March 2024 Texas Dental Journal

TDA

Texas Dental Journal

MARCH 2024

76

TDA MEETING PREVIEW THE GIFT OF A SYSTEMATIC APPROACH FOR APPROPRIATE TREATMENT

SPEAKER: DR KEVIN KWIECIEN

81

ASK THE POWERS CENTER

RADE PARAVINA, DDS, MS, PHD

84

FBI: FOUND BUT NOT IDENTIFIED (YET)

KATHLEEN A. KASPER DDS, D-ABFO

90

ETHICS CORNER:

HOW TO MANAGE THE PRINCIPAL-AGENT PROBLEM IN DENTISTRY

BEN BALEVI, DDS, DIP EBHC (OXFORD), MSC

Anesthesia Education & Safety Foundation

Two ways to register: Call us at 214-384-0796 or e-mail us at sedationce@aol.com Visit us on the web: www.sedationce.com

NOW Available: In-Office ACLS & PALS renewals; In-Office Emergency Program

Live Programs Available Throughout Texas

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 M edications and Provider Prescription Program

Fulfills rules 104.1 and 111.1

SEDATION & EMERGENCY PROGRAMS:

Nitrous Oxide/Oxygen Conscious Sedation Course for Dentists:

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

Level 1 Initial Minimal Sedation Permit Courses:

*Hybrid program consisting of Live Lecture and online combination

Credit: 20 hours lecture with 20 clinical experiences

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

ONLINE LEVEL 3 AND 4 SEDATION REPERMIT AVAILABLE! (Parenteral Review) Level 3 or Level 4 Anesthesia Programs (In Class, Webcast and Online available):

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

NOTE: ACLS or PALS Renewal can be completed by itself at any combined program Combined ACLS-PALS-BLS and Level 2, 3 and 4 Program

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

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

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

3. There may be a post-test after the online course concludes, so you will receive immediate CE credit for attendance

4. With the webcast, you can enjoy real-time interaction with the course instructor, utilizing a question and answer format

OUR MISSION STATEMENT: To provide affordable, quality anesthesia education with knowledgeable and experienced instructors, both in a clinical and academic manner while being a valuable resource to the practitioner after the programs. Courses are designed to meet the needs of the dental profession at all levels.

Our continuing education programs fulfill the TSBDE Rule 110 practitioner requirement in the process to obtain selected Sedation permits. AGD Codes for all programs: 341 Anesthesia & Pain Control; 342 Conscious Sedation; 343 Oral Sedation This is only a partial listing of sedation courses. Please consult our www.sedationce.com for updates and new programs.

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

contents

FEATURES

76

Editorial Staff

Jacqueline M. Plemons, DDS, MS, Editor

Juliana Robledo, 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 141 | 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.

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Board of Directors

Texas Dental Association

PRESIDENT

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

PRESIDENT-ELECT Georganne P. McCandless, DDS 281-516-2700, gmccandl@yahoo.com

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

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

VICE PRESIDENT, NORTHWEST Summer Ketron Roark, DDS 806-793-3556, summerketron@gmail.com

VICE PRESIDENT, NORTHEAST Jodi D. Danna, DDS 972-377-7800, jodidds1@gmail.com

VICE PRESIDENT, SOUTHEAST Shailee J. Gupta, DDS 512-879-6225, sgupta@stdavidsfoundation.org

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

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

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

SENIOR DIRECTOR, SOUTHEAST

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

DIRECTOR, SOUTHWEST

Melissa Uriegas, DDS 956-369-9235, meluriegas@gmail.com

DIRECTOR, NORTHWEST

Adam S. Awtrey, DDS 314-503-4457, awtrey.adam@gmail.com

DIRECTOR, NORTHEAST

Drew M. Vanderbrook, DDS 214-821-5200, vanderbrookdds@gmail.com

DIRECTOR, SOUTHEAST

Matthew J. Heck, DDS 210-393-6606, matthewjheckdds@gmail.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

in memoriam

Those in the dental community who have recently passed

Louis Rocco Cannatti

Austin

March 6, 1938–December 29, 2023

Good Fellow: 1987 • Life: 2003 • Fifty Year: 2012

James B Clayton III

Dallas

March 13, 1941–October 9, 2023

Good Fellow: 1994 • Life: 2006 • Fifty Year: 2019

William Francis Donahy

Llano

May 1, 1936–January 3, 2024

Good Fellow: 1996 • Life: 2001 • Fifty Year: 2020

Michael R Ellis

Tyler

September 2, 1948–December 23, 2023

Good Fellow: 2001 • Life: 2013

Perry V Goldberg

Richardson

April 10, 1947–September 25, 2023

Good Fellow: 2021

Barry James Gomel

Houston

September 23, 1964–November 14, 2023

John A Grinaldi

Richardson

May 26, 1946–December 3, 2023

Life: 2013

Warren S Guy

Lufkin

September 7, 1942–January 8, 2024

Good Fellow: 2003 • Life: 2007 • Fifty Year: 2023

Don Terrell Henderson

Galveston

December 2, 1935–September 9, 2023

Good Fellow: 1986 • Life: 2000 • Fifty Year: 2011

Ted Pettet Hughes

Haughton, LA

July 19, 1936–July 30, 2023

Good Fellow: 1986 • Life: 2001 • Fifty Year: 2011

Patrick H Le Blanc

Dallas

January 14, 1931–October 29, 2023

Good Fellow: 1981 • Life: 1996 • Fifty Year: 2005

Dewitt Talmage Lee Jr

Bishop

December 3, 1932–November 25, 2023

Good Fellow: 1984 • Life: 1997 • Fifty Year: 2008

David Franklin Lovett

Lubbock

June 2, 1948–November 3, 2023

Good Fellow: 2000 • Life: 2013

Thomas Calvin McCulloch

La Porte

December 28, 1943–September 19, 2023

Good Fellow: 2006 • Life: 2018

Dwight Ford Nielsen

Estes Park, CO

February 3, 1933–December 24, 2023

Good Fellow: 1985 • Life: 1998 • Fifty Year: 2010

Albert Perkins Jr

Cleburne

January 10, 1920–December 7, 2023

Good Fellow: 1975 • Life: 1985 • Fifty Year: 2000

Dallas Pierre

Lufkin

June 9, 1933–November 6, 2023

Good Fellow: 1994 • Life: 2000 • Fifty Year: 2019

Charles S Sanford III

Spring

February 2, 1946–January 12, 2024

Good Fellow: 1998 • Life: 2011

Joseph V Weir

McAllen

May 5, 1930–December 30, 2023

Good Fellow: 1983 • Life: 1995 • Fifty Year: 2006

1. Do you have or have you considered an exit strategy?

2. How long do you plan on being a practice owner? If your health allows, would you like to continue practicing after that point?

3. Do you know what your practice is worth today? How do you know? When was your last Practice Valuation done?

4. Have you met with a financial planner and have a documented plan? Have you established a liquid financial resources target that will enable you to retire with your desired lifestyle/level of income?

OFFICIAL CALL TO THE 2024

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 154th 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 AM on Thursday, May 16, 2024. The second meeting of the House will be at 1:30 PM on Friday, May 17, 2024. The third meeting of the House will be at 8:00 AM on Saturday, May 18, 2024, followed by the fourth meeting at 10:00 AM 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.

FINANCIAL

FORUM: The TDA Secretary-Treasurer will facilitate a question-and-answer financial forum at 10:00 AM, or 15 minutes after adjournment of the first meeting of the House of Delegates, on Thursday, May 16, 2024, open to all members who are present in the Hemisfair C-3 Ballroom of the Henry B. Gonzalez Convention Center, 900 E. Market Street, San Antonio, Texas (same room as the House of Delegates meetings). Reference Committee hearings will follow the financial forum.

REFERENCE COMMITTEE

HEARINGS:

Reference Committee hearings will be combined and facilitated to follow the financial forum at approximately 10:30 AM on Thursday, May 16, 2024, and open to all members who are present in the Hemisfair C-3 Ballroom of the Henry B. Gonzalez Convention Center, 900 E. Market Street, San Antonio, Texas (same room as the House of Delegates meetings). Hearings will conclude when no further testimony is presented.

Combined Topics:

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

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

• Dental Education, Dental Economics, Health and Dental Care Programs

• Legislative, Legal and Governmental Affairs

• Constitution, Bylaws, Ethics & Peer Review

The agenda for the Reference Committee hearings will be included in the Reference Committee section of the House Documents.

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.

TDA CANDIDATES FORUM:

The TDA “Meet the Candidates Forum” will be held on Friday, May 17, 2024, from 10:30 AM to 11:30 AM in the in the

Hemisfair C-3 Ballroom of the Henry B. Gonzalez Convention Center, 900 E. Market Street, San Antonio, Texas (same room as the House of Delegates meetings). There will not be an ADA candidates forum this year due to scheduling conflicts.

DIVISIONAL CAUCUSES:

Divisional Caucuses (Northwest, Northeast, Southwest, Southeast) will be facilitated at 5:30 PM on Friday, May 17, 2024, in the Convention Center and open to all current members— please see the TDA website for details and additional information. (Room assignments: SE-303C; SW-304A; NE304B; NW-304C).

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 March 2024 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).

TDA CANDIDATES FORUM

Every year, in accordance with the TDA Bylaws, the TDA House of Delegates elects the officers, directors, and council members of the Association for the coming year. Candidates for council positions are nominated by the president-elect, and candidates for directorship are nominated by their respective division caucuses.

Three offices are considered statewide “at large” offices as their nominations are not restricted to a candidate’s respective division; as long as one meets the qualifications for office, one can be nominated by an individual who has privilege of the floor of the House, who is a delegate or alternate delegate, when seated as a delegate, or by the Board of Directors if no nomination has been received for that office by the winter meeting of the Board. These offices are the Secretary-Treasurer, the Editor, and the Speaker of the House of Delegates (Ref. The TDA Manual on Caucus Procedures, Campaigns, Nominations and Elections for details). Every third year, the President-elect is an at-large statewide elected office (Ref TDA Bylaws, Chapter VI, Section 30-A).

This year, 2 outstanding individuals have announced they are seeking the opportunity to fill the Speaker of the House position: Dr Gregory W. Rashall of Liberty and Dr M. David Tillman of Fort Worth. TDA members are urged to consider their statements and to communicate with their delegates regarding the choice for this important position.

gregory ward

rashall, dds

Liberty, Texas

I would like to take this opportunity to share a little about myself, as well as my qualifications and goals as a candidate for the Texas Dental Association (TDA) Speaker of the House of Delegates.

