New Dentist Summer 2010 by The New Dentist

THE #1 JOURNAL FOR NEW DENTISTS

Rising out of DEBT to SUCCESS P LUS

Internationally recognized periodontist Dr. Marc Nevins discusses Regenerative Periodontics Discover What Ultradent is offering New Dentists SUMMER 2010

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FROM THE PUBLISHER’S DESK SUMMER 2010

Dear Readers,

PUBLISHER

elcome to the summer issue of The New Dentist™. The temperatures outside are climbing. For new dentists, unfortunately, debt is on the rise as well. According to the American Dental Education Association, dental students graduating in 2009 left school with well over $150,000 in debt on average. For some, that number was above $200,000. Consequently, many new dentists enter the profession feeling the pressure to produce. They experience anxiety about making major purchases. And many struggle to enjoy their chosen career in the early years because of the weight of this huge financial burden. In this issue of The New Dentist™, Dr. Sepideh Malekpour shares her “debt to success” story, and what she did to get her financial situation under control. Also, internationally recognized periodontist Dr. Marc Nevins writes about recent advances in regenerative therapies, such as periodontal regeneration, which have significantly improved the ability to restore damaged periodontal tissues. In addition, we decided to start asking dental companies the question: What are You Doing for New Dentists? Discover what Ultradent is doing specifically to help new dentists as well as dental students, from sizeable special discounts on supplies and equipment, to assistance for students transitioning from academic to professional life, and more. In addition, Dr. Josh Austin shares information on the five essential dental procedures that every new dentist must be prepared to perform. Don’t leave school without these! Finally, I recently had the pleasure of talking to New Dentist reader, Dr. James Lucero of Overland Park, KS. He called to request an extra copy of the magazine. Interestingly, The New Dentist™ and JADA are the only two publications he keeps on his desk. I asked him what he liked about The New Dentist™ and for this busy doctor, it comes down to the fact that the publication is quick and easy to read and the information is relevant to today’s new dentists. I hope that each of you finds that to be the case as well. And I encourage you to learn more about the many services available to new dentists at www.thenewdentist.net. You’ll discover a wealth of materials to guide you at every step throughout your dental career.

Fondly,

Sally McKenzie, Publisher

visit www.thenewdentist.net #1 Web-site for New Dentists 2 WWW.THENEWDENTIST.NET S U M M E R 2 0 1 0

Sally McKenzie Sally@thenewdentist.net DESIGN AND PRODUCTION

Picante Creative picantecreative.com Managing Editor

Tess Fyalka Tess@thenewdentist.net Consulting Editors

Tom Snyder, DMD, MBA Jim Stehman, DMD Keith W. Dickey, BS, DDS, MBA, SIU, School of Dental Medicine SALES AND MARKETING

For display advertising information contact ads@thenewdentist.net or visit our digital media book at www.thenewdentist.net/ mediabook.htm The New Dentist™ Magazine is published quarterly by The McKenzie Company (3252 Holiday Court, Suite 110, La Jolla, CA 92037) on a controlled/complimentary basis to dentists in the first 10 years of practice in the United States. Single copies may be purchased for $8 U.S., $12 international (prepaid US dollars only). Copyright ©2010 The McKenzie Company. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical without permission in writing from the publisher. Authorization to photocopy items for internal or personal use is granted by The McKenzie Company for libraries and other users registered with the Copyright Clearance Center. Disclaimer – The New Dentist™ does not verify any claims or other information appearing in any of the advertisements contained in the publication and cannot take responsibility for any losses or other damages incurred by readers’ reliance on such content. The New Dentist™ cannot be held responsible for the safekeeping or return of solicited or unsolicited articles, manuscripts, photographs, illustrations, or other materials. The opinions, beliefs and viewpoints expressed by the various authors and contributors in this magazine or on the companion website, www. thenewdentist.net, do not necessarily reflect the opinions, beliefs, and viewpoints of The New Dentist™ Magazine or The McKenzie Company. Contact Us - Questions, comments, and letters to the editor should be sent to Tess@thenewdentist.net. For advertising information contact ads@thenewdentist.net or visit our website at www.thenewdentist. net to download a media kit.

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TABLE OF CONTENTS

SUMMER 2010

12 F E AT U R ES

6 From Debt to Success: A New Dentist’s Path By Leslie Franklin

9 5 Procedures Every

New Dentist Must Perform By Josh Austin, DDS

12 Get A ‘Buzz’ with Patient Education

By Tess Fyalka, Managing Editor

14 Periodontal Regeneration By Marc L. Nevins, DMD, MMSc

16 What is Ultradent Doing

for Today’s New Dentists?

20 You Have the Degree …

Now, is it Associate, Partner, or Owner? By Jason P. Wood, Esq. and Patrick J. Wood, Esq.

6 DEPARTMENTS 2 Publisher’s Desk 19 Dental Students: What’s on Your Mind?

23 Skinny on the Street 23 Ad Index

23 4 WWW.THENEWDENTIST.NET S U M M E R 2 0 1 0

The one advantage only certain dentists can have As a dentist, you have a lot of people counting on you: Your patients. Your colleagues. Your family. But if you’re an ADA member dentist, you have a better way of handling all that responsibility. Because you have exclusive access to ADA Insurance Plans, with a set of benefits designed specifically for your unique needs. From comprehensive coverage at exceptionally low rates to Plan Specialists who work only with dentists, ADA Insurance Plans delivers the advantage you need. For more information, call 866-607-5330 or visit www.insurance.ada.org

©2010 Great-West Life & Annuity Insurance Company. The inverse boomerang logo is a registered trademark of Great-West Life & Annuity Insurance Company. All Rights Reserved. This ad is an outline only and not a contract. Benefits are provided under group policies issued to the American Dental Association, filed in the state of Illinois, and underwritten and administered by Great-West Life. All policies are subject to, governed by, and shall be construed in accordance with Illinois law. Eligible ADA and ASDA members residing in any U.S. state or territory may apply for coverage. NDAD10-ND

Protecting the practice—and the life—you’ve built. Life • Disability • Business Overhead • Hospital & Critical Illness

FROM DEBT TO SUCCESS:

A New Dentist’s Path

hen it comes to earning income, six figures sounds great. Take, for example, a $230,000 average annual net income for dentists who own their practice. But six figures can feel overwhelming when talking debt, as in an average educational debt at graduation from dental school of $170,000 and an average loan of $450,000 to buy a practice. No wonder more than half of all new dentists report that debt has affected their practice options after graduation. The recent recession hasn’t helped, either, but here’s the good news: With patience, planning, and smart debt management, you can pursue your dream of owning a successful business.

