March 2022
TEXAS DENTAL
INSIDE:
C. difficile:
An Update for Dentistry
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101
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Texas Dental Journal | Vol 139 | No. 3
Compliance & Supplies
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www.tda.org | March 2022
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Contents March 2022 Established February 1883 n Vol 139, No. 3
FEATURES 120 | C. difficile: An Update for Dentistry Hillary Bui, BS Sydney Pham, BSA Andrew Roberts, BBA Mason Tobola, BS Jayme Witek, BS Arthur Jeske, PhD, DMD C. difficile infection (CDI) is a potential complication of antibiotic
Texas bluebonnet from above
therapy, and while frequently associated with regimens of clindamycin, it is known to occur with any antibiotic. As such, practitioners should be aware of the signs and symptoms of CDI and the potential severity of the disorder, which may lead to death if not promptly and effectively managed.
DEPARTMENTS
143 | Oral and Maxillofacial
108 | President’s Message
Month Diagnosis and
111 | TDA Governance: Officia Call for Nominations 114 | TDA Governance: Official Call to the 2022 Texas Dental Association House of Delegates 116 | Oral and Maxillofacial
Pathology Case of the Management 146 | Value for Your Profession: Email Cybersecurity is Critical for Your Practice—Know How to Protect Your Office 149 | Calendar of Events
Pathology Case of the Month
TDA members, use your smartphone to scan this QR Code and access the online Texas Dental Journal.
104
134 | TDA Governance: Texas Dental Association 2022 Financial Report, 2023 Proposed Budget
Texas Dental Journal | Vol 139 | No. 3
150 | Advertising Briefs 159 | 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 2022 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
www.tda.org | March 2022
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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
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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)
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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
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Credit: 18 hours lecture/participation (you must complete the online portion prior to the clinical part)
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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.
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Texas Dental Journal | Vol 139 | No. 3
CELEBRATING 30 YEARS
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| March 2022
107
Chewon this
Women’s History Month
I
n 1980, the week of March 8 was declared by then President Jimmy Carter to be National Women’s History Week. This recognition was renewed by later presidents until 1987, when Congress designated March as “Women’s History Month.” At a recent TDA Board meeting, I was reminded of the achievements, courage, and perseverance that women have similarly made in the profession of dentistry. For the first time in TDA history, the women on the TDA Board outnumber their male counterparts. As we take time to recognize and honor the growing diversity within the TDA, I would first like to honor the women who helped lay the foundation for myself and for countless others within the profession. Their contribution to the dental profession is invaluable. Emeline Roberts Jones, a New England native, married dentist Daniel
Jones in 1854 at the age of 18. Jones believed that women were not suited for the profession because of their “frail and clumsy fingers.” Emeline began to secretly study dentistry. After she had filled and extracted several hundred teeth, her husband allowed her to practice with him. At the time she was just 19. At the age of 23, she became his partner. She eventually took over the practice when her husband died in 1865. Emeline traveled around Connecticut and Rhode Island before settling in New Haven. She practiced for 6 decades and in 1914 was made an honorary member of the National Dental Association. While Emeline Roberts Jones was the first woman to practice dentistry, it wasn’t until 1866 that the first woman, Lucy Hobbs Taylor, earned her DDS at age 33. Dr Taylor and her 9 siblings were orphaned when she was just 12 years old and she spent much of her childhood supporting her family by working as a seamstress.
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Emeline Roberts Jones
Dr Lucy Hobbs Taylor
Dr Ida Gray
Dr Leonie von Meusebach–Zesch Photos courtesy of Wikipedia Creative Commons
She still devoted time to her education and moved to Michigan where she taught for 10 years. Because of her gender, Dr Taylor was denied entry into the medical college to which she applied. Not taking no for an answer, she went directly to the faculty and a supervisor from Eclectic Medical College agreed to tutor her. From there she applied to the Ohio College of Dentistry but was refused admission again. However, Dr Jonathan Taft of the Ohio College of Dentistry, agreed to tutor Lucy. Eventually Dr Taylor opened her own practice in Cincinnati in 1861, and finally, 7 years after she had begun her dental studies, she received her DDS degree in 1866 through the Ohio College of Dental Surgery. Dr Taylor met her husband the following year and her love for dentistry was contagious! She convinced him to pursue his degree and the pair practiced for another 20 years. By 1900, nearly 1,000 women followed in Lucy Taylor’s footsteps as they began a
career in dentistry. Ida Gray, the first AfricanAmerican dentist, (also referred to as Ida Gray Rollins or Ida Gray Nelson) grew up an orphan much like Lucy Hobbs Taylor. Overcoming an unfortunate childhood, Dr Gray was also tutored by Dr Jonathan Taft when she began working in his office while studying at Gaines High School in Chicago. She gained enough knowledge to enter the University of Michigan School of Dentistry in 1887 and graduated in 1890. While Dr Gray grew up attending a segregated school, she became famous first in Cincinnati for seeing both Black and white patients. When she began to practice in Chicago, she inspired one of her patients, Olive M. Henderson, to become the city’s second Black female dentist. Dr Gray’s passion about civic matters was as strong as her passion for dentistry. She was the vice president of the Professional Women’s Club of Chicago, the vice president of the Eighth Regiment Ladies’ Auxiliary, and she was a member
TDA President Debrah J. Worsham, DDS
of the Phyllis Wheatley Club (a group that worked to maintain the only Black women’s center in Chicago). In the late 1800s and early 1900s, female dentists were becoming influencers both in the field of dentistry and in their communities. Dr Leonie von Meusebach– Zesch’s impacted the lives of those affected by the San Francisco earthquake of 1906, the Great Depression, and beyond. In 1902, she earned her DDS from the San Francisco College of Physicians and Surgeons. Leonie began as a dentist’s assistant but soon forged her own dental career path, leaving a legacy that spanned Texas to Alaska. Following the devastating San Francisco earthquake, Dr Meusebach-Zesch became a dental surgeon with the U.S. Army and www.tda.org www.tda.org || March March 2022 2022
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treated earthquake refugees with her mother helping her document survivors as a volunteer with the Red Cross. Following the earthquake recovery efforts, Dr Meusebach-Zesch went into private practice and worked as a dentist in the San Francisco Children’s Hospital and in the Maria Kipp Orphanage. In 1912, she began to hold mobile dental clinics out of her Model T Ford in the state of Arizona, treating all school children free of charge. After moving to Alaska in 1915, she often traveled using a dog sled to reach patients. Returning to California in 1930, with the Great Depression in full swing, she joined the Unemployed Exchange
Association and offered dental services on a barter basis. Dr Meusebach-Zesch also donated services to unemployment camps and school children. In 1937 she became the dentist for the California Institute for Women where she taught female inmates to assist. She also worked with migrant laborers and convict labor camps. If her life sounds amazing, that’s because it was! One thing these women all had in common was determination and perseverance and most had mentors who influenced their careers. I challenge each of you to take the time to mentor a predental student, dental student, or new dentist. The impact could last for decades!
Finally, the National Women’s History Alliance designates a yearly theme for women’s history month and the theme for 2022 is “women providing healing, promoting hope.” According to the group this is “both a tribute to the ceaseless work of caregivers and frontline workers during this ongoing pandemic and also a recognition of the thousands of ways that women of all cultures have provided both healing and hope throughout history.” I’d like to take this opportunity to thank all of the women on the frontlines of healthcare during the last two and half years for their contribution to women’s history.
Female Dentists Make TDA History
For the first time in TDA history, female members of the TDA Board outnumber their male counterparts. Picture are the most recent TDA Board meeting are (L-R) Dr Georganne McCandless, Dr Carmen Smith, Dr Glenda Owen, Dr Shailee Gupta, Immediate Past President Dr Jacqueline Plemons, President Dr Debrah Worsham, Executive Director Linda Brady, Dr Jodi Danna, Dr Summer Roark, Dr Teri Lovelace and Dr Elizabeth Goldman.
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OFFICIAL CALL FOR NOMINATIONS OFFICIAL CALL FOR CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS: SPEAKER OF THE HOUSE, SECRETARY-TREASURER, AND EDITOR OFFICIAL CALL FOR SPEAKER OF THE HOUSE CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS Candidacy announcements for the statewide elective office of Texas Dental Association (TDA) Speaker of the House may be submitted to TDA Secretary-Treasurer Dr Cody C Graves for the upcoming 2021 House elections. Only an active, life, or retired member in good standing of this Association shall be eligible. A curriculum vitae (CV) must be submitted, and the candidate will also have to sign a conflict of interest statement. Nominations are in order at the first meeting of the House of Delegates and remain open until the close of the second meeting of the House of Delegates; however, announcements of candidacy should be made as early as possible so that membership eligibility can be verified. To become a nominee, a delegate must place the name of the candidate in nomination at the first meeting of the House of Delegates. Please see the Manual on Caucus, Campaigns, Nominations and Elections at tda.org for full details. Duties of the Speaker of the House are enumerated in the Bylaws and include the following: 1. To serve as an ex-officio member of the Board of Directors without vote or the privilege of proposing resolutions. 2. To serve as an ex-officio member of the Executive Committee without vote or the privilege of proposing resolutions. 3. To preside at all meetings of the House of Delegates. 4. To determine the order of business for all meetings, subject to the approval of the House of Delegates, in accordance with
Section 140B of this chapter. 5. To appoint tellers to assist him/her in determining the result of any action taken by vote. 6. To appoint members of reference committees in consultation with the president, president-elect, and the immediate past president by the Board of Directors’ first meeting of the calendar year. 7. To notify the divisional officers and the Committee on Credentials, Rules and Order, prior to the annual session, the number of delegates and alternates necessary to constitute a quorum. 8. To meet with the divisional officers prior to the meeting of the divisional caucuses at the annual session to review the Rules for Caucus Procedures, Nominations, And Elections. 9. To appoint a parliamentarian pro tem, should it become necessary for the parliamentarian to be absent during a session of the House of Delegates. 10. To serve as presiding officer of the TDA Candidates Forum, unless the Speaker is in a contested race, at which time the Speaker Pro-tem will preside. 11. To be a certified parliamentarian or be in the process of certification Candidacy announcements are to be mailed to TDA Secretary-Treasurer Dr Cody C Graves, Texas Dental Association, 1946 S IH-35 Ste 400, Austin, Texas 78704; or, emailed to TDA Executive Director Linda Brady: lbrady@tda.org. (See TDA Bylaws, Chapter IV, House of Delegates—Sections 100 (Officers), 110A (Duties), 150C(3), 150D, Chapter V, Board of Directors—Sections 10 (Composition); TDA House Manual; Speaker Manual).
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OFFICIAL CALL FOR SECRETARY-TREASURER CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS Candidacy announcements for the statewide elective office of Texas Dental Association (TDA) Secretary-Treasurer may be submitted to TDA Secretary-Treasurer Dr Cody C Graves for the upcoming 2021 House elections. Only an active, life, or retired member in good standing of this Association shall be eligible. A curriculum vitae (CV) must be submitted, and the candidate will also have to sign a conflict of interest statement. Nominations are in order at the first meeting of the House of Delegates and remain open until the close of nominations at the end of the second meeting of the House of Delegates; however, announcements of candidacy should be made as early as possible so that membership eligibility can be verified. To become a nominee, a delegate must place the name of the candidate in nomination at the first meeting of the House of Delegates. Please see the Manual on Caucus, Campaigns, Nominations and Elections at tda.org for full details. Duties of the TDA Secretary-Treasurer are enumerated in the Bylaws and include the following: 1. Serve as chair, without vote, of the Budget, Assets and Finance Committee. 2. Examine the income and expenses of this Association and report at each meeting of the Board of Directors. 3. Ensure that the minutes of the House of Delegates and the Board of Directors be maintained. 4. To be responsible and perform such other duties as shall be specified by the Board of Directors and the Bylaws. Other duties as Secretary include the following: • Serve as recording officer and custodian of the records of the House of Delegates and the Board of Directors. • Serve as secretary to the Executive Committee, without the right to vote.