I was born in Beaumont and raised in Houston. I attended the University of Houston and went on to earn my dental degree from the University of Texas Dental Branch—now the UT Health Houston School of Dentistry. After working as an associate dentist for a few years, I opened a solo practice in the city of Liberty in 1996 and have practiced there ever since. Shortly after I graduated from dental school, a colleague invited me to a Greater Houston Dental Society (GHDS) meeting. Afterward, I joined the tripartite because it seemed like the right thing to do. Getting involved in the society right away, it didn’t take me long to realize the actual benefits of being a member of organized dentistry.

Involvement in the GHDS eventually led to involvement in the Texas Dental Association and the American Dental Association. I have served on many committees, councils, and boards at all three levels, but rather than list them all here, I invite the reader to review my Curriculum Vitae.

I do want to highlight a few positions that I have held, however, as they are pertinent to my qualifications for the office of Speaker of the House. In 1997 I was elected as an alternate delegate to the TDA House of Delegates. Dr Richard “Dick” A. Eklund was the speaker and I watched with fascination as he led the House through its business with both precision and ease. Returning to Houston, I immersed myself in the bylaws of the GHDS and the TDA and eventually parliamentary texts. I was hooked on rules and procedures. I have served as a delegate or alternate delegate every year since and have looked forward to every annual session. Over the years, I have benefited from parliamentary mentors such as Drs Don Tamplen, H.M. “Mit” Sorrels, and Glen Hall and I became increasingly comfortable coming to the microphone to offer testimony or to participate in debate. I have served on multiple reference committees as both member and chair and have provided support to the staff when compiling the final committee reports for presentation to the House. I have also served as parliamentarian of the Association and the House of Delegates for 5 presidencies and have worked closely with the current Speaker of the House Dr John W. Baucum III. After that many years in the House, there is not much that I haven’t seen or experienced.

Continued on page 74

M. david tillman, dds

fort worth, texas

I appreciate the opportunity to tell you about myself and to let you know why I am running for TDA Speaker of the House. I want to become the speaker because I have a passion for dentistry and love the deliberative process that occurs at the TDA House of Delegates, watching an idea become a resolution, and through the input of delegates and consent of the majority, become policy. I feel I can help the TDA continue to be the true “Voice of Dentistry in Texas” as speaker by facilitating impartial, unbiased discussions on critical matters in dentistry. The TDA House is filled with like-minded passionate dentist delegates who desire the best for their patients and their profession and bring different perspectives to the table. As speaker, I hope to help facilitate these discussions.

TDA’s greatest asset is its membership. You and I make the TDA great. But your voice must be heard. My job as speaker will be to safeguard your right as a member of the TDA House to assure and protect your voice through an orderly, courteous, and fair process. The American Institute of Parliamentarians, the AIP, provides this framework and its Standard Code of Parliamentary Procedure is used to facilitate TDA House discussions. As presiding officer of the Texas State Board of Dental Examiners, I used the parliamentary process to lead difficult discussions on the role of corporate dentistry, dental anesthesiology and dental safety during Covid and sought the input of all stakeholders to help us make the best decision for Texas dentists. I will use those skills as TDA Speaker to make sure your voice is heard.

After completing my dental education at The University of Texas School of Dentistry at Houston and 2 years in Benin, West Africa, as a dental missionary, I attended a GPR at St. Anthony Hospital in Oklahoma City where I met my wife, Julie. I quickly became involved in organized dentistry, joining the American Dental Association, the Fort Worth Dental Society, and the Academy of General Dentistry. I was fortunate to be mentored by men like Drs Michael Stuart, Mark Peppard, and Ralph Cooley. Dr Glen Hall is another one of those dentists. As TDA House Speaker, he mastered the art of facilitating important discussions. On many occasions he helped new delegates wordsmith resolutions and amendments on the House floor so their thoughts and ideas could contribute to the discussion. Through his actions more members and specifically more young dentists

Continued on page 75

GREGORY WARD RASHALL, DDS, continued

Another position that I feel adds greatly to my qualifications as a candidate for this office is my tenure on the Council on Constitution and Bylaws, as well as its successor, the Council on Governance. I have served continually on these councils since 2012 and have been chair since 2013. As a member, and chair, of this council, I have developed a profound knowledge base of TDA rules and procedures, including those which govern the operations of the House of Delegates.

Knowledge of the rules and procedures of the Association is paramount to presiding over the House, but equally so is a thorough understanding of parliamentary procedure. There are many parliamentary references, each differing in many ways from the other. The TDA has adopted the American Association of Parliamentarians Standard Code (AIPSC)—formally Sturgis Standard code of Parliamentary Procedure, as our parliamentary reference. I have recently participated in an AIP presiding practicum where participants improve and hone their presiding skills through instruction and mock presiding scenarios. Although I have a passion for rules and procedure, I understand that this passion must be tempered with the reality of applying these very rules and procedures within the context that they exist.

If elected speaker, I want to continue the efficient and streamlined operation of the House that our current speaker has developed over the years. I also want to build on that operation in an inclusive fashion that encourages participation by the members of the House as well as being approachable and available as a resource for TDA members and staff. To summarize, experience matters. All members of the TDA bring knowledge and skill to the Association, but the office of Speaker of the House of Delegates requires a specialized knowledge that only experience can bring as well as a skill that can only be developed by active participation over numerous years. My many years as a member of the House of Delegates, a member and chair of the Council on Constitution and Bylaws and Council on Governance, and as TDA parliamentarian and a continuing student of parliamentary procedure, makes me uniquely qualified to be the next Speaker of the House.

I humbly ask for your support in my candidacy for this office and pledge to work for the betterment of the House of Delegates, our Association, its members, and our profession.

Education:

Curriculum Vitae

C. E. King High School; Houston, Texas; Graduated1985

San Jacinto College—North; Attended July 86August 86

University of Houston—University Park; Attended Sept 85 - May 88

University of Texas Dental Branch; Attended July 88 - May 92

Doctor of Dental Surgery Degree May 23, 1992

Academic: National Merit Commended Student 1983

University of Houston Alumni Scholarship, 1985-1988

Who’s Who Among Students in American Colleges and Universities, 1989-1992

Omicron Kappa Upsilon honored freshman, 1989

Houston Women of Rotary Outstanding Student Award ,1991

UTDB representative to AFDH/Gordon Christensen Conference, Provo UT, 1992

Omicron Kappa Upsilon National Dental Honor Society, 1992

Southwest Prosthodontist Society Award, 1992

Academy of Dental Materials Award 1992

Quintessence Award in Periodontics 1992

Southwest Academy of Restorative Dentistry Award, 1992

Teaching/Clinical:

UTDB 1990-1991, Anatomical Sciences Tutor

UTDB 1991-1992, General Academic Tutor

Hermann Hospital—March 1991, Mini-GPR

Special Oral Pathology Clinical Rotation with Dennis Lynch, DDS, Oct.-Dec. 1991

Dental Assistant Education Seminar, Greater Houston Dental Society Clinician—November 14, 2003

Greater Houston Dental Society Dental Assistant

Examination Review Seminar Clinician, 2004-2005

Texas Dental Association Dental Assistant Registration Course — multiple classes taught from Sept 2006May 2013

Employment:

Alexander Overweg, DDS, 1988-1989—Part-time Lab Technician

UTDB ,1990-1991— Dental Equipment Repair Technician

Medi-Plex Dental Group, 1992-1996—Associate Dentist

Private Solo Practice, Liberty, TX, 1996-present

Professional:

American Dental Association

• Member since 1992 Council on Members Insurance and Retirement Programs, 2011-2013; Task Force on Governance Chairman, 2013

• ADA Advisory Circle, 2016-present

Texas Dental Association

Member Since 1992

Alternate Delegate/Delegate to House of Delegates, 1999-2022

• Council on Dental Education, Trades, and Ancillaries, 2004-2012; Chairman, 2010-2012

The Texas Meeting, Signs/Handouts Chairman, 2006 Council on Constitution and Bylaws/Council on Governance 2012-present; Chairman, 2013-present

• Parliamentarian, 2014-2018

• Task Force on Governance, Chair 2015-2016

• TDA President’s Award, 2017

Greater Houston Dental Society

• Member since 1992

• Recruitment and Retention Committee, 1993-1994

• Dental Assistant Training Program, 1993-1998; Cochair 1994; Chairman/Director, 1995-1998

• Houston Dental Meeting/Star of The South Host/Class Captain, 1993-1995; Clinician Evaluation Committee Chair, 1996-2000; Table Clinic Chairman 2001-2004

• Science and Engineering Fair of Houston Awards Committee Member, 1994-2000; Chairman, 19952000

Dental Health Committee, 1995-1996, 1999-2000

• Nominee for Texas New Dentist Leadership Award, 1998, 2000

• Judicial Committee, 1998-1999

• Board of Directors, 1999-2017

Task Force on Committee Structure, 1999

Task Force on Electronic Communication, 20002001

• Chairman, Constitution and Bylaws Committee, 2000-2019

• 2nd Vice President, 2001-2002

• Secretary-Treasurer, 2002-2003, 2003-2004

• Chairman, Task Force on Executive Director Search, 2003

Task Force on Building, 2003

• 2nd Vice President, 2004-2005

• 1st Vice President, 2005-2006

• President-elect ,2006-2007

• President, 2007-2008

Editor, The Journal of the Greater Houston Dental Society, 2008- 2017

• Jack Harris Recognition Award, 2014

• Peer Review Committee, 2017-2022; Chair 20202023

Baytown Dental Study Club Member, 1996-2005, 2010-present President, 1998-2000

President, 2011-2013

• Vice President, 2013-2014

Southwest Society of Oral Medicine

• Member, 1998, 1999

International College of Dentists Inducted, 2008

Pierre Fauchard Academy Inducted, 2022

American Institute of Parliamentarians

• Member, 2013-2014, 2016-2017, 2022-present

Community:

North Channel Area Chamber of Commerce Member, 1993-1996

• Board of Directors, 1994-1996

• Community Awareness Committee Chairman, 1994-1995

Northshore Rotary Club Member, 1993-1996 Vocational Service Committee Chair, 1993-1994

• Committeeman of the Year Award, 1993-1994

• Board of Directors, 1994-1996

• Club Service Committee Chairman, 1994-1995

• Elected Treasurer for 1996-1997

Liberty-Dayton Chamber of Commerce Member, 1996-present

Liberty Rotary Club

• Member, 1996-2006

• Club Service Chairman, 1997-1998

• Sergeant-at-Arms, 2000-2001

• Paul Harris Fellow, 2006

Liberty Smiles on Wheels Charitable Dental Event Aug. 2012 Community Chairman

Cub Scout Pack 1454

• Committee Chairman, 1999-2000

• Wolf Den leader, 2000-2001, 2003-2004

• Bear Den Leader, 2001-2002, 2004-2005 Cubmaster, 2001-2002 Tiger Den Leader, 2002-2003

• Assistant Cubmaster, 2003-2005

• Webelos I Den Leader, 2005-2006

• Webelos II Den Leader, 2006-2007

• Flaming Arrow District Den Leader of the Year, 2005

Boy Scout Troop 9

• Committee Chairman, 2004-2009

• Cross and Flame Award, 2004

• Assistant Scoutmaster, 2009-2011

• Scoutmaster, 2011-2013

• Assistant Scoutmaster ,2013-2016

BSA Venture Crew 9

• Committee Chairman, 2008-2013

• Crew Advisor, 2013-2016

Harris Co. Sheriff’s Office Junior Mounted Posse Drill Team

• Vice President, 2009-2010

• President, 2010-2018

First United Methodist Church—Humble

• Staff Parish Relations Committee, 2002-2005; Chairman, 2004-2005

• Usher, 2002-2012

• Church Council ,2003-2005, 2012-2014

• Chancel Choir, 2011-2016

• Praise Band Electric Guitar, 2011-present

• Staff-Parish Relations Committee, 2012-2014; Chairman 2013-2014

M. David Tillman, DDS, continued

participated to critical conversations. I aspire to be a Speaker like Dr Hall. These leaders and many others modelled for me the servant-leadership skills that I desire and used as Fort Worth Dental Society vice president, Texas AGD president, on AGD’s Board of Directors, and during my 8 years on the TSBDE.

