kellogg Executive Management Program (ADAKEMP) in Chicago, IL. For more information, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 4402599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org. 23 & 24 The El Paso District Dental Society will hold its 48th annual El Paso Dental Conference at the El Paso Convention Center in El Paso, Texas. For more information, please contact El Paso Dental Conference, 8815 Dyer, Suite 210, El Paso, TX 79904. Phone: (915) 581-6688; Web: elpasodentalconference.org. 25 The TDA Smiles Foundation will hold a Smiles on Wheels in Cactus. For more information, please contact the TDA Smiles Foundation, 1946 S. IH 35, Ste. 300, Austin, TX 78704. Phone: (512) 448-2441; Web: tdasf.org. 27 – October 2 The American Association of Oral Maxillofacial Surgeons will hold its 92nd annual meeting at McCormick Place in Chicago, IL. For more information, please contact Dr. Robert C. Rinaldi, AAOMS, 9700 W. Bryn Mawr, Rosemont, IL 60018. Phone: (847) 678-6200; FAX: (847) 678-6286; Web: aamos.org.

October 2010

2&3 The Indian Dental Association (USA) will hold its convention in Queens, NY. For more information, please contact Dr. Chad P. Gehani, Indian Dental Association (USA), 3540 82nd St., Jackson Heights, NY 113735159. Phone: (718) 639-0192; FAX: (718) 639-8122; E-mail: ngehani@aol.com; Web: ida-usa.org. 6&7 The American Association of Dental Editors (AADE) will hold its annual conference in Orlando, FL. For more information, please contact Mr. Detlef Moore, AADE, 750 N. Lincoln Memorial Dr., Suite 422, Milwaukee, WI 53202. Phone: (404) 272-2759; FAX: (404) 272-2754; E-mail: aade@dentaleditors.org; Web: dentaleditors.org. 7&8 The American College of Dentists will hold its annual meeting at the Rosen Centre Hotel in Orlando, FL. For more information, please contact Dr. Stephen A. Ralls, ACD, 839J Quince Orchard Blvd., Gaithersburg, MD 20878-1614. Phone: (301) 977-3223; FAX: (301) 977-3330; E-mail: info@facd.org; Web: www.facd.org. 9 – 12 The American Dental Association will hold its 151st annual session at the Orange County Convention Center in Orlando, FL. For more information, please visit ada.org. 20 – 23 The American Society of Dental Aesthetics will hold the 34th Annual American Society of Dental Aesthetics International Conference in San Antonio, TX. For more information, please contact Dr. Dan Lambert, ASDA, 635 Madison Ave., New York, NY 10022. Phone: (800) 454-2732; E-mail: ddssmile@aol.com; Web: asdatoday.com. 20 – 24 The American Academy of Implant Dentistry will hold its 59th annual meeting at the Boston Marriott Copley Place in Boston, MA. For more information, please contact Ms. Sara May, AAID, 211 East Chicago Ave., Suite 750, Chicago, IL 60611-2637. Phone: (312) 335-1550; FAX (312) 335-9090; E-mail: info@aaid.com; Web: aaid.com.

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


30 – November 2 The American Academy of Periodontology will hold its 96th annual meeting at the Hawaii Convention Center in Honolulu, HI. For more information, please contact Ms. Susan Schaus, AAP, 737 N. Michigan Ave., Suite 800, Chicago, IL 60611. Phone: (312) 787-5518; FAX: (31) 787-3670; E-mail: susan@perio.org; Web: perio.org.

November 2010 3–6 The Dental Trade Alliance will hold its annual meeting at the Hyatt Grand Champions Resort in Indian Wells, CA. For more information, please contact Ms. Mary Dolan, Dental Trade Alliance, 2300 Clarendon Road, Suite 1003, Arlington, VA 22201. Phone: (703) 379-7755; FAX: (703) 931-9429; E-mail: info@dentaltradealliance.org; Web: dentaltradealliance.org. 3–6 The American College of Prosthodontists will hold its 40th annual session at the Hyatt Grand Cypress in Orlando, FL. For more information, please contact Ms. Melissa Kabadian, ACP, 211 E. Chicago Ave., Suite 1000, Chicago, IL 60611. Phone: (312) 573-1260; FAX: (312) 573-1257; E-mail: mkabadian@prosthodontics.org; Web: prosthodontics.org. 4–9 The ADA will hold its Kellogg Executive Management Program (ADAKEMP) in Chicago, IL. For more information, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@ada.org; Web: ada.org. 7 – 13 The US Dental Tennis Association will hold its meeting at the Grand Wailea Resort in Maui, HI. More than 16 continuing education AGD/PACE-approved opportunities available. Phone: (800) 445-2524; E-mail: dentaltennis@gmail.com; Web: dentaltennis.org.

December 2010 6&7 The ADA Institute for Diversity in Leadership will hold its meeting at the ADA in Chicago, IL. For more information, please contact Ms. Stephanie Starsiak, 211 E. Chicago, Ave., Chicago, IL 60611. Phone: (312) 440-4699; FAX: (312) 440-2883; E-mail: starsiaks@ada.org; Web: ada.org.

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 Drive, 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 East Chicago Avenue, Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: polanieckir@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

28 – 30 The Hispanic Dental Association will hold its annual meeting in Chicago, IL. For more information, please contact Ms. Rita Brummett, HDA, 3085 Stevenson Drive, Suite 200, Springfield, IL 62703. Phone: (217) 529-6517; FAX: (217) 529-9120; E-mail: hispanicdental@hdassoc.org; Web: hdassoc.org.

