August 2021
TEXAS DENTAL
INSIDE:
THE STATE OF ORAL HEALTH CARE ACCESS IN TEXAS www.tda.org | August 2021
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Texas Dental Journal | Vol 138 | No. 8
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www.tda.org | August 2021
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Contents August 2021 Established February 1883 n Vol 138, No. 8
FEATURES 534 | The State of Oral Health Care Access in Texas Jeffery L. Hicks, DDS, Dip. ABSCD Suman N. Challa, BDS, MSPH, Dip. ABDPH William D. Hendricson, MS, MA Magda A. de la Torre, RDH, MPH Rochisha S. Marwaha, BDS, MPH, DPH Department of Comprehensive Dentistry, University of Texas Health San Antonio, San Antonio, Texas
Airfield Falls Trailhead and Conservation Park, Fort Worth Photo by Keeweeboy, Big Stock.
DEPARTMENTS 528 | President’s Message 530 | Oral and Maxillofacial Pathology Case of the Month 548 | Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management TDA members, use your smartphone to scan this QR Code and access the online Texas Dental Journal.
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551 | Calendar of Events
Texas Dental Journal | Vol 138 | No. 8
557 | In Memoriam | Memorials/Honorariums 552 | Value for Your Profession: Provide Sedation? Here’s What You Need to Know About Monitors—What makes a device a monitor? What meets state requirements and my practice needs? 558 | Advertising Briefs 570 | 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 Debrah J. Worsham, DDS 936-598-2626, worshamdds@sbcglobal.net PRESIDENT-ELECT Duc “Duke” M. Ho, DDS 281-395-2112, ducmho@sbcglobal.net PAST PRESIDENT Jacqueline M. Plemons, DDS, MS 214-369-8585, drplemons@yahoo.com VICE PRESIDENT, NORTHEAST Carmen P. Smith, DDS 214-503-6776, drprincele@gmail.com VICE PRESIDENT, SOUTHEAST Georganne P. McCandless, DDS 281-516-2700, gmccandl@yahoo.com VICE PRESIDENT, SOUTHWEST J. Ted Thompson, DDS 361-242-3151, tedito@aol.com 817-238-6450, pdalw@yahoo.com VICE PRESIDENT, NORTHWEST E. Dale Martin, DDS SENIOR DIRECTOR, NORTHEAST Elizabeth S. Goldman, DDS 214-585-0268, texasredbuddental@gmail.com SENIOR DIRECTOR, SOUTHEAST Glenda G. Owen, DDS 713-622-2248, dr.owen@owendds.com SENIOR DIRECTOR, SOUTHWEST Carlos Cruz, DDS 956-627-3556, ccruzdds@hotmail.com SENIOR DIRECTOR, NORTHWEST Teri B. Lovelace, DDS 325-695-1131, lovelace27@icloud.com DIRECTOR, NORTHEAST Jodi D. Danna, DDS 972-377-7800, jodidds1@gmail.com DIRECTOR, SOUTHEAST Shailee J. Gupta, DDS 512-879-6225, sgupta@stdavidsfoundation.org DIRECTOR, SOUTHWEST Richard M. Potter, DDS 210-673-9051, rnpotter@att.net DIRECTOR, NORTHWEST Summer Ketron Roark, DDS 806-793-3556, summerketron@gmail.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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iHDS
2021 CALENDAR OF EVENTS
2021 DATES
FACULTY & COURSE
Aug 20-21 8am-4pm
Dr. Federico Presicci Hands-on Ceramics for Better Bridges
Sep 10-11 8am-5pm
Fall Implant Fellowship: Session 1 Session 2-3: Oct 1-2, Nov 12-13, Session 4 TBA
Sep 18 SAT 8am-5pm
Dr. Danny Holtzclaw Pterygoids and Zygos
Sep 24-25 8am-4pm
Daniel Ramos, Gustavo Giordani, John Karotkin Octavio Cintra, E. Todd Scheyer, Giancarlo Romero Beyond Perio-Ortho Limits
Oct 8-9 8am-5pm
Dr. Giancarlo Romero & Dr. Aldo Sordelli From CBCT to Surgical Guide
Oct 22-23 8am-4pm
Dr. Virgilio Gutierrez & Dr. Giancarlo Romero Digital Photography
Oct 29-30 8am-5pm
Dr. Giancarlo Romero & Dr. Aldo Sordelli Ridge Preservation & Immediate Implant Placement & Provisionalization in the Esthetic Zone
Nov 5-6 8am-4pm
Dr. Rolando Nuñez & Dr. Aldo Sordelli Severe Worn Down Dentition
Dec 3 FRI afternoon
iHDS Symposium Followed by Christmas Party
All events subject to change -- Stay current & connected: www.ihds-ce.com.
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Chewon this
Medicare Dental Benefit
B
y now you have received several emails and alerts from ADA and TDA about a Medicare dental benefit. Perhaps you didn’t read them because you are quite sure you will not be accepting any Medicare dental plans. If you chose not to read them, I get it! However, here are some important things to consider because a Medicare dental benefit will impact all dentists. 1. Congress has been hinting at a Medicare dental benefit for some time. With the change in leadership resulting from the 2020 elections, Democrats now have momentum in support of a Medicare dental benefit. 2. The 2020 ADA House of Delegate anticipated this possibility and adopted a policy for financing oral health care for adults age 65 and older. The policy: • Covers individuals under 300% FPL; • Covers the range of services necessary to achieve and maintain oral health; • Is primarily funded by
•
•
•
the federal government and not fully dependent upon state budgets; Is adequately funded to support an annually reviewed reimbursement rate such that at least 50% of dentists within each geographic area receive their full fee to support access to care; Includes minimal and reasonable administrative requirements; and Allows freedom of choice for patients to seek care from any dentist while continuing to receive the full program benefit.
Regardless if you plan to participate in Medicare or opt-out, Medicare expansion will affect you. You could lose patients and face reductions in fees for all commercial insurance plans you accept. It is critical for you to respond when a call to action is sent out! Our Texas congressional delegation needs to hear from you! They need to know about the ADA’s counter proposal,
528 Texas TexasDental DentalJournal Journal | |Vol Vol 138 138| No. | No. 8
TDA President Debrah J. Worsham, DDS
which is best for patients and dentists. The ADA’s Medicare proposal is based on ADA policy. It calls for a dental benefit separate from Medicare Part B. It is patient centered and dentist friendly. It provides comprehensive dental care to low-income seniors who need it the most instead of making the benefit available to all seniors (even those with unlimited incomes). For dentistry to have a say in how dental benefits should be offered in Medicare, you need to make your voices heard. Read the emails and respond to the action alerts. The ADA webinar (https://www.ada.org/en/ advocacy/congress-considersa-medicare-dental-benefit) is excellent for getting up to speed on all things Medicare. Thank you for all you do for dentistry! Stay safe and stay informed!
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Our Pathologists: Jerry E. Bouquot, DDS, MSD Kalu U.E. Ogbureke, BDS, DMSc, JD, MSc
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ORAL
and maxillofacial pathology
Clinical History
A 27-year-old woman had been intermmitently experiencing “peeling skin” of her oral mucosa for more than 6 years, with no noticeable change in severity or frequency of “episodes.” Her dentist noticed it on several occasions but did nothing for it since it was asymptomatic and “seemed not to bother her much at all.” It occurred repeatedly in the same 2 locations, producing at both sites a “slimy” white patch which slowly developed,
case of the month starting as gray and then becoming more and more white over several days and eventually starting to slough off. The patches were never symptomatic and for the most part were relativey well demarcated. There had never been ulceration or mucosal erythema, and every 3-5 days she had “treated” it by gently scraping the white film off with a damp wash cloth; within 5-8 days the cycle would start over again.
A
B
C
D
Figure 1A-D. Gray/white plaques at examination. A) Right maxillary buccal and vestibular mucosa (abfraction also present on molars and premolars); B) Same lesion after gentle tongue blade pushing from the edge toward the center, with the white material easily peeling off, revealing normal underlying mucosa; C) Left mandibular gingival/vestibular pseudomembrane: D) Same lesion after being gently scraped with a tongue blade (for a pap smear sample), showing normal underlying mucosa.