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• •
Serve as secretary to the House of Delegates. Serve as the secretary of the American Dental Association Fifteenth Trustee District Delegation.
Candidacy announcements are to be mailed to TDA Secretary-Treasurer Dr Cody C Graves, Texas Dental Association, 1946 S IH-35 Ste 400, Austin, Texas 78704; or, emailed to TDA Executive Director Linda Brady: lbrady@tda.org. (Ref. TDA Bylaws, Chapter IV, House of Delegates—Sections 70A-B (Notice and Publication—Official Call & Publication of Actions, 110B (Duties); Chapter V, Board of Directors —Sections 10 (Composition), 80B (Officers-Secretary); Chapter VI, Elective Officers—Section 90G (Duties); Chapter VIII, Fifteenth Trustee District American Dental Association Delegates and Alternate Delegates—Section 80 (Delegation Secretary); Board Manual; Secretary-Treasurer Manual).
OFFICIAL CALL FOR EDITOR CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS Candidacy announcements for the statewide elective office of Texas Dental Association (TDA) Editor may be submitted to TDA SecretaryTreasurer Dr Cody C Graves for the upcoming 2021 House elections. Only an active, life, or retired member in good standing of this Association shall be eligible. A curriculum vitae (CV) must be submitted, and the candidate will also have to sign a conflict of interest statement. Nominations are in order at the first meeting of the House of Delegates and remain open until the close of nominations at the end of the second meeting of the House of Delegates; however, announcements of candidacy should be made as early as possible so that membership eligibility can be verified. To become a nominee, a delegate must place the name of the candidate in nomination at the first meeting of the House of Delegates. Please see the Manual on Caucus, Campaigns,
Nominations and Elections at tda.org for full details. Duties of the editor are enumerated in the Bylaws and include the following: 1. To be editor-in-chief of all journals and publications of the Association and exercise full editorial control over such publications, subject only to policies established by the House of Delegates, Board of Directors, and these Bylaws and provided such content is not in conflict with or contrary to the TDA’s established policies, legislative agenda, or advocacy efforts. 2. To control the selection of scientific material published in the Journal. The editor may appoint associate editors, with the concurrence of the Board of Directors, to gather and/or review material for publication. Such associate editors shall serve as long as the editor deems necessary; but never longer than the term of the editor. 3. To attend all open meetings of the Board of Directors and the House of Delegates of this association, and the annual session of the American Dental Association. 4. To hold no other elective office in this association or the American Dental Association while serving as editor, except the editor may be elected as delegate or alternate delegate to the ADA House of Delegates from his/her respective division. 5. To cooperate with his/her successor upon termination of the Editor’s term of office. Should the position of Editor become vacant ad interim, the Board of Directors shall appoint an Editor to act in the vacated position until such time as an Editor is nominated and elected in accordance with Chapter V, Sections 40B,b and Chapter IV, Sections 30B,b and 150 of these Bylaws. Candidacy announcements are to be mailed to TDA Secretary-Treasurer Dr Cody C Graves, Texas Dental Association, 1946 S IH-35 Ste 400, Austin, Texas 78704; or, emailed to TDA Executive Director Linda Brady: lbrady@tda.org.
JKJ Pathology Oral Pathology Laboratory
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Protecting your patients, limiting your liability
(Ref. TDA Bylaws, Chapter VI, Elective Officers —Section 90I (Duties); Policy Manual). www.tda.org | March 2022
113
OFFICIAL CALL TO THE 2022 TEXAS DENTAL ASSOCIATION HOUSE OF DELEGATES HOUSE OF DELEGATES:
REFERENCE COMMITTEE HEARINGS:
In accordance with Chapter IV, Section 70, paragraph
Reference Committee
A-1 of the Texas Dental
hearings will be facilitated
Association (TDA) Bylaws,
on Thursday, May 5, 2022
this is the official call for the
open to all members who
152nd Annual Session of
are present (any changes
the Texas Dental Association
to committee start times
House of Delegates. All
will be posted on the TDA
sessions of the House
website and announced
will be in the Lost Pines
at the first meeting of the
Ballroom of the Hyatt
House of Delegates):
Regency Lost Pines, Bastrop, Texas. The
10:00 AM
opening session of the House will convene at 8:00 a.m. on Thursday, May 5, 2022. The second meeting of the House will be at 1:30
REFERENCE COMMITTEES A & B (COMBINED) LOST PINES 1
p.m. on Friday, May 6, 2022. The third meeting of
COMMITTEE A:
the House will be at 8:00
Administration, Budget,
a.m. on Saturday, May 7,
Building, House of
2022, followed by the fourth
Delegates, Membership
meeting at 1:30 p.m. until
Processing
close of business. 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
COMMITTEE B: President’s Address, Miscellaneous Matters, Component Societies, Subsidiaries, Strategic Planning, Annual Session
Delegates.
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1:00 PM REFERENCE COMMITTEES C & D (COMBINED) LOST PINES 2 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 LOST PINES 3 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.
REFERENCE COMMITTEE REPORTS: Reference Committee Reports will be posted on the TDA website and
participation by candidates
electronically at least 30
for ADA elected offices, the
days prior to the Annual
Candidates Forum will not
Session. The supplements
be held.
to the House Documents,
DIVISIONAL CAUCUSES:
containing the agenda and subsequent reports, will be sent after the March 2022 TDA Board of Directors
emailed in PDF format to the members of the House
Divisional Caucuses
meeting. The minutes of the
of Delegates (reports may
(Northwest, Northeast,
TDA Board shall be posted
be downloaded from any
Southwest, Southeast)
on the members’ side of
location with Internet
will be facilitated entirely
the TDA website and made
access). Printed copies will
through electronic virtual
available to the general
not be provided.
means at 6:00 p.m. CDT as
TDA membership once the
follows:
minutes are approved by
FINANCIAL FORUM:
the TDA Board of Directors •
Monday, April 25, 2022
in accordance with Policy
Northeast Division
26-2018-H. Delegates and alternates will receive all
The TDA SecretaryTreasurer will facilitate
•
a 1-hour questions and
Tuesday, April 26, 2022
House Documents in PDF
Southeast Division
format. Printed copies of the House Documents will not
answer financial forum open to all members who are
•
Wednesday, April 27, 2022
be provided.
Southwest Division
present at 9:30 a.m. on Thursday, May 5, 2022 in the same meeting room as Reference Committee A & B
•
Thursday, April 28, 2022
Wireless internet
Northwest Division
access will not be provided in the House
(Lost Pines 1). Registration is required
of Delegates meeting
CANDIDATES FORUM:
and open to all current
room—please download
The ADA and TDA
additional information.
Candidates Forums will be held in Lost Pines 1 and 2 of the hotel on Friday, May
members—please see the
all House materials on
TDA website for details and
a fully-charged laptop
DELEGATE MATERIALS:
or device prior to attendance (charging stations will be centrally located in the meeting rooms).
6, 2022, from 10:30 a.m. to 12:00 p.m. In the event
In accordance with
there are no contested TDA
TDA Bylaws, the House
statewide elections and no
documents will be sent
www.tda.org | March 2022
115
ORAL
and maxillofacial pathology
Clinical History
A 15-year-old male presented to his dentist with pain involving the left mandible of unknown duration in the region of tooth #17. The patient otherwise appeared to be in good health, without any significant underlying medical conditions. Intraoral examination revealed no associated lesion and the associated tooth was vital. Radiographic examination showed an ill-defined radiolucency associated with the apical area of tooth #17 (Figure 1).
case of the month AUTHORS Kalu U.E. Ogbureke, BDS, MSc, DMSc, JD, FDSRCPS, FDSRCSEdin, FRCPath Professor, Department of Diagnostic and Biomedical Sciences, The University of Texas School of Dentistry at Houston, Houston, Texas
Dr Ahmad Millwala Katy, Texas
Ezinne I. Ogbureke, BDS, DMD Associate Professor, Department of General Practice and Dental Public Health, The University of Texas School of Dentistry at Houston, Houston, Texas
Figure 1. Panoramic radiograph shows an ill-defined radiolucency (arrow) associated with tooth #17.
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Figure 2. Hematoxylin and eosin-stained histologic sections of the curetted lesion. (A; mag. X40) shows histiocytes interspersed with eosinophils (bright red) at low power. (B; mag x200) shows giant cells (arrow) present in LCH. (C; mag. x400) shows aggregates of eosinophils (within oval circle) and interspersed with numerous lobulated (coffee bean-shaped) histiocytes, Langerhans cells.
of mononuclear histiocytic The following clinical decalcification and routine cells with irregular differential diagnoses tissue processing. lobulated nuclei admixed were considered: with small lymphocytes, developmental odontogenic Microscopic examination occasional plasma cells, lesions, including of hematoxylin and eosin giant cells, and clusters of odontogenic keratocyst stained sections from degranulating eosinophils and odontogenic tumors, the specimen revealed (Figure 2).The mononuclear such as amelobastoma. multiple soft tissue histiocytes were positive Malignancies, including a fragments of granulation for CD1a, S100, CD207 metastatic lesion was also tissue interspersed with (langerin), and CD163 considered in the clinical occasional dense fibrous (Figure 3; CD1a and S100 differential diagnosis. connective tissue and not shown). Curettage of the lesion was numerous hemorrhagic performed, and the entire foci. The granulation What is your diagnosis? specimen was submitted tissue was remarkable for histopathologic for the presence of an See page 143 for the answer examination. The gross intense inflammatory cell and discussion. appearance of curetted infiltrate chiefly composed specimen revealed multiple tan and hemorrhagic fragments measuring approximately 1.1 x 0.9 x 0.6 cm in aggregate. The entire specimen was Figure 3. Immunohistochemistry stains show diffuse immunopositivity for CD163 (A; mag. x200), and (B; mag. X200) CD207 (langerin) in Langerhans cells. submitted for short www.tda.org | March 2022
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C. difficile: An Update f
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for Dentistry Abstract C. difficile infection (CDI) is a potential complication of antibiotic therapy, and while frequently associated with regimens of clindamycin, it is known to occur with any antibiotic. As such, practitioners should be aware of the signs and symptoms of CDI and the potential severity of the disorder, which may lead to death if not promptly and effectively managed. The purpose of this review article is refamiliarize dentists with the basic microbiology of C. difficile and its toxicity, and to review the diagnosis and clinical management of the disease based on current scientific literature, including relevant information on probiotics and their relationship to antibiotic-associated diarrhea and CDI.
Keywords C. difficile, antibiotic-associated diarrhea, probiotics, fidaxomicin, vancomycin
Disclaimer The information contained in this article is not intended as advice for the care and management of specific patients. The opinions expressed here are those of the authors, and are not necessarily those of the University of Texas School of Dentistry at Houston or the Texas Dental Association.