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Oral and Maxillofacial Pathology Case of the Month Clinical History For more than 4 weeks, this 21year-old man experienced a painful, ulcerated enlargement of the right retromolar area. A course of broad spectrum antibiotics was not successful in relieving his symptoms and the lesion continued to enlarge under that treatment. At initial examination a dark red, moderately firm, friable mass was seen to measure 3 x 4 x 2 cm (Figure 1). It was fixed to the underlying tissues and showed extensive but superficial necrosis with focal areas of hemorrhage. The patient had anesthesia of his right lower lip and chin, and was having difficulty swallowing. A pantograph revealed only a distal-angular, partial bony impaction of the lower right third molar (Figure 2). There was no cervical lymphadenopathy and the patient’s medical and social histories were unremarkable. Incisional biopsy showed chronic inflammation of fibrovascular tissue, beneath a surface ulcer bed of fibrinoid necrotic debris. One week after the biopsy, the patient returned with a complaint of continued and more rapid growth of the lesion, increased chin numbness, chills, and increased difficulty with swallowing. He had an oral temperature of 102.7°F and the right retromolar mass had enlarged to the point that it was preventing the teeth from occluding and produced a visible extraoral swelling. A CT scan revealed only homogenous soft tissue edema on the right side, without bone erosion or encroachment of the airway (Figure 3). Bacterial and fungal cultures showed only normal oral bacterial flora; HIV Elisa assay and skin TB test were negative; and the complete blood count was normal. A second biopsy specimen, larger and deeper, was obtained for additional microscopic evaluation and immunostaining. The larger sample

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Nagi M. Demian, D.D.S., M.D., Assistant Professor, Stephen Schoolman, D.D.S., Resident, Department of Oral & Maxillofacial Surgery, and Jerry E. Bouquot, D.D.S., M.S.D., F.I.C.D., F.A.C.D., Professor and Chair, Department of Diagnostic Sciences, University of Texas Dental Branch at Houston, Houston, Texas.

Schoolman

Bouquot

revealed diffuse sheets of somewhat immature lymphocytic cells admixed with larger, more open, ovoid cells consistent with histiocytes (Figure 4). Occasional pleomorphism and hyperchromatism of tumor cell nuclei suggested a possibility of leukocytic malignancy and a battery of immunohistochemical studies were used to evaluate for lymphoma. The majority of lesional cells were reactive to CD68 and nonreactive to lymphoma markers CD3, CD5, CD20 and CD79a, as well as the carcinoma marker cytokeratin (Figure 5). This suggested that the lesional cells were proliferating or immature histiocytes, not lymphocytes or epithelial cells. Moreover, tumor cells were nonreactive to S100 protein, which marks the histiocytes of Langerhans cell disease. The patient was hospitalized for treatment of fever and dehydration, and was discharged with no fever and improved oral symptoms 2 days later, without specific treatment for the oral mass. Five days after discharge, the mass was less than 10 percent of its maximum size and the partially impacted right mandibular third molar crown was partially visible, with a small rim of necrotic bone distal to it. After an additional 4 weeks, no signs or symptoms remained and the impacted molar was extracted without incident (Figure 6). Two years later, there was no recurrence of the mass or the symptoms. What is the final diagnosis?

See page 704 for the answer and discussion.

Figure 1. Large fungating, ulcerative mass at initial examination.


Figure 2. Pantograph shows partial bony impaction of right mandibular third molar, with no obvious tumor destruction of the bone.

Figure 4. Histopathology revealed sheets of lymphocytic and histiocytic cells with scattered large epithelioid cells showing open nuclei (arrows).

Figure 6. One week after biopsy the mass has diminished to the point where at the molar is visible once again.

Figure 3. CT scan demonstrated no bony involvement by the tumor, only diffuse, nonspecific soft tissue enlargement, consistent with edema.

Figure 5. CD68 immunoreactivity was strong against the lesional cells.

Figure 7. Five weeks after onset the mass has almost completely disappeared. Texas Dental Journal l www.tda.org l July 2010

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

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Dental Artifacts

The Clark Revolving Dental Cabinet Kim Freeman, M.A., D.M.D., M.S. The late Victorian era (1890 – 1915) produced some of the most elegant dental cabinets in all of history. Many of these cabinets had large hinged sections that spun out for access to myriad small drawers. During this era, a smaller dental supply company came up with a novel idea: ask dentists what they really needed in a cabinet! The cabinet you see (Figures 1, 2) was the result; its revolving drawers allowed for easy access to dental supplies and equipment. This cabinet was patented in 1905 by the A.C. Clark Company of Chicago, IL. This company also sold dental spittoons, bracket tables (Figure 3), and a variety of office furnishings. It was started by Albert Charles Clark, who was born in Mattoon, Illinois, February 7, 1868. In 1884, he came to Chicago for work. His first job was as a day laborer, sorting scrap iron in the North Chicago Rolling Mills Company, for the sum of $1.50 a day. Following that, he had a 5-year stint in the insurance business; and from 1890 to 1892 was a salesman in a dental supply house. In 1892, he decided to venture on his own, selling furnishing and fixtures to dentists. Figure 3 His most notable achievement was the revolving octagonal cabinet (Figures 4, 5). Historically important because of its design, it is prominently displayed at the Smithsonian. Reported in print, but not confirmable, was that only 125 of the octagonal cabinets were produced. Later on, Mr. Clark became an Illinois legislator. He was instrumental in helping pass a parks bill, which at that time connected Calumet, Illinois, to the Sanitary District of Chicago.