As a new dentist, I opened a solo dental practice in Fort Worth and quickly realized the importance of organized dentistry. My experiences on TDA’s Council of Dental Education, Trade, and Ancillaries (DETA), TDA’s Communications Committee, and as a TDA delegate helped me gain experience in organized dentistry. While on DETA, we worked to develop protocols for EFDA’s, expanded function dental assistants. In the Medicaid Stakeholder’s Committee, we worked to improve the disparities in dentist distribution across Texas and strategized ways to improve dentist access to care for pediatric patients in underserved areas. For several years I worked with Dr Bill Wathen on the Communications Committee to improve lines of communication within the TDA and to its members. Currently I am working with the Dental Education Council to develop dental business continuing education through TDA’s Dental Concierge App, which I believe is sorely needed for dentist entrepreneurs. Yes, I have gained much experience working within the TDA. But experience and age are not 4-letter words. In fact, “experience” has 10 letters and “age,” 3.

So, I ask for your support as TDA Speaker of the House. I pledge to use my parliamentary skills for the TDA and continue to be a student of parliamentary law. The TDA has many challenges ahead including the dental hygiene shortage, decreasing TDA membership numbers, dental insurance, and access to dental care. I believe it is critical for TDA’s speaker to have experience within the TDA and as a parliamentary leader. I have that experience. It will help me assure that your voice is heard and impacts the TDA and dentistry’s future.

Education:

Baylor University, BA Biology

Curriculum Vitae

UT School of Dentistry at Houston, DDS

St. Anthony Hospital, Oklahoma City, GPR

Professional Activities:

Texas Dental Association:

Fort Worth Dental Society Board of Directors, 2009-2014

President Elect, Vice President, Secretary

Council of Dental Education, Trade, Ancillaries, 2002-2008

Communications Committee, 2007-2009

Medicaid Stakeholders Committee, 2006-2009

Council on Ethics & Jurisprudence, 2013-2014

TDA House of Delegates: Legislative Subcommittee, Delegate, Alternate Delegate

Texas State Board of Dental Examiners

TSBDE Board Member, 2014-2021 Board Secretary, 2016-2018 Presiding Officer, 2018-2021

Academy of General Dentistry

Texas AGD Board of Directors, 2000-2007

TAGD Board President, 2005-2006

Legislative & Governmental Affairs Council, 2005-2011

AGD Regional Director Region 18, 2010-2016

AGD Trustee Region 18, 2016-2022

Community/Professional Service:

SIM Benin, West Africa Dental Missionary, 1990-1992

Aledo ISD, School Board Trustee, 2012-2019

Birchman Baptist Church, Teacher, Deacon, Choir, Praise Team

Professional Awards:

Fellowship, Academy of General Dentistry Mastership, Academy of General Dentistry LLSR, Academy of General Dentistry Fellowship, International Congress of Oral Implantologists Fellowship, Pierre Fauchard Academy Fellowship, American College of Dentists Fellowship, International College of Dentists

TDA Meeting Preview

The Gift of A Systematic Approach for Appropriate Treatment

By Dr kevin kwiecien

Have you ever been a patient in a healthcare setting where the provider completed a quick cursory exam after a brief conversation regarding your history? Maybe after the quick assessment, you were put in what seemed to be a typical or common category and the treatment plan seemed almost like a recipe, regardless of variations of signs and symptoms.

I would like to assume that intentions to help you were genuine and that the plan might have been appropriate if the diagnosis was correct. Moreover, the inappropriate treatment plan probably works for some people and might have resulted in some benefit for you at some point. But if it wasn’t a correct diagnosis, you might actually get worse even while doing everything you were told, maybe even exacerbating the symptoms. You wanted to be better. You were getting worse.

The stomatognathic system is no different. Have you ever had a patient with pain that seemed to get worse with biting or temperature or both? The iced coffee in the morning with the gluten-free bagel that has brought happiness and joy to the beginning of a new day for that patient for years is creating the opposite. The thought of giving that up seems almost depressing. Equally as concerning, some days eating even softer foods produced discomfort too. The chronic discomfort with episodic exacerbations had previously led to a lot of episodic dentistry. Not only did the symptoms continue, they became more consistent and intense. The new restorations required many adjustments for comfort and spaces seemed to be growing between the new white front teeth.

The back teeth started to look flat, eating got harder and the pain got worse. Did something change? Was it just bad luck? Was the diagnosis correct? Was there actually a diagnosis? Was the treatment plan incorrect or incomplete for the correct diagnosis?

Speaker: Dr Kevin Kwiecien

Event: Every Case is a Big Case

Date: Thursday, May 16

Time: 8:00 AM – 11:00 AM

Event: Predictable Dentistry: Is Occlusion Really the Key?

Date: Thursday, May 16

Time: 1:00 PM – 4:00 PM

Event: Systematic Equilibration: Hands-on Workshop

Date: Friday, May 17

Time: 8:00 AM – 11:00 AM

Figure 1

Was the treatment plan appropriate for the wrong diagnosis? It is a complicated system in a complicated body.

There are so many dentists who did wonderfully in dental school who repair teeth every day, have very good technical skills and have genuine intent to help every patient. What key components will give him or her a more predictable experience?

1. Listening to the patient story and history with a bit more intention.

Hear about contributing factors, lifestyle, habits, and values that will help determine an appropriate customized treatment plan.

2. A comprehensive exam that examines the entire system in which we work (not just the teeth).

How are the joints, muscles, teeth, and periodontium working as a unit.

3. Form a working diagnosis

A system to make sure that all components of the exam will be rationally placed into a category that will help guide you through a systematic evaluation. You can put into words a diagnosis for the teeth, the muscles, the joints, and periodontium.

4. A systematic way to evaluate every patient

A process that you can predictably trust. A starting point for every patient to minimize confusion and begin to unveil the compromises that led to the current condition or that will jeopardize future treatment.

5. Treat appropriately

A way to create a stable environment to evaluate the signs and symptoms (the body’s response) to that environment. You can observe if the signs and symptoms change when placed in a harmonious environment (physiologic occlusion and/or protected). One of 3 things will happen to the signs and symptoms:

They will get better

They will get worse

They will stay the same

Esthetics (Edge Position)

Function (Occlusion)

Structure (Material)

Biology (Foundation)

Figure 2

Figure 3

Figure 4

Wouldn’t you like to know this before beginning irreversible treatment?

6. Assess and re-assess during treatment for necessary “coursecorrections.”

You have proven to yourself and your patient that you can create sustainable comfort. If not, you have a new working diagnosis or your new educated best guess, based on your initial hypothesis and now coupled with your new knowledge.

Said very simply:

A deeper understanding of the system than most had in school

An exam that comprehensively evaluates that system

A systematic approach to diagnose the system

A way to test a very educated guess

For a lot of dentists it can sound like everything has to do with the joints or muscles or periodontium or occlusion. It’s about understanding the system at a deeper level and identifying what is appropriate for each patient.

It can be uncomfortable to some because it’s different. It’s intimidating because it’s more than we learned in school. It’s challenging because it requires change. It’s rewarding because a person can have a proper diagnosis, a proper treatment plan, and appropriate treatment for who they are and where they are in life.

Systematic treatment planning varies between teaching institutions and individual educators. The nuances can be respectfully debated; however, there is consensus that the outside-in approach of using the face to determine the proper position of the teeth is the cornerstone of a process that can have a very profound positive impact on restorative dentists, specialists, and team members. Not only can the process increase productivity and profitability, but it can also make every patient’s treatment more predictable, reduce daily and overall anxiety, while simultaneously resulting in more personal satisfaction for the practitioner and team.

Increase

Productivity and Profitability

The systematic approach to treatment planning inherently allows the practitioner to visualize the ideal restorative outcome, which can oftentimes elude practitioners even after the most thorough evaluation of the patient. An even greater consequence is that any compromises of less-than-ideal treatment become very evident, allowing the dentist to discuss them with the patient to determine the most appropriate plan for every patient at that given time. The result of this is the virtual disappearance of the need to sell dentistry or the feeling of selling dentistry. One of the several

Figure 5

downstream outcomes of that is an increase in productivity. The treatment is more logical, resulting in more organized and efficient scheduling. There are less no-charge “adjustment” appointments and no-charge postoperative “emergencies” to clutter the schedule and distract from other appropriately planned and scheduled restorative treatment appointments. A result of the patient not feeling “sold” and seeing the value, it also allows the accounts-receivable system in the office to run more organized and efficiently, minimizing unnecessary time spent collecting money. Starting every patient with a systematic approach creates leverage for more logical and organized systems throughout the office flow, resulting in a more predictable bottom line.

Predictable Treatment

After incorporating systematic treatment planning into practice, it quickly becomes evident that it works for every patient. The approach will inevitably help the practitioner confidently diagnose and treatment plan the most difficult looking cases. In fact, often the cases that seem so overwhelming wind up being simple treatment plans. And conversely, using the systematic process for cases that would have been taken for granted as a “slam dunk” often reveals an oversight of a key component that would have complicated the process mid-treatment, or even worse, after the treatment is complete. The intentional flow of patient assessment, starting with the location of the teeth in the head and face (Edge Position/Esthetics), followed by evaluation of the occlusion (Function/Airway), which teeth will be restored and how the process will be managed (Material/Structure), and finally which teeth will need surgery,

bone augmentation, root canals, or extractions (Foundation/Biology), facilitates the practitioner to diagnose each category and plan accordingly. Moreover, any compromises to the ideal plan will be evident, discussed with the patient, and virtually prevent any surprises during treatment.

