April 2021
TEXAS DENTAL
Inside:
Whitening Strips: Are They Effective Home Care Products?
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Texas Dental Journal | Vol 138 | No. 4
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Contents April 2021 Established February 1883 n Vol 138, No. 4
FEATURES 250 | Whitening Strips: Are They Effective Home Care Products? Asra Sabir Hussain, BDS Taha Mohammad Masood, BDS Amal Taha Alsomaly, BDS Meteib Joraib AlToubity, BDS Loliana Mouner, BDS Mujahed Sultan, BDS The aim of this review was to examine the efficacy and safety profile of whitening strips containing variable concentration of hydrogen peroxide content in comparison to other over-thecounter whitening products.
DEPARTMENTS 240 | President’s Message 242 | TDA Governance: Official Call to the 2021 Texas Dental Association House of Delegates 244 | Oral and Maxillofacial Pathology Case of the Month 248 | Calendar of Events
TDA members, use your smartphone to scan this QR Code and access the online Texas Dental Journal.
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249 | In Memoriam | Memorials/Honorariums
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272 | Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management 274 | Value for Your Profession: Does Dentistry Have an Essential Role in the Fight Against Coronavirus, Heart Disease, Osteoporosis and More? 278 | Advertising Briefs 290 | Index to Advertisers
Editorial Staff Daniel L. Jones, DDS, PhD, Editor Paras B. Patel, DDS, Associate Editor Nicole Scott, Managing Editor Barbara Donovan, Art Director Lee Ann Johnson, CAE, Director of Member Services
Editorial Advisory Board Ronald C. Auvenshine, DDS, PhD Barry K. Bartee, DDS, MD Patricia L. Blanton, DDS, PhD William C. Bone, DDS Phillip M. Campbell, DDS, MSD Michaell A. Huber, DDS Arthur H. Jeske, DMD, PhD Larry D. Jones, DDS Paul A. Kennedy Jr, DDS, MS Scott R. Makins, DDS, MS Daniel Perez, DDS William F. Wathen, DMD Robert C. White, DDS Leighton A. Wier, DDS Douglas B. Willingham, DDS
The Texas Dental Journal is a peer-reviewed publication. Texas Dental Association 1946 S IH-35 Ste 400, Austin, TX 78704-3698 Phone: 512-443-3675 • FAX: 512-443-3031 Email: tda@tda.org • Website: www.tda.org Texas Dental Journal (ISSN 0040-4284) is published monthly (one issue will be a directory issue), by the Texas Dental Association, 1946 S IH-35, Austin, TX, 787043698, 512-443-3675. Periodicals Postage Paid at Austin, Texas and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S IH 35, Austin, TX 78704. Copyright 2018 Texas Dental Association. All rights reserved. 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 NonADA Affiliated. For in-state orders, add 8.25% sales tax. Contributions: Manuscripts and news items of interest to the membership of the society are solicited. Electronic submissions are required. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. For more information, please refer to the Instructions for Contributors statement printed in the September Annual Membership Directory or on the TDA website: tda.org. All statements of opinion and of supposed facts are published on authority of the writer under whose name they appear and are not to be regarded as the views of the Texas Dental Association, unless such statements have been adopted by the Association. Articles are accepted with the understanding that they have not been published previously. Authors must disclose any financial or other interests they may have in products or services described in their articles. Advertisements: Publication of advertisements in this journal does not constitute a guarantee or endorsement by the Association of Association of the quality of value of Dental Editors and such product or of the claims made of Journalists. it by its manufacturer.
Board of Directors PRESIDENT Jacqueline M. Plemons, DDS, MS 214-369-8585, drplemons@yahoo.com PRESIDENT-ELECT Debrah J. Worsham, DDS 936-598-2626, worshamdds@sbcglobal.net PAST PRESIDENT Charles W. Miller, DDS 817-478-2300, cwdam@sbcglobal.net VICE PRESIDENT, NORTHEAST Robert A. Neal, DDS 972-377-7333, raneal@msn.com VICE PRESIDENT, SOUTHEAST Jesse “Jay” G. Welch Jr, DDS 713-486-4259, jesse.g.welch@uth.tmc.edu VICE PRESIDENT, SOUTHWEST James S. Bone, DDS 830-257-3000, jamie@hcfdental.com VICE PRESIDENT, NORTHWEST Xochitl Anderton, DDS 806-495-3600, anderton@postfamilydentistry.com SENIOR DIRECTOR, NORTHEAST Carmen P. Smith, DDS 214-503-6776, drprincele@gmail.com SENIOR DIRECTOR, SOUTHEAST Georganne P. McCandless, DDS 281-516-2700, gmccandl@yahoo.com SENIOR DIRECTOR, SOUTHWEST J. Ted Thompson, DDS 361-242-3151, tedito@aol.com SENIOR DIRECTOR, NORTHWEST E. Dale Martin, DDS 817-238-6450, pdalw@yahoo.com DIRECTOR, NORTHEAST Elizabeth S. Goldman, DDS 214-585-0268, texasredbuddental@gmail.com DIRECTOR, SOUTHEAST Glenda G. Owen, DDS 713-622-2248, dr.owen@owendds.com DIRECTOR, SOUTHWEST Carlos Cruz, DDS 956-627-3556, ccruzdds@hotmail.com DIRECTOR, NORTHWEST Teri B. Lovelace, DDS 325-695-1131, lovelace27@icloud.com SECRETARY-TREASURER* Cody C. Graves, DDS 325-648-2251, drc@centex.net SPEAKER OF THE HOUSE* John W. Baucum III, DDS 361-855-3900, jbaucum3@gmail.com PARLIAMENTARIAN** Glen D. Hall, DDS 325-698-7560, abdent78@gmail.com EDITOR** Daniel L. Jones, DDS, PhD 214-828-8350, editor@tda.org LEGAL COUNSEL Carl R. Galant William H. Bingham, Advisor *Non-voting member **Non-voting attendee
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Terry Watson, D.D.S.
Jeremy Brown, J.D.
Frank Brown, J.D., LL.M.
Free Dental Practice Valuation
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Texas Dental Journal | Vol 138 | No. 4
New from Elsevier:
Mosby’s Dental Drug Reference 13th Edition, Arthur H. Jeske, Ph.D., D.M.D., Editor in Chief
Key Features • More than 800 drug monographs include each drug’s generic name, pronunciation, brand names, drug class, controlled substances schedule, mechanism of action, uses/ indications, pharmacokinetics, doses & routes of administration, and more; • Detailed dental considerations at the end of each monograph include an easy-to-use list of specific dental-related information, saving you time with information that is dentistry-focused and easy to use; • Convenient reference information in the front of the book includes a primer on the management of medically-compromised patients, and the back of the book includes convenient appendices on abbreviations, drugs associated with dry mouth, drugs that affect taste, information on oral contraceptives, prevention of medication errors, and improving medication safety;
2022
• Evolve website. This link to internet-based information includes additional monographs on biologic agents, images of common oral pathologic conditions, alternative medications, and drugs of abuse.
About the author: Arthur H. Jeske is Professor in the Department of General Practice and Dental Public Health and Associate Dean for Strategic Planning and Continuing Dental Education, University of Texas School of Dentistry at Houston. He is a Life Member of the Texas Dental Association and holds Fellowships in the American College of Dentists, the International College of Dentists, the Academy of Dentistry International, and the Pierre Fauchard Academy. Dr. Jeske earned his Ph.D. (Pharmacology) and D.M.D. degrees from the Medical College of Georgia. He has served as Chair of the American Dental Association’s Council on Scientific Affairs and as an evidence reviewer for the ADA Center for Evidence-Based Dentistry.
Available at: https://www.elsevier.com www.tda.org | April 2021
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ToothTalk
Jacqueline Plemons
DDS, MS
87th Texas Legislature—A Record Year
A
s most of you know, the 87th Texas Legislature began on January 12, 2021, and runs through May 31. Actual bill filing ended on March 12 with a total of 7,000 bills being filed—the third highest number in Texas history. While COVID-19 may have initially slowed the overall legislative process, it did not delay the activities of our TDA legislative team in any way. In fact, the team has been more targeted and strategic than ever in representing issues important to Texas dentists. “Appearing” busy and being productive are sometimes 2 very different things. It’s often the “behind-the-scenes” efforts that bring compromise and opportunities for real change. From backyard visits to regular COVID screening and testing in advance of often limited in-person meetings, the team has adapted to our “new world.” The process may have started more slowly than usual, but that is certainly not the case for our legislative and regulatory team! The TDA is currently tracking over 400 bills which can affect dentistry. Our approved legislative agenda this session includes: • Teledentistry • Insurance issues (network leasing and retroactive denials) • Access to oral health care (Dental Education Loan Repayment Program and funding and administration of Texas public health dental programs including Medicaid and CHIP) • Support of dental school and Texas State Board of Dental Examiners funding • Preserving dentists’
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•
independent professional judgement in dental practice models Protecting Texas dental patients in scope of practice issues
Here a few highlights of issues that are receiving much attention from our legislative team at the Texas Capitol right now! TDA’s insurance bill (HB 1934) has been filed by House Insurance Committee Chair Representative Tom Oliverson (R–Houston). The bill is aimed at state-regulated dental insurers and will help create transparency in network leasing laws by insuring that dentists can review contracts before participating in a leased, sold, or rented network. It also requires reasonable procedures and time frames for insurance companies to follow in payment recovery efforts. A committee substitute was voted favorably out of the House Insurance Committee and continues to work its way through the legislature. Currently there are 2 teledentistry bills being considered by the House Public Health Committee. Representative Stephanie Klick (R– Fort Worth), chair of the House Public Health Committee, filed a companion bill (HB 2056) to Senate Health and Human Services Committee Vice-Chair Senator Charles Perry’s (R–Lubbock) teledentistry legislation (SB 488). The second teledentistry bill currently being considered by the House Public Health Committee (HB 1742) was filed by House Public Health Committee Vice Chair Representative Bobby Guerra (D–Mission). The TDA legislative team remains in active discussion with bill authors and other
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stakeholders to ultimately negotiate a bill that aligns with TDA’s teledentistry policy supporting the same standard of care whether patients are receiving dental treatment in person or via a teledentistry platform. Current standard of care requires Texas dentists, at a minimum, on an annual basis, to document findings from a tactile and visual clinical examination of the soft and hard tissues of the patient’s oral cavity. TDA successfully worked with Representative Tom Oliverson (R– Houston) who ultimately amended his medical billing tax legislation to specifically include dental insurance claims in the sales tax exclusion for medical billing services. The bill was voted unanimously out of the House and favorably out of the Senate Finance Committee as of April 12. Our legislative team drives the dayto-day efforts during a Legislative session, but our grassroots efforts are often successful in using relationships between people to bring opportunities for change and progress. Be sure to watch your emails for calls to action allowing you to communicate your view on TDA issues directly to your legislators via Voter Voice!
,
The 8 Th Linda C. niessen GeriaTriC denTisTry symposium
NAVIGATING DIFFICULT DENTISTRY FOR GERIATRIC PATIENTS
V I R T U A L S Y M P O SIUM ONLINE vi a ZOOM
Friday, June 18, 2021 8:30 am - 4:30 pm
Linda C niessen,
,
(CT)
,
dmd, mph, mpp
event organizer
Dean, Kansas City University College of Dental Medicine
helena Tapias perdigon, dds, ms
Associate Professor Comprehensive Dentistry
Gregory J. Folse,
Gretchen Gibson,
SCDA Geriatric Fellow Private Nursing Facility Practice Lafayette, LA
Director, Oral Health Quality Group VHA Office of Dentistry Fayetteville, AR
DDS
DDS, MPH
7 Hours CE credits provided through Texas A&M College of Dentistry Office of Continuing Education
R egisteR online ht tps://8thlindaniessenlec tureship.eventbrite.com/
Questions? Contact Dr. Helena Tapias: 214.828.8940 or htapias@tamu.edu www.tda.org | April 2021
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OFFICIAL CALL TO THE 2021 TEXAS DENTAL ASSOCIATION HOUSE OF DELEGATES HOUSE OF DELEGATES:
In accordance with Chapter IV, Section 70, paragraph A-1 of the Texas Dental Association (TDA) Bylaws, this is the official call for the 151st Annual Session of the Texas Dental Association House of Delegates. All sessions of the House will be in the Lonestar Ballroom of the Grand Hyatt Hotel in San Antonio, Texas. The opening session of the House will convene at 8:00 a.m. on Thursday, May 6, 2021. The second meeting of the House will be at 1:30 p.m. on Friday, May 7, 2021. The third meeting of the House will be at 8:00 a.m. on Saturday, May 8, 2021, followed by the fourth meeting at 1:30 p.m. until close of business. Registration is required for certified delegation members to attend the 2021 Annual Session of the House of Delegates (please see the meeting mobile app or the TDA website for additional information on how to register). Attendees must register before April 14, 2021, to receive a badge at no cost. There are conditions required of TDA to hold
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in-person meetings at the hotel at this time, including physical distancing and wearing masks. Therefore, meeting rooms will be set up with physical distancing in mind with only certified seated members of each delegation participating on the Floor of the House in this Annual Session of the House of Delegates. Component Societies are urged to certify an accurate list of Delegates and Alternates to fill each of their seats on the floor of the TDA House of Delegates as only members who are on the floor of the House may enter the room. Substituting alternates for delegates while the House is in session is allowed but must be orchestrated while keeping restrictions in place.
