august 2010

Texas Dental Journal l www.tda.org l August 725

Texas Dental Association 140th Annual Session 2010 TEXAS Meeting Photo Contest

Award: Best of ShowPhotographer: Dr. Roy TiemeyerTitle: “Skimmers”

August 2010

TEXAS DENTALTEXAS DENTALTEXAS DENTALJournal

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728 Texas Dental Journal l www.tda.org l August 2010

ContentsTEXAS DENTAL JOURNAL n Established February 1883 n Vol. 127, Number 8, August 2010

ARTICLES

735 Conflicts of Interest in Research: Is Clinical Decision-Making Compromised? An Opinion Paper Shawn Abidi, D.D.S. Richard D. Bebermeyer, D.D.S., M.B.A.

The authors discuss how a lack of transparency in funded research can compromise clinical decision-making in an evidence based practice.

749 Fluoride Varnish: The Top Choice for Professionally Applied Fluoride Ryan L. Quock, D.D.S., Donna P. Warren-Morris, R.D.H., M.Ed. Theauthorsdiscusshowfluoridevarnishcombinescariespreventionand efficacywithsafetyandversatility.

767 Texas Medicaid — TDA Dentists Making a Difference William D. Steinhauer, D.D.S.

The author reports on the state’s Medicaid program statistics and TDA’s involvement to improve access to dental care for children in Texas.

ON THE COVERThe cover photo, “Skimmers,” was taken by Dr. Roy Tiemeyer of Corpus Christi. It won Best in Show at the May 2010 TEXAS Meeting Photo Contest in San Antonio. Wildlife and bird photography is Dr. Tiemeyer’s hobby, and he took the photo in August 2009 at the Leonabelle Turnbull Birding Center in Port Aransas. With a clear blue summer sky and no breeze, these skimmers were the only movement that morning. Dr. Tiemeyer is a 1978 graduate of the University of Texas Dental Branch at Houston and operates a general practice in Corpus Christi.

For more information on the 2011 TEXAS Meeting Photo Contest, please visit texasmeeting.comorcalltheTDAcentraloffice,(512)443-3675.


Texas Dental Journal is a member of the American Association of Dental Editors.

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BOARD OF DIRECTORSTEXAS DENTAL ASSOCIATION

PRESIDENTRonald L. Rhea, D.D.S.

(713) 467-3458, [email protected]

J. Preston Coleman, D.D.S.(210) 656-3301, [email protected]

IMMEDIATE PAST PRESIDENTMatthew B. Roberts, D.D.S.

(936) 544-3790, [email protected] PRESIDENT, SOUTHEAST

R. Lee Clitheroe, D.D.S.(281) 265-9393, [email protected]

VICE PRESIDENT, SOUTHWESTJohn W. Baucum III, D.D.S.

(361) 855-3900, [email protected] PRESIDENT, NORTHWEST

Kathleen M. Nichols, D.D.S.(806) 698-6684,

[email protected] PRESIDENT, NORTHEAST

Donna G. Miller, D.D.S.(254) 772-3632,

[email protected] DIRECTOR, SOUTHEAST

Karen E. Frazer, D.D.S.(512) 442-2295, [email protected] DIRECTOR, SOUTHWEST

Lisa B. Masters, D.D.S.(210) 349-4424, [email protected]

SENIOR DIRECTOR, NORTHWESTRobert E. Wiggins, D.D.S.

(325) 677-1041, [email protected] DIRECTOR, NORTHEAST

Larry D. Herwig, D.D.S.(214) 361-1845, [email protected]

DIRECTOR, SOUTHEASTRita M. Cammarata, D.D.S.

(713) 666-7884, [email protected], SOUTHWEST

T. Beth Vance, D.D.S.(956) 968-9762, [email protected]

DIRECTOR, NORTHWESTMichael J. Goulding, D.D.S.

(817) 737-3536, [email protected], NORTHEASTArthur C. Morchat, D.D.S.


Ron Collins, D.D.S.(281) 983-5677, [email protected]

SPEAKER OF THE HOUSEGlen D. Hall, D.D.S.


Michael L. Stuart, D.D.S.(972) 226-6655, [email protected]

EDITORStephen R. Matteson, D.D.S.

(210) 277-8595, [email protected] DIRECTOR

Ms. Mary Kay Linn(512) 443-3675, [email protected]

LEGAL COUNSELMr. William H. Bingham


MONTHLY FEATURES

730 President’s Message

732 The View From Austin

776 What’s on tda.org?

778 Value for Your Profession

784 In Memoriam / TDA Smiles Foundation

782 Calendar of Events

786 Oral and Maxillofacial Pathology Case of the Month

788 Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management

790 Advertising Briefs

806 Index to Advertisers

EDITORIAL STAFF

Stephen R. Matteson, D.D.S., Editor

Nicole Scott, Managing Editor

Barbara S. Donovan, Art Director

Paul H. Schlesinger, Consultant

EDITORIAL ADVISORY BOARD

Ronald C. Auvenshine, D.D.S., Ph.D.

Barry K. Bartee, D.D.S., M.D.

Patricia L. Blanton, D.D.S., Ph.D.

William C. Bone, D.D.S.

Phillip M. Campbell, D.D.S., M.S.D.

Tommy W. Gage, D.D.S., Ph.D.

Arthur H. Jeske, D.M.D., Ph.D.

Larry D. Jones, D.D.S.

Paul A. Kennedy, Jr., D.D.S., M.S.

Scott R. Makins, D.D.S.

Robert V. Walker, D.D.S.

William F. Wathen, D.M.D.

Robert C. White, D.D.S.

Leighton A. Wier, D.D.S.

Douglas B. Willingham, D.D.S.

The Texas Dental Journal is a peer-reviewed publication.

Texas Dental Association1946 South IH-35, Suite 400

Austin, TX 78704-3698 Phone: (512) 443-3675

FAX: (512) 443-3031E-Mail: [email protected]

Website: www.tda.org

Texas Dental Journal (ISSN 0040-4284) is published monthly, one issue will be a directory issue, by the Texas Dental Association, 1946 S. IH-35, Austin, Texas, 78704-3698, (512) 443-3675. Periodicals Postage Paid at Austin, Texas and at additional mailing offices.POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S. Interregional High-way, Austin, TX 78704.Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, Out-of-state ADA Affiliated $49.50. In-state Non-ADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA Affiliated, $17 Non-ADA Affiliated, September issue $17 ADA Affiliated, $65 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. The Editor prefers electronic submis-sions although paper manuscripts are accept-able. Manuscripts should be typewritten, double spaced, and the original copy should be submit-ted. For more information, please refer to the Instructions for Contributors statement printed in the September Annual Membership Direc-tory or on the TDA website: www.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.


President’s MessageRonald L. Rhea, D.D.S., TDA President

Time does fly. Even though still enveloped by the oppressive heat that blankets us in a Texas sum-mer, we realize that the time for vacations and recreation is coming to a close. We must recom-mit ourselves to the new beginnings brought by commencement of a new school year and all the changes in activities and attitudes that this brings. Even those of us who no longer have school aged children cannot avoid the change in pace dictated by the arrival of fall activities. I hope you are all refreshed and anxious to begin the cycle of learning, regardless of your age. Each of us must either learn and grow or wither and perish. Eric Hoffer said, “In times of change, the learners will inherit the earth while the learned will find themselves superbly equipped to live in a world that no longer exists.” I hope you will find helpful the articles presented here by the professors from the University of Texas Dental Branch at Houston.

With thoughts now naturally turning toward children and in our case specifically toward their continued oral health, the article “Fluoride Var-nish: The Top Choice for Professionally Applied Fluoride” by Dr. Ryan L. Quock and Ms. Donna Warren-Morris should be of special interest. The American Dental Association Council on Scien-tific Affairs recommends fluoride varnish as the

only professionally applied fluoride for moderate to high risk patients of all age groups. Professors Quock and Morris discuss this modality’s effec-tiveness, safety enhancement, and acceptability.

This time of year should also bring to us a recom-mitment to ethical behavior in all of our endeav-ors. The news media constantly remind us of the failures of our politicians, entertainers, and public servants. We, as professionals, are held to a higher standard of ethical behavior and must cognizantly strive to perceive the ethical dilem-mas presented to us daily. Many of our decisions must rely on the results of research over which we have little control. The article “Conflicts of Interest in Research; Is Clinical Decision-Making Compromised?” by Drs. Shawn Adibi and Rich-ard Bebermeyer deserves consideration. Profes-sors Adibi and Bebermeyer bring to bear again the almost clichéd concept of transparency as it applies to ethics in research. They discuss how full disclosure of conflicts of interest in funded research is critical to our evaluation of the mate-rial and conclusions. They suggest methods for assuring this transparency.

I hope you enjoy this issue of the Texas Dental Journal and incorporate the new ideas presented into your daily professional decisions.

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Stephen R. Matteson, D.D.S., Editor

Superior teachers are a fabulous asset to society. Stu-dents know who these people are; although, sadly, some-times the teachers do not receive the recognition that they deserve by members of the public or school officials. Dr. Thomas (Tom) D. Marshall was one of those fabulous teachers. He died recently in San Antonio, and his students did appreciate his special efforts to help them learn operative dentistry skills.

Think back, and I’ll bet readers can identify several teachers who had major impacts in their lives. I can think of several. Doc Summers was the acknowledged best chemistry teacher at Columbia High School in Maplewood, New Jersey. Today, his class would be designated as a college prep course. The learning in his class helped yours truly pass three college chemistry courses and the biochemistry in dental school. He asked his students to send their college chemistry course exams to him so he could evaluate colleges and relay that information to his high school students. His rankings helped many of us select the col-lege we would attend.

Then there was Professor McKin-ney who was professor of chemis-try at Rutgers University and taught the quantitative analysis course. He wrote the book on that subject and his lectures followed the chapters in that book precisely. One could sit in lecture and follow along with the principles and chemistry problems along with the textbook. I found that a great way to learn. He was also a very kind person who would help students with their studies individually.

At dental school, there were several of these superior teachers of the dental profession. Dr. Lester W. Burkett was dean of the University of Pennsylvania’s School of Dental Medicine and also wrote the oral medicine textbook of the day. Dur-ing the lectures with 140 students in the lecture hall, he would call on a student and ask a question from the reading that was to be done before class. If that student could not answer the question, he asked that student to call on one of his classmates. This caused consider-able stress for all attending students and oral medicine was recognized by students as one not to ignore. One day, he was seen walking among the steel workers who were engaged in the construction of an adjacent building. During his next

The View From Austin

lecture, he told us how hard the steel workers had to work and that we should emulate their work ethic. He was highly regarded by the stu-dents and faculty.

Dr. Louis Grossman demonstrated the meticulous attention to detail required by dentists in his endodon-tic classes and clinic. His secretary appeared at the beginning of one of his lectures with a tape recorder. He was known for his timeliness and she started the taped lecture at 1:00 PM sharp. Towards the end of the session, all eyes were on the wall clock and sure enough, his taped lecture ended at exactly 1:50 PM to the second. Also, small lights that blinked on and off every 20 seconds were installed at each dental chair so that we could time exactly the endodontic files in our bead steril-izers. He also wrote the textbook of the day on his subject. Students had to check out their final cases with him personally, and it had to look right.

Finally, Dr. Harrison Berry, professor of radiology, gave the lectures on radiographic diagnosis. His slides of all the conditions were very high quality and one could find most of the examples in his textbook. I found what he was doing as very attractive and I am sure that his


example led to my eventual career in dental radiology.

Texas has lost one of these expert teachers. Dr. Tom Marshall, profes-sor of restorative dentistry at the University of Texas Health Science Center at San Antonio Dental School, was one of those men. He was the beloved teacher and mentor of thousands of students. He would show up Saturday mornings to help students who were working on their operative den-tistry skills. Students related years later that he always brought orange juice and donuts along with a toolbox that contained ivoreen teeth each with the succeeding step of class II preparations. He extended his mentoring into the student clinics and is remembered for his kind supervision during students’ early clinical experiences.

If you knew him, you know what I mean. If you did not know him, you may think of those teachers in your life that had major impact on you. This Editor would welcome Letters to the Editor describing the great teachers in your experience. Please send them to Ms. Nicole Scott, managing editor of this journal, [email protected]. You can also post them on the TDA Facebook group wall. For more information, please see “What’s on tda.org” on page 776 of this issue.

ObituaryThomas Donald Marshall, D.D.S.

Thomas Donald Marshall D.D.S., died at home, of ALS, Monday, May 31, 2010, surrounded by his loving family. He was the best husband, father, grandfather, brother, uncle, teacher, and friend in this world. He will be deeply missed.

Dr. Marshall was born in Detroit, Michigan, on September 18, 1925, to Wil-liam Wilford Marshall and Florence Emma (Field) Marshall. He married Caro-lyn Darice Emmett on June 14, 1949, in South Bend, Indiana. Dr. Marshall grew up in Milford, Michigan, and enlisted in the Army Air Corps in 1943, and was stationed at San Antonio Aviation Cadet Center (now Lackland Air Force Base). In 1949, he graduated from Indiana University with an A.B. (Bachelor’s Degree) in Chemistry and in 1953, he graduated with an M.S.Ed in Educa-tional Counseling, also from Indiana University. In 1953, he entered the Indiana University School of Dentistry from which he graduated in 1957 with a Doctor of Dental Surgery degree, with honors. From 1957 to 1972, Dr. Marshall was in private dental practice in Indianapolis, Indiana. From 1974 to 1978, he was on the faculty at the University of Texas Health Science Center Dental Branch in Houston, Texas. From 1978 to 1980, he was on the faculty at the University of Mississippi School of Dentistry. In 1980, he joined the faculty at the University of Texas Health Science Center at San Antonio Dental School where he taught thousands of dental students until his retirement in 2006. He won every teach-ing award at the University of Texas Health Science Center at San Antonio Dental School including the Omicron Kappa Upsilon National Dental Honor Society’s Stephen H. Leeper Award for Teaching Excellence in 2003. Dr. Mar-shall worked as a forensic specialist for National Geographic/UTSA expedition in Rio Azul, Guatemala in 1986. In May of 1997, he lectured at Chulalongkorn Dental Hospital’s first International Geriatric Dentistry Conference in Bangkok, Thailand. In November of 1997, he worked as practitioner/faculty for the King of Thailand’s Annual Public Health Dental Treatment Program in villages of Northeast Thailand. Dr. Marshall lectured at the GuangHua College of Stoma-tology Sun Yat-Sen University, Guanzhou, R. P. China in 2005.

Drs. Tom and Carolyn Marshall enjoyed several hobbies, including archaeol-ogy, weaving, and photography. They traveled a great deal and particularly en-joyed their camping and hiking trips to the southwestern United States. He was preceded in death by his parents as well as his brother, Wilford Jerry Marshall, and his sister, June Delores Marshall Fields.

He is survived by his wife, Dr. Carolyn Marshall; his daughter, Dr. Cynthia Mar-shall Kennedy; his son, Shawn Marshall; and grandson, Joseph Emmett Ken-nedy; as well as his brother, Richard William Marshall; and sister, Mary Joyce Marshall Wolff; and also numerous nieces and nephews. At Dr. Marshall’s retirement, he was recognized for 32 years of professional excellence and total dedication to dental education as a master clinician, educator, mentor, and friend. He rests from his labors and his works do follow him.

Reprint permitted by Dr. Marshall’s family, Porter Loring Mortuary, and the San Antonio Express-News.


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AbstractLack of transparency in funded research can compromise clinical decision-making in an evidence-based practice. Transparency can be defi ned as full disclosure of all fi nancial assistance and support to authors and investiga-tors. There is a perception that ethical principles are eroding and that research data can be biased due to confl icts of interest. These research outcomes biased or not, are used for clinical decision-making in the evidence-based practice. One suggested solution to this common ethi-cal dilemma is to continue the dialogue on transparency in research and to create oversight bodies which include representa-tives from business and industry, private practice, academia, and research. There is increasing evidence of the need for more ethics education at all levels.

KEY WORDS: Ethics, professional misconduct, bioethics, confl ict of interest, research personnel, ethics com-mittees, evidence-based practice (EBP), research disclosure, Institutional Review Boards (IRBs)

Tex Dent J 2010;127(8):735-741.

Conflicts of Interest in Research: Is Clinical Decision-Making Compromised? An Opinion PaperShawn Abidi, D.D.S.

Richard D. Bebermeyer, D.D.S., M.B.A.

Dr. Adibi is an assistant professor, Department of Diagnostic Sciences, University of Texas Health Sci-ence Center at Houston Dental Branch (UTDB). In addition to practice leadership responsibilities, the author teaches diagnostic sciences, including in the Treatment Planning Clinic, Assessment Clinic, and courses such as Introduction to Clinic and Laser Dentistry (elective) at UTDB.

Dr. Bebermeyer is professor and chairman, Department of Restorative Dentistry and Biomaterials, University of Texas Health Science Center at Houston Dental Branch. The department is responsible for curriculum on ethics, professionalism, and jurisprudence, among other restorative dentistry and biomaterials courses for predoctoral dental students and general dentistry residents.

Abidi Bebermeyer

Introduction

Currently, there is a perception that ethical prin-

ciples are eroding and that research data can

be biased. These research outcomes, biased or

not, are used for clinical decision-making in the

evidence-based practice. Relationships among

practitioners, investigators, patients, and the

healthcare industry can be affected when com-

mercialism taints research outcomes and/or clini-

Abidi Bebermeyer


cal decision-making (1). Gifts

and financial support from com-

mercial business and industry

to practitioners, educators, and

investigators have potential

for conflicts of interest (2). The

investments in health care re-

search, for example by the den-

tal materials, oral health care products, or pharma-

ceutical companies, can lead to doubts about the

objectivity of the results from sponsored research.

Issues pertaining to conflicts of interest have risen

for several reasons. One reason, for example, is

that many investigators are not aware of all legal

and ethical aspects of working with healthcare and

pharmaceutical businesses and industries.