Reduce Anxiety

One of the greatest benefits of a systematic approach to compiling data that rationally fits into just four categories, is that it frees the practitioner up to learn with the patient. Traditionally, dentist-patient interaction starts with performing an exam, documenting the existing conditions, highlighting what is wrong, telling the patient what is broken or wrong, how it can be fixed, and hoping they will agree to it.

When assessing and diagnosing the four areas with the patient, the practitioner can wonder and be curious about the findings, as they are discovered. Using facially generated treatment planning to systematically visualize the ideal end will also, by default, allow the practitioner to identify consequences to any compromises. The result is two-fold:

First, the practitioner can have a factbased conversation with every patient.

1. What do I see?

2. What will most likely happen if nothing is done?

3. How can it be fixed/restored?

4. What are the benefits of treatment (outcomes from treatment, as opposed to doing nothing)?

Second, any compromise to ideal treatment resulting in either intraappointment complications, lessthan-ideal outcomes, or a generalized reduction in predictability will ironically now be predictable.

By learning about the patient with the patient (assessing and diagnosing each of the four categories together), having a fact-based conversation, and understanding the consequences of compromise, the anxiety around traditional case presentation and treatment complications is virtually eliminated, creating an environment in which the practitioner can thrive.

Personal Satisfaction

Anxiety, depression, and unethical choices can feed off of each other, creating momentum for a downward spiral from which it is difficult to recover, let alone reverse. Many practitioners feel a constant pressure just to survive. Financial pressure, treatment complications, and patients saying “no” to treatment can create the perfect recipe for the spiral. Facially generated treatment planning creates a platform for reliable systems in the office, consistent conversations with patients, and an office culture that supports health.

The systematic and predictable system eliminates the need to sell dentistry. Instead, the practitioner and dental team can facilitate health, helping patients make healthy and appropriate choices. If anything is being “sold,” it is health, a commodity in which the majority of patients have an interest and desire to acquire. That said, the practitioner has the opportunity and honor to work with the patient and for the patient, not on the patient. As a result, the practitioner will develop more confidence and competence creating momentum for an upward spiral that will feed itself for many years of rewarding and satisfying healthcare, creating beautiful teeth with predictable function and long-lasting comfort for which patients will pay with gratitude and appreciation.

Recruit for Rewards

You know first-hand the value you receive from your ADA membership. Through the community and resources you’ve come to count on, the ADA provides the support you need to help achieve your goals. You can help colleagues and friends thrive by inviting them to join the ADA.

For every 5 new members you recruit, you’ll receive a chance to win a 7-day interisland Hawaiian cruise* for you and a guest.

Eligibility

Who can recruit? Any ADA member dentist (including graduate student, resident, active licensed, active life, retired and retired life) is eligible to participate as a recruiter

Who can be recruited? Any degreed dentist who was not an ADA member in 2023 (including graduate students, residents)

Who is not eligible to be recruited for this program?

• A renewing member (someone who was a member in 2023)

• Dental students

• Retired dentists

How to Participate

• Newly recruited members are required to indicate the recruiter’s name and contact information as a referral on the membership application.

• ADA member recruiters will receive an email notification after the dentist referred has been accepted into membership.

• A raffle entry for quarterly drawings will be awarded for each new, active member recruited who pays national dues (as applicable) in the current year. Recruiters will receive a chance to win a 7-day Hawaiian cruise* for every five new recruited members who pay national dues (as applicable).

Recognition

• All recruiters will be recognized at SmileCon 2024. Top recruiters will receive additional recognition.

• Quarterly winners and top recruiters will be announced in ADA Morning Huddle.

For each new member

you recruit, you’ll be entered into a quarterly drawing for a chance to win $1,000 in prizes from ADA-endorsed providers or products from the ADA Store.

Program Rules

• This program will run January 1 – August 31, 2024.

• For each new, active member who joins in that timeframe, the referring member’s name will be entered into quarterly drawings for a chance to win $1,000 in prizes from ADAendorsed providers or products from the ADA Store. Referring members will also receive a chance to win a 7-day interisland Hawaiian cruise* for every five new, eligible members they recruit.

• Referring members will receive a qualifying entry each time their name is listed as the “referring member” on the new member’s application (one entry for quarterly drawings for every one member recruited, one entry for the grand prize drawing for every five members recruited). There is no limit to the number of new members who can be recruited or entries in the drawing.

• Referring members will automatically win a quarterly prize (up to $1,000 value) when they recruit 25 eligible new members. Quarterly prize winners are also eligible to win the grand prize should they recruit at least five new members.

• The grand prize drawing will take place at SmileCon® 2024 in New Orleans. SmileCon attendance is not required to win.

Ask the Powers Center

UTHealth Houston School of Dentistry

John M. Powers, PhD, Center for Biomaterials & Biomimetics

By Rade D. Paravina, DDS, MS, PhD Professor, Department of Restorative Dentistry and Prosthodontics; Director, John M. Powers, PhD, Center for Biomaterials & Biomimetics (PCBB); Ralph C. Cooley, DDS Distinguished Professor in Biomaterials; Vice President, American Academy of Esthetic Dentistry (AAED); Editor-in-Chief, Journal of Esthetic and Restorative Dentistry (JERD, Wiley, Impact Factor 3.2)

Chameleon Effect— Illusion or Reality?

Color-related properties of dental materials are closely associated with their esthetic performance. Resin composites with pronounced color adjustment potential (CAP), or “chameleon” effect in dental jargon) with surrounding enamel and dentin, improve the esthetic appearance of the restoration. These materials “work” for dental professionals by compensating for suboptimal shade matching or lack of an excellent match in the used material. Potential clinical benefits of resin composites with pronounced CAP include chairside efficiency, simplified shade matching, enhanced esthetics, and increased patient satisfaction. The “chameleon” effect of resin composites is currently a “hot topic” in restorative dentistry. Omnichroma (Tokuyama) was the first one-shade-fits-all resin composite that initiated a new trend, and quite a few one-shade or cloud/cluster shade composites (with a reduced number of shades, typically 3 to 5) have been introduced since then.

Some of the presently available one-shade composites: Clearfil Majesty ES-2 Universal (Kuraray); Charisma Diamond/Topaz (Kulzer); Transcend Universal, Ultradent; ZenChroma (President Dental); Admira Fusion x-tra (VOCO); Omnichroma (Tokuyama); Vittra APS Unique (FGM); Essentia Universal (GC). Another concept includes 3-5 cloud/cluster shades representing 16 Vita Classical shades.

Factors that influence the CAP of resin composites are related to a) Composite—brand, type, shade, filer size, and content; b) Cavity—type, size, depth, and beveling of cavity margins—due to high translucency, a blocker might be needed for classes III and IV; and c) Hard dental tissues surrounding the restoration—tooth shade, translucency, and enamel prism orientation.

Center: A Zenopal denture tooth with a class I cavity; Middle circle: Omnichroma replicas of denture teeth; Outer circle: A1-D4 denture teeth with class I Omnichroma restorations. The instrumental and visual comparisons of intact denture teeth and Omnichroma replicated teeth revealed a huge color mismatch. In contrast, the differences between denture teeth and their class I Omnichroma restorations were minimal, indicating a very good to excellent match.

References

1. Pereira Sanchez N, Powers JM, Paravina RD. Instrumental and visual evaluation of the color adjustment potential of resin composites. J Esthet Restor Dent. 2019; 31:465-70.

2. Ismail EH, Paravina RD. Color adjustment potential of resin composites: Optical illusion or physical reality, a comprehensive overview. J Esthet Restor Dent. 2022; 34:42-54.

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Practices For Sale

We are pleased to announce...

Hulen Dental

Mark Malone, D.D.S. has acquired the practice of have acquired the practice of Houston, Texas

Fort Worth, Texas

Veronica Y. Chen, D.D.S.

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

Jini P. Kuruvilla, D.D.S.

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

MULTI-MILLION DOLLAR PRACTICE OPPORTUNITY: Large GP located north of Houston is available with real estate. The office is in a stand-alone building with 8 ops and is in excellent condition, with digital x-rays, Pano, and paperless charts. The office operates 45 hours per week with 3 clinicians. There is over 6,500+ active patients, 70% Medicaid & 30% PPO/FFS, with an average of 96 new patients per month. Opportunity ID: TX-01979

ROOM FOR GROWTH WITH POSSIBLE IMMEDIATE MERGER OPTION: Fort Worth GP located in the retail level of a live/work/play community. The office has 3 ops fully equipped with digital x-ray, Pan and paperless patient files; 2 additional ops are available. The office is in excellent condition with newer equipment. The practice currently operates on 4 doctor days and one hygiene day per week. This practice has over 2,000 active patients that are a blend of 20% FFS, 65% PPO, & 15% Medicaid. Opportunity ID: TX-01913

HOUSTON HIGH-END OPPORTUNITY: L.V.I. trained GP located in a retail center with a popular anchor store next door. This office has 6 fully equipped ops and 1 plumbed. The office equipment averages 6 years old, including digital X-ray and Pano, as well as paperless charts. The practice is 90% FFS patients with a small amount of PPO. The office collected over $876K on a four-day workweek. This is a fantastic practice with the potential to grow for a motivated purchaser. Opportunity ID: TX-01884

TYLER/LONGVIEW OPPORTUNITY: Established GP located in a professional building. The office is 3,000 sq. ft. and in excellent condition. The office has 5 ops with digital X-rays, Pano and paperless charts. The practice recently collected $606K on just 3 doctor and 5 hygiene days per week. This 100% FFS practice has over 1,400 active patients. There is plenty of opportunity for growth by expanding both operating hours and procedures. Opportunity ID: TX-01373

Go to our website or call to request information on other available practice opportunities! 800.232.3826

5465 BLAIR ROAD STE 120, DALLAS,

FBI: Found But not Identified (yet)

The following is part of a series of articles intended to assist Texas medical examiners in giving a name to “unidentified” individuals using postmortem dental evidence.

Do you recognize the dental work/conditions presented?

Kathleen A. Kasper, DDS, D-ABFO

The Extent of the Problem

Over 600,000 individuals go missing in the United States every year. Fortunately, many missing children and adults are quickly found, alive and well. However, tens of thousands of individuals remain missing for more than 1 year—what many agencies consider “cold cases”.1

It is estimated that 4,400 unidentified bodies are recovered each year, with approximately 1,000 of those bodies remaining unidentified after 1 year.2

Medical examiner and coroner offices reported 11,380 unidentified remains on record as of 2018.3

The challenge in giving a name to these unidentified decedents is that the research and time invested can be extensive, expensive, and after normal protocols have been exhausted, many individuals still remain unidentified. The hope in writing this series of articles on long-term, unidentified deceased individuals in Texas is that one of the many Texas dentists who read the Texas Dental Journal will recognize the dental work presented as theirs or possibly remember a dental condition or feature that can give a name to the unidentified and help bring closure to the family.

