March 2023 Texas Dental Journal

TDA

Texas Dental Journal

MARCH 2023

110

THE #ETHICS BEHIND SOCIAL MEDIA INFLUENCERS IN DENTISTRY

KATHLEEN NICHOLS, DDS RENEE PAPPAS, DDS

90

ULTRATHIN CAD-CAM GLASS CERAMIC AND COMPOSITE RESIN OCCLUSAL VENEERS FOR THE TREATMENT OF SEVERE DENTAL EROSION: AN UP TO 3-YEAR RANDOMIZED CLINICAL TRIAL

LUÍS HENRIQUE SCHLICHTING, DDS, BBA, MS, PHD TAYANE HOLZ RESENDE, DDS, MS, PHD KÁTIA RODRIGUES REIS, DDS, MS, PHD ALINE RAYBOLT DOS SANTOS, DDS, MS, PHD IVO CARLOS CORREA, DDS, MS, PHD PASCAL MAGNE, DMD, PHD

74

OFFICIAL CALL TO THE 2023 ANNUAL SESSION OF THE TEXAS DENTAL ASSOCIATION HOUSE OF DELEGATES

106

TDA MEETING PREVIEW HPV AND ORAL CANCER: FEAR, FACTS, AND THE FUTURE SPEAKER: THOMAS SCHLIEVE DDS, MD

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

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.

New TSBDE requirement of Pain Management

Two programs available (satisfies rules 104.1 and 111.1)

Live Webcast (counts as in-class CE) or Online (at your convenience)

All programs can be taken individually or with a special discount pricing (ask Dr. Canfield) for a bundle of 2 programs: Principles of Pain Management

Fulfills rule 104.1 for all practitioners Use and Abuse of Prescription Medications and Provider Prescription Program

Fulfills rules 104.1 and 111.1

SEDATION & EMERGENCY PROGRAMS:

Nitrous Oxide/Oxygen Conscious Sedation Course for Dentists:

Credit: 18 hours lecture/participation (you must complete the online portion prior to the clinical part)

Level 1 Initial Minimal Sedation Permit Courses:

*Hybrid program consisting of Live Lecture and online combination

Credit: 20 hours lecture with 20 clinical experiences

SEDATION REPERMIT PROGRAMS: LEVELS 1 and 2 (ONLINE, LIVE WEBCAST AND IN CLASS)

ONLINE LEVEL 3 AND 4 SEDATION RE PERMIT AVAILABLE!

(Parenteral Review) Level 3 or Level 4 Anesthesia Programs

(In Class, Webcast and Online available):

American Heart Association Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) Initial and Renewal Programs

NOTE: ACLS or PALS Renewal can be completed by itself at any combined program

Combined ACLS-PALS-BLS and Level 2, 3 and 4 Program

WEBCASTING and ONLINE RENEWALS AVAILABLE! Live and archived webcasting to your computer in the comfort of your home. Here are the distinct advantages of the webcast (contact us at 214 -384-0796 to see which courses are available for webcast):

1. You can receive continuing education credit for simultaneous live lecture CE hours.

2. There is no need to travel to the program location. You can stay at home or in your office to view and listen to the cou rse.

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 Sedat ion permits.

AGD Codes for all programs: 341 Anesthesia & Pain Control; 342 Conscious Sedation; 343 Oral Sedation

This is only a partial listing of sedation courses. Please consult our www.sedationce.com for updates and new programs.

Two ways to Register: e-mail us at sedationce@aol.com or call us at 214-384-0796

Dr. Canfield

FEATURES

74 OFFICIAL CALL TO THE 2023 ANNUAL SESSION OF THE TEXAS DENTAL ASSOCIATION HOUSE OF DELEGATES

90 ULTRATHIN CAD-CAM GLASS CERAMIC AND COMPOSITE RESIN OCCLUSAL VENEERS FOR THE TREATMENT OF SEVERE DENTAL EROSION: AN UP TO 3-YEAR RANDOMIZED CLINICAL TRIAL

LUÍS HENRIQUE SCHLICHTING, DDS, BBA, MS, PHD

TAYANE HOLZ RESENDE, DDS, MS, PHD KÁTIA RODRIGUES REIS, DDS, MS, PHD ALINE RAYBOLT DOS SANTOS, DDS, MS, PHD IVO CARLOS CORREA, DDS, MS, PHD PASCAL MAGNE, DMD, PHD

Editorial Staff

Jacqueline M. Plemons, DDS, MS, 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. Established February 1883 • Vol 140 | No. 2

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 except January-February and August-September, which are combined issues, by the Texas Dental Association, 1946 S IH-35, Austin, TX, 78704-3698, 512-443-3675. PeriodicalsPostage Paid at Austin, Texas and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S IH 35 Ste 400, Austin, TX 78704. Copyright 2023 Texas Dental Association. All rights reserved.

Annual subscriptions: Texas Dental Association members $17. Instate 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. 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 included in the online 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 the quality of value of such product or of the claims made.

editor’s note

This March is Women’s History Month. You’ve probably seen posts on social media highlighting the accomplishments women have made and the strides we’ve taken in history.

The website https://womenshistorymonth.gov/, established by The Library of Congress, National Archives and Records Administration, National Endowment for the Humanities, National Gallery of Art, National Park Service, Smithsonian Institution, and United States Holocaust Memorial Museum, includes pictures and stories of such events, and says we should all “join in commemorating and encouraging the study, observance, and celebration of the vital role of women in American history.”

Jacqueline Plemons, DDS, MS

As a dentist for 37 years, I’ve found the sisterhood within our profession to be strong, inspirational, and committed. I have stood beside our female and male counterparts to share a partnership and mutual desire to continue the inclusivity of this profession and provide the best care for our patients. So, we celebrate my sisters in dentistry this month, and in this issue we’re highlighting one new member.

Dr Lauren Mauban from Austin joined TDA just 2 years ago after graduating from dental school; however, in that short time she has served as Chair of the study club for the Capital Area Dental Society and is an incoming member of their Board of Directors. She has also participated in two TMOM events—Dallas and Houston. She is off and running full speed in service to our profession.

I’ll admit I was a slow starter in organized dentistry compared to Dr Mauban! I joined my local component right after dental school and have been a member ever since. Leadership positions came later for me as my service ebbed and flowed based on where life took me. There’s some beauty in that—we can all contribute when the time is right!

As you read more about Dr Mauban, you’ll see that she was moved to become involved in organized dentistry at the beginning of her career because more “experienced” peers urged her on and provided support and advice. Our profession is made better through the voices of all our members. Reaching out and being open to opportunities along the way is a recipe for success.

Surely Dr Mauban and other young women dentists of today will make a little history themselves. You may also be the “peer” who opens the door, plants the seeds of service, and offers support all along the way. From my view, the future of dentistry is in good hands.

JKJ Pathology

Oral Pathology Laboratory

John E Kacher, DDS

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johnkacher@jkjpathology.com

Protecting your patients, limiting your liability

Board of Directors Texas Dental Association

PRESIDENT

Duc “Duke” M. Ho, DDS 281-395-2112, ducmho@sbcglobal.net

PRESIDENT-ELECT

Cody C. Graves, DDS 325-648-2251, drc@centex.net

PAST PRESIDENT

Debrah J. Worsham, DDS 936-598-2626, worshamdds@sbcglobal.net

VICE PRESIDENT, SOUTHEAST Glenda G. Owen, DDS 713-622-2248, Dr.owen@owendds.com

VICE PRESIDENT, SOUTHWEST Carlos Cruz, DDS 956-627-3556, ccruzdds@hotmail.com

VICE PRESIDENT, NORTHWEST

Teri B. Lovelace, DDS 325-695-1131, lovelace27@icloud.com

VICE PRESIDENT, NORTHEAST

Elizabeth S. Goldman, DDS 214-585-0268, texasredbuddental@gmail.com

SENIOR DIRECTOR, SOUTHEAST Shailee J. Gupta, DDS 512-879-6225, sgupta@stdavidsfoundation.org

SENIOR DIRECTOR, SOUTHWEST

Richard M. Potter, DDS 210-673-9051, rnpotter@att.net

SENIOR DIRECTOR, NORTHWEST Summer Ketron Roark, DDS 806-793-3556, summerketron@gmail.com

SENIOR DIRECTOR, NORTHEAST Jodi D. Danna, DDS 972-377-7800, jodidds1@gmail.com

DIRECTOR, SOUTHEAST Laji J. James, DDS 281-870-9270, lajijames@yahoo.com

DIRECTOR, SOUTHWEST

Krystelle Anaya, DDS 915-855-1000, krystelle.barrera@gmail.com

DIRECTOR, NORTHWEST

Stephen A. Sperry, DDS 806-794-8124, stephenasperry@gmail.com

DIRECTOR, NORTHEAST Mark A. Camp, DDS 903-757-8890, macamp1970@yahoo.com

SECRETARY-TREASURER*

Carmen P. Smith, DDS 214-503-6776, drprincele@gmail.com

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**

Jacqueline M. Plemons, DDS, MS 214-369-8585, drplemons@yahoo.com

LEGAL COUNSEL Carl R. Galant

*Non-voting member **Non-voting

DENTIST to DENTIST

RELATIONSHIP. MENTORSHIP. COMMUNICATION. “Roads? Where

There’s a lot going on within the Texas Dental Association, and although the destination – true member value for the everyday dentist —is very familiar territory, the road traveled is proving to be much more interesting. We are expanding our member services by advocating for a very robust legislative agenda which includes insurance reform, student loan repayment programs, and increases in Medicaid reimbursements, expanding our reach with continuing education, putting money back into our member’s hands with the Employee Retention Credit, and providing support with mental health toolkits and mutual aid guides.

Can we do more? Of course. But strength in numbers matter and we can’t do more without your membership. So, join us on this journey by visiting: https://www.tda.org/ member-center/join-renew — or scan the QR code.

Now, for an update of what’s going on in the Association: Council on the Annual Meeting and Continuing Education Programs

• May 4-6, 2023, The TDA Meeting—Registration is now open for this year’s TDA Meeting in San Antonio with the “Early Bird” deadline (free registration for TDA members and their teams) on March 31 quickly approaching. The council has worked long and hard to put together a program that features nationally recognized speakers along with activities and events to make your visit fun and memorable. Did I mention it was free to members?

• July 21, 2023, Regional Meeting—Held in Lubbock this year with Digital Dentistry as its topic, the intent of this meeting is to bring continuing education to many different components in a region where traveling to larger meetings may be difficult. To accomplish this goal, outreach beyond Lubbock is important and will hopefully include Amarillo, Abilene, and other neighboring parts of Texas.

• November 3-5, 2023, Dentist Symposium at the Omni Barton Creek Resort & Spa—This program will focus on both education and building more community fellowship within our association by featuring high level continuing education in the morning and networking opportunities through various social activities in the afternoon.

From education to advocacy—with the legislative session in full gear, your Association completed a very successful Legislative Day with over 130 members and students meeting with key legislators and their staffs to advance our legislative agenda.

The Council on Legislative, Regulatory and Governmental Affairs

• Insurance Reform—HB 1527 was filed by Rep. Tom Oliverson (R-Cypress) dealing with insurance reform by setting time limits for insurance companies to request refunds (retroactive denials), preventing the leasing of dentist networks from one company to another without the dentist’s knowledge (network leasing), and inhibiting insurance companies from precluding a dentist from collecting from a patient for a non-covered service.

• Clear Aligners—SB 384 was filed by Sen. Lois Kolkhorst (R-Brenham) and mandates a comprehensive exam by a dentist prior to the sale of any clear aligners. Although this would seem obvious, such is not currently the case, and this bill would be the first of its kind in the country to mandate an exam.

• Increases in Medicaid Dental Reimbursements—the last increase occurred as the result of a lawsuit in 2007 and many dentists are slowly leaving Medicaid as it has become more expensive to provide care. Increasing reimbursement (making it whole to 2007 levels) will attract more providers and help address the needs of over 4 million children who have qualified for Medicaid.

Compliance and Regulatory Matters

Lastly, I would like to give an additional plug for a new resource aptly named “Ask Diane”. As the senior policy manager for the Texas Dental Association, Diane has filed away more rules and regulations than we will ever know. Literally. So, if you have a question about staying in compliance, following regulations of the State Board or simply a complicated insurance question, visit https://www.tda.org/askdiane/questionsubmission and submit your question. Your question will be shared on other platforms and media to hopefully help others unless the question is highly specific to you as a member, and then you will receive a personalized email from Diane.

As our membership grows, so does our influence; let’s see where these roads, or no roads, take us!

we’re going, we don’t need roads.”

—Dr Emmett Brown, “Back to the Future”

Duc “Duke” M. Ho, DDS, FAGD TDA President

Terry Watson, D.D.S. Jeremy Brown, J.D. Frank Brown, J.D., LL.M.

Official call to the 2023 Annual Session of the Texas Dental Association House

of Delegates

HOUSE OF DELEGATES: In accordance with Chapter IV, Section 70, paragraph A-1 of the Texas Dental Association (TDA) Bylaws, this is the official call for the 153rd Annual Session of the Texas Dental Association House of Delegates. All sessions of the House will be in the Hemisfair C-3 Ballroom of the Henry B. Gonzalez Convention Center, 900 E. Market Street, San Antonio, Texas. The opening session of the House will convene at 8:00 a.m. on Thursday, May 4, 2023. The second meeting of the House will be at 1:30 PM on Friday, May 5, 2023. The third meeting of the House will be at 8:00 AM on Saturday, May 6, 2023, followed by the fourth meeting at 1:30 PM until close of business.

Please see the TDA Meeting website for details and additional information (www.tdameeting.com).

Component Societies are urged to certify an accurate list of Delegates and Alternates to fill each of their seats on the floor of the TDA House of Delegates.