Figures 4 and 5

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Figures 1 and 2


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Oral and Maxillofacial Pathology Diagnosis and Management

Atypical Histiocytic Granuloma (Pseudolymphoma) Oral and Maxillofacial Pathology Case of the Month (from page 698)

Discussion The routine microscopic appearance of this lesion was strongly suggestive of a lymphocytic lymphoma, but immunostains showed that it was actually a benign, lymphohistiocytic reactive lesion sometimes confused with lymphoma, i.e., a pseudolymphoma. This look-alike lesion has a confusing array of different diagnostic names, including benign lymphoproliferative disease, recurrent ulcerating lymphohistiocytic lesion, atypical histiocytic granuloma, benign lymphoid polyp, lymphoid pseudotumor, lymphocytic pseudotumor and atypical lymphohistiocytic infiltrate (1-6). Atypical histiocytic granuloma seems to be the terminology preferred currently, although the pseudotumor name is still popular in dermatology. It was first described by none other than Kaposi in 1891 (7). The oral pseudolymphoma is a decidedly uncommon reactive lesion of unknown origin and is similar to lesions arising from the orbit, skin (sometimes referred to as sarcomatosis of Spiegler-Fendt), gastrointestinal tract, lungs, nasopharynx, larynx, and breast (2, 7). Enlarged lymph nodes with a similar pseudolymphomatous reaction have occasionally been reported in patients taking a wide variety of drugs, especially diphenylhydantoin, sulfonamides, and allopurinol (7). The drug-induced pseudolymphoma is a much more

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serious entity, possibly a Type IV hypersensitivity reaction, which results in death from liver, cardiac damage or true lymphoma development in up to 10 percent of cases (7). A few cases have also been reported in association with titanium implants, infections (Borrelia, herpes simplex), hepatitis vaccinations, and collagen injections (7). Pseudolymphoma not related to drug use runs a much more benign course and its true etiology is almost completely unknown, even though its microscopic features are identical to the drug-associated lesions (4-6). In the mouth, this disease has been reported to occur on the gingiva, lips, alveolar mucosa and lateral tongue (lingual tonsil region), but the posterior hard palate is the most likely site of involvement (2, 3, 5). It most frequently occurs in older women and presents as an asymptomatic soft to firm non-ulcerated mass. It is occasionally bilateral and may be associated with cervical lymphadenopathy. Clinical laboratory investigations are almost always normal. After an initial rapid growth, the oral pseudolymphoma behaves in a benign manner and spontaneous regression has been the typical outcome. A small number of patients have developed recurrences after local excision, but none have shown evidence of a malignant process with long-term follow-up (1, 3, 6).

The oral pseudolymphoma does not require aggressive therapy of the type necessary for malignancy or systemic histiocytic disease and, for this reason, the use of immunohistochemistry is essential in order to rule out lymphoma and Langerhans cell disease (4, 5). In the present case, the primary tumor cell was shown to be an immature histiocyte, not a dysplastic lymphocyte or the unique histiocyte of Langerhans cell disease. With that determination, follow-up evaluation was elected and since the mass began shortly to diminish without treatment, it was allowed to heal on its own. If a pseudolymphoma does not follow such a behavior and continues to enlarge, conservative surgical excision or intralesional injection of corticosteroids can be performed, or rituximab may be given, but the lesion seems most often to regress spontaneously without treatment, almost always within 3-8 weeks (13, 7, 8). The present case followed a typical behavior, with complete resolution of the lesion within 5 weeks and with no recurrence after 2 years of follow. Removal of the underlying impacted third molar did not stimulate additional tissue proliferation. This case was, however, atypical in that it presented with local symptoms and was associated with an underlying infection of a partially impacted tooth. The infection was, presumably, largely responsible for the symptoms, since the pseudolymphoma is typically


asymptomatic. The extensive surface ulceration of our lesions was also atypical, but was perhaps explained by the location in the posterior mandible, with subsequent trauma from opposing dentition. This case very nicely illustrates the diagnostic and management dilemma associated with pseudolymphoma. The diagnostic criteria are not well defined and the diagnosis is never easy. The lesion may become large very, very rapidly, causing considerable alarm, and it can be easily misdiagnosed at the microscopic level as either a systemic disorder (Langerhans cell disease), an innocuous inflammatory hyperplasia (which was the first biopsy diagnosis in the present case), or a malignancy (lymphoma). Prior to the advent of immunohistochemistry techniques, there were, undoubtedly, individuals with this lesion who were treated for lymphoma. Fortunately, pseudolymphoma is a relatively rare condition and so the dilemma is unlikely to arise in a general practitioner’s office. Nevertheless, he or she must be ever alert for the odd lesion which does not seem to follow the normal presentation of more well established, better known entities in oral pathology. References 1. Kabani S, Cataldo E, Folkerth R, et al. atypical lymphohistiocytic infiltrate (pseudolymphoma) of the oral cavity. Oral Surg Oral Med Oral Pathol 1988:66:587-92. 2. De Vicente Rodriguez JC, Santos Oller JM, Junquera Gutierrez LM, Lopez Arranz JS. Atypical histiocytic granuloma of the tongue: case report. Brit J Oral Maxillofac Surg 1991; 29:350-352. 3. Del Rio E, Sanchez Yus E, Requena L, Garcia Puente L, Vazquez Veiga H. Oral pseudolymphoma: a report of two cases. J Cutan Pathol 1997:24:5155. 4. Jham BC, Binmadi NO, Scheper MA, et al. Follicular lymphoid hyperplasia of the palate: case report and literature review. J Craniomaxillofac Surg 2009; 37:79-82. 5. Shin JB, Seo SH, Kim BK, Kim IH, Son SW. Cutaneous T cell pseudolymphoma at the site of a semipermanent lip-liner tattoo. Dermatol 2009; 218:75-78. 6. Yamakawa PE, Andrade EH, Watanabe-Silva CH, Dos Santos Neto LL. Lingual tonsil pseudolymphoma and obstructive sleep apnea. Braz J Otorhinolaryngol 2009; 75:469-471. 7. Albrecht J, Fine LA, Piette W. Drug-associated lymphoma and pseudolymphoma: recognition and management. Dermatol Clin 2007; 25:233-244. 8. Witzig TE, Inwards DJ, Habermann TM, et al. Treatment of benign orbital pseudolymphomas with the monoclonal anti-CD20 antibody rituximab. Mayo Clin Proc 2007; 82:692-699.