REFERENCE COMMITTEE HEARINGS:
Reference Committee hearings will be facilitated through electronic virtual means on Thursday, May 6, 2021 (please see the meeting mobile app or TDA website for additional information on how to participate and for any
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changes to committee start times which will also be announced to the House of Delegates at the first meeting of the House of Delegates):
10:00 AM REFERENCE COMMITTEES A & B (COMBINED) COMMITTEE A: Administration, Budget, Building, House of Delegates, Membership Processing COMMITTEE B: President’s Address, Miscellaneous Matters, Component Societies, Subsidiaries, Strategic Planning, Annual Session
1:00 PM REFERENCE COMMITTEES C & D (COMBINED) COMMITTEE C: Dental Education, Dental Economics, Health and Dental Care Programs Committee D: Legislative, Legal and Governmental Affairs
3:30 PM REFERENCE COMMITTEE E: Constitution, Bylaws, Ethics & Peer Review
The agendas for these committee meetings will be included in the Reference Committee section of the Delegate materials and sent to the Delegates and Alternate Delegates at least 30 days in advance of the meetings.
Grand Hyatt hotel on Friday, May 7, 2021, from 10:30 a.m. to 12:00 p.m. In the event there are no contested TDA statewide elections, the TDA Candidates Forum will not be held.
REFERENCE COMMITTEE REPORTS:
Registration is required to attend the Candidates Forum—please see the meeting mobile app or TDA Meeting website for additional information.
Reference Committee Reports will be posted on the TDA website and emailed in PDF format to the members of the House of Delegates (reports may be downloaded from any location with Internet access). Printed copies will not be provided.
FINANCIAL FORUM: The TDA SecretaryTreasurer will facilitate a one-hour questions and answer financial forum at 9:30 a.m. in the Lonestar Ballroom of the Grand Hyatt hotel on Friday, May 7, 2021 open to all members who are present in San Antonio—please see meeting mobile app or TDA website for scheduled time, additional information, and room assignment.
CANDIDATES FORUM: As a reminder, the ADA & TDA Candidates Forums will be held in the Lonestar Ballroom of the San Antonio
DIVISIONAL CAUCUSES: Divisional Caucuses (Northwest, Northeast, Southwest, Southeast) will be facilitated entirely through electronic virtual means at 6:00 p.m. CDT on Monday and Tuesday, April 26 and 27, 2021. Registration is required and open to all current members—please see the meeting mobile app for schedules, additional information.
DELEGATE MATERIALS:
sent after the March 2021 TDA Board of Directors meeting. The minutes of the TDA Board shall be posted on the members’ side of the TDA website and made available to the general TDA membership once the minutes are approved by the TDA Board of Directors, in accordance with Policy 26-2018-H. Delegates and alternates will receive all House Documents in PDF format. Printed copies of the House Documents will not be provided.
Wireless internet access will not be provided in the House of Delegates meeting room— please download all House materials on a fully charged laptop or device prior to attendance (charging stations will be centrally located in the meeting rooms).
In accordance with TDA Bylaws, the House documents will be sent electronically at least 30 days prior to the Annual Session. The supplements to the House Documents, containing the agenda and subsequent reports, will be
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ORAL
and maxillofacial pathology
Clinical Presentation
A 22-year-old White female was referred to the oral surgeon because of a rapidly enlarging mass involving her left mandibular gingiva. Review of the patient’s medical history revealed that she was 29 weeks pregnant. The patient was otherwise healthy with no underlying medical conditions and was currently taking prenatal vitamins. Clinical examination revealed an erythematous exophytic mass involving the lingual, interproximal and buccal gingival tissues of the left mandibular first premolar, #21 (Figure 1A, 1B). Slight tooth mobility was observed and the lesion was tender to palpation and bled readily upon manipulation. The patient reported that the
Figure 1A. Clinical image of the exophytic lesion involving the lingual, distal-interproximal, and buccal aspects of #21. The lesion appears hemorrhagic and is red-purple in color with overgrowth along the occlusal aspect.
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case of the month lesion had been present for approximately 2 months with rapid growth over the last 2 weeks. A radiograph was taken at the time, showing no overt evidence of an intraosseous component or marked bone loss (Figure 2). Given the clinical features, an excisional biopsy was performed with the use of local anesthetic and submitted for histopathologic evaluation. The histopathologic findings revealed a hyperplastic mucosal nodule with overlying ulceration (Figure 3A). The specimen showed numerous dilated blood vessels and proliferating endothelial cells within a fibrous stroma with scattered subacute inflammation (Figure 3B).
What is your diagnosis? See page 272 for the answer and discussion.
Figure 1B. Buccal aspect of the lesional area shows edema and erythema of the tissue without an exuberant overgrowth.
Figure 2. Periapical radiograph showing no obvious bone loss or an osseous lesion.
AUTHORS Paras Bharatkumar Patel, DDS Assistant Professor, Oral and Maxillofacial Pathology, Department of Diagnostic Sciences, TAMU College of Dentistry, Dallas, Texas
Colten Ducote, DDS, MD Oral and Maxillofacial Surgeon, Private practice: ArkLaTex Oral and Maxillofacial Surgery, Shreveport, Louisiana
Figure 3A. Low power view of the lesion showing a nodular lesion with an ulcerated surface with prominent dilated blood vessels (H&E, Original mag x4).
Figure 3B. Higher power view showing a proliferation of endothelial cells forming variable sized blood vessels in a fibrous stroma with scattered subacute inflammation (H&E, Original mag x 40).
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Anesthesia Education & Safety Foundation Two ways to register: Call us at 214-384-0796 or e-mail us at sedationce@aol.com Visit us on the web: www.sedationce.com
NOW Available: In-Office ACLS & PALS renewals; In-Office Emergency Program
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Two ways to Register for our Continuing Education Programs: e-mail us at sedationce@aol.com or call us at 214-384-0796
OUR GOAL: To teach safe and effective anesthesia techniques and management of medical emergencies in an understandable manner. WHO WE ARE: We are licensed and practicing dentists in Texas who understand your needs, having provided anesthesia continuing education courses for 34 years. The new anesthesia guidelines were recently approved by the Texas State Board of Dental Examiners. As practicing dental anesthesiologists and educators, we have established continuing education programs to meet these needs.
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New TSBDE requirement of Pain Management Two programs available (satisfies rules 104.1 and 111.1) Live Webcast (counts as in-class CE) or Online (at your convenience)
All programs can be taken individually or with a special discount pricing (ask Dr. Canfield) for a bundle of 2 programs:
Principles of Pain Management Fulfills rule 104.1 for all practitioners
Use and Abuse of Prescription Medications and Provider Prescription Program Fulfills rules 104.1 and 111.1
SEDATION & EMERGENCY PROGRAMS: Nitrous Oxide/Oxygen Conscious Sedation Course for Dentists:
Credit: 18 hours lecture/participation (you must complete the online portion prior to the clinical part)
Level 1 Initial Minimal Sedation Permit Courses:
*Hybrid program consisting of Live Lecture and online combination Credit: 20 hours lecture with 20 clinical experiences
SEDATION REPERMIT PROGRAMS: LEVELS 1 and 2 (ONLINE, LIVE WEBCAST AND IN CLASS) ONLINE LEVEL 3 AND 4 SEDATION REPERMIT AVAILABLE!
(Parenteral Review) Level 3 or Level 4 Anesthesia Programs (In Class, Webcast and Online available): American Heart Association Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) Initial and Renewal Programs NOTE: ACLS or PALS Renewal can be completed by itself at any combined program
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WEBCASTING and ONLINE RENEWALS AVAILABLE! Live and archived webcasting to your computer in the comfort of your home. Here are the distinct advantages of the webcast (contact us at 214-384-0796 to see which courses are available for webcast): 1. You can receive continuing education credit for simultaneous live lecture CE hours. 2. There is no need to travel to the program location. You can stay at home or in your office to view and listen to the course. 3. There may be a post-test after the online course concludes, so you will receive immediate CE credit for attendance 4. With the webcast, you can enjoy real-time interaction with the course instructor, utilizing a question and answer format
OUR MISSION STATEMENT: To provide affordable, quality anesthesia education with knowledgeable and experienced instructors, both in a clinical and academic manner while being a valuable resource to the practitioner after the programs. Courses are designed to meet the needs of the dental profession at all levels. Our continuing education programs fulfill the TSBDE Rule 110 practitioner requirement in the process to obtain selected Sedation permits.
AGD Codes for all programs: 341 Anesthesia & Pain Control; 342 Conscious Sedation; 343 Oral Sedation This is only a partial listing of sedation courses. Please consult our www.sedationce.com for updates and new programs.
Two ways to Register: e-mail us at sedationce@aol.com or call us at 214-384-0796
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THE
i N S T I T UT E of HOUSTON DENTAL SYNERGY
LIVE learning returns to the Institute of Houston Dental Synergy’s state-of-the-art facility! Engage with the dental community and elevate your practice through multi-disciplinary CE. Visit www.ihds-ce.com to learn more & register!
2021 Dates
Faculty & Course
May 13
Dr. Manish Garala
TH 6-9pm
Resorption - Etiology, Diagnosis and Management What We All Need to Know
May 14
Ralph Georg
June 4
Dr. Tracy Nguyen & Dr. Michelle Weddle
June 5
Dr. A.H. Kawaiah
Sep 10-11
Implant Fellowship 3: Session 1
Sep 18-19
Dr. Miguel Ortiz
Sep 24-25
Daniel Ramos, E. Todd Scheyer, John Karotkin, Octavio Cintra & Giancarlo Romero
FRI 8am-4pm FRI 8am-4pm SAT 8am-Noon 8am-5pm SAT-SUN 8am-4pm 8am-4pm
DSDApp Day!
The Dentist’s New Role in Airway Management MSE for Ortho
Session 2-3: Oct 1-2, Nov 12-13, Session 4 TBA The Art of Veneers
Beyond Perio-Ortho Limits
Oct 22
Dr. Miguel Stanley
Oct 29-30
Dr. Giancarlo Romero & Dr. Aldo Sordelli
FRI 8am-4pm 8am-5pm
Dec 3
FRI afternoon
No Half Smiles & Slow Dentistry Ridge Preservation & Immediate Implant Placement & Provisionalization in the Esthetic Zone
iHDS Symposium
Followed by Christmas Party
All events subject to change -- Stay current & connected: www.ihds-ce.com. www.tda.org | April 2021 www.tda.org | October 2020
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Calendar
of events
JKJ Pathology Oral Pathology Laboratory
John E Kacher, DDS • Available for consultation by phone or email • Color histology images on all reports • Expedited specimen shipping with tracking numbers • Reports available online through secure web interface
Professional, reliable service with hightechnology solutions so that you can better serve your patients. Call or email for free kits or consultation. jkjpathology.com 281-292-7954 (T) 281-292-7372 (F) johnkacher@jkjpathology.com
Protecting your patients, limiting your liability
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Texas Mission of Mercy Schedule 2021 JUNE 4-5, 2021: San Angelo, Texas
JULY 9-10, 2021: Brady, Texas
AUGUST 27-28, 2021: Luling, Texas
NOVEMBER 5-6, 2021: San Antonio, Texas
Due to the COVID-19 global crisis, please check each meeting’s website for up-to-date information related to cancellations or rescheduling. THE TEXAS DENTAL JOURNAL’S CALENDAR will include only meetings, symposia, etc., of statewide, national, and international interest to Texas dentists. Because of space limitations, individual continuing education courses will not be listed. Readers are directed to the monthly advertisements of courses that appear elsewhere in the Journal.