Gaining Speed Sepideh Malekpour, DDS, illustrates how it can be done. She started her dental career with hefty student loans, took on even more debt when she bought a practice, and yet today is running a successful operation and is well on her way toward paying off her obligations. “I always imagined working for myself, but when I graduated from Creighton Dental School, I knew I wasn’t ready to launch a business,” she recalls. “I first wanted to build more confidence in my skills and pick up speed. Plus, I was worried about going further into debt for a practice loan because I already owed a significant amount for my education.” Joining a national dental franchise proved to be the temporary solution Dr. Malekpour needed. While there, she gained skills, speed, and confidence, and took advantage of the company’s relocation allowance to experiment with living in Oregon and Arizona.

Taking the Plunge Three years after graduation, Dr. Malekpour learned that 6 WWW.THENEWDENTIST.NET S U M M E R 2 0 1 0

By Leslie Franklin

Arrowhead Desert Dental in Glendale, Arizona, was up for sale and that the owners were looking for someone to assume their practice loans. It was decision time. “Was I hesitant to take on more debt?” she asks rhetorically. “Absolutely! But I liked the office and the location, and I was ready to be in charge of determining what was best for my patients. I decided to take the plunge and think of debt as a necessary evil to get me there.” Dr. Malekpour ended up with three loans. The terms of the sale required that she assume two loans from the previous owners; a third loan covered the balance of the sale price. For the new loan, the lender required Dr. Malekpour to purchase life and disability insurance and assign the coverage to the lender as collateral. That way, if she were to die before the loan was paid off, the lender would be reimbursed out of the life insurance proceeds. Similarly, if she became disabled, the disability insurance would guarantee that the loan payments would continue to be made. Because Dr. Malekpour is a member of the American Dental Association, she was eligible to take advantage of the ADA’s group insurance plans for members. An ADA plan specialist recommended term insurance to satisfy the lender’s life insurance requirement. The specialist also suggested business overhead expense insurance (a type of disability coverage that reimburses a Leslie Franklin, is Director of New Dentist Markets at Great-West Life & Annuity Insurance Company. She meets regularly with new dentists and dental students across the country to help them understand how to use insurance to attain personal and professional goals. Great-West underwrites and administers the ADA Insurance Plans and is the sole provider of ADAsponsored life and disability insurance to ADA members. For more information, call 888-463-4545, go to www.insurance. ada.org, or contact Leslie at leslie.franklin@gwl.com.

Take Control of Your Debt

disabled dentist for certain practice expenses) to meet the lender’s disability insurance requirement. He explained that premiums are relatively inexpensive and generally can be deducted as a business expense under current law. In addition, using business overhead insurance as collateral keeps a dentist’s disability income insurance for its intended use—to replace personal income if disabled. Dr. Malekpour agreed with the recommendations, and the plan specialist helped her with the insurance applications and collateral assignment paperwork needed to close the sale. “I didn’t know I’d have to go through this process, but it went well,” she says. “I’d recommend to other new dentists that they get help from a knowledgeable insurance expert like I did. Work with someone who can guide you through the technical aspects of using insurance as collateral for a loan and how to keep premium costs to a minimum.”

Tips from Experience Dr. Malekpour shares a few additional tips: Gain experience before buying. Whether it’s working as an associate, for a franchise, or in the military, hone your skills before leaping into your own practice. Know what you can afford. Dr. Malekpour is a big believer in budgeting, saving, and living frugally. “I drove an old, old car for many years, and I didn’t take expensive vacations,” she says. “When I budget, I prioritize my practice expenses, my mortgage, and my student loan CONTINUED ON PAGE 21 >>

The more control you have over your personal debt, the better position you’ll be in to negotiate a practice loan at the most favorable interest rate and terms, counsels Mike Wilson, a Certified Financial Planner™ professional in Orland, Indiana. Here are eight tips Wilson suggests for taking charge of your debt.

• Favor “good” debt over “bad” debt. Good debt is related to

anything that increases in value over time—like educational or business loans. Bad debt does not typically result in an investment in yourself or your future—for example, running up your credit card to pay for an expensive vacation or taking out a loan for a chic new SUV.

• Follow the 28/35 rule. According to Wilson, aim to spend

no more than 28 percent of your gross income (before taxes) on your mortgage payment or rent. No more than 35 percent of your gross income should be used for all personal debt payments, including a mortgage, car loan, student loan, credit card payments, and so on. “This rule of thumb has been around for decades, and it’s still valid,” he says. “If people had paid more attention to it during the recent recession, many would have avoided foreclosures and bankruptcy.”

• Pay bills on time. Late payments hurt your credit rating. • Apply only for the credit you need. Having a lot of credit cards can count against your credit score.

• Pay your credit card balance in full every month. Or at

least pay more than the minimum due to keep interest costs as low as possible.

• Pay down debts with the highest interest rate first, instead

of debts with the highest balance. You’ll save more money in the end by eliminating costlier debts first.

• Consolidate educational loans when appropriate. It’s more convenient to have just one student loan payment, but Wilson says to make sure the interest rate on a consolidated loan is not higher than you’re already paying. In addition, look for a loan consolidation plan that gives you several repayment options with the ability to switch between them as your circumstances change. (For more information, visitwww.loanconsolidation.ed.gov.)

•

Use insurance to manage debt risk. When you have life insurance, you know that the insurance benefit can help repay your debts if you die unexpectedly, rather than burdening your family with these obligations. Similarly, if you are disabled, a monthly disability insurance benefit can provide a source of income to help make your loan payments and cover other business and personal expenses, thereby protecting your credit rating. “The 2008 Survey of Dental Practice,” American Dental Association. “Annual ADEA Survey of Dental School Seniors: 2008 Graduating Class,” Journal of Dental Education, August 2009. Gavin Shea, Director of Partner Services, Matsco, January 2010. ADA Survey of New Dentists, reported on ADA.org, January 2010.