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T HANK S TDA would like to extend a special thank you to Districts 2, 5, 7, and 9 for their support and assistance in this year’s TEXAS Meeting

Dr. Mark Albritton Dr. Courtney Alexander Dr. Barton Allen Dr. Kevin Altieri Ms. Melena Armentor Dr. Josh Austin Mr. Grady Basler Dr. Robert Beatty Dr. Doug Becker Ms. Mona Bejarano Dr. Kyle Bess Ms. Sylvia Bradford Ms. Charletta Briggs Ms. Bonnie Brooks Dr. Monica Brown Dr. Jason Browning Ms. Sharon Bryant Ms. Tina Burchfield Dr. Rene Casavantes Dr. Jeremy Chance Dr. Jim Chancellor Dr. Pat Chancellor Dr. John Chandler Ms. Terri Cloy Ms. Gayle Marie Connell Dr. Ralph Cooley Ms. Ann Cotton Dr. Taylor Cotton Ms. Nancy Crouch Ms. Beth Daigle Dr. Tommy Davis Dr. Andy Doerfler Ms. Mary Doerfler Dr. Ingrid Duebbert Dr. Richard Dyck

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Ms. Linda Fambrough Dr. Cindy Flanagan Dr. Brandon Fleshman Dr. Lawrence Freidman Dr. Leslie Fullerton Dr. Clay Fuselier Dr. David Garrett Dr. Jathen Garrett Dr. Terri German Dr. Kathy Gibson Dr. Bill Glenn Ms. Paula Glenn Dr. Whitney Gomez Dr. June Goodall Dr. Tor Gotun Dr. John Hackbarth Dr. Kelly Hale Ms. Jenny Hall Dr. Robert Hall Dr. Shirley Hamamcy Ms. Stephanie Hammond Ms. Tracy Hargave Dr. Tommy Harrison Dr. Jennifer Hathaway Dr. Kimber Holmes Dr. Milton Howard Ms. Darlene Howden Dr. Maria Lopez Howell Ms. Robin Hubier Dr. Mary Dawn Hurst Dr. Tom Hurst Dr. Joe Hutchins Ms. Amber Infante Ms. Mary Kay James Dr. Robert Kelly

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

Dr. Paul Kennedy, III Dr. Trisha Kimes Dr. Greg Kunz Dr. Galen Trey Lacy Dr. Galin Latham Ms. Christi Lawson Dr. Edwardo Lorenzana Ms. Danya Lough Dr. Anne Lyon Dr. Scott Makins Ms. Bridget Mariott Dr. Rise' Martin Dr. Lisa Masters Dr. Celeste Narro Gonzalez Ms. Rachel Newman Ms. Claudia Oelfke Dr. Katie Olson Triska Dr. Elizabeth Palacio Ms. Annalynn Pappas Dr. Jayu Patel Ms. Brenda Phillips Dr. Jim Reisman Ms. Kyra Resweber Dr. Sue Ellen Richardson Dr. Ron Risinger Dr. Jim Root Dr. Kelly Sawyer Dr. Craig Scasta Dr. Meredith Scott Dr. Jeffrey Siebert Dr. Sam Showalter Dr. Felicia Simpson Dr. Mark Smith Dr. Robert Smith Ms. Connie Sonnier

Ms. Thelma Swearingen Ms. Dodie Taubert Ms. Sophia Teel Ms. Jennifer Thigpen Dr. Melissa Tucker Dr. Karen Troendle Dr. Herb Wade D’Ette Waldrop Dr. Karen Walters Dr. Gary Weeks Ms. Lucy Weeks Dr. Jay Welch Dr. Mike Westwood Ms. Connie Williams Dr. Thomas F. Williams Dr. Jon Williamson Dr. Grant Wolfe Ms. Stacy Wolfford Dr. David Woolweaver Dr. Stephen Wright Dr. Tom Wright Dr. Bonita Wynkoop Dr. Stan Zebrowski


g n i rtis

e v Ad

Briefs

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. *

Practice Opportunities

Advertising brief rates are as follows: 30 words or less — per insertion…$35. Additional words 10¢ each.

CORPUS CHRISTI: Three operatory, feefor-service crown and bridge oriented family practice in a great location. High grossing practice on 3-day week. Doctor ready to retire. Make an offer! ID #098.

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.

MCLERRAN AND ASSOCIATES: AUSTIN: High grossing, family practice located in retail center with seven operatories was recently remodeled. Near major highway. High growth area. Practice boasts solid, well-established patient base. ID #1-0110.

HILL COUNTRY AREA: Well-established family practice located in desirable hill country town. Practice would be an excellent satellite office or starter practice. The doctor currently works 2 days per week. The practice is located in growing area with new subdivisions being built, is 20 minutes from Concan Country Club (a top rated new course in Texas) and is in an excellent retirement area. ID #063. RIO GRANDE VALLEY: Excellent four operatory, 20-year-old general practice. Modern, new finish out in retail location with digital radiography. Fee-for-service patient base and very good new patient count. Great numbers. Super upside potential. ID #093. RIO GRANDE VALLEY: Three op Medicaid oriented practice grossing high six figures on part-time work week. Excellent opportunity. ID #100.

high income area in very visible retail office center. The seven op office is in excellent condition, has a modern design, and is equipped with almost new equipment, all digital X-rays, and is fully computerized. Practice grossed seven figures last year. Price slashed! ID #094. SAN ANTONIO, NORTH WEST: Excellent four-chair general family practice in high traffic retail center across from busy mall location. Solid income on 30 hours a week. Ideal opportunity for doctor wanting a quick start in low overhead operation. ID #086. SAN ANTONIO: Prosthodontic practice with almost new equipment and build out. Doctor wants to sell and continue to work as associate. Beautiful office! Perfect for stand alone or satellite office. ID #060. SAN ANTONIO: Three operatory general practice in condominium located in highly desirable and conveniently located medical center area. This practice would be an excellent starter practice and has tremendous upside potential. The condo is also for sale. ID #084. SAN ANTONIO, NORTH CENTRAL: Twoop practice just off major freeway; perfect starter office. Terrific pricing. ID #009. SOUTH TEXAS BORDER: General practitioner with 100 percent ortho practice. Very high numbers, incredible net. ID #021.