Author

Kathleen A. Kasper DDS, D-ABFO

Dr Kasper has been practicing general dentistry in Carrollton, Texas, for 29 years. She is a graduate of the University of Iowa College of Dentistry.

She provides 3 counties in the Dallas-Ft. Worth Area with forensic dental services. These include Collin, Dallas, and Tarrant Counties. She is currently the only active board certified forensic dentist in north Texas.

She received her formal forensic odontology training at the University of Texas Health Science Center San Antonio, Texas, Center for Education and Research in Forensics (CERF) in 2003-2004.

Dr Kasper obtained Board Certification from the American Board of Forensic Odontology in 2010.

She is a fellow of the American Academy of Forensic Sciences, a member of the American Board of Forensic Odontology, and a member of the American Society of Forensic Odontology.

She is the current American Board of Forensic Odontology Dental Age Assessment Committee Chair.

Dr Kasper is also a published author in the Journal of Forensic Sciences and co-author of a chapter in each of 3 forensic textbooks.

Perhaps one of her greatest undertakings was chairing a working group for the American Dental Association that has published the “Technical Report” for Forensic Dental Age Estimation which went on to become a “standard” for the Organization of Scientific Area Committees (OSAC) for Forensic Science.

The Medical Examiner’s Protocol

to Legally

Identify Individuals

Medical examiners follow a specific protocol to identify individuals who are found without any presumptive identity. This protocol is described below and, in this order, depending on the condition of the body.

By far Latent Prints (finger, palm, sole), are the fastest and least expensive way to make a positive identification. This method of identification is not always possible if remains are severely decomposed, incinerated, or skeletonized.

Medically Implanted Devices (hip/ joint replacements, pacemakers), require knowing what hospital/ physician placed the device to get the matching serial number, which can be difficult.

Dental Records are also an easy, fast, and inexpensive way to identify a decedent; however, success depends on a presumptive identity and availability/ existence/quality of those antemortem (before death) dental records. If all leads for a presumptive identity are exhausted, then a postmortem (after death) dental charting/profile is created and entered in the NamUs (National Missing and Unidentified Persons System) and NCIC (National Crime Information Center) databases.

Anthropologic Methods will use skeletal features to make a positive identification.

DNA samples are collected. This takes the longest period of time and is most expensive. Depending upon the individual, it may involve obtaining DNA samples not only from the decedent but also from family members or multiple family members if known. If no matches are obtained, then:

DNA samples are submitted to CODIS (Combine DNA Index System) which is a computer program that operates local, state, and national databases of DNA profiles from convicted offenders, unsolved crime scene evidence, unidentified remains and missing persons. This is maintained by the Federal Bureau of Investigation. If this search fails then, the State of Texas requires medical examiners to submit a DNA sample from long-term unidentified decedents to the University of North Texas Center for Human Identification for additional genetic testing and comparison. This comparison may take up to a year to process, and a decedent may still remain unidentified once completed. This is the proverbial end of the road; therefore, all Texas dentists, dental auxiliaries and staff; can you help the Southwestern Institute of Forensic Sciences at Dallas County Medical Examiner’s Office give a name to the unidentified female decedent described in the following pages?

The Unidentified Individual:

Southwestern Institute of Forensic Sciences at Dallas County Medical Examiner (DCME) Case #IFS-20-15267

Date of Death (decedent found): August 18, 2020

Cause of Death: Blunt force trauma/sharp force injury to torso

Manner of Death: Homicide

Body Condition: Decomposed/partially skeletonized

Sex: Female

Ancestry: African American (Black)

Age: 20-27 years

Scene Description: An unknown Black female was found decomposing in a heavily wooded area near Pemberton Hill Road in Dallas, Texas.

Dental Evidence Recovered: Maxilla and Mandible, note; Tooth #7 , upper right lateral incisor, was not recovered.

Dental Postmortem Radiographs DCME Case #IFS-20-15267:

Note: Nose ring appears on periapical radiograph left maxillary sinus area apical tooth #16, upper left third molar. This decedent may have been wearing a nose ring before death, which postmortem is viewable in the left maxillary sinus.

Closing

If you believe you have any dental records, dental radiographs, intraoral/ extraoral dental photographs, dental scans, or other dental information regarding the unidentified female decedent described above as DCME Case #20-15267, please contact the Southwestern Institute of Forensic Sciences at Dallas County Medical Examiner’s Office at 214-920-5900, Press 1 and ask for Steven Kurtz, chief medicolegal death investigator or Keara St Louis, deputy chief medicolegal death investigator.

Please help give this individual a name!

References

1. Between 2007 and 2020, an average of 664,776 missing persons records annually were entered into the National Crime Information Center. See https://www.fbi.gov/ services/cjis/ncic.

2. Medical Examiners And Coroners’ Offices, 2004. Matthew J. Hickman, Ph.D., Kristen A. Hughes, M.P.A., Bureau of Justice Statistics, Kevin J. Strom, Ph.D., Jeri D. Ropero-Miller, Ph.D., DABFT, RTI International.

3. Medical Examiner and Coroner Offices, 2018. Connor Brooks, Bureau of Justice Statistics, November 2021.

Dental Existing Conditions

DCME Case #IFS-20-15267:

ethics corner

TDA Council on Ethics and Judicial Affairs

How to manage the principal-agent problem in dentistry

Ben Balevi, DDS, Dip EBHC (Oxford), MSc

This article is reprinted from The Journal of the American Dental Association and may not be copied, distributed, or modified without written permission from the American Dental Association. The article was reprinted with permission from The Journal of the American Dental Association (JADA) and published in the The Journal of the American Dental Association; 2022 Jun;153(6):588-589. doi: 10.1016/j.adaj.2022.04.001. ©2022 American Dental Association (ADA). Reprinted with permission from the ADA. All rights reserved.

Evidence-based clinical decision making between a dentist and the individual patient occurs in a world of imperfect information, uncertainty, and choice. In this dentistpatient relationship, there exists an asymmetry of knowledge in which the patient seeks the dentist’s specialized knowledge, which the patient lacks, to help make decisions that will maintain or improve their oral health. Hence, the relationship between the dentist and patient must be grounded on the patient’s trusting that the dentist functions in their best interest.

Sometimes, the patient may question the motives behind the dentist’s health care decision. Economists refer to this as the principal-agent problem, in which the dentist is the agent for the patient (that is, the principal).1 The problem refers to the imbalance of power between the patient and the dentist, based on knowledge differential. The patient may wonder whether the dentist’s priority is self-serving or whether they themselves have enough knowledge to make the best self-interested decision. The former addresses the risk of a moral hazard from the point of the dentist’s decision making, and the latter addresses the risk of adverse selection from the point of the patient’s decision making.

A moral hazard exists if the agent obtains all the rewards but incurs no consequence if the risks of the decision are realized.2 For example, a patient has an unrestorable abscessed third molar without any opposing tooth for occlusion and replacing it would not make the patient better off functionally or esthetically. However, the dentist may recommend an implant because it is profitable for them. The patient, however, incurs all the risks, including implant failure or a medical misadventure as an outcome of the surgery. This results in economically inefficient use of the patient’s limited health care resources.

Regulation addresses moral hazard through dental boards and colleges, whose missions are to assure patients that health care providers are held to an acceptable standard of care.

Adverse selection occurs when the patient follows through with treatment that, unbeknownst to them, is of minimal to no benefit or even harmful.2 For example, a dentist may comply with a patient’s request to replace their clinically sound amalgam restorations with composites because the patient read on the internet that there is an association between dental amalgams and multiple sclerosis.3 In such a case, the patient is using their economic resources inefficiently and risks potential future harm from dental surgery on a service they believe is beneficial when it is not.4

The patient can minimize the risk of adverse selection by seeking a second opinion or basing their oral health care decision on reliable information. Dentists can play a key role in minimizing this risk by serving as consultants in the shared decision-making approach.5 The dentist guides the patient in balancing the likelihood of achieving the desired outcomes against the cost and risk of harm for each treatment alternative. Better guidance and, therefore, better decisions result from quality information.6

In our current information age, patients seek and quickly find an abundance of information; however, the quality varies greatly depending on the source. Such sources include mass media, various internet-accessible outlets, word of mouth,

Dr Balevi is a practicing dentist and an adjunct professor, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.

Address correspondence to Dr Balevi, 306-805 W Broadway, Vancouver, BC, V4Z 1K1, Canada, email drben@dentalben.com.

Disclosures. Dr Balevi did not report any disclosures.

Dr Balevi thanks Dr Joel Epstein for his helpful suggestion on the preparation of this article.

Copyright ª

and the opinions of trusted friends. Despite advances in information access, patients still place the most trust in the guidance and opinion of their health care professional, particularly their dentist.7

Today, dentists are not only clinicians but are chief executive officers of small ambulatory dental hospitals. They have a responsibility to ensure their dental hospitals are economically sustainable.8 Dental practice sustainability requires that a dental practice efficiently use the available limited resources to allow for the continued running of its business while still maintaining its fiduciary duty to the patient. The fiduciary duty entails that the patient’s interest is paramount in any decision made concerning their care.

Patients expect that the care they receive from their dentist is evidence based. Specifically, clinical decision making should be based on the highest level of scientific evidence available, be based on clinical experience, and be patient-centered. Science alone does not dictate decisions but guides decisions along with the other components of evidence-based decision making.

Science is the systematic process of discovering nature’s secrets via objective means (that is, experimentation). Truth is rarely achieved from a single study. Science requires evidence from basic science to clinical outcomes from repeated studies that are well designed and, ideally, controlled and prospective in nature. A well-conducted systematic review of the scientific evidence is considered the best resource to assist in clinical decision making.9 At the patient level, this science guides the dentist-patient decision-making process in a world of imperfect information,

uncertainty, and choice. Hence, the skill of critically appraising information by means of assessing its validity, its clinical significance, and its applicability to the individual patient’s care is essential for the practical application of science to clinical decision making.

Critically appraising information requires the clinician and patient to address 3 fundamental questions:

1. Is the scientific resource trustworthy? All human investigative activities, including science, are prone to bias. The clinician must identify the biases in the resource and determine how much they threaten the validity of its assertions. Suppose overwhelming commercial interest is at play, in which case the resource may be less reliable and hence may play less of a role in the clinical decision.10 This can be addressed by assessing the study design and critically reviewing study methods, statistics, results, and discussion.