SUMMER 2010

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5 Procedures Every

New Dentist Must Perform BY Josh Austin, DDS

s another school year comes to an end, another class of new dentists graduates and prepares to enter the trenches of private practice. These new dentists all carry the weight of their own expectations, which can be crippling enough by themselves. We didn’t grind out four years of dental school just to graduate and struggle adjusting to private practice. We all expect to join or start a practice and immediately be greeted with schedules full of high-value production and more patients than we know what to do with. Unfortunately, this is a fairytale for most new dentists. Getting started in private practice is tough. Whether you are an associate, the owner of a new start-up, or purchasing an existing practice, there are certain things you can do to maximize your production and keep busy even with a limited patient base. As a new dentist, there are five things that you must be comfortable performing. Let’s review them!

Learn how to easily convey the diagnostic information to the patient to help them make a decision. With some polished efficiency, you will learn how to deal with almost any emergency situation in a timely manner. 3. Extractions: This follows along with dental emergencies a bit. Upon graduation from dental school, I felt that I was perhaps most confident performing extractions compared to many other procedures. Dental school prepared me very well in this area. I am not sure that others share this same confidence after graduation or what other dental schools teach, but extractions and oral surgery can help new dentists fill their schedules. Many senior doctors refer out most of their oral surgery procedures. But associates can keep the extractions they are comfortable with in-house. Sure, full bony impacted mandibular third molars may not be your cup of tea, but there are many extractions that can easily be performed by a

“Take as much endodontic continuing education as possible.“ 1. Pediatrics: New dentists need to feel comfortable performing procedures on children. Parents prefer to have all their kids seen at the same time. It cuts down on the number of trips they have to make to your office. If you are an associate in a practice, the senior dentist or hygienist(s) might be seeing one child, leaving the new dentist to see the other. Spend 30 minutes on an exam, bitewings, and prophy. Odds are they need either restorations or sealants. Knock those out too, all of a sudden you’ve had a nice morning of production and hopefully had some fun with the kiddo. Now that child will want to see you from here on out, and everyone is happy! 2. Emergencies: As a new dentist, you are probably going to have holes in your schedule. That’s just life. If you can learn the skills of dealing with emergencies, these schedule gaps can be useful. If a patient calls in with a toothache, trauma, lost restoration, or any other sort of dental emergency, they want to be seen quickly. If you are an associate, odds are the senior doctor is booked up. That leaves you to see the patient during one of those schedule gaps. Sure, the patient probably hasn’t seen you before, but, due to the emergency, they will be thrilled to let you work on them. Learn how to quickly narrow down pain symptoms to a diagnosis.

general dentist. As I said before with emergencies, a toothache will help encourage a patient to see a new dentist. If handled efficiently and comfortably, this could lead to a new comprehensive care patient for the new dentist. The patient gets out of pain and the new dentist earns a patient for life. It’s definitely a win-win situation for everyone! 4. Endodontics: Many new dentists feel underprepared for endodontics after graduation. This fear needs to be beaten! Practice on extracted teeth. Take as much endodontic continuing education as possible. Do whatever you need to CONTINUED ON PAGE 11 >>

Dr. Josh Austin is a graduate of the University of Texas Health Science Center San Antonio Dental School. After working as an associate for two years, Dr. Austin opened his own practice last fall. He is a regular columnist for The New Dentist™ magazine and website. He can be reached at jaustindds@thenewdentist. net or www.thenewdentist.net/clinicalblog.php.

What has been your experience as a new dentist? Were you prepared for the challenges? Tell Dr. Austin. Blog on at www.thenewdentist.net/clinicalblog.php.

SUMMER 2010

WWW.THENEWDENTIST.NET

Create New CoNNeCtioNs with Your PatieNts • Now available for Apple iPad™ • Award-winning dental education solutions • Patented education method, Stop, Draw and Teach™ • Help patients understand and accept more treatment

GuruTV 2010 packs the power of Guru into an easy-to-use DVD in your reception area, so you can start case acceptance and promote good hygiene habits — even before patients see you.

Guru Libraries feature smart integration with Dentrix Presenter and the Dentrix Treatment Plan. Now available for iPad, Guru Libraries quickly create sleek, compelling case presentations anywhere in your office, and connect patients with their best possible treatment right in the chair.

Guru Web and Guru Email connect you to patients in their homes with email-ready Guru playlists and Guru animations on your practice website, so your patients can research your recommendations, share treatment decisions and trust you to provide the best care.

e xClusive Ne w DeNTis T speCiAl: Get a FREE Apple iPad when you purchase Guru! Just mention code GURUND-Q310.

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5 Procedures

continued from page 9

do to become comfortable with at least simple endodontics. There are several reasons for this. Again, pain is a factor. Pain will push a patient to a new dentist. Manage it well and reap the rewards. Remember, many senior doctors will refer out most, if not all, of their endodontics. Show the senior doctor that they can keep much of this production in-house by letting you do it. Endodontics precipitates other restorative procedures. After the root canal, the patient will need a buildup and a crown. In addition, endodontics is the highest producing procedure you can perform without an associated lab fee. Endodontics will most definitely help fill your schedule. 5. Hygiene: I know it’s not what you want to hear. No one wants to graduate from dental school and join, start, or buy a practice to be a hygienist. It’s not fun. It’s not glamorous. It’s not exciting, but it is one thing: production. If you are doing nothing else, why not fill some of your time with hygiene? Doing so could lead to a more profitable procedure. Most associates join practices in the summer when hygiene schedules are packed full. If patients do not pre-book their appointments with the hygienist, odds are they will have a

long wait during the summer to get their prophy appointment. As a new dentist, this is a no-brainer. Do the prophy, exam, and bitewings. The patient gets a chance to meet you and test you out with a low-stress procedure and may then be more willing to schedule any restorative work with you. For an associate, it is a good way to show the senior doctor that you are willing to be a team player. If you are purchasing or starting your own practice, doing your own hygiene can not only generate production, it can also save overhead. Hygienists are expensive; they will be your most costly employee. Doing your own hygiene for a time gives you a chance to get to know and impress your new patients. In addition, it gives you a much longer look at a patient’s oral condition while you are cleaning. This may lead to identifying more restorative opportunities. At some point, your schedule will be filled with enough restorative procedures to allow a part-time or full-time hygienist. Until then, keep it simple and do your own hygiene. Your patients will appreciate it! Starting private practice after graduation from dental school is an intimidating prospect. By becoming comfortable with hygiene, endodontics, extractions, emergencies, and pediatrics, you can transition into practice with less stress, helping ease the burdens presented by post-dental school life.