Authors Hillary Bui, BS Second-year dental student, University of Texas School of Dentistry at Houston, Houston, Texas
Sydney Pham, BSA Second-year dental student, University of Texas School of Dentistry at Houston, Houston, Texas
Andrew Roberts, BBA Second-year dental student, University of Texas School of Dentistry at Houston, Houston, Texas
Mason Tobola, BS Second-year dental student, University of Texas School of Dentistry at Houston, Houston, Texas
Jayme Witek, BS Second-year dental student, University of Texas School of Dentistry at Houston, Houston, Texas
Arthur Jeske, PhD, DMD Professor, Department of General Practice & Dental Public Health and Associate Dean for Strategic Planning and Continuing Dental Education, University of Texas School of Dentistry at Houston, Houston, Texas Conflict of interest: The authors declare no conflict of interest regarding the products mentioned in the manuscript. Address correspondence to: Dr Arthur Jeske, University of Texas School of Dentistry 7500 Cambridge St, Ste 6350, Houston, Texas 77054; Arthur.H.Jeske@uth.tmc.edu; 713-486-4506
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Introduction C. difficile suprainfection continues to represent a serious and potentially lifethreatening complication associated with the prescription of antibiotics in both the inpatient and outpatient settings, despite the introduction of newer agents and therapeutic regimens to treat it. Dentists should be aware that while some antibiotics appear to be more likely to be associated with clinically-significant C. difficile complications (e.g., clindamycin), virtually any antibiotic can create conditions favorable to this disease, including amoxicillin.1
Dentists should be aware that while some
antibiotics appear to be more likely to be associated with clinically-significant C. difficile complications (e.g., clindamycin),
virtually any antibiotic can create conditions favorable to this disease
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Once these complications pass the stage of antibiotic-associated diarrhea, medical management becomes mandatory to prevent further development and eventual progression to pseudomembranous colitis. The purpose of this article is to provide a review of recent publications related to C. difficile infection (CDI) and its diagnosis and management in order to update dental practitioners on this important topic.
RECLASSIFICATION OF CLOSTRIDIUM DIFFICILE TO CLOSTRIDIOIDES DIFFICILE In 2016, Lawson et al., based on moleculargenetic typing (16S rRNA gene sequence analyses), proposed that the organism then classified as Clostridium difficile was most closely related to Clostridium mangenotii, genetically and physiologically.2 According to an earlier publication by this group (2015)3, the genus Clostridium should be restricted to certain organisms genetically closely related to the type species (Clostridium butyricum), and organisms that fell outside of this organism’s RNA Cluster (I) should be reclassified, which included the former Clostridium difficile. And while Clostridium difficile would otherwise have been renamed to its appropriate cluster (Cluster XI), in the genus Peptostreptococcaceae, such a new designation would likely be very disruptive, necessitating changes in a large number of publications, informational websites, medical insurance codes,
and pharmaceutical labels, among others. Therefore, Lawson et al. proposed a new name, which would retain the same abbreviation for the genus (C) and retain the original species, allowing preservation of the universally-used and universally-understood name, “C. difficile”, and Clostridioides difficile became the type species of this new genus.2 Conveniently, abbreviations like “C diff”, “CDAD” and “CDI” can continue to be used.
RELEVANT FEATURES OF THE ORGANISM Clostrioides difficile is a gram-positive, anaerobic, spore-forming bacillus found in the gastrointestinal tract of humans, animals and in the environment. C. difficile is a member of the normal gut microflora, but its growth is suppressed by more dominant anaerobes. Nevertheless, even minor disruptions of the gut (e.g., during antibiotic therapy) can lead to an imbalance of the microflora and create adverse effects on the host, in a process known as dysbiosis. Its spores are resistant to heat, acid, and antibiotics,
and spore germination is stimulated by bile acids, which partially explains the organism’s rapid growth within the gastrointestinal tract4 under conditions in which it gains a competitive environmental advantage. It is transmitted by fecaloral route, and is a common cause of nosocomial infections associated with poor hand hygiene of hospital personnel. C. difficile produces 3 protein toxins, including C. difficile transferase toxin (CDT), C. difficile toxin A (TcdA), and toxin B (TcdB)5. The latter two are the main virulence factors—toxin A facilitates transport of toxins A and B intracellularly, and toxin B causes inflammation in the colon.6,7 These toxins result in damage to the epithelial cell cytoskeleton and ultimately result in breakdown of the gut mucosal barrier. The pathophysiologic outcome of this is severe loss of fluid and electrolytes from the lower GI tract.
CLINICAL FEATURES OF CDI4 Symptoms of C. diff. infection include severe diarrhea and lifethreatening colitis that may www.tda.org | March 2022
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Symptoms of C. diff. infection include severe
diarrhea and lifethreatening colitis that may result in death, and the severity of the disease can range from mild diarrhea to
toxic megacolon.
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result in death, and the severity of the disease can range from mild diarrhea to toxic megacolon. Most cases are preceded by antibiotic-associated diarrhea, which can be related to any antibiotic commonly used in dental practice. There is no single test that can stand alone to confirm if patients have CDI, and it is important to differentiate the symptoms from other forms of diarrhea. Common types of diarrhea and their characteristics are: Diarrhea8 • Having 3 or more loose or watery stools/day due to reduced water absorption or increased water secretion—acute (lasting < 2 weeks) or chronic (lasting > 4 weeks) Travelers’ Diarrhea9 • Definition: 3 or more loose stools/day in addition to at least one other symptom (abdominal cramps, nausea, vomiting, tenesmus, fecal urgency, fever or dysentery) • Frequent problem with travelers from high-income
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•
•
areas to lower- and middle-income areas Incidence rates remain high in Central America, risks increase with warmer temperatures Disease is usually selflimited (many cases spontaneously cured within 48 hours)
Lactose Intolerance10 • Definition: reduced lactase activity in the small bowel cellular brush borders • Lactase deficiency leads to lactose malabsorption and lactose is instead fermented • Symptoms: vomiting, diarrhea, flatulence (accumulation of gas), and abdominal pain Celiac Disease11 • Definition:chronic small intestinal inflammation due to gluten intolerance • Can lead to mucosal inflammation and villous atrophy, resulting in malabsorption • Symptoms: diarrhea, steatorrhea (abnormal quantities of fat in feces), loss of weight Irritable Bowel Syndrome (IBS)12 • Categorized as diarrhea-predominant, constipation-
•
•
predominant, or mixed Symptoms: abdominal pain, bloating, diarrhea, constipation—can overlap with Celiac disease Additional features include reduced quality of life, anxiety and depression
Inflammatory Bowel Disease (IBD)13 • Definition: chronic inflammation of gastrointestinal tract due to inappropriate inflammatory responses to intestinal microbes • Crohn’s disease (involves any part of GI tract) and ulcerative colitis (involves rectum and colon) • Symptoms: abdominal pain, diarrhea, rectal bleeding, fever, weight loss Clostridium difficile Infection (CDI)14 • C. difficile lives harmlessly in the colon, but can replace normal gut flora when individuals take antibiotics • Symptoms: diarrhea, fever, pain, abdominal tenderness progressing to colitis, death
LABORATORY TESTS FOR C. DIFFICILE Diagnosis is based on detection of C. difficile toxins in the feces.4 Falsenegative results occur frequently due to improper storage and transportation of samples (which may allow the specimen to become warmed). These tests include: • Cytotoxicity Assay15 o Tests effects of toxins on a cell culture after incubation o Limited use due to lack of lab standardization, long turn-around time • Nucleic Acid Amplification Test (NAAT)7 o PCR—test for gene that produces toxin B o High cost, very sensitive • Enzyme Immunoassay (EIA)7,15 o Test for glutamate dehydrogenase (GDH) • Metabolic enzyme expressed by all C. difficile strains o Test for toxins A and B • Less sensitive, low cost, easy to use, rapid turnaround time (1-2 hours) www.tda.org | March 2022
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In its early phase (antibiotic-
discontinuation of the
No single test should be used as a stand-alone test to diagnose CDI. Therefore, a 2-step algorithm is used to improved diagnostic reliability. This includes 1) GDH EIA or NAAT for a high negative predictive value (to rule out infection), and 2) testing for toxins A/B EIA (for a high positive predictive value).
offending antibiotic may
TREATMENTS FOR C. DIFFICILE INFECTION
associated diarrhea),
be sufficient to restore gut flora and gut health.
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It is imperative that antibiotic therapy be discontinued with the appearance of diarrhea, regardless of the type of antibiotic that was prescribed. Patients should be made aware of the serious implications of diarrhea and this should be noted on the prescription (in the Signa section). It is also imperative that no over-the-counter or prescription antidiarrheal drugs be prescribed (e.g., Kaopectate®, loperamide). In its early stages, diarrhea helps rid the GI tract of C. difficile toxins and is actually a protective mechanism for the patient.
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o
o
Recommended treatments are based on the severity of the disease. In its early phase (antibiotic-associated diarrhea), discontinuation of the offending antibiotic may be sufficient to restore gut flora and gut health. For more advanced forms (colitis), antimicrobial therapy continues to be considered as the treatment of first choice.16 Published antibiotic regimens for the management of CDI include7: o Metronidazole (500 mg intravenously 3 times a day for 10–14 days);
Vancomycin (125 mg orally 4 times a day for 10–14 days) (dose may be increased to 500mg per day if patients do not respond between 24-48 hours); If patients cannot tolerate vancomycin, fidaxomicin (Dificid®) may be considered with a 200-mg dose, twice daily.
Dentists may not be familiar with fidaxomicin, which was approved by the FDA in 2011 and is now regarded as the drug of choice for CDI, primarily because its use is limited to the management of this disorder. It is a macrolide, but cannot be used interchangeably with other macrolides (e.g., azithromycin) because it is designed to act locally within the G.I. tract, having very low systemic absorption. It is available in both liquid and solid dose forms and is contraindicated only in cases of fidaxomicin allergy. The most common adverse effects are nausea, vomiting, abdominal pain, gastrointestinal bleeding, anemia and neutropenia.
In pediatric patients, fever and constipation may also be observed. If patients do not achieve improvement in their treatment, a promising alternate therapy would be suggested, known as fecal microbiota transplantation.4,17 Discussion of this treatment option, however, is outside the scope of this article. Recurrent CDI is not infrequent, even after successful antibiotic therapy of the initial infection.18 Risk factors for recurrence include advanced age, use of an antibiotic, gastric acid suppression, infection with a hypervirulent strain, and renal insufficiency.