2. Are the results and conclusions of the resource clinically important? If the first question is satisfied, the dentist must assess whether the study’s results are clinically significant. In other words, is the estimated effect or outcome large enough that it is worthy of consideration or so small that it is likely clinically insignificant?

3. Is the information asserted from the resource important to the patient? Finally, the clinician and patient must decide whether the clinically significant reported outcome is relevant to them. For example, Rao and colleagues reported a statically significant improvement in periodontal outcomes in smokers treated with

Dental practice sustainability requires that a dental practice efficiently use the available limited resources to allow for the continued running of its business while still maintaining its fiduciary duty to the patient.

1% metformin in conjunction with nonsurgical periodontal therapy.11 Although this study may be relevant to patients who smoke, no conclusion is appropriate for nonsmoking patients.12

CONCLUSIONS

Dentists are privileged to be helping professionals, alleviating human suffering, and promoting our patients’ oral health. Dentists must be conscious of their position of power over the patient to avoid taking advantage of it. Specifically, care should be safe, evidence based, and respectful of the patient’s personhood and should involve patients actively in all clinical decisions regarding their oral health care.

References

1. Hashimzade N, Myles G, Black J. A Dictionary of Economics. 5th ed. Oxford University Press; 2017.

2. Calhoun C. Dictionary of the Social Sciences. Oxford University Press; 2002.

3. Inacio P. MS patients should avoid ‘silver’ tooth fillings due to mercury, FDA advises. Multiple Sclerosis News Today. October 2, 2020. Accessed January 20, 2022. https:// multiplesclerosisnewstoday.com/news-posts/2020/1 0/02/ fda-advises-ms-patients-avoid-amalgam-tooth-fillingsdue-to-mercury-content/

4. Dental amalgam fillings recommendations: graphics. U.S. Food & Drug Administration. Accessed January 20, 2022. https://www.fda.gov/medical-devices/dental-amalgamfillings/dental-amalgam-fillings-recommendationsgraphics.

5. Beach MC, Sugarman J. Realizing shared decisionmaking in practice. JAMA. 2019;322(9):811-812.

6. Alonso-Coello P, Schünemann HJ, Moberg J, et al.; the GRADE Working Group. GRADE evidence to decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices, 1—introduction. BMJ. 2016;353:i2016.

7. Hendrick B. Survey shows Americans trust their doctors: most in U.S. don’t feel they need to get a second opinion. WebMD. December 3, 2010. Accessed January 20, 2022. http://www.webmd.com/news/20101203/ survey-shows-americans-trust-their-doctors

8. Spangenberg JH. Economic sustainability of the economy: concepts and indicators. Int J Sustainable Dev. 2005;8(1–2):47-64.

9. Carrasco-Labra A, Brignardello-Petersen R, Azarpazhooh A, Glick M, Guyatt G. How to use a systematic review and meta-analysis. In: Carrasco-Labra A, BrignardelloPetersen R, Glick M, Azarpazhooh A, Guyatt G, eds. How to Use Evidence-Based Dental Practices to Improve Your Clinical Decision-Making. American Dental Association Publishing; 2020.

10. Lundh A, Lexchin J, Mintzes B, Schroll JB, Bero L. Industry sponsorship and research outcome. Cochrane Database Syst Rev. 2017;2:MR000033.

11. Rao NS, Pradeep AR, Kumari M, Naik SB. Locally delivered 1% metformin gel in the treatment of smokers with chronic periodontitis: a randomized controlled clinical trial. J Periodontol. 2013;84(8):1165-1171.

12. Balevi B. Applying basic math to periodontal decisionmaking. Gen Dent. 2021;69(4):56-63.

ORAL and maxillofacial pathology

case of the month

Case History

A 68-year-old Caucasian female was referred by her general dentist to an oral surgeon, for the management of asymptomatic, adherent white plaques of unknown duration, suspicious for frictional keratosis. She had an extensive adherent white plaque located on her left buccal mucosa. A similar adherent white plaque was observed on her right buccal mucosa and she had a white film over her right edentulous crestal mandibular gingiva, anterior to the retromolar pad region in site of missing tooth #32 (Figures 1, 2). The white film located on

AUTHORS

Ngozi Nwizu, BDS, MMSc, PhD, TTS

Associate Professor

Board Certified Oral and Maxillofacial Pathologist

Department of Diagnostic and Biomedical Sciences

UTHealth at Houston School of Dentistry, Houston, Texas

Jeff Alford, DDS

Board Certified Oral & Maxillofacial Surgeon, Austin, Texas

Figure 1. Image of left buccal mucosa

Figure 2. Image of right buccal mucosa

the gingiva partially wiped off with gauze. The patient’s medical history was significant for noninsulin dependent diabetes mellitus, psoriasis, and gastroesophageal reflux disease (GERD) (OTC meds only). Her family history was significant for cancer (father—type unknown). The oral surgeon obtained 2 biopsy specimens from the left buccal mucosa.

One tissue specimen was placed in formalin for routine light microscopy studies. The second tissue specimen was placed in Michel’s solution for direct immunofluorescence (DIF) testing.

Microscopic analysis showed a wedge of oral mucosa covered by a thick layer of orthokeratinized, stratified squamous epithelium exhibiting epithelial atrophy, mild lymphocytic exocytosis, and thickening of the basement membrane zone. In addition, focal areas of basal cell degeneration were present and a segment of the epithelium showed complete separation from the underlying connective tissue stroma (subepithelial clefting). The papillary lamina propria demonstrated scattered hyperemic blood capillaries and a “band-like” infiltrate of inflammatory cells, consisting predominantly of lymphocytes.

Examination of the deeper layers of the connective tissue stroma revealed the presence of lobules of mature adipocytes amidst thicker-walled blood vessels (Figures 3, 4).

What is the differential diagnosis?

What is the final diagnosis?

See page 98 for the answer and discussion.

Figure 4. Demonstrates the presence of epithelial atrophy and a “bandlike” infiltrate of inflammatory cells, consisting predominantly of lymphocytes. (Medium magnification x 50).

Figure 3 Reveals a thick layer of orthokeratinized, stratified, squamous epithelium, demonstrating epithelial separation from the underlying connective tissue stroma. (Low magnification x 20).

ORAL and maxillofacial

pathology

diagnosis and management—from page 97

DIAGNOSIS: LICHEN PLANUS PEMPHIGOIDES

Diagnosis

The clinical features resembled the plaque-like variant of lichen planus. The microscopic features were also consistent with the plaque-like variant of lichen planus, although the presence of focal subepithelial clefting was more suggestive of bullous lichen planus or mucous membrane pemphigoid. The results of the DIF studies performed, with appropriate positive and negative controls, were similar to those seen in mucous membrane pemphigoid. Strong linear deposition of IgG at the epithelium-connective tissue interface, mild positivity for C3, and focal positivity with fibrinogen were seen. DIF was negative for IgA and IgM, respectively (Figures 5–7).

Discussion

Lichen planus pemphigoides (LPP) is a rare acquired autoimmune vesiculobullous condition that primarily affects the skin but infrequently affects the mucous membranes.1,2 LPP is considered idiopathic in origin, however, certain medications have been identified as triggering agents. The use of Captopril, an anti-hypertensive drug, and Simivastatin, used in the treatment of hyperlipidemia, have been reported in the scientific literature to trigger the development of LPP.3,4 Several other medications have also been implicated and include ramipril, furosemide, and cinnarizine.4 Other known triggers include viral infections such as varicella and hepatitis B and C infections.5

LPP has a slight female predilection with a mean age at presentation of 54 years.6 When it occurs in children, the palms and soles of feet are the most often affected.6 LPP is characterized clinically by the presence of bullous lesions that develop within or adjacent to pre-existing lichen planus or lichenoid lesions.1 The average time period between the development of lichen planus and the subsequent development of LPP is about 8 months.6 The gingiva and buccal mucosa are the most affected sites in oral LPP, where it presents as desquamative gingivitis, ulcerations, and adherent white striations (Wickham striae). Bullae formation is occasionally present.1 Patients with LPP tend to run a course of extensive blistering disease more than those with traditional lichen planus.7 The microscopic findings display combined features of a lichenoid and bullous lesion. The lichenoid features of LPP comprise of hyperkeratosis, vacuolar change at the epithelial-connective junction with Civatte bodies, interface mucositis,

Figure 5. Direct immunofluorescence studies showing strong, linear positivity with IgG. (High magnification x 100).

LPP was formerly thought to belong to the pemphigoid group of disease conditions. Computer-aided fluorescence overlay antigen mapping and laser scanning confocal microscopy of the tissue specimen, demonstrate in situ antibodies colocalized with beta4 integrin. Beta4 integrin is a marker for the keratinocyte basal plasma membrane and upper lamina lucida, which is consistent with the location of bullous pemphigoid antigens.2

Antibodies seen in patients with LPP have also been shown to be directed against BP 180 kDA antigen, which is expressed in the hemidesmosomes, at the dermal-epidermal junction.9 Furthermore, LPP has been linked with the development of autoantibodies against type XVII collagen (COL17).5 These research studies all favor LPP being a part of the pemphigoid group of disease conditions. However, more recent research evidence indicates that LPP should be considered a distinct disease category, different from the bullous pemphigoid or lichen planus families.5

and a subepithelial band-like lymphocytic infiltrate.8 The bullae associated with LPP are subepithelial in nature and resemble those of bullous pemphigoid or mucous membrane pemphigoid, although they are usually accompanied by increased numbers of neutrophils in comparison to bullous pemphigoid.7 The gold standard for the confirmation of LPP is the recognition of the typical clinical features of lichen planus/lichenoid reaction, in addition to the demonstration of IgG and C3, along the dermal-epidermal junctional zone, using direct immunofluorescence of perilesional biopsies.5,8

Our patient’s LPP lesions were limited to the oral mucosa. Although LPP is more commonly seen on the skin, there have been documented cases of LPP lesions restricted to the mucous membranes.1,10 Our patient also has a history of psoriasis, and although LPP and psoriasis are 2 distinct entities, there has been at least one case report of the coexistence of both conditions and of LP and psoriasis.11,12 There is significant overlap between the clinical and microscopic features of oral LPP, and lichen planus (LP), bullous pemphigoid (BP) and mucous membrane pemphigoid (MMP), respectively. The accurate diagnosis of LPP necessarily involves the exclusion of these other disease entities.

Figure 6. Direct immunofluorescence studies showing mild, linear positivity with IgG. (High magnification x 100).

Figure 7. Direct immunofluorescence studies showing focal positivity with fibrinogen. (High magnification x 100).