REFERENCE COMMITTEE HEARINGS: Reference Committee hearings will be facilitated in the Convention Center on Thursday, May 4, 2023, and open to all members who are present (any changes to committee meeting rooms and start times will be posted on the TDA website and announced at the first meeting of the House of Delegates):

• Reference Committee A: 10:00 AM (Room 304A)

Administration, Budget, Building, House of Delegates, Membership Processing

• Reference Committee B: 11:30 AM (Room 303C)

President’s Address, Miscellaneous Matters, Component Societies, Subsidiaries, Strategic Planning, Annual Session

• Reference Committee C: 1:00 PM (Room 304B)

Dental Education, Dental Economics, Health and Dental Care Programs

• Reference Committee D: 2:00 PM (Room 304C)

Legislative, Legal and Governmental Affairs

• Reference Committee E: 3:30 PM (Room 304A)

Constitution, Bylaws, Ethics & Peer Review

The agendas for the committee hearings will be included in the Reference Committee section of the Delegate materials.

REFERENCE COMMITTEE REPORTS: Reference Committee Reports will be made available in PDF format to the members of the House of Delegates (reports may be downloaded from any location with Internet access). Printed copies will not be provided.

FINANCIAL FORUM: The TDA Secretary-Treasurer will facilitate a half hour questionand-answer financial forum open to all members who are present at 10:00 AM on Thursday, May 4, 2023, in the same meeting room as the Reference Committee A hearing.

CANDIDATES FORUM: The ADA & TDA Candidates Forums will be held on Friday, May 5, 2023, from 10:30 AM to 12:00 PM in the Convention Center (room assignment to be posted on the TDA website and announced at the first meeting of the House of Delegates).

DIVISIONAL CAUCUSES: Divisional Caucuses (Northwest, Northeast, Southwest, Southeast) will be facilitated at 5:30 PM on Friday, May 5, 2023, in the Convention Center and is open to all current members—please see the TDA website for details and additional information (room assignments to be posted on the TDA website and announced at the first meeting of the House of Delegates).

DELEGATE MATERIALS: In accordance with TDA Bylaws, the House documents will be available 30 days prior to the Annual Session of the House of Delegates. The supplements to the House documents, containing the agenda and subsequent reports, will be sent after the April 2023 TDA Board of Directors meeting. The minutes of the TDA Board shall be posted on the members’ side of the TDA website and made available to the general TDA membership once the minutes are approved by the TDA Board of Directors in accordance with Policy 26-2018-H. Delegates and alternates will receive all House Documents in PDF format. Printed copies of the House Documents will not be provided. Wireless internet access will not be available in the House chamber—please download all House materials on a fully charged laptop or device prior to attendance (charging stations will be centrally located in the meeting rooms).

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 SecretaryTreasurer Dr Carmen P Smith for the upcoming 2023 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 may 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 Carmen P Smith, 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).

OFFICIAL CALL FOR SECRETARYTREASURER 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 Carmen P Smith for the upcoming 2023 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.

• 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 Carmen P Smith, 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 Secretary-Treasurer Dr Carmen P Smith for the upcoming 2023 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 Carmen P Smith, 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 VI, Elective Officers—Section 90I (Duties); Policy Manual).

Official Call for Nominations: Statewide Election of TDA President-elect

CHAPTER VI, Section 30 of the TDA Bylaws state that the president-elect shall be nominated in turn clockwise from and by the members of each of the 4 divisions—Southeast, Southwest, Northwest, and Northeast. Every third year the president-elect shall be nominated on a statewide basis, which will occur in 2023. The divisional rotation of the president-elect will continue in the intervening years.

Announcement of candidacy for the statewide elective office of Texas Dental Association (TDA) presidentelect may be submitted to TDA Secretary-Treasurer Dr Carmen P Smith for the upcoming 2023 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 any time until the close of nominations at the beginning of the next to the last meeting of the House of Delegates; however, announcements of candidacy should be made as early as possible so that membership eligibility can be verified.

Duties of the president-elect are enumerated in the Bylaws and include the following:

a. To preside in the absence of the president.

b. To assist the president as requested.

c. To serve as an ex-officio member of the Board of Directors and the House of Delegates.

d. To perform such other duties as may be provided in the TDA Bylaws.

e. To succeed to the office of president at the next annual session of the House of Delegates following his/ her election as president-elect.

f. To serve on the Council of Legislative and Regulatory Affairs.

Duties of the subsequent position of president are also enumerated in the Bylaws and include the following:

a. To serve as official representative of this Association in its contacts with governmental, civic, business, and professional organizations for the purpose of advancing the objects and policies of this Association.

b. To serve as an ex-officio member of the Board of Directors of the Association.

c. To be presiding officer of the Board of Directors of this Association.

d. To be the supervising authority of the Executive Director on behalf of the Board of Directors.

e. To annually appoint the Parliamentarian for the Association who shall serve as the Speaker Pro-tem of the House of Delegates, should it become necessary for the Speaker to be absent.

f. To call special sessions of the House of Delegates and Board of Directors as provided in Chapters IV and V of these Bylaws.

g. To appoint, with approval of the Board of Directors, the members of all committees and such others as may be necessary to the work of the Association except as otherwise provided in these Bylaws.

h. To submit an annual report to the House of Delegates at the first session concerning his/her activities during the year and presenting such matters as should be brought to their attention or may require their action.

i. To conduct annually a presidents-presidents-elect conference for component presidents and presidents-elect.

j. To perform such other duties as may be provided in the TDA Bylaws.

Nominations are to be mailed to TDA Secretary-Treasurer Dr Carmen P Smith, Texas Dental Association, 1946 S IH-35 Ste 400, Austin, TX 78704; or e-mailed to TDA Executive Director Ms Linda G Brady, lbrady@tda.org.

(Ref. TDA Bylaws, Chapter VI, Elective Officers—Section 30, Nominations, and Section 90A,B, Duties of the President and President-elect)

Financial Report of the Texas Dental Association Looking Back and Moving Forward

Greetings, fellow TDA Members! It is my distinct honor and pleasure to carry on the baton from Dr Cody Graves, as your new secretary/treasurer. For those that I have not had the pleasure to meet, I am Dr Carmen Smith, general dentist from Dallas, Texas. I received my undergraduate degree from Texas A&M University, followed by my DDS from Baylor College of Dentistry, and finally my MBA from Southern Methodist University. While all these credentials sound fancy, I am truly just a dentist who loves her profession and wants to do her part in supporting and advancing the field of dentistry.

Dr Carmen Smith Secretary-Treasurer, TDA

In 2022, the world was still turning the corner from the COVID pandemic and many economic events occurred, including but not limited to, inflation, rising interest rates, a very volatile job market, crash of crypto currency, war between Russia and Ukraine, and major legislation such as the Inflation Reduction Act. Most industries, including dentistry, have received a direct or indirect affect from these occurrences. From a preliminary outlook (the annual audit has not occurred at the time of this article), the Texas Dental Association made some positive headway in the midst of all the economic downturn of 2022.

2022 in Review

• TDA had revenues over expenses of approximately $62,635. (Woo-Hoo)!

• TDA did not have an annual meeting, instead co-hosting SmileCon with the ADA and Greater Houston Dental Society. This joint venture brought $583,910 in gross revenue to TDA.

• Communications fell short of the budgeted revenues, due to loss in advertising dollars and an increase in postage, printing, and production.

• Continuing education programs—These are CE events sponsored by the TDA outside of our annual meeting. TDA Perks launched the TDA Concierge app, which generated revenue dollars; a regional CE meeting was planned for Texarkana; however, due to unforeseen circumstances, was cancelled. Planning immediately began for a regional meeting in 2023 for Lubbock.

• TDA Building Leases—Our revenue increased (due to increase in tenant rents) and expenses decreased.

• Operating—1) Dues exceeded budget expectation by 103% and 2021 actuals by 106%. 2) We received miscellaneous revenue from grants from the ADA for marketing campaigns, sponsorships through MCI (company that solicits advertising and sponsorships for TDA), final payment from FSI for Concierge development, and sponsorship from Perks to fund the Texas reception at the ADA HOD meeting. 3) We received payment from our for-

profit arm (FSI) for administrative support of staff and equipment.

4) TDA received the full budgeted cash distribution of $275,000 from TDA Member Benefits, Ltd (MBL)—TDA is a limited partner.

• TDA non-budgeted contingency expenses are related to 1) relief assistance to Florida, Puerto Rico; 2) a contribution to Dr Craig Armstrong’s campaign for president-elect of the ADA; and 3) a contribution to the Massachusetts Ballot initiative.

• Central Office, Board of Directors, Councils and Committees expenses were all less than budgeted.

• The ADA expense was higher than budgeted, which again was offset by the sponsorships.

• The TDA House of Delegates expenses exceeded budget due to a venue change (no annual session at the convention center) and the associated expenses.

• Lastly concerning 2022, with the volatility of the stock markets, TDA saw less than a 1% unrealized loss of our long-term reserves.

The 2024 budget is presented below. This budget, as with all budgets, presented many challenges. TDA has had 1 annual meeting in the last 3 years. There are 2 new programs (Regional Meeting and Dentist Symposium) that are included in the budget with no data basis to establish a revenue projection. With that stated, here are some highlights for the 2024 budget…

• The TDA Meeting revenues (based on trends preceding COVID) is forecasted to exceed expenses. The TDA will be

utilizing less meeting space which reduces costs (room, AV, etc).

• Continuing Education revenues forecasted to exceed expenses due to continued growth of the Concierge App, and the addition of revenue from a Regional Meeting and the Dentist Symposium.

• Communications still remains in a deficit as TDA Editor Dr Plemons and her team continue the transition that the task force has implemented.

• The TDA Building is status quo at the time of this article. As many may or may not know, the Texas Department of Transportation has plans of a project that will widen I-35, which may have effects on the TDA Building. Discussion and planning are still happening at this time.

• Our Dues revenue is based on a projection of 5,508 full-dues paying active members. This number takes into account a 10% attrition.

• TDA is forecasting $95,000 in general sponsorship revenue, and $75,000 in sponsorship revenue for the Texas reception for the ADA House of Delegates. The ADA reception expenses are expected to be fully covered by these sponsorships.

• Our affiliate administration revenues and MBL Partnership distribution is expected to slightly increase.

• The Central Office is expected to add an additional staff member to assist with the Annual Meeting and Continuing Education due to the addition of the new programs.

• Councils and Committees expenses are reduced mainly due to the fact of a non-legislative year.

• Finally, with the success of past Leadership Conferences, the Budget Committee decided to make this a line item on our budget. The expense is forecasted at $20,000 to be supported by budgeted miscellaneous sponsorship revenue.

Overall, the 2024 budget proposal is $5,730,930. With an emphasis on the development of new programming in an effort to encourage membership growth, the board, with thoughtful deliberation and intention, has voted on the presented budget with the recommendation of an $8 dues increase. The budget is balanced in accordance to TDA Bylaws without using methods of financing outside of expected revenues. The riders, which allow limitations to revisions of the budget, are also included. Any additional initiatives that are not included in this budget, will need to be funded from reserve funds, subject to Board approval.

A special thank you to the Budget Staff Members TDA Executive Director Linda Brady and Director of Finance

Kelly Doolittle for your guidance and direction in providing the necessary resources for developing the budget; the Budget Committee for recommending a budget that is forward thinking and operational; and to the Board of Directors for approving a budget for our members that will allow us to continue to grow and move forward through the good and challenging times.

Central Office Departments

Board of Directors, Councils, Committees, ADA, HOD

2024 Proposed Budget Texas Dental Association

2024 Proposed Budget Texas Dental Association

RIDERS

1. General Revision Authority. The Board of Directors is authorized to revise and amend the 2024 budget, in the aggregate or any single line item, during the time period August 1, 2023, and November 30, 2023, 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.

ULTRATHIN

Glass ceramic and composite resin occlusal veneers for the treatment of severe dental erosion:

An up to 3-year randomized clinical trial

This article was published in The Journal of Prosthetic Dentistry, Volume 128, Issue 2; Luís Henrique Schlichting, DDS, BBA, MS, PhD, Tayane Holz Resende, DDS, MS, PhD, Kátia Rodrigues Reis, DDS, MS, PhD, Aline Raybolt dos Santos, DDS, MS, PhD, Ivo Carlos Correa, DDS, MS, PhD, and Pascal Magne, DMD, PhD; Ultrathin CAD-CAM glass ceramic and composite resin occlusal veneers for the treatment of severe dental erosion: An up to 3-year randomized clinical trial, 158.e1-158. e12. Copyright Elsevier Science & Technology Journals 2022.

Luís Henrique Schlichting, DDS, BBA, MS, PhD

Associate Professor, Operative Dentistry, Division of Comprehensive Oral Health, UNC Adams School of Dentistry, Chapel Hill, NC.

Tayane Holz Resende, DDS, MS, PhD

Assistant Professor, Department of Prosthodontics and Dental Materials, School of Dentistry, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.

Kátia Rodrigues Reis, DDS, MS, PhD

Associate Professor, Department of Prosthodontics and Dental Materials, School of Dentistry, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.

Aline Raybolt dos Santos, DDS, MS, PhD

Associate Professor, Department of Prosthodontics and Dental Materials, School of Dentistry, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.

Ivo Carlos Correa, DDS, MS, PhD

Professor, Department of Prosthodontics and Dental Materials, School of Dentistry, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.

Pascal Magne, DMD, PhD

The Don and Sybil Harrington Professor of Esthetic Dentistry, Restorative Sciences, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA

Funding: This work was supported by grant no. E-26/112.046/2012 from FAPERJ (Carlos Chagas Filho Foundation for the Support of Research in the State of Rio de Janeiro).