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IN MEMORIAM
Texarkana June 23, 1924–March 8, 2021 Life: 1989 • Fifty Year: 1997
John Sutherlin Guttry
Longview May 25, 1931–February 18, 2021 Good Fellow: 1979 • Life: 1996 • Fifty Year: 2006
Armando R Mejia
Houston October 30, 1955–January 8, 2021
Jack Aten Lyons
Hearne June 30, 1926–March 20, 2021 Good Fellow: 1973 • Life: 1991 • Fifty Year: 1999
Daniel C Bush
Arlington March 19, 1952–March 2, 2021 Good Fellow: 2003 • Life: 2017
MEMORIAL/HONORARIUM
Those in the dental community who have recently passed
Memorial and Honorarium Donors to the Texas Dental Association Smiles Foundation Donna Carter
submitted by Linda, Keith, and Dr David May Jr Your memorial contribution supports: • •
Educating the public and profession about oral health Improving access to dental care for the people of Texas Please make your check payable to: TDA Smiles Foundation, 1946 S IH 35 Austin, TX 78704
www.tda.org | April 2021
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Whitening Strips: Are They Effective Home Care Products? AUTHORS Asra Sabir Hussain, BDS Post Doc Restorative Dentistry Certificate (University of Michigan)* (Corresponding Author); MS student (Clinical Research) New York University, New York USA Taha Mohammad Masood, BDS Henry M Goldman School of Dental Medicine, Boston University, USA Amal Taha Alsomaly, BDS Dental Resident, Primary Health Care Center, Bisha KSA Meteib Joraib AlToubity, BDS General Dentist, King Fahad General Hospital, Jeddah KSA Loliana Mouner, BDS General Dentist, Dubai UAE Mujahed Sultan, BDS General Dentist, King Abdulaziz Hospital, Makkah KSA Corresponding Author: Asra Sabir Hussain, BDS Email: dr.asrasabir@gmail.com or as14025@nyu.edu Conflict of interest: The authors declare no conflict of interest to the products mentioned in the manuscript.
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Abstract
Tooth bleaching procedures are often considered as the preferred esthetic approach for treating extrinsic tooth discoloration cases that are commonly present in dental clinics. Most patients desire to have whiter teeth for cosmetic reasons. Moreover, a variety of over-thecounter whitening products, including whitening oral rinses, dentifrices, paint-on gels, chewing gum, dental floss, and whitening strips are available as home care products. Moreover, the potential determinant factors in the effectiveness of whitening treatment are usually the concentration of the bleaching agent and the duration of the exposure time.
Objectives
The aim of this review was to examine the efficacy and safety profile of whitening strips containing variable concentration of hydrogen peroxide content in comparison to other over-the-counter whitening products.
Clinical Significance
Clinical trials effectively support the evidence of longterm safety profile and effectiveness of tooth whitening with gel strips containing 14% hydrogen peroxide, resulting in 42-49% improvement in tooth color and faster whitening onset without clinical evidence of increased oral tissue irritation.
Key words
Whitening strips; bleaching strips; whitening agents; novel strips; novel bleaching; dental whitening; dental bleaching; OTC products Texas Dental Journal | Vol 138 | No. 4
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Introduction Tooth bleaching procedure are often considered the preferred esthetic approach for treating extrinsic tooth discoloration cases that commonly present in dental clinics. Most patients desire to have whiter teeth for cosmetic reasons. In-office tooth bleaching or professional bleaching techniques are known to be conservative, safe, effective, and provide long-lasting, predictable clinical outcomes. Moreover, a variety of over-the-counter whitening products such as whitening oral rinses, dentifrices, paint-on gels, chewing gum, dental floss, and whitening strips are readily available as home care products. However, there is insufficient clinical evidence available in the literature with relevance to the safety and effectiveness of these over-the-counter (OTC) products. Whitening strips are proven to show some predictable esthetic outcomes, but these results have insufficient clinical relevance as the studies were based on short term evaluations. In fact, legislation varies in different countries across the globe regarding the use of OTC dental bleaching products as a home care intervention. Especially in young individuals, these products might cause significant harmful results. It is the foremost responsibility of a dentist to be aware of these types of products and educate their patients regarding the associated drawbacks of frequently using OTC bleaching products. Independent clinical trials are required to prove the clinical efficacy of using OTC bleaching products.1
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Historically, the first hydrogen-peroxide containing whitening strips were introduced in the year 2000. Along with other available methodologies, digital image analysis or digital photographs are considered as an effective tool in the assessment of color change and have contributed to global clinical research on whitening strip product development. A series of randomized controlled clinical trials have been conducted with whitening strips containing variable hydrogen peroxide concentrations (5.3%, 6-6.5%, 9.5%, 10%, and 14%). Nevertheless, further prospective clinical trials with large sample sizes and distinctive study designs are required to address the effectiveness and long-term safety of whitening strips.2 The aim of this review was to examine the efficacy and safety profile of whitening strips containing variable concentration of hydrogen peroxide content in comparison to other OTC whitening products.
Overview Numerous clinical trials have been published that discussed the efficacy of using whitening strips (WS) (different %) in relevance to other OTC products.
Strength of Evidence (Whitening strips with 5.3% hydrogen peroxide concentration) A clinical study with 37 healthy individuals was conducted to discuss the whitening response of self-directed whitening strips with different concentrations of hydrogen peroxide. Based on the corresponding tooth color at the screening stage, the individuals were randomized to one of three groups that were given hydrogen peroxide strips (HPS) with concentrations of 1.8%, 3.3%, or 5.3% respectively. Patients were instructed to use the whitening strips twice daily for 30 minutes over 28 days. Tooth color evaluations were performed using conventional digital images analysis of the anterior teeth on days 7, 14, and 28. On day 7, significant tooth color improvement (P< 0.05) was observed with hydrogen peroxide concentrations ranging from 1.8-5.3%. Overall higher HPS concentrations tended to show significant reduction in yellowness and increased lightness at all time points. All three hydrogen peroxide strips were well tolerated and none of the subjects showed treatment-related adverse effects.3 On the other hand, a study by Gerlach, with 57 participants was conducted to evaluate the clinical effectiveness whitening strips containing a 5.3% hydrogen peroxide bleaching gel (Crest White strips) in comparison to a placebo group.4 The protocol for using whitening strips was twice per day for 30 minutes for approximately 2 weeks. The efficacy of the strips was then evaluated by comparing digital photographs of anterior teeth at day 1, day 14 and post-treatment phase (after 6 months).
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Whitening strips with 5.3% hydrogen peroxide produced a significant (P< 0.0001) tooth color improvement including reduction in yellowness and increased lightness versus the placebo group. Tooth color change was consistent after 6 months when the patients were recalled for a follow up visit. It was evident that younger participants tended to show greater initial tooth color reduction in yellowness as compared to older subjects, but this didn’t appear relevant for color retention after the treatment. Perhaps age is a potential factor to be considered that might have an impact on initial color improvement. Oral or gingival irritation and minor tooth sensitivity issues were the predominant clinical findings reported during the treatment. The whitening strips were well tolerated and no persistent treatment-related adverse effects were observed during the 6-month posttreatment monitoring period. Therefore, it is evident from the clinical trials that 5.3% HPS can produce predictable clinical results. Nonetheless, the time frame of using whitening strips should
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be taken into consideration. Gerlach RW stated the improvement in tooth color using 5.3% HPS over 2 weeks.4
Strength of Evidence (Whitening strips with 6-6.5% hydrogen peroxide concentration) Another study with 40 healthy individuals evaluated the clinical effectiveness and safety profile of using whitening strips with 6% hydrogen peroxide twice per day for 30 minutes over an extended period of 6 weeks.5 The response was evaluated biweekly after 2 weeks and extended further to 4 and 6 weeks. The authors concluded that whitening strips with 6% hydrogen peroxide, if used twice per day, showed promising whitening versus the placebo group (without peroxide content) during the initial
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2 weeks of treatment. Likewise, a meta-analysis with a larger sample population involving 148 healthy individuals supported the use of whitening strips with 6% hydrogen peroxide twice per day for 30 minutes over 2 weeks, resulting in significant tooth color improvement from baseline. Hence, it has been shown that whitening strips containing 6% hydrogen peroxide can be an effective and safe bleaching procedure.6 On the other hand, Farrell S, et al evaluated the safety profile of 6% HPS used continuously for 12 months. Results indicated that the occurrence of reported oral irritation was low in the group using 6% hydrogen peroxide content, as two individuals discontinued the treatment due to an adverse effect, demonstrating the use of 6% HPS over a longer duration with minimal adverse events. The only critical appraisal can be made from this study is that if the optimal results are achieved within two weeks, it doesn’t seem relevant to continue the use of HPS for 12 months even if it is deemed to be safe.7 An RCT was conducted by Lo EC et al with 87 adults who used either 6% HPS, 18% carbamide peroxide whitening gel, or fluoride toothpaste (placebo group) daily for 2 consecutive weeks. Significant differences in tooth color improvements were observed among groups with reported changes in brightness (L*=P< 0.001), yellowness (b*=P< 0.001) and redness units (a*=P < 0.001) using the one-
way ANOVA (Bonferroni test) method. Overall, the greatest changes were observed in L* a* b* with the 6% HPS group. Thus, 6% HPS group demonstrated significantly (P < 0.01) higher whiteness improvement, whitening satisfaction, and overall impression as compared to whitening gel and the placebo groups.8 A 12-week RCT with 46 healthy adults compared the efficacy of using 6% HPS for 30 minutes twice per day over 2 weeks in comparison to 2 whitening dentifrices (sodium fluoride (NaF) or sodium monofluorophosphate (MFP), that were recommended at least twice daily for approximately 12 weeks. Treatment response was then recorded after using the strip for 2 weeks and the dentifrice for 12 weeks respectively. Hence, there were no significant (P> 0.18) differences found between the whitening dentifrice groups at any time intervals. All whitening procedures were welltolerated while minor tooth sensitivity issues and gingival irritation were the predominant adverse events observed in these patients.9
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Likewise, a study by Xu X, et al with 52 participants was conducted to determine the efficacy and safety profile of strips containing 6% hydrogen peroxide content (Crest White strips) and paint-on gel with 5.9% hydrogen peroxide (Colgate Simply White). Patients were instructed to use the strips for 30 minutes twice daily for 2 weeks and the gel twice daily for 12 weeks, compared to a non-peroxide experimental (water rinse) control group. Therefore, significant end-of-treatment reduction in yellowness (Deltab*) and tooth color improvements were observed in the whitening strips group. Nevertheless, all treatments were found to be well-tolerated.10 Another RCT study consisted of 72 individuals comparing whitening strips containing 6% hydrogen peroxide (Crest White strips) relative to 19% sodium percarbonate film (Crest Night Effects). Efficacy and safety were evaluated after 2 weeks and at eight time points over a period of 18 months. Significant differences (P< 0.02) were seen at the end of treatment and during the post-treatment intervals. All procedures were well tolerated and no adverse events were visible during follow up visits. However, both whitening systems revealed consistent color retention during the 18-months follow-up visits.11
Patients were instructed to use strips for 30 minutes twice daily for almost 2 weeks and a painton gel twice daily for 12 weeks relative to a non-peroxide experimental (water rinse) control group. Therefore, significant end-oftreatment reduction in yellowness (Deltab*) and tooth color improvements were observed in the whitening strips
Likewise, a similar study with 43 individuals was conducted to evaluate the clinical response of using whitening strips with 6% hydrogen peroxide concentration (Crest White strips) and a customized tray system containing 10% carbamide peroxide (Opalescence 10%) for 30 minutes twice daily at home over 2 weeks. Treatment response was assessed after 2 weeks (at the end of treatment) and 6 weeks (4 weeks post-treatment). At the end of treatment both groups showed significant tooth color improvement. However, the strip group showed 89-92% reduction in
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group.