The call for an increase in evidence-based practice (EBP) seems to face many obstacles (3). The need for more ethics education — education in research ethics, clinical ethics — to increase inves-tigators’ and practitioners’ awareness of these everyday ethical dilemmas has become increasingly evident. Whether this increase in ethics education is needed for predoctoral, postdoctoral or con-tinuing dental education — or even for license renewal — is left for future discussions in each locale.

Many ethical and legal problems can be prevented by avoiding con-flicts of interest and through transparency, i.e., full disclosure to all audiences of all financial assistance and support to authors and investigators. For example, patients recruited for studies are quite often given consent forms to sign, and procedures are completed, without the patient thoroughly understanding all risks versus benefits involved with the treatment. Patients may not be aware of the financial assistance and support given the investigators; there

Conflicts of Interest in Research

Gifts and financial

support from

commercial business

and industry to

practitioners,

educators, and

investigators have

potential for

conflicts of

interest.


is no transparency to the study. This can often contribute to problems with the doctor-patient relationship, and can lead to patient dissatisfac-tion. Patients often have high expectations for treatment outcomes in a clinical investigation. Time spent with the patient discussing treat-ment expectations and outlining all aspects of the investigation is essential. Patients benefit from clear discussion of possible risks versus benefits and the potential benefits to society through scientific discovery. Moreover, patients must be made aware of the research funding and the potential conflicts of interest. Not only will this increase compliance with protocols, but this also creates the transparency required among investigators, subjects, and the scientific com-munity and health professions (4).

Conflicts of Interest in ResearchIn many instances, investigators are under pres-sure to participate in research, to seek funding to support this research, and then to recruit enough subjects to conduct a statistically signifi-cant project. In addressing these needs, conflicts of interest can arise. If these conflicts of interest are not dealt with transparently, the ethics of the study are compromised. Are there any restric-tions in the amount of money or other incentives offered to a patient for participation in study? Are practitioners given money to recruit or refer patients to study centers? Are study subjects vulnerable when offered financial incentives? These questions describe some of the poten-tial conflicts of interest and present the ethical questions or dilemmas (5). It is clear that ethi-cal questions arise when financial incentives are used to attract subjects to a study. These ques-tions influence the doctor/patient relationship—and the investigator/subject relationship.

The amount of financial incentive ethically and legally acceptable may be dependent on the ethi-cal standards of the locale in the very same way that issues with human subject protection are addressed by local Institutional Review Boards (IRBs). Accepting money for referring patients to a research center can be ethical if it is within the cultural norm of that community.

Oral health care professionals can collect and interpret patient data for internal use, but when they seek to publish these findings, spe-cific ethical standards apply, including approval by an independent review board or as stipu-lated by the specific biomedical journal. Private practitioners wishing to publish results of an investigation or a case study, and seeking help, can contact an IRB at a local academic institu-tion or they can contact an independent review board or ethics board (6).

Commercial Influence of SponsorsCan commercially sponsored and published results be ethically sound? It is now obvious to many in the research community that bio-materials and pharmaceutical companies are engaged actively in the “ghost management” and sometimes “ghost writing” of the scientific literature. Management and manipulation of in-vestigations by companies can allow self-serving interests. This undue influence on the investi-gation and the research community is a mat-ter of ethical concern in that it serves more the commercial interests of profitability and mar-keting, rather than furthering the contributions to the science for broader human benefits. For instance, in a survey of National Institutes of Health researchers, one-third of the scientists reported that they had been involved in some sort of research misbehavior during the past 3 years (7).

There is no doubt that the relationship be-tween healthcare professionals and business and industry is presently under intense scru-tiny. Many accusations of corrupt practices have been reported in both professional and business publications. Many in business and industry believe that they need to adapt and change with the needs of society. They claim that self-regulation is increasing. However, to facilitate improvements in regulations and practices, there is need for more effective dia-logue between business and industry, investiga-tors and health professionals (8). Some in the professions believe that if health care journals want to ensure that the research they publish


is ethically sound, they should not publish articles that are com-mercially sponsored (9). However, transparency measures can be set out to disclose all relevant ethical issues, as well as conflicts of interest inherent in projects. It is a primary responsibility of a publisher and its editing staff to evaluate the ethics of a study, any possible conflicts of interest, and the transparency of a study before approval for publishing.

Research support from business and industry continues at an ac-tive level, but investigators increasingly find themselves in posi-tions that present conflicts of interest, affecting the patients who are their research subjects. One of the suggested solutions to this common ethical dilemma has been to create an oversight body consisting of pharmaceutical and manufacturing representatives, marketing representatives, investigators, private practitioners, and educators, to establish an ethical common ground that is mutually respectful of all, and which includes patient protection and public trust (10).

Public Policy Influence in ResearchThe Bayh-Dole Act (PL 96–517) was passed in 1980 to speed the transfer of technology developed at university laboratories to private industry and ultimately to the public sector. It has also helped to stimulate academic research as investigators have be-come increasingly involved in privately funded work. Although this legislation appears to have led to the creation of many new compa-nies, jobs, and innovative technologies, it has also created ethical ground unfamiliar to many in the academic research environment. Increases in funding, especially from private, for-profit pharmaceu-tical and biotechnology firms, appear to have increased concerns in the scientific community, in professional organizations, and in the public sector about conflicts of interest experienced by inves-tigators (11). Conversely, support for education and research is somewhat dependant on the continued financial support of private business and industry. Consequently, the patients’ quality and quantity of care can be indirectly affected (12, 13).

Ethics EducationComprehensive reviews of the literature reveal lack of sufficient education pertaining to ethics education for dental and medical students (14). Publications mention that studying ethics as a part of a predoctoral dental curriculum does not necessarily translate to behavioral changes (15, 16). There may be several reasons for



this disconnect between knowledge and action which concerns academia. There are tremendous opportunities and needs for predoctoral ethics curricula for medical, dental, and allied health care professionals. Health education programs around the country should modify their curricula to fill this evident deficiency (17). In fact, it is notable that in the dental profession, both the American Dental Association (ADA) and the American Dental Education As-sociation (ADEA) have statements on professionalism (18).

In a study published recently by the University of Minnesota, pre-test scores were analyzed for 41 professionals referred for ethics assessment by a dental licensing board. Two were exempt from instruction based on pretest performance on five well-validated measures; 38 completed an individualized course designed to remediate deficiencies in ethical abilities. Statistically significant change was observed for ethical sensitivity, moral reasoning, and role concept. Of particular interest is the way this model helped referred professionals see character and ethics as capacities that can be further developed. The performance-based assessments were particularly useful in identifying shortcomings in ethical implementation. Referred practitioners valued highly the emphasis on ethical implementation, suggesting the importance of address-ing what to do and say in ethically challenging cases. Finally, the required self-assessments of learning confirm the value of the process for professional renewal (i.e., a renewed commitment to professional ideals) and of enhanced abilities not only to reason about moral problems, but also to implement actions (19).

Disclosure for PublicationsStrategies for disclosing investigators’ financial interests to poten-tial research participants have been adopted by many research institutions. However, little is known about how decisions are made regarding disclosures of financial interests to potential research participants, including what is disclosed and the ratio-nale for making these determinations. A study by Weinfurt et al reported the attitudes, beliefs, and practices of institutional review board chairs, conflict of interest committee chairs, and investiga-tors regarding disclosure of financial interests to potential research participants. Respondents cited several rationales for disclosure, including enabling informed decision making, promoting trust in researchers and research institutions, and reducing legal liability. There was general agreement that disclosure should happen early in the consent process. Respondents in this study had little agree-ment about whether to disclose the amounts of particular financial interests. However, respondents were in agreement about ensuring the integrity of clinical research (20).


Conclusions and Recommendations • Transparency and full disclosure: Lack of transparency in

funded research can compromise clinical decision-making in an evidence-based practice. Many investigators collaborate with business and industry to succeed with research and career goals, without knowing all the legal and ethical rami-fications involved with possible conflicts of interest. Many ethical and legal problems can be prevented by avoiding con-flicts of interest, and through transparency, defined as full disclosure of all financial assistance and support to authors and investigators. Transparency and clearly communicated full disclosure not only prevent conflicts of interest between investigators, health care professionals, patients, and sub-jects, but can also lead to crucial improvements in ethical research behavior. If transparency does not eliminate con-flict of interest, it will certainly minimize ethical problems in research and will facilitate decision-making in the evidence-based practice.

• Expanded ethics education: The need for expanded ethics education for pre- and post-doctoral students is becoming increasingly apparent. Education in ethics and profession-alism will increase practitioners’ and investigators’ aware-ness of ethical and professional dilemmas that present on a routine basis. Whether this ethics education alone can enhance ethical behaviors adequately will be addressed by local licensing authorities and editorial boards, based on the ethical and cultural norms of the locale.

• Continuation of the dialogue: Additional suggested solutions to these common ethical dilemmas include continuing the dialogue on transparency in research, and creating over-sight bodies that include representatives from business and industry, private practice, academia, and research.

References

1. Boyd MA, Roth K, Ralls SA, Chambers DW. Beginning the discussion of commer-cialism in dentistry. J Calif Dent. Assoc. 2008 Jan; 36(1):57-65.

2. Parker LS, Satkoske VB. Conflicts of interest: are informed consent an appro-priate mode and disclosure an appropriate remedy? J Am Coll Dent, 2003 sum-mer; 74(2):19-26.

3. Hannes K, Norre D, Goed-huys J, Aertgeerts B. Obstacles to implementing evidence-based dentistry: a focus group-based study. J Dent Educ. 2008 Jun; 72(6):736-44.

4. Grandy C. Ethical Prin-ciples in Clinical Research, Chapter 2: Principles and Practice of Clinical Re-search, 2007.15-26.

5. Draper H, Wilson S, Flana-gan S, Ives J. Center for Biomedical Ethics, Depart-ment of Primary Care and General Practice, University of Birmingham, Edgbaston, Birmangham B15 2TT,UK. Fam Pract. 2009 Mar 3; (E pub ahead of print).


Transparency and clearly communicated full disclosure not only

prevent conflicts of interest between investigators, health care

professionals, patients, and subjects, but can also lead to crucial

improvements in ethical research behavior.


13. Wieting MW, Mevis H, Zuckfeman. The role of industry in internet educa-tion. Clin Orthop Relat Res. 2003 Jul; (412):28-32.

14. Eckles RE, Meslin EM, Gaffney M, Helft PR. Divi-sion of hematology/oncol-ogy, Indiana University School of Medicine, 535 Barnhill Drive, Room 473, Indianapolis, IN 46202, USA. Medical ethics educa-tion: Where are we? Where should we be going? A re-view. Acad Med. 2005 Dec; 80(12): 1134-52.

15. Bertolami CN. School of Dentistry, University of California, San Francisco 94143, USA. Why our eth-ics curricula don’t work. J Dent Educ. 2004 Apr; 68(4):414-25.

16. Dunn WJ. Ethical Re-search. J Am Dent Assoc. 2009 Dec; 138(12):153-5: discussion 1435.

17. Deming N, Fryer-Edwards K, Dudzinski D, Starks H, Culver J, Hopley E, Robins L. Incorporating Principles and Practical Wisdom in Research Ethics Education: A Preliminary Study, Jan 2007; 82:18-23.

18. American Dental Education Association. ADEA State-ment on Professionalism in Dental Education as Ap-proved by the 2009 ADEA House of Delegates, March 2009.

19. Bebeau MJ. Enhancing professionalism using eth-ics education as a dental licensure board’s disciplin-ary action. Part 2 Evidence of the process. J Am Coll Dent. 2009 Fall; 76(3):32-45.

6. Glick M. Ethical consid-erations in publishing research involving human subjects. J Am Dent Assoc. 2007 Oct; 138(10):1300-2.

7. Martinson BC, Anderson MS, de Vries R. Scientists behaving badly. Nature 2005; 435(7043):737-8.

8. Leather DA, Davis SC. Glaxosmith Kline UK Ltd, Building 10, Stockley Park West, Uxbridge, Middlesex UB11 1BT, UK. Paediatri-cians and the pharmaceu-tical industry perspective of the challenges ahead. Paediatr Respir Rev. 2006 Mar; 7(1):60-6.

9. Sismondo S, Doucet M. Department of Philoso-phy at Queen’s University. Publication ethics and the ghost management of medi-cal publications. Bioethics. 2009 Feb10; (E pub ahead of print).

10. Epps CH, Jr. Division of Orthopaedic Surgery, How-ard University Hospital, Washington, DC 20060, USA. Ethical guidelines for orthopaedists and industry. Clin Orthop Relat Res. 2003 Jul; (412):14-20.

11. T. D. Warner, J. P. Gluck. Department of Psychiatry, 1 University of new Mexico School of Medicine, 2400 Tucker NE, Albuquerque, NM 87131, USA. Psychop-harmacology (Berl). 2003 Dec; 171(1):36-46. E pub 2003 Nov 18.

12. Wilson FS. Continuing Medical Education: Ethi-cal Collaboration between sponsors and industry. Clin Orthop Relat Res. 2003 Jul; (412):33-7.

20. Weinfurt KP, Friedman JY, Dinan MA, Allsbrook JS, Hall MA, Dhillon JK, Sugar-ma J. Disclosing conflict of interest in clinical research: views of institutional review boards, conflicts of interest committees, and investi-gators. J Law Med Eth-ics.2006 Fall; 34(3); 581-91,481.

Full Disclosure: Dr. Adibi has received honorar-ia and educational assistance from: Biolase Technology, Hoya Conbio, Ivoclar Vivadent, and Deka Laser Technologies Sys-tem in support of continuing education presentations.

Acknowledgement: The authors thank the editor and reviewers of the Texas Den-tal Journal for their contribu-tions and editorial assistance with this manuscript.

742 Texas Dental Journal l www.tda.org l August 2010550 Texas Dental Journal l www.tda.org l June 2010

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Fluoride Varnish: The Top Choice for Professionally Applied FluorideRyan L. Quock, D.D.S., Donna P. Warren-Morris, R.D.H., M.Ed.

Abstract

Although various modes of delivery for profession-ally applied fl uoride exist, one form has emerged that combines caries prevention effi cacy with safety and versatility. The American Dental Association Council on Scientifi c Affairs recom-mends fl uoride varnish as the only professionally applied fl uoride for moder-ate to high risk patients of all age groups. In addition to demonstrating effective-ness equivalent to fl uoride gels, fl uoride varnish pro-vides improved safety and acceptability. Furthermore, fl uoride varnish has shown promise in preventing den-tal caries in special groups, such as orthodontic pa-tients and the elderly.

KEY WORDS: fl uoride, fl uoride varnish, professionally applied fl uoride

Tex Dent J 2010;127(8):749-759.

Dr. Quock is an assistant professor, Department of Restorative Dentistry & Biomaterials, University of Texas Dental Branch at Houston.Ms. Warren-Morris is an associate professor, Department of Periodontics, University of Texas Dental Branch at Houston.Address correspondence and reprint requests to Dr. Ryan Quock, Department of Restorative Dentistry & Biomaterials, University of Texas Dental Branch, 6516 M. D. Anderson Blvd., Ste. 493, Houston, TX 77030; Phone: (713) 500-4276; Fax: (713) 500-4108; E-mail: [email protected].

Introduction

As the dental profession continues to lead the way in providing quality health care in the United States, it must address the challenge still posed by dental caries. Signifi cantly, dental caries is the most common chronic childhood disease in this country (1). Dentistry has the unique privilege and responsibility of treating dental caries, and preven-tion is the centerpiece of any strategy for treating caries. Of course, discussion of dental caries pre-vention inevitably turns to the success of fl uoride, which has been proven to reduce the incidence of dental caries and favorably alter the progression of existing carious activity (2). Fluoride aids in both protecting tooth structure from acid attack and in

remineralizing affected teeth.

Quock Warren-Morris Quock Warren-Morris


Our patients are exposed to flu-oride daily through toothpastes and fluoridated drinking water. These routes of exposure are certainly beneficial with re-gard to caries prevention, but many patients at moderate to high risk for caries additionally require professionally adminis-tered fluorides (2). While most toothpaste contains fluoride concentrations of 1000-1100 ppm, in-office professionally applied fluorides achieve much higher concentrations (2). Per-haps the most common profes-sionally applied topical fluoride is the gel form, either 1.23 percent acidulated phosphate fluoride (APF) at 12,300 ppm or 2 percent sodium fluoride (NaF) at 9,050 ppm (3). When applied in trays for the recom-mended 4 minute duration, fluoride gels have demonstrated success in caries prevention

Fluoride Varnish

(4). However, the major draw-back of professional fluoride gel is accidental ingestion of the fluoride during the required four minute application — re-sultant adverse gastrointestinal effects due to acute fluoride toxicity are well known to most practitioners (4). Indeed, this risk of over ingestion of fluoride makes fluoride gels not recom-mended for use in children aged 6 and under, ironically a vulnerable patient population that in many cases benefits from professionally applied flu-oride (4). Additionally, APF gel is contraindicated for patients with glass ionomer or porcelain restorations, because the acid in the formulation will etch and damage such restorations (5). Is there a form of professionally applied fluoride that is proven to match the caries preven-

tion efficacy of fluoride gels, while also avoiding the inher-ent drawbacks of gels? Yes – fluoride varnish combines a higher concentration of fluo-ride (22,600 ppm in the typi-cal 5 percent NaF form) with a reduced risk of over-ingestion (6). The efficacy and safety of fluoride varnish make it recom-mended for caries prevention in moderate to high risk pa-tients of all ages by the Ameri-can Dental Association (ADA) Council on Scientific Affairs (3), the Center for Disease Control and Prevention (2), and the FDI World Dental Federation (5). In addition to the effec-tiveness and safety of fluoride varnishes, ease of application, increased patient acceptance, and lower overall cost have also been reported as benefits (3,7-9). Given fluoride varnish’s anti-caries effect and advantag-

Figure 1. Fluoride Varnish Application

Step 1. Remove excess Biofilmanddebris.


es, it would seem the obvious choice for professional fluoride in every dental office; indeed, fluoride varnish has been the standard of practice for profes-sional fluoride in Europe for decades (10-11). This article seeks to present a practical re-view of fluoride varnish theory and application, so that the dental practitioner may be well equipped to provide the most effective preventive treatment for his or her patients.