CAD-CAM

Abstract

Statement of problem: Ultrathin bonded posterior occlusal veneers represent a conservative alternative to traditional onlays and complete coverage crowns for the treatment of erosive dental wear. Data regarding the clinical performance of ceramic and composite resin ultrathin occlusal veneers are lacking.

Purpose:

The purpose of this prospective randomized clinical trial was to evaluate the influence of computer-aided design and computeraided manufacturing (CAD-CAM) restorative material (ceramic versus composite resin) on the clinical performance of ultrathin occlusal veneers bonded to worn posterior teeth.

Material and methods:

Dental erosion starts early in life, with the prevalence of pathological erosive wear in the permanent teeth of children and adolescents reported to be 30.4%.1 During adulthood, severe tooth wear has been observed in 3% of the population at 20 years increasing to 17% at 70 years.2 Risk assessment and diagnosis are essential in the contemporary management of erosive tooth wear, which includes preventative measures such as occlusal devices and diet modification.3 When restorative treatment is essential because of sensitivity, active caries, difficulty in mastication, compromised oral hygiene, and evidence of progression strategies based on the maximum preservation of the remaining tooth tissue should be implemented.3-6

Direct composite resins are the first choice for restoring small defects. For larger tooth loss, as seen in severe erosive tooth wear, a direct approach is still possible, yet its success is dependent on the skills of the operator and patient tolerance for longer chair time, in addition to higher expected maintenance.3,5-9 When indirect restorations are chosen, ultrathin

Eleven participants (mean age, 30.4 years) had their posterior teeth restored with 24 ceramic (e.max CAD) and 36 composite resin (Lava Ultimate) ultrathin occlusal veneers. The material type was assigned randomly. The tooth preparations were trial restoration driven and included immediate dentin sealing (OptiBond FL). The intaglio surfaces of the ceramic restorations were etched with hydrofluoric acid and silanated, and the composite resins were airborne-particle abraded and silanated. The tooth preparations were airborneparticle abraded and etched with phosphoric acid before restoration insertion. All restorations were adhesively luted with preheated composite resin (Filtek Z100). The participants were evaluated according to the modified United States Public Health Service (USPHS) criteria at baseline and then each year for up to 3 years. Survival rates were estimated with time to failure (primary outcome of interest) as the endpoint (scores 4 or 5).

Results:

No restorations were lost. Five partial failures, in the form of chipping (all scored 4), were observed in the composite resin group (Lava Ultimate). The Kaplan-Meier survival rates were 100% for ceramic and 84.7% (SE 0.065%) for composite resin. Differences between the 2 groups were not statistically significant (P=.124). In the surviving restorations, significant difference (P=.003) was found for surface roughness as restorations in the composite resin group experienced some surface degradation.

Conclusions:

The findings of this medium-term clinical trial suggest that ceramic (e.max CAD) and composite resin (Lava Ultimate) CAD-CAM ultrathin occlusal veneers presented statistically comparable performance regardless of the minor partial failures (restorable chipping) observed in the composite resin group. Higher surface degradation was observed in the composite resin group.

Clinical Implications

CAD-CAM composite resin and ceramic ultrathin occlusal veneers provide optimal and similar clinical performance. If composite resin is chosen, more maintenance might be expected.

occlusal veneers (OVs) can address the principles of optimal form, occlusion, and function while abiding by the biomimetic rule of maximum tissue conservation (Figure 1A, B).10-12 In patients with severe generalized wear, for which the vertical dimension of occlusion (VDO) is frequently increased, reducing intact tissues may even become unnecessary because clearance is created by the new VDO (Figure 1C, D).13,14 However, because of the intrinsic thinness of OVs, only limited increase in the VDO is needed, which is always preferred in patients with class II occlusion.

The ultrathin design also brings simplicity to the indirect restorative method. Their reduced thickness, ranging from 0.4 to 0.6 mm at the fissures to 1.0 to 1.3 mm at the cusp tips, requires a more straightforward approach, essentially driven by interocclusal clearance and anatomic considerations.10,11 Even thinner designs have been proposed.8,15-17 Margins should be kept distant from gingiva and without the need to involve proximal contacts.10-14 As a result, the thickness of the surrounding enamel is retained, resulting in improved bonding.18 Regarding the restorative material, only ceramics and composite resins are able to satisfy the biomimetic principles of maximum tissue preservation and esthetics. However, these materials will only perform to their full capacity when restoration and tooth structure are ideally bonded to each other through an optimized bonded protocol, such

Figure

strategies

on management of VDO. A and B, Ultrathin OVs with VDO maintained, require some preparation (still conservative compared with conventional onlays or crowns). Indicated with localized erosion or wear (single or few restorations). Previous and new dentin exposure from preparation immediately sealed (red). C and D, Ultrathin OVs with increased VDO allow for minimal or no preparation (multiple restorations, complete mouth rehabilitation), increasing possibility of preserving intact enamel and dentinoenamel junction (blue arrows). OVs, occlusal veneers; VDO, vertical dimension of occlusion.

1. Schematic comparison of 2 OV

based

as immediate dentin sealing, providing an assembly that has been termed the principle of combined action.19-25 The development of stronger ceramics such as lithium disilicate, which are machinable and bondable after hydrofluoric acid (HF) etching, has increased indications for bonded restorations.26,27 In the early 2000s, a high-performance polymer (HPP) block (Paradigm MZ100 CAD-CAM block; 3M) for computer-aided design and computer-aided manufacturing (CAD-CAM) was introduced, followed by HPP blocks from other manufacturers.28 Key properties of composite resin restorations include their low abrasiveness to antagonist teeth, better absorption of functional stresses, and better handling properties, including in situ reparability.29,30 In vitro accelerated fatigue studies have demonstrated that CADCAM composite resin OVs significantly increase the fatigue resistance when compared with ceramic OVs.10,11 However, data regarding the clinical performance for ceramic and composite resin OVs are lacking.

Enrollment

Therefore, the purpose of this randomized clinical trial was to evaluate the influence of CAD-CAM restorative material (ceramic versus composite resin) on the clinical performance of ultrathin OVs. The null hypothesis was that material selection would not influence the clinical performance of ultrathin OVs.

MATERIAL AND METHODS

This randomized, parallel-group, clinical trial was conducted in the Department of Prosthodontics and Dental Materials of the School of Dentistry of the Federal University of Rio de Janeiro (UFRJ). The study was approved by the Research Ethics Committee of the Hospital Universitário Clementino Fraga Filho at the UFRJ (protocol: 04874713.3.0000.5257) and registered at clinicaltrials.gov (NCT03112278). Details of participant allocation and follow-up are presented in a CONSORT flow diagram (Figure 2).31

Assessed for eligibility (n=67 patients)

Excluded (n=56 patients)

Not meeting inclusion criteria (n=52)

Had minimum wear, need only instructions (n=18)

Had extreme dental erosion including missing teeth and loss of VDO, need of traditional onlays, partial crowns (n=11)

Had bruxism only (2)

Missing teeth/no dental erosion (n=21)

Declined to participate (n=0)

Other reasons (n=4)

Randomized (n=11 patients, 60 teeth)

Allocated to intervention e.max CAD (n=6 patients, 24 teeth)

Received allocated intervention (n=24 teeth)

Lost to follow-up (n=0 patient)

Discontinued intervention (n=0 patient)

Allocated to intervention lava ultimate (n=5 patients, 36 teeth) Received allocated intervention (n=36 teeth)

Analysed (n=24 restorations)

Excluded from analysis (n=0)

situation,thetrialrestorationswereremoved,andthe thinnestareasweremeasuredandmappedinthemouth withpencilmarks).Anaverageocclusalclearanceof0.4to 0.6mm(centralgroove)to1.0to1.3mm(cusptips)was

Lost to follow-up (n=0 patient)

Discontinued intervention (n=0 patient)

Analysed (n=36 restorations)

Excluded from analysis (n=0)

Lithiumdisilicaterestorationswere firstcrystalized, thencharacterized(IPSe.maxCeramShadeandEssence; IvoclarAG),andthenglazed(IPSe.maxCeramGlaze PasteFluo;IvoclarAG)inaceramicfurnace(Programat

Figure 2. CONSORT 2010 flow diagram showing participant recruitment and follow-up up to 3 years. CONSORT, consolidated standards of reporting trials.

Figure2. CONSORT2010 flowdiagramshowingparticipantrecruitmentandfollow-upupto3years.CONSORT,consolidatedstandardsofreporting trials.

Between October 2013 and April 2017, 60 posterior teeth in 11 participants (8 men and 3 women) were restored with 24 ceramic and 36 composite resin ultrathin OVs. The mean participant age was 30.4 years (range, 23.5 to 38.2 years). The sample size was calculated based on the expected difference in survival of composite resin and ceramic of 70%, a power of 0.8, and a significance level of 0.05 (Select Statistical Services). In a previous in vitro study, ultrathin OVs fabricated with MZ100 and e.max CAD presented a survival rate of 90% and 20%, respectively, when subjected to loads of 800 N.11

Participants had been referred by the university clinics and by practitioners from both public and private services as a result of an advertising campaign with flyers posted around the university campus and direct communication with dental care providers. Randomization was performed by a computerized random number generator. Given the specific aspects involving the fabrication of the restorations, the blinding of operators (L.H.S. and T.H.R.) was not possible. However, participants and evaluators were not aware of the material assignment. Written informed consent was provided by each participant. All the dental treatment, directly or indirectly related to this study, was carried out at no cost to the participants.

Inclusion criteria were a minimum age of 14 years presenting localized or generalized advanced erosive wear (hard tissue loss >50% of the occlusal surface) according to the basic erosive wear examination (BEWE) score system, with good oral hygiene, without active periodontal or pulpal diseases, and willingness to wear an occlusal device upon completion of the restorative treatment.32 Dentin hypersensitivity associated with dentin exposure subsequent to active erosion was not a reason for exclusion. Exclusion criteria included minimal dental wear requiring only direct composite resin restorations or severe dental wear requiring thicker restorations, such as traditional onlays. Nonvital teeth and the absence of antagonist teeth were also reasons for exclusion.

The participants were initially counseled regarding behavioral risk factors and the changes necessary to prevent the progression of their erosion. Nightguard vital bleaching (Opalescence 10%; Ultradent Products, Inc) was provided when indicated and at the participants’ request. Cavitated carious lesions and noncarious cervical lesions (NCCLs) were restored with a direct composite resin (IPS Empress Direct; Ivoclar AG).

An additive diagnostic waxing was provided for all participants from single tooth to complete arch treatments and was used

Figure 3. A: Severe erosion of 30-year-old participant possibly associated with combination of intrinsic and extrinsic acids. First molar more affected on occlusal surface while premolars on buccal. B: Preparation driven by trial restoration (Protemp 4; 3M ESPE).

C: Preparation completed. D: Immediate dentin sealing (OptiBond FL; Kerr Corp). E and F: Occlusal and buccal views (slightly opened mouth). Note excellent tooth-restoration blending (ultrathin OVs on first molaree.max CAD A2 HT) on both occlusal and buccal views.

NCCLs on first mandibular molar and maxillary and mandibular premolars restored with direct composite resin (Empress Direct; Ivoclar AG). NCCLs, noncarious cervical lesions.

to position silicone guides intraorally for fabricating trial restorations, selective preparation, and interim restorations. The diagnostic waxing also served as the blueprint for the use of the Biogeneric Copy function in the CAD software program (CEREC inLab v4.0.2; Dentsply Sirona) to generate the definitive restorations. The complete sequence has been described in depth in clinical reports by Schlichting et al and Resende et al, including the use of bilaminar veneers in the anterior dentition (combination of palatal composite resin and labial ceramic veneers) when indicated in complete mouth treatments.13,14

The teeth were selectively reduced with tapered diamond rotary instruments (850,314,023; Komet) either through the trial restorations (Figures 3A, 3B) or directly (in this situation, the trial restorations were removed, and the thinnest areas were measured and mapped in the mouth with pencil marks). An average occlusal clearance of 0.4 to 0.6 mm (central groove) to 1.0 to 1.3 mm (cusp tips) was generated for the ultrathin OVs.13,14 Under dental dam, all areas of exposed dentin were immediately sealed (Figure 3C, D) using a 3-step etch-and-rinse dentin bonding system (OptiBond FL; Kerr Corp).33-36 The diagnostic waxing was scanned first for correlation (Cerec Bluecam; Dentsply Sirona), and the prepared teeth were then scanned.

the restorations were designed by correlating the diagnostic waxing with the preparations. The ultrathin OVs were milled from a lithium disilicate ceramic (e.max CAD HT; Ivoclar AG) or a composite resin (LAVA Ultimate HT; 3M ESPE). The restorations were inspected for cracks or chips from the milling process. The composition and the batch number of the materials are listed in Table 1.

Lithium disilicate restorations were first crystalized, then characterized (IPS e.max Ceram Shade and Essence; Ivoclar AG), and then glazed (IPS e.max Ceram Glaze Paste Fluo; Ivoclar AG) in a ceramic furnace (Programat P300; Ivoclar AG) according to the manufacturer instructions. The 3 steps were conducted separately. The composite resin restorations were characterized (Kolor + Plus; Kerr Corp) and then polished mechanically (Jiffy Brush; Ultradent Products, Inc).