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4/5/10 3:42:30 PM

GET A ‘BUZZ’ WITH

PATIENT EDUCATION

t’s one thing to provide superior dentistry. It’s another for patients and staff to “create a buzz” about it. Sure, lots of practices provide quality care. Teams from coast-to-coast are friendly. The majority of dentists are quite competent. But nice and competent alone do not ensure success for any new dentist. Most patients trot in for a dental appointment about every six months and aside from a couple of daily spins

Practice websites are ideal for patient education.

Guru allows dentists to add notes directly on the screen.

with the electric toothbrush, few give more than a passing thought to dental care needs or opportunities. Patients do not know what their dental options are because too often dental teams don’t take the time to educate them. In other cases, patients don’t pursue treatment because they don’t understand what the doctor is recommending or why it is necessary. Create the desire for your care and a clear understanding of why it is necessary and you create greater case acceptance – not to mention a fair amount of “buzz” about your dentistry. For today’s new dentists there are a variety of multimedia tools to help patients better understand both the diagnoses and the recommended treatments. Case in point: Dr. Nathan Dustin’s practice in Portland, OR. This graduate of Oregon Health Sciences University finds that Guru, a patient education package from Henry Schein, offers a number of options that he can integrate into daily patient education protocols. For him, treatment education needs to capture the interest of the patient, but it also needs to be quick and easy to use. “One thing I’ve found to be crucial when using patient education tools is they have to be fast. If it takes time to get it loaded or to play the message, I’m much less likely to use it.” Dr. Dustin understands well the value of patient education. After all, when they understand what the doctor is recommending and why, patients are far more likely to proceed with treatment. “It’s very effective in helping patients to understand root canals, implants, things that people have misperceptions about. For example, a lot of people walk around thinking that a root canal is a horribly painful procedure. They think that root canal means that we are pulling the root out. I needed something that clearly explains what we are actually doing.” Dr. Amanda Lewis is a 2004 graduate from Southern Illinois University School of Dental Medicine. This general practitioner in Decatur, IL finds that the CAESY patient education system enables her to perform more dentistry. She says that she has been using the system daily with multiple patients for the past 18 months. “The biggest benefit is the visual for the patient. They just don’t understand what I’m recommending until they can see it.” CONTINUED ON PAGE 18 >>

12 WWW.THENEWDENTIST.NET S U M M E R 2 0 1 0

Photos courtesy of Guru

By Tess Fyalka, Managing Editor

Scheduling DR (Digital Radiography)

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Visit MacPractice.com for product information, events, screenshots and a demo.

Periodontal Regeneration

ecent advances in regenerative therapies such as periodontal regeneration, root coverage procedures with soft tissue grafting, and procedures combined with dental extractions or post-extraction for implant site development, have significantly improved the ability to restore damaged periodontal tissues. Early diagnosis is critical to periodontal disease management and offers a patient the best chance of preserving their natural tooth dentition. Over the past 20 years, it has become accepted in much of the dental community to provide a staged approach to periodontal therapy. In fact, much of todayâ&#x20AC;&#x2122;s periodontal therapy consists of supervised dental hygiene programs and early stage treatment regimes including scaling and root planing, and systemic and local antibiotic therapy. For many patients with limited clinical attachment loss and alveolar bone loss, this approach may result in successful outcomes. However, for patients presenting with more advanced disease, either localized to limited sites or more generalized, this often leads to a delayed evaluation for advanced therapeutic options such as regenerative periodontal procedures. Early diagnosis and appropriate referral lead to the most favorable patient outcomes. Comprehensive periodontal examination with full mouth radiographs and full mouth clinical attachment level charting combined with medical history and risk assessment can be utilized to determine the best course of therapy.

An Introduction to Periodontal Regeneration Periodontal regeneration is a histologic term and only those procedures that have been documented through human histology to demonstrate regeneration can satisfy this definition.1 These include, bone autografts, allografts, xenografts, enamel matrix derivative (Emdogain), recombinant human platelet â&#x20AC;&#x201C; derived growth factor BB enhanced matrices (GEM 21S). Periodontal regenerative procedures work by regenerating the periodontal tissues including alveolar bone, periodontal ligament and new cementum. These procedures are best managed when the tooth or teeth being treated can be protected from 14 WWW.THENEWDENTIST.NET S U M M E R 2 0 1 0

BY Marc L. Nevins, DMD, MMSc

traumatic occlusal forces and mobility present is controlled prior to surgical treatment as this will have a negative effect on the wound healing process. Multitudes of biomaterials have been recommended for periodontal surgery to stimulate regeneration. Alloplastic biomaterials such as hydroxyapatite or bioglass ceramic materials have been shown to stimulate repair but not periodontal regeneration. The extent of furcation invasion is an important determinant of successful periodontal regeneration. The extent of furcation invasion is important to determining the prognosis, which is a first step in the decision-making process of whether to save the tooth and how to treat the periodontal disease. Grade II furcations are generally good candidates for regenerative therapy with mandibular molars and maxillary buccal furcations being the most predictable due to the improved access compared to interproximal furcation sites.2 Grade III furcation defects are poor candidates for regenerative therapy as they are unpredictable. This is another reason why early diagnosis and referral for treatment is advantageous.

Determining Predictable Outcomes Accurate diagnoses and control of primary and contributing secondary etiologic agents continues to be an important factor in determining the predictability of periodontal therapy. In determining the diagnosis of a deep periodontal pocket, differential considerations include, endodontic infection and root fracture. Vitality testing and endodontic consultation are often necessary components of the diagnostic process. In teeth with previous endodontic therapy, it is important to rule out a root fracture as a potential etiology of a deep periodontal pocket. Signs and symptoms of root fracture may include a deep periodontal pocket that is highly localized, pain on biting, and sometimes a fistula present if the drainage of infection is away from the gingival sulcus or periodontal pocket. If a fistula is identified, it should be traced with an opaque marker and imaged radiographically to aid in diagnosis. In determining whether to save a tooth or place a dental implant, the identification of a fracture should lead to a treatment plan for dental extraction, potential ridge preservation and tooth replacement, potentially with a dental implant.

Smoking as a Risk Factor Smoking is a risk factor for periodontal disease and has a negative impact on periodontal therapy such as non-surgical and surgical approaches, and for regenerative therapy.3,4 Periodontal research supports the benefit of complete cessation over a reduction as light smoking seems to have persistent negative effects. It is advisable to educate patients on the direct effects of smoking on oral health and specifically periodontal disease. When patients understand that the treatment options may be directly determined by the presence or absence of smoking this may become a key factor in smoking cessation for a patient who is already considering this option. Patients may even be motivated to consider complete cessation when they understand that the treatment plan will vary depending on the presence or absence of this risk factor.