Fluoride Varnish is Effective Understanding how fluoride in general works to prevent dental caries is the key to understand-ing why fluoride varnish specif-ically is so effective. Although fluoride ingested systemically during tooth development may incorporate into the crystal-line structure of non-erupted teeth, it is currently understood that the primary mechanism of

Step 2. Dry teeth with gauze or air syringe.

action of fluoride is topical on already erupted teeth (2, 12, 13). As cariogenic bacteria in dental plaque metabolize car-bohydrates and produce acids, surface enamel of teeth begins to demineralize. Minerals like calcium and phosphorus leave the enamel and are retained in the plaque. Ironically, dental plaque now can act as a res-ervoir for minerals that can be reincorporated into the enamel — remineralization. Fluoride is the chief catalyst that attracts minerals back into the enamel, thereby counteracting the ef-fects of demineralization (2). Any fluoride present in the mouth can also be retained in dental plaque. As pH lev-els drop with the increase in acids produced by cariogenic bacteria, fluoride in the plaque is released (14). This fluoride, along with calcium and phos-phorus, is incorporated into the surface enamel structure. The resultant remineralized enamel is more resistant to acid attack

(15-16). Thus, fluoride aids in remineralization as well as making enamel more resistant to demineralization. It is im-portant to note that as pH lev-els rise and fall in the mouth, the pendulum swings between demineralization and remin-eralization at the tooth-plaque interface throughout the life of a tooth (2). Fluoride, therefore, must be present in the oral environment throughout the patient’s lifetime in order to maximize its anti-caries effect. As noted earlier, daily use of fluoride toothpaste and fluori-dated drinking water introduce fluoride to the oral environ-ment in small quantities. This fluoride remains in the saliva for about 1-2 hours; during that time, dental plaque can be “recharged” with fluoride for fu-ture remineralization (17). For patients at low-risk for dental caries, such daily exposures to fluoride may be effective enough for caries prevention (3).


However, for patients at mod-erate to high risk for dental caries, professionally applied fluorides of high concentration are recommended (3). Fluo-ride varnish or gel application results in the formation of calcium fluoride (CaF2) globules directly on the enamel surface; the fluoride in these globules can aid in remineralization. Paradoxically, CaF2 binds more efficiently to demineralized enamel than to sound enamel (18). Although both varnish and gel applications result in high levels of fluoride release, fluoride varnish has the added benefit of a longer exposure time to enamel. Fluoride var-nish consistently elevates sali-vary fluoride levels for about 24 hours, while fluoride gels and other delivery systems tend to present with dramatic fluoride loss at a much earlier time.

The longer fluoride exposure time demonstrated by fluoride varnish has been associated with greater efficiency and ef-fectiveness in the remineraliza-tion process (19,20). In short, increased duration of contact of professionally applied fluo-ride, as observed with fluoride varnish, is linked to increased efficacy.

Fluoride varnishes were devel-oped in the 1960’s with caries prevention in mind. Specifi-cally, the desire was to increase contact time between fluoride and enamel (21). Fluoride varnish adheres to the enamel surface tenaciously because of the natural resin in its formu-lation, a neutral colophonium base (6, 20). Varnish is usually applied with a brush and sets upon contact with intraoral moisture (18). In contrast to

Fluoride Varnish

Fluoride Varnish Application

fluoride gels, which remain in contact with teeth for 4 min-utes and then are expectorated, fluoride varnishes remain in contact with teeth for at least several hours. Furthermore, it is the tenacious adherence of fluoride varnish to teeth that minimizes risk for accidental ingestion; fluoride gels do not adhere to teeth and are often ingested, especially by young children. Thus, fluoride var-nish combines high fluoride concentration (5 percent NaF, 22,600 ppm) with the ability to remain in contact with teeth for longer durations than other professionally applied fluorides.

Systematic reviews of scientific studies involving fluoride var-nish tend to validate its effec-tiveness. In studies of children up to the age of 16 that lasted at least 1 year, fluoride var-

Step 3. Mix the varnish thoroughly.


nishes demonstrated caries prevention efficacy similar (and in some cases slightly higher) to that of fluoride gels (21-23). It is important to note that fluo-ride varnish has been shown to be effective in preventing caries regardless of the fluoridation status of a patient’s community drinking water. Data from re-cent clinical studies of children and adolescents in the United States, Sweden, and Germany have also strongly pointed to the caries preventive efficacy of fluoride varnish, both in primary and permanent denti-tion (11, 24–26). Furthermore, fluoride varnish has shown promise in preventing dental caries in special populations, like those in orthodontic brack-ets and the institutionalized elderly (27, 28). Such compel-ling data has lead the American Dental Association Council on Scientific Affairs to recommend fluoride varnish for the preven-tion of caries in moderate to high risk patients of any age group (3).

Fluoride Varnish is Safe Although both fluoride gels and varnishes have been shown to be effective in preventing dental caries, one major drawback of fluoride gels is the real risk of over ingestion of fluoride, especially in younger patients. When properly administered in trays for 4 minutes, excess flu-oride gel can be inadvertently swallowed. Most practitioners are familiar with the adverse effects of acute fluoride toxic-ity — nausea and vomiting. In some rare cases, fluoride overdose from gel may result in death (3, 4, 29).

Fluoride varnish minimizes the risk of over ingestion in at least a few ways. To begin, because fluoride varnish sets upon contact with the teeth and clings tenaciously to the enam-el, there is little to no excess varnish to be swallowed (18).

Furthermore, a relatively small amount of fluoride varnish is needed to treat each patient. It takes about 0.5 ml of fluoride varnish to treat a child; this quantity contains 3-11 mg of fluoride. The probable toxic dose (PTD) of fluoride is 5 mg/kg — so even if the child swal-lowed all of the fluoride varnish applied during a treatment, he or she would have con-sumed well below the probable toxic dose (21). In contrast, a small tray filled one third full with APF fluoride gel contains about 2.5 ml. The PTD of this product for a 22 pound child would be 4 ml. Clinical studies of plasma fluoride concentra-tion following topical fluoride treatment found that the peak plasma fluoride concentration following fluoride varnish was about the same as that fol-lowing brushing with fluoride toothpaste, and significantly lower than that following treat-ment with APF gel (30-31). Various fluoride varnish manu-facturers advise that their

Step 4. Apply a thin coat to all to facial, lingual, and interproximal surfaces with a brush.


product should not be used in patients with ulcerative gingivi-tis and stomatitis. This may be related to a hypothetical sensi-tivity to the colophonium resin in the varnish (18). Although fluoride varnish has been the standard professionally applied fluoride in Europe for 30 years, to the authors’ knowledge, only two case studies report-ing contact allergy to varnish have been published in that time period (32,33). Fluoride varnish’s benefit of prevent-ing acute fluoride toxicity on a regular basis in our patients will likely outweigh the appar-ently minimal occurrence of contact sensitivity to it.

Fluoride Varnish is Easy, Accepted, and AffordableIt has been noted that fluoride varnish is easy to administer, es-pecially in young children (3, 9). Varnish is simply brushed onto enamel surfaces, hardening upon contact with saliva or water. This usually takes less time than the required 4 minutes that are necessary for fluoride gel tray application as approved by the ADA (3-4, 8). As a result, fluoride varnish elicits less gagging from pa-tients than tray-based methods (8). In fact, a recent survey report-ed that hygienists prefer administering, and patients prefer receiv-ing, fluoride varnish over fluoride gel (3, 34). Furthermore, while unit cost of fluoride varnish and APF gel is roughly equivalent (18), fluoride varnish takes less time to apply (3, 8). When labor costs are factored in, fluoride varnish is at least as cost effective, if not more cost effective, than fluoride gel. Patient acceptance is also in-creased since the required 30 minute wait after fluoride gel admin-istration before eating and drinking is not necessary with fluoride varnish.

Step 5.“Set” the varnish with water or saliva.

Step 6. Give post-op instructions: No brushing, flossing, or hard foods for 12 hours.

Fluoride Varnish Application

Fluoride Varnish


Fluoride Varnish and Geriatric PatientsIt is widely known that the U.S. population is becoming older, with the group of adults over the age of 65 increasing the most rapidly. Systemic conditions often force elderly patients to be treated with multiple medications that can result in xerostomic side effects. This trend, coupled with their lack of dexterity or mental aware-ness for self-care, make many elderly at moderate or high risk for dental caries (3). Fluoride varnish is an excellent therapy for use with elderly patients or periodontal patients who have clinical attachment loss exposing root surfaces to caries risk. In institu-tionalized elderly, tray treatments would be very difficult to apply unless suction was available. Even with available suction, tray treatments are not an option for use with an intubated or uncon-scious patient.

American Dental Association Recommendations Based upon a review by its Council on Scientific Affairs of the best available evidence, the American Dental Association recently pub-lished its recommendations for use of professionally applied topi-cal fluoride (3). A summary of the recommendations, especially as they relate to fluoride varnish, follows:

• Patients at low risk for caries may not benefit from profession-ally applied topical fluoride (3).

• Fluoride varnish applied every 6 months is effective in prevent-ing caries in primary and permanent dentition of children, adolescents, and high-risk populations (3).

• For patients younger than 6 years old of moderate or high risk for caries, fluoride varnish applied at least every 6 months is the only professionally applied fluoride that is recommended

(3, 6).• For patients aged 6 to 18 years of moderate or high risk for

caries, fluoride varnish or gel applied at least every 6 months is recommended (3).

• For patients older than 18 years of moderate or high risk for caries, fluoride varnish or gel applied at least every 6 months is recommended (3).

Thus, fluoride varnish is the only professionally applied fluoride that is recommended by the American Dental Association (ADA) for use in all age groups. It is beneficial to note that the ADA strongly endorses this “off-label” use of fluoride varnish for caries preven-tion; the Federal Drug Administration officially approves fluoride varnish for use as a cavity liner or desensitizer.

Although fluoride

varnish has been

the standard

professionally

applied fluoride in

Europe for 30 years,

to the authors’

knowledge, only

two case studies

reporting contact

allergy to varnish

have been published

in that time period.


NAME CHARACTERISTICS MANUFACTURER

CavityShield® 5 percent NaF 3M ESPE www.3MESPE.com/preventivecare

ClearShield® 5 percent NaF, Xylitol, clear Zenith Dental varnish, gluten free www.zenithdental.com

Duraflor Halo ® 5 percent NaF, Xylitol, white Medicom varnish, gluten free www.medicom.com

DuraShield® Amber tinted, 5 percent Sultan Dental Products NaF, Xylitol [email protected]

Enamel Pro Varnish® Delivers ACP (Amorphous Premier Dental Products Company Calcium Phosphate), 5 percent http://www.premusa.com/dental/hygiene. NaF, white varnish asp#enamelprovarnish

Fluoride Varnish 5 percent NaF, Oral BioTech white varnish [email protected]

PreviDent ®Varnish 5 percent NaF, Colgate Oral Pharmaceuticals white varnish http://www.colgateprofessional.com/products/ Colgate-PreviDent-Varnish-Rx-only/specifics

VANISH® 5 percent NaF, 3M ESPE white varnish www.3MESPE.com/preventivecare

Vanish™ Resin-modified glass ionomer; 3M ESPEXT Extended delivers fluoride, calcium, and www.3MESPE.com/preventivecareContact Varnish phosphate to seal dentinal tubules

VarnishAmerica™ 5 percent NaF, natural tooth Medical Products Laboratories colored http://www.medicalproductslaboratories.com/

Vella 5 percent NaF, Xylitol, Preventech white varnish http://www.preventech.com/

Waterpik UltraThin® 5 percent NaF, Waterpik thinner consistency www.ultrathin.waterpik.com

Table 1. Fluoride Varnish Products and Manufacturers

Fluoride Varnish

Thislistnotintendedtobeanexclusivelistingofallfluoridevarnishproducts.


Clinical Application of Fluoride VarnishFluoride varnish application is very simple and requires less than a minute to apply. A review of studies that inves-tigated the most efficacious techniques for fluoride varnish application reported the follow-ing steps, which are outlined and illustrated in Figure 1 (6). Excess biofilm and debris should be removed with either a toothbrush or rubber cup. Even though manufacturers suggest that varnish can be applied to moist teeth, all of the reviewed studies applied the varnish to dry teeth and one study that reported the re-sults of applying it to wet tooth surfaces found fluoride uptake to be greater on dry teeth (35). The teeth can be dried with air or gauze. Since some varnish-es have a tendency to separate, be sure to mix the product well with the applicator brush before applying. The varnish is then applied to facial/lingual surfaces with a small brush and can be applied to inter-proximals with dental floss. The teeth are then rinsed with water or the patient can simply close and allow saliva to set the varnish. The last step is to give the patient post-operative in-structions to eat soft foods for 12 hours and to abstain from toothbrushing and flossing for 12 hours as well, allowing the varnish to remain in contact with the teeth.

Fluoride varnish products have been in use in the United States since 1994 when they were approved as cavity liners and used off-label for fluoride applications (18). The first generation of varnishes was amber colored colophonium resins that were met with some resistance due to imparting a temporary yellowing of the teeth. The second generation products are tooth colored and are invisible after application. A non-exhaustive list of prod-ucts and their manufacturers is listed in Table 1.

Fluoride Varnish Reduces HypersensitivityThe most widely accepted theory of dentinal hypersen-sitivity is that it is a result of hydrodynamics which is the outward fluid movement within the pulp that creates pressure on the nerves causing pain. This condition has been esti-mated to effect between 14 and 30 percent of the population and is ever increasing with the aging population and the use of whitening agents (36). Fluo-rides have been shown to form a layer of CaF2 on the exposed cervical dentin surface blocking the tubules and reducing hy-persensitivity (37,38). Fluoride varnishes have ADA approval for dentinal hypersensitivity and have the advantage over fluoride gels, rinses, and foams due to their retention on the tooth surface for extended time periods. They have been shown to be effective in reducing sen-

sitivity to air and cold for up to 34 weeks after application (39). The procedure for application is the same as outlined previ-ously.

The Role of the Dental TeamAs with all dental procedures, the safe use of evidence based practices and products should be the first concern of the den-tist, dental hygienist, and den-tal assistant. Fluoride varnish is recommended by the ADA for caries prevention, and it is the only professionally applied fluoride product recommended for children under age 6. In addition to assessing patient caries risk level and prescrib-ing an appropriate professional fluoride regimen according to ADA recommendations, the dentist should assure that his/her auxiliaries are properly educated and trained in the correct use of all fluoride prod-ucts, including varnishes. The dental auxiliary responsible for administering fluoride should update his/her knowledge of fluorides frequently and fol-low appropriate procedures to ensure efficacy and safety. In conclusion, fluoride var-nishes are recommended by the ADA for prevention of caries in moderate to high risk patients of any age group — this is a unique distinction. Efficacy, safety, ease of administration, and patient acceptability con-tribute to this winning combi-nation. Thus, when consid-ering professionally applied fluoride, think fluoride varnish!


References

1. US Department of Health and Human Services. Oral Health in America: A Re-port of the Surgeon Gen-eral – Executive Summary. Rockville, MD: U.S. Depart-ment of Health and Human Services, National Institute of Dental and Craniofacial Research, National Insti-tutes of Health, 2000.

2. Center for Disease Control and Prevention. Recom-mendations for using fluo-ride to prevent and control dental caries in the United States. MMWR 2001;50(No.RR-14) 2.

3. American Dental Asso-ciation Council on Scien-tific Affairs. Professionally applied topical fluoride: evidence-based clinical rec-ommendations. Journal of the American Dental Asso-ciation 2006; 137(8):1151-1159.

4. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride gels for prevent-ing dental caries in children and adolescents. The Co-chrane Database of System-atic Reviews 2002, Issue 1. Art. No.: CD002280. DOI: 10.1002/14651858.CD002280.

5. Chu CH, Mei ML, Lo EC. Use of fluorides in dental caries management. Gen-eral Dentistry 2010 Jan-Feb; 58(1)37-43.

6. Miller EK, Vann WF. The use of fluoride varnish in children: a critical review

with treatment recommen-dations. The Jounral of Clinical Pediatric Dentistry 2008; 32(4):259-264.

7. Petersson LG, Twetman S, Dahlgren H, Norlund A, Holm A-K, Nordenram G, Lagerlof F, Soder B, Kall-estal C, Mejare I, Axelsson S, Lingstrom P. Professonal fluoride varnish treatment for caries control: a sys-tematic review of clinical trials. Acta Odontol Scand 2004; 62:170-176.

8. Hawkins R, Noble J, Locker D, Wiebe D, Murray H, Wie-be P, Frosina C, Clarke M. A comparison of the costs and patient acceptability of professionally applied topical fluoride foam and varnish. Journal of Pub-lic Health Dentistry 2004; 64(2):106-110.

9. Tinanoff N, Douglass JM. Clinical decision-making for caries management in primary teeth. Journal of Dental Education 2001; 65(10):1133-1142.

10. Autio-Gold J. Recommen-dations for fluoride varnish use in caries management. Dentistry Today 2008; 27(1):64-67.

11. Autio-Gold JT, Courts F. Assessing the effect of fluoride varnish on early enamel carious lesions in the primary dentition. Journal of the American Dental Association 2001; 132(9):1247-1253.

12. Singh KA, Spencer AJ, Brennan DS. Effects of water fluoride exposure

at crown completion and maturation on caries of per-manent first molars. Caries Res 2007; 41:34-42.

13. Griffin SO, Regnier E, Grif-fin PM, Huntley V. Effec-tiveness of fluoride in pre-venting caries in adults. J Dent Res 2007; 86(5):410-415.

14. Tatevossian A. Fluoride in dental plaque and its effects. Journal of Dental Research 1990; 69(special issue):645-652.

15. Featherstone JDB. Preven-tion and reversal of dental caries: role of low level fluoride. Community Den-tistry and Oral Epidemiol-ogy 1999; 27:31-40.