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At her request she was referred to an Oral & Maxillofacial Pathologist who saw 2 areas with thick white plaques, with peripheries that were semitranslucent and gray in color (Figure 1). The patient said that they were typical of past involvement and had always recurred in those 2 sites. The white plaques at this examination were 5 days old, and the previous episode concluded 7 days prior to their onset. The plaques could be easily peeled off the underlying mucosa with gentle tongue blade pressure and the mucosa looked perfectly normal after their removal. The patient indicated that the plaques typically could not be scrapped off until day 3 or 4. The removed tissue was placed into a biopsy bottle and after fixation was centrifuged into a compact conglomerate, then processed for H&E histopathologic examination. Under the microscope the sample consisted of a uniformly thick layer of parakeratin that did not seem necrotic or inflamed (Figures 2a and 2b).
A
AUTHORS Jerry E. Bouquot, DDS, MSD, DABOMP, DABOM(Hon), FICD, FACD
Emeritus Professor and Past Chair, Department of Diagnostic & Biomedical Sciences, University of Texas School of Dentistry at Houston, Houston, Texas
Makayla Grisham, DDS
Resident in Oral & Maxillofacial Pathology, Department of Diagnostic Sciences, University of North Carolina, Chapel Hill, North Carolina
Shawn Adibi, DDS, MEd, FAAOM Professor, Department of General Practice & Dental Public Health, University of Texas School of Dentistry at Houston, Houston, Texas
B
Figure 2A-B. Microscopic appearance of the lesions. A) Scraped off maxillary pseudomembranes were comprised of uniformly thick, non-necrotic parakeratin; B) Same as A, showing residual nuclei and a complete lack of inflammatory cells.
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ORAL
and maxillofacial pathology, continued
A tentative diagnosis of TIME (toothpaste-induced mucosal etching), a mild chemical burn associated with whitening toothpastes and mouthwashes, was suggested.1 However, the patient claimed to have never used such a product. Nevertheless, over the next 6 months, she tried different types and brands of nonwhitening toothpastes, brands without sodium lauryl sulfate (Sensodyne) and baking soda brands (Arm & Hammer). No changes were noted in her oral lesions
with any of these products. Topical and systemic prednisolone treatments were also ineffective. The patient asked that a biopsy be performed in an attempt to “solve this problem.” Accordingly, she returned to the dental school on day 4 of a new lesional episode. Microscopic evaluation of her mandibular lesion showed no inflammatory changes, but the epithelium was hyperplastic and there was an abnormally thickened layer of
C
parakeratin on the surface. The full keratin layer was literally tearing away from the underlying epithelial cells (Figures 2c and 2d). The epithelial cells under the tear, and those adjacent to it, appeared completely normal. A portion of the biopsy was processed for immunofluorescence in order to rule out pemphigus, pemphigoid, lichen planus, etc.; all tests were negative.
What is the final diagnosis? See page 548 for the answer and discussion.
D
Figure 2C-D. Microscopic appearance of the lesions. C) Biopsy of mandibular lesion showing thick hyperkeratosis with the upper keratin pulling away from the lowest layers of keratin, with epithelial atrophy and occasional lymphocytes in the subepithelial stroma; D) Higher power of C showing keratin pulling away from normal appearing spinous layer (arrow).
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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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Approved PACE Program Provider FAGD/MAGD Credit. Approval does not imply acceptance by a state of provincial board of dentistry or AGD endorsement. 8/1/2018 to 7/31/2022. Provider ID# 217924
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.
Dr. Canfield
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:
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*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
Combined ACLS-PALS-BLS and Level 2, 3 and 4 Program
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 State of Oral Health Jeffery L. Hicks, DDS, Dip. ABSCD Suman N. Challa, BDS, MSPH, Dip. ABDPH William D. Hendricson, MS, MA Magda A. de la Torre, RDH, MPH Rochisha S. Marwaha, BDS, MPH, DPH Department of Comprehensive Dentistry, University of Texas Health San Antonio, San Antonio, Texas
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h Care Access in Texas Inequities in access to oral health care in Texas are fueled by rapid population growth in relation to the dental workforce, lack of oral health services in specific geographic regions, high proportion of uninsured/ underinsured, limited dental provider capacity, and/or lack of provider willingness to treat vulnerable groups.
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Abstract This article delineates the status of access to oral health care in Texas. As a state with many underrepresented minority citizens, extensive rural areas, and high poverty rates in many geographic areas, Texas has developed a great need for oral health care providers. A literature search was conducted that sought factors that have led to the need for and access to oral health care among the general and specific populations in Texas. Specific populations require health care providers not only that are professionally competent but who can deliver care with high cultural competency. However, the ethnic and cultural background of current providers does not match the rates of citizens in underrepresented minority groups. In 2019, 21% of all third grade children in Texas had untreated decay. In contrast, the untreated caries prevalence among Mexican American and poor children was 33%. There are insufficient numbers of oral health care providers in Texas to deliver effective care. Unemployment and under-insurability of citizens contributes to financial barriers in seeking care. The oral health workforce must address health issues in communities and significant societal/ demographic changes creating challenges to the health care system. Providers must acquire new competencies to address population-based health needs. It is important to increase the number of underrepresented minority groups who are providers because they are more likely to practice where services are in short supply and more likely to practice in areas with high percentages of racial and ethnic populations. Dental educational programs must increase support for enrollment of students from underrepresented minority, low-income, and rural populations, and recruit and retain faculty with experience and expertise in caring for underserved and vulnerable populations.
key words
Health, minority, oral health, access to health care, caries, dental, Texas
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Introduction This article serves as a primer for a companion article that describes a project of the University of Texas Health San Antonio School of Dentistry (UTHSA) to address identified access deficiencies. The population of Texas in 2019 was 29.1 million, up from 25.1 million in 2010, representing an annual growth rate of 1.80%—the third highest in the U.S.1 However, in 2016, Oral Health America ranked Texas 43rd of 50 states in a composite score of: edentulism, Medicaid dental benefits, water fluoridation, state oral health plans, and completion of basic screening surveys.2 The percent of Texans served by fluoridated drinking water decreased from 79% in 2014 to 69% in 2017.3 The poverty rate in Texas is 13.6%.4 Nearly 1 in 10 Texans experiences food insecurity, and household food insecurity prevalence exceeds 60% in some areas of the state. Children from food-insecure households have significantly higher rates of untreated dental
caries and dental pain resulting from caries, and receive more irreversible dental services, such as tooth extractions.5 Food insecure families lacking money to pay for basic needs like food are unlikely to have enough money to afford dental or health care.5 In data reported to the Centers for Disease Control (CDC) between 2008 and 2013, Texas ranked third worst (39th) among US states for the percent of third graders who have experienced dental caries and seventh worst (35th) for the percent with
untreated dental caries.6 In 2019, the CDC reported that in Texas, 53% of kindergarten children had experienced dental decay and 20% had untreated decay. By the third grade, 67% of children had dental caries and 21% had untreated decay. The nationwide prevalence of untreated caries among children aged 2–5 years was 23% during 2011– 2016. In contrast, the untreated caries prevalence among Mexican American and poor children was 33%.3 In 2016, the CDC found that 59% of adults in Texas
The poverty rate in Texas is 13.6%.4 Nearly 1 in 10 Texans experiences food insecurity, and household food insecurity prevalence exceeds 60% in some areas of the state. Children from food-insecure households have significantly higher rates of untreated dental caries and dental pain www.tda.org | August 2021
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aged 18+ had a dental visit in the past year and 40% had not. In 2018, 13.1% of Texas adults aged 65+ were edentulous and 11.6% of adults were found to have poor oral health.7 Approximately 5 million Texans have no health insurance and only limited access to primary and preventive care. Texas has the highest rate of those without health insurance in the U.S., and as many as 42% are uninsured in Texas’ border regions. Children without dental insurance are more than twice as likely to have dental needs and 4 times more likely to have urgent needs than children with private insurance.8 Over 3 million Texas children have Medicaid coverage, but about onethird of Texas counties have no dentists enrolled as Medicaid providers.9 Texas has chosen not to implement a Medicaid insurance expansion. Failure to expand this coverage deprives the state of approximately $66 billion in federal payments over 10 years and an estimated $35-40 billion more in secondary benefits, such as jobs and better health. This
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decision left a coverage gap for nearly 1 million Texans who are not eligible for Medicaid, most of whom are working poor with no employee health insurance, denying them access to primary and preventive care.10
Difficulty in Accessing Oral Health Care Accessing oral health care in Texas is difficult for certain populations, including those in underserved areas, those living below the poverty line and the uninsured, children insured by CHIP and Medicaid, Hispanics, residents of rural areas, and people with disabilities. A 2015 report projects the current supply of dentists (6%) will not meet the increased demand (10%). This same report states that moderately increasing the supply of dentists will not meet the increased demand (10% increase).11 Within the next decade, it is projected that more than one-third of Texas’ general dentists will be at or past retirement age.12 This
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unmet demand will worsen access problems severely for underserved populations who forgo basic oral health care. The dental workforce in Texas is disproportionately concentrated in urban areas; nearly 93% of dentists in the state practice in metropolitan areas. While 15% of Texas’ population resides in rural areas, just 7% of dentists practice outside of the state’s urban centers.13.14 The dentist to population ratio in south Texas is approximately 18 per 100,000 compared to 61 per 100,000 for the US.15 Over 46 million persons in the US currently live in Dental Health Profession Shortage Areas (DHPSA). In Texas, there are a total of 290 DHPSAs and an additional 328 dental providers would be necessary to remove these shortage designations. By 2025, the number of additional dental providers necessary to remove these designations is projected to rise to 490.16
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Table 1.