ORAL

and maxillofacial pathology continued

Lichen planus (LP) is a chronic, autoimmune condition mediated by T-cells, predominantly cytotoxic CD8+ cells.13 It involves the skin and/ or mucous membranes, hair and nails, and affects all ages, but middle-aged adults are most often affected, while children are rarely affected14. There is no racial or sex predilection among patients with cutaneous involvement, however, 60%–70% of females, especially perimenopausal women, are predominantly affected in cases with oral mucosa involvement.14 Oral lichen planus has a prevalence rate of approximately 1.5% of the population.15

Cutaneous lichen planus is usually recognized by the presence of pruritic, planar (flat-topped), polygonal, purplish, papules, (the 5Ps) against a background of fine white lines (Wickham’s striae), localized to the wrists, forearms, distal lower extremities and the presacral area.16,17 The oral lesions usually present as adherent white patches in a reticular, lace-like pattern on the buccal mucosa bilaterally, tongue or other mucosal sites. Other mucosal areas may also be involved such as the genitalia and esophagus. Mucosal lesions are often asymptomatic or may be accompanied by burning sensation or erosive lesions.16,17 Microscopic findings are characterized by the presence of hyperkeratosis, colloid bodies within the epithelium, basal cell degeneration, a band-like infiltrate at the superficial lamina propria, and sometimes, subepithelial clefting.18 DIF studies demonstrate a strong, shaggy positivity with fibrinogen along the basement membrane zone.19

Bullous pemphigoid (BP) is a common autoimmune blistering condition that predominantly affects the elderly (above the age of 70 years, and both sexes equally.20,21 Lesions usually present as itchy, tense, often hemorrhagic blisters, involving the skin. The axillary folds, lower abdomen, inguinal area and inner parts of the thighs and extremities are often affected. Mucosal surfaces are involved in only about 10%–30% of the cases, mostly in the oral, esophageal and genital regions.22 Microscopic features are characterized by the presence of eosinophilic spongiosis or subepithelial bullae with eosinophils. Direct and indirect immunofluorescent studies show IgG and/or C3 deposition at the basement membrane. Enzymelinked immunosorbent assay (ELISA) can also be used to measure circulating autoantibodies against BP180 and/or BP230.22

Mucous membrane pemphigoid (MMP) is a chronic autoimmune subepithelial blistering condition that mainly affects the mucous membranes and often heals with scarring.23 Affected persons are usually in their eighties and women are affected twice as often as males.24 The oral mucosa (85%) and ocular mucosa (65%) are most commonly affected, but the skin is less commonly involved (25%-30%).25 The manifestations of the disease can be very serious and early diagnosis of the disease is crucial because once scarring occurs, therapeutic options are limited.26 Histologic features show the presence of subepithelial bullae associated with a mixed inflammatory cell infiltrate of eosinophils,

lymphocytes and neutrophils.25 DIF testing shows a linear positivity of IgG and/or C3, and less commonly, IgA, along the epithelial basement membrane zone.21,27 Ophthalmology consultation is usually recommended to detect incipient lesions and prevent the possibility of subsequent progression to blindness.

Individuals with LPP present in their forties or fifties, with milder lesions that are mostly limited to the extremities. This contrasts sharply with those individuals with BP, who are usually older and present with pruritic, generalized and more severe lesions.1,5,28 LPP, LP, and BP can be all be triggered by certain medications.5

LPP patients are usually treated by topical or systemic corticosteroids, depending on clinical severity and are usually co-managed with dermatologists when skin lesions are present. Patients who develop LPP due to a medication may benefit from cessation of the medication, in addition to the use of corticosteroid therapy.

Definitive diagnosis of oral LPP usually requires the identification of the clinical and microscopic features of the oral mucosal lesions, showing concomitant LP/lichenoid lesions and bullae formation/ulcerations, reminiscent of BP or MMP. DIF testing of perilesional tissue is used to confirm the diagnosis, demonstrating strong linear IgG and C3 positivity along the dermal-epidermal junctional zone. Isolated oral LPP without skin lesions is quite rare and is often not considered in the differential diagnosis of lesions that appear lichenoid in nature. As a consequence, biopsy specimens are often sent for routine light microscopic analyses. This case report highlights the importance of conducting ancillary DIF testing, in conjunction with routine light

microscopic analyses, to confirm the presence of LPP and to rule out LP, BP, or MMP.

References

1. Sultan A, Stojanov IJ, Lerman MA, Kabani S, Haber J, Freedman J, Woo SB. Oral lichen planus pemphigoides: a series of four cases. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015 Jul;120(1):5868. doi: 10.1016/j.oooo.2015.03.012. Epub 2015 Apr 13. PMID: 25953638.

2. Solomon LW, Helm TN, Stevens C, Neiders ME, Kumar V. Clinical and immunopathologic findings in oral lichen planus pemphigoides. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 Jun;103(6):808-13. doi: 10.1016/j. tripleo.2006.03.020. Epub 2006 Sep 12. PMID: 17531940.

3. Ben Salem C, Chenguel L, Ghariani N, Denguezli M, Hmouda H, Bouraoui K. Captopril-induced lichen planus pemphigoides. Pharmacoepidemiol Drug Saf. 2008 Jul;17(7):722-4. doi: 10.1002/pds.1618. PMID: 18489011.

4. Stoebner PE, Michot C, Ligeron C, Durand L, Meynadier J, Meunier L. Lichen plan pemphigoïde induit par la simvastatine [Simvastatin-induced lichen planus pemphigoides]. Ann Dermatol Venereol. 2003 Feb;130(2 Pt 1):187-90. French. PMID: 12671581.

5. Hübner F, Langan EA, Recke A. Lichen Planus Pemphigoides: From Lichenoid Inflammation to AutoantibodyMediated Blistering. Front Immunol. 2019 Jul 2;10:1389. doi: 10.3389/ fimmu.2019.01389. PMID: 31312198; PMCID: PMC6614382.

6. Zaraa I, Mahfoudh A, Sellami MK, Chelly I, El Euch D, Zitouna M, Mokni M, Makni S, Ben Osman A. Lichen planus pemphigoides: four new cases and a review of the literature. Int J Dermatol. 2013 Apr;52(4):406-12. doi: 10.1111/j.1365-4632.2012.05693.x. Epub 2013 Jan 20. PMID: 23331194.

7. Gawkrodger DJ, Stavropoulos PG, McLaren KM, Buxton PK. Bullous lichen planus and lichen planus pemphigoides—clinico-pathological comparisons. Clin Exp Dermatol. 1989 Mar;14(2):150-3. doi: 10.1111/j.13652230.1989.tb00914.x. PMID: 2598489.

8. Stingl G, Holubar K. Coexistence of lichen planus and bullous pemphigoid. A immunopathological study. Br J Dermatol. (1975) 93:313–20. 10.1111/ j.1365-2133.1975.tb06497.

9. Tamada Y, Yokochi K, Nitta Y, Ikeya

T, Hara K, Owaribe K. Lichen planus pemphigoides: identification of 180 kd hemidesmosome antigen. J Am Acad Dermatol. (1995) 32:883–7. 10.1016/0190-9622(95)91554-0.

10. Mignogna MD, Fortuna G, Leuci S, Stasio L, Mezza E, Ruoppo E. Lichen planus pemphigoides, a possible example of epitope spreading. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Jun;109(6):837-43. doi: 10.1016/j. tripleo.2009.12.044. Epub 2010 Apr 9. PMID: 20382044.

11. Khushboo, Subramanian S, Venkateswaran S, Nydile SV, Navein RK, Lichen planus pemphigoides in coexistence with psoriasis: A case report. IP Indian J Clin Exp Dermatol 2019;5(2):176-179. https://doi. org/10.18231/j.ijced.2019.038

12. Shiohara T, Hayakawa J, Nagashima M. Psoriasis and lichen planus: coexistence in a single patient. Are both diseases mutually exclusive? Dermatologica. 1989;179(4):178-82. doi: 10.1159/000248355. PMID: 2533568.

13. Sugerman PB, Satterwhite K, Bigby M. Autocytotoxic T-cell clones in lichen planus. Br J Dermatol. 2000 Mar;142(3):449-56. doi: 10.1046/j.13652133.2000.03355.x. PMID: 10735949.

14. Le Cleach L, Chosidow O. Clinical practice. Lichen planus. N Engl J Med. 2012 Feb 23;366(8):723-32. doi: 10.1056/NEJMcp1103641. PMID: 22356325.

15. McCartan BE, Healy CM. The reported prevalence of oral lichen planus: a review and critique. J Oral Pathol Med. 2008 Sep;37(8):447-53. doi: 10.1111/j.1600-0714.2008.00662.x.

Epub 2008 Jul 9. PMID: 18624932.

16. Ioannides D, Vakirlis E, Kemeny L, Marinovic B, Massone C, Murphy R, Nast A, Ronnevig J, Ruzicka T, Cooper SM, Trüeb RM, Pujol Vallverdú RM, Wolf R, Neumann M. European S1 guidelines on the management of lichen planus: a cooperation of the European Dermatology Forum with the European Academy of Dermatology and Venereology. J Eur Acad Dermatol Venereol. 2020 Jul;34(7):1403-1414. doi: 10.1111/jdv.16464. PMID: 32678513.

17. van der Meij EH, van der Waal I. Lack of clinicopathologic correlation in the diagnosis of oral lichen planus based on the presently available diagnostic criteria and suggestions for modifications. J Oral Pathol Med. 2003 Oct;32(9):507-12. doi: 10.1034/j.16000714.2003.00125.x. PMID: 12969224.

18. Woo, S.B., 2016. Oral Pathology E-Book: A Comprehensive Atlas and Text. Elsevier Health Sciences.

19. Kulthanan K, Jiamton S, Varothai S, Pinkaew S, Sutthipinittharm P. Direct immunofluorescence study in patients with lichen planus. Int J Dermatol. 2007 Dec;46(12):1237-41. doi: 10.1111/j.13654632.2007.03396.x. PMID: 18173515.

20. Ujiie H, Nishie W, Shimizu H. Pathogenesis of bullous pemphigoid. Dermatol Clin. 2011;29:439–446. ix.

21. Schmidt E, Zillikens D. Pemphigoid diseases. Lancet. 2013 Jan 26;381(9863):320-32. doi: 10.1016/ S0140-6736(12)61140-4. Epub 2012 Dec 11. PMID: 23237497.

22. Miyamoto D, Santi CG, Aoki V, Maruta CW. Bullous pemphigoid. An Bras Dermatol. 2019 Mar-Apr;94(2):133-146. doi: 10.1590/abd1806-4841.20199007. Epub 2019 May 9. PMID: 31090818; PMCID: PMC6486083.

23. Alrashdan MS, Kamaguchi M. Management of mucous membrane pemphigoid: a literature review and update. Eur J Dermatol. 2021 Oct 27. doi: 10.1684/ejd.2021.4132. Epub ahead of print. PMID: 34704944.