PROBIOTICS AND CDI Many dentists and dental patients consider coingestion of probiotics with antibiotics to be a safe and effective preventive measure to avoid antibioticassociated diarrhea and even CDI. While controversial, this approach is supported by some evidence, particularly when specific types of probiotic formulations are utilized in well-designed, randomized clinical trials.19, www.tda.org | March 2022
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However, these formulations are not without risk, including possible Lactobacillus bacteremia in medically compromised patients.20 A recent systematic review found that probiotics are effective in preventing antibioticassociated diarrhea, and “may also be a beneficial strategy for CDIs, but randomized controlled trials are scarce.19” Significantly, none of the probiotic studies included in the review significantly improved secondary prevention of CDI. 20, 21
SUMMARY AND CONCLUSIONS C. difficile infection remains a significant and potentially life-threatening illness in patients taking antibiotics, and can become extremely serious when patients and/ or their healthcare providers ignore the initial symptoms (e.g., diarrhea) or attempt palliative treatment with over-the-counter and prescription anti-diarrheal agents or probiotics. Dentists should warn patients about the implications of diarrhea whenever an antibiotic is prescribed, regardless of the antibiotic class or the use of a probiotic. Failure to discontinue the antibiotic and appropriately refer the patient for medical evaluation and treatment when serious signs and symptoms occur can have lethal consequences. In the event that the dentist encounters a patient with signs and symptoms of C. diff. infection possibly related to another practitioner’s antibiotic prescription, the dentist should inform the patient of their current health condition without passing judgement on the prescribing dentist, who may not be aware of the patient’s condition.22 Furthermore, once informed about their patient’s condition, the prescribing dentist should involve himself/herself as appropriate, which may involve providing information about the prescription, the need for the prescription, etc., and only to entities authorized to receive the information under the provisions of HIPAA. REFERENCES 1. 2. 3. 4. 5.
Beacher N, Sweeney MP, Bagg J. Dentists, antibiotics and Clostridium difficileassociated disease. Brit. Dent. J. 2015;219(6):275-279. Lawson PA, Rainey FA, Tyrrell KL, Finegold SM. Reclassification of Clostridium difficile as Clostridioides difficile (Hall and O’Toole 1935 Prevot 1938). Anaerobe 2016;40:9599. Lawson PA, Rainey FA. Proposal to restrict the genus Clostridium (Prazmowski) to Clostridium butyricum and related species. Int. J. Syst. Evol. Microbiol. 2015;66:10091016. Czepiel J. et al. Clostridium difficile infection: review. Eur. J. Clin. Microbiol. Infect. Dis. 2019;38(7):1211-1221. Aktories K, Schwan C, Jank T. Clostridium difficile toxin biology. Ann. Rev. Microbiol. 2017;71:281-307.
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7.
8.
9. 10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Mada PK, Alam MU. Clostridium difficile. StatPearls (internet), Jan. 2021. https://pubmed.ncbi.nlm.nih. gov/28613708/ Kelly CR et al. ACG Clinical Guidelines: Prevention Diagnosis and Treatment of Clostridioides difficile Infections. Am. J. Gastroenterol 2021;116(6):1124-1147. Nemeth V, Pfleghaar N. Diarrhea. StatPearls (internet), Jan. 2021. https://pubmed.ncbi.nlm.nih. gov/28846339/ Steffen R. Epidemiology of traveler’s diarrhea. J. Travel Med. 2017;24(Suppl. 1):S2-S5. Leis R et al. Effects of prebiotic and probiotic supplementation on lactase deficiency and lactose intolerance: A systematic review of controlled trials. Nutrients 2020;12(5):1487. El-Metwally A et al. The epidemiology of celiac disease in the general population and high-risk groups in Arab countries: A systematic review. Biomed. Res. Intl. 2020;1-13,12. Usai-Satta P et al. Irritable bowel syndrome and glutenrelated disorders. Nutrients 2020;12(4):1117-1124. Selveratnam S et al. Epidemiology of inflammatory bowel disease in South America: A systematic review. World J. Gastroenterol. 2019;25(47):68666875. Nelson RL, Suda KJ, Evans CT. Antibiotic treatment for Clostridium difficile-associated diarrhea in adults. Cochrane Database Syst. Rev. 2017;3(3):CD004610. Gateau C, Couturier J, Coia J, Barbut F. How to diagnose infection caused by Clostridium difficile. Clin. Microbiol. Infect. 2018;24(5):463468. Peng Z et al. Advances in the diagnosis and treatment of Clostridium difficile infections. Emerging. Microbes Infection. 2018;7(1):15-29. Imdad A. et al. Fecal microbiota transplantation for the treatment of recurrent Clostridioides difficile. Cochrane Database Syst. Rev. 2021, Issue 2:CD013871. Song JH, Kim YS. Recurrent Clostridium difficile infection. Risk factors, treatment and prevention. Gut and Liver 2019;13(1):16-24. McFarland LV. Probiotics for the primary and secondary prevention of C. difficile. Infections: A metaanalysis and systematic review. Antibiotics 2015;4(2):160-178. Goldstein EJC, Johnson SJ, Maziade P-J, Evans CT, Sniffen JC, Millette M, McFarland LV. Probiotics and the prevention of C. difficile infection. Anaerobe 2017;45:114-119. McFarland LV, Ship N, Auclair J, Millette M. Primary prevention of Clostridium difficile infections with a specific probiotic combining Lactobacillus acidophilus, L. casei, and L. rhamnosus strains: assessing the evidence. J. Hosp. Infect. 2018;99(4):443-452. ADA Principles of Ethics and Code of Professional Conduct, American Dental Association, 2020, Chicago, IL.
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Covid, A Hybrid Meeting, and a Dues Increase
U
sually with this annual article we highlight the end-of-year differences between our budget versus our actuals. This year our auditors were delayed due to unforeseen issues so there are no official audited numbers to discuss with the members prior to the TDA House of Delegates meeting in May. Yet we will discuss some of the “unofficial” numbers from 2021 to explain why the TDA will have a small loss for the year, plus detail why there will be a request for a $20 dues increase in 2023. To reflect on 2021, the TDA, along with just about every other business, experienced several obstacles that have impacted our financial outcome. Our biggest two revenue sources, membership dues (7a) and annual session (1 and 8), both took negative hits in 2021. TDA also ramped up in-person meetings and this caused travel expenses to increase compared to nearly a full year of Zoom meetings in 2020. The annual session meeting was one of the very first dental meetings in the country to return to an in-person meeting. TDA was also the second meeting to be hosted at San Antonio’s Henry B. Gonzalez Convention Center in 2021. Even though the TDA did not produce as much revenue as was budgeted (budget = $348,351, actual = $35,400), it still gave our membership the expected valued continuing education. Dr. Hutto and the Council on Annual Meeting and Continuing Education Programs (CAMCEP) persevered through many hurdles (Covid restrictions, hotel issues, IT upgrades to offer virtual access, speaker requirements, etc…), all to create an environment for quality education. It was not a normal year and they deserve significant praise for being able to get a meeting together, much less a hybrid meeting. So, Thank You Red Coats for helping to meet our CE needs. As for membership, TDA ended 2021 with 8,857 members, with 7,335 of them being active licensed dentists. We continue down the road to recovery from a drop in membership and the corresponding dues revenue (line 7a) due to COVID and other factors. The actual dues revenue received in 2021 was $2,468,330 versus
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Texas Dental Journal | Vol 139 | No. 3
Dr Cody Graves
Secretary-Treasurer, TDA •
That’s a real old picture up there. I look young!
•
The proposed 2023 budget is $5,769,988.
•
Dues are suggested to increase for the first time since 2015 by $20.
•
The budget is balanced in accordance with TDA Bylaws without using methods of finance outside of expected revenues.
•
The riders, allowing limited revisions to the budget, are included in this budget. The TDA Smiles Foundation has been eliminated this year due to financial constraints.
•
The 2023 budget is a basic operational budget. Any strategic plan, membership initiatives, or additional meetings not currently funded will need to be funded from our reserves, subject to Board approval.
a budget of $2,598,712 (a shortfall of -$130,382 and once again not audited numbers). Wrapping up 2021 does not consist of all bad news. TDA received forgiveness on a PPP loan to cover personnel salary of $255,100 and our expenses (under 80% of budget) were well controlled. Also, the financial markets allowed our long-term investments, (life to date) as of 12/31/2021, to increase close to a million dollars of unrealized gain. Ultimately, once the audit is completed, we can determine the exact numbers, but the TDA is estimated to lose about -$100,000 to -$130,000 in 2021. That brings us to the 2023 budget. I’ll treat you readers like I do the board. Start on the back page of the budget, which is the Building (6 and 13). TDA has the entire first floor vacant and one suite on the second but the remainder of the building is leased out. We are forecasting (if everything stays the same) a small surplus revenue from our building in 2023. Next page up is Communications (3-5, 10-12), which is Dr Dan Jones’ arena. An item to note on this page is the breakdown of TDA’s three outsourced consultants in each of the area’s expenses (10a, 11a, 12a). The addition of Sales Commissions (10e, 11d, 12b) from TDA’s soonto-be new outsourced sales
and marketing company (MCI Sales). Advertising continues to be the biggest driver of revenue and $17 dollars from every dues paying member goes to the Texas Dental Journal, plus $5 goes to the TDA Today. Pages 4 and 5 are the Annual Session and Continuing Education (1, 2, 8, 9) sections. The budget estimates about a 15% reduction from 2019 actuals for clinics for continuing education (1b) and registration (1g) revenue. Expenses assume increases in audio-visual costs (8a). The consultants line item (8h) includes outsourced Strategic Association Management’s services and MCI Sales. The CE programs consist of revenues and expense estimated for the dental concierge app subscriptions, 18 online courses, 2 regional meetings, and a dentist-only conference. These items are only estimated due to no historic trends. Getting closer to the front page, page 3 is the BOD, Councils, Committees, ADA, HOD, and other Expenses (17-22). With such a jump in expenses this year to try and kick start our membership growth, most of these line items have been reduced to help control expenses. Next year will be a legislative year for Texas (beginning January 10, 2023), the ADA will be in Orlando, and we should begin to have regular Texas HOD meetings.
Page 2 is Central Office Departments (16) in which a new meetings director employee is scheduled to be added. Health insurance (16d) took a big 12% increase in 2022 and we estimate another 8% increase in 2023. All Other Expenses (aa-gg) have been reduced. Finally, to the first page. Most of these line items have been covered except for MBL partnership revenue (7f) which is budgeted to stay the same. Expenses were reduced for Capital Improvements (14), Non-budget Contingency (15) and the TDA Smiles Foundation (23) due to budget constraints. With these adjustments to both expense increases and revenue decreases, the TDA Board of Directors is recommending a $20 dues increase. Once again, TDA’s dues have been constant for 7 years, so please allow a small increase to cover expenses to keep providing our membership value. Once again, I want to thank the Budget, Assets, and Finance Committee for recommending a budget that remains operational, yet efficient, and the TDA Board of Directors for approving this budget for the TDA House of Delegates to discuss. It is my honor to serve as the Texas Dental Association’s Secretary/Treasurer. Please feel free to ask any question. If I can answer it, I will. If I do not know the answer, I’ll find it. www.tda.org | March 2022
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2023 Proposed Budget Texas Dental Association
PLEASE NOTE: For individual line-item explanations, please visit tinyurl.com/budget-explanation
2021 Budget
Revenues ANNUAL SESSION
PUBLICATIONS/ WEBSITE
1.
Annual Session
2. Continuing Education Programs 43,000 3. Journal 333,444 4. TDA Today 43,115 5. TDA Website 37,000 Total Publications/Website
BUILDING OPERATIONS
PUBLICATIONS/ WEBSITE
413,559
583,910
2023 Proposed 1,329,968
150,000
664,699
326,151 40,970 37,000
358,806 38,384 45,000
404,121
442,191
6. Building 351,531 313,562 304,713 7. Operating a. Dues 2,598,712 2,549,468 2,571,971 b. Investment Earnings-Sweep 50,000 40,000 10,000 c. Miscellaneous 35,000 168,640 75,000 d. Affiliates Administration 92,740 96,908 96,446 e. MBL Partnership 290,000 275,000 275,000 Total Operating 3,066,452 3,130,016 3,028,417 TOTAL REVENUES
Expenses
ANNUAL SESSION
1,418,383
2022 Budget
5,292,925
4,581,609
5,769,988
8. Annual Session 1,070,032 76,083 1,043,700 9. Continuing Education Programs 5,500 30,000 354,110 10. Journal 230,050 230,050 305,220 11. TDA Today 110,500 110,500 98,750 12. TDA Website 44,800 55,800 53,750 Total Publications/Website
385,350
396,350
457,720 295,235
BUILDING
13.