SAN ANTONIO AREA: Three operatory offices in small town with no competition. Very good income and low, low overhead. Priced to sell. ID #013.

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: High gross and net income general family practice located in

SAN ANTONIO: Four operatory general family practice located in professional Texas Dental Journal l www.tda.org l July 2010

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g

in s i t r e dv

A

Briefs

office building off of busy thoroughfare in affluent north central side of town. Very nice equipment and decor. Excellent opportunity. ID #003. 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: Well-established, endodontic specialty practice with solid referral base. Located in growing, upper middle income area. Contact for more information. ID #074. NEW! 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 #0113. NEW! 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 #1-0112. NEW! 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 #1-0111. NEW! CENTRAL TEXAS: Well-established, FFS family practice in five op office located in growing community. Office has been recently updated, boasts a committed staff and strong hygiene program, and has seen increasing revenue in the high six figures the last 3 years. ID #1-0108.

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NEW! 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 #1-0107. WACO AREA: Modern and high-tech, 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 #1-0106. AUSTIN: Associate to ownership opportunity. Five operatory general family practice with high quality fee-for-service patient base. State-of-the-art, all digital and paperless office is as attractive as they come. Grossing above mid-six figures with very low overhead. ID #103. CORPUS CHRISTI: Doctor retiring, six op office with excellent visibility and access. Good numbers, excellent patient base, good upside potential. Excellent practice for starting doctor. Priced to sell. ID #023. 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 ith high net income. ID #106. NEW! SAN ANTONIO, NORTH CENTRAL: Beautiful, almost new, state-of-the-art six operatory office. Terrific location, great signage, affluent patient base, beautiful decor. Owner has family issues, must sell. ID #1-0114. SAN ANTONIO, NORTH SIDE: Eight oepratory, high grossing, fee-for-service


family practice in historic, free-standing building. Affluent neighborhood. Huge patient base and super hygiene program. ID #104. NEW! AUSTIN: North, high grossing, five operatory practice in free-standing building. Plenty of room to expand. Feefor-service patient base, good equipment. Owner wishes to sell and continue parttime as an associate. ID #1-0115. Contact McLerran Practice Transitions, Inc.: statewide, Paul McLerran, DDS, (210) 737-0100 or (888) 656-0290; in Austin, David McLerran, (512) 750-6778; in Houston, Tom Gugliemo and Patrick Johnston, (281) 362-1707. Practice sales, appraisals, buyer representation, and lease negotiations. See www.dental-sales. com for pictures and more complete information. HOUSTON AREA PRACTICE OPPORTUNITIES! MCLERRAN & ASSOCIATES: CONROW: ASSOCIATE BUY-IN grossing high six figures, six ops, great location on Loop 336 in exploding suburb north of Houston. Doctor wants to retire, looking for associate buy-in. Great opportunity for success now and well into the future. #H105. HOUSTON: Established crown and bridge/removable practice with digital X-rays, great new patient flow, production in high six figures. PPO and feefor-service only. Tremendous cash flow. #H109. HOUSTON: Buy-in opportunity with premier group practice. Requires existing patient base close to Texas Medical Center aera. Beautiful 12 operatory, high tech office with low overhead. Partner financed. #H115. HOUSTON: General family practice located southwest of Houston, high visibility, grossing midsix figures. Five operatories, two ready for expansion. Building and up to four acres of real estate ready for development included in sale. #H108. GOLDEN TRI-

ANGLE: Eight op general family practice grossing seven figures plus. Modern, open concept design in a highly residential area, strong new patient flow with high net. #H107. HOUSTON: Established general and family practice inside 610 for transition. #H112. HOUSTON: Beautiful four operatory general practice, very new equipment, digital X-rays, grossing in mid six figures. Located in premier Houston neighborhood. Fee-for-service only. #H106. Contact McLerran & Associates in Houston: Tom Gugieimo and Patrick Johnson, (800) 474-3049 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: Economy is strong in Texas. Many referring dentists. Retiring surgeon; outright sale or transition; seven-figure gross. Seller will work for buyer on limited basis. We have the best sources for 100 percent buyer funding. Gary Clinton is 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 SOUTH TEXAS / BROWNSVILLE / HARLINGEN AREA: Excellent practice with flexible transition. Primarily fee-for-service and Delta Dental. High operating profits; more than seven figures in collections. Lovely office. Some ortho easily expanded to larger perTexas Dental Journal l www.tda.org l July 2010

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centage of practice. Outright sale. Seller will transition / work for new owner as needed. We have the best sources for 100 percent buyer funding. Gary Clinton is 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 BRYAN / COLLEGE STATION PRACTICE FOR SALE. Transition/outright sale. Retiring dentist. Beautiful office; Restorative practice. Well-established recall. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 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 LUBBOCK / PANHANDLE AREA PRACTICE FOR SALE: P-l Four operatories, retiring dentist, high gross/net. Just over 1 hour away from large community. Near sevenfigure gross. Profit from hygiene will pay debt service. P-2 Doctor will sell/transition. High collections/net; five operatories, full hygiene. We have the best sources for 100 percent buyer funding. Gary

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Clinton is 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 NORTH DALLAS 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 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: 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: Austin, San Antonio, DFW area, and Houston. Have buyers for orthodontic, oral surgery, periodontic, pedodontic, and general dentistry practices. Values for practices have never been higher. 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 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 SAN ANGELO / ABILENE AREA PRACTICE FOR SALE: S-1 San Angelo area — Very sharp office. Plenty of patient to work 5 days a week; exceptional value. S-2 San Angelo —Excellent well-established restorative practice. Very nice equipment. Dentist relocation. Transitional/outright sale. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 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 North Dallas — Fast growing, highly desirable suburb; digital equipment; doctor relocating; will transition. O-2 West Central Texas mid-sized to larger community — Ideal transition; pro-

fessional referral based; traditional feefor-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-3 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. We have the best sources for 100 percent buyer funding. Gary Clinton is 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. SOUTH TEXAS CORPUS CHRISTI PERIODONTIC PRACTICE FOR SALE — GARY CLINTON / PMA: Doctor retiring for health reasons. Urgent sale. Great value. Nice office close to beach. Wellestablished practice. Staff will stay. We have the best sources for 100 percent buyer funding. Gary Clinton is 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. Texas Dental Journal l www.tda.org l July 2010