yellowness and lightness units after 6 weeks of treatment as compared to the customized tray group.12 A study by Sulieman M also demonstrated that carbamide peroxide and hydrogen peroxide home based whitening systems can achieve considerable predictable tooth whitening outcomes.13 A 3-week RCT including 48 healthy adults evaluated the efficacy and safety profile of 3 popular whitening products: a paint-on gel (18% carbamide peroxide), a whitening dentifrice, and whitening strips (6% hydrogen peroxide) products twice daily over 3 weeks, with the exception that the strips that were applied for only 14 days, per the manufacturer’s instructions. Overall, significant (P < 0.0001) color improvement was visible in the strip group. The results showed that 14-day use of 6% HPS resulted in superior tooth color improvement in comparison to the other products.14 Recently, a new strip-based vital tooth bleaching product has been introduced that is effective in providing a whitening effect equivalent to a 10% carbamide peroxide tray, while reducing the wear time. This whitening system consists of 42 maxillary and 42 mandibular strips with 6.5% hydrogen peroxide concentration. The whitening system also consists of a dual-action whitening dentifrice that might be beneficial in preventing future post treatment staining, including an ultra-soft toothbrush. Clinically, this strip-based whitening approach was 96% more effective in rcomparison to 10% carbamide peroxide tray treatment and produced 52% more whitening than the strip system containing 5.3% hydrogen peroxide content.15,16
Strength of Evidence (Whitening strips with 9.5% hydrogen peroxide concentration) A clinical study of 54 adult volunteers was conducted to determine the effectiveness and tolerability of an experimental whitening strip with 9.5% hydrogen peroxide content in comparison to a placebo control over 3 weeks. Efficacy was measured on days 4, 7, 15, and 21 using digital imaging. The experimental group showed significant (p < 0.004) improvement in tooth color on day 4 and at all subsequent followup visits as compared to the controls. Minor tooth sensitivity was reported by 12% of the subjects in the strip group and 11% of the placebo group. However, none of the participants discontinued use due to an adverse effect. Strip with 9.5% hydrogen peroxide content provided significant tooth color improvement in comparison to a placebo strip after 3
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days of product use.17 Another in vitro study supported the finding that whitening strips with 9.5% hydrogen peroxide concentration (Crest 3D White strips CWS) produced significantly greater color changes than the other OTC products.18
Strength of Evidence (Whitening strips with 10% hydrogen peroxide concentration) A clinical study with 16 subjects was conducted to evaluate the clinical effectiveness of 10% hydrogen peroxide gel (Crest White Strips Premium). The product was used under supervision, and strips were then removed after 5, 10, 30, and 60 minutes. After sample collection, peroxide levels were derived using a colorimetric peroxide assay. The median peroxide concentrations for strips, teeth, and gingiva were 7.3%, 6.4%, and 0.7% respectively at five minutes, declining to 4.6%, 2.9%, and 0.1% at 30 minutes. Moreover, the median peroxide concentrations on strips and teeth samples were above 2% after 60 minutes. The gingival peroxide concentration was relatively lower than the teeth samples. In conclusion, whitening strips with 10% hydrogen peroxide concentration provided effective tooth whitening within a short time.19 An RCT with 28 participants was conducted to evaluate the effectiveness and safety profile of a whitening oral rinse with 2% hydrogen peroxide concentration twice per day as compared with normal tooth brushing over 1 week and a whitening strip (10% hydrogen peroxide) control group.20 The 10% hydrogen peroxide whitening strip group showed significant (P <.001) tooth color improvement on day 3, continuing (P <.001) through day 8 relative to baseline. The oral rinse group did not show any significant (P >.12) tooth color change on day 3 and a significant (P=.033) increase in yellowness was visible on day 8. Both whitening products were well tolerated and none of the participants discontinued the treatment as a result of an adverse effect. The authors concluded that 7-day use of the whitening strips containing 10% hydrogen peroxide resulted in
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significant tooth color improvement in comparison to 2% hydrogen peroxide pre-brushing whitening oral rinse. Another study with 40 adults ranging from 1948 years was conducted to compare the treatment response of two different gel formulations containing different levels of peroxide.21 Crest White Strips Premium consists of 10% hydrogen peroxide (0.13 mm) bleaching gel while Crest White Strips contain 6% hydrogen peroxide (0.20 mm) respectively. Patients were instructed to use Crest White Strips Premium for
The oral rinse group did not show any significant (P>.12) tooth color change on day 3 and significant (P=.033) increase in yellowness visible on day 8.
were
ORAL RINSE
one week and Crest White Strips for 2 weeks, twice daily for 30 minutes. However, both whitening systems resulted in statistically significant tooth color improvement (p < 0.001) and the results were evident at the beginning of one week. The yellowish reduction for the 10% strips was greater than for 6% strip group. However, mild adverse events were reported. In conclusion, vital bleaching with 10% hydrogen peroxide strips at 1 week was as effective as 6% hydrogen peroxide strips used for 2 weeks. A similar study by Gerlach RW, et al with 39 individuals was conducted to determine the effectiveness and safety profile of a 10% hydrogen peroxide strip-based whitening system twice per day for 30 minutes over 1 week.22 The 10% hydrogen peroxide containing strip group showed significant (p < 0.0001) tooth color improvement after 3 days of treatment. From day 4 to day 8, continuation of strip use resulted in significant (p < 0.002) incremental improvement in both yellowness and lightness units. The authors concluded that 10% hydrogen peroxide whitening strips produced significant tooth whitening and the results were evident after 3 days of product use. Further incremental improvement in tooth color was observed with continued usage over seven days. Another study with a larger sample size of 78 participants supported the finding that 10% hydrogen peroxide whitening strips significantly lightened teeth with minimal gingival irritation and tooth sensitivity effects.23
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Strength of Evidence (Whitening strips with 14% hydrogen peroxide concentration) A novel whitening strip with 14% hydrogen peroxide concentration formally known as Crest White Strips Supreme was introduced in the year 2003. This new advanced whitening system consists of a thinner but relatively more concentrated gel on each strip. Therefore, higher concentration gel with lowered gel volume was effective in producing improved whitening without adversely affecting oral tissues. Moreover, 14% hydrogen peroxide containing strips showed significant (p<0.05) tooth color improvement compared to placebo or positive controls. Overall, the research of 408 patients showed effective clinical efficacy and tolerability for the 14% hydrogen peroxide containing strips in comparison to a positive control group.24 Moreover, using strips with higher peroxide concentrations for
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professional home-based vital bleaching approach might in increasing patient’s compliance. An RCT with 38 adults was conducted to determine the safety profile and clinical effectiveness of using concentrated bleaching gel strip twice daily versus the control product.25 The 2 whitening system differed only in concentration (14% versus 6%) and gel layer thickness (0.10 mm versus 0.20 mm). However, significant (P<.001) improvement in yellowness, brightness, and tooth color change was visible in both the groups. Tooth color improvement (P < .003) was greater in the experimental strip relative to the control group. Clinical examination depicted a low level (11%) of “minor oral irritation.” Moreover, both products were well tolerated by the patients. Therefore, 14% hydrogen peroxide gel strip provided greater whitening, including 42 to 49% greater improvement in tooth color and faster whitening onset as compared to 6% hydrogen peroxide strip, without clinical evidence of oral-tissue irritation.
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Another clinical trial including 29 subjects tested the safety profile and clinical effectiveness of a whitening system based upon the manufacturer’s recommendation of 3-week treatment regimen.26 Tooth whitening response was assessed using the VITA Classic Shade Guide. Participants in the experimental group achieved a VITA shade nearly 8 steps lighter that a placebo control, with minimal side effects. Likewise a similar clinical trial with 17 healthy adults supported the feasibility of vital bleaching with a thin layer of 14% hydrogen peroxide gel, with minimal gingival or salivary hydrogen-peroxide exposure.27
“Tray less” system A novel flexible polyethylene bleaching strip often categorized as a “tray less” system offers advantages to overall peroxide dose, contact time, and ease of use as compared to other delivery systems.28 Several clinical trials reported that
strip bleaching system can be considered as an effective approach for tooth whitening. Minimal sensitivity issues were associated with this whitening system. All sensitivity issues were relieved upon discontinuance of the whitening agent.29
Effects of Hydrogen Peroxide on the Enamel Surface One study discussed the efficacy, drawbacks, and patient compliance of using 2 OTC bleaching systems: strips versus gel in comparison to the bleaching times required to attain 6 grades of whitening effect in human teeth.30 The conclusion was drawn that both systems aided in achieving statistically significant whitening effects when a comparison was made to baseline. There were minimal side effects caused by the 2 systems. None of the teeth
studied showed detectible enamel surface changes. Both methods were proven to be well accepted by the patients. Other studies support the contention that whitening strips with controlled doses of hydrogen peroxide around 11.7% and 14% concentrations do not produce changes in surface microhardness, histomorphology, or micro-chemical mineral composition of teeth.31,32
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Genotoxic Effect of Hydrogen Peroxide Hydrogen peroxide is the active ingredient in most tooth whitening systems, and this agent might induce DNA damage. One study has reported that individuals exposed to whitening strips with 10% hydrogen peroxide concentration exhibit increased genotoxic and oxidative damage.33 Moreover, self-direction of whitening systems should be handled carefully since it may have an impact on human health. On the contrary, no genotoxic effects of 10% hydrogen peroxide concentration were reported in patients using home-based whitening systems for 30 min/day over 14 days, or even 30 days after the end of treatment.34
OTC Products Old vs New System OTC tray-based whitening systems should be used with caution because ill-fitting trays are known to cause soft tissue injury, malocclusion, and poor patient compliance, while non-tray-based systems are inexpensive, convenient, and easy to use.35
Novel Whitening Formulation A novel whitening strip showed a significant lightening effect relative to an OTC whitening strip has recently been introduced. The test formulations contain natural ingredients and are free of peroxide compounds (Oral Essentials® Whitening strips, Oral Essentials, Beverly Hills, CA). However, further studies are required to determine the effects of this novel formulation on tooth sensitivity, gingival health and the enamel surface.36
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Hydrogen peroxide is the active ingredient in tooth whitening and this agent might induce DNA damage. Therefore, a study reported that individuals exposed to whitening strips with 10% hydrogen peroxide concentration exhibit increased genotoxic and oxidative damage.
Evidence-Based Approach A question may arise about which current whitening procedure or system works most effectively? It is evident from the available literature that all whitening approaches work, and whether a night guard with 10% carbamide peroxide gel (that contains 3% hydrogen peroxide concentration), application of available OTC whitening strips, or in-office professional bleaching with 25-35% hydrogen peroxide is performed, the ultimate clinical results are relatively the same. Predictable outcomes are obtained as the mechanism of action is the same. Nevertheless, some whitening approaches are more preferred. The key determinant factor in the effectiveness of any whitening treatment is usually the concentration of the bleaching agent and the duration of the exposure time.37 Nevertheless, all clinical trials were evaluating the clinical efficacy of bleaching agents on a short-term basis and certainly had high risk of bias. Therefore the current evidence is insufficient to draw a conclusion regarding the superiority of home-based bleaching agents. Moreover, further prospective long-term and independent clinical trials are required to address the clinical efficacy of whitening strips.38,39
Recent Approaches to reduce Drawbacks Tooth hypersensitivity is the most common clinical side effect patients experience as a result of whitening procedures. New treatments are constantly being developed to decrease this and other side effects. Moreover, different agents have been added to tooth whitening gels formulations, such as potassium nitrate and amorphous calcium phosphate (ACP) to reduce hypersensitivity. A dentifrice with 5% potassium nitrate aided in reducing tooth hypersensitivity of in-office professional bleaching during the first week, and it did not affect the efficacy of the whitening outcome.40 There remains, however, a need to develop efficient and longlasting whitening treatments.