2012
2025 Projected
Demand Region/ Supply Shortage Supply Demand Difference State as Captured (2012 (Supply Supply and by DHPSA Demand Shortage + DHPSA) as Captured by DHPSAs) Texas
13,087
(354)
Approximately 17% of all Texans and 1 in 4 Texas children live in poverty, which adversely affects their health and educational attainment. Poverty rates for Latino (33%) and Black children (32%) are nearly 3 times higher than they are for White (11%) and Asian children (12%).17 Poor children suffer twice as much dental caries as their more affluent peers, and their disease is more likely to be untreated as 25% of poor children have not seen a dentist before kindergarten.18,19 The majority of Texans with health insurance enroll in coverage through the workplace. Unemployment projections for south Texas are almost double compared to the US as a whole, a fact that impacts families’ insured rate.
540
13,441
17,365
Estimates of the number of Texans with dental coverage are not publicly available. However, medical insurance enrollment is a strong predictor of access to dental care. Texas has the highest rate of uninsured in the United States at 19.7%. Approximately 5.4 million Texans have no health insurance coverage and thus have limited access to primary and preventive care .20 For each child without medical insurance, there are at least 2.6 children without dental insurance.21 Uninsured children are 2.5 times less likely than insured children to receive dental care. Children from families without dental insurance are 3 times more likely to have dental needs than children with either public or private insurance.22
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17,501
(490)
Medicaid has not been able to fill the gap in providing dental care to poor children. Although programs such as the Children’s Health Insurance Program (CHIP) increased the number of insured children, many are left without effective dental coverage. For children ages 2-18, 51.3% have private dental benefits, 38.5% are covered by Medicaid or CHIP, and 10.3% do not have dental benefits. As a result, many Texans seek dental care in hospital emergency rooms. In 2016 in Texas, there were 122,096 emergency department visits for nontraumatic dental conditions with an average charge of $1,853 and 10 patients with a primary diagnosis of non-traumatic dental condition died.23
Table 2.
SOURCE: CDC/NICH, National Health and Nutrition Examination Survey, 2011-2012.
Oral health problems disproportionately affect underrepresented minority (URM) groups. Health disparities affect groups who experience obstacles to health based on racial/ethnic group and socioeconomic status.24 From the 2010 US Census, more than 1/2 of the growth in the population between 2000 and 2010 was due to increases in the Hispanic population. Texas ranks 2nd of 50 states in its number of Hispanic citizens. South Texas contains 25% of the state’s population and 60% to 97% are Hispanic.25
Patients who do not speak English well have communication problems including not understanding medical instructions and being treated with disrespect, resulting in poor patient compliance or medical errors. Hispanic persons are least likely, among underrepresented minority groups, to have a usual primary care provider.26
Hispanic persons are least likely, among underrepresented minority groups, to have a usual primary care provider.26
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Table 3. Population and Active Dentists Percentage of Race and Hispanic Ethnicity, 2016
There is significant lack of racial/ethnic concordance between active dentists in the U.S. and the state of Texas and the public. In Texas, 38% of the population was Hispanic in 2016, but only 9.6% of dentists were Hispanic.
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A similar discordance exists among AfricanAmerican dentists and the general population.27 Increasing the number of members of URM groups as primary care providers is important because they are more likely to practice
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where services are in short supply and more likely to practice with high percentages of racial and ethnic populations and with understanding and appreciation of cultural health care beliefs.28
Table 4. Ratio of Texas Population to General Dentist, by County
SOURCE: Texas Department of Statewide Health Services, Health Professions Rescources Center, 2015
In the US Census Bureau report, Americans with Disabilities: 2010, approximately 57 million citizens have a disability affecting their lives. The disability of 38 million persons is severe.29 The oral health of individuals with special health care needs (SHCN) versus the general population is adversely impacted. For
example, • the SHCN populations have more untreated caries, and receive less frequent dental care, • those with intellectual disabilities have higher rates of periodontal disease, • children with SHCN are more prone to develop malocclusion, • individuals with
disabilities frequently experience orofacial trauma, and, • 67% of SHCN residential facilities report inadequate access to dental care. The large majority of general dentists do not provide care or provide only minimal care to patients with disabilities.30 Reasons www.tda.org | August 2021
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include that dentists are often: 1) unwilling to accept patients with disabilities, 2) unwilling to announce they are willing to treat patients with SHCN, or 3) unwilling to deliver comprehensive care and only provide care on a limited basis. The Institute of Medicine report, Improving Access to Oral Health Care for Vulnerable and Underserved Populations, 2011 recommended dental educational programs should: 1) increase support for enrollment of students from underrepresented minority, low-income, and rural populations; and 2) recruit and retain faculty with experience and expertise in caring for underserved and vulnerable populations.31 In Texas, few general dentists are trained to treat individuals with special health care needs. In 2009, the Texas Dental Association identified policy recommendations to address the goal of improving the oral health of all Texans by creating new programs to encourage general dentists and specialists to treat underserved populations.32
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Conclusions We must improve oral health literacy, provider cultural competence, and understanding of cultural health care beliefs. The primary care workforce must address health issues in communities and significant societal/ demographic changes creating challenges to the health care system. The primary care workforce must be equipped to address health issues in underserved communities as well as significant societal and demographic changes creating challenges to the health care system. Providers must acquire new competencies to address population-based health needs. It is important to increase the number of URM groups who are providers because they are more likely to practice where services are in short supply and more likely to practice in areas with high percentages of racial and ethnic populations. The HRSA-sponsored Conference on Dental Care Considerations of Disadvantaged and Special Care Population states that patients with special needs
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would benefit from an expanded group of trained dental professionals, better integration between systems delivering medical and oral health care including joint oral health training of medical, dental and nursing providers, and expansion of dental residency programs providing training in care of these persons.33 The Committee on Oral Health Access to Services; Institute of Medicine and National Research Council said that people with SHCN face systematic barriers to oral health care: transportation barriers, cost, and oral health professionals who are not trained to work with patients with SHCN.34 Lastly, but most importantly, dental educational programs must increase support for enrollment of students from underrepresented minority, low-income, and rural populations, and recruit and retain faculty with experience and expertise in caring for underserved and vulnerable populations.31 As the principal source of dental education in south and central Texas, the UTHSA School of Dentistry
is striving to address these oral health access barriers by proactive collaboration with Community Health Centers and Nursing Homes in the region to expand dental services for the vulnerable and concurrently enhance the readiness of future dentists to serve this population. References 1. QuickFacts Texas United State Census Bureau, Department of Commerce, 2020. Available from: https://www. census.gov/quickfacts/TX 2. Oral Health America, A State of Decay, Volume 3, 2016. Available from:https://nhoralhealth.org/blog/ wp-content/uploads/2016/05/State-ofDecay-2016-Vol-3.pdf 3. Oral Health in Texas Bridging Gaps and Filling Needs: A Report on the Burden of Oral Disease in Texas, Texas Health Institute, 2018. Available from:https:// www.texashealthinstitute.org/ uploads/3/9/5/2/39521365/thi_ report_final.pdf 4. US Census Data, United State Census Bureau, Department of Commerce, 2020. Available from: https://data.census.gov/cedsci/ profile?g=0400000US48 5. Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2019. Available from: https://www. cdc.gov/oralhealth/pdfs_and_other_ files/Oral-Health-Surveillance-Report2019-h.pdf.