16. Chow LC. Tooth-bound fluoride and dental car-ies. Journal of Dental Research 1990; 69(special issue):595-600.

17. Rolla G, Ekstrand J. Fluo-ride in oral fluids and den-tal plaque. In: Fejerskov O, Ekstrand J, Burt BA, eds. Fluoride in dentistry. 2nd ed. Copenhagen: Munksgaard, 1996; 215-229.

18. Beltran-Aguilar ED, Gold-stein JW, Lockwood SA. Fluoride varnishes: a review of their clinical use, cariostatic mechanism, ef-ficacy and safety. Journal of the American Dental As-sociation 2000; 131(5):589-596.

19. Eakle WS, Featherstone JDB, Weintraub JA, Shain SG, Gansky SA. Salivary fluoride levels following ap-

Fluoride Varnish


plication of fluoride varnish or fluoride rinse. Commu-nity Dent Oral Epidemiol 2004; 32:462-469.

20. Strohmenger L, Brambilla E. The use of fluoride var-nishes in the prevention of dental caries: a short re-view. Oral Diseases 2001; 7:71-80.

21. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluo-ride varnishes for prevent-ing dental caries in children and adolescents. The Co-chrane Database of System-atic Reviews 2002, Issue 1. Art. No.: CD002279. DOI: 10.1002/14651858.CD002279

22. Marinho VCC, Higgins JPT, Sheiham A, Logan S. One topical fluoride (tooth-pastes, or mouthrinses, or gels, or varnishes) versus another for preventing den-tal caries in children and adolescents. The Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002780.pub2. DOI: 10.1002/14651858.CD002780.pub2.

23. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Topical fluoride (tooth-pastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents. The Co-chrane Database of System-atic Reviews 2003, Issue 4. Art. No.:CD002782. DOI: 10.1002/14651858.CD002782.

24. Kallestal C. The effect of five years’ implementation of caries-preventive meth-ods in Swedish high-risk adolescents. Caries Re-search 2005; 39:20-26.

25. Skold UM, Petersson LG, Lith A, Birkhed D. Effect of school-based fluoride varnish programmes on approximal caries in adoles-cents from different caries risk areas. Caries Research 2005; 39:273-279.

26. Dohnke-Hohrmann S, Zim-mer S. Change in caries prevalence after implemen-tation of a fluoride varnish program. Journal of Pub-lic Health Dentistry 2004 Spring; 64(2):96-100.

27. Stecksen-Blicks C, Ren-fors G, Oscarson ND, Bergstrand F, Twetman S. Caries-preventive effective-ness of a fluoride varnish: a randomized controlled trial in adolescents with fixed orthodontic applianc-es. Caries Research 2007; 41:455-459.

28. Innes N, Evans D. Caries prevention for older people in residential care homes. Evidence Based Dentistry 2009; 10(3):83-87.

29. $750,000 Given in child’s death in fluoride Case: boy, 3, was in city clinic for routine cleaning. New York Times January 20, 1979.

30. Ekstand J, Koch G, Peters-son LG. Plasma fluoride concentration and urinary fluoride excretion in chil-dren following applica-tion of fluoride-containing varnish. Caries Research 1980; 14:185-189.

31. Ekstrand J, Koch G, Peters-son LG. Plasma fluoride concentration in pre-school children after ingestion of fluoride tablets and tooth-paste. Caries Research 1983; 17:379-384.

32. Sharma PR. Allergic con-tact stomatitis from coloph-

ony. Dental Update 2006; Sep;33(7):440-442.

33. Isaksson M, Bruze M, Björkner B, Niklasson B. Contact allergy to Du-raphat. Scandinavian Journal of Dental Research 1993; Feb;101(1): 49-51.

34. Warren DP, Henson HA, Chan JT. Dental hygienist and patient comparisons of fluoride varnishes to fluo-ride gels. Journal of Den-tal Hygiene 2000 Spring; 74(2):94-101.

35. Koch G, Hakeberg M, Petersson LG. Fluoride uptake on dry versus water-saliva wetted human enamel surfaces in vitro after topical application of a varnish (Duraphat) contain-ing fluoride. Swed Dent J 1988; 12:221-225.

36. Chabanski MB, Gillam DG. Aetiology, prevalence and clinical features of cervical dentine sensitivity. J Oral Rehab 1997; 24:15-9.

37. Gangarosa LP Sr. Cur-rent strategies for dentist-applied treatment in the management of hypersensi-tive dentine. Arch Oral Biol 1994; 39:101S-6S.

38. Ehrlich J, Hochman H, Gedalia I, Tal M. Residual fluoride concentrations and scanning electron micro-scopic examination of root surfaces of human teeth after topical application of fluoride in vivo. J Dent Res 1975; 54:897-900.

39. Ritter AV, de L. Dias W, Miguez P, Caplan DJ, Swift EJ. Treating cervical den-tin hypersensitivity with fluoride varnish. Journal of the American Dental As-sociation 2006; 137:1013-1030.

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Free CE Credits Are Just a Click Away.

To view courses online, visit www.txhealthsteps.com.

*Accredited by the Texas Medical Association, American Nurses

Credentialing Center, National Commission for Health Education

Credentialing, Texas State Board of Social Worker Examiners,

Accreditation Council of Pharmacy Education, UTHSCSA Dental

School Office of Continuing Dental Education, Texas Dietetic

Association, Texas Academy of Audiology, and International

Board of Lactation Consultant Examiners.

CE Courses Include:• First Dental Home• Oral Health Examination

by Dental Professionals• Oral Evaluation and

Fluoride Varnish• Children with Diabetes• Children with Asthma• Case Management• Texas Health Steps Overview• Many othersReferral Guidelines• Pediatric Depression• High Blood Pressures

in the Office• Atopic Dermatitis• Gatroesophageal Reflux

in Infants• Exercise-Induced Dyspnea • Referral Guidelines Overview

Taking New Steps

Now you can choose the time and place to take the courses you need and want. We’ve made

it easy to take free CE courses online. Dentists and dental hygienists can get free continuing

education (CE) credits for the First Dental Home and the Oral Health Examination by Dental

Professionals courses. Learn more about Texas Health Steps (Medicaid for children) and other

health-care services with Texas Health Steps Online Provider Education.

The CE courses were developed by the Texas Department of State Health Services and

the Texas Health and Human Services Commission. All courses are accredited for eligible

participants.*

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Texas Medicaid… TDA Dentists Making a DifferenceWilliam D. Steinhauer, D.D.S.

Dr. Steinhauer is a pediatric dentist in private practice in San Antonio. He is the 2010-11 chair of the TDA Committee on Access, Medicaid, and CHIP.

Steinhauer

The 2000 U.S. Surgeon General’s report, Oral

Health in America: A Report of the Surgeon Gen-

eral, raised awareness about the oral health

disparities that persist in the United States,

despite the many improvements in the nation’s

overall oral health. Included in the report is

information that we in dentistry have known

for many years — there are serious oral health

disparities for those segments of the child popu-

lation that come from indigent, low income, and

uninsured families (1).

Free CE Credits Are Just a Click Away.

To view courses online, visit www.txhealthsteps.com.

*Accredited by the Texas Medical Association, American Nurses

Credentialing Center, National Commission for Health Education

Credentialing, Texas State Board of Social Worker Examiners,

Accreditation Council of Pharmacy Education, UTHSCSA Dental

School Office of Continuing Dental Education, Texas Dietetic

Association, Texas Academy of Audiology, and International

Board of Lactation Consultant Examiners.

CE Courses Include:• First Dental Home• Oral Health Examination

by Dental Professionals• Oral Evaluation and

Fluoride Varnish• Children with Diabetes• Children with Asthma• Case Management• Texas Health Steps Overview• Many othersReferral Guidelines• Pediatric Depression• High Blood Pressures

in the Office• Atopic Dermatitis• Gatroesophageal Reflux

in Infants• Exercise-Induced Dyspnea • Referral Guidelines Overview

Taking New Steps

Now you can choose the time and place to take the courses you need and want. We’ve made

it easy to take free CE courses online. Dentists and dental hygienists can get free continuing

education (CE) credits for the First Dental Home and the Oral Health Examination by Dental

Professionals courses. Learn more about Texas Health Steps (Medicaid for children) and other

health-care services with Texas Health Steps Online Provider Education.

The CE courses were developed by the Texas Department of State Health Services and

the Texas Health and Human Services Commission. All courses are accredited for eligible

participants.*

STEPS-0262 Physician Campaign Texas Dental JournalTRIM: 8.5x11 BLEED: 8.75x11.25 4 Color ProcessFor Questions, call Helena Abbing @ 512.600.3733

STEPS-0262 OPE DentalAd_fl_V2.indd 1 6/25/10 3:13 PM


In Texas, public health programs such as Medicaid, the Children’s Health Insurance Program, and Head Start have requirements de-signed to provide a full range of health services for at-risk children. Specifically, Medicaid services, including dental, are provided to eligible children under 21 through the Early and Periodic Screen-ing, Diagnosis, and Treatment program (EPSDT), also known as Texas Health Steps (THSteps).

Although Medicaid includes a wide range of preventive and thera-peutic services, historically low reimbursement rates and adminis-trative hassles have discouraged many dentists from participating in the program.

In 2007, the TDA played an important role in the State of Texas’ successful effort to settle the long-running Frew v Suehs (formerly Frew v Hawkins) lawsuit, which alleged that children enrolled in THSteps were not adequately receiving the preventive and thera-peutic services (including dental care) legally available to them through the EPSDT program.

Although the TDA was not a party to the lawsuit, state officials consulted with the Association’s leadership during negotiations that led to the settlement agreement. Rep. Warren Chisum (R-Pampa), chair of the 80th Legislative Session House Committee on Appropriations, and Sen. Steve Ogden (R-Bryan), chair of the 80th Legislative Session Senate Committee on Finance, requested and obtained the Association’s support for various proposals to boost fees for dental services in an effort to increase the number of den-tists participating in the Medicaid program.

Under the Frew settlement, the state Medicaid program received a total of $1.8 billion in new funding, including more than $700 mil-lion in state funds. State funds equaling $259 million were used to increase fees for dental services, with another $150 million budget-ed for “strategic dental and medical initiatives” to increase access to care, including dental treatment, in underserved areas (2).

While the Frew reimbursement rate increases directly contributed to more dentists participating in the program, the TDA’s deliberate and systematic efforts to recruit and retain Medicaid dental pro-viders also played a significant role. Texas now has approximately 2,260 Medicaid dental providers actively treating eligible children (3). Since 2006, the number of active dental Medicaid providers in-creased 26.2 percent. As a result, Texas is now third in the nation for the highest percentage of Medicaid eligible children receiving dental care in 2009 (4).

Medicaid

In the first 6 months

of implementation,

a total of 161

individual OEFV

providers billed 5,733

THSteps claims.

This means that, most

likely, an additional

5,733 children were

referred by THSteps

Medical providers into

a waiting dental home.


The Department of State Health Services Oral Health Program (OHP) administers two Frew dental-related initiatives — the “First Dental Home (FDH)” and the Oral Evaluation and Fluoride Varnish in the Medical Home (OEFV).”

The FDH provides training and enhanced reimbursements for pediatric and general dentists who agree to provide exams and other care for very young children (i.e., those aged 6 months to 3 years) enrolled in the Medicaid. A separate but related project, the OEFV, reimburses pediatric physi-cians who provide oral evalu-ations and fluoride varnish to very young children enrolled in Medicaid with the goal of transitioning the patients into a dental home.

Initial data from the FDH and OEFV projects strongly indi-cates that dentists are inter-ested and actively participating in both of these programs. The TDA’s FDH marketing efforts, along with those by the OHP, have resulted in dentists ac-tively providing FDH services as indicated by the high pro-portion (82.6 percent) of FDH trained dentists billing for FDH services during the report’s evaluation period (5).

OEFV implementation was de-layed until September 2008 so that an adequate FDH network of dental providers were avail-able to accept dental referrals from THSteps medical checkup providers for THSteps children ages 6 months through 35 months.

In the first 6 months of imple-mentation, a total of 161 indi-vidual OEFV providers billed 5,733 THSteps claims. This means that, most likely, an additional 5,733 children were referred by THSteps Medical providers into a waiting dental home (5).

TDA member dentists also improved the dental health of Medicaid children overall. A 2010 OHP report studied the following three groups of third grade children; 1) enrolled in Medicaid; 2) not enrolled in Medicaid but receiving free/

reduced school lunch, and 3) not enrolled in Medicaid or the free/reduced lunch program. The report showed that Medic-aid enrolled children had better dental outcomes than those not enrolled in Medicaid regardless of whether the children re-ceived free school lunch.

The Frew settlement agreement also included funding to cre-ate a Children’s Medicaid Loan Repayment Program (CMLRP) which provides student loan repayment assistance to physi-cians and dentists who provide services to children enrolled in


Medicaid. Award recipients must provide eligible services for 4 consecutive years and meet the target number of Medicaid visits by children under the age of 21 for each 12-month period as stated in the program requirements.

To date, 101 of the entire 300 loan repayment awards went to dentists and those dentists are now practicing in underserved communities treating Medicaid children that might otherwise go without dental care (7).

As evidenced above, the TDA is diligently work-ing to improve access to dental care for children in Texas by encouraging its members to mean-ingfully participate in public health programs and support initiatives designed to improve the oral health of the state’s most vulnerable chil-dren. The TDA looks forward to continuing to work with legislators and other state officials to provide needed oral health services, which will make a real difference in the lives of thousands of Texas children.

Resources

1. U.S. Department of Health and Human Services. National Call to Action to Promote Oral Health. Rockville, MD: U.S. Depart-ment of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental and Craniofacial Research. NIH Publication No. 03-5303, Spring 2003.

2. Texas Health and Human Services Commis-sion. House Bill 15 Frew Expenditure Plan, September 2007.

3. Texas Health and Human Services Commis-sion. THSteps Active Provider Participation Report 1996-2010. Case 3:93-cv-00065-RAS Document 762, April 2010.

4. Electronic communication from the Texas Department of State Health Services Oral Health Program, July 22, 2010.

Medicaid

5. Texas Department of State Health Services Division of Family and Community Health Office of Program Decision Support. Evalua-tion of Dental Strategic Initiatives: First Den-tal Home and Oral Evaluation and Fluoride, July 13, 2010.

6. Texas Department of State Health Services Division of Family and Community Health Office of Program Decision Support. Assess-ment of Child Dental Services As Required by Frew v. Suehs, December 2009.

7. Electronic communication from the Texas Health and Human Services Commission, September 16, 2009.


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Art: PDF (300), New: YesPick Up From: n/aNotes:Publication Contact email & Phone Number:Nicole Scott, Publications Coordinator, Texas Dental AssociationTel: 512-443-3675, ext. 124 <[email protected]>

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Publication Contact email & Phone Number:TEXAS DENTAL ASSOCIATION1946 South IH-35, Suite 400Austin, Texas 78704-3698Nicole Scott,Advertising ManagerPhone: (512) 443-3675FAX: (512) 443-3031E-mail: [email protected]

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aceOnHold.com delivers 50+ polished, professionally recorded and personalized on-hold messages, music and digital equipment at very reasonable prices, and has received excellent reviews from TDA members. There are no contracts or monthly fees, and aceOn-Hold.com offers a 100% satisfaction guarantee.

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Stefanie Clegg, TDA Web & New Media ManagerDepartment of Member Services & Administration

The Texas Dental Association has created groups on Facebook, LinkedIN, and Twitter. The goal of these groups is to provide updates on events and current issues.

If you do not have a Facebook, LinkedIn, or Twitter account, you can set one up in minutes!

The View From Austin article on page 734 asks for Letters to the Editor describing the great teachers in your experience. Join the Texas Dental Association group on Fa-cebook and post your experience on the group wall. The first five posts will receive a FREE personal web page or link to an existing website on tda.org for 1 year!!

A personal web page offers office, background, special services, insurance information and, includes a photo of the dentist or dental staff. When a user on the public side of the website looks up a dentist, they can click on the dentist’s name and go to that dentist’s web page. TDA members can also access personal web pages on the member side of the site.

For more information or to sign up online for your personal web page or link to your existing website, log in at tda.org click on “Personal Web Pages” under Membership Info -> CONTACTS.

Questions? Contact Stefanie Clegg, TDA web & new media manager, at [email protected].


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Sound AdviceHow to Leverage Your Telephone’s On-Hold Feature to

Build Loyalty and Enhance Patient Experience

By Ron Schott, aceOnHold.com

Impressions, impressions, impressions! Making multiple dental impressions in a given day is pretty normal, but can the same

be said about the number of advertising impressions you make? Professionally produced on-hold messages can help on both accounts.

Every day, we’re presented with op-portunities. Some we make the most of, others we miss. If you are running a business, you are probably aware of something called “opportunity cost,” the monetary value associ-ated with missed opportunities. An often overlooked, disregarded, or under-rated opportunity is the time your patients spend on-hold when calling your practice. Your telephone system’s on-hold feature is tanta-mount to your own private radio station, which provides an opportu-nity to inform, educate, entertain and communicate—in other words, it’s an opportunity to advertise for your practice!


By The Numbers*…Minutes per day the average person spends on hold

Percent of people who made a decision based on something they heard while on hold.

Seconds before callers with “silence-on-hold” hang up.

Percent of small busi-ness callers put on hold

*Survey results from AT&T, North American Telecom Association and CNN Studies

Using professionally produced on-hold messages dramat-ically increases the number of advertising impressions you make with your existing and prospective patients. On-hold messages work tirelessly as a dedicated spokes-person, conveying relevant practice information that subtly reinforces patient loyalty and enhances profes-sionalism. And with a small amount of research, it doesn’t have to take a big bite out of your marketing budget.