Building
315,603
325,141
CAPITAL IMPROVEMENTS
14.
Capital Improvements
10,000
10,000
0
CONTINGENCY
15.
Non Budgeted Contingency
19,000
29,000
5,000
CENTRAL OFFICE
16.
Central Office Departments
2,701,911
2,866,450
BOARD OF DIRECTORS
17.
COMMITTEES COUNCILS ADA/NATIONAL ORGANIZATIONS
2,971,172
Board of Directors 205,985 204,665 18. Committees 21,045 21,220 19. Councils 203,594 164,895
181,895
20.
18,070 164,230
ADA /National Organizations
186,205
165,815
135,180
65,700
45,350
80,675
OTHER EXPENSE
21. House of Delegates 22. Other expense
53,000
196,640
38,000
CONTRIBUTIONS
23.
TDA Smiles Foundation
50,000
50,000
25,000
TOTAL EXPENSES
5,292,925
4,581,609
5,769,988
REVENUE OVER EXPENSE
0
0
0
HOUSE OF DELEGATES
24. 25.
Method of Finance Adjustment TDA Financial Services, Inc. Cash Dividend ADJUSTED REVENUE OVER EXPENSE
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Texas Dental Journal | Vol 139 | No. 3
0
0
0
Central Office Departments
2023 Proposed Budget Texas Dental Association 2021 Budget
2022 Budget
2023 Proposed
16. Central Office Departments PERSONNEL
Personnel: a. Regular Salaries 1,536,820 1,655,619 1,753,146 b. Payroll Taxes 117,567 125,395 133,662 c. Health Insurance 167,567 173,634 206,053 d. Retirement 134,079 157,868 163,400 Total Personnel
OFFICE OPERATIONS
SERVICES
OTHER EXPENSES
1,956,033
2,112,516
2,256,261
Office Operations: e. Insurance—Directors/Officers 50,477 59,733 57,681 f. Leases—Equipment 39,651 42,447 34,526 g. Maintenance 14,038 15,800 16,550 h. Postage and Couriers 22,802 10,975 7,975 i. Printing 16,200 12,300 12,300 j. Supplies—Office 14,150 13,112 8,112 k. Taxes—State and Local 4,039 3,539 4,500 l. Information Technology 13,500 10,728 10,672 Total Office Operations 174,857 168,634 152,316 Services: m. Accounting Services—Payroll 4,800 4,800 4,800 n. Accounting and Auditing Services 32,412 35,000 36,450 o. Bank Charges 17,500 19,000 19,000 p. Consultants 30,396 31,200 31,200 q. Legal Services 154,000 159,000 159,000 r. Lobbying 201,500 190,500 201,500 s. Gifts and Memorials 1,000 1,950 1,450 Total Services 441,608 441,450 453,400 Other Expenses: t. Dues Processing 85,000 100,000 75,000 u. Education and Organizational Development 11,250 10,000 7,500 v. Meetings 2,600 4,000 2,000 w. Professional Dues & Memberships 3,150 3,430 2,800 x. Subscriptions 2,949 6,800 5,850 y. Recruiting 1,000 1,000 500 z. Travel 23,465 18,620 15,545 Total Other Expenses 129,414 143,850 109,195 Total Central Office 2,701,911 2,866,450 2,971,172
www.tda.org | March 2022
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Board of Directors, Councils, Committees, ADA, HOD BOARD OF DIRECTORS
COMMITTEES
COUNCILS
2023 Proposed Budget Texas Dental Association 2021 Budget
Total Board of Directors 205,985 204,665 181,895 18. Committees: a. Audit 1,540 1,615 0 b. Awards 17,095 17,095 17,220 c. Budget, Assets and Finance 0 0 0 d. Community Fluoride 1,300 1,300 600 e. Strategic Affairs 1,110 1,210 250 Total Committees 21,045 21,220 18,070 19. Councils: a. Annual Meeting and CE Programs 10,350 10,850 7,970 b. Legislative and Regulatory Affairs 100,699 58,560 87,995 c. DENPAC 38,575 40,345 32,425 d. Dental Licensing, Standards and Education 9,680 10,155 7,475 e. Ethics and Judicial Affairs 2,080 2,180 1,980 f. Governance 7,660 7,910 2,760 g. Membership, New Dentists and Students 19,000 18,695 16,525 h. Peer Review 2,550 2,600 1,500 i. Professions and Trends 5,000 5,250 3,340 j. Public Health and Access to Care 8,000 8,350 2,260 k. TOHPAC 0 0 0 164,230
186,205
165,815
135,180
65,700
45,350
80,675
22. Other Expense a. Federal Income Tax 35,000 35,000 30,000 b. TDA Advocacy Academy 0 0 0 c. TDA Conferences 10,000 10,000 0 d. Alliance/TDAA Stipends 8,000 8,000 8,000 e. Building Loan Interest 0 143,640 0 Total Other Expense
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164,895
21. House of Delegates: a. HOD 50 Year and Life Luncheon 5,700 7,700 7,700 b. HOD Headquarters 58,000 35,650 70,975 c. HOD Past President’s Breakfast 2,000 2,000 2,000 Total House of Delegates
OTHER EXPENSE
203,594
20. ADA /National Organizations: a. ADA Delegates 150,405 120,015 135,180 b. ADA 15th Trustee Headquarters 0 10,000 0 c. ADA Texas Reception 35,800 35,800 0 Total ADA /National
HOUSE OF DELEGATES
2023 Proposed
17. Board of Directors: a. President 27,000 28,705 20,985 b. Presiden—Stipend 36,000 36,000 32,400 c. President Elect 8,830 8,520 7,070 d. President Elect—Stipend 8,400 8,400 7,200 e. Past President 5,400 5,230 4,830 f. Secretary Treasurer 5,400 5,230 4,830 g. Secretary Treasurer—Stipend 8,400 8,400 7,200 h. Editor 4,000 3,830 3,430 i. Editor—Stipend 8,400 8,400 7,200 j. Vice Presidents 21,860 21,280 19,480 k. Senior Directors 21,860 21,280 19,480 l. Directors 21,860 21,280 19,480 m. Other Officers 9,050 8,460 7,910 n. Board Meetings 19,525 19,650 20,400
Total Councils ADA/NATIONAL ORGANIZATIONS
2022 Budget
Texas Dental Journal | Vol 139 | No. 3
53,000
196,640
38,000
2023 Proposed Budget Texas Dental Association Annual Session
2021 Budget
2022 Budget
2023 Proposed
ANNUAL SESSION REVENUE
Annual Session Revenue a. Advertising 4,000 0 8,000 b. Clinics for Continuing Education 812,383 0 690,525 c. Exhibits 415,000 0 450,000 d. Miscellaneous 0 583,910 0 e. Other Groups 17,000 0 17,000 f. Registration 95,000 0 74,443 g. Sponsorships 75,000 0 90,000 Total Annual Session Revenue 1,418,383 583,910 1,329,968
ANNUAL SESSION EXPENSE
8.
1.
Annual Session Expense a. Audio—Visual 164,337 0 150,000 b. Bank Charges 30,000 0 25,000 c. Clinician Honorariums 200,000 0 150,000 d. Clinician Support 100,000 0 90,000 e. Consultants 100,000 50,000 228,250 f. Exhibits 160,000 0 150,000 g. Hospitality Suite 20,000 0 15,000 h. Insurance 4,000 0 10,425 i. Miscellaneous 1,750 0 1,750 j. Onsite Program 6,000 0 0 k. Other Groups 16,000 0 16,000 l. Postage 6,000 0 6,000 m. President’s Reception 0 0 0 n. Promotion 30,000 0 20,000 o. Registration 137,000 0 125,000 p. Shuttle Services 10,000 0 10,000 q. Stipends 15,000 15,000 15,000 r. Supplies 200 0 200 s. Information Technology 0 0 0 t. TDA Party 30,000 0 0 u. Travel 24,745 11,083 31,075 v. VIP Reception 15,000 0 0 Total Annual Session Expense 1,070,032 76,083 1,043,700 Annual Session Net Revenue (Loss) 348,351 507,827 286,268
www.tda.org | March 2022
139
2023 Proposed Budget Texas Dental Association
Continuing Education REVENUE
2021 Budget
2022 Budget
2023 Proposed
2.
Continuing Education Revenue a. Advertising 0 0 6,000 b. Clinics for Continuing Education 43,000 150,000 213,738 c. Exhibits 0 0 11,500 d. Miscellaneous 0 0 9,335 e. Subscriptions 0 0 40,446 f. Registration 0 0 332,640 g. Sponsorships 0 0 51,040 Total Continuing Education Revenue 43,000 150,000 664,699
EXPENSE
140
9.
Continuing Education Expense a. Audio—Visual 0 0 30,000 b. Bank Charges 0 0 6,000 c. Clinician Honorariums 5,500 30,000 85,000 d. Clinician Support 0 0 12,000 e. Consultants 0 0 102,806 f. Exhibits 0 0 1,000 g. F&B 0 0 85,750 h. Insurance 0 0 0 i. Miscellaneous 0 0 900 j. Postage 0 0 100 k. Promotion 0 0 10,000 l. Registration 0 0 2,000 m. Stipends 0 0 0 n. Supplies 0 0 1,000 o. Travel 0 0 5,350 p. Information Technology 0 0 12,204 Total Continuing Education Expense 5,500 30,000 354,110 Continuing Education Net Revenue (Loss) 37,500 120,000 310,589
Texas Dental Journal | Vol 139 | No. 3
2023 Proposed Budget Texas Dental Association Publications/ Website
2021 Budget
JOURNAL REVENUE
3.
TDA TODAY REVENUE
4.