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GARY CLINTON ARLINGTON, TEXAS PRACTICE FOR SALE / TRANSITION: Seven figure gross; well-established cosmetic restorative practice. Arlington is one of the best places to be in Texas. Home of the Dallas Cowboys, Texas Rangers, Six Flags, and more. We have the best sources for 100 percent buyer funding. Gary Clinton is 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 HOUSTON GENERAL PRACTICE FOR SALE: CLEAR LAKE/NASA/BAY AREA: Wellestablished practice. Retiring dentist will transition (limited). Superb recall care program. Exceptional location with very good lease rate. Facility on freeway frontage road; high visibility. We have the best sources for 100 percent buyer funding. Gary Clinton is 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: Exceptional premier

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restorative practice; seven figure gross requiring experienced dentist. Newer equipment; attractive facility. We have the best sources for 100 percent buyer funding. Gary Clinton is 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 FORT WORTH AREA SOUTH GENERAL RESTORATIVE PRACTICE FOR SALE: Still an excellent rate of growth with new schools. Very nice office and equipment. We have the best sources for 100 percent buyer funding. Gary Clinton is 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 re-


tirement in low competition community. Contact The Hindley Group at (800) 8561955. Visit us at www.thehindleygroup. com. CENTRAL EAST TEXAS — SALE: Outstanding practice for sale in beautiful East Texas. Moderate FFS revenues with three fully equipped operatories and an excellent staff. Doctor leaving for the mission field and interested in optimal transition. If you are an older doctor who needs to re-complete his retirement package after the stock market drop, and want to practice in a less competitive more relaxed environment, this is a must-see opportunity. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. DALLAS / FORT WORTH: Area clinics seeking associates. Earn significantly above industry average income with paid health and malpractice insurance while working in a great environment. Fax (312) 944-9499 or e-mail cjpatterson@ kosservices.com. SOUTH OF HOUSTON GENERAL DENTAL PRACTICE — SALE: Outstanding practice with very high growth potential experiencing a strong new patient flow. Moderate revenues with a healthy profit margin on 4 days per week. Building also for sale. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. (Ginjupalli). WACO PEDIATRIC DENTAL PRACTICE — SALE: Well-established practice with moderate revenues and high profit margin on 4 days per week. Due to limited competition and a large facility, there is ample room to grow in this community that is home to Baylor University. All ortho cases are being completed, unless purchaser would like to expand new cas-

es. No Medicaid being seen, but good opportunity with enhanced state fee schedule. Experienced staff and steady new patient flow. Wonderful mentor. Building also available. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. (McGregor). NORTHWEST TEXAS GENERAL DENTAL PRACTICE — SALE: Established practice located across from large shopping mall. Wonderful staff and strong new patient flow. Digital X-rays. Ten operatories. Doctor to facilitate transition. Contact The Hindley Group, LLC,at (800) 856-1955. Visit us at www. thehindleygroup.com. (Williams). 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 buy-in terms. SOUTH CENTRAL TEXAS PERIODONTAL —Wonderful practice 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, thsi is an outstanding opportunity. WEST TEXAS GENERAL DENTAL PRACTICE — Associateship with pre-determiend buy-in and partnership terms. Nine operatories. Strong mentor Texas Dental Journal l www.tda.org l July 2010

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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. Wellestablished. 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 dentistry practices. EAST TEXAS AREA — Two general dentistry practices and one pedo practice. WEST TEXAS — Three general dentistry practices (El Paso and West Texas). NEW MEXICO — Two general dentistry practices (Sante Fe, Albuquerque). For more information and current listings, please visit our website at www.adstexas.com or call ADS Watson, Brown & Associates at (469) 2223200. SAN ANGELO: For sale — general practice, 100 percent fee-for-service. Well-established practice in a growing community of over 100,000. Excellent patient-to-dentist ratio; many dentists in community are nearing retirement so patient-to-dentist ratio expected to get even better. Five operatories — four equipped, fifth is plumbed and ready to equip. All operatories are comput-

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erized using Dentrix software. Highly productive practice with excellent collections. Staff is young, friendly, energetic and loyal with excellent clinical and managerial skills. Continued growth each year with minimal advertising, low overhead. Full-time CDT in office produces crown and bridge as well as removable prosthodontics. All lab equipment included with practice. Owner moving out of state; priced to sell. Please inquire by e-mail at sanangelodds@hotmail.com. DALLAS / FORT WORTH: Dental One is opening new offices in the upscale suburbs of Dallas and Fort Worth. Dental One is unique in that each office of our 60 offices has its own, individual name such as Riverchase Dental Care and Preston Hollow Dental Care. All our offices have top-of-the-line Pelton and Crane equipment, digital X-rays, and intra-oral cameras. We are 70 percent PPO, 30 percent full fee. We take no managed care or Medicaid. We offer competitive salaries and benefits. To learn more about working for Dental One, please contact Rich Nicely at (972) 755-0836. HOUSTON DENTAL ONE is opening new offices in the upscale suburbs of Houston. Dental One is unique in that each office of our 50+ offices has its own individual name. All our offices have top-of-the-line Pelton and Crane equipment, digital X-rays, and intraoral cameras. We are 100 percent FFS with some PPO plans. We offer competitive salaries, benefits, and equity buyin opportunities. To learn more about working for Dental One, please call Andy Davis at (713) 343-0888. 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 wtthin 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.

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.

SUGAR CREEK / SUGAR LAND: General dentist looking for periodontist, endo, ortho specialist to lease or sell. Suite is 1,500 sq. ft. with four fullyequipped treatment rooms, lab, business office, telephone system, computers, reception and playroom; 5 days per week. If seriously interested, please call (281) 342-6565.