Cost ConsiderationsMessages on hold (MOH) run the gamut when it comes to pricing. You can scrimp and defeat your efforts to portray professionalism, or overpay for unnecessary licensing and service fees. As with any purchase, cheaper options aren’t always the best. Solutions under $200 typically include generic messages on a compact disc or e-mailed in MP3 format. Then they leave it up to you to provide the playback solution and lower-priced options rarely offer technical support. On the flip-side, high-priced options can run $1,000-$1,500 annually. Of course, you’re offered custom message programs, writing assistance, digital playback equipment, technical support, and unlimited updates. While these are truly helpful in certain business circumstances, it’s probably overkill for a dental practice.

If you’re like me, researching options, no matter what the topic, feels overly time consuming, so I put it off. For eval-uating message on-hold options, I recommend answering three questions to help clarify your real needs:

1. “Am I okay using a CD player, which is likely to require daily attention, or would I prefer a device designed for 24/7 playback?”

2. “When it comes to frequency of updating on-hold messages, do I prefer a ‘one and done’ solution, or a ‘keep it fresh’ approach?”

3. “With regard to my time, am I available to write mes-sages to keep the content current or is it worth hav-ing it done for me?”

Depending on your answers to the above questions, you should be able to find a satisfactory MOH solution in the $400-$700 range with frequency options for updates that match your needs. Once you are set up with equipment, annual charges should be substantially lower or non-exis-tent depending on whether you continue receiving update options, and the music licensing approach used by your on-hold message supplier.

There are plenty of payment options that include one-time, monthly and all sorts of combinations thereof. Be clear about whether you will own or lease equipment and understand the consequences of terminating or discon-tinuing the use of your on-hold message system. Con-tracts and licensing and/or termination fees can cause

you plenty of tribulations. As with any service, few people enjoy dealing with contracts that lock them into rules and regulations they don’t feel they signed up for; nor do they enjoy paying a hefty sum if they decide to cancel the ser-vice. Today, there are plenty of options that don’t require a contract or monthly fees — nonetheless, make sure to read all of the fine print!

Quality Makes a DifferenceIt’s easy for callers to tune out when they are put on hold. That’s why the quality of your on-hold production matters. It should include an upbeat music background, with pro-fessional voice talent (preferably a combination of male and female), delivering well-written messages that talk about products, services, upcoming events or pertinent practice information. Updating your message content on a regular basis creates a feeling that there’s something “new and exciting” to talk about.

Some business owners try and take the easy way out by playing the radio or music CD they own. DON’T DO THAT! First of all, it’s illegal without proper licensing (organizations such as ASCAP, BMI, CCLI, and SESAC handle music licensing), which costs hundreds of dollars per year. Secondly, playing the radio creates the oppor-tunity for information to be presented that you wouldn’t

10204070


want your callers to hear, such as advertisements for competitors or content of which you may not approve. Not to mention, using the radio or just music means you still miss the opportunity to brand your own professional image.

Closely related to the quality of your on-hold production is the quality of your phone support staff. The care with which they place calls on-hold and resume them has a huge impact on the impression left with your callers. It’s impera-tive to train all members of your team to use genuine politeness and permission-based hold techniques. Simply put, ask, “May I put you on-hold for a moment?” and then WAIT FOR A RE-SPONSE! Upon retrieving a holding caller, be sure to say, “Thank you for holding, how may I help you?”

What about Compatibility?Most phone systems provide a message-on-hold feature as part of its basic setup. This usually consists of a MOH input, normally located on the main unit (PBX). A simple audio cable connects your on-hold player to your phone system. Of course, not all businesses use actual busi-ness-grade phone systems. Some opt for simple multi-line business phones available from office-supply and elec-tronics retailers, or Voice over Internet (VoIP). Still, there are on-hold solutions available depending on your particular setup. The chart to the right represents some of the more popular phone systems and their MOH options.

Final NotesWhen it comes to running a business, it pays to advertise and inform whenever possi-ble. Every company that uses the telephone as an integral part of daily business should utilize on-hold messages because it enables regular communication with an audience that is already established as clients—your patients. It lets them know you respect their “waiting” and realize that their time is valuable. And instead of sitting in silence wonder-ing if they are still connected, patients can be informed and educated. Keep in mind, according to a Telemarketing magazine survey, 20 percent of callers have actually made a purchase or a decision based on information heard while they were on hold.

So the next time you call a small business and you’re put on hold, tune your ears to whether it’s missing opportunities, or maximizing the moment to make a great on-hold impression.

aceOnHold is a TDA Perks Program partner that delivers personalized and profes-sional on-hold messaging with no contracts or monthly fees. aceOnHold offers a 100 percent satisfaction guarantee. For more information, contact aceOnHold at: (800) 892-9179, or visit: https://www.aceonhold.com/home/tda/. For more information re-garding other TDA Perks Programs, visit tdaperks.com, or call (512) 443-3675.

Table of Phone Systems and Message On-Hold Options

Description

PopularBrands

On-HoldMessageOption

No PBX (KSU-less)

Two- and four-line phones purchased at office supply stores and electronics retailers.

AT&T 944, 974, 984, 1040, 1070RCA Executive SeriesPanasonic KX Series

Requires adapter to “emulate” the on-hold feature and allow MOH to play through phone lines. Often includes pressing

( * * Hold) to engage music.

NOTE: Still requires a playback source connected to adapter (such as a CD player or digital on-hold device). Some digital players have analog adapters built-in.

Hardware PBX

Phones connect to a central onsite “brain” that manages incom-ing calls, transfers, holds and other features.

Nortel Norstar (CICS and MICS), Sam-sung, Toshiba, NEC, Mitel, Avaya, Allworx, InterTel, and many others.

Seamless integration of MOH by con-necting a playback source (CD or digital on-hold player). Connects with a sin-gle audio cable from playback source to MOH input on main PBX unit.

Continuous loop playback provides best rotation of messages.

Virtual PBX

Manages incom-ing calls, transfers, holds, and features through a web-based internet service.

Packet 8 (8x8), Fonality, Asterisk, Aptela, RingCentral, Thinking Phones and many others.

Does not require hardware playback device. Upload digital files (.mp3 or .wav) or email to provider for placement.

NOTE: Messages typically play from the beginning each time “hold” is initi-ated, which limits the rotation of what is heard by callers.

[email protected]

Place a classified ad in the Journal!It’s a member benefit! Reach more than 8,000 of your colleagues!

Cost: $35 for the first 30 wordsDeadline: 20th, 2 months prior

Managing Editor


September 201010 – 15The ADA will hold its Kellogg Executive Management Program (ADAKEMP) in Chicago, IL. For more informa-tion, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: [email protected]; Web: ada.org.

23 & 24The El Paso District Dental Society will hold its 48th annual El Paso Dental Conference at the El Paso Con-vention Center in El Paso, Texas. For more information, please contact El Paso Dental Conference, 8815 Dyer, Suite 210, El Paso, TX 79904. Phone: (915) 581-6688; Web: elpasodentalconference.org.

25The TDA Smiles Foundation will hold a Smiles on Wheels in Cactus. For more information, please contact the TDA Smiles Foundation, 1946 S. IH 35, Ste. 300, Austin, TX 78704. Phone: (512) 448-2441; Web: tdasf.org.

27 – October 2The American Association of Oral Maxillofacial Surgeons will hold its 92nd annual meeting at McCormick Place in Chicago, IL. For more information, please contact Dr. Robert C. Rinaldi, AAOMS, 9700 W. Bryn Mawr, Rosemont, IL 60018. Phone: (847) 678-6200; FAX: (847) 678-6286; Web: aamos.org. October 20102 & 3The Indian Dental Association (USA) will hold its convention in Queens, NY. For more information, please contact Dr. Chad P. Gehani, Indian Dental Association (USA), 3540 82nd St., Jackson Heights, NY 11373-5159. Phone: (718) 639-0192; FAX: (718) 639-8122; E-mail: [email protected]; Web: ida-usa.org.

6 & 7The American Association of Dental Editors (AADE) will hold its annual conference in Orlando, FL. For more information, please contact Mr. Detlef Moore, AADE, 750 N. Lincoln Memorial Dr., Suite 422, Milwaukee, WI 53202. Phone: (404) 272-2759; FAX: (404) 272-2754; E-mail: [email protected]; Web: dentaleditors.org.

7 & 8The American College of Dentists will hold its annual meeting at the Rosen Centre Hotel in Orlando, FL. For more information, please contact Dr. Stephen A. Ralls, ACD, 839J Quince Orchard Blvd., Gaithersburg, MD 20878-1614. Phone: (301) 977-3223; FAX: (301) 977-3330; E-mail: [email protected]; Web: facd.org.

9 – 12The American Dental Association will hold its 151st annual session at the Orange County Convention Center in Orlando, FL. For more information, please visit ada.org.

20 – 23The American Society of Dental Aesthetics will hold the 34th Annual American Society of Dental Aesthetics International Conference in San Antonio, TX. For more information, please contact Dr. Dan Lambert, ASDA, 635 Madison Ave., New York, NY 10022. Phone: (800) 454-2732; E-mail: [email protected]; Web: asdatoday.com.

20 – 24The American Academy of Implant Dentistry will hold its 59th annual meeting at the Boston Marriott Copley Place in Boston, MA. For more information, please contact Ms. Sara May, AAID, 211 East Chicago Ave., Suite 750, Chicago, IL 60611-2637. Phone: (312) 335-1550; FAX (312) 335-9090; E-mail: [email protected]; Web: aaid.com.

28 – 30The Hispanic Dental Association will hold its annual meeting in Chicago, IL. For more information, please contact Ms. Rita Brummett, HDA, 3085 Stevenson Drive, Suite 200, Springfield, IL 62703. Phone: (217) 529-6517; FAX: (217) 529-9120; E-mail: [email protected]; Web: hdassoc.org.

30 – November 2The American Academy of Periodontology will hold its 96th annual meeting at the Hawaii Convention Center in Honolulu, HI. For more information, please contact Ms. Susan Schaus, AAP, 737 N. Michigan Ave., Suite 800, Chicago, IL 60611. Phone: (312) 787-5518; FAX: (312) 787-3670; E-mail: [email protected]; Web: perio.org.C

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November 20103 – 6The Dental Trade Alliance will hold its annual meeting at the Hyatt Grand Champions Resort in Indian Wells, CA. For more information, please contact Ms. Mary Dolan, Dental Trade Alliance, 2300 Clarendon Road, Suite 1003, Arlington, VA 22201. Phone: (703) 379-7755; FAX: (703) 931-9429; E-mail: [email protected]; Web: dentaltradealliance.org.

3 – 6The American College of Prosthodontists will hold its 40th annual session at the Hyatt Grand Cypress in Or-lando, FL. For more information, please contact Ms. Melissa Kabadian, ACP, 211 E. Chicago Ave., Suite 1000, Chicago, IL 60611. Phone: (312) 573-1260; FAX: (312) 573-1257; E-mail: [email protected]; Web: prosthodontics.org.

4 – 9The ADA will hold its Kellogg Executive Management Program (ADAKEMP) in Chicago, IL. For more informa-tion, please contact Mr. Ron Polaniecki, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: [email protected]; Web: ada.org.

7 – 13The US Dental Tennis Association will hold its meeting at the Grand Wailea Resort in Maui, HI. More than 16 continuing education AGD/PACE-approved opportunities available. Phone: (800) 445-2524; E-mail: [email protected]; Web: dentaltennis.org.

December 20106 & 7The ADA Institute for Diversity in Leadership will hold its meeting at the ADA in Chicago, IL. For more informa-tion, please contact Ms. Stephanie Starsiak, 211 E. Chicago, Ave., Chicago, IL 60611. Phone: (312) 440-4699; FAX: (312) 440-2883; E-mail: [email protected]; Web: ada.org.

January 201113 – 15The Dallas County Dental Society will hold the Southwest Dental Conference at the Dallas County Convention Center in Dallas, Texas. For more information, please contact Ms. Jane Evans, DCDS, 13633 Omega Drive, Dallas, TX 75244. Phone: (972) 386-5741; FAX: (972) 233-8636; E-mail: [email protected]; Web: dcds.org

23 – 25The American Dental Association will hold its Presidents Elect Conference in Chicago, IL. For more information, please contact Mr. Ron Polaniecki, ADA, 211 East Chicago Avenue, Chicago, IL 60611. Phone: (312) 440-2599; FAX: (312) 440-2883; E-mail: [email protected]; Web: ada.org.

February 20114The American Dental Association’s Give Kids a Smile Day occurs nationwide. For more information, please contact Ms. Lynne Mangan, ADA, 211 East Chicago Ave, Chicago, IL 60611-2678. Phone: (312) 440-2500; FAX (312) 440-7494; E-mail: [email protected]; Web: ada.org.

24The American Equilibration Society will hold its 55th annual meeting at the Chicago Downtown Marriott in Chi-cago, IL. For more information, please contact Mr. Kenneth Cleveland, AES, 207 E. Ohio St., Ste. 399, Chicago, IL 60611. Phone: (847) 965-2888; FAX (609) 573-5064; E-mail: [email protected]; Web: aes-tmj-org.

Ca

len

da

r of E

ven

tsThe Texas Dental Journal’s Calendar will include only meetings, symposia, etc., of statewide, national, and international interest to Texas dentists. Because of space limitations, individual

continuing education courses will not be listed. Readers are directed to the monthly advertisements of courses that appear elsewhere in the Journal.


Appleton, F. GeorgeHaltom City, Texas

July 21, 1924 – June 15, 2010Good Fellow, 1993 • Life, 1989 • Fifty Year, 2007

Bird, Albert D.McKinney, Texas

June 15, 1926 – June 15, 2010Good Fellow, 1978 • Life, 1991 • Fifty Year, 2002

Jones, Mackin L.

Bryan, TexasNovember 20, 1920 – September 14, 2009

Good Fellow, 1973 • Life, 1985 • Fifty Year, 1998

McNutt, John HowardAustin, Texas

October 1, 1923 – June 16, 2010Good Fellow, 1982 • Life, 1988 • Fifty Year, 2007

Moore, John George

Corpus Christi, TexasFebruary 12, 1934 – August 11, 2008

Good Fellow, 1990 • Life, 2000

Oliver, Victor T.Staunton, Virginia

February 28, 1913 – May 8, 2010Good Fellow, 1960 • Life, 1978 • Fifty Year, 1984

Rhodes, William H.

Frisco, TexasJanuary 30, 1927 – April 13, 2010

Good Fellow, 1978 • Life, 1992 • Fifty Year, 2003

Robnett, James HulenLubbock, Texas

September 19, 1922 – May 3, 2010Good Fellow, 1977 • Life, 1987 • Fifty Year, 2002

Smith, Robert F.

March 19, 1928 – October 4, 2010Good Fellow, 1980 • Life, 1993

Tipton, Talmage H.

Lubbock, TexasFebruary 25, 1922 – August 1, 2009

Good Fellow, 1979 • Life, 1987

Wester, Bill G.Weatherford, Texas

August 7, 1928 – June 3, 2010Good Fellow, 1980 • Life, 1984 • Fifty Year, 2005

Zernial, Gerald Allen

Brenham, TexasAugust 21, 1937 – December 23, 2009

Life, 2003

In MemoriamThose in the dental community who have recently passed

In Memory of:

Dr. John HammerickBy Ralph Martin, D.D.S.

Dixie McCutcheon

By Ralph Martin, D.D.S.

Memorial andHonorarium Donors

to the Texas Dental Association Smiles Foundation

Your memorial contribution supports:

• educating the public and profession about oral health; and

• improving access to dental care for the people of Texas.

Please make your check payable to:

TDA Smiles Foundation, 1946 S IH 35, Austin, TX 78704

TDA Video Highlights on tda.org

Due to the positive feedback and overall success with the TDA New Dentist Committee podcast series and the TDA Video Library on TDA Express, TDA has added a new TDA Video Highlights section on the homepage of tda.org. Members can browse through dozens of videos from TDA events, like the TEXAS Meeting.

Listen to TDA members share their opinions on issues such as, “Why Join TDA” and “The Value of Membership.” Watch shout-outs from various events at the TEXAS Meeting like the House of Delegates, TDA GOLD reception or exhibit hall.

Thank you to all the participants! We hope to include more footage in the future and welcome any feedback.

Questions? Contact Stefanie Clegg, TDA Web & New Media Manager at (512) 443-3675 or [email protected]


Clinical HistoryA 49-year-old African American female was referred for evaluation of erythema and edema limited to the maxillary facial gingiva. Her chief complaint was the pain in the maxil-lary region that had lasted the past 6 months and failed to resolve after conventional periodontal treatment. The patient reported some improve-ment in her gingival inflammation when she used a chlorhexidine oral rinse prescribed by her periodontist. However, the improvement was lim-ited and she was unable to use this mouth rinse consistently because it caused a burning sensation in her gums. She also complained that her mouth felt dry. The patient denied skin or other mucosal lesions. No specific triggers or inciting medica-tions for this gingival lesion could be elicited from history.

The patient’s medical history was significant for sarcoidosis affect-ing the brain (neurosarcoidosis), diabetes insipidus, chronic sinusitis, anemia, and depression. The patient also reported loss of vision in the right eye and compromised vision on the left due to the neurosarcoidosis. She underwent multiple imaging studies that showed sarcoidosis was limited to her brain only; there was no history of involvement of the lung, bone, or any other internal organs. Her current medications included IV dexamethasone 200 mg, every 3 weeks for neurosarcoidosis, Car-imune (IV immunoglobulin) given to prevent infection due to long-term corticosteroid treatment, desmopres-

Oral and Maxillofacial Pathology

Case of the Month

Kavitha Parthasarathy, B.D.S., M.S.;Jessica Wu, B.S.;Nadarajah Vigneswaran, D.M.D., Dr. Med. Dent.The University of Texas Dental Branch at Houston WuParthasarathy

sin acetate nasal spray for diabetes insipidus, levothyroxine for hypothyroid-ism and Prozac (fluoxetine) for depression.

The extraoral exam was unremarkable and there was no cervical lymphade-nopathy. The intraoral exam revealed a diffuse, inflamed and swollen gingiva with a granular red surface (Figure 1A). This gingival involvement was restrict-ed to the maxillary facial region from tooth #5-13. The edema and redness involved the free gingiva as well as the attached gingiva (Figure 1A). There were no erosions or ulcerations in the affected gingiva. Pressure applied to this area failed to produce blisters (negative for Nikolsky’s sign).