Conclusion All whitening strips with higher concentrations provide optimal clinical results. Moreover, the potential determinant factor in the effectiveness of whitening treatment is usually the concentration of the bleaching agent and the duration of the exposure time. Nevertheless, further prospective clinical trials with large sample size and stronger study designs are required to evaluate the clinical efficacy and safety profile of whitening strips.
Clinical Significance Clinical trials effectively support the longterm safety profile and effectiveness of tooth whitening with gel strips containing 14% hydrogen peroxide, resulting in 4249% improvement in tooth color and faster whitening onset without clinical evidence of increased oraltissue irritation.
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Clinical Trials Showing the Comparison of Different % of Hydro 5.3% Hydrogen Peroxide Whitening Strips Study/Clinical Trials
Product
Sample Size
Ferrari M et al
1.8% hydrogen peroxide strips (HPS), 3.3% HPS or 5.3% HPS
37
Gerlach RW
5.3% hydrogen peroxide bleaching gel (Crest White strips) or placebo strips
57
6-6.5% Hydrogen Peroxide Whitening Strips Study/Clinical Trials
Product
Sample Size
Swift EJ Jr et al
6% hydrogen peroxide whitening strip vs placebo control (no hydrogen peroxide content)
40
Gerlach RW et al
6% hydrogen peroxide whitening strip
148
Farrell S et al
6% hydrogen peroxide strips or placebo strips.
80
Lo EC et al
(1) 6% hydrogen peroxide whitening strips, (2) 18% carbamide peroxide whitening gel, and (3) a placebo (fluoride toothpaste) control group
87
Yudhira R et al
6% hydrogen peroxide whitening strips and two whitening dentifrices
46
Xu X et al
6% hydrogen peroxide WS (Crest White strips), 5.9% hydrogen peroxide paint-on gel (Colgate Simply White), or water rinse as an experimental group
52
Bizhang M et al
6% hydrogen peroxide WS and a 19% sodium percarbonate film
72
Ferrari M et al
6% hydrogen peroxide WS and 10% carbamide peroxide
43
Gerlach RW
The paint-on gel (18% carbamide peroxide) and the whitening strips (6% hydrogen peroxide)
48
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ogen Peroxide Whitening Strips Outcome With Other Products Duration of Product Use
Outcome
Drawbacks
Twice per day for 30 minutes over 28 days
Hydrogen peroxide at concentrations ranging from 1.8-5.3% resulted in significant (P<0.05) improvement
Minimal side effects
Twice daily for 30 minutes each over 2 weeks
Significant (P<0.0001) improvements in tooth color
Minor tooth sensitivity and oral irritation
Duration of Product use
Outcome
Drawbacks
Twice daily 30 minutes for 6 weeks
Significant color improvement by 6% hydrogen peroxide WS group
Minor tooth sensitivity issues
Twice daily 30 minutes for 2 weeks
Significant color improvement after 1 week (p<0.0001) and 2 weeks in relevance to baseline.
Oral irritation (22%) and tooth sensitivity (20%)
5 min daily for 12 months.
Groups did not differ significantly (p>0.49)
Oral irritation and tooth sensitivity.
Daily for 2 consecutive weeks.
Whitening strip group showed significantly (P<0.01) more favorable results than other groups
Minor tooth sensitivity and oral irritation
Strips either peroxide or placebo for twice daily 30 mins for 2 weeks while dentifrices twice daily 12 weeks
No significant (P>0.18) differences between the whitening dentifrice groups
Minor tooth sensitivity and oral irritation
Strip twice daily over 7 days while paint-on gel and rinse were used twice daily over 14 days
Whitening strips provided the greatest end-of-treatment reduction in yellowness (Deltab*). Groups differed significantly (P<0.007) Deltab* (yellowness) and DeltaL* (lightness)
Minor tooth sensitivity and oral irritation
2 weeks
Groups differed significantly (P<0.02) at end-of-treatment and throughout posttreatment
No adverse effects with long term follow ups
Twice daily 30 ins for 2 weeks
Strip group retained 89% while the tray group had 80-90%. 92% color improvement
Minor tooth sensitivity and oral irritation
Twice-daily use over 3 weeks
Strip group exhibited significant (P< 0.0001) delta b* improvement.
Minimal side effects
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9.5% Hydrogen Peroxide Whitening Strips Study/Clinical Trials Simon JF et al
Product 9.5% hydrogen peroxide whitening strip (WS) Vs placebo control
Sample Size 54
10% Hydrogen Peroxide Whitening Strips Study/Clinical Trials
Product
Sample Size
Gerlach RW et al
Crest White strips Premium, a thin layer of 10% hydrogen peroxide gel
16
Gerlach RW et al
Pre-rinse (2% hydrogen peroxide) and whitening strips (10% hydrogen peroxide)
28
Shahidi H et al
Two different peroxide-containing gel formulations one-week 10% hydrogen peroxide thin (0.13 mm) bleaching gel (Crest White strips Premium) to a marketed 2-week 6% hydrogen peroxide strip (0.20 mm) control (Crest White strips)
40
Matis BA et al
Ranir Whitening Wraps (WW2) and Crest White strips Premium (WP2) were used twice a day and Ranir Whitening Wraps (WW1) were used once a day
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Gerlach RW et al
10% hydrogen peroxide whitening strips (Crest White strips Premium) or placebo strips
39
14% Hydrogen Peroxide Whitening Strips Study/ Clinical trials
Product
Sample Size
Swift EJ Jr et al
(Crest White strips Supreme)
29
Gerlach RW et al
Crest White strips Supreme (14% hydrogen peroxide)
17
Gerlach RW
14% hydrogen peroxide (Crest White strips Supreme)
408
Gerlach RW
Thin, concentrated bleaching gel strip versus the effects of a control product
38
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Duration of Product use
Outcome
Drawbacks
30 minutes daily for 20 days
Significant (p<0.004) color improvement experienced by 9.5% hydrogen peroxide WS group
12% subjects reported Minor tooth sensitivity issues
Duration of Product use
Outcome
Drawbacks
Strips were removed after five, 10, 30, and 60 minutes
Samples differed significantly (p<0.01) concerning the 30- and 60-minute
Minor tooth sensitivity and oral irritation
Twice daily over 1 week
The strip group exhibiting significantly (P<.001) greater whitening on day 8
Minor tooth sensitivity and oral irritation
Twice daily for 30 mins for 1 week (Crest White strips Premium) while 2-week (Crest White strips)
10% hydrogen peroxide strips at 1 week was as effective as 6% hydrogen peroxide strips used for two weeks
Minor tooth sensitivity and oral irritation
(WW2), (WP2) twice a day. (WW1) once a day.
WW2 lightened more than WP2 and WW1
WW1 and WP2 caused less gingival sensitivity than WW2
Twice daily for 30 minutes over 7 days.
10% hydrogen peroxide strip group had significant (p<0.0001) color improvement
Tooth sensitivity and oral irritation
Duration of Product use
Outcome
Drawbacks
3-week treatment regimen
Significant tooth color improvement (8 VITA shades)
Minimal side effects
4 times
77% higher hydrogen-peroxide levels on teeth for the 14% hydrogen-peroxide strip
Minimal side effects
14% hydrogen peroxide strips were significantly (p<0.05) better than the placebo
Minimal side effects
Strip groups exhibited significant (P<.001) improvement
Minimal side effects
Twice-daily use
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2008 Sep;36(9):726-30. doi: 10.1016/j.jdent.2008.05.004. Epub 2008 Jul 16. Lo EC1, Wong AH, McGrath C. A randomized controlled trial of home tooth-whitening products. Am J Dent. 2007 Oct;20(5):315-8. Yudhira R1, Peumans M, Barker ML, Gerlach RW. Clinical trial of tooth whitening with 6% hydrogen peroxide whitening strips and two whitening dentifrices. Am J Dent. 2007 Sep;20 Spec No A:32A-36A. Xu X et al. Randomized clinical trial comparing whitening strips, paint-on gel and negative control. Am J Dent. 2007 Sep;20 Spec No A:28A-31A. Bizhang M et al. Clinical trial of long-term color stability of hydrogen peroxide strips and sodium percarbonate film. Am J Dent. 2007 Sep;20 Spec No A:23A-27A. Ferrari M et al. Daytime use of a custom bleaching tray or whitening strips: initial and sustained color improvement. Am J Dent. 2007 Sep;20 Spec No A:19A-22A. Sulieman M1, MacDonald E, Rees JS, Newcombe RG, Addy M. Tooth bleaching by different concentrations of carbamide peroxide and hydrogen peroxide whitening strips: an in vitro study. J Esthet Restor Dent. 2006;18(2):93-100; discussion 101. Gerlach RW1, Barker ML. Clinical response of three direct-to consumer whitening products: strips, paint-on gel, and dentifrice. Compend Contin Educ Dent. 2003 Jun;24(6):458, 461-4, 466 passim.
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15. Sagel PA1, Jeffers ME, Gibb RD, Gerlach RW. Overview of a professional toothwhitening system containing 6.5% hydrogen peroxide whiteningstrips. Compend Contin Educ Dent. 2002 Jan;23(1A):9-15; quiz 49. 16. Kugel G1, Aboushala A, Zhou X, Gerlach RW. Daily use of whitening strips on tetracycline-stained teeth: comparative results after 2 months. Compend Contin Educ Dent. 2002 Jan;23(1A):29-34; quiz 50. 17. Simon JF, Powell L, Hollis S, Anastasia MK, Gerlach RW, Farrell S. Placebo-controlled clinical trial evaluating 9.5% hydrogen peroxide highadhesion whitening strips. J Clin Dent. 2014;25(3):49-52. 18. Karadas M1, Duymus ZY1. In Vitro Evaluation of the Efficacy of Different Overthe-Counter Products on Tooth Whitening. Braz Dent J. 2015 Jul-Aug;26(4):373-7. doi: 10.1590/010364402013x0111. 19. Gerlach RW1, Barker ML, Sagel PA, Ralston CS, McMillan DA. In-use peroxide kinetics of 10% hydrogen peroxide whitening strips. J Clin Dent. 2008;19(2):59-63. 20. Gerlach RW1, Tucker HL, Anastasia MK, Barker ML. Clinical trial comparing 2 hydrogen peroxide tooth whitening systems: strips vs pre-rinse. Compend Contin Educ Dent. 2005 Dec;26(12):874-8. 21. Gerlach RW1, Barker ML, McMillan DA, Sagel PA, Walden GL. In-use comparative kinetics of professional whitening strips: peroxide recovery from strips, teeth, gingiva, and
22.
23.
24.
25.
26.
27.
saliva. Compend Contin Educ Dent. 2004 Aug;25(8 Suppl 2):14-20. Gerlach RW et al. Placebocontrolled clinical trial evaluating a 10% hydrogen peroxide whitening strip. J Clin Dent. 2004;15(4):11822. Matis BA et al. A clinical evaluation of bleaching using whitening wraps and strips. Oper Dent. 2005 SepOct;30(5):588-92. Gerlach RW1, Barker ML. Professional vital bleaching using a thin and concentrated peroxide gel on whitening strips: an integrated clinical summary. J Contemp Dent Pract. 2004 Feb 15;5(1):117. Gerlach RW1, Sagel PA. Vital bleaching with a thin peroxide gel: the safety and efficacy of a professionalstrength hydrogen peroxide whitening strip. J Am Dent Assoc. 2004 Jan;135(1):98100. Swift EJ Jr1, Miguez PA, Barker ML, Gerlach RW. Three-week clinical trial of a 14% hydrogen-peroxide, strip-based bleaching system. Compend Contin Educ Dent. 2004 Aug;25(8 Suppl 2):2732. Gerlach RW1, Barker ML, McMillan DA, Sagel PA, Walden GL. In-use comparative kinetics of professional whitening strips: peroxide recovery from strips, teeth, gingiva, and saliva. Compend Contin Educ Dent. 2004 Aug;25(8 Suppl 2):14-20.