Photos courtesy of Dr. Marc Nevins

Growth Factors

FIGURE 1

FIGURE 2

FIGURE 3

The use of growth-factor enhanced matrices combining recombinantly engineered human platelet-derived growth factor-BB (rhPDGFBB) with a bone replacement graft scaffold is an excellent option for stimulating periodonFIGURE 4 tal regeneration.5 Precise surgical procedures are important to prepare the recipient site for the graft. Flap design should anticipate achieving primary closure over the grafted site to improve graft stability and to provide protection from the oral environment. The defect must be completely debrided and the root surfaces meticulously scaled and root planed often with a combination of hand instrumentation, ultrasonic or piezoelectric instruments, and rotary instrumentation as well as chemical treatment with citric acid or FIGURE 5 tetracycline or neutral ph EDTA. Once the root surfaces are prepared the growth-factor enhanced matric (GEM) is placed in the defect and the flaps positioned for closure with sutures over the treatment site.

The Healing Process The post-operative healing process continues for six-12 months. It is important to control mechanical oral hygiene not to traumatize the surgical site during the early healing

(two-to-four weeks). Often an antibacterial mouthrinse is prescribed during this time and modified toothbrushing techniques are taught to maintain supra-gingival hygiene. Professional visits for supra-gingival instrumentation for plaque removal should be provided on two-to-six week intervals during this time depending on the patientâ&#x20AC;&#x2122;s level of plaque accumulation. The occlusion is checked during these visits for any traumatic occlusal forces or interference and may be adjusted as needed. If mobility increases post-surgically, the teeth may be splinted to provide stability. As discussed earlier, if necessary, smoking cessation is encouraged throughout the treatment process and beyond. Long-term prevention and maintenance with periodontal supportive therapy is necessary along with meticulous oral hygiene to maintain the results of therapy and present further disease progression or recurrence.

Case Example A 27-year-old female patient presents with the chief concern being that her dentist advised her of bone loss present at the mandibular right lateral incisor where she noted recent tenderness to the interdental gingival. Periapical radiograph (figure 1) reveals 80% vertical bone loss on the distal surface of the mandibular right lateral incisor associated with a 9mm probing depth and 9mm clinical attachment level (0mm recession). The patient is in excellent medical health and a non-smoker not taking any daily medications. There are localized 4-5mm posterior probing depths for the maxillary and mandibular molars. A treatment plan is established to provide scaling and root planing for the maxillary teeth and the mandibular posterior teeth and a regenerative periodontal surgical therapy for the mandibular right lateral incisor. CONTINUED ON PAGE 17 >>

Dr. Marc Nevins is in the private practice of Periodontics and Implant Dentistry in Boston, Massachusetts. He is Assistant Clinical Professor of Periodontology at the Harvard School of Dental Medicine and is a Diplomate of the American Board of Periodontology. Dr. Nevins is the Associate Editor of The International Journal of Periodontics and Restorative Dentistry. He can be reached via email at E-Mail: marc_nevins@hms.harvard.edu

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What is ULTRADENT Doing for Today’s New Dentists? Editor’s note: Ultradent President and CEO Dr. Dan Fischer and Ms. Vicki Drent, director of major accounts, recently answered a few questions for The New Dentist TM to help our readers better understand some of the products and services offered by Ultradent that are tailored specifically for new dentists and dental students. Do new dentists receive any additional benefits to those offered regular customers? Ms. Drent – Yes, Ultradent offers benefits designed to meet the specific needs of a new dental practice. This includes a 25% discount on their first order of consumables and equipment. We provide marketing materials at no charge, field representatives (in most areas), and practice building tips when requested. Ultradent has also established a phone line (1-800-7935215) for students only. How will Ultradent’s support benefit a new dental practice? Ms. Drent – We offer a 40% discount to graduating students until December 15th of their graduation year. This allows them time to figure out where they will land and still get a great discount to help them get started. After that, the first order for new offices is 25% off. Every few years, Ultradent offers a new dentist conference. We pay for the majority of expenses to train new clinicians at our corporate office. We even address topics such as practice management, and we typically cover tips and techniques within categories such as bonding, composite, whitening, and endodontics. What is unique about Ultradent’s relationship with students and new graduates? Dr. Fischer – Our University program is one of the cornerstones of our business. I’ve always believed in the power of continuing education even after graduation from dental school. This is due in large part to the fast pace at which technological advancements take place. We’ve invested a great deal in our university program and students are encouraged to visit us at every major tradeshow around the country. Our 16 WWW.THENEWDENTIST.NET S U M M E R 2 0 1 0

tradeshow representatives are trained on the importance of working with students and introducing them to new technologies. When students visit our booth, we offer them a generous sample pack that is customized with the products they’ll need to take their board exams. Ms. Drent – Education has always been a main focus of ours. I’m responsible for managing a team dedicated specifically to servicing dental students and universities. This team provides special attention and service to students as they transition from school to practice. While in school, students can take advantage of a dedicated customer service line and we support student events such as “vendor days.” Ultradent also offers teaching modules for the classroom, including clinical studies, literature, and corresponding PowerPoint presentations for training. All of this is provided to the professors free of charge. Are there opportunities for learning once the student graduates? Dr. Fischer – We offer a variety of options for training and education. These are delivered in various media to suit the needs of the student or those in practice for a few years. We support an ongoing schedule of continuing education courses. Topics range from basic tissue management concepts to troubleshooting difficult cases. Ultradent has a full library of podcasts and webinars, some of which are available for CE credit. And, for individuals who prefer the live education format, we host “lunch and learns” as well as didactic and hands-on-courses throughout the year. Why would a dental student be interested in Ultradent’s product offerings? Dr. Fischer – Our focus has always been on quality and easeof-use. We’ve been described by our customers as a company that is “progressive and trustworthy.” We put a great deal of emphasis on products and procedures that eliminate or minimize the need for costly laboratory fabrication or the need for expensive equipment. We’re driven to help clinicians reach more patients, especially in a downturned economy. This is important for new graduates trying to establish their own practices. In fact, this is the basis upon which Ultradent was built! When I started my own practice, my patients consisted of many larger families, so I searched for more efficient ways of doing dentistry. This resulted in development of products that are not only of the highest quality, but also easy to use and time saving – adding to affordability. For further information visit www.ultradent.com.