2022 Budget
2023 Proposed
TDA Journal Revenue a. Advertising 222,248 222,248 265,600 b. Single Issue Purchases 255 255 100 c. Subscriptions 110,941 103,648 93,106 d. Miscellaneous 0 0 0 Total TDA Journal Revenue 333,444 326,151 358,806 JOURNAL EXPENSE 10. TDA Journal Expense a. Consultants 49,500 49,500 49,500 b. Meetings 200 200 200 c. Postage and Couriers 50,000 50,000 45,000 d. Printing and Production 129,950 129,950 140,500 e. Sales Commissions 0 0 69,720 f. Supplies 200 200 100 g. Travel 200 200 200 Total TDA Journal Expense 230,050 230,050 305,220
TDA Today Revenue a. Advertising 11,000 11,000 11,000 b. Subscriptions—Membership Dues 32,115 29,970 27,384 Total TDA Today Revenue 43,115 40,970 38,384 TDA TODAY EXPENSE 11. TDA Today Expense a. Consultants 49,500 49,500 35,000 b. Postage 31,000 31,000 31,000 c. Printing and Production 30,000 30,000 30,000 d. Sales Commissions 0 0 2,750 Total TDA Today Expense 110,500 110,500 98,750 WEBSITE REVENUE
WEBSITE EXPENSE
5. TDA Website Revenue a. Advertising 37,000 37,000 45,000 b. TDA Affiliates Advertising 0 0 0 Total TDA Website Revenue 37,000 37,000 45,000 12. TDA Website Expense a. Consultants 39,000 50,000 42,000 b. Sales Commissions 0 0 11,250 c. Software and Software Support 300 300 0 d. Subscriptions—Publications 500 500 100 e. Website Hosting 5,000 5,000 400 Total TDA Website Expense 44,800 55,800 53,750 3-5. Total Publication/Web Revenues 413,559 404,121 442,191 10-12. Total Publication/Web Expense 385,350 396,350 457,720 Communications Net Revenue (Loss) 28,209 7,771 (15,529)
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2023 Proposed Budget Texas Dental Association Buildings
2021 Budget
2022 Budget
2023 Proposed
BUILDING REVENUE
TDA Building Revenue a. Lease Income 351,531 313,562 304,713 Total TDA Building Revenue 351,531 313,562 304,713
BUILDING EXPENSE
13. TDA Building Expense a. Building Lease Broker Fees 9,000 9,000 0 b. Building Management Fees 22,703 23,000 28,000 c. Insurance—Operating 28,000 34,141 23,235 d. Repairs and Maintenance—Equipment 40,000 40,000 30,000 e. Service Contracts 85,000 85,000 90,000 f. Supplies 5,000 5,000 2,000 g. Taxes—State & Local 80,000 82,500 85,000 h. Utilities 45,900 46,500 37,000 Total TDA Building Expense 315,603 325,141 295,235
6.
BUILDING MAINTENANCE
Building Net Revenue (Loss)
35,928
(11,580)
9,478
RIDERS 1. General Revision Authority. The Board of Directors is authorized to revise and amend the 2023 budget, in the aggregate or any single line item, during the time period August 1, 2022 and November 30, 2022, with such authority subject to the following: a. The Board must, upon review and recommendation by the Secretary-Treasurer, certify a new revenue estimate. Such estimate shall be based on reasonable projections using know factors affecting dues and non-dues revenues. b. The originally budgeted expenditures for the House of Delegates shall not be reduced unless the Speaker recommends to the Board in writing or verbally as reflected in the minutes of the Board, that the originally budgeted expenditures be reduced. c. Overall expenses may not, in aggregate, be increased by an amount greater than 10% of the original amount. Any expected net gain net of 10% adjustment in expenses will be allocated to non-budgeted contingency items. d. The revised budget shall be published in the Texas Dental Journal and delivered electronically to the Speaker for distribution to the House of Delegates. 2. Report of Expenditures and Methods of Finance. Any amounts expended pursuant to a duly adopted rider shall be reported in a manner that is consistent with reporting for other expenditures, and shall be clearly identified with the enabling rider and method of finance.
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ORAL
and maxillofacial pathology diagnosis and management—from page 117
Langerhans Cell Histiocytosis Discussion Langerhans cell histiocytosis (LCH) was previously known as “histiocytosis X”, because of a poor understanding of its etiology.1,2 It is now known to be a reticuloendothelial system disorder manifesting as a clonal disease of myeloid dendritic cells.3 Although LCH has been diagnosed in all age groups, the disease predominantly affects children in the age range of 1 to 4 years.3 The relative rarity of LCH increases the risk of underdiagnosis and misdiagnosis, and therefore underscores the need for a high index of suspicion for osteolytic bone lesions presenting with no apparent etiology.4 Historically, LCH was characterized by 3 clinical variants: Letterer-Siwe, affecting mainly infants, presents as an acute disseminated disease involving multiple organ systems; Hand-SchullerChristian disease, which
also may involve the skeletal and extraskeletal tissues; and eosinophilic granuloma, which presents as a chronic, localized form of LCH typically involving the skeleton, but occasionally also extraskeletal tissues in adults.4 A congenital and syndromic form of LCH, called Hashimoto– Pritzker syndrome, is also recognized, and patients present with deep subcutaneous skin lesions.4 A recent revision of the classification of histiocytosis by the Histiocyte Society, classifies LCH as “single system”-, “lung”- and “multisystem” based on site and organ (liver, spleen, bone marrow) dysfunction.4,5 In single system LCH, the skin is most commonly affected, followed by the lymph nodes and lungs.6 When the skeleton is affected, the skull, long bones, pelvis, ribs, vertebra, and posterior mandible are the most common sites.4,7
Clinical presentations of oral cavity LCH are hardly straight forward resulting in significant challenges when attempting to establish a differential diagnosis. Common sites are the jaw bones as well as the gingiva and periodontium. In these locations, the clinical features often mimic a constellation of more common entities related to periodontal diseases, such as gingival epulides, granulomatous or ulcerative lesions, or malignancies.8,9 Furthermore, early intraoral lesions confined to the maxillofacial skeleton are not always apparent during oral examination and are only discovered fortuitously on radiographs, where they present as radiolucent osteolytic processes. Such instances generate additional considerations in the differential diagnosis, including odontogenic lesions, as in the present case, thereby necessitating a biopsy to determine the histopathologic diagnosis of the lesion. Radiographically, LCH of the jaw presents as www.tda.org | March 2022
143
ORAL
and maxillofacial pathology, continued
a punched out radiolucency with ill-defined borders, often accompanied by severe alveolar bone resorption leading to the typical tooth/teeth “floating in space” as in the present case.2
as a surrogate marker for Birbeck granules.8 These immunophenotypic
Figure 3. Immunohistochemistry stains show diffuse immunopositivity for CD163 (A; mag. x200), and (B; mag. X200) CD207 (langerin) in Langerhans cells.
The classic histopathologic features of LCH include the identification of numerous histiocytes exhibiting coffee bean-shaped (lobulated) nuclei and inconspicuous nucleoli with eosinophilic cytoplasm.10 These are interspersed with variable numbers of aggregated and degranulating eosinophils throughout the sections, in additions to neutrophils, plasma cells, lymphocytes, and sometimes, multinucleated giant cells.10 Diagnosis is usually confirmed with immunostains for CD1a, S100, CD207 (langerin), and CD163 positivity in the Langerhans cell population.11,12 Further evaluation by electron microscopy, demonstrates the presence of Birbeck granules, which are tennis racket shaped organelles, within the cytoplasm of the histiocytes. The recently discovered CD207 (langerin) serves
144
characteristics of LCH were confirmed in the present case (Figure 3).
Texas Dental Journal | Vol 139 | No. 3
The mainstay of treatment for localized oral LCH is surgery. In certain instances, surgery is augmented with steroid injections.4 In cases of recurrence, or extensive lesions, patients may be treated with radiotherapy, singly or in combination with surgery.4 However, in the case of extensive disease with organ dysfunction, or in classic systemic LCH, chemotherapy significantly improves outcome.4,5 Relatively new treatment includes the administration of monoclonal CD1a antibody in combination with any of the above traditional therapies.13 The prognosis of localized LCH is good. Overall prognosis however, is dependent on the age of patient, number of sites involved, whether or not disease is multisystemic, and whether or not disease has already resulted in organ/system dysfunction. Prognosis is generally poor in patients younger than 2 years of age, those with multiple sites or multiorgan involvement, and those with organ dysfunction at the time of diagnosis.5
References 1.
2.
3.
4.
5.
6.
7.
Gorsky M, Silverman S Jr., Lozada F, Kushner J. 1983. Histiocytosis X: Occurrence and oral involvement in six adolescent and adult patients. Oral Surg Oral Med Oral Pathol. 55(1):24-28. Altay MA, Sindel A, Özalp Ö, Kocabalkan B, Özbudak İH, Erdem R, Salim O, Baur DA. 2017. Langerhans cell histiocytosis: A diagnostic challenge in the oral cavity. Case Rep Pathol 2017:1–6. Lian C, Lu Y, Shen S. Langerhans cell histiocytosis in adults: a case report and review of the literature. 2016. Oncotarget. 5;7(14):18678-18683. Cherian LM, Sasikumar D, Sathyan P, Varghese BE. 2021. Langerhans cell histiocytosis: A diagnostic enigma in the oral cavity. J Oral Maxillofac Pathol. 25(Suppl 1):S27-S31. Rao DG, Trivedi MV, Havale R, Shrutha SP. 2017. A rare and unusual case report of Langerhans cell histiocytosis. J Oral Maxillofac Pathol. 21:140–144. Hicks J, Flaitz CM. 2005. Langerhans cell histiocytosis: Current insights in a molecular age with emphasis on clinical oral and maxillofacial pathology practice. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontology. 100(2):S42– 66. Bedran NR, Carlos R, de Andrade BAB, Bueno APS, Romañach MJ, Milito CB. 2018. Clinicopathological and Immunohistochemical study of head and neck langerhans cell histiocytosis from Latin
8.
9.
10.
11.
12.
13.
America. Head Neck Pathol. 12:431–439. Morimoto A, Oh Y, Shioda Y, Kudo K, Imamura T. 2014. Recent advances in Langerhans cell histiocytosis. Pediatr Int. 56(4):451-461. Aricò M, Girschikofsky M, Généreau T, Klersy C, McClain K, Grois N, Emile JF, Lukina E, De Juli E, Danesino C. 2003. Langerhans cell histiocytosis in adults. Report from the International Registry of the Histiocyte Society. Eur J Cancer. 39(16):2341-2348. Felstead AM, Main BG, Thomas SJ, Hughes CW. 2013. Recurrent Langerhans cell histiocytosis of the mandible. Br J Oral Maxillofac Surg. 51(3):264-265 Sahm F, Capper D, Preusser M, Meyer J, Stenzinger A, Lasitschka F, et al. 2012. BRAFV600E mutant protein is expressed in cells of variable maturation in Langerhans cell histiocytosis. Blood. 120:e28–34. Grana N. Langerhans cell histiocytosis. 2014. Cancer Control. 21:328–334. Ramos-Gutierrez E, AlejoGonzalez F, Ruiz-Rodriguez S, Garrocho-Rangel J, PozosGuillen A. 2016. Langerhans cell histiocytosis: Current concepts in dentistry and case report. J Clin Exp Dent. 8:e102–108.
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VALUE
for your
Provided by:
profession
EMAIL CYBERSECURITY IS CRITICAL FOR YOUR PRACTICE KNOW HOW TO PROTECT YOUR OFFICE By Robert McDermott; President and CEO, iCoreConnect
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Texas Dental Journal | Vol 139 | No. 3
D
o you feel you’re hearing a
lot about ransomware, phishing, and hacking these days? You’re not imagining the increase—these buzzwords are everywhere: news media, compliance reports, technology
PHISHING The primary ways your practice can be compromised are through your IT infrastructure and email. The weakest link in the vulnerability chain is people. Cybercriminals have gotten quite effective at using malicious email to gain access to Protected Health Information (PHI) and other personal information through what’s called “phishing.” They will send email posing as coming from a trusted source (like a bank, online payment site, or even a social networking site) designed to get you to click a link, call a number or respond with personal information. Every day, criminals steal everything from patient and insurance records to passwords, social security numbers, credit card information and account numbers.