The restorations were delivered without local anesthesia.23

The intaglio surface of the ceramic restorations was etched with 10% hydrofluoric acid (Dentsply Sirona) for 20 seconds. After rinsing under tap water for 20 seconds, the restorations were subjected to postetching cleaning using phosphoric acid (Ultra-Etch; Ultradent Products, Inc) with a brushing motion for 60 seconds, followed by air-water spray cleaning for 30 seconds. After air-drying, the intaglio surfaces were silanated with a brushing motion for 20 seconds (Monobond Plus; Ivoclar AG), air dried, and heat dried at 68 C for about 5 minutes (Calset; AdDent Inc). The same protocol was used

Figure3. A,Severeerosionof30-year-oldparticipantpossiblyassociatedwithcombinationofintrinsicandextrinsicacids.Firstmolarmoreaffectedon occlusalsurfacewhilepremolarsonbuccal.B,Preparationdrivenbytrialrestoration(Protemp4;3MESPE).C,Preparationcompleted.D,Immediate dentinsealing(OptiBondFL;KerrCorp).EandF,Occlusalandbuccalviews(slightlyopenedmouth).Noteexcellenttooth-restorationblending (ultrathinOVson firstmolar e.maxCADA2HT)onbothocclusalandbuccalviews.NCCLson firstmandibularmolarandmaxillaryandmandibular premolarsrestoredwithdirectcompositeresin(EmpressDirect;IvoclarAG).NCCLs,noncariouscervicallesions.

By using the design tools of the CAD software program (CEREC InLab v4.0.2; Dentsply Sirona) set in Biogeneric Copy,

Table1. Brandnames,manufacturers,class,composition,andbatchnumbersofmaterialsused

OptiBondFLKerrCorp Etch-and-rinse3-stepadhesive system

Primer:HEMA,ethanol,GPDM,MMEP,water,CQ, BHT

Adhesive:TEGDMA,UDMA,GDMA,HEMA,BisGMA, filler,CQ,approximately48wt% filled

PorcelainetchUltradentProducts,IncHydrofluoricacid Buffered9%hydrofluoricacid

MonobondPlusIvoclarAG Universalprimer Ethanol,3-trimethoxysilylpropylmethacrylate, methacrylatedphosphoricacidester

FiltekZ100A1/A23MESPE

e.maxCADHTA1/ A2 IvoclarAG

Micro-hybridcompositeBIS-GMA,TEGDMA,zirconia/silica fillers

Lithiumdisilicateglass-ceramicSiO2,Li2O,K2O,P2O5,ZnO2,Al2O3,MgO,and coloringoxides

IPSe.maxCeram GlazePasteFluo IvoclarAG Glaze Oxides,glycerine,butandiol,poly(vinyl pyrrolidone)

IPSe.maxCeram StainandGlaze Liquid

IvoclarAG Diluent Butandiol,pentandiol

IPSe.maxCeram Essence IvoclarAG Stain Oxides

LavaUltimateHT A1/A2/A3 3MESPE

Nanoparticulateprepolymerized resincomposite

EmpressDirectIvoclarAG Nanohybrid

minutes(Calset;AdDentInc).Thesameprotocolwas usedforthecompositeresinrestorations,exceptthat airborne-particleabrasionwith50-mmaluminaoxide

Bis-GMA,Bis-EMA,UDMA,TEGDMA,silica particles(20nm);zirconiaparticles(4to11nm); nanoparticleclusters

Bis-GMA,UDMA,TCDD,bariumalumina fluorosilicateglass,mixedoxide,ytterbium trifluoride

4788192

507351

T29123

N414951

R77046,T24176/R81821,T28586

T45071

T44225

S00854

N574684/N814642

R65565

fittingsurfacesof therestorationandtoothandleftunpolymerizedand

4 Crack’slengthgreaterthanorequalto2mmandinvolvingthesurfaceof therestorationand/orchippingfracturesaffectingmarginalquality;bulk fractureswithpartialloss(lessthan1/3ofrestoration)

Table2. Listofcriteria(modifiedUSPHSadaptedforthisstudy)usedforclinicalobservationsofultrathinocclusalveneers

for the composite resin restorations, except that airborne-particle abrasion with 50mm alumina oxide (Bio-Art) at 0.2 MPa and air-water spray cleaning for 30 seconds were used instead of the hydrofluoric etching step. Under dental dam, the tooth preparations were airborne-particle abraded and etched for 30 seconds with 37.5% phosphoric acid (Ultra-Etch; Ultradent Products, Inc), rinsed, and dried. Adhesive resin (OptiBond FL, bottle 2; Kerr Corp) was applied to both fitting surfaces of the restoration and tooth and left unpolymerized and protected from direct light. The luting material (Filtek Z100; 3M ESPE) was preheated to 68 C (Calset) and applied to the tooth, and the OVs were seated, followed by the removal of the excess composite resin and initial light polymerization. Each surface was exposed at 1000 mW/cm2 (Valo; Ultradent Products, Inc) for 60 seconds (20 seconds per surface, repeated 3 times). The margins were covered with an oxygen blocker (K-Y Jelly; Johnson & Johnson) and light polymerized for an additional period of 20 seconds. Minimal or no occlusal adjustment was necessary. In the following appointment, margins were finished and polished with diamond ceramic polishers (W16Dg, W16Dmf, and W16D; EVE Diapol; EVE Ernst Vetter GmbH) and silicon carbideeimpregnated rubber polishers (Jiffy; Ultradent Products, Inc).

The participants were evaluated approximately 1 week after restoration delivery and then once a year. They had been advised to call immediately in case of problems. The restorations and teeth were assessed by 2 experienced independent examiners (A.R.S. and I.C.C.), calibrated before the baseline assessment. Dental mirrors (Singlesided #5; Hu-Friedy), explorers (Double-ended EXD5; Hu-Friedy), and periodontal probes (PCPUNC156; Hu-Friedy) aided vision, tactile discrimination, and measuring, respectively. Transillumination (Microlux; AdDent) was used for crack detection. Moisture control was achieved with cotton rolls and suction and compressed air. The restorations were evaluated according to the modified United States Public Health Service (USPHS) criteria. Failure was considered whenever a restoration received a score 4 or 5 (Table 2). Restorations graded 4 were considered unacceptable but still repairable, while restorations graded 5 were considered failures with immediate need of replacement.37 The percentage of agreement of scores was 84.1% (kappa coefficient=0.42). Discrepancies were then resolved by consensus.

The data were analyzed with a statistical software program (IBM SPSS Statistics for Macintosh, v27.0; IBM Corp). Time to failure was the event of interest. Restorations not presenting failure at the final recall were censored. Kaplan-Meier survival probabilities, standard errors, and 95% confidence interval were estimated for the 2 restorative materials. Differences in survival between the groups were assessed with the Mantel-Cox log rank test (a=.05). A nonparametric test (Mann-Whitney U) was applied for the qualitative evaluation of the data.

The participants were initially counseled regarding behavioral risk factors and the changes necessary to prevent the progression of their erosion.

RESULTS

The mean follow-up time was 27.1 months (SD, 6.1 months; range, 9.6 to 35.6 months), and no participants were lost to follow-up. At the final follow-up, 16 OVs had been evaluated 4 times (baseline, first year, second year, and third year), 42 OVs were evaluated three times (baseline, first year, and second year), and 2 OVs were evaluated 2 times (baseline and first year). Of these 60 OVs, 9 were bonded to first premolars, 12 to second premolars, 23 to first molars, and 16 to second molars. The average thickness of the restorations was 0.55 mm at the central groove, 0.89 mm at the internal cusp slope, 1.00 mm at the cusp tip, and 0.78 mm at the marginal ridge.

The survival estimate was not statistically significantly different (P=.124, Cl=95%) for e.max CAD compared with Lava Ultimate (100% versus 84.7%; SE, 0.065%) (Figure 4). The pooled Kaplan-Meier 3-year survival rate for ultrathin OVs was 88.4% (SE, 0.054%) (Figure 5).

In the Lava Ultimate group, 5 partial failures (all score 4) were observed as chipping fracture affecting the margin integrity. The first event occurred 8.3 months after baseline on the buccal margin of a mandibular left first premolar (Figure 6A). The second failure was identified on a mandibular right first molar, with a chip on the distal buccal cusp. A third fracture was also observed in the same patient, same quadrant, on the distal marginal ridge of a first premolar. Both fractures happened 13 months after baseline (Figure 6B). A fourth chip was seen 23.5 months after baseline on a maxillary left second molar in another patient with loss of the fragment of the mesial lingual cusp. The last event occurred

veneer material Lava ultimate e.max CAD Lava ultimate-censored e.max CAD-censored

Group Occlusal veneers Occlusal veneers-censored

Survivalestimateforceramicandresinultrathinocclusalveneers(88.4%,eventsn=5)asfunctionoftime.

occlusalcompositeresinthatwasreplacedowingto hypersensitivity.Thistoothwascensoredforthe Kaplan-Meiersurvivalanalysis.Regardless,overall patientresponsewasoptimalwithallparticipants, except1e.maxOV(score3),showingentiresatisfaction (score1).

DISCUSSION

Totheknowledgeoftheauthors,thisisthe

domizedclinicaltrialonOVs,whichconstitutesavaluablestepafteroriginalinvitrostudiespublishedin 2010,10 2011,11 and2012.12 Thenullhypothesisthatno

THEJOURNALOFPROSTHETICDENTISTRY Schlichtingetal occlusalcompositeresinthatwasreplacedowingto hypersensitivity.Thistoothwascensoredforthe Kaplan-Meiersurvivalanalysis.Regardless,overall patientresponsewasoptimalwithallparticipants, except1e.maxOV(score3),showingentiresatisfaction

domizedclinicaltrialonOVs,whichconstitutesavaluablestepafteroriginalinvitrostudiespublishedin

Figure 4. Survival estimate for e.max CAD (100%, events n=0) and Lava Ultimate (84.7%, events n=5) ultrathin occlusal veneers as function of time.

veneer material

ultimate e.max CAD Lava ultimate-censored e.max CAD-censored

Figure4. Survivalestimatefore.maxCAD(100%,eventsn=0)andLavaUltimate(84.7%,eventsn=5)ultrathinocclusalveneersasfunctionoftime.

Figure5.

Figure4. Survivalestimatefore.maxCAD(100%,eventsn=0)andLavaUltimate(84.7%,eventsn=5)ultrathinocclusalveneersasfunctionoftime.

Figure5. Survivalestimateforceramicandresinultrathinocclusalveneers(88.4%,eventsn=5)asfunctionoftime.

Figure 5. Survival estimate for ceramic and resin ultrathin occlusal veneers (88.4%, events n=5) as function of time.

at 30.8 months, on a mandibular right second premolar with a slight chip at the buccal margin. All these fractures were repaired with direct composite resin (IPS Empress Direct; Ivoclar AG) under dental dam isolation. Most of the repaired restorations survived until the last follow-up, except the mandibular right first molar that had to be repaired again at 30.8 months on the same distal buccal cusp.

The performance of restored teeth was also clinically assessed by using the USPHS criteria (Table 2). Comparisons between baseline and the last follow-up revealed significant differences between

groups only for the first criterion (Table 3). Composite resin OVs exhibited more surface roughness changes than ceramic ones (Mann-Whitney U=230, P=.003) (Figures 7A, 7B). Eight of the Lava Ultimate restorations were scored 3 because of increased roughness located at the occlusal contacts. The other criteria did not have statistically significant differences. Surface/marginal staining and color match were slightly better in the ceramic group, but not statistically significant (Mann-Whitney U=468, P=.809 and U=318.5, P=.280). Postoperative sensitivity transient pain elicited under stimulation with a cold spray (Endo Ice; Coltène) was present

at baseline in 8 teeth and at the last follow-up in 7 teeth. Recurrence of erosion or secondary caries was not detected.

One tooth with an e.max CAD OV developed an irreversible pulpitis requiring endodontic treatment. The endodontic access was performed through the OV, which was later replaced. Originally, before the preparation and delivery of the OV, this tooth presented a large NCCL that was restored as well as a large class 1 occlusal composite resin that was replaced owing to hypersensitivity. This tooth was censored for the Kaplan-

Figure 6. A: Chipping fracture of ultrathin composite OV on mandibular left first premolar. Note that crack started from occlusal contact (wear facet from opposing canine: blue arrow). B: Chipping fractures on mandibular right first molar (distobuccal cusp) and first premolar (distal marginal ridge). Observe minor marginal staining in distolingual aspect on second premolar.

Figure 7. A: Occlusal view of ultrathin composite resin OVs (premolars and molars) at baseline. B: Same restorations 31 months later. Note increased roughness located at occlusal contacts. OVs, occlusal veneers.

strengthcouldremainhigherthanthatofLavaUltimate,40 explainingtheimprovedbehaviorofe.maxCAD intheareasofhighmechanicalstress.However,this

findingwillneedtobecon firmedwithasubsequent clinicaltrial,whichisunderway.Additionally,asunderlinedbyHecketal,8 thepreparedteethdisplayeda

Table3. USPHSevaluationsoftheultrathinocclusalveneersatbaselineand

Meier survival analysis. Regardless, overall patient response was optimal with all participants, except 1 e.max OV (score 3), showing entire satisfaction (score 1).

DISCUSSION

To the knowledge of the authors, this is the first randomized clinical trial on OVs, which constitutes a valuable step after original in vitro studies published in 2010, 2011, and 2012.10-12 The null hypothesis that no significant difference in terms of clinical survival would be found between the 2 materials evaluated in this study for OVs was accepted. The overall survival rate of 88.4% up to 36 months was considered clinically acceptable.

The participant enrollment process was influenced by the strict inclusion criteria and was slower than expected, taking almost 3.5 years to complete the sample size of 11 participants. In addition, some participants presented with multiple worn teeth with an indication for ultrathin OVs. During the planning of the study, a split-mouth design or mixing materials in the same participants was considered. However, the potential for unbalanced wear between different restorative materials in opposing arches or sides of the mouth led to rejection of this study design. The participants and evaluators were blinded except for the 2 operators. The average thickness of the restorations in both groups was similar, suggesting that nonblinded operators had minimum impact in the preparation and design phases, a key aspect in the performance of the ultrathin OVs. Therefore, the internal validity of the study was considered to be acceptable despite the particularities of this RCT. Regarding external validity, the protocol was executed by experienced

operators in a university setting under controlled conditions; however, practitioners familiar with conservative techniques and adhering to bonding protocols should be able to replicate the restorations.