Periodontal probing in this area exhibited no significant increase in probing depths, however bleeding on probing was elicited. The rest of the mucosa appeared within normal limits and no significant pathosis was detected. The patient demonstrated a moderate to severe degree of xerostomia. Incisional biopsies were obtained from the maxillary facial gingiva between teeth #11 and #12 and submitted for routine histopathologic and direct immunofluores-cence studies.

Microscopic examination revealed mucosal fragments which were surfaced by parakeratinized stratified squamous epithelium. The underlying lamina propria exhibited an intense non-caseating chronic granulomatous inflammation consisting of a collection of histiocytes, lymphocytes, and multinucleated giant cells (Figure 1B). Microscopic examination revealed the presence of neither polarizable nor non-polarizable foreign body material. Special stains for deep fungal infections and acid-fast bacilli were negative. Direct immunofluores-cence staining for IgG, IgA, IgM, c3 and fibrinogen were performed in fresh-frozen tissue sections and were negative for lichen planus, mucous membrane pemphigoid and pemphigus vulgaris. The gingival lesions improved dramati-cally when treated with intralesional corticosteroid injection(s) (Figure 1C).

See page 788 for the answer and discussion.

Vigneswaran


Figure 1 (A-C).

Clinical picture of initial presentation reveals erythematous enlargement of the anterior maxillary facial gingiva (A).

Microscopic findings of the biopsy showing epithelioid granulomas (B).

Dramatic improvement of the gingival lesions after intralesional corticosteroid injections (C).


Gingival SarcoidosisOral and Maxillofacial Pathology Case of the Month (from page 776)

Oral and Maxillofacial Pathology

Diagnosis and Management

DiscussionThe persistence of gingival inflam-mation after stringent plaque control with traditional periodontal therapy is a feature of non plaque-induced gingivitis (1, 2). Therefore, distinc-tion hinges on good clinical history combined with histopathologic and direct immunofluorescence findings. Non-plaque-associated gingival lesions include infectious diseases produced by specific bacterial (i.e., tuberculosis), viral (i.e., primary herpetic gingivostomatitis) and fun-gal (i.e., histoplasmosis) organisms (1, 3). Clinical history, the absence of cervical lymphadenopathy and the microscopic findings were not consistent with an infectious etiology for this case. Plasma cell gingivitis is an asymptomatic and distinct form of allergic gingival reaction which clini-cally presents as a diffuse red area that is sharply demarcated within the attached facial gingiva (4). Micro-scopic examination would reveal the presence of abundant plasma cells in the connective tissue beneath the epithelium. Cinnamon flavored chewing gum, herbal tooth paste, mint candy, and spices used in food preparations are the most common etiologic agents implicated in the development of plasma cell gingivitis (4). Other forms of allergic gingivitis commonly present localized or dif-fused swollen red gingiva triggered by constituents of mouthwashes, dentifrices, and dental restorative materials (4). A thorough clinical

examination and careful history are essential for the diagnosis of allergic gingivitis. An incisional biopsy of the affected gingiva is indicated to rule out other causes of non-plaque-associated gingivitis.

Desquamative gingivitis is a mani-festation of various mucocutaneous diseases which presents as diffuse and swollen red gingiva which spon-taneously sloughs, leaving painful ulcerated or erosive gingival lesions (4, 5). The most common mucocu-taneous disease that manifests as desquamative gingivitis is lichen planus, followed by mucous mem-brane pemphigoid (5, 6). Pemphigus vulgaris, linear IgA disease, bullous pemphigoid, and epidermolysis bullosa acquisita are less frequently associated with desquamative gingi-vitis (5, 6). Histopathologic and direct immunofluorescence findings in this case ruled out these mucocutaneous diseases.

Granulomatous gingivitis clinically presents as a localized or diffuse area of swollen and red gingiva that upon microscopic examination re-veals chronic granulomatous inflam-mation (4, 7). A number of localized and systemic disorders may present as granulomatous gingivitis (4, 7, 8). These include tuberculosis, deep fungal infections, foreign body reac-tions, Crohn’s disease, and sarcoido-sis (4, 7, 8). Special stains excluded specific infections such as tuberculo-sis and systemic fungal infections in

this case. Microscopic examination failed to show exogenous material in the biopsy specimen. Hence, the diagnosis of granulomatous gingivitis associated with gingival sarcoidosis was made based on the clinical his-tory and the microscopic findings. Sarcoidosis is a multisystem disorder of unknown etiology that is charac-terized by the presence of nonca-seating granulomas (9, 10). Sarcoi-dosis affects people of all racial and ethnic groups and usually develops before the age of 50 years (9, 10). Women are affected more often than men and the adjusted annual incidence among African Americans is three times that among Caucasian Americans (9, 10). Moreover, sarcoi-dosis is more likely to be chronic and fatal in African Americans compared to other ethnic groups (9). Exposure to various environmental agents (i.e. insecticides, inorganic particles, and mold) has been implicated as triggers for the development of sar-coidosis because it most commonly involves the lungs, eyes, and skin (9). Currently, it is believed that sar-coidosis develops as an aberrant im-mune response to various ubiquitous environmental triggers (9). Suscepti-bility to sarcoidosis is determined by both genetic and environmental fac-tors (9). Certain HLA class II alleles (i.e., HLA-DB1 and DQB1) are more prevalent in patients with sarcoidosis than in the general population (9).

The clinical presentation is often variable, with the lungs and bilat-


eral hilar lymph nodes being the most commonly involved organs (9, 10). However, the skin, eyes, liver, heart, central nervous, musculoskeletal, genitourinary, and endocrine systems are also frequently affected (9, 10). Gingival presentation and systemic symptoms of sarcoidosis share similarities with tuberculosis which include fatigue, night sweats, and weight loss (3). Acute presen-tation of sarcoidosis, known as Löfgren’s syndrome, consists of arthritis, erythema nodosum (tender erythematous nodules of the skin), and bilateral hilar lymphadenopathy (9). Sarcoidosis may also present with parotid enlargement, anterior uveitis of the eye, facial nerve paralysis and fever which is commonly known as uveoparotid fever (Heerfordt’s syndrome) (9).

Our patient had sarcoidosis involving the central nervous system, commonly known as neurosarcoidosis which occurs in 10 percent of all patients with sarcoidosis (11). Neurosarcoidosis is more common in African Americans, with a female predominance(11). Patients with neurosarcoidosis may develop cranial nerve pal-sies, headache, ataxia, cognitive dysfunction, and seizures (11). Moreover, neurosarcoidosis may affect the hypothalamus/pitu-itary axis and cause diabetes insipidus and panhypopituitarism (10, 11). It should be noted our patient had diabetes insipidus as a complication of neurosarcoidosis. In the head and neck area, sarcoidosis commonly involves the salivary glands causing dry mouth in affected patients (12). Oral manifestations of sarcoidosis are uncommon and may present as a submucosal mass or nodule rather than erythematous gingivitis (12). The buccal mucosa is the most commonly affected area followed by the gingiva, floor of the mouth, tongue and palate (12). Sarcoidosis may occur in an intraosseous location, frequently involving the anterior maxilla and posterior mandible (13).

Histopathologic findings of noncaseating granulomas in one or more organs in the absence of microorganisms and foreign body material are sufficient to make the diagnosis of sarcoidosis when the clinical and radiographic findings are compatible. Sarcoid granulomas produce angiotension-converting enzyme (ACE); hence, serum ACE levels are elevated in 60 percent of sarcoi-dosis patients (9). However, the diagnostic value of serum ACE levels in sarcoidosis remains inconclusive (9). Recently, 18F-fluordeoxyglucose position-emission tomography (18FDG-PET) has been used to evaluate the extent of sarcoid involvement in multiple organ systems (14). The initial therapy for sarcoidosis is corticosteroid therapy. The prognosis of sarcoidosis varies signifi-cantly among affected patients. Disease remission with few or no consequences is noted in two-thirds of patients with sarcoidosis (9). The remainder of the patients will have chronic sarcoidosis with episodic remission and recurrence. Approximately 5 percent of patients die of this disorder, usually due to pulmonary fibrosis leading to respiratory failure (9).

References: 1. Holmstrup P: Non-plaque-induced gingival

lesions. Ann Periodontal 1999;4:202. Laskaris G, Scully C: Introduction. In

Laskaris G, Scully C (eds): Periodontal man-ifestations of local and systemic diseases (ed. Berlin Heidelberg New York: Springer-Verlag, 2003:3.

3. Gill JS, Sandhu S, Gill S: Primary tuberculo-sis masquerading as gingival enlargement. Br Dent J;208:343

4. Neville B, Damm D, Allen C, Bouquot J: Periodontal diseases. In Neville B, Damm D, Allen C, Bouquot J (eds): Oral & Maxil-lofacial Pathology, (ed. St. Louis, Missouri: SAUNDERS/ELSEVIER, 2009:154.

5. Lo Russo L, Fedele S, Guiglia R et al.: Di-agnostic pathways and clinical significance of desquamative gingivitis. J Periodontal 2008;79:4

6. Yih WY, Maier T, Kratochvil FJ, Zieper MB: Analysis of desquamative gingivitis using direct immunofluorescence in conjunction with histology. J Periodontal 1998;69:678

7. Lourenco SV, Lobo AZ, Boggio P et al.: Gingival manifestations of orofacial granulo-matosis. Arch Dermatol 2008;144:1627

8. Vigneswaran N, Morreti AJ, Braden WF: Oral and maxillofacial pathology case of the month. Foreign body gingivitis. Tex Dent J 2007;124:530

9. Iannuzzi MC, Rybicki BA, Teirstein AS: Sar-coidosis. N Engl J Med 2007;357:2153

10. Newman LS, Rose CS, Maier LA: Sarcoido-sis. N Engl J Med 1997;336:1224

11. Delaney P: Neurologic manifestations in sarcoidosis: review of the literature, with a report of 23 cases. Ann Intern Med 1977;87:336

12. Blinder D, Yahatom R, Taicher S: Oral manifestations of sarcoidosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:458

13. Suresh L, Aguirre A, Buhite RJ, Radfar L: Intraosseous sarcoidosis of the jaws mim-icking aggressive periodontitis: a case report and literature review. J Periodontal 2004; 75:478

14. Nunes H, Brillet PY, Valeyre D et al.: Imag-ing in sarcoidosis. Semin Respir Crit Care Med 2007;28:102


B r i e f s

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Practice Opportunities

MCLERRAN AND ASSOCIATES:

AUSTIN: Associate to ownership op-portunity. Five operatory general family practice with high quality fee-for-service patient base. State-of-the-art, all digital and paperless office is as attractive as they come. Grossing above mid-six fig-ures with very low overhead. ID #103.

AUSTIN: Well-established, FFS family practice in five op office located in grow-ing community. Office has been recently updated, boasts a committed staff and strong hygiene program, and has seen increasing revenue in the high six fig-ures the last 3 years. ID #1-0108.

CORPUS CHRISTI: Doctor retiring, six op office with excellent visibility and ac-cess. Good numbers, excellent patient base, good upside potential. Excellent practice for starting doctor. Priced to sell. ID #023.

CORPUS CHRISTI: Three operatory, fee-for-service crown and bridge oriented family practice in a great location. High grossing practice on 3-day week. Doctor ready to retire. Make an offer! ID #098.

HILL COUNTRY AREA: Well-established family practice located in desirable hill country town. Practice would be an ex-cellent satellite office or starter practice. The doctor currently works 2 days per week. The practice is located in growing area with new subdivisions being built, is 20 minutes from Concan Country Club (a top rated new course in Texas) and is in an excellent retirement area. ID #063.

NEW! AUSTIN NORTH: Beautiful five operatory (two equipped, all plumbed) family practice off busy thoroughfare grossing mid six figures. Digital X-ray, digital pano, floor-to-ceiling windows in all ops, solid patient base and cash flow at start-up price. Excellent opportunity. ID #1-0107.

NEW! AUSTIN: North, high grossing, five operatory practice in free-standing building. Plenty of room to expand. Fee-for-service patient base, good equipment. Owner wishes to sell and continue part-time as an associate. ID #1-0115.

NEW! AUSTIN: Very modern, newly built out, eight operatory family prac-tice in highly visible location. Practice is underperforming and has tremen-dous upside potential. Grossed mid six figures with one doctor working limited schedule. ID #116.

NEW! CENTRAL TEXAS: Well-estab-lished, FFS family practice in five op office located in growing community. Office has been recently updated, boasts a committed staff and strong hy-giene program, and has seen increasing revenue in the high six figures the last three years. ID #1-109.

NEW! SAN ANTONIO: Well-established, endodontic specialty practice with solid referral base. Located in growing, upper middle income area. Contact for more information. ID #074.

NEW! SAN ANTONIO: Oral surgery spe-cialty practice. Very good referral base. Almost new build out, great location, and excellent equipment. Good gross and net. Transition available. ID #0113.


NEW! SAN ANTONIO, NORTH CEN-TRAL: Six operatory general practice located in high growth area. All op-eratories have large windows with great views. Very nice equipment, solid patient base, great hygiene program. Priced to sell. ID #1-0112.

NEW! SAN ANTONIO, NORTH CEN-TRAL: Three operatory office in retail/office center with great visibility and access. New equipment and nice build out. Good solid numbers, very low over-head. ID #1-0111.

NEW! SAN ANTONIO, NORTH CEN-TRAL: Five operatory, state-of-the-art facility with new equipment. Located in a medical professional building in high growth, affluent area. Grossing seven figures with high net income. ID #106.

NEW! SAN ANTONIO, NORTH CEN-TRAL: Beautiful, almost new, state-of-the-art six operatory office. Terrific location, great signage, affluent patient base, beautiful decor. Owner has family issues, must sell. ID #1-0114.

RIO GRANDE VALLEY: Excellent four operatory, 20-year-old general practice. Modern, new finish out in retail loca-tion with digital radiography. Fee-for-service patient base and very good new patient count. Great numbers. Super upside potential. ID #093.

RIO GRANDE VALLEY: Three op Medic-aid oriented practice grossing high six figures on part-time work week. Excel-lent opportunity. ID #100.

SAN ANTONIO AREA: Three operatory office in small town with no competi-tion. Very good income and low, low overhead. Priced to sell. ID #013.

SAN ANTONIO NORTH CENTRAL: High gross and net income general family practice located in high income area in very visible retail office center. The seven op office is in excellent con-dition, has a modern design, and is equipped with almost new equipment, all digital X-rays, and is fully comput-erized. Practice grossed seven figures last year. Price slashed! ID #094.

SAN ANTONIO, NORTH WEST: Excel-lent four-chair general family practice in high traffic retail center across from busy mall location. Solid income on 30 hours a week. Ideal opportunity for doctor wanting a quick start in low overhead operation. ID #086.

SAN ANTONIO: Prosthodontic practice with almost new equipment and build out. Doctor wants to sell and continue to work as associate. Beautiful office! Perfect for stand alone or satellite of-fice. ID #060.

SAN ANTONIO: Three operatory gen-eral practice in condominium located in highly desirable and conveniently located medical center area. This practice would be an excellent starter practice and has tremendous upside potential. The condo is also for sale. ID #084.

SAN ANTONIO, NORTH CENTRAL: Two-op practice just off major free-way; perfect starter office. Terrific pricing. ID #009.

SOUTH TEXAS BORDER: General practitioner with 100 percent ortho practice. Very high numbers, incred-ible net. ID #021.


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SAN ANTONIO: Solid, five op general family practice located in high visibility retail project in medical center. Good equipment, nice decor, and loyal patient base. ID #105.

SAN ANTONIO: Four operatory general family practice located in professional office building off of busy thoroughfare in affluent north central side of town. Very nice equipment and decor. Excel-lent opportunity. ID #003.

SAN ANTONIO: Six operatory practice with three chair ortho bay located in 3,400 sq. ft. building. Modern office with newer equipment. Free-standing building on busy thoroughfare. Practice has grossed in seven figures for last 3 years. Great location with super upside potential. ID #055.

SAN ANTONIO, NORTH SIDE: Eight operatory, high grossing, fee-for-service family practice in historic, free-standing building. Affluent neighborhood. Huge patient base and super hygiene pro-gram. ID #104.

SAN ANTONIO: Medical center, four operatory family practice in very nice professional building. Great picture window views. Very nice, modern office, good patient base. Perfect size for start-ing doctor. ID #1-0067.

WACO AREA: Modern and high-tech, three op general family practice gross-ing in mid-six figures with high net income. Large, loyal patient base. Office is well equipped for doctor seeking a modern office. ID -1-0106.

Contact McLerran Practice Transitions, Inc.: statewide, Paul McLerran, DDS, (210) 737-0100 or (888) 656-0290; in

Austin, David McLerran, (512) 750-6778; in Houston, Tom Guglielmo and Patrick Johnston, (281) 362-1707. Practice sales, appraisals, buyer repre-sentation, and lease negotiations. See www.dental-sales.com for pictures and more complete information.

HOUSTON AREA PRACTICE OPPORTUNITIES! MCLERRAN & ASSOCIATES:

CONROE: ASSOCIATE BUY-IN grossing high six figures, six ops, great location on Loop 336 in exploding suburb north of Houston. Doctor wants to retire, looking for associate buy-in. Great op-portunity for success now and well into the future. #H105.

SOLD! HOUSTON: Established crown and bridge/removable practice with digital X-rays, great new patient flow, production in high six figures. PPO and fee-for-service only. Tremendous cash flow. #H109.

HOUSTON: General family practice located southwest of Houston, high visibility, grossing mid-six figures. Five operatories, two ready for expansion. Building and up to four acres of real estate ready for development included in sale. #H108.

GOLDEN TRIANGLE: Eight op general family practice grossing seven figures plus. Modern, open concept design in a highly residential area, strong new patient flow with high net. #H107.

HOUSTON: Established general and family practice inside 610 for transition. #H112.