6. Florida Department of Health Public Health Dental Program. The oral health status of Florida’s third grade children 2013-2014, 2016. Available from: https://cod-oralhealthflorida.sites. medinfo.ufl.edu/files/2017/03/oralhealth-third-grade-2013-2014.pdf. 7. U.S. Centers for Disease Control and Prevention, Oral Health Data, 2020. Available from:https://nccd. cdc.gov/oralhealthdata/rdPage. aspx?rdReport=DOH_DATA.ExploreByL ocation&isILocation=48&iclTopic=ADT &islYear=2016 8. Texas has the most people without health insurance in the nation — again. Texas Tribune, Sept 10, 2019. Available from:https://www. texastribune.org/2019/09/10/texashas-most-people-without-healthinsurance-nation-again/. 9. Oral Health by the Numbers, Third grade Oral Health Screening Survey, 2017-2018 Texas Health and Human Services, Texas Department of Health Services, 2020. Available from: https://dshs.texas.gov/dental/OralHealth-by-the-Numbers.aspx 10. Medicaid Expansion in Texas: Potential Economic and Employment Implications, The Commonwealth Fund, 2020. Available from: https:// www.commonwealthfund.org/ publications/issue-briefs/2019/aug/ medicaid-expansion-texas-potentialeconomic-employment-implications 11. National and State-Level Projections of Dentists and Dental Hygienists in the U.S., 2012-2025, U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce National Center for Health www.tda.org | August 2021
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Workforce Analysis, February, 2015. 12. Professionally Active Dentists, State Health Facts, Kaiser Family Foundation, 2020. Available from: https://www.kff.org/other/stateindicator/total-dentists/?currentTimefr ame=0&sortModel=%7B%22colId%22 :%22Location%22,%22sort%22:%22a sc%22%7D 13. U.S. Census Bureau. (2017). Urban and rural population of Texas, 2010 Census. Available from: https://factfinder.census. gov/faces/tableservices/jsf/pages/ productview.xhtml?pid=DEC_10_SF1_ P2&prodType=table 14. Texas Statewide Health Coordinating Council. (2015). Dentist and Allied Dental Health Professionals Demographics and Trends. Health Professions Resource Center. Texas Department of State Health Services. Available from: https:// www.dshs.state.tx.us/chs/hprc/ publications/2014DentistTrends.pdf 15. Kaiser Family Foundation, Custom State Report. Available from: https:// www.kff.org/statedata/custom-statere port/?i=32495~32496~32497&g=tx& view=3 16. Health Profession Shortage Area Designation, Texas Health and Human Services, 2020. Available from:https://www.dshs.texas.gov/ chpr/Health-Professional-ShortageArea-Designation.aspx 17. State of Texas Children 2016 Race and Equity, Center of Public Policy Priorities, 2016. Available from: https://everytexan.org/images/ KC_2016_SOTCReport_web.pdf
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18. Children’s Oral Health, Centers for Disease Control and Prevention, 2020. Available from: https://www.cdc.gov/oralhealth/ basics/childrens-oral-health/index.html 19. The State of Little Teeth, American Academy of Pediatric Dentistry https://www.aapd.org/assets/1/7/ State_of_Little_Teeth_Final.pdf 20. A Mess for Years to Come, Houston Chronicle, September 17, 2020. Available from:https://www. houstonchronicle.com/business/ article/Texas-again-leads-the-nationin-uninsured-rates-15573305. php#:~:text=Approximately%20 5.2%20million%20Texans%20 were,national%20average%20of%20 9.2%20percent 21. National Call To Action To Promote Oral Health, Office of the Surgeon General (US).Rockville (MD): National Institute of Dental and Craniofacial Research (US); 2003.Report No.: 03-5303. 22. Social Inequalities in Childhood Dental Caries: The Convergent Roles of Stress, Bacteria and Disadvantage, Boyce et al Soc Sci Med. 2010;71(9):1644-52. 23. Oral Health in Texas, Emergency Department and Inpatient Hospitalization for Non-Traumatic Dental Conditions in Texas, Texas Health Institute, October, 2018Available from: https:// www.texashealthinstitute.org/ uploads/1/3/5/3/13535548/ emergency_department_and_ inpatient_hospitalization_for_dental_ conditions_in_texas.pdf
24. Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health. Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care; Washington (DC): National Academies Press (US); 2003. 25. 2010 US Census, United States Census Bureau, Department of Commerce, 2020. Available from: https://www. census.gov/data.html 26. The Evidence Base for Cultural and Linguistic Competence in Health Care, Goode, et al, National Center for Cultural Competence, Center for Child and Human Development, Georgetown University, 2006. 27. Professionally Active Dentists, State Health Facts, Kaiser Family Foundation. Available from: https://www.kff.org/ other/state-indicator/total-dentists/?cu rrentTimeframe=0&sortModel=%7B% 22colld%22:%22Location&22,%22sort %22:%22asc%22%7D 28. Brown LJ, Wagner KS, Johns B. Racial/ ethnic variations of practicing dentists. J Am Dent Assoc. 2000;131(12):17504. 29. Americans With Disabilities: 2010, report number P70-131. July 2012. Available from:https://www.census. gov/library/publications/2012/demo/ p70-131.html 30. American Academy of Developmental Medicine and Dentistry, Consensus Statement on Health Disparities for Persons with Neurodevelopmental Disorders and Intellectual Disabilities. Available from:http:// aadmd.org/ articles/health-disparities-consensusstatement. 2017.
31. Improving Access to Oral Health Care for Vulnerable and Underserved Populations, Institute of Medicine report, 2011. Available from: https:// www.hrsa.gov/sites/default/files/ publichealth/clinical/oralhealth/ improvingaccess.pdf 32. Building better oral health: a dental home for all Texans. Tex Dent J. Winter 2008;Suppl:1-56. 33. Dental Care Considerations of Disadvantaged and Special Care Populations: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Medicine and Dentistry, Division of Nursing, 2001 34. Improving Access to Oral Health Care for Vulnerable and Underserved Populations. Consensus Study Report, National Research Council; Institute of Medicine; Board on Children, Youth, and Families; Board on Health Care Services; Committee on Oral Health Access to Services, 2011
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ORAL
and maxillofacial pathology diagnosis and management—from page 532
Idiopathic Subcortical Acantholytic Keratosis (ISAK) This clinically was most similar to toothpasteinduced musocal etching
(TIME), a common but much underreported chemical burn of oral
If not TIME, what can it be? We usually assume a sloughing mucosal pseudomembrane represents a collapsed bulla or large blister, presumably from an autoimmune condition or allergic attack, e.g. pemphigus, pemphoid, IgA disease, bullous lichen planus, etc., or sometimes from developmental flaws of skin/membrane integrity.2 The epithelium from the top of such a ruptured bulla easily scrapes off, but this leaves an open ulcer or a prominent erythematous base.
A
B Figure 3. Example of TIME, i.e. hyperkeratosis and superficial chemical burn from whitening toothpaste. A) Grayish white keratotic plaque can be scraped off with finger; B) Subkeratin tearing/clefting (arrow) with enlarged, pale superficial keratoinocytes damaged by low pH, also with atrophy of epithelium and chronic inflammation of the stroma.
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mucosa, from oral hygiene products (Figure 3).1 However, no etiology could be identified and there was no microscopic evidence of a chemical “burn” of superficial cells, which suggests that this likely represents a different problem. Nor were any skin abnormalities present.
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Furthermore, the above bullous disorders are distinguished, one from another, by specific
Table 1. White oral and plaques that can be scrapped off, completely or partially (altered from Neville et al.)1-3 Disease
Cause Comment
White coated tongue Bacteria
Only a small part can be scraped off, with difficulty
Psuedomembranous Fungus candidiasis
Scraps off, often completely and easily, but usually reveals erythema of the underlying mucosa
Moriscatio buccarum Cheek biting
Portions can be completely scraped off, but not frequently
White sponge nevus
Developmental anomaly
Sometimes the top half of the whitish epithelium can be peeled off
Leukoedema
Developmental anomaly
Very rarely, the top half of the whitish macule can be peeled off
Thermal burn Pizza, etc.
Painful, abrupt onset, erythema/ulcer of affected mucosa
Cotton roll burn
Painful, difficult to slough off, can usually scrape off only a small amount
Desiccation from contact with cotton roll
Acid burn Aspirin, etc.