All failures in the composite resin group (Lava Ultimate) occurred under the criteria “fracture of restoration.” These 5 chips were limited to the restoration margins without involvement of the remaining tooth structure and rated as unacceptable (score 4), but reparable, which is essential for the long-term survival of the remaining sound tooth structure. The results of the present study conflicted with the in vitro findings by Magne et al and Schlichting et al, who reported that CAD-CAM composite resin ultrathin OVs (Paradigm MZ100) demonstrated increased fatigue resistance when compared with ceramic ultrathin OVs (e.max CAD and Empress CAD), possibly because of differences between MZ100 and Lava Ultimate.10,11 At the time of this randomized clinical trial, MZ100 was not available in Brazil, where the study was conducted. Lava Ultimate, however, had been recently introduced to the Brazilian market with supposedly better mechanical properties than its predecessor MZ100.38,39 Nevertheless, the original indications for Lava Ultimate were subsequently restricted by the manufacturer, who limited its use to partial restorations (inlays and onlays) and recommended only adhesive luting. Additionally, for the original in vitro studies using MZ100 OVs,the simulated masticatory forces were applied vertically by the closedloop servo-hydraulic simulator to reproduce a highly standardized tripodic contact, but which did not reproduce the typical cusp-tip fossa-tomarginal ridge relationship and did not simulate eccentric movements during

parafunction.10,11 Many participants in the present study reported a history of bruxism, including one of those who had experienced restoration failures. This participant only started wearing his nightguard after 13 months, which could have made the restorations more vulnerable to the parafunction during this period. The low prevalence of cracks in the central groove area (Table 3) suggests that extreme occlusal loads (for example, higher than 600 N) were not reached in the ceramic group and likely not in the composite resin group, in contrast with the in vitro studies when higher loads (up to 1400 N) repeatedly induced cuspal flexure.11,12 In contrast, clinical peripheral fractures (chips) were in part a product of repetitive functional or parafunctional loading. As demonstrated by Belli et al, composite resins and ceramics are affected by mechanical aging with similar degradation of their mechanical properties.40 However, because e.max CAD has a higher initial flexural strength, its residual fatigue strength could remain higher than that of Lava Ultimate, explaining the improved behavior of e.max CAD in the areas of high mechanical stress.40 However, this finding will need to be confirmed with a subsequent clinical trial, which is underway. Additionally, as underlined by Heck et al, the prepared teeth displayed a dentin core with a relative low elastic modulus (16 MPa) surrounded by an enamel rim with a significant higher elastic modulus (80 GPa).8 From a biomimetic perspective, this restorative scenario would benefit from a material with an elastic modulus (glass-ceramic approximately 65 GPa) similar to that of enamel. The dissipation of high occlusal loads over the enamel ring area would be less natural for a composite resin such as Lava Ultimate with a lower modulus (approximately 13 GPa).

The luting procedure included immediate dentin sealing (sealing the freshly cut dentin with a dentin bonding agent directly after tooth preparation, before the definitive impression) associated with the application of a preheated light-polymerized restorative composite resin material as a luting agent.24 This has been considered the state of the art in bonding indirect restorations, as demonstrated by Gresnigt et al in a recent clinical trial.41

Increased surface roughness at the occlusal contacts was observed in the composite resin OVs (8 of 31, score 3) (Table 3). The increased roughness was detected under air drying and using magnification (Figure 7). Saratti et al reported a similar pattern of pitted surface in indirect composite resin restorations including a CAD-CAM Lava Ultimate overlay with evidence of occlusal surface degradation from a combined process of matrix cracking (cyclic mechanical fatigue) and matrixfiller interface debonding (hydrolysis from the biofilm).42 This phenomenon should not be overlooked since microcracks are likely to be associated and eventually become macrocracks. No restoration was repolished since it would have changed the occlusion scheme.

Slight deviation from the ideal anatomic form (score 2) was often perceived between baseline and the final follow-up regardless of the material type and could be attributed to the manufacturing process; grinding tools cannot replicate the sophisticated anatomy of the occlusal fissures. However, this is a limitation that does not significantly compromise masticatory function. In fact, it resembles natural teeth when fissures are sealed, and it protects the occlusal surface from harmful tensile stress

concentrations.43 Further studies are required to assess the clinical performance of ultrathin OVs with endodontic treated teeth as well as to evaluate newly marketed CAD-CAM blocks.

CONCLUSIONS

Based on the findings of this randomized clinical trial, the following conclusions were drawn:

1. The survival rates of ultrathin bonded OVs used to treat posterior teeth subjected to erosive wear, observed up to 36 months, demonstrated high patient satisfaction and provided favorable performance, with a slight advantage for ceramic (e.max CAD) than for composite resin (Lava Ultimate) that was not statistically significant.

2. No restorations were lost. Failures were only partial and easily and successfully repaired up to the last evaluation.

3. Slight surface degradation at the occlusal contact area of composite resin OVs was observed.

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9. Attin T, Filli T, Imfeld C, Schmidlin PR. Composite vertical bite reconstructions in eroded dentitions after 5.5 years: A case series. J Oral Rehabil 2012;39:73-9.

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11. Schlichting LH, Maia HP, Baratieri LN, Magne P. Novel-design ultra-thin CAD/ CAM composite resin and ceramic occlusal veneers for the treatment of severe dental erosion. J Prosthet Dent 2011;105:217-26.

12. Magne P, Stanley K, Schlichting LH. Modeling of ultrathin occlusal veneers. Dent Mater 2012;28:777-82.

13. Schlichting LH, Resende TH, Reis KR, Magne P. Simplified treatment of severe dental erosion with ultrathin CAD-CAM composite occlusal veneers and anterior bilaminar veneers. J Prosthet Dent 2016;116:474-82.

14. Resende TH, Reis KR, Schlichting LH, Magne P. Ultrathin CAD-CAM ceramic occlusal veneers and anterior bilaminar veneers for the treatment of moderate dental biocorrosion: a 1.5-year followup. Oper Dent 2018;43:337-46.

15. Sasse M, Krummel A, Klosa K, Kern M. Influence of restoration thickness and dental bonding surface on the fracture resistance of full-coverage occlusal veneers made from lithium disilicate ceramic. Dent Mater 2015;31:907-15.

16. Yazigi C, Kern M, Chaar MS. Influence of various bonding techniques on the fracture strength of thin CAD/ CAM-fabricated occlusal glass-ceramic veneers. J Mech Behav Biomed Mater 2017;75:504-11.

17. Krummel A, Garling A, Sasse M, Kern M. Influence of bonding surface and bonding methods on the fracture resistance and survival rate of fullcoverage occlusal veneers made from lithium disilicate ceramic after cyclic loading. Dent Mater 2019;35:1351-9.

18. Edelhoff D, Ahlers MO. Occlusal onlays as a modern treatment concept for the

reconstruction of severely worn occlusal surfaces. Quintessence Int 2018;49:52133.

19. Scherrer SS, De Rijk WG, Belser UC. Fracture resistance of human enamel and three all-ceramic crown systems on extracted teeth. Int J Prosthodont 1996;9:580-5.

20. Krämer N, Lohbauer U, Frankenberger R. Adhesive luting of indirect restorations. Am J Dent 2000;13:60D-76D.

21. Pashley EL, Comer RW, Simpson MD, Horner JA, Pashley DH, Caughman WF. Dentin permeability: sealing the dentin in crown preparations. Oper Dent 1992;17:13-20.

22. Paul SJ, Schärer P. The dual bonding technique: a modified method to improve adhesive luting procedures. Int J Periodontics Restorative Dent 1997;17:536-45.

23. Magne P. Immediate dentin sealing: a fundamental procedure for indirect bonded restorations. J Esthet Restor Dent 2005;17:144-55.

24. Magne P, Kim TH, Cascione D, Donovan TE. Immediate dentin sealing improves bond strength of indirect restorations. J Prosthet Dent 2005;94:511-9.

25. Callister WD Jr. Composites. In: Callister WD Jr, editor. Materials science and engineering: an introduction. 4th ed. New York: John Wiley & Sons; 1997. p. 510-48.

26. Tinschert J, Natt G, Mautsch W, Augthun M, Spiekermann H. Fracture resistance of lithium disilicate-, alumina-, and zirconia-based three-unit fixed partial dentures: a laboratory study. Int J Prosthodont 2001;14:231-8.

27. Beuer F, Schweiger J, Edelhoff D. Digital dentistry: an overview of recent developments for CAD/CAM generated restorations. Br Dent J 2008;204: 505-11.

28. Rusin RP. Properties and applications of a new composite block for CAD/CAM. Compend Contin Educ Dent 2001;22:3541.

29. Kunzelmann KH, Jelen B, Mehl A, Hickel R. Wear evaluation of MZ100 compared to ceramic CAD/CAM materials. Int J Comput Dent 2001;4:171-84.

30. Magne P, Perakis N, Belser UC, Krejci I. Stress distribution of inlay-anchored adhesive fixed partial dentures: a finite element analysis of the influence of restorative materials and abutment preparation design. J Prosthet Dent 2002;87:516-27.

31. Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, et al. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c869.

32. Bartlett D, Ganss C, Lussi A. Basic Erosive Wear Examination (BEWE):

a new scoring system for scientific and clinical needs. Clin Oral Investig 2008;12(Suppl 1):S65-8.

33. Tay FR, Pashley DH. Resin bonding to cervical sclerotic dentin: a review. J Dent 2004;32:173-96.

34. Zimmerli B, De Munck J, Lussi A, Lambrechts P, Van Meerbeek B. Longterm bonding to eroded dentin requires superficial bur preparation. Clin Oral Investig 2012;16:1451-61.

35. Magne P, Douglas WH. Porcelain veneers: dentin bonding optimization and biomimetic recovery of the crown. Int J Prosthodont 1999;12:111-21.

36. Dietschi D, Monasevic M, Krejci I, Davidson C. Marginal and internal adaptation of class II restorations after immediate or delayed composite placement. J Dent 2002;30:259-69.

37. Hickel R, Roulet JF, Bayne S, Heintze SD, Mjör IA, Peters M, et al. Recommendations for conducting controlled clinical studies of dental restorative materials. Science Committee Project 2/98–FDI World Dental Federation study design (Part I) and criteria for evaluation (Part II) of direct and indirect restorations including onlays and partial crowns. J Adhes Dent 2007;9(Suppl 1):121-47.

38. Johnson AC, Versluis A, Tantbirojn D, Ahuja S. Fracture strength of CAD/CAM composite and composite-ceramic occlusal veneers. J Prosthodont Res 2014;58:107-14.

39. Egbert JS, Johnson AC, Tantbirojn D, Versluis A. Fracture strength of ultrathin occlusal veneer restorations made from CAD/CAM composite or hybrid ceramic materials. Oral Sci Int 2015;12:53-8.

40. Belli R, Geinzer E, Muschweck A, Petschelt A, Lohbauer U. Mechanical fatigue degradation of ceramics versus resin composites for dental restorations. Dent Mater 2014;30:424-32. Erratum in: Dent Mater 2014;30:1204.

41. Gresnigt MMM, Cune MS, Schuitemaker J, van der Made SAM, Magnef P, Özcang M, et al. Performance of ceramic laminate veneers with immediate dentine sealing: An 11 year prospective clinical trial. Dent Mater 2019;35:104252.

42. Saratti CM, Rocca GT, Durual S, Lohbauer U, Ferracane JL, Scherrer SS. Fractography of clinical failures of indirect resin composite endocrown and overlay restorations. Dent Mater 2021;37:e341-59.

43. Magne P, Belser UC. Rationalization of shape and related stress distribution in posterior teeth: a finite element study using nonlinear contact analysis. Int J Periodontics Restorative Dent 2002;22:425-33.

Corresponding author:

Dr Luís Henrique Schlichting

The University of North Carolina at Chapel Hill, Adams School of Dentistry

Division of Comprehensive Oral HealthOperative Dentistry, 441 Brauer Hall-Campus Box 7450, Chapel Hill, NC 27599-7450; Email: luishschlichting@gmail.com

Acknowledgments

The authors thank FAPERJ for the grant No. E-26/112.046/2012; Federal University of Rio de Janeiro for the inLab MC XL milling unit; Dr. Silvana Marques Miranda Spyrides (then Chair, Department of Prosthodontics and Dental Materials, School of Dentistry, Federal University of Rio de Janeiro) for her support on building the CAD-CAM laboratory as well as the buying process of the milling unit MCXL through the university; Sirona Brazil for the discount for the Cerec System and for Hugo stool; Mr Holger Kappler (Kappler, Germany), for the discount for the Cerec MCXL cabinet; Mr Herbert Mendes and Dr Camila Madruga (Ivoclar, São Paulo, Brazil) for Variolink Veneer Kit and Empress Direct and for the discount on IPS e.max CAD blocks, owen Programat P300 and other dental materials from Ivoclar; Mr Rodrigo Negreiros (3M ESPE, Brazil) for Protemp 4; Dr Joshua Friedman (AdDent, Danbury, Conn) for Calset and Microlux; Dr Byoung Suh (Bisco Dental Products) for Pro-V Coat; Dr. Richard Tuttle (Ultradent) for Ultra-Etch, Ultrapak, Opalescence 10%, Jiffy Kit; Ms Leigh Anne Jones (territory manager, Kerr Restoratives) for OptiBond FL and Kolor + Plus and Mr Arno Egon (Dental Design, Caxias do Sul, Brazil) for the diagnostic wax-ups; and Dr Marco Gresnigt for his important advice on the data analysis.