HOUSTON: This general, 100 percent fee-for-service practice has been estab-lished for more than 25 years. Pro-duced near mid-six figures with retiring doctor only working 2 days per week. Spacious facility with three operatories, custom cabinetry throughout and great outside views can be expanded to four or five operatories. #H113.

NORTHWEST OF HOUSTON: General family practice, grossing mid six fig-ures. Strong recall system with about 1,200 active patients, four operatories, equipment in very nice condition. PPO and fee-for-service, in thriving commu-nity. Low overhead means great cash flow. #H119.

Contact McLerran & Associates in Houston: Tom Guglielmo and Patrick Johnson, (800) 474-3049 or (281) 362-1707. Practice sales, appraisals, buyer representation, and lease negotiations. See www.dental-sales.com for more complete information.

ORAL SURGERY PRACTICE FOR SALE, HOUSTON AREA — GARY CLINTON, PMA: Economy is strong in Texas. Many referring dentists. Retir-ing surgeon; outright sale or transition; seven-figure gross. Seller will work for buyer on limited basis. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Apprais-ers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized clos-ing agent/escrow agent for numerous financial institutions. Certified apprais-als based upon the comparables. More than 2,000 comparables to ensure

accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA SOUTH TEX-AS / BROWNSVILLE / HARLINGEN AREA: Excellent practice with flexible transition. Primarily fee-for-service and Delta Dental. High operating profits; more than seven figures in collections. Lovely office. Some ortho easily ex-panded to larger percentage of practice. Outright sale. Seller with transition / work for new owner as needed. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Apprais-ers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized clos-ing agent/escrow agent for numerous financial institutions. Certified apprais-als based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA BRYAN / COLLEGE STATION PRACTICE FOR SALE. Transition/outright sale. Retir-ing dentist. Beautiful office; Restorative practice. Well-established recall. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Autho-rized closing agent/escrow agent for numerous financial institutions. Certi-fied appraisals based upon the compa-


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rables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA LUBBOCK / PANHANDLE AREA PRACTICE FOR SALE: P-l Four operatories, retiring dentist, high gross/net. Just over 1 hour away from large community. Near seven-figure gross. Profit from hygiene will pay debt service. P-2 Doctor will sell/transition. High collections/net; five operatories, full hygiene. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Apprais-ers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized clos-ing agent/escrow agent for numerous financial institutions. Certified apprais-als based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA NORTH DAL-LAS AREA PRACTICE FOR SALE: Well-established practice; exceptional recall; full general service practice with lots of crown and bridge. Retiring den-tist. Will continue to work as needed 1 day per week. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Insti-tute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representa-tion. Authorized closing agent/escrow agent for numerous financial institu-

tions. Certified appraisals based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA: Serving the dental profession since 1973: I have buyers! Sell your practice and travel while you have your health. In many cases, you can stay on to work 1-2 days per week if you wish. I need practices to sell/transition as follows: Austin, San Antonio, DFW area, and Houston. Have buyers for orthodontic, oral surgery, periodontic, pedodontic, and general dentistry practices. Values for practices have never been higher. One hundred percent funding available, even those valued at more than seven figures. Call me confidentially with any ques-tions. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 compa-rables to ensure accuracy of appraisal (specialty and general). Very confiden-tial. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA SAN ANGELO / ABILENE AREA PRACTICE FOR SALE: S-1 San Angelo area — Very sharp office. Plenty of patients to work 5 days a week; exceptional value. S-2 San Angelo — Excellent well-established restorative practice. Very nice equip-


ment. Dentist relocation. Transitional/outright sale. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Insti-tute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representa-tion. Authorized closing agent/escrow agent for numerous financial institu-tions. Certified appraisals based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

ORTHODONTIC PRACTICES FOR SALE / TRANSITION — GARY CLIN-TON / PMA TEXAS: O1 North Dallas — Fast growing, highly desirable suburb; digital equipment; doctor relocating; will transition. O2 West Central Texas Mid-sized to larger community — Ideal transition; professional referral based; traditional fee-for-service, referral, highly productive. Gorgeous build-ing with room for two in this planned 50/50 partnership; within 5 years complete buy-out with owner working 1-2 days as needed. O3 South Texas retiring orthodontist —100 percent buy-out / transition; seller will stay 1-2 days per week as needed. Seven figure practice collections; 60 percent profits; lovely building. He is ready to spend time with his grandchildren. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Apprais-ers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized clos-

ing agent/escrow agent for numerous financial institutions. Certified apprais-als based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

SOUTH TEXAS CORPUS CHRISTI PERIODONTIC PRACTICE FOR SALE — GARY CLINTON / PMA: Doctor retiring for health reasons. Urgent sale. Great value. Nice office close to beach. Well-established practice. Staff will stay. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 compa-rables to ensure accuracy of appraisal (specialty and general). Very confiden-tial. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON ARLINGTON, TEXAS PRACTICE FOR SALE / TRANSITION: Seven figure gross; well-established cosmetic restorative practice. Arlington is one of the best places to be in Texas. Home of the Dallas Cowboys, Texas Rangers, Six Flags, and more. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Apprais-ers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized clos-


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ing agent/escrow agent for numerous financial institutions. Certified apprais-als based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA HOUSTON GENERAL PRACTICE FOR SALE: CLEAR LAKE/NASA/BAY AREA: Well-established practice. Retiring dentist will transition (limited). Superb recall care program. Exceptional location with very good lease rate. Facility on freeway frontage road; high visibility. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Apprais-ers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized clos-ing agent/escrow agent for numerous financial institutions. Certified apprais-als based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA MCKINNEY/ FRISCO AREA: Exceptional premier restorative practice; seven figure gross requiring experienced dentist. Newer equipment; attractive facility. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Apprais-ers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized clos-ing agent/escrow agent for numerous

financial institutions. Certified apprais-als based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA FORT WORTH AREA SOUTH GENERAL RESTOR-ATIVE PRACTICE FOR SALE: Still an excellent rate of growth with new schools. Very nice office and equip-ment. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/transition/sale. No conflict of interest/dual representation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 compa-rables to ensure accuracy of appraisal (specialty and general). Very confiden-tial. DFW: (214) 503-9696; WATS: (800) 583-7765.

GOLDEN TRIANGLE GENERAL DEN-TAL PRACTICE — SALE: Outstanding practice for sale developed by published mentor. Supported by outstanding staff and latest in dental equipment. Strong revenues and profit margin. Excellent new patient flow. Given high level of FFS revenues, doctor to transition to comfort level of purchaser. Come build your retirement in low competition community. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

CENTRAL EAST TEXAS — SALE: Outstanding practice for sale in beauti-ful East Texas. Moderate FFS revenues


with three fully equipped operatories and an excellent staff. Doctor leaving for the mission field and interested in optimal transition. If you want to prac-tice in a less competitive more relaxed environment, this is a must-see op-portunity. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

HOUSTON GENERAL DENTAL PRAC-TICE — SALE: Small practice in attrac-tive office in southwest Houston profes-sional building. Four treatment rooms. Affordable terms. Wonderful mentor. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

WEST HOUSTON GENERAL DENTAL PRACTICE — SALE: Outstanding op-portunity in rapidly growing community west of Houston. Excellent revenues and profit margin. Four operatories. Some Medicaid. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

SOUTH HOUSTON GENERAL DENTAL PRACTICE — SALE: Most attractive office located on busy thoroughfare in rapidly growing south Houston suburb. Six treatment rooms, five fully equipped. Two additional spaces plumbed. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

WEST HOUSTON GENERAL DEN-TAL PRACTICE — SALE: new, well-appointed office space in fast growing west Houston. Strong new patient flow, excellent staff, and highly qualified mentor. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

NORTH CENTRAL TEXAS GENERAL DENTAL PRACTICE — SALE: Wonder-ful opportunity in small town that is 1 hour north of DFW metroplex. Four operatories. Good new patient flow. Excellent staff. Building also for sale. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

NORTH TEXAS GENERAL DENTAL PRACTICE — SALE: Small, well-estab-lished practice in mid-sized community in north Texas. Three fully-equipped operatories. Experienced staff with excellent skills. Doctor will assist with transition. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

NORTHWEST TEXAS GENERAL DEN-TAL PRACTICE — SALE: Established practice located across from large shop-ping mall. Wonderful staff and strong new patient flow. Digital X-rays. Ten operatories. Doctor to facilitate transi-tion. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

CORPUS CHRISTI GENERAL DENTAL — SALE: Moderate revenues with a very healthy profit margin. Experienced and loyal staff. Totally digital and highly efficient facility layout. If you need to practice to refund your retirement, but don’t want to fight the competitiveness of the city, come see this practice. Con-tact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

SOUTHEAST HOUSTON GENERAL DENTAL PRACTICE — SALE: Incred-ible general dental practice with six operatories in new facility. High rev-


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enues with excellent profit margin. Doc-tor relocating but is most interested in smooth transition. This is a wonderful opportunity to accumulate a substan-tial retirement nest egg with a low level of risk. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

DALLAS / FORT WORTH: Area clinics seeking associates. Earn significantly above industry average income with paid health and malpractice insurance while working in a great environment. Fax (312) 944-9499 or e-mail [email protected].

SOUTH OF HOUSTON GENERAL DEN-TAL PRACTICE — SALE: Outstanding practice with very high growth potential experiencing a strong new patient flow. Moderate revenues with a healthy profit margin on 4 days per week. Build-ing also for sale. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

WACO PEDIATRIC DENTAL PRAC-TICE — SALE: Well-established prac-tice with moderate revenues and high profit margin on 4 days per week. Limited competition and a large facility. Ample room to grow in this community that is home to Baylor University. All ortho cases are being completed, un-less purchaser would like to expand new cases. No Medicaid being seen, but good opportunity with enhanced state fee schedule. Experienced staff and steady new patient flow. Wonderful mentor. Building also available. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

ASSOCIATESHIPS: EAST TEXAS GEN-ERAL DENTAL PRACTICE — Small but busy practice generating mid-range rev-enues on 4 days per week. Located in quaint small town with excellent access to forests and lakes for hunting, fish-ing, and boating. Excellent opportunity for dentists looking ahead to separa-tion from the military. Pre-determined buy-in terms. SOUTH CENTRAL TEXAS PERIODONTAL — Wonderful practice completing periodontal treatment seeks long-term associate who desires to be a partner within 1-2 years. Great location with strong new patient flow. Pre-deter-mined purchase and partnership terms. Wonderful mentor looking for an “equal-ly-yoked” individual. Excellent staff. SAN ANTONIO PERIODONTAL AND ENDODONTIST ASSOCIATESHIPS — Periodontal associateship with pre-de-termined buy-in for very active, multi-office periodontal practice. Endodontist associate also needed in this practice. Outstanding mentor and cohesive staff. If you are the right person, this is an outstanding opportunity. DWF METRO-PLEX AND ORAL AND MAXILLOFACIAL SURGERY — Parkland trained surgeon seeking an “equally yoked” associate desiring to acquire the entirety of his practice within the next 3-5 years. Well-established practice enjoying 2008 rev-enues exceeding seven figures from two locations. Wonderful opportunity for a resident who has recently completed their program and who wish to transi-tion into practice ownership. You could not find a superior partner. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

HOUSTON AREA PRACTICE FOR SALE: Profitable practice for sale. Well-established. Call Jim Robertson at (713) 688-1749.


ADS WATSON, BROWN & ASSOCI-ATES: Excellent practice acquisition and merger opportunities available. DALLAS AREA — Six general dentistry practices available (Dallas, North Dal-las, Highland Park, and Plano); five specialty practices available (two ortho, one perio, two pedo). FORT WORTH AREA — Two general dentistry prac-tices (north Fort Worth and west of Fort Worth). CORPUS CHRISTI AREA— One general dentistry practice. CEN-TRAL TEXAS — Two general dentistry practices (north of Austin and Bryan/College Station). NORTH TEXAS — One orthodontic practice. HOUSTON AREA — Three general dentistry practices. EAST TEXAS AREA — Two general den-tistry practices and one pedo practice. WEST TEXAS — Three general dentistry practices (El Paso and West Texas). NEW MEXICO — Two general dentistry practices (Sante Fe, Albuquerque). For more information and current list-ings, please visit our website at www.adstexas.com or call ADS Watson, Brown & Associates at (469) 222-3200.

SAN ANGELO: For sale — general practice, 100 percent fee-for-service. Well-established practice in a growing community of over 100,000. Excellent patient-to-dentist ratio; many dentists in community are nearing retirement so patient-to-dentist ratio expected to get even better. Five operatories — four equipped, fifth is plumbed and ready to equip. All operatories are computerized using Dentrix software. Highly produc-tive practice with excellent collections. Staff is young, friendly, energetic and loyal with excellent clinical and mana-gerial skills. Continued growth each year with minimal advertising, low over-head. Full-time CDT in office produces crown and bridge as well as removable

prosthodontics. All lab equipment in-cluded with practice. Owner moving out of state; priced to sell. Please inquire by e-mail at [email protected].

DALLAS / FORT WORTH: Dental One is opening new offices in the upscale suburbs of Dallas and Fort Worth. Dental One is unique in that each office of our 60 offices has its own, individual name such as Riverchase Dental Care and Preston Hollow Dental Care. All our offices have top-of-the-line Pelton and Crane equipment, digital X-rays, and intra-oral cameras. We are 70 percent PPO, 30 percent full fee. We take no managed care or Medicaid. We offer competitive salaries and benefits. To learn more about working for Dental One, please contact Rich Nicely at (972) 755-0836.

HOUSTON DENTAL ONE is opening new offices in the upscale suburbs of Houston. Dental One is unique in that each office of our 50+ offices has its own individual name. All our offices have top-of-the-line Pelton and Crane equipment, digital X-rays, and intra-oral cameras. We are 100 percent FFS with some PPO plans. We offer competi-tive salaries, benefits, and equity buy-in opportunities. To learn more about working for Dental One, please call Andy Davis at (713) 343-0888.

TEXAS PANHANDLE: Well-established 100 percent fee-for-service dental practice for immediate transition or complete sale at below market price by retiring dentist. Relaxed work sched-ule with community centrally located within 1 hour of three major cities. The office building can be leased or pur-chased separately and is spaciously designed with four operatories, doctors’


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private office and separate office rental space. This is an excellent and profit-able opportunity for a new dentist, a dentist desiring to own a practice, or a satellite practice expansion. Contact C. Vandiver at (713) 205-2005 or [email protected].

SUGAR CREEK / SUGAR LAND: Gen-eral dentist looking for periodontist, endo, ortho specialist to lease or sell. Suite is 1,500 sq. ft. with four fully-equipped treatment rooms, lab, busi-ness office, telephone system, comput-ers, reception and playroom; 5 days per week. If seriously interested, please call (281) 342-6565.

TOP OF THE HILL COUNTRY GEN-ERAL PRACTICE FOR SALE. Beauti-ful free-standing building in growing Clifton medical/arts district. Well established, quality oriented, five ops, FFS. Easy proximity to Dallas, Austin, and Lake Whitney. Doctor relocating but willing to provide flexible transition terms. If you are tired of patient turn-over and want to make a difference in patients’ lives, this is the opportunity you’ve been looking for. Call (254) 675-3518 or e-mail [email protected].

AUSTIN: Unique opportunity. Associ-ateship and front-office position avail-able for husband/wife team. Southwest Austin, Monday through Thursday. Option to purchase practice in the future. Send resume and questions to [email protected].

GALVESTON ISLAND: Unique oppor-tunity to live and practice on the Texas Gulf coast. Well-established fee-for-service, 100 percent quality-oriented practice looking for a quality oriented

associate. Ideal for a new graduate or for an experienced dentist want-ing to relocate and become part of an established practice with a reputation for providing comprehensive, quality dental care with a personable approach. Practice references available from local specialists. Contact Dr. Richard Krum-holz, (409) 762-4522.

EL PASO: FULL- OR PART-TIMEASSOCIATE NEEDED. Would be sole practitioner at location. Threeoperatories for DDS plus one for hy-gienist, equipment less than 1 yearold. Past compensations up to five figures per week. No administrative responsibilities. Call (702) 510-7795 or e-mail [email protected].

DALLAS / FT. WORTH: DENTAL ONE is opening new offices in the upscale suburbs of Dallas and Fort Worth. Den-tal One is unique in that each office of our 50 offices have its own, individual name. Our latest office to open is Park Lakes Dental Care in Humble. All our offices have top-of-the-line Pelton and Crane equipment, digital X-rays, and intra-oral cameras. We are 100 percent FFS with some PPO plans. We offer competitive salaries, benefits, and equi-ty buy-in opportunities. To learn more about working for Dental One, please call Rich Nicely at (972) 755-0836.

ASSOCIATE NEEDED — NE TEXAS: Pittsburg is surrounded by beautiful lakes and piney woods. Well-estab-lished, quality-oriented, busy cosmetic and family practice. Associate to part-nership opportunity. Call Dr. Richard-son at (903) 856-6688.

HOUSTON: General dentist with pediat-ric experience needed. Full-time posi-


tion available. Excellent compensation. Please send CV to [email protected].

ASSOCIATE FOR TYLER GENERAL DENTISTRY PRACTICE: Well-estab-lished general dentist in Tyler with 30+ years experience seeks a caring and motivated associate for his busy practice. This practice provides excep-tional dental care for the entire family. The professional staff allows a doctor to focus on the needs of their patients. Our office is located in beautiful East Texas and provides all phases of quality dentistry in a friendly and compassion-ate atmosphere. The practice offers a tremendous opportunity to grow a solid foundation with the doctor. The practice offers excellent production and earning potential with a possible future equity position available. Our knowledgeable staff will support and enhance your growth and earning potential while helping create a smooth transition. Interested candidates should call (903) 509-0505 and/or send an e-mail to [email protected].