Periodontal Regeneration continued from page 15 Lingual flap extending to the adjacent teeth and buccal mini-flap localized to the interproximal site provided access for debridement of the defect and root preparation. A deep intrabony defect was identified (Figure 2). The root surface was scaled and planed with hand instrumentation and treated chemically with a tetracycline paste. A growth factor enhanced matrix was prepared combining mineral collagen bone substitute (Bio-Oss Collagen, Osteohealth Co.) and rhPDGF-BB (GEM 21S, Osteohealth Co.) and the matrix was placed into the defect and condensed into place (Figure 3). The flap was coronally repositioned over the grafted site for primary closure (Figure 4). Post-operative care included five days of systemic antibiotic therapy and three weeks of topical antimicrobial mouthrinse (chlorhexidine digluconate 0.2%). Oral hygiene instruction was modified to supragingival care during the first eight weeks post-operative with professional supragingival healing every two-to-three weeks for the first three months. After 18 months of healing, the probing depth is 3mm with 4mm clinical attachment level (1mm recession).

Orthodontic therapy was initiated and the two-year postoperative radiograph evidences bone fill. The site has healed well and is maintaining well during orthodontic therapy. The patient follows a three-month periodontal health maintenance program. Reynolds MA, Aichelmann-Reidy ME, Branch-Mays GL, Gunsolley JC. The efficacy of bone replacement grafts in the treatment of periodontal osseous defects. A systematic review. Ann.Periodontol. 2003;8(1):227-265. 2. Pontoriero R, Lindhe J. Guided tissue regeneration in the treatment of degree II furcations in maxillary molars. J Clin Periodontol 1995;22:756-63. 3. Grossi SG, Zambon JJ, Ho AW, Kocj RG, Machtei EE, Norderyd OM, Genco RJ. Assessment of risk for periodontal disease. I. Risk indicators for attachment loss. J Periodontol 1994;65:260-7. 4. Tonetti MS, Pini-Prato G, Cortellini P. Effect of cigarette smoking on periodontal healing following GTR in infrabony defects. A preliminary retrospective study. J Clin Periodontol 1995;22:229-34. 5. Nevins M, Camelo M, Nevins ML, Schenk RK, Lynch SE. Periodontal regeneration in humans using recombinant human platelet-derived growth factor-BB (rhPDGF-BB) and allogenic bone. J Periodontol 2003;74:1282-92. 1.

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Patient Education continued from page 12 Dr. Lewis and her hygienists particularly like the modules that explain the use of local antibiotics after a deep cleaning. “It goes over everything, including postoperative instructions. We also use patient education every time we do a crown. It shows the patient what a temporary is, how it’s placed, and what to do if it comes off.” With the variety of dental education multimedia programs that are available in the marketplace today, the process has become simpler, faster, and far more effective. Depending on the type of patient education tools used in a practice, teaching the patient can take place virtually anywhere, in the practice reception area using DVD videos; in the treatment room using a combination of multimedia animations, patient images, and the doctor’s own notes and illustrations. “The system I use is very efficient because the animation can demonstrate the concept or treatment that I am recommending to the patient faster than I can explain it,” notes Dr. Dustin. Additionally, he finds that flexibility is essential when trying to clearly explain specifics of treatments to patients. He can quickly fast forward to the point in the presentation that explains exactly what he wants to convey to the patient. “If I can just play a 20-second animation of a root canal and stop it on the spot that I want to further explain, that’s more efficient for me than having the patient watch an entire video of a procedure.” Some systems, such as Guru, also allow the doctor to stop animations to highlight an important point and add their own notes directly on the screen. Dr. Lewis notes that her system is particularly effective when working with new patients. “We can integrate new patient digital images into the system and it enables the patient to see what I see, and that has been the biggest advantage.” Similarly, Dr. Dustin finds that having the patient education package fully integrated into the practice management system he uses is a real plus. “We take a lot of photographs and all of our digital images are stored inside Dentrix, so we can bring up the patient’s digital image

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Patient education systems now allow treatment plans complete with animations to be emailed directly to patients.

side-by-side with Guru, play the animation, and then demonstrate on the image of the patient’s tooth what the animation is showing. It is very effective.” Remember, the education doesn’t stop when the patient leaves the practice. Collect email addresses and develop a quarterly newsletter designed to educate and inform patients about practice services. Spotlight a specific topic, such as veneers, root canals, amalgam vs. composite restorations, etc. and feature it in the newsletter. Include information such as what a root canal is or what veneers are. Explain what types of patients make good candidates for the procedures, time involved, special considerations, etc. Keep copies of the newsletter at the front desk for patients to pick up and read while they are waiting or take with them when they leave. Additionally, explore whether your patient education system offers customized playlists of educational videos and animations that can be emailed to patients or accessed on the practice website. These can be particularly useful when the patient needs to “talk it over” with her/ his significant other. “If I have recommended treatment to a patient and she wants to go home and talk about it with her husband, I can email the animation that I’ve just shown her to explain the treatment and then she can play it for her husband, so that he can better understand what I’m recommending and why. That is pretty cool. And it’s a lot more powerful than sending home a treatment plan on paper with a bunch of dental jargon that they don’t understand,” notes Dr. Dustin.

DENTAL STUDENTS: What’s on Your Mind? The New Dentist™ recently talked with Corwyn Hopke, President of the American Student Dental Association, about what he considers to be some of the major issues for new dentists. He will graduate from Columbia University College of Dental Medicine in 2011.

“the live patient exam.” These exams, as outlined in the American Student Dental Association’s “White Paper on Ethics and Professionalism in Dental Education,” create many ethical dilemmas. Students feel tremendous pressure to delay treatment of their patients to “save” difficult to find lesions for the licensure exam. Some are forced to take medically unnecessary radiographs in order to conform to bureaucratic TND: What do you feel is the greatest requirements. Still others end up challenge (other than the cost of edu- prepping lesions that probably could cation) facing dental students today? remineralize. The list goes on. Students Corwyn: Transitioning to life as a licensed find themselves heavily penalized; the dentist is clearly the most stressful aspect likelihood of getting a license after of dental school. Nearly all states require graduating is greatly reduced because us to pass one of the many high-stakes, of our refusal to sacrifice our ethics. In one-shot examinations performed on my experience, few challenges weigh human subjects frequently referred to as heavier on students than this.