CRediT authorship contribution statement:

Luís Henrique Schlichting: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Resources, Data curation, Writing e original draft, Writing e review & editing, Supervision, Project administration, Funding acquisition. Tayane Holz Resende: Investigation, Resources, Data curation, Project administration. Kátia Rodrigues Reis: Investigation, Resources, Funding acquisition. Aline Raybolt dos Santos: Investigation, Funding acquisition. Ivo Carlos Correa: Investigation, Funding acquisition. Pascal Magne: Methodology, Writing e review & editing.

Copyright © 2022 by the Editorial Council for The Journal of Prosthetic Dentistry. https:// doi.org/10.1016/j.prosdent.2022.02.009

Member SPOTLIGHT

TDA Membership Drive is in Full Swing

e mem·ber·ship /’memb r,SHip/ noun

The fact of being a member of a group.

More than 8,800 members make up the Texas Dental Association. Each member is unique in background, education, and practice but share the same vision—to provide the best care for his or her patients. And, each member has a story.

Meet Dr Lauren Mauban of Austin. Dr Lauren Mauban lived in North Carolina most of her life but fell in love with Texas, specifically Austin, on a 2017 visit. After graduating from East Carolina University with a Bachelor of Science in biology and the Missouri School of Dentistry and Oral Health in 2021, she made the leap west.

“I wanted to move to a completely new city as a new grad and had heard great things about Austin even before I visited,” she says. “Austin is the place to be! Both in dentistry and lifestyle!”

Dr Mauban practices at Rose Dental Group and says that organized dentistry has given her a direction in the profession, allowing her to connect with dentists across the state and country to share clinical advice and information.

“Coming out of school and starting in a busy practice is a pretty stressful process,” she says. “Organized dentistry has allowed me to meet other dentists in the area and find true mentorship and share similar experiences in the profession, life in general, and life in dentistry.”

In dental school, she trained in a federally qualified health center in downtown St Louis, Missouri, which opened her servant’s heart to public health and serving her community. Coupled with her grandmother’s impactful stories of when she was a dentist in the Philippines, Dr Mauban has altruism in her blood. So, it was natural to volunteer at a TDA Smiles Foundation Texas Mission of Mercy event in April 2022 where she met TDA President Dr Duc “Duke” Ho.

From there, the wheels were in motion. Capital Area Dental Society (CADS) Past President Dr Shailee Gupta helped Dr Mauban become involved locally. According to the Capital Area’s executive director, Dr Mauban will start her service on the Board of Directors later in the year. She is currently chair of its study club.

“Being involved with CADS and attending my first local TDA Perks meeting has given me a voice in dentistry and my community, and I couldn’t be more grateful for that! When Dr Gupta asked me to serve on the CADS board, it was an easy decision for me to make.”

Though she’s at the beginning of her profession, she says it’s never too early to participate in organized dentistry. “If you’re worried about being a young or newer dentist, I can assure you that the members are extremely welcoming and make you feel comfortable right away. Organized dentistry is very inclusive and allows you to have a voice in your profession!”

Dr Mauban

Dr Douglas Bogan, Dr Mauban, and Dr Shwetha Ramanathan volunteer at TMOM in Marble Falls in February 2023.

Dr Danesa Nunez (center), her assistant Savanna (left), and Dr Mauban volunteer at the TMOM in Garland.

Practices For Sale

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$430K HARLINGEN OPPORTUNITY: Great GP located in a busy shopping center. The practice is a mix of FFS/PPO and has a very strong patient base. The practice currently runs on 4 doctor, and 4 hygiene days a week with collections of $430K. The doctor refers out difficult oral surgery, endo and implants. You could expect the first year’s earnings to exceed $130K on a relaxed workweek. Add more days and take the practice to the next level. Opportunity ID: TX-7129

MULTIPLE LOCATIONS: Is your credit or previous bankruptcy preventing you from ownership in a practice? AFTCO has practice buy-in opportunities throughout the country! AFTCO has teamed up with a private company that is offering a unique purchase opportunity where you have 40% ownership, 100% seller financing, quarterly distributions and a 50% purchase price forgiveness after 24 months. This is a great opportunity to have ownership in a practice and not worry about the day-to-day operations allowing you to focus on clinical dentistry. Opportunity ID: TX-7637

Go to our

While no one likes to think about it, things do ha

While no one likes to think about do happen and it’s always important to be prepared.

Knowing your practice’s value can make the diff ’s can difference between selling your practice or having it become unsella your or it become unsellable. That is why practice owners should have an up-to-date prac owners should have an practice valuation.

A Henry Schein Dental Practice Transitions v ransitions valuation considers both tangible and intangible assets of considers both and assets of the practice and can provide the many key factors which influenc can the many factors which influence the practice’s value.

To get started on your practice valuat To get started on your valuation or schedule a complimentary consulta or schedule a consultation, give us a call at 866-335-2947.

We are pleased to announce...

We are please to have represented all parties in these transitions.

& David C. Sun, D.D.S.

Jini P. Kuruvilla, D.D.S.

Robert C. Stewart III, D.D.S.

Veronica Y. Chen, D.D.S.

TDA Meeting Preview

HPV and Oral Cancer: Fear, Facts, and the Future

Event: HPV and Oral Cancer in Young Patients: What Have We Learned?

Speaker: Thomas Schlieve, DDS, MD

Date: Friday, May 5

Time: 1:30 PM - 4:00 PM

Code: F26

Speaker

Thomas Schlieve, DDS, MD

UT Southwestern Medical Center

Texas Health- Dallas Presbyterian Medical Center, Parkland Memorial Hospital

Correspondence: Thomas Schlieve

6333 Forest Park Blvd, Dallas, TX 75390-9193

Thomas.Schlieve@utsouthwestern.edu

Ph: 214-645-3999 • Fax: 214-645-3989

Cell: 262-993-3432

The increasing rate of head and neck cancer is alarming. In 2005, approximately 29,000 oral cavity and pharyngeal cancers were documented in the United States. In 2015 that number rose to 48,000 and most recently it is estimated that there are 66,000 cases annually representing an increase of over 100% in just 15 years. These numbers are even more staggering when we consider the number of cases specific to the tongue and pharynx and when in comparison to other cancers, such as cervical cancer. It is estimated that there will be over 36,000 tongue and pharynx cancers this year, with over 26,000 of those cancers in males. Increases of 130% and 160% respectively. In contrast, cervical cancer has decreased from 9.7 cases per 100,000 people to 7.5 cases per 100,000 people during that same time period. Along with an overall increase in head and neck cancer, there has been a greater than 4-fold increase in oral squamous cell carcinoma in patients younger than 40 years of age (Figure 1,2). An investigation into the cause of this drastic increase in cancer incidence is of paramount importance.

The history of human papillomavirus (HPV) in the head and neck regions began in 1901 with the discovery of transmission of oral warts between individuals. Further research on HPV was driven by its infection of cervical tissues and the discovery of koilocytic atypia as a sign of HPV infection. It was not until 1989 that HPV16 DNA was noted in tonsillar squamous cell carcinoma, 2000 when the first causal associations of HPV and Head and Neck Cancer were reported, and 2010 when a survival advantage to HPV positive cancer was demonstrated. Since that time, our understanding of HPV infection, carcinogenesis, risk stratification, and treatment has evolved considerably.

Figure 1.

Left tongue squamous cell carcinoma in a less than 40-year-old female

Figure 2.

Right tongue squamous cell carcinoma in a less than 30-year-old male

In addition to the discovery of the connection between HPV and infection, the role of infection and inflammation in numerous cancer subtypes has been deciphered. In 1863, Rudolph Virchow first hypothesized that cancers could be driven by an inflammatory process and it is this observation that evolved into the current concept that the inflammatory microenvironment represents a risk factor for cancer development. It is accepted that infection with Hepatitis virus, Epstein-Barr virus, and Heliobacter Pylori bacteria can cause cancers of the liver, nasopharynx, and stomach respectively. Chronic inflammatory conditions such as Celiac disease, inflammatory bowel disease, chronic pancreatitis and gastric reflux can lead to cancers such as lymphoma, colon cancer, pancreatic cancer, and gastric cancer.

HPV is an epitheliotropic oncogenic double stranded circular deoxyribonucleic acid virus with over 120 different genotypes and only infecting humans. The larger group of papillomaviruses is one of the oldest known viruses with a history of some 330 million years. HPV causes both cutaneous and mucosal infection, with a specific subset of genetic types associated with the development of cancer (termed High Risk Subtypes). A much larger group of these viruses causes the “common” hand and foot warts that many people are familiar with or the oral papilloma that many dentists are accustomed to seeing (Figure 3). These visible lesions associated with HPV are not precursors to cancer or indicative of infection with one of the cancer-causing subtypes. It is important therefore to understand that there is no pre-malignant oral or throat lesion warning us to the presence of HPV infection and/or carcinogenesis in progress. Another important but often confusing feature of HPV-induced cancer is the very long latency period- the time from infection to cancer. Most individuals will contract HPV at a young age, becoming chronic carriers of the virus, and then develop their throat cancer some 30 years or more later. An HPV related cancer does not imply infidelity.

Cervical cancer, oropharyngeal cancer, penile cancer, anal cancer, vaginal cancer and vulvar cancer have all been associated with high-risk HPV infection and the percentage of these cancers attributable to HPV is on the rise as we develop improved methods of detection. If we know that PHV infection can lead to cancer, the medical miracle would be a medication, shot, IV infusion or other treatment that could prevent the infection and subsequent development of so many cancers. Fortunately, that medical miracle is already here in the form of the HPV vaccine.

The HPV vaccine has been in use since 2006. Systematic reviews of available data have demonstrated a high safety profile in over 60 million people. Vaccination has effectively decreased the rate of oral HPV infection, cervical HPV infection, and the precancerous changes associated with HPV infection.

Figure 3. Oral tongue papilloma due to low-risk HPV subtype

TDA Council on Ethics and Judicial Affairs

This article is a reprint of a previously published article. For citation purposes, please use the original publication details; Nichols K; Pappas R. The #ethics behind social media influencers in dentistry. J. Am. Dent. Assoc. 2022; 153(10):1010-1011. https://doi.org/10.1016/j.adaj.2022.07.008.

The #ethics behind social media influencers in dentistry

Kathleen Nichols, DDS, Renee Pappas, DDS

QI have engaged a social media influencer to promote my dental practice on various social media platforms. They have agreed to share messages and content regarding my practice in exchange for financial compensation, as well as for dental services. When my messages are shared under their byline, I have seen increases in patient engagement. The social media influencer was not a patient of record in my practice when I engaged them to share testimonials and other social media content. Later, the influencer became a patient through a services exchange agreement. Using the American Dental Association Principles of Ethics and Code of Professional Conduct (ADA Code) as a guide, are these arrangements ethical?

AAdvertising and promoting one’s practice through social media is not, per se, unethical. In fact, patients increasingly are turning to online reviews to assist in choosing a health care provider.1 Although the use of a social media influencer in marketing your practice may or may not include a “review” of services, being aware that patients are making choices on the basis of what they see on social media, you are obligated to adhere to principles of ethics and standards of professionalism. It may be helpful to understand what a social media influencer is before discussing the ethical considerations in using them as part of your marketing strategy. “Social media influencers are people who have large audiences of followers on their social media accounts, and they leverage this to influence or persuade this following to buy certain products or services.”2 The influencer creates impact through interactions and posts, usually regarding a specific topic.3 An influencer may disseminate content targeted toward those involved in their respective field, and they can also encourage dialogue and discussion regarding the content. “An influencer’s impact can be measured through connectedness (number of users following and users followed) and the effect the posts create in the topic community (likes, retweets, visibility).”3

The scenario described presents 2 potential ethically problematic issues: compensation to the influencer and the type of content that is being shared. If the influencer is merely sharing information about hours and services available, this likely does not present any ethical concerns, but if they are sharing “reviews” of services or product and procedure promotions, this may be more problematic. The California Dental Association Code of Ethics, for example, states that, “A dentist who compensates or gives anything of value to a representative of the press, radio, television or other communication medium in anticipation of, or in return for, professional publicity must make known the fact of such compensation in such publicity.”4 Even more problematic is if the reviews are of services that were provided as part of a quid pro quo exchange, wherein you provide the service at no cost so that the influencer will then favorably review the care and services received.

The preamble of the ADA Code states that the primary goal of all conduct must be the benefit of the patient.5 Applying this concept, the dentist must ensure that the patient’s best interests are at the forefront. For example, patients would benefit from promotions that would encourage dental health–related topics, such as frequency of visits to the dentist. All marketing efforts, including any posting from social media influencers, should reflect honesty, compassion, kindness, integrity, fairness, and charity.5 All social media content should reflect the dentist’s efforts to strive to do that which is right and good.5

Section 1 of the ADA Code, principle: Patient Autonomy (“self-governance”), would require that the patient is engaged in their treatment decisions.5 As such, when promoting specific procedures or products available in your office, it must be clear that each case is unique and specific criteria (such as periodontal health or occlusal function) must be individually evaluated to assist the patient in their decision-making process. When using an influencer on social media to promote one’s practice, photographs of a specific type of treatment are often included. In that case, it is necessary to safeguard the patient’s privacy according to Section 1 of the ADA Code.5

If a patient’s photograph is used in which they may be identified, they must give their informed consent to have their photo used in advance of the post, or it would be considered unethical and may be a violation of state or federal laws regarding patient privacy in health care. Certainly, a more ideal option would be to avoid using a photograph with any identifiable characteristics in the first place.