Red Flags
represent more than
Your staff needs to know how to spot phishing; and what to do and what not to do when they do come across it. The Federal Trade Commission’s Consumer Division explains phishing emails and text messages often tell a story to trick you into clicking on a link or opening an attachment.
just the latest media
These emails may:
and trade journals; the list goes on. But they
buzz. They’re real threats. Cybercrimes remain a problem for
● ●
dental and medical
●
professionals with little
● ●
sign of going away anytime soon.
●
●
Say they’ve noticed some suspicious activity or login attempts. Claim there’s a problem with your account or your payment information. Say you must confirm some personal information. Include a fake invoice. Want you to click on a link to make a payment. Say you’re eligible to register for a government refund. Offer a coupon for free stuff.
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What happens if someone in your office clicks a link (and your email isn’t secure)?
HOW TO KEEP EMAIL SAFE
Well, you’ve just left the back door unlocked and let a cybercriminal sneak into your business. Once a cybercriminal gets into your system, usually without detection, they have one goal: wreak havoc to get money. They can lock up your entire records system and hold it for ransom, usually requiring payment in Bitcoin. Every day, thousands of attacks are launched with much success. It’s a scenario you don’t want to deal with; and fortunately is preventable.
Use a HIPAA-compliant email service.
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As a dental health provider, confirm every email with any connection to PHI, payments, passwords, or other sensitive information, is being sent through a secure, HIPAA-compliant email service. •
Check to make sure your secure email service uses its own private network to transmit messages, not the public internet.
•
You’ll also know if your email is fully secure and compliant based on the way email communication is initiated. If your practice must initiate the first message in an email conversation, then your system is highly secure. I.e., no one can randomly email you or your staff if you didn’t send a secure email to them first. And since cybercriminals can’t reach you, phishing and hacking would not be possible. Once you have that first email interaction with another doctor, pharmacy, patient, etc., your workflow is the same as it would be with any other email.
•
If you’re sending PHI via Google, verify you’re using the paid version, Google Workspace Gmail. Even then, bring in compliance experts to verify that your system meets every federal standard for compliance when sharing PHI electronically.
If you’re using regular Gmail with any modifications, you are most likely gambling with the security and compliance of transmitting PHI. You may want to consider using Gmail and other similar services for sending everything that isn’t PHI or sensitive information. Secure and non-secure emails can often be accessed in the same email interface, which means only one login would be necessary to access all your email accounts.
Educate your staff. Teach your staff—or bring in an IT Managed Services Provider (MSP) to talk with your office—about the best practices to prevent phishing scams. •
Learn to identify a suspicious email and report it to your IT or MSP team. (See the “red flags” section.)
•
Most important, never click on buttons/ links, call the listed phone number, or respond to the message, especially with personal information.
•
If you have a moderately-secure email service, replace it with a truly secure, HIPAA-compliant email service, and you’ll significantly decrease the risk of your data being accessed through email.
Following the simple advice in this article can save you headaches and heartbreaks from having PHI stolen or captured and paying a high ransom to get your practice running again.
TDA Perks Program endorses iCoreExchange HIPAA-compliant email. iCoreExchange not only meets or exceeds every compliance and security requirement, it also allows you to attach as many large files as you want to any single email. Learn more about iCoreExchange and how it can speed your workflow and protect patients and your practice. Check out the convenient and compliant service at http://land. icoreconnect.com/TX2 or tdaperks.com (Compliance & Supplies). TDA members receive a substantial discount on iCoreExchange.
Calendar
of events
TMOM 2022 SCHEDULE Houston—April 22-23 Dallas—November 4-5
SMILECON
Houston—October 13-15, 2022 House of Delegates, October 15-18 Due to COVID-19, please check each meeting’s website for up-to-date information related to cancellations or rescheduling. THE TEXAS DENTAL JOURNAL’S CALENDAR will include only meetings, symposia, etc., of statewide, national, and international interest to Texas dentists. Because of space limitations, individual continuing education courses will not be listed. Readers are directed to the monthly advertisements of courses that appear elsewhere in the Journal.
www.tda.org | March 2022
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ADVERTISING BRIEFS PRACTICE OPPORTUNITIES
us at 512-900-7989 or info@
ALL TEXAS LISTINGS FOR
#T521): This highly productive,
MCLERRAN & ASSOCIATES: To
implant-focused, general dentistry
request more information on our
practice located in a growing
listings, please register at www.
community approximately 30 miles
dentaltransitions.com or contact
from the Austin metro area. Current
dentaltransitions.com. AUSTIN (ID
annual revenue is approximately 7
Opportunities Online at TDA.org and Printed in the
Texas Dental Journal ADVERTISING BRIEF INFORMATION
figures with net cash flow in excess of 6 figures. The modern facility is located in a retail space and equipped with 6 operatories, CBCT, and paperless charts. The ideal buyer would be 1-2 high producing doctor(s) who are well
DEADLINE
versed in placing implants. AUSTIN/
Copy text is due the 20th of the month, 2 months prior to publication (ie, January issue has a due date of November 20.)
SAN ANTONIO (ID #T530): FFS/ PPO general dentistry practice
MONTHLY RATES
San Antonio. The office features 5
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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ideally located between Austin and operatories, computers throughout, CAD/CAM (Cerec), a CBCT, and all the bells and whistles. The owner is surgically inclined, but that has ultimately led to an abundance of restorative, cosmetic, and ortho treatment being readily available for the incoming buyer. AUSTIN (ID #T532): This turn-key, GD practice in west Austin is located in a approximately 2,500 sq ft, modern facility featuring 6 operatories, digital radiography,
paperless charts, a digital Pano, and a
skill set. The facility is shared with
Cerec Omnicam with milling unit. The
another dentist who has an entirely
practice serves a large FFS/PPO patient
separate patient base. The practice is
base with over 2,700 active patients.
priced at a level that will allow for the
The office offers significant upside
buyer to make immediate upgrades to
potential by way of keeping specialty
the facility or equipment post-sale.
procedures in-house, implementation
EAST TEXAS (ID #H486): Located in
of a marketing/advertising campaign,
a growing east Texas community, this
and the potential to expand office
general practice caters to a dedicated
hours. NORTH OF AUSTIN (ID
multi-generational active patient base.
#T515): GD Practice + Real Estate.
The well-appointed 2,500 sq ft space
Excellent location situated in a
contains 5 fully equipped operatories,
rapidly growing community north
digital pano, plumbed nitrous, and
of Austin. The practice is located in
computers throughout. EAST TEXAS
a free-standing building, contains
(ID #H489): This highly profitable,
4 fully equipped operatories, digital
general dentistry practice and real
X-ray units, and CBCT. This 100%
estate is located in an east Texas
fee-for-service practice boasts a
town. The practice serves a large FFS/
strong hygiene recall program, which
PPO patient base and is on pace to
produces a third of practice revenue
exceed seven figures in revenue in
and a fantastic online reputation.
2021 while maintaining a 45%+ profit
DFW METRO AREA (ID #T529):
margin. The office has 3 fully equipped
100% fee-for-service practice, located
operatories with possible room for
just north of Arlington, is equipped
expansion, digital radiography, and
with 4 computerized operatories and
computers throughout. HOUSTON
paperless charts. The practice has a
(ID #H472): This established,
large active patient base of 1,630 and
boutique practice is located in a highly
averages mid-6 figures. Nearly all
desirable area of central Houston. The
specialty procedures are being referred
practice provides general, implant,
out, which allows immediate growth
and cosmetic dentistry services to
potential for a buyer with an expanded
a 100% FFS patient base and has
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151
ADVERTISING BRIEFS an excellent reputation in the local
an excellent hygiene program,
community. The beautiful facility
and further upside via numerous
features high-end finishes/décor, 3
specialty procedures being referred
fully equipped operatories, digital
out. HOUSTON-NORTHEAST (ID
radiography, and a CBCT. HOUSTON,
#H488): FFS/PPO practice + Real
ORTHODONTICS (ID #H480): This
Estate. Growing suburb 45 minutes
productive, FFS orthodontic practice
NE of Houston. 1,800 total patients,
occupies an attractive free-standing
steady flow of new patients, solid
building situated on a high traffic
hygiene recall, and consistent revenue
street in a desirable community in the
of high-6 figures per year. The office
heart of east Texas. The practice has
contains 6 fully equipped operatories,
realized annual revenue of 7 figures
plumbed nitrous, digital X-ays, CBCT,
with exceptional profitability. The
and computers throughout. HOUSTON
office features a 4-chair ortho bay,
(ID #H490): General/cosmetic
2 exam rooms, and digital Pan/Ceph
practice located west of Houston in the
unit. The real estate is also available
highly desirable Memorial area. With
for purchase. HOUSTON-EAST (ID
roughly 40% of the production being
#H483): 100% FFS GD practice
generated from the hygiene program
+ Real Estate. Situated in a 2,200
and numerous specialty procedures
square foot, free standing building
being referred out, there is immediate
with 5 fully equipped operatories.
upside potential to be discovered.
Hygiene production is very healthy and
The office occupies 1,700 sq ft, has 3
the practice has seen 1,700+ active
equipped operatories with room for a
patients in the last 24 months with a
4th, digital radiography, and computers
steady new patient flow. HOUSTON-
throughout. HOUSTON-SOUTHEAST
NORTH (ID #H487): 100% FFS
(ID #H491): 100% FFS practice in a
practice in The Woodlands/Spring area.
growing suburb southeast of Houston.
Modern facility with 4 equipped ops,
The 1,685 sq ft facility contains 3 fully
digital X-ray sensors, an iTero, and
equipped operatories with room for
paperless charts. This practice checks
expansion, digital radiography, and
all of the boxes—strong profitability,
computers throughout. With most
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Texas Dental Journal | Vol 139 | No. 3
ADVERTISING BRIEFS specialty procedures being referred
west of San Antonio. Serves a PPO/
out and little to no marketing, this
FFS patient base, sees approximately
practice offers a tremendous level
30+ new patients per month, and
of upside potential. HOUSTON-
offers consistent annual revenue with
SOUTHWEST (ID #H492): Turn-key,
substantial upside potential through
general dentistry practice located in a
expanding the procedures offered in-
highly desirable suburb in southwest
house. The turn-key office features
Houston. This well-appointed 2,800
3 fully equipped operatories, digital
sq ft office features 6 operatories,
sensors, intra-oral cameras, and a
digital radiography, digital pano, digital
digital pano. SAN ANTONIO (ID
scanner, and paperless charts. The
#T501): Located in a highly sought-
practice serves a large FFS/PPO patient
after area along Loop 1604 in north
base (over 2,500 active patients) and
San Antonio. The practice serves a
features strong hygiene production (40% of total revenue), and solid new patient flow. HOUSTON-NORTH (ID #H493): 100% fee-for-service practice located north of Houston in the high growth area of Spring/ The Woodlands. The office occupies a spacious, standalone office condo and features 5 fully equipped operatories, digital technology, computers
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
throughout, and 2 plumbed operatories prepared for future expansion.
Austin
512-900-7989
This is an excellent opportunity to
DFW
214-960-4451
purchase a successful legacy practice
Houston
281-362-1707
poised for growth. SAN ANTONIOWEST (ID #T454): GD Practice + Real Estate. Located in a rural community approximately 75 miles
San Antonio 210-737-0100 South Texas 361-221-1990 Emai l : t ex as@ den t al t r an si t i o n s.co m www.dentaltransitions.com
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153
ADVERTISING BRIEFS large PPO/FFS patient base and is
BEAUMONT—GENERAL
located in a spacious office condo
(REFERENCE “BEAUMONT”):
with 6 fully equipped operatories,
Small town practice near a main
digital pano, digital X-rays, and
thoroughfare, 80 miles east of
digital sensors. SAN ANTONIO
Houston. Collections in 7 figures.