28. Gerlach RW1, Zhou X. Vital bleaching with whitening strips: summary of clinical research on effectiveness and tolerability. J Contemp Dent Pract. 2001 Aug 15;2(3):116. 29. Donly KJ1, Gerlach RW. Clinical trials on the use of whitening strips in children and adolescents. Gen Dent. 2002 May-Jun;50(3):242-5. 30. Auschill TM1, Barcsay LA, Arweiler NB. [Strips versus gel: a clinical comparison of two over-the-counter bleaching systems]. Schweiz Monatsschr Zahnmed. 2007;117(8):843-56. 31. Götz H et al. Physical, morphological, and microRaman chemical studies on bleaching strip effects on enamel, coronal dentin, and root dentin. J Clin Dent. 2007;18(4):112-9. 32. Götz H1, Duschner H, White DJ, Klukowska MA. Effects of elevated hydrogen peroxide ‘strip’ bleaching on surface and subsurface enamel including subsurface histomorphology, microchemical composition and fluorescence changes. J Dent. 2007 Jun;35(6):457-66. Epub 2007 Mar 6. 33. Del Real García JF et al. In vivo evaluation of the genotoxicity and oxidative damage in individuals exposed to 10% hydrogen peroxide whitening strips. Clin Oral Investig. 2019 Jul;23(7):3033-3046. doi: 10.1007/s00784-018-27163. Epub 2018 Nov 14.
34. Monteiro MJF et al. Evaluation of the genotoxic potential of different delivery methods of at-home bleaching gels: a single-blind, randomized clinical trial. Clin Oral Investig. 2019 May;23(5):2199-2206. doi: 10.1007/s00784-018-26598. Epub 2018 Oct 2. 35. Kugel G1. Over-the-counter tooth-whitening systems. Compend Contin Educ Dent. 2003 Apr;24(4A):376-82. 36. Takesh T1, Sargsyan A1, Anbarani A1, Ho J1, WilderSmith P1. Effects of a Novel Whitening Formulation on Dental Enamel. Dentistry (Sunnyvale). 2017 Apr;7(4). pii: 424. doi: 10.4172/21611122.1000424. Epub 2017 Apr 3. 37. Heymann HO1. Tooth whitening: facts and fallacies. Br Dent J. 2005 Apr 23;198(8):514. 38. Hasson H1, Ismail AI, Neiva G. Home-based chemicallyinduced whitening of teeth in adults. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD006202. 39. Eachempati P1, Kumbargere Nagraj S, Kiran Kumar Krishanappa S, Gupta P, Yaylali IE. Home-based chemically-induced whitening (bleaching) of teeth in adults. Cochrane Database Syst Rev. 2018 Dec 18;12:CD006202. doi: 10.1002/14651858. CD006202.pub2. 40. Rodríguez-Martínez et al. Tooth whitening: From the established treatments to novel approaches to prevent side effects. A review paper. J Esthet Restor Dent.2019;1– 10.
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ORAL
and maxillofacial pathology diagnosis and management—from page 245
Pyogenic Granuloma (Pregnancy Tumor, Granuloma Gravidarum) Discussion
vascular smooth muscle and vasodilation.5,6
Pyogenic granuloma, is considered to be a reactive vasoproliferative tumorlike growth that is most often the result of local stimulating or irritating factors. The name itself is deceiving as the lesion is not pyogenic, as there is no association with any pyogenic organisms, nor does it consist of granulomatous inflammation. Pyogenic granulomas can affect the mucosa as well as the skin, and while it can affect both the attached and unattached tissues in the oral cavity, the most common intraoral location is the gingiva.1,2 The lesion has a tendency to affect females more often than males and is more commonly seen in children and young adults.1-4 Female predilection is thought to be related to the fluctuating effects of sex hormones, specifically estrogen and progesterone, which have been observed to play a role in angiogenesis as well as have an effect on
Clinically, pyogenic granulomas most often present as a nodular or lobular exophytic lesion with a pedunculated or sessile base. The lesions can vary in size from a few millimeters to as large as several centimeter. The surface can appear smooth, but often shows evidence of ulceration or has a hemorrhagic appearance with variation in red-bluepurple coloration.1,3 While lesions can be painless, they may have a tendency to produce some local discomfort and many lesions do bleed easily upon manipulation.1,3 The typical duration of a lesion can vary, but in a large study previously published, the mean duration of the lesion was shown to be 4 months.3
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Pyogenic granulomas have a longstanding history with pregnancy, given the increased susceptibility of these individuals, and the association with the rising levels of both estrogen
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and progesterone. The term “pregnancy tumor” or “granuloma gravidarum” has been used historically to describe epulides in pregnant females and is used synonymously for pyogenic granulomas in this clinical setting.7,8 These lesions have been observed developing more frequently within the second and third trimester, which correlates with increasing hormone levels.7,8 While the increased levels of hormones are a contributing factor, a stimulus is still thought to be necessary in many cases, such as preceding trauma or a local irritating factor, such as plaque. On occasion, some lesions have been shown to undergo resolution after childbirth as the hormonal levels drop. Another common clinical presentation of a pyogenic granuloma, termed “epulis granulomatosa”, is observed in the setting of an extraction socket.1 Clinically, the lesion will present as a vascular ulcerated mass protruding
from the site of a recent extraction. Often, a nidus, such as a boney spicule is found to be the stimulating factor. The clinical presentation does warrant some concern as malignancies, both primary and metastatic can mimic this process.
or if any questions should arise, contact with the patient’s obstetrician should be considered. Preventative care and oral hygiene should be made a priority amongst pregnant females, who may be more susceptible to developing these lesions.
reactive lesions, such as a pyogenic granuloma. Therefore, proper clinical evaluation with treatment and submission of tissue for histopathologic evaluation is necessary to ensure that patients are adequately managed.
Treatment of pyogenic granulomas typically consists of complete excision, while being cognizant of the initiating factors. Therefore, procedures such as scaling and root planing around gingival tissues is typically helpful in reducing the risk of recurrence. In cases of pregnancy, if an incisional biopsy is performed, there is value in waiting until after childbirth, knowing that some lesions may regress. The recurrence rates vary from 3%-23% and have been shown to be higher in those studies looking at pyogenic granulomas in the setting of pregnancy.1,3,4,8 Given the current American Dental Association recommendations, it is safe for pregnant women to receive some degree of routine preventive, diagnostic and restorative dental treatment, as long as proper safety measures and guidelines are followed. In cases of complicated pregnancies
When reviewing your differential diagnosis for an exophytic lesion of the gingiva, most cases are definitively diagnosed as one of four entities, pyogenic granuloma, peripheral ossifying fibroma, peripheral giant cell granuloma, or fibrous hyperplasia (fibroma, inflammatory fibrous hyperplasia)11. All four entities are reactive in nature, and are typically treated and managed the same. While all of the aforementioned lesions have clinically overlapping characteristics, it is prudent to be aware that metastases to the oral cavity also have a predilection for the gingiva, second only to the gnathic bones. While most individuals are aware of their primary disease, an oral metastasis may be the first sign of the underlying malignancy in 25% of cases.11 Metastatic lesions involving the gingival tissues are known to clinically mimic the common
1.
References Neville BW, Damm DD, Allen CM, Chi AC. (2016) Oral and Maxillofacial Pathology. 4th ed. St. Louis, MI: Elsevier, pp. 483485. 2. Ribeiro JL, Moraes RM, Carvalho BFC, Nascimento AO, Milhan NVM, Anbinder AL. Oral pyogenic granuloma: An 18-year retrospective clinicopathological and immunohistochemical study. J Cutan Pathol. 2021 Jan 23. doi: 10.1111/ cup.13970. Epub ahead of print. PMID: 33486806. 3. Gordon-Nunez MA, de Vasconcelos Carvalho M, Benevenuto TG, Lopes MF, Silva LM, Galvao HC. Oral pyogenic granuloma: a retrospective analysis of 293 cases in a Brazilian population. J Oral Maxillofac Surg. 2010;68(9):2185–8. 4. Saravana GH. Oral pyogenic granuloma: a review of 137 cases. Br J Oral Maxillofac Surg. 2009;47(4):318–9 5. Losordo DW, Isner JM. Estrogen and angiogenesis: A review. Arterioscler Thromb Vasc Biol. 2001 Jan;21(1):612. doi: 10.1161/01.atv.21.1.6. PMID: 11145928. 6. Barbagallo M, Dominguez LJ, Licata G, Shan J, Bing L, Karpinski E, Pang PK, Resnick LM. Vascular Effects of Progesterone: Role of Cellular Calcium Regulation. Hypertension. 2001 Jan;37(1):142-147. doi: 10.1161/01. hyp.37.1.142. PMID: 11208769. 7. Cardoso JA, Spanemberg JC, Cherubini K, Figueiredo MA, Salum FG. Oral granuloma gravidarum: a retrospective study of 41 cases in Southern Brazil. J Appl Oral Sci. 2013;21(3):215-218. doi:10.1590/1679775720130001 8. Daley TD, Nartey NO, Wysocki GP. Pregnancy tumor: an analysis. Oral Surg Oral Med Oral Pathol. 1991 Aug;72(2):196-9. doi: 10.1016/00304220(91)90163-7. PMID: 1923399. 9. American Dental Association. Current Policies: Adopted 1954-2016. Chicago: American Dental Association; 2017. 10. Kfir Y, Buchner A, Hansen LS. Reactive lesions of the gingiva. A clinicopathological study of 741 cases. J Periodontol. 1980 Nov;51(11):655-61. doi: 10.1902/ jop.1980.51.11.655. PMID: 6936553. 11. Hirshberg A, Shnaiderman-Shapiro A, Kaplan I, Berger R. Metastatic tumours to the oral cavity - pathogenesis and analysis of 673 cases. Oral Oncol. 2008 Aug;44(8):743-52. doi: 10.1016/j. oraloncology.2007.09.012. Epub 2007 Dec 3. PMID: 18061527.
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VALUE
for your
Provided by:
profession
DOES DENTISTRY HAVE AN ESSENTIAL ROLE
in the Fight Against Coronavirus, Heart Disease, Osteoporosis, and More? By Gary Kadi for CareCredit
T
he coronavirus (COVID-19) helped educate patients how good hygiene habits, such as hand washing, can help prevent contagious infection. It also highlighted how important having a healthy immune system is if you do become exposed and contract an infection. As patients return to the practice for hygiene and clinical care, it may be valuable to ensure they understand the connection between their oral health and other health issues in their body, including their immune system. When talking with patients about the connection between their oral and overall health, it’s important
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to introduce the topic and provide details in a way patients can understand and absorb the information. Having patients complete health history forms, taking their blood pressure and proactively discussing the oral systemic health connection may be well received and appreciated. I have found a system, which I call the 5 Ps, that creates a great framework for this important conversation.
STEP 1: POSITIONING
To start the conversation, you want to set patient expectations that you and your practice are unique in your approach to oral health because you understand the systemic oral health link. It’s important that you introduce the idea and value of oral systemic health early in your patient’s journey.
STEP 2: PLEASING BENEFIT
The next step is to explain, in easy to understand language, what a total health practice is and how it directly benefits the patient. It’s important that the patient understands this is added value you are providing, not added cost, as cost is often the barrier to treatment acceptance.
STEP 3: PROOF STORY
If possible, having a summary of the oral system health connection available to review with the patient and adding a story of a patient who has benefited from total health dentistry can help new patients understand the value in real-life terms.
STEP 4: ASK PERMISSION
The fourth step is to gain the patient’s permission to be treated with total health dentistry as the foundation of their ongoing care. Ultimately it is the patient’s decision on the level and type of care they want to receive. We have found that when patients have a choice, they usually select the option that will benefit them most.