EL PASO: FULL- OR PART-TIME ASSOCIATE NEEDED. Would be sole practitioner at location. Three operatories for DDS plus one for hygienist, equipment less than 1 year old. Past compensations up to five figures per week. No administrative responsibilities. Call (702) 510-7795 or e-mail drartbejarano@gmail.com.

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) 6753518 or e-mail dnicholsdds@earthlink. net.

ASSOCIATE NEEDED — NE TEXAS: Pittsburg is surrounded by beautiful lakes and piney woods. Well-established, quality-oriented, busy cosmetic and family practice. Associate to partnership opportunity. Call Dr. Richardson at (903) 856-6688.

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.

HOUSTON: General dentist with pediatric experience needed. Full-time position available. Excellent compensation. Please send CV to cvanalfen@yahoo. com. ASSOCIATE FOR TYLER GENERAL DENTISTRY PRACTICE: Well-established general dentist in Tyier 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. Texas Dental Journal l www.tda.org l July 2010

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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 avaialble. Our knowledgable staff will support and enhance your growth and earning potential while helping create a smooth transition. Intereted candidates should call (903) 509-0505 and/or send an e-mail to steve.lebo@sbcglobal.net. HOUSTON: Retiring dentist is seeking his successor. Located in the Heights area of Houston, this two operatory practice consistently generates revenuein the low six figures because the owner wanted it that way. What’s really remarkable about this practice is the number of active patients. A maintenance practice like this will usually have a high active patient count but relatively low revenue, which makes this acquisition a dream come true for the dentist that appreciates value and growth. The potential for this practice will only be limited by you, so open your mind and let your eyes see. Inquire to practiceinfo@comcast.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

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renee@austindentalcares.com; FAX (512) 238-9250; or call (512) 238-9250 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 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 fastpaced 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 managment 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 — 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 immeidately 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) 6976152 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. Email 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/ benefts, 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 Texas’ 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-oftown practice and must sell. Call Jim Dunn at (8.00) 930-8017. DALLAS / ROCKWALL: Seeking fulland part-time endodontists. Expanding a busy, TEAM-oriented, modern practice with a well-established referral Texas Dental Journal l www.tda.org l July 2010

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base. Must have strong clinical and people skills. E-mail endo.dr.888@ gmail.com. LUBBOCK — 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. Contact at dentist.lubbock@ gmail.com. HOUSTON MEDICAL CENTER GENERAL PRACTICE: Practice dentistry the way you have always dreamed! Incredible opportunity for general dentist to work as an associate and transition to partnership in this prestigious Texas Medical Center/Houston, four general dentists, LLP practice. Doctor retiring in 2-4 years after a 40+-year career, and wills stay for introductions and successful transition of a new dentist. Large number of loyal patients in recare. The office, located in Smith Tower of The Methodist Hospital, is convenient to the West University, Bellaire, River Oaks, and Mid-Town neighborhoods and is the beneficiary of referrals from physicans practicing in the Medical Center. State-of-the-art clinical and business systems throughout, including professional management, contemporary equipment, and an in-house dental laboratory staffed by three talented lab techs. See our website, www.ddsassociates.com, for more information, and direct any inquires to Ms. Sanders or Ms. Manovich at (713) 797-0846. HILL COUNTRY AUSTIN AREA: This is an exceptional opportunity for a general dentist to share a beautiful new office building in the Lakeway area; 3,250 sq. ft., seven ops, paperless, three existing staff members. Minimum

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investment for a start-up/finish out two to four ops and personal office. Sub-lease space for satellite location. Relocate your existing practice for more space. Great opportunity for a general dentist who surgically places implants. Opportunity to become a partner. Location pictures are avaialable. Call Sherri, (972) 562-1072 or (214) 697-6152. DENTIST FOR JCAHO-ACCREDITED COMMUNITY HEALTH CENTER IN SOUTH TEXAS. Texas license or eligible. Full-time or part-time. Competitive compensation package, and great working hours. Contact Nuestra Clinica del Valle, PO Box 1689, Pharr, TX 78577; Phone: (956) 787-8915; FAX: (956) 787-2021; E-mail: hchcc@hiline. net. EOE. 6 DAY DENTAL & ORTHODONTICS is an established group practice model, providing all dental servcies to our patients under one roof. Our general dentists and specialists work together to provide the most convenient and quality dental care possible. We have a 25 percent earned equity (no money down) opportunity for a general dentist to prosthodontist. Contact Dr. John Bond at jbond@6daydental.com and Jody Hardy at jhardy@6daydental.com. PART-TIME ASSOCIATE NEEDED IN ALLEN: Established two doctor practice moving to a beautiful new building. Must have a least 2 years experience. E-mail resume to cosmeticdentists@ me.com. PEDIATRIC DENTIST OPPORTUNITY in a well-established, fast-paced dental practice located in El Paso. Tremendous career opportunity for an associate seeking mentorship or affiliation with a senior pediatric dentist in a full-time or part-time position. As well, the practice requires a personable, caring, and


energetic individual who is looking for an enterprising opportunity. For further information, please visit our website at www.iamallsmiles.com. Please forward CV to rose@iamallsmiles.com. SAN ANGELO, ABILENE: Associates — outstanding earnings. Historically proven at over twice the national average for general dentists; future poential 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. EXPERIENCED DENTIST IS NEEDED FOR AN ESTABLISHED PRIVATE GROUP PRACTICE located in Katy. General dentistry practice with a comfortable and friendly atmosphere without administrative responsbilities. Full- and part-time positions with competitive compensation, benefits, and flexible schedule. Great opportunity for a quality oriented person. Please call Dr. Akerman at (832) 934-2044 or email at yourhappydentist@aol.com. BUSY PRACTICE SEEKING ASSOCIATE/PARTNER close to Texas Panhandle in Northwest Oklahoma. Seven ops, Cerec, digital Schick, Casey lasers. Seven figures production in 2009. Call (580) 938-2566 or e-mail kabdds@ hotmail.com. FANTASTIC OPPORTUNITY FOR GENERAL DENTIST to learn and incorporate orthdontics into career; no experience required. Become a partner/owner, full-time or part-time while building your general dental practice concurrently. All training and business support provided. Easy and affordable financing. Call now, (469) 232-3100.