HOUSTON: Retiring dentist is seeking his successor. Located in the Heights area of Houston, this two operatory practice consistently generates rev-enue in the low six figures because the owner wanted it that way. What’s really remarkable about this practice is the number of active patients. A main-tenance practice like this will usually have a high active patient count but relatively low revenue, which makes this acquisition a dream come true for the dentist that appreciates value and growth. The potential for this practice will only be limited by you, so open your mind and let your eyes see. In-quire to [email protected].

ASSOCIATE NEEDED FOR NURSING HOME DENTAL PRACTICE. This is a non-traditional practice dedicated to delivering care onsite to residents of long term care facilities. This practice is centered in Austin but visits homes in the central Texas area. Portable and mobile equipment and facilities are used, as well as some fixed office visits. Patient population presents unique technical medical, and behavioral chal-lenges, seasoned dentist preferred. Buy-in potential high for the right individual. Please toward CV to e-mail [email protected]; FAX (512) 238-9250; or call (512) 238-9250 for additional information.

PEDIATRIC DENTIST: Pediatric Dental Wellness is growing and needs a dy-namic dentist to work full time in our pediatric practice. The perfect comple-ment to our dedicated staff would be someone who is compassionate, goal oriented, and has a genuine love for working with children. If you are a motivated self-starter that is willing to give us a long-term commitment, please apply. Salary plus benefits. Looking to fill position immediately. Send resumes and cover letters to [email protected].

GREAT OPPORTUNITY FOR A PEDI-ATRIC DENTIST OR GP to join our ex-panding practice. We are opening a new practice in the country (Paris, Texas), just 1 hour past the Dallas suburbs and our original location. The need for a pediatric dentist out there is tremen-dous, and we are the only pediatric office for 70 miles in any direction. We are looking for someone that is person-able, caring, energetic, and loves a fast-paced working environment in a busy pediatric practice. We are willing to


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train the right individual if working with children is your ambition. This position is part-time initially, and after a short training period will lead to full-time. If you join our team, you will be mentored by a Board certified pediatric dentist and will develop experience in all facets of pediatric dentistry including behavior management using oral conscious seda-tion as well as IV sedation. For more information, please visit our websites at www.wyliechildrensdentistry.com and www.parischildrensdentistry.com. Please e-mail CV to [email protected].

SOUTHWEST FT. WORTH — GEN-ERAL DENTAL PRACTICE WITH BUILDING FOR SALE OR LEASE: This very successful, well-established prac-tice has an excellent patient base with referrals from near and far. The seller is retiring immediately or will negoti-ate a comfortable transition. With a low overhead and excellent profit margin, this practice makes a great investment for just the right person. Five treatment rooms, 3,200 sq. ft. plus 800 sq. ft. for additional expansion or rental space. The practice is located in a high vis-ibility and stable economic community. With this practice comes an experi-enced staff, computers in all treatment rooms, nice equipment, imaging soft-ware, and much more. Get out of that associate position and be an owner! Ap-praisal performed by a CPA/CFP/CVA. Call (972) 562-1072 or (214) 697-6152 or e-mail [email protected].

ASSOCIATE SUGAR LAND AND CY-PRESS: Large well-established practice with very strong revenues is seeking an associate. Must have at least 2 years experience and be motivated to learn and succeed. FFS and PPO practice that ranks as one of the top practices

in the nation. Great mentoring oppor-tunity. Possible equity position in the future. Base salary guarantee with high income potential. Two days initially going to 4 days in the near future. E-mail CV to Dr. Mike Kesner, [email protected].

SEEKING ASSOCIATE DENTISTS. Dental Republic is a well-established general dental practice with various successful locations throughout the Dallas Metroplex. A brand new state-of-the-art facility in a bustling location will be opening soon. Join our outstand-ing and professional team in creating beautiful healthy smiles for all. Let us give you the opportunity to enhance your professional career with excellent hours, competitive salary/benefits, and by forming long-lasting friendships with our patients and staff members. Please contact Phong at (214) 466-8450 or e-mail CV to [email protected].

CARE FOR KIDS, A PEDIATRIC FOCUSED PRACTICE, is opening new practices in the San Antonio and Houston area. We are looking for en-ergetic full-time general dentists and pediatric dentists to join our team. We offer a comprehensive compensation and benefits package including medi-cal, life, long- and short-term disabil-ity insurance, flexible spending, and 401(K) with employer contribution. New graduates and dentists with experience are welcome. Be a part of our outstand-ing team, providing care for Texas’ kids. Please contact Anna Robinson at (913) 322-1447; e-mail: [email protected]; FAX: (913) 322-1459.

THRIVING PRACTICE IN GALVESTON providing the best of both worlds ... the great outdoors and a laid back life-style, yet quick access to metropolitan


Houston. This 15-year-old practice has three fully equipped operatories, private office, full-time hygienist, and a great staff. Ownership of free-standing build-ing is available. Generating mid-six fig-ure gross collections on only 3 days per week. Earn a six-figure income as the owner of one of the most well-known, well-respected practices in Galveston. Owner currently splits time with out-of-town practice and must sell. Call Jim Dunn at (800) 930-8017.

LUBBOCK — GENERAL PRACTICE: Associate/partner. Growing group practice is looking for a motivated, long-term, career-minded dentist to provide quality care for our established and tremendous number of new patients. Experienced or new grad welcome. Con-tact at [email protected].

HOUSTON MEDICAL CENTER GEN-ERAL PRACTICE: Practice dentistry the way you have always dreamed! In-credible opportunity for general dentist to work as an associate and transition to partnership in this prestigious Texas Medical Center/Houston, four general dentists, LLP practice. Doctor retiring in 2-4 years after a 40+-year career, and will stay for introductions and success-ful transition of a new dentist. Large number of loyal patients in recare. The office, located in Smith Tower of The Methodist Hospital, is convenient to the West University, Bellaire, River Oaks, and Mid-Town neighborhoods and is the beneficiary of referrals from physi-cians practicing in the Medical Center. State-of-the-art clinical and business systems throughout, including profes-sional management, contemporary equipment, and an in-house dental laboratory staffed by three talented lab techs. See our website, www.ddsassociates.com, for more informa-

tion, and direct any inquires to Ms. Sanders or Ms. Manovich at (713) 797-0846.

HILL COUNTRY AUSTIN AREA: This is an exceptional opportunity for a general dentist to share a beautiful new office building in the Lakeway area; 3,250 sq. ft., seven ops, paperless, three existing staff members. Minimum investment for a start-up/finish out two to four ops and personal office. Sub-lease space for satellite location. Relocate your existing practice for more space. Great opportu-nity for a general dentist who surgically places implants. Opportunity to become a partner. Location pictures are avail-able. Call Sherri, (972) 562-1072 or (214) 697-6152.

DENTIST FOR JCAHO-ACCREDITED COMMUNITY HEALTH CENTER IN SOUTH TEXAS. Texas license or eligi-ble. Full-time or part-time. Competitive compensation package, and great work-ing hours. Contact Nuestra Clinica del Valle, PO Box 1689, Pharr, TX 78577; Phone: (956) 787-8915; FAX: (956) 787-2021; E-mail: [email protected]. EOE.

6 DAY DENTAL & ORTHODONTICS is an established group practice model, providing all dental services to our patients under one roof. Our general dentists and specialists work together to provide the most convenient and quality dental care possible. We have a 25 percent earned equity (no money down) opportunity for a general dentist to prosthodontist. Contact Dr. John Bond at [email protected] and Jody Hardy at [email protected].

SAN ANGELO, ABILENE: Associates — outstanding earnings. Historically proven at over twice the national aver-age for general dentists; future poten-


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tial even greater. Thriving, established practice in great location. Bright and spacious facility. Experienced, efficient, loyal staff. Best of all worlds; big city, earnings, small-town easy lifestyle, out-standing outdoor recreation. Contact Dr. John Goodman at [email protected] or (325) 277-7774.

EXPERIENCED DENTIST IS NEEDED FOR AN ESTABLISHED PRIVATE GROUP PRACTICE located in Katy. General dentistry practice with a comfortable and friendly atmosphere without administrative responsibili-ties. Full- and part-time positions with competitive compensation, benefits, and flexible schedule. Great opportunity for a quality oriented person. Please call Dr. Akerman at (832) 934-2044 or e-mail at [email protected].

BUSY PRACTICE SEEKING ASSOCI-ATE/PARTNER close to Texas Pan-handle in Northwest Oklahoma. Seven ops, Cerec, digital Schick, Casey lasers. Seven figures production in 2009. Call (580) 938-2566 or e-mail [email protected].

ARLINGTON ORAL SURGERY PRAC-TICE — SALE: Oral and maxillofacial practice for sale in Arlington. It is lo-cated in a three unit professional office building and has two other dentists and an orthodontist. The building and office interior are very attractive and situated in a good area with a large referral base locally and the DFW area. This would be a good opportunity if you are seri-ously considering purchasing your own practice at an attractive price. If you would like any further information, call (817) 917-4536 or e-mail at [email protected].

Office Space

SPACE AVAILABLE FOR SPECIAL-IST. New professional building located southwest of Fort Worth in Granbury between elementary and junior high schools off of a state highway with high visibility and traffic. Call (817) 326-4098.

HIGH TRAFFIC SHELL BUILDING IN ROUND ROCK, north of Austin, in one of the fastest-growing counties. Avail-able at $155 / sq. ft. For more informa-tion, e-mail [email protected] or call (512) 848-2509.

SHERMAN — 1,750 SQ. FT. DENTAL OFFICE. Building has established general dentist and perio/implant dentist. Plumbed and ready to go. High traffic and visibility with lots of park-ing. Sherman is beautiful and growing town 50 miles north of Dallas and near Lake Texoma, the second largest lake in Texas. It has great schools, a vibrant arts community, and is home to many, many Fortune 500 companies such as Texas Instruments and Tyson Foods. Call (760) 436-0446.

ALLEN — 1,885 SQ. FT. DENTAL OF-FICE available September 2010. High traffic visibility with lots of parking. Es-tablished dentist. Five treatment rooms plumbed and ready; reception, office, conference room, two bath. Alien is one of the top five growing cities in Texas. Affluent residential, average income $98,500 within 3-miles. Contact Levin Reality, (323) 954-1934.

ROUND ROCK — DENTAL SPACE AVAILABLE FOR LEASE: 323 Lake Creek, 2,032 sq. ft. Lease rate is $18 PSF + $6.50. PSF NNN. Existing air


lines and plumbing. Call Darren Quick, (512) 255-3000.

BUILT-OUT DENTAL OFFICE SPACE FOR LEASE in Northwest Houston close to 1-45 and FM 1960; 2,527 sq. ft. and 4,357 sw. ft. available. Across street from elementary school opening in August. Jay, (713) 304-0033, [email protected].

TURNKEY, FULLY-EQUIPPED DEN-TAL OFFICE OPPORTUNITY FOR LEASE IN KATY: Modern 2,400 sq. ft., six operatory refurbished office now available. Call (281) 414-8870 or e-mail [email protected] for more information.

INGLESIDE DENTAL BUILDING FOR SALE! 1,700 sq. ft., two chairs plumbed. Rental side, near Corpus Christi. Busy main street location. Vacant, no equipment. Landscaping, parking, owner/dentist, $124,900; financing, photographs. E-mail [email protected] or call (702) 480-2236.

ROUND ROCK — ORTHODONTIST SPACE FOR LEASE: On IH-35, be-tween FM 620 and Hwy. 79. Call Dar-ren Quick, (512) 255-3000.

For Sale

ESTABLISHED, FULLY EQUIPPED THREE OPERATORY LAB FOR SALE OR LEASE in Plainview. High visibility location. Seller retiring. Mentor to tran-sition possible. Call (806) 293-2686 or (806) 292-3156.

Interim Services

TEMPORARY PROFESSIONAL COV-ERAGE (Locum Tenens): Let one of our

distinguished docs keep your overhead covered, your revenue-flow open wide, your staff busy, your patients treated and booked for recall, all for a flat daily rate not a percent of production. Na-tion’s largest, most distinguished team. Short-notice coverage, personal, mater-nity, and disability leaves our specialty. Free, no obligation quotes. Absolute confidentiality. Trusted integrity since 1996. Some of our team seek regular part-time, permanent, or buy-in oppor-tunities. Always seeking new dentists to join the team. Bread and butter proce-dures. No cost, strings, or obligations —ever! Work only when you wish. Name your fee. Join online at www.doctorsperdiem.com. Phone: (800) 600-0963; e-mail: [email protected].

OFFICE COVERAGE for vacations, maternity leave, illness. Protect your practice and income. Forest Irons and Associates, (800) 433-2603 (EST). Web:www.forestirons.com. “Dentists Helping Dentists Since 1983.”

Miscellaneous

DOCTORSCHOICEGOLDEXCHANGE.COM: Try our high prices for dental scrap. Check sent 24 hours after you approve our quote. See why we have so many repeat customers. Visit www.DoctorsChoiceGoldExchange.com.

STATE FAIR OF TEXAS, DALLAS: Texas licensed dentists needed to visit with public during Texas State Fair in Dallas, September 24 through October 17. Have an enjoyable time and earn money, too. Work as many or few hours as you wish: days, evenings, weekends, or weekdays. Contact Dr. Duane Taylor at (214) 330-7771, ext. 109.


Type of Coverage IncludesBasic Plan(Level I)

Intermediate Plan(Level II)

Plus Plan(Level III)

Preventative(2 visits/year)

Preventative care, cleanings, X-rays

$75 per visit $100 per visit $100 per visit

Basic Services Fillings, Tooth Extractions

$25 - $200Based on procedure



Major ServicesCrowns, root canals, oral surgery

None None$20 - $1,000Based on procedure

$1500* $500 $1,000 $1,500*

*Maximum for combined basic and major services

Immediate Preventative (up to $100, Twice Yearly) Immediate Basic and/or Major (at 50% of Fee Schedule) 12 Months and Longer = 100% of Fee Schedule!

Better Freedom-of-Choice, No-Network Dental Insurance for your Patients!

New Features as of Sept. 1** Three affordable and convenient

plans to choose from: Basic, Intermediate, and Plus.

Rates from: $15/month/adult; $42/family (Level I)

No underwriting; it’s easy to apply. Benefi ts available immediately:

the day after coverage ispurchased.

Immediate wellness benefi ts(all plans)

In-house claims administration and customer service. No third-party administrators.

Assurant Health fee-for-service plans continue to offer coverage that’s:

Guaranteed issue Guaranteed renewable Portable. Patients can visit any

dentist. No network restrictions

The plans also continue toprovide benefi t-payment choice.Payment can be sent directly to the insured, or to insured’s provider

NO Precertifi cation, Narratives or X-Rays Needed!

**New plans available in states where approved. Dental Insurance from Assurant Health. Assurant Health is the brand name for products underwritten and issued by Time Insurance Company.

For more informationLearn how you can share this information with your patients. Contact MarkDeschenes at:

(888) 350-2416

Your Patients Trust You. Who can YOU Trust?

The Professional Recovery Network (PRN) addresses personal needs involving counseling services for dentists, hygienists, dental students and hygiene students with alcohol or chemical dependency, or any other mental or emotional difficulties. We provide impaired dental profes-sionals with the support and means to confiden-tial recovery.

If you or another dental professional are con-cerned about a possible impairment, call the Professional Recovery Network and start the recovery process today. If you call to get help for someone in need, your name and location will not be divulged. The Professional Recovery Network staff will ask for your name and phone numbers so we may obtain more information and let you know that something is being done.

Statewide Toll-free Helpline800-727-5152

Emergency 24-hour Cell:512-496-7247

Professional Recovery Network12007 Research Blvd. Suite 201

Austin, TX 78759www.rxpert.org


Type of Coverage IncludesBasic Plan(Level I)

Intermediate Plan(Level II)

Plus Plan(Level III)

Preventative(2 visits/year)

Preventative care, cleanings, X-rays

$75 per visit $100 per visit $100 per visit

Basic Services Fillings, Tooth Extractions




Major ServicesCrowns, root canals, oral surgery

None None$20 - $1,000Based on procedure

$1500* $500 $1,000 $1,500*

*Maximum for combined basic and major services

Immediate Preventative (up to $100, Twice Yearly) Immediate Basic and/or Major (at 50% of Fee Schedule) 12 Months and Longer = 100% of Fee Schedule!

Better Freedom-of-Choice, No-Network Dental Insurance for your Patients!

New Features as of Sept. 1** Three affordable and convenient

plans to choose from: Basic, Intermediate, and Plus.

Rates from: $15/month/adult; $42/family (Level I)

No underwriting; it’s easy to apply. Benefi ts available immediately:

the day after coverage ispurchased.

Immediate wellness benefi ts(all plans)

In-house claims administration and customer service. No third-party administrators.

Assurant Health fee-for-service plans continue to offer coverage that’s:

Guaranteed issue Guaranteed renewable Portable. Patients can visit any

dentist. No network restrictions

The plans also continue toprovide benefi t-payment choice.Payment can be sent directly to the insured, or to insured’s provider

NO Precertifi cation, Narratives or X-Rays Needed!

**New plans available in states where approved. Dental Insurance from Assurant Health. Assurant Health is the brand name for products underwritten and issued by Time Insurance Company.

For more informationLearn how you can share this information with your patients. Contact MarkDeschenes at:

(888) 350-2416

NOW


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Contact us for your FREE no-obligation quote: • Call 1-800-524-9400 and mention client #110024

• Go to www.libertymutual.com/tda • Or visit a Liberty Mutual office near you

*Discounts and savings are available where state laws and regulations allow, and may vary by state. Certain discounts apply to specific coverages only. **Figure based on a February 2008 sample of autopolicyholder savings when comparing their former premium with those of the Liberty Mutual Advantage program. Individual premiums and savings will vary. Coverage provided and underwritten by LibertyCounty Mutual Insurance Company and its affiliates, 2100 Walnut Hill Lane, Irving, TX. A consumer report from a consumer reporting agency and/or a motor vehicle report, on all drivers listed on your policy,may be obtained where state laws and regulations allow.© 2009 Liberty Mutual Insurance Company. All Rights Reserved.

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Did you know that TDA members could save up to $327.96 or more a year on auto insurance?

august 2010

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