STEP 5: PRESENT A PAYMENT SOLUTION
When patients value their oral health by seeing how it connects to their overall health, they are often more willing to invest in needed dentistry. Then, all that remains is enabling them to get the care by overcoming other barriers, such as cost and time. Addressing cost concerns, especially as the economy recovers, will be more important than ever. Having a financing solution like the CareCredit credit card can help in this area by enabling patients to use promotional financing and pay over time. Dentistry is essential health care and it’s important for patients to understand how oral health is connected to conditions such as heart health, diabetes, transient ischemic attack, osteoporosis and their immune system. When you provide total health dentistry, you provide value which not only builds patient trust and loyalty, it differentiates your practice from others and helps patients understand that dentistry is not a commodity—it is a pathway to overall health and wellness. TDA Perks Partner CareCredit makes it easier for patients to access care by providing a healthcare credit card that helps families manage out-of-pocket expenses for dental procedures. For information on CareCredit, visit tdaperks. com (Insurance, Dental Benefits & Marketing) or call 800-300-3046 x 4519. Author Gary Kadi is CEO of dental education company NextLevel Practice. This content is subject to change without notice and offered for informational use only. You are urged to consult with your individual business, financial, legal, tax and/or other advisors with respect to any information presented. Synchrony and any of its affiliates, including CareCredit (collectively, “Synchrony”), makes no representations or warranties regarding this content and accepts no liability for any loss or harm arising from the use of the information provided. All statements and opinions in this podcast are the sole opinions of Gary Kadi. Your receipt of this material constitutes your acceptance of these terms and conditions.
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Whether it’s a time of uncertainty, or business as usual, find out what TDA can do for you every day.
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ADVERTISING BRIEFS PRACTICE OPPORTUNITIES ALL TEXAS LISTINGS FOR MCLERRAN & ASSOCIATES: To request more information on our listings, please register at www.dentaltransitions.com or contact us at 512-900-7989 or info@dentaltransitions. com. HOUSTON (ID #H472): This is an
Opportunities Online at TDA.org and Printed in the
Texas Dental Journal
opportunity to purchase an established, boutique practice located in a highly desirable area of central Houston. The practice provides general, implant, and cosmetic dentistry services to a 100% FFS patient base and has an excellent reputation in the local community. The beautiful facility features high-end finishes/ décor, 3 fully equipped operatories, digital radiography, and a CBCT. The seller is planning to transition into retirement but is available to stay on post-closing to facilitate a smooth transition of ownership.
ADVERTISING BRIEF INFORMATION DEADLINE Copy text is due the 20th of the month, 2 months prior to publication (ie, January issue has a due date of November 20.)
MONTHLY RATES PRINT: First 30 words—$60 for ADA/TDA members & $100 for non-members. $0.10 each additional word. ONLINE: $40 per month (no word limit). Online ads are circulated on the 1st business day of each month, however an ad can be placed within 24 business hours for an additional fee of $60.
SUBMISSION Ads must be submitted, and are only accepted, via www.tda.org/Member-Resources/TDAClassified-Ads-Terms. By official TDA resolution, ads may not quote specific incomes or revenues and must be stated in generic terms (ie “$315,000” should be “low-to-mid-6 figures”). Journal editors reserve the right to edit and/or deny copy.
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SAN ANTONIO (ID #T464): This is an opportunity to purchase a well-established set of practices located in the same facility in an upscale area of northwest San Antonio. The seller had operated both practices independently for many years before merging them into the same 2,500 sq ft facility in 2016. Combined, the practices have around 2,600 active patients and have collected over 7 figures annually over the past 3 years. The practice is located in a high-trafficked retail area, and is equipped with 5 operatories, digital X-ray sensors, a digital pano, and a CEREC digital scanner and milling unit. We have priced this practice to sell quickly as the seller is moving out of state, but would be available
for a short transition. CENTRAL TX (ID
general dentistry practice located in a
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an attractive, 4,500 sq ft, free-standing
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College Station and Huntsville. The practice
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fee-for-service patient base and realized
a primarily FFS practice located in the
collections of mid-6 figures in 2019. The
coastal community of Corpus Christi. With
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solid hygiene recall, a dedicated patient
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base, consistent revenue, and solid cash
8 chairs (6 equipped) and a digital pano/
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SOUTHEAST, PEDIATRIC (ID #H463):
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additional plumbed 4th operatory,
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WORTH (ID #T448): This is an
large, predominantly FFS/PPO patient base
opportunity to purchase a successful
(only 10% Medicaid), annual revenue of www.tda.org | April 2021
279
ADVERTISING BRIEFS over 7 figures with an upward trend over
SOUTHEAST (ID #H466): This
the past 3 years, and exceptional net cash
established, FFS/PPO practice is located
flow (after debt service). This beautiful,
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turn-key office is situated directly on a
professional building. The office has 5
high-traffic thoroughfare and features 5
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private, fully equipped operatories (with an
pan/ceph unit) and computers throughout.
additional operatory available for
There are over 1,600 active patients with
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healthy new patient flow. HOUSTON-
paperless charts. HOUSTON-CONROE (ID
NORTHWEST (ID #H467): This is an
#H464): This fee-for-service practice is
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located in a beautiful, free-standing
practice and real estate in the heart of the
building in the bustling town of Conroe
Houston Heights. The practice occupies the
(north of Houston). The office has 7 fully
downstairs of a approximately 2,100 sq ft
equipped operatories, digital X-rays, a
building that could also be converted to
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accommodate an upstairs tenant. The
The real estate is also for sale. HOUSTON-
practice serves a large FFS/PPO patient
NORTH (ID #H465): This is an
base and is thoughtfully designed with 5
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practice in a growing suburb approximately
HOUSTON, PERIODONTIAL (ID
60 miles North of Houston. This office
#H468): This established periodontal
serves a large FFS patient base and
practice has been at its current professional
revenue has been trending upward for the
office building location in The Galleria/
past 3 years, averaging over 7 figures. The
Memorial area of West Houston for 26
3,900 sq ft facility offers ample room for
years. There are 6 operatories in the 2,200
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with digital radiography (including a CBCT
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unit). The FFS/PPO patient base has
computers throughout. HOUSTON-
produced historical practice revenues over
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Texas Dental Journal | Vol 138 | No. 4
ADVERTISING BRIEFS 7 figures annually, with a strong net
fully equipped operatories with space to
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add a 4th operatory. SAN ANTONIO (ID
referral base. HOUSTON-NORTHWEST
#T433): This is an opportunity to purchase
(ID #H471): This established, general
an established general dentistry practice
dentistry practice is located along a heavily
with strong upside potential and a turn-key
trafficked intersection of Highway 6. The
facility in northeast San Antonio. The office
office is situated on the top floor of a
is situated in a busy retail center and
professional building and has 5 fully
features 4 fully equipped operatories,
equipped operatories with digital
digital sensors, and a digital pano. The
technology throughout. Practice revenues
practice serves a large PPO/FFS patient
have consistently been 7 figures and is in
base with increasing revenue levels over
the midst of making a full recovery due to
the past 3 years. This practice will provide
the Covid-19 pandemic. With a primarily
the buyer with a solid foundation (hygiene
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accounts for 25-27% of total collections
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(nearly all specialty procedures are being
many other characteristics of a successful
referred out). SAN ANTONIO-WEST (ID
practice, this is a very attractive acquisition
#T454): This is an opportunity to purchase
opportunity. SAN ANTONIO (ID #T432):
an established, general dentistry practice
This is an opportunity to purchase an
and real estate located in a rural
established, general dentistry practice and
community approximately 75 miles west of
building located in a growing suburb along
San Antonio. The practice serves a PPO/FFS
the I-35 corridor north of San Antonio. The
patient base, sees about 30+ new patients
practice serves a large PPO/FFS patient
per month, and offers consistent annual
base and has a tremendous amount of
revenue with substantial upside potential
untapped potential, as approximately 40%
through expanding the procedures offered
of total production is derived from hygiene
in-house. The turn-key office features 3
services and the seller is referring out most
fully equipped operatories, digital sensors,
specialty procedures. The facility features 3
intra-oral cameras, and a digital pano.
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ADVERTISING BRIEFS SOUTH TEXAS (ID #T460): This is an
Located in highly sought-after affluent
opportunity to purchase an established,
Austin area that is in very high demand and
legacy practice and free-standing building
closely proximate to downtown between
in a charming south Texas town. The office
entertainment and hi-tech corridors (in
is located in a 2-story, free-standing
the “Heart of Austin”). In a single-story
building and has a spacious layout that
stand-alone building that draws from
includes 6 fully equipped operatories (one
mature upscale neighborhood and nearby
additional plumbed for expansion, digital
schools. Practice produces 7 figures, in 5
sensors, a digital pano, CBCT, and
operatories (3 dental and 2 hygiene) within
computers throughout. With a large fee-
2,000 sq ft. Immaculate equipment, all
for-service patient base and a steady flow
digital with pano. Majority of patients 41
of new patients, this office generates
and older with 98% collection ratio. NOTE:
consistent annual revenue of over 7 figures
Practice recently acquired additional patient
per year. To request more information on
base that should boost production, new
our listings, please register at www.
patients, and collections. Contact Jim Dunn
dentaltransitions.com or contact us at
at 800-930-8017 or sales@ddrdental.com
512-900-7989 or info@dentaltransitions.
and reference “Austin Cosmetic.”
com. AUSTIN: Pediatric dentist. Progressive AUSTIN, CORPUS, SAN ANTONIO &
pediatric dental practice in Austin is looking
DFW AREA (DDR DENTAL). (See also
for an energetic pediatric dentist to join
HOUSTON for other DDR Dental listings
our team. We offer a comprehensive
and visit www.ddrdental.com for full
compensation package. New grads
details. AUSTIN: General/prosthodontic
welcome to apply. Please email CV to
practice provides comprehensive care but
joinourpractice2010@gmail.com.
focuses on TMJ, occlusal rehabilitation and high-end cosmetic procedures. Must
CORPUS CHRISTI: Incredible opportunity
be prosthodontist or like training to apply.
to purchase at a great price. Established
Owner prepared to remain and train in
(approximately 36 years) general dentistry
latest occlusal rehabilitation techniques.
practice on the beautiful gulf coast of
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ADVERTISING BRIEFS Texas. Excellent southside location at major
overhead. All furnishings and equipment
intersection with outstanding visibility,
convey. Priced to sell at $175,000. Will
access, and traffic flow. More than 25,000
consider owner-finance with substantial
vehicles pass by each day. Stoplight in
down payment. Contact Marvin, 361-739-
front of office is also great for visibility/
2859 or email mwanner@albmlaw.com.
marketing. Doctor/owner would like to
Metlife, Delta, Humana, United Concordia,
retire but COVID-19 has interfered with
Cigna, BC/BS provider.
plans. Incredibly priced — 4 fully equipped operatories with 2 intraoral X-ray machines.
DALLAS: Office to share. Ready to cut back
In 2018, 2 brand new chairs and 3 delivery
to a couple of days or start a new practice?
units were added to replace old equipment;
Share my beautiful, fully digital office,
5 computers networked throughout. All
located in the Richardson Telecom/City Line
patient charting and notes are digital. Large
area. 5 ops, all computers (Eaglesoft) and
front desk area seats 3-4 comfortably with
electronic services (support, back up, and
lots of storage. Large, shared reception
patient communication) in place. Office
area. Break/lunch/meeting area, lab
currently used 3.5 days/week but willing
area, sterilization area, private office for
to cut back to 3; must see to appreciate.
doctor. Lease available. Fee-for-service/
Contact jack@drjackbodie.com or 972-235-
PPO, NO MEDICAID. Prior to COVID-19,
4767.
revenues/collections just below mid-6 figures on 3.5 days/week. When working
EL PASO: Well-established, dentist
4.5 days/week, production and collections
owned and operated practice, seeking an
was over mid-6 figures. Word-of-mouth
associate dentist for a part-time position
advertising only — no marketing. Buyer
in El Paso. Associate dentist will work
can increase these numbers quickly and
along with the owner dentists in a team-
easily by incorporating marketing as well as
oriented environment that allows you to
implants, ortho, perio, and other specialty
focus on what you do best, dentistry. We
procedures that are currently referred out.
offer guaranteed base and percentage
Exceptional start-up opportunity or even
of production with uncapped earning
satellite location for existing doctor. Low
potential. An ideal candidate is dependable
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283
ADVERTISING BRIEFS and adaptable, committed to patient care,
Located within a beautiful single-story,
provide accurate exams and patient-
free-standing building, built in 1996 and is
focused treatment planning; Deliver
also available for purchase. Natural light
patient-focused preventive, restorative,
from large windows within 2,300 sq ft with
and surgical procedures; compassionately
4 operatories (2 hygiene and 2 dental).
communicate treatment plans and
Includes a reception area, dentist office,
instructions; assist the practice towards
a sterilization area, lab area, and break
excellence in oral health care requirements.
room. All operatories fully equipped. Does
Candidates must have current Texas
not have a pano but does have digital
Dental Board License, CPR, DEA, NPI, and
X-ray. Production is 50% FFS and 50%
malpractice insurance. New graduates are
PPO (no Medicaid), with collection ratio
welcome to apply. Contact Rosie Mireles
above 95%. Providing general dental and
at rosiem@starcitydental.com or 915-591-
cosmetic procedures, producing mid-6
7117.
figure gross collections. Contact Chrissy Dunn at 800-930-8017 or sales@ddrdental.