TND: What do you see as the greatest challenge facing the dental profession today? Corwyn: Ensuring the quality of our profession is the most important challenge facing new dentists. This includes refusing to outsource the rights, rigors, or terminology of the profession to nonprofessionals. That involves keeping up with modern communication to accurately educate dentists and the general public about not just oral health, but dentistry as a profession. CONTINUED ON PAGE 22 >>

Dental students, tell us what’s on your mind. Email Managing Editor Tess Fyalka at tess@thenewdentist.net. We want to hear from you.

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You Have the Degree … Now, is it Associate, Partner, or Owner?

Jason P. Wood, Esq. and Patrick J. Wood, Esq.

s you walk off of the stage, your hand still clutching the document that you have spent your entire adult life pursuing, it hits you: “Now what?” In far too many dental schools across America the “after life” is not discussed, or is rushed through because of other curriculum requirements. This is unfortunate because far too many young dentists make egregious mistakes that compromise the full potential of their careers simply because they didn’t know better. This article provides information that will help you to avoid pitfalls during your career, whether in an associate position, entering into a partnership, or acquiring a practice.

Associateships In a perfect world, you wouldn’t desperately need a job as a dentist to pay off your massive student loan debt, which would afford you the ability to negotiate every provision in an associate agreement. However, chances are you are kicking yourself for ordering pizza for the last three-to-four years because “my loans can pay for it.” Therefore, we need to focus on a few main points: • Compensation - Many owners will attempt to negatively influence your compensation in two main ways. First, they will make you an “independent contractor” rather than an “employee.” This affects you negatively because you do not get to participate in any employee benefit programs (ie, health benefits, 401k) and you pay more in taxes because you will pay a “self employment” tax. Secondly, owners will try to compensate you based upon “collections” rather than your “production.” The problem with this is you are now bound to how good the office is at collecting money from patients, something that you have no control over! • Restrictive Covenants - In some states, covenants not to compete are unenforceable against associates after the contract has been terminated; however, in all states they are enforceable during the duration of the contract. If you plan on staying in the area and you live in a state that allows covenants not to compete after the 20 WWW.THENEWDENTIST.NET S U M M E R 2 0 1 0

•

contract is terminated, then focus on negotiating one of these restrictions but not both. Potential Buy-in - This must be negotiated in connection with the associate agreement, not after you have been there for a year. Your right to acquire needs to be addressed in the document, otherwise it is merely an idea. The formula for the buy-in should be clearly spelled out in the document so there is no confusion later, and, if possible, the purchase agreement and partnership agreement should be agreed upon as well.

Partnerships Far too many companies nationwide have jumped on the partnership bandwagon. Due to the complexity of a partnership, many companies have successfully created a “perception of value” seemingly based upon the more confusion they can create! The problem with this approach is that it interferes with the proper formation of the partnership structure. A partnership strategy is not complex, it is simply two parties coming together to allow for a greater return for each individual doctor. The complexity lies in whether these two parties are compatible, both in their personal and professional lives. Just because one doctor wants to spend more time with her children and the other wants more time practicing does not mean they are a good fit for a partnership! Questions involving patient care, treatment philosophy, career goals, family stability, if there has been a previous divorce, plans for additional children, retirement, etc. all need to be addressed prior to forming a partnership. Even if the parties find they are compatible, the partnerCONTINUED ON PAGE 22 >>

Jason P. Wood, B.A., J.D. and Patrick J. Wood, B.A., J.D. Jason is partner in the law firm of Wood & Delgado, and Patrick is the founder and senior partner of Wood & Delgado, a law firm which specializes in representing dentists for their business transaction needs. Wood & Delgado represents dentists nationally and can be reached at (800) 499-1474, www.dentalattorneys.com or by email at jason@ dentalattorneys.com or pat@dentalattorneys.com.

Debt

continued from page 7 payments. I’ve also saved money in an emergency fund in case something unexpected happens.” Refinance when it makes sense. Dr. Malekpour recently refinanced one of her practice loans to get a lower interest rate. “Even though we hear about tight credit in today’s economy, the lender approved my loan application readily,” she says. “I think that’s because I have a good credit history, always make timely payments on my loans, and 7.375" x 4.875 had already partially paid down the loan I wanted to

refinance.” (She also pays more than the minimum on her student loans.) Avoid prepayment penalties. One of the loans Dr. Malekpour assumed from the previous owner has a prepayment penalty. “I didn’t have any choice because the sales contract required me to assume the loan,” she explains. “But when I took out the new loan, I made sure there was no penalty for paying off the loan early.” Remove the collateral assignment as soon as possible. Last year, Dr. Malekpour repaid enough of one loan that the lender no longer required life insurance

as collateral. She immediately notified the insurance company to release the assignment. “I’ll keep the insurance to protect my family,” she says. Use your insurance. Dr. Malekpour originally purchased business overhead expense insurance to meet the lender’s loan collateral requirements. Turns out, however, she was able to use the insurance two years ago during a period of disability. “I was unable to practice for several months,” she says. “The insurance benefit helped cover my loan payments, office rent, and the salaries of my employees.”

Seven years after buying Arrowhead Desert Dental, does debt still bother her? “Sure it does!” Dr. Malekpour says. “I’ll enjoy my practice a lot more when it’s 100 percent mine and there’s no debt hanging over my head. “Owning a practice involves a lot of responsibilities, challenges, and stress,” she reflects. “But I look at it like having a child—difficult to go through at times, but well worth it in the end.” Editor’s Note: This article does not constitute legal, tax, or financial advice. Please seek professional input as appropriate to your situation.