Painful; only top portion of wound sloughs off, may be erythematous and ulcerated beneath
TIME Chemicals in (toothpaste-induced toothpaste or mucosal etching) mouthwash Mucous patch Secondary syphilis
Sloughs off easily and completely, leaving normal appearing underlying mucosa; recurs frequently
Diptheria slough Diptheria
Thick necrotic layer can be scrapped off with difficulty
Can be scraped off with difficulty and not completely; disappears on its own in a week or 2
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ORAL
and maxillofacial pathology, continued
immunofluorescence patterns and the location of the lysis or disruption of the squamous epithelium: between keratinocytes or at the level of the basement membrane. Immunofluorescent studies in the present lesion were negative, and its lysis occured in an extremely unusual microscopic location: immediately beneath the keratin layer. It should here be noted that there are several oral white keratotic patches which can be partially peeled away (Table 1), but they all have known causes, different histopathology and/or clinical features, which are quite different from the present entity.1-3 There are, likewise, a few skin lesions characterized by lysis (acantholysis, epidermolysis) and excess keratin. One of them, epidermolytic hyperkeratosis, would seem by its very terminology to fit perfectly, but its epithelial lysis usually occurs lower in the epithelium and it is a developmental, inherited disorder with a very early onset.4
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In fact, only one skin lesion, subcorneal pustular dermatitis (SneddonWilkinson disease), shows epithelial lysis immediate beneath a thickened keratin layer. It differs significantly, however, in that it clinically mimicks pimples and microscopically has thousands of neutrophils in the cleft/lysis beneath the keratin layer.5-7 This disease appears to be produced by a monoclonal gammopathy, although some consider it to be a variant of pustular psoriasis. No oral lesions have been reported, and our present case shows absolutely no neutrophils. It appears that this woman’s lesion has not been previously reported. We recommend a diagnostic/descriptive name of idiopathic subcorneal acantholytic keratosis (ISAK), that reflects: A) Our inability to identify a cause; B) A site-specific rupture of intercellular bridges between the flattened surface keratinocytes and the underlying more rounded spinous layer cells; C) Excessively thick keratin layer.
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References 1. Bouquot JE, Koeppen RA, Haddad Y. Toothpaste-induced mucosal etching (TIME). J Texas Dent Assoc 2014; 131:574-576, 610-612. 2. Neville B, Damm D, Allen C, Bouquot J. Oral and Maxillofacial Pathology, 3rd edition. Philadelphia: W. B. Saunders, 2008. 3. McDonald G, Bouquot J. White sponge nevus. J Texas Dent Assoc 2008; 125:692-693, 707-708. 4. Ross R, DiGiovanna JJ, Capaldi L, Argenyi Z, Fleckman P, RobinsonBostom L. Histopathologic characterization of epidermolytic hyperkeratosis: A systematic review of histology from the National Registry for Ichthyosis and Related Skin Disorders. J Am Acad Derm 2008; 59:86-90 5. Cheng S, Edmonds E, BenGashir M, Yu RC. Subcorneal pustular dermatosis: 50 years on. Clin Exp Dermatol 2008;33:229–233. 6. Ranieri P, Bianchetti A, Trabucchi M. SneddonWilkinson disease: a case report of a rare disease in a nonagenarian. J Am Geriatr Soc 2009;57:1322–1323. 7. Ceccarelli G, Molinelli E, Campanati A, Goteri G, Offidani A. Sneddon-Wilkinson Disease and Monoclonal Gammopathy of Undetermined Significance in the Elderly: Case Report. Case Rep Dermatol 2019; 11:209-214.
Calendar
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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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VALUE
for your
Provided by:
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PROVIDE SEDATION? HERE’S WHAT YOU NEED TO KNOW ABOUT MONITORS WHAT MAKES A DEVICE A MONITOR? WHAT MEETS STATE REQUIREMENTS AND MY PRACTICE NEEDS? By Rose Dodson, MS, President, Sedation Resource
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While it’s generally considered a safe practice, there’s a level of mortality accompanying sedation. The standards of monitoring continue to be advanced by professional organizations with the objective of improving care. Texas regulations1 on sedating a patient include monitoring the level of consciousness, oxygenation, ventilation, and circulation; and documentation—a written, time-oriented record of a patient’s various vital signs. In order to determine the type of monitor needed for the sedation provided at your practice, you need to understand what makes a device a monitor and meets state requirements. Of course, you also want the monitor to meet the preferences of your practice.
Monitoring To be clear, the best monitor can’t be purchased and is not a device; it’s the practitioner. It’s important to never lose a sense of awareness and to always pay attention to the patient. In fact, over 50% of each area to be monitored requires the practitioner’s senses. • Level of Consciousness: Practitioners use their senses to monitor consciousness. It involves simply checking for responsiveness to verbal commands. For example, asking the patient, “Hey, Susie, how are you feeling?” would prompt a patient to respond. A patient is obviously conscious if they can respond to
anything asked of them. • Oxygenation: Here again, practitioners use their senses to look at the color of mucosa and skin to ascertain a certain level of oxygenation. However, a pulse oximeter—a device that measures oxygen saturation in a patient—can also be used. • Ventilation: A patient’s breathing can be assessed either through observing chest movements or verbal communication. It can also be assessed through listening to breath sounds, which can often be heard by the practitioner placing their ears downwards toward the patient’s mouth or nose. However, a pre-tracheal stethoscope can be used to listen more efficiently. Additionally, ventilation can be determined through use of a capnograph—also known as a CO2 monitor—which measures the level of CO2 a patient breathes out. • Circulation: Measuring blood flow or cardiac output is done by taking a patient’s blood pressure, measuring heart rate, and/or by utilizing an electrocardiograph.
What makes a device a monitor? By definition, a monitor is used for observing, checking, or keeping a continuous record of something. As a verb, it is “to watch, check or observe for a special purpose,” but specifically to “warn.” A monitor is actually a device intended to warn a practitioner of an ongoing issue. Diagnostic devices, such as a finger pulse
1. Texas Rules and Regulations Administrative Code Title 22 Part 5 Chapter 110 www.tda.org | August 2021
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VALUE
continued
oximeter, a blood pressure measuring device, and a thermometer can typically be found at a dental office. Why couldn’t the finger pulse oximeter be simply used every 10 minutes and a reading recorded? Here are the features that make a simple device a monitor: Audible and visual alarms. Tones and alarms are an absolute must for a device to be an actual monitor. It eliminates the need for the practitioner and/or staff to continually stare at that pulse oximeter and gives a warning if the reading drops below an acceptable level. During a busy sedation case, a drop in the pulse oximeter tone is an important indicator to bring attention to a potential physiological change. Automatic blood pressure monitor. An automatic blood pressure device can be set to a specific interval and inflates on its own to record a patient’s blood pressure at the given interval. There are semi-automatic blood pressure diagnostic devices that necessitate pressing a button every time the blood pressure is to be taken. However, beside the fact they don’t have alarms, they leave room for delayed readings or forgetting to press the button and missing a reading altogether. Respiration rate. Respiration is the one baseline vital sign that is not a standard on a basic monitor. Perhaps this is one of the reasons it’s termed the forgotten vital sign.
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What are your options for obtaining a respiration rate on a monitor? Typically, respiration rate on a monitor is obtained by electrocardiogram (ECG). It works by measuring the thoracic impedance across the ribs, measuring the rise and fall of the chest to calculate the respiration rate. This works best in patients who are still and comfortably sedated. Patient movement and incorrect placement of ECG pads often result in excessive false alarms. Another way respiration rate is determined through a monitor is by utilizing capnography. As the monitor is measuring the level of end-tidal CO2, respiration rate is also determined. This reading is often differentiated with a term such as awRR (airway respiration rate) or BRm (breath rate per minute).
Documentation The patient’s measured vitals must be documented. At all levels of sedation, including nitrous, baseline vital signs must be recorded in accordance with Texas State Board of Dental Examiners Rules 108.7 and 108.8. This is repeated at every level of sedation. Everyone must record baseline vital signs. These include: • Pulse oximetry • Heart rate • Respiratory rate • Blood pressure While all levels of sedation need baseline vital signs recorded, there are a few
variances for the subsequent timeoriented documentation. For example, SpO2 (oxygen saturation) must be used for level 1 sedation only if nitrous is added to a single drug sedative. In terms of the time-oriented record though, records may be documented every 10 minutes, according to the regulations. For levels 2 (oral sedation) and 3 (IV sedation), it is very plain: records must be documented every 10 minutes. These include pulse ox, heart rate, respiratory rate, and blood pressure. For level 4 (deep sedation), records must be documented every 5 minutes. To fulfill the requirement of having a timeoriented record of sedation, many prefer to have a printer on their monitor. The bottom line is that once the anesthesia or sedation case is complete, the record needs to show values for all the vitals that were monitored.