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) 3264098. HIGH TRAFFIC SHELL BUILDING IN ROUND ROCK, north of Austin, in one of the fastest-growing counties. Available at $155 / sq. ft. For more information, e-mail jacque@rgtate.com or call (512) 848-2509. 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 — 1,885 SQ. FT. DENTAL OFFICE available September 2010. High traffic visibility with lots of parking. Established dentist. Five treatment rooms plumbed and ready; reception, office, conference room, two bath. Allen is one of the top five growing cities in Texas. Affluent residential, average income $98,500 within 3-miles. Contact Levin Reality, (323) 954-1934. 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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BUILT-OUT DENTAL OFFICE SPACE FOR LEASE in Northwest Houston close to 1-45 and FM 1960; 2,527 sq. ft. and 4,357 sw. ft. available. Across street from elementary school opening in August. Jay, (713) 304-0033, jsurles@cbcingram.com. TURNKEY, FULLY-EQUIPPED DENTAL OFFICE OPPORTUNITY FOR LEASE IN KATY: Modern 2,400 sq. ft., six operatory refurbished office now available. Call (281) 414-8870 or e-mail rwhdds@sbcglobal.net for more information. INGLESIDE DENTAL BUILDING FOR SALE! 1,700 sq. ft., two chairs plumbed. Rental side, near Corpus Christi. 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. ROUND ROCK — ORTHODONTIST SPACE FOR LEASE: On IH-35, between FM 620 and Hwy. 79. Call Darren Quick, (512) 255-3000. FOR SALE ESTABLISHED, FULLY EQUIPPED THREE OPERATORY LAB FOR SALE OR LEASE in Plainview. High visibility location. Seller retiring. Mentor to transition possible. Call (806) 293-2686 or (806) 292-3156, INTERIM SERVICES TEMPORARY COVERAGE (LOCUM TENENS): Professional temporary coverage of your dental practice by a colleague during maternity and disability leaves, vacation, or just some shortterm relief. Short-notice coverage is our specialty. Flat daily rate. Free quotes. No obligation, ever. A few “superstars”

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on our team seek full-time positions. All inquiries treated with absolute confidentiality. Since 1996, the nation’s largest team of distinguished dentists. Register online at www.doctorsperdiem. com; (800) 600-0963. 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 distinuished 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 —ever! Work only when you wish. Name your fee. Join online at www.doctorsperdiem. com. Phone: (800) 600-0963; 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.” MISCELLANEOUS ESTABLISHED DENTAL ASSISTING SCHOOL searching for general dental office to lease on 1 weekend day and 1 weeknight in Plano and Austin. Ongoing 12-week course. Lease payments of $1000-$1500 / month for minimal light use of the office. Please call Dr. Peter Najim, (800) 509-2864, pnajim@dentalassist.org.


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-plano.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.

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Your Patients Trust You. Who can YOU Trust? The Professional Recovery Network (PRN) addresses personal needs involving counseling services for dentists, hygienists, dental students and hygiene students with alcohol or chemical dependency, or any other mental or emotional difficulties. We provide impaired dental professionals with the support and means to confidential recovery.

Recovery are conIf you or Professional another dental professional Network cerned about a possible impairment, call the Professional Recovery Network and start the recovery pu process today. If you call to get help June for someone in need, your name and location p 630 will not be divulged. The Professional Recovery Network staff will ask for your name and phone numbers so we may obtain more information and let you know that something is being done. Statewide Toll-free Helpline 800-727-5152 Emergency 24-hour Cell: 512-496-7247 PRN Staff Donna Chamberlain, LCSW, CAS Director . . . . . . . . . . 512-615-9176 Paige Peschong, LMSW Social Worker . . . . . 512-615-9155 Courtney Bolin, MSW Social Worker . . . . . 512-615-9182 Professional Recovery Network 12007 Research Blvd. Suite 201 Austin, TX 78759 www.rxpert.org

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Perks’ Group Purchasing Equals Energy Savings Perks Group Members Pay Only a Low Million kW-h Rate!* TDA Perks Program has partnered with JLT Energy Consultants, a company that develops master programs with multiple energy providers to provide special rates for large groups of individuals. This means that through TDA Perks Program, TDA members living in deregulated areas now have access to lowertier energy prices. Following are some of the features of the TDA Perks Program contract: •Rather than an office paying a rate based on its own usage, each office under the Perks Program will be quoted as if the office used 1 million kW-h annually.

•If you sell or move your business, your contract can either be taken to your new location, or terminated without penalty. •If the price of electricity goes down during the term of your agreement, you can request “blend and extend” to take advantage of these lower rates. •The Contract is for a FIXED rate per kilowatt, regardless of usage. •The contract can be for one year up to four years; each dentist office has a choice, and is only responsible for his/her own contract.

To Qualify for TDA Perks Group Electricity Program: 1. You must be a TDA member. 2. *Your area must be deregulated to permit competition. 3. Your current contract must be expired or expiring. When your contract expires, you can join other TDA members who qualify for a lower-tier rate, and save thousands of dollars per year. If your office uses 80,000, 90,000 or less than 250,000 kW-h, it can sign a new contract to pay the same rate as those using 1-million to 2-million kilowatt hours of electricity per year. Your new rate will effectively give you a savings equal to free electricity for the last two months of every year.

Learn more: tdaperks.com

For more information, call JLT Energy:

(682) 224-1385

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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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Texas Dental Journal l www.tda.org l July 2010 “The Hartford” is The Hartford Financial Services Group, Inc. and its subsidiaries. ©2009 The Hartford.


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