The principle of Patient Autonomy also obligates dentists to involve patients in making treatment decisions in a meaningful way.5 Many potential patients seeking options in esthetic dentistry may turn to social media platforms to acquire information before choosing which dental practice they will call to initiate a consultation for such treatment. Therefore, a dentist who is compensating someone to influence the choice of these patients can possibly compromise the patient’s best interests. Although internet searching may be efficient, a patient’s expectations can be altered greatly by means of the information they find online. This information may directly affect a patient’s autonomy in making important decisions about their treatment. Search engine optimization of a particular dental treatment or of a specific practice in their area may lead them to a website that directly affects decisions they make about their own treatment. In some instances, it may lead them to seek a second opinion from a dentist other than the one they are already seeing for oral health care. This is not necessarily unfavorable unless the treatment they are interested in having done on the basis of an internet search is not evidencebased. Therefore, it is especially important that the information posted is factual and accurate.6 Social media is a powerful tool that can educate potential patients, but it can also be misleading by means of falsely advertising a certain level of expertise simply because of the dentist’s prominent social media presence as a result of using influencer marketing.6 Patients may perceive influencers as experts or unbiased and, as such, could accept the information presented on social media without hesitation, thereby projecting specific results or opinions as appropriate for the specific patient or condition.

Section 2, principle: Nonmaleficence (“do no harm”) details the importance of a dentist keeping one’s skills and knowledge up to date, as well as avoiding interpersonal relationships that could impair their professional judgment or risk the possibility of exploiting the confidence a patient placed in them.5 Furthermore, the

The scenario described presents 2 potential ethically problematic issues: compensation to the influencer and the type of content that is being shared. If the influencer is merely sharing information about hours and services available, this likely does not present any ethical concerns, but if they are sharing “reviews” of services or product and procedure promotions, this may be more problematic.

influencers should never encourage treatments or products that are potentially harmful to the patients’ health, but instead should encourage patients to explore options that are appropriate for their health based on consultation with the dentist regarding their own circumstances.

According to Section 5, principle: Veracity (“truthfulness”), experimental or nonsubstantiated claims or proclamations that are not evidencebased should be avoided at risk of harm to the patient.5

Beneficence obligates the dentist to improve the health of the community.5 The influencer’s posts should advance knowledge rather than upsell services. The dentist also has an obligation to maintain a professional demeanor in the work-place at all times, which may include any social media interactions.5 The influencers must be encouraged to establish posts that are not demeaning to the profession and that promote the integrity of the particular practice, as well as the general practice of dentistry.

According to Section 4, principle: Justice (“fairness”), social media posts must avoid offering rebates or other fee incentives.5 Offering fee differentials or waivers of copayment may not be legal or ethical based on the circumstance but may also lure a patient to a practice on the basis of misrepresentations. Any testimonials should be based on actual patient experiences and if a post or testimonial is compensated monetarily or with a free or discounted service, this should be disclosed.

Of all the important principles listed, Veracity is particularly applicable. “The dentist has a duty to communicate truthfully.”5 Using social media influencers in a way that would misrepresent outcomes, fees, or safety would not be ethical. Unsubstantiated

information may mislead a patient to make a decision on the basis of inaccurate information.

Social media influencers are going to be more and more common in patients’ decision making about the dentist they choose to see and the services they may request. It is critical that dentists adhere to the highest standards of ethics, not just in practice but in social media marketing as well.

https://doi.org/10.1016/j.adaj.2022.07.008

Copyright ª 2022 American Dental Association. All rights reserved.

This article was reprinted with permission from The Journal of the American Dental Association (JADA) and published in JADA, Vol 153, Issue 10, Kathleen Nichols, DDS; Renee Pappas, DDS, The #ethics behind social media influencers in dentistry, pp 10101011, ©2022 American Dental Association (ADA). Reprinted with permission from the ADA. All rights reserved.

Dr Nichols practices general dentistry in Lubbock, Texas, and is a member of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs. Address correspondence to the American Dental Association Council on Ethics, Bylaws and Judicial Affairs, 211 E Chicago Ave, Chicago, IL 60611.

Dr Pappas practices general dentistry in Arlington Heights, Illinois, and is a member of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs.

Disclosures: Drs Nichols and Pappas did not report any disclosures.

The views expressed are those of the authors and do not necessarily reflect

the opinions of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs or official policy of the ADA.

References

1. Lin Y, Hong YA, Henson BS, et al. Assessing patient experience and healthcare quality of dental care using patient online reviews in the United States: mixed methods study. J Med Internet Res. 2020;22(7):e18652. https://doi. org/10.2196/18652

2. Kirwan D. Are social media influencers worth the investment? Forbes. August 21, 2018. Accessed March 2, 2022. https://www.forbes. com/sites/forbesagencycouncil/ 2018/08/21/are-social-mediainfluencers-worth-the-investment/ ?sh¼66999f34f452

3. Elson NC, Le DT, Johnson MD, et al. Characteristics of general surgery social media influencers on Twitter. Am Surg. 2021;87(3):492-498.

4. CDA Code of Ethics. California Dental Associ- ation. Accessed February 28, 2022. https://www. cda. org/Portals/0/pdfs/code_of_ ethics/code-of-ethics-2020. pdf

5. American Dental Association Principles of Ethics & Code of Professional Conduct. With Official Advisory Opinions Revised to November 2020. Accessed July 29, 2022. https:// www.ada.org/-/media/project/ ada-organization/ada/ada-org/ files/ about/ada_code_of_ethics. pdf?rev 86aeaa6fb0d0467f8

a380a3de35e8301&hash

89BAA88FB9305B8F134414

E337CAE55A

6. Gupta N, Dorfman R, Saadat S, Roostaeian J. The plastic surgery social media influencer: ethical considerations and a literature review. Aesthet Surg J. 2020;40(6):691-699.

Calendar of Events

TDA Meeting May 4-6, 2023 • San Antonio (tdameeting.com)

TMOM 2023 Events

TMOM Bonham: April 14-15, 2023

TMOM Abilene: July 14-15, 2023

TMOM Edinburg: September 15-16, 2023

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

Those in the dental community who have recently passed

Jerry Robert Beachum Lubbock

September 11, 1934–December 17, 2022

Good Fellow: 1983 • Life: 2001 • Fifty Year: 2009

Stanley L Wyll Dallas

January 25, 1937–January 22, 2023

Good Fellow: 1986 • Life: 2002 • Fifty Year: 2011

Jack E Parker Merit

October 29, 1932–January 10, 2023

Good Fellow: 1988 • Life: 1997 • Fifty Year: 2013

Peter A Cecic San Antonio

February 13, 1949–January 12, 2023

Good Fellow: 2020 • Life: 2014

Thomas Lee Sevier Westworth Village

May 21, 1932–December 31, 2022

Life: 1997 • Fifty Year: 2006

Thomas D Wilten

Dallas

January 10, 1941–April 17, 2020

Life: 2006 • Fifty Year: 2020

William Warren Grogan

Longview

August 19, 1930–October 3, 2020

Life: 1995 • Fifty Year: 2008

Richard Donald Mogle College Station

September 19, 1943–February 4, 2023

Good Fellow: 1998 • Life: 2008 • Fifty Year: 2020

Michael Gonzalez

Houston

October 9, 1951–October 27, 2022

Good Fellow: 2008 • Life: 2016

Alexanderia K Lane

Houston

December 3, 1957–February 1, 2023

Douglas Randolph Hodge

Mount Pleasant

December 10, 1929–February 12, 2023

Good Fellow: 1979 • Life: 1994 • Fifty Year: 2004

Wesley W Burgess

Dallas

February 18, 1926–February 16, 2023

Good Fellow: 1972 • Life: 1991 • Fifty Year: 1998

Lee Blake McKaskle

Katy

November 16, 1941–February 8, 2023

Good Fellow: 1996 • Life: 2007

Arthur Fourment

Brownwood

May 28, 1920–December 5, 2022

Good Fellow: 1977 • Life: 1985 • Fifty Year: 2002

The Importance of Undergoing a Digital Transformation at Your Practice

By Robert McDermott President/CEO, iCoreConnect

With so many challenges facing practices—staffing shortages, for example—offices absolutely must implement digital tools to simplify practice management—as well as aid with efficiency, speed and accuracy in workflows. A bonus: these often lower costs.

This process is called a digital transformation, which often includes technology upgrades and software solutions that streamline, simplify, and often automate repetitive and time-consuming tasks.

Automations can save tens of hours a week.

Automation is often the first place to look when it comes to improving efficiency. Simply implementing modern cloud-based software for everyday tasks to fully automate parts of your business workflow can save tens of hours a week.

If your already-stretched team is working on outdated computer systems and performing manual procedures that should be automated, you’re facing compounded inefficiency at your practice. You’ll see some examples of automation in the next few sections.

ePrescribing speeds prescribing time, increases patient safety.

Different ePrescription softwares provide different features. But in addition to sending a prescription to your patient’s pharmacy, a solid solution will increase your speed and efficiency by:

• Autofilling patient information

• Offering “favorites” for prescription combos and pharmacies

• Connecting with your practice management software

• Enabling you to prescribe from any location on any device through cloud-based access

Streamlining your clinical workflow is gold. But with nearly a quarter of prescription errors attributable to illegible handwriting, a primary benefit of ePrescribing is its ability to improve the accuracy of prescriptions. Additionally, ePrescribing increases patient safety by:

• Checking the state’s PMP database, TX PMP AWARxE, to ensure you’re safely prescribing controlled medications

• Providing alerts and warnings for interactions and contraindications

Technology’s long played a role in improving patient diagnoses, treatment, and care. But what’s just now being realized is its potential to revolutionize the business side of dentistry.

value for your profession

Automated analytics can reveal revenue opportunities, help you improve care.

If you’re not monitoring patient analytics such as available insurance coverage, you may miss opportunities to provide better care and increase revenue. But manually keeping track of the data you need is an overwhelming job.

Technology that integrates with your practice management software can pull the information for you in near real time.

The solution should offer easy-to-access, automated reports based on your goals, and track key practice performance metrics. A robust analytics dashboard can even:

• Identify patients in need of procedures or with unscheduled treatments

• Reveal untapped insurance revenue, i.e., identify patients who have insurance that will at least partially cover those needed procedures

With this information, your team can confidently book appointments with patients before they leave your office—and increase acceptance of treatment plans without post-visit communications. An analytics dashboard can also maximize your staff’s time by:

• Including staff prompts and functionality to close treatment plans

• Highlighting scheduled patients that have open AR to be collected

These features will streamline your team’s workflow and untie them from handling increasingly complex insurance verifications and scheduling patients over the phone.

HIPAA-compliant email ensures security and protects PHI.

Setting your practice up with fully HIPAA-compliant, cloud-based email is critical. This is different from providers like Hotmail, Yahoo, and Gmail; even though some have a few HIPAA-compliant qualities like encryption.

A fully HIPAA-compliant email service will protect your patient data and practice from cybercriminals and enable you to meet the requirement to ensure data security and privacy as you:

• Store and share electronic health records

• Collaborate and refer with other dental or health professionals

• Securely communicate with your patients

You want an email service built on HIPAA compliance with added security to prevent your inbox from receiving spam or phishing emails. Look for an email service that:

• Transmits across a private encrypted network with end-to-end encryption

• Encrypts email in transit and ‘at rest’ in your inbox

• Meets all required HIPAA technical safeguards

Also look for practical features that will increase efficiency:

• Provides a broad referral network

• Enables you to send large files and images without file-size restrictions or limits on the number of attachments.

With all the demands placed on dentists, practice managers, and the entire team, it’s critical to leverage every available tool to improve and simplify dental practice management. A digital transformation is a paradigm shift that could substantially secure and boost your revenue streams.

TDA Perks Program endorses multiple iCoreConnect cloud-based software products, including revenue analytics dashboard, iCoreHuddle; cloud ePrescribing solution, iCoreRx; and encrypted, HIPAA-compliant email, iCoreExchange. Call (888) 810-7706 or visit iCoreConnect.com/TX2 to learn more. For more information about the TDA Perks Program, please visit tdaperks.com.

Dallas, Texas

Comprehensive Dentistry at Texas A&M University School of Dentistry invites applications for the Director of the Advanced Education in General Dentistry (AEGD) Residency Program. This is a full-time tenure track or tenure review upon hire, 11-month academic appointment beginning as quickly as possible. Responsibilities include coordinating clinical activity, supervising patient care, evaluating resident professionalism, clinical progress/performance, counseling residents. Position includes clinical and didactic teaching in ALL areas of comprehensive dentistry. Salary and academic rank commensurate with qualifications and experience of selected applicant. Interested individuals should have a strong commitment to teaching and service. Opportunity for extramural private practice is available.

Learn more and or apply at https://faculty.tamu.edu/Positions

Texas A&M University is an Equal Opportunity/Affirmative Action/Veterans/Disability employer committed to building a culturally diverse educational environment. Applications from veterans, individuals with disabilities, women, minorities, and members of other underrepresented groups are strongly encouraged.

DENTAL EXPERT witness training

DAY ONE - learnDAY TWO - experience -

less chairside, more income

Are you a Dentist who is becoming tired of working chairside, near the end of your career, or merely looking for supplemental income? Dental Expert Witness work could be the answer for you!

Until now there have been no lectures and no instruction available on what it is, what it takes, and how to market yourself as an Expert Witness. Our exclusive workshop is the first ever of its kind!

Using their 30 years of experience, Dr. Boeke DDS & Dr. Krueger DDS/JD have created a 2 day workshop on the beautiful Texas A&M-Commerce campus, that will teach you the ins and outs of becoming an Expert Witness in a way that is informative, effective, and fun.

- what it is to BE a Dental Expert Witness - how it helps serve your peers and community

- how it generates additional income outside of the chair -how to market yourself as an Expert Witness.

- Dr. Krueger’s firsthand records and depositions of trials past

- mock testimonies based on those trials, complete with testimony from a witness stand

- end your day with a Texas BBQ experience on Dr. Boeke's Ranch

For an exclusive experience, our program is limited to 10 seats per sessio n!