A Monitor to Check All the Boxes Looking for a monitor that meets the requirements for your level of sedation permit would be a great starting point. At a minimum, most basic vital signs monitors have a pulse oximeter to determine oxygenation. Additionally, they include non-invasive automatic blood pressure monitoring and will give the heart rate, which will check the circulation box. It should be noted, however, that for level 3 and 4, an ECG is required. Two things that are closely related are ventilation and respiration. How will
ventilation be monitored? And how will respiration rate be measured and documented? If the preference is to have respiration rate recorded on the monitor, then a fullparameter monitor that includes ETCO2 may be the ticket—even for a level 2 or 3 sedation provider. Capnography is required for a level 4 sedation permit holder. Capnography measures ventilation and will also give you a respiration reading for your documentation. As mentioned, ventilation can also be measured by auscultation of breath sounds with a pre-tracheal stethoscope. Since this is a very accurate and effective way to measure ventilation, it’s often utilized, even though it’s not required. When using a pre-tracheal stethoscope, respiration rate will need to be calculated and documented manually. What about level of consciousness? While there’s a monitoring component called EEG or electroencephalogram that measures level of consciousness, it’s not considered necessary for conscious sedation. Thus, responsiveness to verbal command is deemed to be adequate for all levels of conscious sedation.
Conclusion Choosing a monitor to meet sedation regulations may seem like a daunting task, however the ultimate goal is increased patient safety. A monitor that meets the regulations and works well with the practice needs will make sedation simple, safe, and effective.
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Must Be Monitored (All Sedation Levels) Measured through: Level of Consciousness
Observation
Oxygenation
Observation Pulse Oximeter
Ventilation
Circulation
Observation ECG (electrocardiogram): Required for Levels 3, 4 Capnograph (CO2 monitor): Required for Level 4 Pre-Tracheal Stethoscope: (very accurate, effective tool. Often utilized, but not required. Respiration rate needs to be calculated, documented manually.) Blood pressure monitor Measuring heart rate Electrocardiograph: Required for Levels 3, 4
Must Be Documented (All Sedation Levels) Can be Measured through:
Frequency
SPO2
Pulse Oximeter
HR
Pulse Oximeter, Blood Pressure, Electrocardiogram (ECG)
Baseline Vital Sign
RR
BP
Capnograph Electrocardiogram (ECG) Pre-Tracheal Stethoscope (manually calculated)
Every 10 minutes (Levels 2, 3) Every 5 minutes (Level 4)
Automatic Blood Pressure
TDA Perks Program endorsed partner Sedation Resource is a customer-focused company that carries an extensive line of sedation equipment and supplies at reasonable prices and is a great source for PPE. TDA members receive a 10% discount on all sedation supplies and year-round discounted pricing on equipment. Enter code “TDAPERKS” at checkout. For more information, visit tdaperks.com (Compliance & Supplies) or call Sedation Resource at 800-753-6376.
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LAW OFFICES OF MARK J. HANNA EXPERIENCED LEGAL REPRESENTATION FOR TEXAS DENTISTS •
Representation Before the Texas State Board of Dental Examiners
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Medicaid Audits and Administrative Hearings
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Employment Issues—Texas Workforce Commission Hearings
Mark J. Hanna JD Former General Counsel, Texas Dental Association
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Those in the dental community who have recently passed IN MEMORIAM
Michael Don Vaclav Amarillo June 17, 1947–July 23, 2021 Good Fellow: 2000 Life: 2012
Frank King Eggleston Houston December 4, 1942–July 25, 2021 Good Fellow: 1994 Life: 2007 Fifty Year: 2019
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#H480): This productive orthodontic
located in a growing suburb south of
practice occupies an attractive free-
downtown Houston. There are 5 fully
standing building situated on a high
equipped operatories, digital radiography,
traffic street in a desirable community in
computers throughout, and a 3D Cone
the heart of east Texas. The practice has
Beam CT in the well-appointed 2,400
a loyal fee-for-service patient base and
square foot modern space. HOUSTON-
has realized annual revenue of 7 figures
WEST (ID #H471): This established,
with exceptional profitability over the
general dentistry practice is located along
past few years. The office features a
a heavily trafficked intersection of
4-chair ortho bay, 2 exam rooms, and
Highway 6. The office is situated on the
digital pan/ceph unit. The real estate is
top floor of a professional building and
also available for purchase. HOUSTON
has 5 fully equipped operatories with
(ID #H481): This established, general
digital technology throughout. With a
dentistry practice is located in a highly
primarily FFS patient base, excellent
desirable area in west Houston. The
hygiene recall, a fantastic reputation
practice serves a large FFS/PPO patient
(over 100 5-star Google reviews), solid
base with over 2,000 active patients. The www.tda.org | August 2021
559
ADVERTISING BRIEFS office features 4 operatories equipped
digital radiography & computers
with computers, digital X-ray units, a
throughout. With the office only seeing
digital pano, and room for expansion by
patients 2.5 to 3 days per week, there is
way of equipping the 5th operatory. The
tremendous upside potential for a new
real estate is also available for purchase.
owner who is able to expand hours to the
HOUSTON (ID #H482): This FFS/PPO
standard 4 to 5 days per week. This is a
general dentistry practice has been
great alternative to starting a practice
operating for almost 40 years in a
from scratch. SAN ANTONIO (ID
community just south of downtown
#T432): This established, general
Houston. The spacious facility boasts 6
dentistry practice and building is located
fully equipped operatories, a CBCT, digital
in a growing suburb along the I-35
radiography, and an open concept pedo/
corridor north of San Antonio. The
ortho bay prepped for future expansion
practice serves a large PPO/FFS patient
(10 ops total). HOUSTON (ID #H483):
base and has a tremendous amount of
This 100% FFS, general dentistry practice
untapped potential, as approximately
has been in operation for over 35 years
40% of total production is derived from
and is situated in a 2,200 sq ft, free
hygiene services and the seller is
standing building with 5 fully equipped
referring out most specialty procedures.
operatories. Hygiene production is very
The facility features 3 fully equipped
healthy and the practice has seen 1,700+
operatories with space to add a 4th
active patients in the last 24 months with
operatory. SAN ANTONIO-WEST (ID
a steady new patient flow, primarily
#T454): This established, general
through word of mouth referrals. The real
dentistry practice and real estate is
estate is also available to purchase.
located in a rural community
HOUSTON (ID #H484): This attractive
approximately 75 miles west of San
practice is located in a high visibility retail
Antonio. The practice serves a PPO/FFS
center at a bustling intersection in
patient base, sees about 30+ new
northwest Houston. The 1,750 sq ft
patients per month, and offers consistent
leased space has a total of 5 plumbed
annual revenue with substantial upside
operatories, 3 are fully equipped with a
potential through expanding the
dental chair and cabinetry in the 4th, and
procedures offered in-house. The turn-
560
Texas Dental Journal | Vol 138 | No. 8
ADVERTISING BRIEFS key office features 3 fully equipped
digital pano, computers throughout, and
operatories, digital sensors, intra-oral
an additional 5 plumbed operatories
cameras, and a digital pano. SAN
available for expansion. The opportunities
ANTONIO (ID #T464): This well-
for growth in this office are endless
established set of practices is located in
through enhancing of the multi-specialty
the same facility in an upscale area of
component, offering pediatric or ortho
northwest San Antonio. The seller had
treatment in the additional space,
operated both practices independently for
increasing in-network coverage, and
many years before merging them into the
launching a marketing program to
same 2,500 sq ft facility in 2016.
increase the new patient count. SOUTH
Combined, the practices have around
TEXAS (ID #T460): This established,
2,600 active patients and collected over 7
legacy practice and free-standing building
figures annually over the past 3 years.
is located in a charming south Texas
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. SAN ANTONIO (ID #T501): This established, premier general dentistry practice is located in a highly sought-after area along Loop 1604 in north San Antonio. The practice serves
McLerran & Associates is the largest dental practice brokerage firm in Texas. When it’s time to buy or sell a practice, we’ve got you covered. P RAC T I C E S AL E S DS O T RAN S ACT I O N S
P RAC T I C E AP P RAISA LS ASSOCIATE PLACEMENT
a large PPO/FFS patient base and is located in a spacious office condo with 6 fully equipped operatories, digital pano, digital X-rays, and digital sensors. SAN ANTONIO (ID #T506): This
Austin
512-900-7989
DFW
214-960-4451
Houston
281-362-1707
San Antonio 210-737-0100
established, FFS/PPO practice and
South Texas 361-221-1990
commercial real estate is located in
Emai l : t ex as@ den t al t r an si t i o n s.co m
northwest San Antonio. The 4,100 sq ft
www.dentaltransitions.com
facility boasts 5 equipped operatories, a www.tda.org | August 2021
561
ADVERTISING BRIEFS town. The office is located in a 2-story,
AUSTIN, VICTORIA, SAN ANTONIO,
free-standing building and has a spacious
AND DFW AREA (DDR DENTAL
layout that includes 6 fully equipped
Listings). (See also HOUSTON for
operatories (one additional plumbed for
other DDR Dental listings and visit www.
expansion, digital sensors, a digital pano,
DDRDental.com for full details. AUSTIN:
CBCT, and computers throughout. With a
GENERAL/PROSTHODONTIC practice
large fee-for-service patient base and a
provides comprehensive care but focuses
steady flow of new patients, this office
on TMJ, occlusal rehabilitation and
generates consistent annual revenue of
high-end cosmetic procedures. Must be
over 7 figures per year. SOUTH TEXAS
prosthodontist or like training to apply.