24. Woo SBGM. Ulcerative, vesicular, and bullous lesions. In: Greenberg MSGM, Ship JA, editors. Burket’s Oral Medicine: Diagnosis and Treatment. 11. Hamilton: B.C. Decker Inc; 2008.

25. Xu HH, Werth VP, Parisi E, Sollecito TP. Mucous membrane pemphigoid. Dent Clin North Am. 2013 Oct;57(4):611-30. doi: 10.1016/j.cden.2013.07.003. Epub 2013 Aug 15. PMID: 24034069; PMCID: PMC3928007.

26. Srikumaran D, Akpek EK. Mucous membrane pemphigoid: recent advances. Current opinion in ophthalmology. 2012;23:523–7.

27. Chan LS, Ahmed AR, Anhalt GJ, et al. The first international consensus on mucous membrane pemphigoid: definition, diagnostic criteria, pathogenic factors, medical treatment, and prognostic indicators. Arch Dermatol. 2002;138:370–9.

28. Hübner F, Recke A, Zillikens D, Linder R, Schmidt E. Prevalence and Age Distribution of Pemphigus and Pemphigoid Diseases in Germany. J Invest Dermatol. 2016 Dec;136(12):2495-2498. doi: 10.1016/j. jid.2016.07.013. Epub 2016 Jul 25. PMID: 27456755.

Our compliance advisors have conducted over 1,500 inspections of dental practices across the country. Here are three often overlooked areas of OSHA and HIPAA compliance that can lead practices to trouble; and what kinds of penalties non-compliant practices could receive.

Three Commonly Overlooked Areas

Annual Training

Annual training is mandated by OSHA’s Department of Labor, and it should be a cornerstone of creating a culture of safety at every practice.

Why? When team members participate in annual training, they implement the nuances of proper personal protective equipment usage, infection control protocols, and hazard communication. In other words, team members gain a deeper understanding of safety protocols, as opposed to a cursory one.

Hazard Communication

Does your practice have an annually updated Hazard Communication written program?

Does it contain a clear explanation of how your practice handles hazardous and secondary chemical labeling? Crucially, is this program effectively implemented? I.e., do all team members have easy access to it and understand its impact on their daily interactions with chemicals in the practice?

If not, you join the ranks of many who are (likely inadvertently) non-compliant with OSHA regulations.

Notices of Privacy Policy

When was the last time you delved into that 5 or 6-page document, Notices of Privacy Policy (NPP)?

If the effective date harks back to September 2013—the last time there were substantial revisions to the patient privacy laws—it’s time for an update. An outdated NPP can draw unwanted attention from the Office for Civil Rights (OCR), the regulatory body governing HIPAA violations.

There’s a myriad of other documents that necessitate regular revisitation and updates, including Safety Data Sheets (SDS), their collection, organization, and maintenance, that are a part of regulatory compliance.

About Penalties

OSHA violations presently average between $4,200–$9,200. This wide range reflects the range of severity a violation could have (e.g., “serious,” “repeat,” or “willful”).

For context, a recent OSHA citation highlighted an unmounted fire extinguisher as a “serious” violation.

Non-compliance in areas such as annual training and practice risk assessments could be what separates a category 1 violation from a category 4 (“willful neglect”) violation.

Often, non-compliance is not a result of willful neglect but a matter of not knowing what one doesn’t know. While there’s an understanding that many practitioners tend to be hard of hearing when it comes to HIPAA standards, regulatory agencies might not be forgiving.

Regardless of the category, a visit from the OCR can bring operations to a standstill while charts are scrutinized and documents obtained. Prevention, as they say, is better than a cure.

What can you do?

OSHA and HIPAA compliance in dentistry requires dedication and a precise understanding of regulatory nuances.

Smart Training advisors have encountered instances where documents, written programs, and training materials were cobbled together via Microsoft Word. While the efforts made are commendable, one can’t help but wonder if the practice owner might have invested their time and resources more wisely taking care of patients rather than hunched over a computer late at night under the soft glow of a Costco office lamp.

Practice owners that don’t have the time or inclination to implement a safety program can benefit greatly from the help of a compliance expert.

Smart Training’s compliance advisors have helped dental practices all over the country get in compliance. TDA members receive a 10% discount off retail pricing. For information on Smart Training, visit tdaperks.com (Compliance & Supplies) or call Smart Training at 469-342-8300.

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ALL TEXAS LISTINGS FOR MCLERRAN & ASSOCIATES. AUSTIN-NORTH (ID #604): Legacy FFS practice with an impeccable reputation located in a budding community north of Austin. The office has relied solely on word-of-mouth referrals with very little marketing/advertising and refers out many specialty procedures leading to upside potential for an incoming buyer. The real estate is also available for purchase. AUSTIN (ID #636): Rare opportunity to purchase a turnkey, FFS/ PPO general dentistry practice and real estate in Austin. This spacious 2,500 sq ft office features 4 operatories, digital radiography, iTero, and paperless charts. The practice is situated in a highly desirable Austin community. AUSTIN (ID #646): Legacy general dentistry practice in south Austin. 1,800+ sq ft office, 4 fully equipped operatories with computers in ops, digital radiography, intraoral cameras, and paperless charts. The practice serves a multi-generation, FFS/PPO patient base with substantial room for growth by way of keeping specialty procedures in-house (orthodontics, oral surgery, endo, implants all referred out). AUSTIN (ID #649): PPO/FFS general dentistry practice in Austin. Located in a retail center off a

busy street, the office features 3 computerized operatories, digital X-ray sensors, digital pano, Itero scanner, and paperless charts. With 1,800+ active patients and 50+ new patients per month, this office is set up for immediate and future success. DALLAS (ID #650): Beautiful, state-of-the-art, general dentistry practice located in a budding suburb just north of the DFW metroplex. The large, freestanding building is ideally located with access to a major thoroughfare and provides ample space for future growth in the 7 well-appointed operatories featuring digital radiography, computers throughout, digital scanner, and a milling unit. The office treats a large PPO/FFS patient base with approximately 20 new patient visits per month, robust hygiene recall, and over 2,200 active patients. HOUSTON-SOUTHWEST (ID #625): Modern GD practice in a highvisibility retail location in a desirable suburb in southwest Houston. Large, 2,800 sq ft office that features 6 fully equipped operatories, computers in operatories, intra oral cameras, a digital scanner, and CBCT. The practice is on track to collect over 7 figures in 2023 with strong historical year over year growth. The office serves a primarily FFS patient base with a limited number of patients in-network, has

over 1,450 active patients, and has added 25+ new patients per month over the last 12 months. HOUSTON-SOUTHEAST (ID #644): 100% FFS, legacy practice in SE Houston. The 2,500+ sq ft office features 7 ops, computers throughout, digital pano, digital X-rays, digital scanner, intraoral cameras, and paperless charts. If you’re looking for a centrally located, profitable practice with a dedicated patient base and room to grow, call us now for more details. 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 #639): Legacy, general dentistry practice with a stellar reputation in north San Antonio. The practice serves a large, majority fee-for-service patient base with over 1,900 active patients and sees approximately 20 new patients per month. The fully digital office has 5 equipped operatories with computers in all ops, digital radiography, intra oral cameras, paperless charts, and a digital pano. SAN ANTONIO (ID #654): PPO/FFS general dentistry practice in San Antonio. The 3,000+ sq ft office

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is prominently located on a busy street and features 6 computerized operatories, digital X-ray sensors, digital pano, digital scanner, intraoral cameras, and paperless charts. With 2,000+ active patients, 25+ new patients a month, and a stellar reputation, this practice is poised for continued success.

TEXAS HILL COUNTRY, ORTHO (ID #616): Rare opportunity to purchase an orthodontic practice located in a serene, rapidly growing community in the Texas hill country (Austin, San Antonio, and the Texas wine country all available within a short drive). State-of-the-art facility with extensive, modern upgrades and top-of-the-line digital technology. The buyer will have the option of purchasing or leasing the real estate. The current owner will be retiring but is available to provide a transition period to the incoming buyer. SOUTH TEXAS (ID #651): General dentistry practice located in south Texas. This state-of-the-art office occupies 3,500 sq ft with room for 10 total operatories, is fully digital with CBCT, a digital scanner, handheld X-ray units, and a 3-D printer. The practice serves a large PPO/ Medicaid patient base with over 3,000 active patients seen over the last 24 months with a strong monthly new patient flow. TO REQUEST MORE INFORMATION ON MCLERRAN &

ASSOCIATESí 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. 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

McLerran & Associates is the largest dental practice brokerage firm in Texas. When it’s time to buy or sell a practice, we’ve got you covered.

SALES

DSO C S

Austin 512-900-7989

DFW 214-960-4451

Houston 281-362-1707

San Antonio 210-737-0100

South Texas 361-221-1990

Email: texas@dentaltransitions.com

www.dentaltransitions.com

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practice on a high visibility outer loop highway near mall, hospital and mature neighborhoods. Located within a beautiful single-story, freestanding 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 800-930-8017 or Christopher@DDRDental. com and reference “Lufkin General or TX#540”.

HOUSTON: GENERAL (SHARPSTOWN). Well established 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 800-930-8017 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 soughtafter upscale neighborhood. It is on a major thoroughfare with high visibility in a strip shopping center. The practice has 3 operatories for hygiene and 2 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 3.5 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”.

LAKE JACKSON: Located 40 minutes outside Houston. Are you seeking a dental practice that is fee-for-service, located in a great community with a robust economy (Dow Chemical, BASF, and Freeport LNG), and strongly rooted in the community with an exceptional reputation? Would you like to work with well trained and tenured staff? If yes, this is a great opportunity for you, we are seeking a dentist committed to excellence and providing the best possible dentistry available. The practice has blended a strong cosmetic and implant practice with family dentistry. Seeking associate for a busy and ever expanding practice. Great compensation, sign on bonus, and benefit package. AGD or GPR preferred or 2 years experience. To inquire about this opportunity contact Dr Brian Bell at bkbellgolf@hotmail. com; office phone: 979-297-1201; 102 Flag Lake Dr, Ste C, Lake Jackson, TX 77566.

ROCKPORT: Practice for sale in Rockport. Two chairs, plumbed for 3. Currently being worked 3 days a week producing near mid-6 figures. Fee for service, no DMO, HMO or PPO contracts. Hygienist 3 days a week and will stay, been with practice since 2019. Digital X-rays, paperless, Newtom 3D/Panorex, 3 X-ray sensors. Practice is in older house, which can be leased or purchased. Great starter practice or for someone slowing down and wants to live on the coast. Send inquires to jim@jlongdds.com or call: 281-726-1812, leave message.

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.