$2,895.00

For more information, class dates, and to reserve your seat, please visit www.drbradboeke.com

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Opportunities Online at TDA.org and Printed in the Texas Dental Journal

CLASSIFIEDS INFORMATION

DEADLINE

Copy text is due the 20th of the month, 2 months prior to publication (ie, January issue has a due date of November 20.)

MONTHLY RATES

PRINT: First 30 words—$60 for ADA/TDA members & $100 for non-members. $0.10 each additional word.

ONLINE: $40 per month (no word limit). Online ads are circulated on the 1st business day of each month, however an ad can be placed within 24 business hours for an additional fee of $60.

SUBMISSION

Ads must be submitted, and are only accepted, via www.tda.org/Member-Resources/TDAClassified-Ads-Terms. By official TDA resolution, ads may not quote specific incomes or revenues and must be stated in generic terms (ie “$315,000” should be “low-to-mid-6 figures”). Journal editors reserve the right to edit and/or deny copy.

PRACTICE OPPORTUNITIES

ALL TEXAS LISTINGS FOR MCLERRAN & ASSOCIATES. AUSTIN-WEST (ID #539): 100% FFS practice in the Texas Hill Country with strong hygiene recall (approximately 30% of total production) and an increasing revenue trend over the past 3 years. Free-standing building, 3 fully equipped operatories, newly installed computers in each room, digital sensors, hand-held x-ray units, practice management software (Dentrix Ascend), and paperless charts. The real estate is also for sale. AUSTIN-NORTH (ID #572): 100% FFS, state-of-the-art office in north Austin featuring a modern buildout with 7 equipped operatories, a CBCT, a digital scanner, and a CEREC milling unit in over 2,600+ sq ft. The office is ideally located in a high visibility retail shopping center with easy access to the surrounding community. AUSTIN-NORTH (ID #575): GD practice in the Killeen/Harker Heights/Copperas Cove area. 4 operatories with recently purchased chairs, digital x-rays, intraoral cameras, and paperless charts. 1,800+ active patients, 40+ new patients per month, revenue of mid-6 figures with 30-35% of total production derived from hygiene procedures, and excellent profitability. AUSTIN-NORTH (ID #580): Established GD practice and real estate in a growing community between Austin and Waco. Located in a 2,184 sq ft professional

building with additional space for future expansion, 5 fully equipped operatories, digital X-ray units, a pano, and a digital scanner. The office serves a large, FFS/PPO patient base (over 3,400 active patients seen in the last 24 months) with 35+ new patient visits per month which supports a strong hygiene recall program (40% of total revenue). AUSTIN, ORTHO (ID #581): Rare opportunity to purchase an orthodontic practice and real estate in a highly desirable area just 15 miles west of downtown Austin. The turn-key facility is located within a free-standing building in a high-traffic retail center. The practice has strong profitability, and the facility includes four chairs, a digital Pan-Ceph, iTero Element digital scanner, and paperless charts. The owner is available post-sale to assist the buyer with a transition period. HOUSTON-NORTHEAST (ID #488): FFS/PPO practice and real estate, growing suburb 45 minutes NE of Houston. 1,800 total patients, steady flow of new patients, solid hygiene recall, and consistent revenue of high6 figures per year. The office contains 6 fully equipped operatories, plumbed nitrous, digital X-rays, CBCT, and computers throughout.

HOUSTON-SOUTHWEST (ID #565): Large, comprehensive GD practice in SW Houston. Spacious 3,200+ sq ft, 8 fully equipped ops (with 10 total operatories), digital radiography, computers in operatories, a digital scanner

and CBCT. Revenue of over 7 figures with over 40% profitability. This is a great opportunity for a highly trained clinician or group that is looking for a large office that they can continue to grow into. HOUSTON-SOUTHEAST (ID #566): GD office located in a growing suburb SE of Houston. PPO/Medicaid patient base, strong and consistent cash flow, a steady flow of new patients, and solid hygiene recall. The 1,950 sq ft, high visibility, retail space features 6 total operatories (5 equipped), a digital pano, paperless charts, an E4D digital scanner/ milling unit, and computers throughout. With almost all expanded procedures being referred out, little to no marketing/advertising, and a stellar location, this practice is primed for future growth. HOUSTON-NORTH (ID #568): Turn-key GD practice in a rapidly growing suburb of Houston. FFS/PPO office, modern build out, 3 equipped operatories, computers in ops, digital radiography, intra oral cameras, paperless charts, and a digital Pano. This is an ideal opportunity for a buyer who is interested in a start-up and is ready to take an office that is primed for growth to the next level! HOUSTON-WEST/ENERGY CORRIDOR (ID #574): GD practice located in west Houston near the energy corridor.

High-visibility retail office with 1,575 sq ft, 5 equipped operatories, digital radiography, computers in ops, and paperless charts. Large

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patient base made up of majority PPO/FFS patients with a small percentage of revenue derived from Medicaid patients. Strong new patient flow (approximately 40 new patients per month) and tremendous upside potential.

MIDLAND/ODESSA (ID #567): 100% FFS GD practice in Midland/Odessa. The 1,440 sq ft condo is well equipped with 3 fully furnished operatories, digital radiography, intra-oral cameras, and a digital pano and CBCT. Dedicated, multi-generational patient base, a fantastic reputation, word of mouth referrals, consistent hygiene recall, low overhead, and strong cash flow. NORTHEAST TEXAS (ID #584): 100% FFS general dentistry practice in a desirable town in northeast Texas with 7 figures in revenue and strong net income. The turn-key practice features 4 fully equipped operatories with digital radiography, intra oral cameras, paperless charts, CBCT, and a digital scanner. SAN ANTONIO (ID #582): Well-established, PPO/FFS family practice in central San Antonio in a high visibility building. 4 fully equipped ops, digital radiography, a digital pano, intraoral cameras, and computers in all ops. Large active patient base and a robust hygiene recall program with no website and minimal external marketing efforts and significant growth potential by way of expanding services

to include endodontics, implant placement, ortho, and oral surgery. SAN ANTONIO (ID #583): 100% FFS, high-tech practice in NW San Antonio. 2,000+ sq ft, 6 operatories, digital radiography, CBCT, milling machine, 3D printer, porcelain and zirconia ovens, computers in ops, and a digital scanner. The practice has high-6 figures of annual revenue, solid monthly new patient flow, a fantastic web presence and a stellar online reputation that the seller has built up over several years. If you enjoy cosmetic dentistry and placing implants with a focus on using state of the art technology, this is the practice for you! SOUTH TEXAS (ID #585): Majority PPO/FFS GD family practice in south Texas. 1,900 sq ft office, 3 fully equipped operatories, computers in all operatories, digital radiography, digital pano, intraoral cameras, digital scanner, and paperless charts. Strong active patient base, an average monthly new patient count of 45+ (over past 12 months) on limited external marketing efforts, healthy hygiene recall program (20% of annual production) and primed for continued success and future growth. TO REQUEST

MORE INFORMATION ON MCLERRAN & ASSOCIATES’ LISTINGS: Please register at www.dentaltransitions.com or contact us at 512-900-7989 or info@dentaltransitions.com.

BEAUMONT: GENERAL (REFERENCE

“BEAUMONT”) Small town practice near a main thoroughfare. 80 miles east of Houston. Collections in 7 figures. Country living, close enough to Houston for small commute. Practice in a stand-alone building built in 1970. The office is 1,675 sq ft with 4 total operatories, 2 operatories for hygiene and 2 operatories for dentistry. Contains reception area, dentist office, sterilization area, lab area. Majority of patients are 30 to 65 years old. Practice has operated at this location for over 38 years. Practice sees patients about 16 days a month. Collection ratio of 100%. The practice is a fee-for-service practice. Building is owned by dentist and is available for sale. Contact Christopher Dunn at 800-930-8017 or christopher@ddrdental.com.

HOUSTON

(SHARPSTOWN AREA): GENERAL (REFERENCE

“SHARPSTOWN GENERAL”) MOTIVATED SELLER. Well-established general dentist with high6 figure gross production. Comprehensive general dentistry in the southwest Houston area focused on children (Medicaid). Very, very high profitability. 1,300 sq ft, 4 operatories in single building. 95% collection ratio. Over 1,200 active patients. 20% Medicaid, 45% PPO, and 35% fee-for-service. 30% of patients younger than 30. Office open 6 days a week and accepts Medicaid. Contact Christopher Dunn at 800-930-8017 or christopher@

ddrdental.com. HOUSTON (BAYTOWN AREA): GENERAL (REFERENCE “BAYTOWN GENERAL”)

MOTIVATED SELLER. Well-established general practice with mid-6 figure gross production. Comprehensive general dentistry in Baytown on the east side of Houston. Great opportunity for growth! 1,400 sq ft, 4 operatories in single story building. 100% collection ratio. 100% fee-for-service. Practice focuses on restorative, cosmetic and implant dental procedures. Office open 3.5 days a week. Practice area is owned by dentist and is available for sale.

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Contact Christopher Dunn at 800-930-8017 or christopher@ddrdental.com. WEST OF AUSTIN: ORTHODONTIC (REFERENCE “HILL COUNTRY ORTHO”). Located in a rapidly growing small town, this practice is in the heart of the Texas hill country. This practice serves the youth of the area. There are 4 operatories in the practice. The practice is 100% fee-for-service. Orthodontic care is the only service provided at this office. 1,300 sq ft. Open 4 days per week. Digital X-rays and pano and Cloud9Ortho software. The practice has excellent visibility and is located near a hospital. Contact Christopher Dunn at 800-930-8017 or christopher@ddrdental.com.

HOUSTON, COLLEGE STATION, AND LUFKIN (DDR DENTAL Listings). (See also AUSTIN for other DDR Dental listings and visit www. DDRDental.com for full details. LUFKIN— GENERAL practice on a high visibility outer loop highway near mall, hospital and mature neighborhoods. Located within a beautiful single-story, free-standing building, built in 1996 and is ALSO available for purchase. Natural light from large windows within 2,300 sq ft with 4 operatories (2 hygiene and 2 dental). Includes a reception area, dentist office, a sterilization area, lab area, and break room. All operatories fully equipped. Does not have a pano but does have digital

x-ray. Production is 50% FFS and 50% PPO (no Medicaid), with collection ratio above 95%. Providing general dental and cosmetic procedures, producing mid-6 figure gross collections. Contact Christopher Dunn at 800930-8017 or Christopher@DDRDental.com and reference “Lufkin General or TX#540”. HOUSTON: GENERAL (SHARPSTOWN). Wellestablished general dentist with high-6 figure gross production. Comprehensive general dentistry in the southwest Houston area focused on children (Medicaid). Very, very high profitability. 1,300 sq ft, 4 operatories in single building. 95% collection ratio. Over 1,200 active patients. 20% Medicaid, 45% PPO, and 35% fee for service. 30% of patients younger than 30. Office open 6 days a week and accepts Medicaid. Contact Chrissy Dunn at 800-9308017 or chrissy@ddrdental.com and reference “Sharpstown General or TX#548”. HOUSTON: GENERAL (PEARLAND AREA). General located in southeast Houston near Beltway 8. It is in a freestanding building. Dentist has ownership in the building and would like to sell the ownership in the building with the practice. One office currently in use by seller. 60% of patients age 31 to 80 and 20% 80 and above. Four operatories in use, plumbed for 5 operatories. Digital pano and digital x-ray. Contact Christopher Dunn at 800-930-8017 or christopher@ddrdental.com and reference

“Pearland General or TX#538”. HOUSTON: PEDIATRIC (NORTH HOUSTON). This practice is located in a highly sought-after upscale neighborhood. It is on a major thoroughfare with high visibility in a strip shopping center. The practice has three operatories for hygiene and two for dentistry. Nitrous is plumbed for all operatories. The practice has digital X-rays and is fully computerized. The practice was completely renovated in 2018. The practice is only open 3-1/2 days per week. Contact Christopher Dunn at 800-930-8017 or christopher@ddrdental.com and reference “North Houston or TX#562”. WEST HOUSTON: MOTIVATED SELLER. Medicaid practice with production over 6 figures. Three operatories in 1,200 sq ft in a strip shopping center. Equipment is within 10 years of age. Has a pano and digital X-ray. Great location. If interested contact chrissy@ddrdental.com. Reference “West Houston General or TX#559”.

SOUTHEAST HOUSTON: Above mid-6 figures of adjusted net production and almost full collection (97%). Fee-for-service and PPO practice, highest-net income. The total collection over total production is about 90%. 4 days / week, free weekends. No Medicaid, No HMO/DMO, no in-network and no hassle. This practice has been in this area for over 40 years; the current practice location was built in

2006 in a new building with all new equipment. 4,000 sq ft, 5 fully equipped operatories, and 5 additional operatories plumbed. CBCT with pano and digital X-ray with a Phosphor-Plate scanner require little to no maintenance. We have a few digital sensors too. Microscopes and Fotona Lasers are available. Doctors over 70 years of age are ready to retire. Instead of using a broker, we are willing to provide a discount equal to the broker fee. Interested parties can contact us by calling or texting our personal cell number 346-754-9643. Email: smile.office@proton.me. Principals only. Sales agents and buyers bonded to the broker, please don’t contact this sales poster. Do NOT contact us with unsolicited services or offers.

WATSON BROWN PRACTICES FOR SALE:

Practices for sale in Texas and surrounding states, For more information and current listings please visit our website at www. adstexas.com or call us at 469-222-3200 to speak with Frank or Jeremy.

INTERIM SERVICES

HAVE MIRROR AND EXPLORER, WILL

TRAVEL: Sick leave, maternity leave, vacation, or death, I will cover your general or pediatric practice. Call Robert Zoch, DDS, MAGD, at 512-517-2826 or drzoch@yahoo.com.