(ID #T470): This high performing
Owner prepared to remain and train in
practice is located in a rapidly growing
latest occlusal rehabilitation techniques.
community in south Texas. The office
Located in highly sought-after affluent
serves a diverse PPO/FFS demographic
Austin area that is in very high demand
with only a small portion of the revenue
and closely proximate to downtown
being derived from Medicaid (about
between entertainment and hi-tech
10%). The expansive 4,000 sq ft facility
corridors (in the “Heart of Austin”). In
boasts 9 fully equipped operatories,
a single-story stand-alone building that
digital X-rays, CAD/CAM, Gendex CBCT,
draws from mature upscale neighborhood
Solea Laser, intraoral cameras, and
and nearby schools. Practice produces
computers throughout. This is an ideal
7 figures, in 5 operatories, (3 dental
situation for a current practice owner
and 2 hygiene) within 2,000 sq ft
looking to expand their footprint, a multi-
Immaculate equipment, all digital with
location group, partnership, or a high
pano. Majority of patients 41 and older
producing dentist looking to venture into
with 98% collection ratio. NOTE: Practice
practice ownership. To request more
recently acquired additional patient
information on our listings, please
base that should boost production, new
register at www.dentaltransitions.com or
patients and collections. Contact Jim
contact us at 512-900-7989 or info@
Dunn at 800-930-8017 or christopher@
dentaltransitions.com.
ddrdental.com and reference “Austin Cosmetic or TX#560.” VICTORIA AREA:
562
Texas Dental Journal | Vol 138 | No. 8
ADVERTISING BRIEFS GENERAL practice provides a wide range
98% collection ratio. Contact Christopher
of procedures for a small town near
Dunn at 800-930-8017 or christopher@
Victoria. Gross collections in the high-6
ddrdental.com and reference “San
figures. The practice has a broad mix of
Antonio or TX569.”
patient ages. Most are middle- to highincome households. Practice is 100%
AUSTIN: Associate to buy, planning on
fee-for-service. In a single story stand-
long transition. Prefer GP interested in
alone building. Only 2 other dental offices
orthodontics. Fee-for-service practice,
within 15 miles. 2,800 sq ft; expanded in
43 years same location, long standing
2000. Located on a high visibility street.
staff, beautiful view. Email Info@
Does have digital X-ray and pano. This
AustinSkylineDental.com.
practice uses mainly word of mouth as its source of new patients. 99% collection ratio. Contact Christopher Dunn at 800930-8017 or christopher@ddrdental. com and reference “Victoria Area or TX#567.” SAN ANTONIO: GENERAL practice provides comprehensive general dentistry in a growing major Texas
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city. The practice is located in a highly trafficked area near a major highway. This practice is 1536 sq ft with the ability to expand into the office next door. It has 2 operatories with 1 used for hygiene. The operatories are plumbed for Nitrous. There is a good mix of patients ages, with the largest percentage between 30 to 65. The practice has been at its current location for 35 years. The practice is mostly fee-for-service, with some PPO insurance accepted. The practice has a
Call Dr Scott for free 2nd opinion
1-800-508-4050 www.DDSprices.com
www.tda.org | August 2021
563
ADVERTISING BRIEFS AUSTIN: Pediatric dentist. Progressive
transition period. The practice itself is
pediatric dental practice in Austin
an hour north of the DFW metroplex
is looking for an energetic pediatric
and just minutes outside the great
dentist to join our team. We offer a
community of Denton! 5 fully equipped
comprehensive compensation package.
operatories. Over 2600 active patients.
New grads welcome to apply. Please
Visit our website for collections and
email CV to Joinourpractice2010@gmail.
EBITDA amounts. To learn more, email
com.
Kaile Vierstra with Professional Transition Strategies: kaile@professionaltransition.
DALLAS: Office to share. Ready to
com or call: 719-694-8320. https://
cut back to a couple of days or start a
professionaltransition.com/properties-list/
new practice? Share my beautiful, fully
denton-tx-area-general-dental-practice-
digital office, located in the Richardson
for-sale/
Telecom/City Line area. 5 ops, all computers (Eaglesoft) and electronic
EL PASO: Well-established, dentist
services (support, back up, and patient
owned and operated practice, seeking
communication) in place. Office currently
an associate dentist for a part-time
used 3.5 days/week but willing to cut
position in El Paso. Associate dentist
back to 3; must see to appreciate.
will work along with the owner dentists
Contact jack@drjackbodie.com or 972-
in a team-oriented environment that
235-4767.
allows you to focus on what you do best, dentistry. We offer guaranteed base and
DENTON: General dental practice for
percentage of production with uncapped
sale. Exciting opportunity north of the
earning potential. An ideal candidate is
DFW metroplex. Experience the charm
dependable and adaptable, committed
of a small, close-knit community with
to patient care, provide accurate exams
easy access to all that DFW offers within
and patient-focused treatment planning;
an hour drive. The current doctor is
Deliver patient-focused preventive,
interested in transition options that
restorative, and surgical procedures;
include a straight buy out or affiliation.
compassionately communicate treatment
They would, however, prefer a short
plans and instructions; assist the practice
564
Texas Dental Journal | Vol 138 | No. 8
ADVERTISING BRIEFS towards excellence in oral health care
have a pano but does have digital x-ray.
requirements. Candidates must have
Production is 50% FFS and 50% PPO
current Texas Dental Board License, CPR,
(no Medicaid), with collection ratio
DEA, NPI, and malpractice insurance.
above 95%. Providing general dental
New graduates are welcome to apply.
and cosmetic procedures, producing
Contact Rosie Mireles at rosiem@
mid six figure gross collections. Contact
starcitydental.com or 915-591-7117.
Christopher Dunn at 800-930-8017 or Christopher@DDRDental.com and
FORT WORTH: Practice for sale in the
reference “Lufkin General or TX#540.”
fast growing southwest area. Average
HOUSTON: GENERAL (SHARPSTOWN).
gross; 6 operatories; Excellent lease.
Well established general dentist
Seller is relocating. Need to move quickly
with high-6 figure gross production.
on this one. DFW 214-503-9696. WATS
Comprehensive general dentistry in
800-583-7765.
the southwest Houston area focused on children (Medicaid). Very, very high
HOUSTON, COLLEGE STATION, AND
profitability. 1,300 sq ft, 4 operatories
LUFKIN (DDR DENTAL Listings). (See
in single building. 95% collection ratio.
also AUSTIN for other DDR Dental listings
Over 1,200 active patients—20%
and visit www.DDRDental.com for full
Medicaid, 45% PPO, and 35% fee-for-
details. LUFKIN: GENERAL practice on a
service. 30% of patients younger than
high visibility outer loop highway near
30. Office open 6 days a week and
mall, hospital and mature neighborhoods.
accepts Medicaid. Contact Chrissy Dunn
Located within a beautiful single-story,
at 800-930-8017 or chrissy@ddrdental.
free-standing building, built in 1996 and
com and reference “Sharpstown General
is ALSO available for purchase. Natural
or TX#548.” HOUSTON: GENERAL
light from large windows within 2,300
(PEARLAND AREA). General located in
sq ft with 4 operatories (2 hygiene
southeast Houston near Beltway 8. It
and 2 dental). Includes a reception
is in a freestanding building. Dentist
area, dentist office, a sterilization
has ownership in the building and
area, lab area, and break room. All
would like to sell the ownership in the
operatories fully equipped. Does not
building with the practice. One office www.tda.org | August 2021
565
ADVERTISING BRIEFS currently in use by seller. A 60 percent
com. Reference “West Houston General
of patients age 31 to 80 and 20% 80
or TX#559.”
and above. Four operatories in use, plumbed for 5 operatories. Digital Pano
KATY: Now is the time to join Grand
and digital X-ray. Contact Christopher
Lakes Dental Group and Orthodontics.