(ID #T531): GD practice in a high
Country living, close enough to
visibility retail center along a major
Houston for small commute. Practice
interstate in northwest San Antonio.
in a stand-alone building built in
The office features 4 operatories,
1970. The office is 1,675 sq ft with
digital radiography, CBCT, digital
4 total operatories, 2 operatories
scanner, and paperless charts.
for hygiene and 2 operatories for
Uniquely placed near the intersection
dentistry. Contains, reception area,
of two major interstates in a retail
dentist office, sterilization area, lab
center with a major anchor tenant,
area. Majority of patients are 30 to
this location offers tremendous growth
65 years old. Practice has operated at
opportunities for a buyer to capitalize
this location for over 38 years. Practice
on the surrounding foot traffic and
sees patients about 16 days a month.
visibility. SOUTH TEXAS (ID #T460):
Collection ratio of 100%. The practice
GD Practice and free-standing building,
is a fee-for-service practice. Building is
located in a charming south Texas
owned by dentist and is available for
town. The office is located in a two
sale. Contact Christopher Dunn at 800-
story, free-standing building and has
930-8017 or Christopher@DDRDental.
a spacious layout that includes 6 fully
com. HOUSTON (SHARPSTOWN
equipped operatories (one additional
AREA)—GENERAL (REFERENCE
plumbed for expansion, digital sensors,
“SHARPSTOWN GENERAL”) MOTIVATED
a digital pano, CBCT, and computers
SELLER. Well Established general
throughout. To request more
dentist with high-6 figure gross
information on our listings, please
production. Comprehensive general
register at www.dentaltransitions.
dentistry in the southwest Houston
com or contact us at 512-900-7989 or
area focused on children (Medicaid).
info@dentaltransitions.com.
Very, very high profitability. 1,300 sq
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Texas Dental Journal | Vol 139 | No. 3
ADVERTISING BRIEFS ft, 4 operatories in single building.
Flexible lease options are available for
95% collection ratio. Over 1,200
well-qualified dentists with no down
active patients. 20% Medicaid, 45%
payments and no interest for up to 2
PPO, and 35% fee-for-service. 30% of
years. Don’t waste time and money on
patients younger than 30. Office open
buildouts when you can have a great
6 days a week and accepts Medicaid.
practice today. Turnkey dental offices
Contact Christopher Dunn at 800-
for sale in the Dallas/Fort Worth metro
930-8017 or Christopher@DDRDental.
and surrounding areas, the offices
com. HOUSTON (BAYTOWN AREA)—
are strategically located in areas for
GENERAL (REFERENCE “BAYTOWN
high production with ample parking.
GENERAL”) MOTIVATED SELLER.
Locations are ideal for emergency
Well established general practice
dental services, Medicaid, insurance
with mid-6 figure gross production.
and FFS. Can be sold separately or as
Comprehensive general dentistry in
a package. Requirements dentists need
Baytown on the east side of Houston.
to have at least 2 years of experience
Great opportunity for growth! 1,400
in private practice/corporate dentistry;
sq ft, 4 operatories in single story
credit and background check. For
building. 100% collection ratio. 100%
more information, please email
fee-for-service. Practice focuses on
Txpracticesales@gmail.com or call/text
restorative, cosmetic and implant
214-995-0806.
dental procedures. Office open 3-1/2 days a week. Practice area is owned
FORT WORTH: Practice for sale in the
by dentist and is available for sale.
fast growing southwest area. Average
Contact Christopher Dunn at 800-930-
gross; 6 operatories; Excellent lease.
8017 or Christopher@DDRDental.com.
Seller is relocating. Need to move quickly on this one. DFW 214-503-
DALLAS: Don’t waste time and money
9696. WATS 800-583-7765.
on buildouts when you can have a great practice today. Great opportunity to start your dental practice without having to pay a big loan and interest.
www.tda.org | March 2022
155
ADVERTISING BRIEFS HOUSTON AREA: Several acquisition
reference “Lufkin General or TX#540”.
opportunities in the greater
HOUSTON—GENERAL (SHARPSTOWN)
Houston area. General, ortho, pedo
Well established general dentist
practices available for sale. Visit
with high-6 figure gross production.
lonestarpracticesales.com or email
Comprehensive general dentistry in
houstondentist2019@gmail.com.
the southwest Houston area focused on children (Medicaid). Very, very
HOUSTON, COLLEGE STATION, AND
high profitability. 1,300 sq ft, 4
LUFKIN (DDR DENTAL Listings).
operatories in single building. 95%
(See also AUSTIN for other DDR Dental
collection ratio. Over 1,200 active
listings and visit www.DDRDental.
patients. 20% Medicaid, 45% PPO,
com for full details. LUFKIN—GENERAL
and 35% fee for service. 30% of
practice on a high visibility outer
patients younger than 30. Office open
loop highway near mall, hospital
6 days a week and accepts Medicaid.
and mature neighborhoods. Located
Contact Chrissy Dunn at 800-930-
within a beautiful single-story, free-
8017 or chrissy@ddrdental.com
standing building, built in 1996 and
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
sq ft with 4 operatories (2 hygiene
in southeast Houston near Beltway
and 2 dental). Includes a reception
8. It is in a freestanding building.
area, dentist office, a sterilization
Dentist has ownership in the building
area, lab area, and break room. All
and would like to sell the ownership
operatories fully equipped. Does not
in the building with the practice. One
have a pano but does have digital
office currently in use by seller. A 60
X-ray. Production is 50% FFS and 50%
percent of patients age 31 to 80 and
PPO (no Medicaid), with collection ratio
20% 80 and above. Four operatories
above 95%. Providing general dental
in use, plumbed for 5 operatories.
and cosmetic procedures, producing
digital pano and digital X-ray. Contact
mid-6 figure gross collections. Contact
Christopher Dunn at 800-930-8017
Christopher Dunn at 800-930-8017
or christopher@ddrdental.com and
or Christopher@DDRDental.com and
reference “Pearland General or
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Texas Dental Journal | Vol 139 | No. 3
ADVERTISING BRIEFS TX#538”. HOUSTON—PEDIATRIC
consultation room, 2 offices, a
(NORTH HOUSTON) This practice
breakroom, and storage. This
is located in a highly sought-after
FFS practice collects in the high-6
upscale neighborhood. It is on a major
figures annually. Current dentist will
thoroughfare with high visibility in a
participate in a 3- to 5-year transition.
strip shopping center. The practice has
Contact 713-781-3599 or email
three operatories for hygiene and two
bkkpallen@gmail.com.
for dentistry. Nitrous is plumbed for all operatories. The practice has digital
KATY: Now is the time to join Grand
X-rays and is fully computerized. The
Lakes Dental Group and Orthodontics.
practice was completely renovated
You will have opportunities to
in 2018. The practice is only open
learn new skills from our team of
3-1/2 days per week. Contact
experienced professionals. If you’re
Christopher Dunn at 800-930-8017
ready to take your career to the next
or christopher@ddrdental.com and
level and gain valuable experience,
reference “North Houston or TX#562”.
apply today! You’ve invested the time
WEST HOUSTON—MOTIVATED SELLER.
to become a great dentist, now let
Medicaid practice with production
us help you take your career further
over 6 figures. Three operatories in
with more opportunity, excellent
1,200 sq ft in a strip shopping center.
clinical leadership and one of the best
Equipment is within 10 years of age.
practice models in modern dentistry.
Has a pano and digital X-ray. Great
In working with our practice you will
location. If interested contact chrissy@
have the autonomy to provide your
ddrdental.com. Reference “West
patients the care they deserve. In
Houston General or TX#559”.
addition, you’ll enjoy the opportunity to earn excellent income and have
HOUSTON: Established general
great work-life balance without the
practice located in the Galleria/
worries of running a practice. You
Memorial Villages area of Houston
became a dentist to provide excellent
for sale. The 4,000 sq ft leased
patient care and have a career that will
space has 8 operatories, 2 dental
serve you for a lifetime. With us, you
labs, 2 sterilization areas, a private
will have a balanced lifestyle, fantastic www.tda.org | March 2022
157
ADVERTISING BRIEFS income opportunities, and you’ll
contact a recruiter anytime. We’d love
work for an office that cares about
to chat, get to know you and share
their people, their patients and their
more about us. Pacific Dental Services
community. Our practice is an office
is an equal opportunity employer and
supported by Pacific Dental Services
does not discriminate against any
(PDS), which means you won’t have to
employee or applicant for employment
spend your career navigating practice
based on race, color, religion, national
administration. Instead, you’ll focus
origin, age, gender, sex, ancestry,
on your patients and your well-being.
citizenship status, mental or physical
Add on excellent benefits, including
disability, genetic information, sexual
malpractice insurance, medical, dental
orientation, veteran status, or military
and vision insurance, retirement plans
status. Apply here:http://www.
and much more and you’ll feel well
Click2Apply.net/gwy6pkn22knbzwzx
taken care of throughout your career.
PI106822492.
The average full-time PDS-supported associate dentist earns low-6 figures
WATSON BROWN PRACTICES FOR
in their first year. The average income
SALE: Practices for sale in Texas
for a PDS-supported owner dentist,
and surrounding states, For more
whose practice has been open at
information and current listings please
least 2 years, is mid-6 figures. As
visit our website at www.adstexas.com
an associate dentist, you will receive
or call us at 469-222-3200 to speak
ongoing training to keep you informed
with Frank or Jeremy.
and utilizing the latest technologies and dentistry practices. If you are interested in a path to ownership, our
INTERIM SERVICES
proven model will provide you with the training needed to become an owner
HAVE MIRROR AND EXPLORER,
of your own office. PDS is one of the
WILL TRAVEL: Sick leave, maternity
fastest growing companies in the US
leave, vacation, or death, I will cover
which means we will need excellent
your general or pediatric practice. Call
dentists like you to continue to lead
Robert Zoch, DDS, MAGD, at 512-517-
our growth in the future. Apply now or
2826 or drzoch@yahoo.com.
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Texas Dental Journal | Vol 139 | No. 3
YOUR PATIENTS TRUST YOU.
WHO CAN YOU TRUST?
ADVERTISERS AFTCO........................................................... 133 Anesthesia Education & Safety Foundation... 106 DentalPost..................................................... 130 E-VAC, Inc..................................................... 132 Henry Schein Financial Services.................... 118
If you or a dental colleague
JKJ Pathology................................................ 113
are experiencing impairment
Law Offices of Hanna & Anderton..................... 132
due to substance use or mental illness, The Professional
Linda C. Niessen Geriatric Dentistry Symposium................................................... 129
Recovery Network is here
McLerran & Associates.................................. 153
to provide support and an opportunity for confidential recovery.
MedPro Group............................................... 119 Professional Recovery Network..................... 159 SmileCon 2022.............................................. 131 Southwest Sedation Education...................... 133 TDA Perks.............................. Inside Front Cover Texas Health Steps........................................ 103 UTHealth San Antonio Pathology Lab............ 118
PRN Helpline (800) 727-5152
Visit us online www.txprn.com
UTHealth Houston Pathology......................... 130 Watson Brown Practice Sales & Appraisals.... 107
www.tda.org | March 2022
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