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What’s on Your Mind?

continued from page 19

Recent attempts to expand the Alaska Dental Health Aide Therapist (DHAT) program provides a perfect example of that distinction. Some parties throw around vague terms like “access to care” and “mid-level provider” to justify replacing properly educated dentists with individuals participating in a two-year community college level education right after

high school. Nobody wants to deny “access to care,” so we cede the terminology, and with it, jeopardize the profession and the health of those who rely on us. When you ask someone, for example, to define “access to care” and address a specific problem related to “access to care,” the dialogue radically changes. The conversation switches from vague platitudes to actual constructive discussion of the problem at hand. If those who care about the profession of dentistry do

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to be addressed to assure the proper formation of a partnership structure. In short, no two partnerships are alike. Also, the doctor who is buying in should not have to wait three-to-five-years to move forward with the acquisition of the partnership interest, a model used by some companies. This Degree unjustifiably places the continued young doctor in a position from page 20 where s/he can be terminated at the very moment s/he is to ship document itself must buy into the practice. If you fit the unique nature, skill have met with this model, set, and personality of the you must secure your future practice. Questions regarding by locking in your right to new patients, compensation acquire the practice in threestructures, discrepancies in to-five years. Otherwise there production figures as well as many other issues need CONTINUED ON PAGE 24 >> not take ownership of that dialogue, then those who don’t care about the profession will. When you consider that new dentists are likely hoping to practice another 25-30 years, preserving the quality of dentistry is clearly the most important challenge we face today.

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INDEX O F A D V E R T I S E R S

Advertisers in this issue of The New Dentist™ have made it possible for you to receive this publication free of charge. Please support these companies. Contact information can be found below or visit www.thenewdentist.net Resource section to receive information from more than one company. American Dental Association......................IBC www.ada.org 800-947-4746 ASPEN Dental.................. 19 www.aspendentaljobs.com 866-748-4299 Bank of America................11 www.bankofamerica.com/ practicesolutions 1-800-497-6076 CareCredit...........................8 www.carecredit.com 800-300-3046 x4519

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by-owner (FSBO) transaction, and 3) the likelihood continued from page 22 of the transaction falling • apart is much greater in is an actual economic benefit FSBO transactions. As such, to the owner doctor if s/he we recommend looking at terminates you the closer you get to acquiring the part- practices that are being sold by reputable dental brokers, nership interest. The practice with extensive experience value is typically determined in the local marketplace. prior to the associate’s comHowever, as the buyer, you pensation being added to the must always remember that practice. Therefore, as you the broker’s true client is the approach your acquisition, seller, not you, even with practice production may companies claiming to prohave increased 50-100%. vide “dual agency.” But, in the owner’s eyes, the The following are a few practice is now selling for key points to consider when less than it is worth. Conseacquiring a dental practice: quently, many transactions • • Practice Production - If are terminated during the your personal monthly year the associate was supexpenses are relatively posed to become an owner. high, you cannot search for a small practice with Practice Acquisitions “room to grow.” You First and foremost, be objecneed to find a practice tive when evaluating a practhat will allow you tice that you are considering to pay your practice acquiring. If you become expenses, service your emotionally attached to debt, and still provide a practice, you will find you with enough money yourself making decisions to pay your monthly based upon emotions, rather expenses and save. than logic. Be methodiDo not focus on the cal in your approach. Our purchase price or the firm typically recommends • monthly loan amount staying away from sellers when searching for who are attempting to sell practices, instead focus their practices on their own on the profitability and for three reasons: 1) owners the salary you should are unrealistic about what receive after you pay their practices are worth, 2) your bills. Does this there is a much higher cost practice provide you associated with a for-sale-

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with income needed to match your lifestyle? Dental Procedures - Are you skilled in the procedures performed by the owner at the practice? If not, this practice is not for you. Our most successful clients find a practice where they can do all of the procedures the current owner does but also have additional training to provide added services to the dental practice, thus allowing the buyer to increase the per patient revenue of the practice. Lease - Far too many dentists never have their leases reviewed by a dental attorney. As such, there are far too many provisions lurking in a “standard” lease that can be used against the future saleability/transferability of the dental practice you are attempting to acquire. Deal with these issues before acquiring the practice. That way, the owner’s problem will not become yours. Practice Systems - Invest in a knowledgeable practice management consultant to evaluate the existing practice systems. These advisors can provide valuable feedback that will allow you to maximize your internal marketing, streamline your practice procedures and increase the productivity of your employees. They can also assess if your philosophy

matches the owner’s, thus preventing a patient exodus after you acquire the dental practice. • Purchase Agreement - As shocking as this may sound, your colleagues do not always have your best interests at heart. Thus, you need to protect yourself and the investment you are about to make with a strong, enforceable purchase agreement. You need multiple restrictive covenants that prevent the owner from raiding your patients and employees and protect you from the owner competing against you. You need a myriad of representations and warranties that the owner must stand behind, such as: Did the owner waive co-payments? Has the owner accelerated treatment prior to the closing date? Provisions regarding retreatment work and uncompleted dental work need to be properly addressed to avoid patient confusion and frustration after the sale. All of these issues, as well as a host of others, are what protect you after the sale. As you can see, your career will not just be about the clinical decisions you make. Key milestones will be in areas where, as a profession, dentists have been ill-equipped. Be prepared for each stage in your career and this will allow you to focus on what you have been trained for – dentistry.

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Save 15% on all practice management products with offer code 10440; Minimum $100 purchase expires 12/31/2010 and may not be combined with any other offers, discounts, or promotions. Shipping and handling not included.

“After the Practice Start Up

“After the Practice Start Up training, I feel better and more conﬁdent about opening my dental practice. For anybody thinking about opening his/her own dental ofﬁce, this training is a must. I received a tremendous increase of knowledge about dental management. Now I know the game plan!!!”

Practice Start Up Program

training, I feel better and more confident about opening my dental practice. For anybody thinking about opening his/her own dental office, this training is a must. I received a tremendous increase of knowledge about dental management. Now I know the game plan!!!

”

PROGRAM PROGRAM

• 2 Days, one-on-one training. • 6 months of follow up support after the training or once you are in your new practice. • Training location - La Jolla, CA or Your City. 16 hours of AGD CE Credits.

and receive Realizing The View course curriculum at Practice’s True Potential, www.mckenziemgmt.com/cons-startup.htm a 5-Hour DVD Set,

FREE

Preferred time 3 to 18 months prior to opening or purchase

6 months of follow up support.

• Training and Support Materials.

ENROLL TODAY•

2 Days, one-on-one training.

• Preferred time 3 to 18 months prior to opening.

Mention this ad and receive a 5 hour DVD Set: Realizing The Practice’s True Potential

Training location - La Jolla, CA or Your City.

Training and Support Materials.

16 hours of AGD CE Credits.

by Sally McKenzie (with your enrollment)

View course curriculum at w w w.mckenziemgmt.com/cons-star t u p. ht m

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. 10/19/2007 to 10/31/2011

1.877.777.6151 training@mckenziemgmt.com