FORT WORTH: Practice for sale in the fast
com and reference “Lufkin General.”
growing southwest area. Average gross;
BRENHAM: General practice only 90
6 operatories; Excellent lease. Seller is
miles northwest of Houston. Mid-6 figure
relocating. Need to move quickly on this
production with practice offered at a below-
one. DFW 214-503-9696. WATS 800-583-
market price to facilitate sale. Located just
7765.
off Highway 290 in a beautiful single-story, free-standing building, that is also available
HOUSTON, BRENHAM, LUFKIN AND
for purchase. 1,900 sq ft with 4 operatories
SOUTH TEXAS (DDR DENTAL). (See
(2 hygiene and 2 dental). Includes a
also HOUSTON for other DDR Dental
reception area, dentist office, sterilization
listings and visit www.ddrdental.com for
and lab area, and break room. All
full details. LUFKIN: General practice on
operatories fully equipped with immaculate
a high visibility outer loop highway near
Adec equipment. Reliable production on
mall, hospital, and mature neighborhoods.
very stable patient base with hygiene recall
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ADVERTISING BRIEFS program. Computers and digital X-rays
collection ratio. Over 1,200 active patients.
upgraded last year. At this location for
20% Medicaid, 45% PPO, and 35% fee-
over 30 years. Contact Jim Dunn at 800-
for-service; 30% of patients younger
930-8017 or sales@ddrdental.com and
than 30. Office open 6 days a week and
reference “Brenham General.” HOUSTON:
accepts Medicaid. Contact Chrissy Dunn
Pediatric/general practice in East Houston,
at 800-930-8017 or sales@ddrdental.
“start-up” with existing patient base.
com and reference “Sharpstown General.”
Mid-6 figure gross on only 2 days a week
HOUSTON (PEARLAND AREA): General
(historical high-6 figure production). High
practice located in southeast Houston near
potential for growth, with established
Beltway 8. It is in a free-standing building.
patient base, with unique opportunity to
Dentist has ownership in the building
quickly grow. Medicaid accepted along
and would like to sell the ownership in
with traditional dental services that include
the building with the practice. One office
hygiene. 1,900 sq ft with 5 operatories
currently in use by seller; 60% of patients
with like-new equipment. Located in strip-
age 31 to 80, and 20% 80 and above.
center with high visibility just off Hwy I-10.
Four operatories in use, plumbed for 5
Over 95% collection ratio. Over 1,200
operatories. Digital pano and digital X-ray.
active patients and with 65% Medicaid,
Contact Christopher Dunn at 800-930-8017
25% PPO, and 5% fee-for-service; 64%
or sales@ddrdental.com and reference
of patients 30 years and younger. Contact
“Pearland General.” HOUSTON (SOUTH/
Chrissy Dunn at 800-930-8017 or sales@
HOBBY AIRPORT): Well-established
ddrdental.com and reference “East Houston
pediatric/general practice and patient
Medicaid.” HOUSTON (SHARPSTOWN):
base at low price. Pediatric/general dentist
Well-established general dentist with high-
practice providing comprehensive general
6 figure gross production. Comprehensive
dentistry in the south Houston area. The
general dentistry in the southwest Houston
dentist owns the building and is open to a
area focused on children (Medicaid).
potential sale of the building together with
Very, very high profitability. 1,300 sq
the practice. Traditional dental services that
ft, 4 operatories in single building. 95%
include hygiene recall. Over 2,500 sq ft of
www.tda.org | April 2021
285
ADVERTISING BRIEFS space with a reception area, a business
KATY: Now is the time to join Grand Lakes
area, dentist office, a sterilization area/
Dental Group and Orthodontics. You will
lab area, and 4 operatories. Office is fully
have opportunities to learn new skills from
functioning but is very dated. Practice has
our team of experienced professionals. If
been at this current location for 40 years.
you’re ready to take your career to the next
The office is open 6 days a week and
level and gain valuable experience, apply
accepts Medicaid. Contact Chrissy Dunn
today! You’ve invested the time to become
at 800-930-8017 or sales@ddrdental.com
a great dentist, now let us help you take
and reference “South Houston Pedo.” WEST
your career further with more opportunity,
HOUSTON, MOTIVATED SELLER: Medicaid
excellent clinical leadership and one of the
practice with production over mid-to-high-6
best practice models in modern dentistry.
figures. Three operatories in 1,200 sq ft in
In working with our practice you will have
a strip shopping center. Equipment is within
the autonomy to provide your patients
10 years of age. Has a Pano and digital
the care they deserve. In addition, you’ll
X-ray. Great location. If interested contact
enjoy the opportunity to earn excellent
chrissy@ddrdental.com. Reference “West
income and have great work-life balance
Houston General.”
without the worries of running a practice. You became a dentist to provide excellent
JACKSONVILLE: Well-established general
patient care and have a career that will
dentistry practice seeking an associate
serve you for a lifetime. With us, you will
with possibility of future buy-in. Located in
have a balanced lifestyle, fantastic income
beautiful East Texas close to Tyler. We are
opportunities, and you’ll work for an office
looking for a highly motivated individual
that cares about their people, their patients
that has excellent patient care and work
and their community. Our practice is an
ethic. We offer a guaranteed base and a
office supported by Pacific Dental Services
percentage of production. This is a full time
(PDS), which means you won’t have to
position and has an immediate opening.
spend your career navigating practice
Contact brad@allsmilesjacksonville.com.
administration. Instead, you’ll focus on your patients and your well-being. Add on
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Texas Dental Journal | Vol 138 | No. 4
ADVERTISING BRIEFS excellent benefits, including malpractice
keep you informed and utilizing the latest
insurance, medical, dental and vision
technologies and dentistry practices. If
insurance, retirement plans and much
you are interested in a path to ownership,
more and you’ll feel well taken care of
our proven model will provide you with
throughout your career. The average full-
the training needed to become an owner
time PDS-supported associate dentist earns
of your own office. PDS is one of the
low-6 figures in their first year. The average
fastest growing companies in the US which
income for a PDS-supported owner dentist,
means we will need excellent dentists like
whose practice has been open at least 2
you to continue to lead our growth in the
years, is mid-6 figures. As an associate
future. Apply now or contact a recruiter
dentist, you will receive ongoing training to
anytime. We’d love to chat, get to know
www.tda.org | April 2021
287
ADVERTISING BRIEFS you and share more about us. Pacific
You became a dentist to provide excellent
Dental Services is an equal opportunity
patient care and have a career that will
employer and does not discriminate
serve you for a lifetime. With us, you will
against any employee or applicant for
have a balanced lifestyle, fantastic income
employment based on race, color, religion,
opportunities, and you’ll work for an office
national origin, age, gender, sex, ancestry,
that cares about their people, their patients
citizenship status, mental or physical
and their community. Our practice is an
disability, genetic information, sexual
office supported by Pacific Dental Services
orientation, veteran status, or military
(PDS), which means you won’t have to
status. Apply here:http://www.Click2Apply.
spend your career navigating practice
net/gwy6pkn22knbzwzx PI106822492.
administration. Instead, you’ll focus on your patients and your well-being. Add on
KATY: Now is the time to join Highlands
excellent benefits, including malpractice
Dental Group. You will have opportunities
insurance, medical, dental and vision
to learn new skills from our team of
insurance, retirement plans and much
experienced professionals. If you’re ready
more and you’ll feel well taken care of
to take your career to the next level and
throughout your career. The average full-
gain valuable experience, apply today!
time PDS-supported associate dentist earns
You’ve invested the time to become a
low-6 figures in their first year. The average
great dentist, now let us help you take
income for a PDS-supported owner dentist,
your career further with more opportunity,
whose practice has been open at least 2
excellent clinical leadership and one of the
years, is mid-6 figures. As an associate
best practice models in modern dentistry.
dentist, you will receive ongoing training to
In working with our practice you will have
keep you informed and utilizing the latest
the autonomy to provide your patients
technologies and dentistry practices. If
the care they deserve. In addition, you’ll
you are interested in a path to ownership,
enjoy the opportunity to earn excellent
our proven model will provide you with
income and have great work-life balance
the training needed to become an owner
without the worries of running a practice.
of your own office. PDS is one of the
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Texas Dental Journal | Vol 138 | No. 4
ADVERTISING BRIEFS fastest growing companies in the US which
EAST TEXAS AREA: 4 general practice.
means we will need excellent dentists like
WEST TEXAS AREA: 1 general practice.
you to continue to lead our growth in the
SAN ANTONIO AREA: 4 general practices.
future. Apply now or contact a recruiter
SOUTHWEST NORTH CAROLINA AREA: 1
anytime. We’d love to chat, get to know
general practice., MINNEAPOLIS AREA:1
you and share more about us. Pacific
general practice, NORTHEAST FLORIDA
Dental Services is an equal opportunity
AREA: 1 general practice. For more
employer and does not discriminate
information and current listings, please
against any employee or applicant for
visit our website at www.adstexas.com or
employment based on race, color, religion,
call Watson Brown, Inc. at 469-222-3200.
national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual
OFFICE SPACE
orientation, veteran status, or military status. Apply here:http://www.Click2Apply.
FORT WORTH: Fort Worth centrally
net/ygmfkqjp6prswyc3.
located dental office space for sublease due to retirement. 1,900 square feet on sixth
KERRVILLE: Well established Hill Country
floor of well-maintained bank building.
dental practice for sale in prime location in
Four operatories with spectacular view of
Kerrville. Would consider associate with buy
downtown Fort Worth, Dickies Arena, TCU.
in agreement. Owner financing available.
Available May 2021. Gary Vasseur, Vasseur,
Call 830-285-0674.
Commercial Real Estate, 817-335-7575.
WATSON BROWN, INC.: Excellent practice acquisition and merger opportunities available. DALLAS/FORT WORTH AREA: 18 general practices, 1 pediatric practice, 1 oral surgery practice. HOUSTON AREA: 5 general practices.
www.tda.org | April 2021
289
YOUR PATIENTS TRUST YOU.
WHO CAN YOU TRUST?
ADVERTISERS Anesthesia Education & Safety Foundation.......... 246 Arthur Jeske, DMD PhD........................................ 239 Card Connect.............................................Back Cover DDR Dental Trust.................................................. 287 Design Ergonomics.........................Inside Back Cover
If you or a dental colleague
E-VAC, Inc............................................................ 249
are experiencing impairment
Greater Houston Dental Society........................... 277
due to substance use or mental illness, The Professional Recovery Network is here to provide support and an
Henry Schein Financial Services........................... 271 Institute of Houston Dental Society...................... 247 JKJ Pathology....................................................... 248
opportunity for
Law Offices of Mark Hanna.....................................270
confidential recovery.
Professional Recovery Network............................ 290 Southwest Sedation Education............................. 271 TDA Perks..................................... Inside Front Cover Texas A&M University College of Dentistry........... 241 Texas Health Steps............................................... 235 UTHealth San Antonio So Texas Pathology Lab..... 270
PRN Helpline (800) 727-5152
Visit us online www.txprn.com
UTHealth School of Dentistry at Houston.............. 277 Watson Brown Practice Sales & Appraisals........... 238
290
Texas Dental Journal | Vol 138 | No. 4
Find Your Amazing
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FH Collins III DDS Winter Springs, FL
For over 25 years, Dr. David Ahearn and the team at Design Ergonomics have designed the Nation’s most efficient, productive and beautiful offices. We’ve helped 1000’s of doctors take their next practice to the next level.
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Call 800.275.2547 or Visit www.desergo.com The Leader in High-Performance Dental Office Design
www.tda.org | April 2021
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