Dunn at 800-930-8017 or christopher@
You will have opportunities to learn new
ddrdental.com and reference “Pearland
skills from our team of experienced
General or TX#538.” HOUSTON:
professionals. If you’re ready to take your
PEDIATRIC (NORTH HOUSTON). This
career to the next level and gain valuable
practice is located in a highly sought-
experience, apply today! You’ve invested
after upscale neighborhood. It is on a
the time to become a great dentist,
major thoroughfare with high visibility
now let us help you take your career
in a strip shopping center. The practice
further with more opportunity, excellent
has three operatories for hygiene and
clinical leadership and one of the best
two for dentistry. Nitrous is plumbed for
practice models in modern dentistry. In
all operatories. The practice has digital
working with our practice you will have
x-rays and is fully computerized. The
the autonomy to provide your patients
practice was completely renovated in
the care they deserve. In addition, you’ll
2018. The practice is only open three
enjoy the opportunity to earn excellent
and a half days per week. Contact
income and have great work-life balance
Christopher Dunn at 800-930-8017
without the worries of running a practice.
or christopher@ddrdental.com and
You became a dentist to provide excellent
reference “North Houston or TX#562.”
patient care and have a career that will
WEST HOUSTON: MOTIVATED SELLER.
serve you for a lifetime. With us, you
Medicaid practice with production over
will have a balanced lifestyle, fantastic
$600,000. Three operatories in 1200 sq.
income opportunities, and you’ll work for
feet in a strip shopping center. Equipment
an office that cares about their people,
is within 10 years of age. Has a pano
their patients and their community. Our
and digital X-ray. Great location. If
practice is an office supported by Pacific
interested contact chrissy@ddrdental.
Dental Services (PDS), which means
566
Texas Dental Journal | Vol 138 | No. 8
ADVERTISING BRIEFS you won’t have to spend your career
against any employee or applicant
navigating practice administration.
for employment based on race, color,
Instead, you’ll focus on your patients
religion, national origin, age, gender, sex,
and your well-being. Add on excellent
ancestry, citizenship status, mental or
benefits, including malpractice insurance,
physical disability, genetic information,
medical, dental and vision insurance,
sexual orientation, veteran status, or
retirement plans and much more and
military status. Apply here:http://www.
you’ll feel well taken care of throughout
Click2Apply.net/gwy6pkn22knbzwzx
your career. The average full-time PDS-
PI106822492.
supported associate dentist earns low-6 figures in their first year. The average
KATY: Now is the time to join Highlands
income for a PDS-supported owner
Dental Group. You will have opportunities
dentist, whose practice has been open
to learn new skills from our team of
at least 2 years, is mid-6 figures. As
experienced professionals. If you’re
an associate dentist, you will receive
ready to take your career to the next
ongoing training to keep you informed
level and gain valuable experience,
and utilizing the latest technologies and
apply today! You’ve invested the time to
dentistry practices. If you are interested
become a great dentist, now let us help
in a path to ownership, our proven
you take your career further with more
model will provide you with the training
opportunity, excellent clinical leadership
needed to become an owner of your own
and one of the best practice models in
office. PDS is one of the fastest growing
modern dentistry. In working with our
companies in the US which means we
practice you will have the autonomy
will need excellent dentists like you
to provide your patients the care they
to continue to lead our growth in the
deserve. In addition, you’ll enjoy the
future. Apply now or contact a recruiter
opportunity to earn excellent income
anytime. We’d love to chat, get to know
and have great work-life balance without
you and share more about us. Pacific
the worries of running a practice. You
Dental Services is an equal opportunity
became a dentist to provide excellent
employer and does not discriminate
patient care and have a career that will
www.tda.org | August 2021
567
ADVERTISING BRIEFS serve you for a lifetime. With us, you
will need excellent dentists like you
will have a balanced lifestyle, fantastic
to continue to lead our growth in the
income opportunities, and you’ll work for
future. Apply now or contact a recruiter
an office that cares about their people,
anytime. We’d love to chat, get to know
their patients and their community. Our
you and share more about us. Pacific
practice is an office supported by Pacific
Dental Services is an equal opportunity
Dental Services (PDS), which means
employer and does not discriminate
you won’t have to spend your career
against any employee or applicant
navigating practice administration.
for employment based on race, color,
Instead, you’ll focus on your patients
religion, national origin, age, gender, sex,
and your well-being. Add on excellent
ancestry, citizenship status, mental or
benefits, including malpractice insurance,
physical disability, genetic information,
medical, dental and vision insurance,
sexual orientation, veteran status, or
retirement plans and much more and
military status. Apply here:http://www.
you’ll feel well taken care of throughout
Click2Apply.net/ygmfkqjp6prswyc3.
your career. The average full-time PDSsupported associate dentist earns low-6
NORTH HOUSTON: General dental
figures in their first year. The average
practice. New to the market is an exciting
income for a PDS-supported owner
general dental practice for sale north
dentist, whose practice has been open
of Houston! The practice is located in
at least 2 years, is mid-6 figures. As
the highly desirable community of The
an associate dentist, you will receive
Woodlands, within an hour of downtown
ongoing training to keep you informed
Houston. The current doctor is interested
and utilizing the latest technologies and
in affiliation with a group, to continue the
dentistry practices. If you are interested
upward trajectory of the practice. Set in
in a path to ownership, our proven
an expansive retail center, the practice is
model will provide you with the training
prominent and easy for patients to visit.
needed to become an owner of your own
5 operatories and expansion opportunity
office. PDS is one of the fastest growing
for 2 additional plumbed ops. 35 new
companies in the US which means we
patients per month. To learn more, email
568
Texas Dental Journal | Vol 138 | No. 8
ADVERTISING BRIEFS Kaile Vierstra with Professional Transition
SAN ANTONIO: General dental practice.
Strategies: kaile@professionaltransition.
San Antonio general practice with doctor
com or call: 719-694-8320. https://
interested in partnering with a group and
professionaltransition.com/properties-
continuing to grow the practice. Located
list/north-houston-tx-general-dental-
in an office complex within 15 minutes
practice-for-sale/
of downtown San Antonio, the practice is in a prime location off Loop 410. 5 fully
NORTH TEXAS: Come establish your
equipped operatories. Nearly 3,000 active
practice in a growing, robust, friendly
patients and 20 new patients per month.
town just 1 hour north of Dallas. Office is
Visit the website to review collections
located on busy street across from park
and EBITDA. To learn more, email Kaile
and football stadium. 4 operatories (1
Vierstra with Professional Transition
unused), panoramic, laboratory, private
Strategies: kaile@professionaltransition.
office, reception area. Outdoor shipping
com or call: 719-694-8320. https://
container for storage. General practice
professionaltransition.com/properties-list/
includes oral surgery, endodontics, crown
san-antonio-tx-general-dental-practice-
and bridge, and removable prosthetics.
for-sale/
Call 903-647-3177. WATSON BROWN PRACTICES FOR SAN ANGELO: West central Texas
SALE: Practices for sale in Texas and
orthodontic specialty practice grosses low
surrounding states, For more information
7+ figures annually with 60% overhead;
and current listings please visit our
100% fee-for-services. Well established
website at www.adstexas.com or call us
in community with strong doctor and
at 469-222-3200 to speak with Frank or
patient referrals. 200+ starts annually.
Jeremy.
Practice was recently appraised. Doctor will stay for smooth transition. Inquire to hilltoportho@gmail.com.
www.tda.org | August 2021
569
YOUR PATIENTS TRUST YOU.
WHO CAN YOU TRUST?
ADVERTISERS Anesthesia Education & Safety Foundation.......... 533
Card Connect.............................................Back Cover
Doctor Scott DDSPrices.com................................. 563
E-VAC, Inc............................................................ 529
If you or a dental colleague are experiencing impairment due to substance use or mental
Institute of Houston Dental Society...................... 526
JKJ Pathology....................................................... 551
illness, The Professional Recovery Network is here to provide support and an opportunity for confidential recovery.
Law Offices of Mark Hanna.....................................557
McLerran & Associates...........................................561
Professional Recovery Network............................ 570
TDA Perks..................................... Inside Front Cover
Texas Health Steps............................................... 523
UTHealth School of Dentistry at Houston.............. 529
Watson Brown Practice Sales & Appraisals........... 527
PRN Helpline (800) 727-5152
570
Visit us online www.txprn.com
Texas Dental Journal | Vol 138 | No. 8
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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. www.tda.org | August 2021
571
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